upper GI endoscopy


upper GI endoscopy

A procedure, in which a fiberoptic endoscope–esophagogastroduodenoscope is inserted by mouth and the mucosa of the esophagus, stomach, duodenum, and proximal jejunum are examined for ulceration, polyps, bleeding sites, strictures, and other changes; at the time of the procedure, suspicious lesions may be sampled and the specimens submitted for culturing or microscopic analysis of cells, tissues, or fluids Indications UGE is used to evaluate acute upper GI bleeding–eg, of the esophagus in cirrhosis, dysphagia–which may be due to strictures, dyspepsia, esophageal pain, and evaluate changes seen by an upper GI study, to identify causes of the gastric outlet syndrome, and to monitor premalignant conditions–eg, Barrett's esophagus, lye-induced strictures; 'low-yield' indications for upper GI endoscopy include atypical chest pain, abdominal pain of unknown origin. Cf Upper GI study.

Esophagogastroduodenoscopy

Synonym/acronym: Esophagoscopy, gastroscopy, upper GI endoscopy, EGD.

Common use

To visualize and assess the esophagus, stomach, and upper portion of the duodenum to assist in diagnosis of bleeding, ulcers, inflammation, tumor, and cancer.

Area of application

Esophagus, stomach, and upper duodenum.

Contrast

Done without contrast.

Description

Esophagogastroduodenoscopy (EGD) allows direct visualization of the upper gastrointestinal (GI) tract mucosa, which includes the esophagus, stomach, and upper portion of the duodenum, by means of a flexible endoscope. The standard flexible fiberoptic endoscope contains three channels that allow passage of the instruments needed to perform therapeutic or diagnostic procedures, such as biopsies or cytology washings. The endoscope, a multichannel instrument, allows visualization of the GI tract linings, insufflation of air, aspiration of fluid, removal of foreign bodies by suction or by snare or forceps, and passage of a laser beam for obliteration of abnormal tissue or control of bleeding. Direct visualization yields greater diagnostic data than is possible through radiological procedures, and therefore EGD is rapidly replacing upper GI series as the diagnostic procedure of choice.

This procedure is contraindicated for

  • high alert Patients who have had surgery involving the stomach or duodenum, which can make locating the duodenal papilla difficult.
  • high alert Patients with a bleeding disorder.
  • high alert Patients with unstable cardiopulmonary status, blood coagulation defects, or cholangitis, unless the patient received prophylactic antibiotic therapy before the test (otherwise the examination must be rescheduled).
  • high alert Patients with known aortic arch aneurysm, large esophageal Zenker’s diverticulum, recent gastrointestinal (GI) surgery, esophageal varices, or known esophageal perforation.

Indications

  • Assist in differentiating between benign and neoplastic tumors
  • Detect gastric or duodenal ulcers
  • Detect upper GI inflammatory disease
  • Determine the presence and location of acute upper GI bleeding
  • Evaluate the extent of esophageal injury after ingestion of chemicals
  • Evaluate stomach or duodenum after surgical procedures
  • Evaluate suspected gastric outlet obstruction
  • Identify tissue abnormalities and obtain biopsy specimens
  • Investigate the cause of dysphagia, dyspepsia, and epigastric pain

Potential diagnosis

Normal findings

  • Esophageal mucosa is normally yellow-pink. At about 9 in. from the incisor teeth, a pulsation indicates the location of the aortic arch. The gastric mucosa is orange-red and contains rugae. The proximal duodenum is reddish and contains a few longitudinal folds, whereas the distal duodenum has circular folds lined with villi. No abnormal structures or functions are observed in the esophagus, stomach, or duodenum.

Abnormal findings related to

  • Acute and chronic gastric and duodenal ulcers
  • Diverticular disease
  • Duodenitis
  • Esophageal varices
  • Esophageal or pyloric stenosis
  • Esophagitis or strictures
  • Gastritis
  • Hiatal hernia
  • Mallory-Weiss syndrome
  • Tumors (benign or malignant)

Critical findings

  • Presence and location of acute GI bleed

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Factors that may impair clear imaging

    • Gas or food in the GI tract resulting from inadequate cleansing or failure to restrict food intake before the study.
    • Retained barium from a previous radiological procedure.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the esophagus and gastrointestinal tract.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, or sedatives.
  • Obtain a history of the patient’s gastrointestinal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent barium or other radiological contrast procedures ordered. Ensure that barium studies are performed after this study.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Note the last time and dose of medication taken.
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort, but the throat will be anesthetized with a spray or swab. Inform the patient that he or she will not be able to speak during the procedure, but breathing will not be affected. Inform the patient that the procedure is performed in a GI laboratory or radiology department, usually by an HCP and support staff, and takes approximately 30 to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications.
  • Inform the patient that a laxative and cleansing enema may be needed the day before the procedure, with cleansing enemas on the morning of the procedure, depending on the institution’s policy.
  • Inform the patient that dentures and eyewear will be removed before the test.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined.
  • Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • May include bleeding and cardiac arrhythmias.

  • Ensure the patient has complied with dietary and medication restrictions and pretesting preparations for at least 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Assess for completion of bowel preparation according to the institution’s procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
  • Obtain and record baseline vital signs.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications. Administer ordered sedation.
  • Spray or swab the oropharynx with a topical local anesthetic.
  • Provide an emesis basin for the increased saliva and encourage the patient to spit out the saliva because the gag reflex may be impaired.
  • Place the patient on an examination table in the left lateral decubitus position with the neck slightly flexed forward.
  • The endoscope is passed through the mouth with a dental suction device in place to drain secretions. A side-viewing flexible, fiberoptic endoscope is advanced, and visualization of the GI tract is started.
  • Air is insufflated to distend the upper GI tract, as needed. Biopsy specimens are obtained and/or endoscopic surgery is performed.
  • Promptly transport the specimens to the laboratory for processing and analysis.
  • At the end of the procedure, excess air and secretions are aspirated through the scope and the endoscope is removed.
  • The needle or catheter is removed, and a pressure dressing is applied over the puncture site.
  • Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Observe the patient for indications of esophageal perforation (i.e., painful swallowing with neck movement, substernal pain with respiration, shoulder pain or dyspnea, abdominal or back pain, cyanosis, or fever).
  • Do not allow the patient to eat or drink until the gag reflex returns; then allow the patient to eat lightly for 12 to 24 hr.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered by the HCP. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Instruct the patient to resume usual activity and diet in 24 hr or as tolerated after the examination, as directed by the HCP.
  • Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
  • Instruct the patient in the care and assessment of the injection site.
  • Inform the patient that he or she may experience some throat soreness and hoarseness. Instruct patient to treat throat discomfort with lozenges and warm gargles when the gag reflex returns.
  • Inform the patient that any belching, bloating, or flatulence is the result of air insufflation and is temporary.
  • Instruct the patient to report any severe pain, fever, difficulty breathing, or expectoration of blood. Immediately report symptoms to the appropriate HCP.
  • Recognize anxiety related to test results, and offer support. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include barium enema, barium swallow, capsule endoscopy, colonoscopy, CT abdomen, esophageal manometry, fecal analysis, gastric acid emptying scan, gastric fluid analysis and gastric acid stimulation test, gastrin and gastrin stimulation test, GI blood loss scan, Helicobacter pylori, MRI abdomen, proctosigmoidoscopy, US pelvis, and upper GI series.
  • Refer to the Gastrointestinal System table at the end of the book for related tests by body system.