2. LEARNING OBJECTIVES
At the end of this seminar, we should be able to
understand :
• The definition of endoscopy and endoscope
• Upper & lower GI endoscopy
• The indication for diagnostic and therapeutic endoscopy/ colonoscopy/
endoscopic retrograde cholangiopancreatography
• The recognition and management of complications
• Briefly on other types of endoscopy,
• Endoscopic ultrasound
• Respiratory
• Cystoscopy
3. • Endoscopy Greek Word ‘Endo’ = Inside ‘scopy ‘= to see
ENDOSCOPY
Examination of the interior of a canal or hollow viscus by means
of a special instrument, such as an endoscope
ENDOSCOPE
Device using fiber optics and powerful lens systems to provide
lighting and visualization of the interior of cavity. The portion of
the endoscope inserted into the body may be rigid or flexible,
depending upon the medical procedure.
INTRODUCTION
4. The digestive tract consists of the followings :
• Mouth
• Throat
• Esophagus
• Stomach
• Duodenum
• Small bowel
• Colon
• Rectum
• Anus
• And other GI organs .
INTRODUCTION
6. • Involves the use of a side-
viewing duodenoscope - passed
through the pylorus and into
the second part of the
duodenum - to visualise the
papilla
• It is cannulated directly with
catheter/ guidewire – requires
small precut
• Visualised under fluroscopy
after contrast injection
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREA TOGRAPHY (ERCP)
9. Indication :
•Relief biliary obstruction – gallstone & biliary stricture
If there is delay in reliefing – require percutaneous drainage
Adequate biliary sphincterotomy normally performed over well positioned guidewire
Gallstones <1 cm will pass spontaneously in days & weeks
Most endoscopists prefer to ensure duct clearance at initial procedure to reduce
risk of impaction, cholangitis / pancreatitis
Trawling of duct using balloon catheter / extraction using wire basket
If standard techniques fail – mechanical lithotripsy is done – placement of
removable plastic stent
Correct stent placement confirmed by flow of bile after release & presence of air in
biliary tree on follow up radiographs
11. Other indications :
• Pancreatic disease
• Pancreatic stone extraction
• Dilatation of pancreatic duct strictures
• Transgastric drainage of pancreatic pseudocysts
• Assessment of biliary dysmotility (sphincter of Oddi
dysfunction)
THERAPEUTIC ERCP
12. • Duodenal perforation (1.3%)/hemorrhage after scope insertion/
sphincterotomy (1.4%)
• Pancreatitis (4.3%)
• Sepsis (3-30%)
• Mortality (1%)
Post sphincterotomy complications :
• CT scan required in patients with pain, tachycardia / hypotension
postprocedure
• Can be severe – extensive pancreatic necrosis
• Recommended to administered per-rectal indomethacin/diclofenac
immediately before / after procedure – to decrease post ERCP pancreatitis
COMPLICATIONS OF ERCP
13. RISK FACTORS FOR POST – ERCP PANCREATITIS
Definite
Suspected SOD
Young age
Normal bilirubin
Prior ERCP – related pancreatitis
Difficult cannulation
Pancreatic duct
contrast injection
Balloon dilatation of biliary
sphincter
Possible
Female
Low volume of ERCP performed
Absent CBD stone
14. ENDOSCOPIC ASSESSMENT OF SMALL BOWEL
(ENTEROSCOPE )
Indications :
• GI blood loss –with recurrent iron deficiency anemia (occult
hemorrhage)/recurrent overt blood loss per rectum (cryptic
hemorrhage) in pt with normal OGD (with duodenal biopsies) &
colonoscopy
• Malabsorption
• Exclusion of cryptic IBD- Crohn disease
• Targeting lesions in imaging
• Inherited polyposis syndrome
15. TECHNIQUE
1) STANDARD ENTEROSCOPE – may reach in proximal small
bowel
• Requires 45 minutes
• May be uncomfortable – requires sedation
• Long thin endoscope inserted transnasally into stomach &
pushed through pylorus with gastroscope passed through mouth
• Carried distally by peristalsis propels balloon inflated at tip
• Limitations – long examination time (6-8 hours), discomfort to
patient, danger of perforation
17. • If area of interest was outside reach of standard
enteroscope , direct access via enterotomy
• Advance technique of small bowel assessment :
• Capsule endoscope allows diagnostic mucosal view of entire
small bowel
• Single/double-balloon enteroscopy – endoscopic access to
entire small bowel for biopsy & therapeutics
20. • Provides good visualisation from mouth to colon with
high diagnostic yield
• ‘Gold standard’ for GI bleeding
• Contraindications :
• Small bowel strictures – may cause acute obstruction
requiring retrieval at laparotomy / via laparoscopy
• Gastroparesis
• Pseudo-obstruction
21. 3) SINGLE/DOUBLE-BALLOON ENTEROSCOPY
• Direct visualisation & therapeutic intervention for entire small
bowel via oral / rectal route
• Developed in Japan 2001 – thin enteroscope & overtube both
fitted with a balloon
23. Technique Advantages Disadvantages
Traditional enteroscopy • Simple technique with wide
availability
• Full range of therapeutics
available
• Performed under sedation
• Some discomfort
• Can only access proximal small
bowel
Capsule endoscopy • Able to visualise the entire
small
• Preferable
• No sedation
• Painless
• No biopsies
• Not controllable & no accurate
localisation
• Variable transit
• Incomplete studies due to
battery life
• Not suitable for patients with
strictures
• Large capsule to swallow
Double/single-balloon
enteroscopy
• Able to visualise the entire
small bowel
• Full range of therapeutic
• Requires sedation/general
anaesthesia
• Patient discomfort
• May take 3-4 hours, require
admission
• Complications - perforation
25. COLONOSCOPY
• Colonoscopy lets the physician look inside
the entire large intestine, from the
lowest part, the rectum, all the way up
through the colon to the lower end of
the small intestine.
• The procedure is used to look for early
signs of cancer in the colon and
rectum, inflamed tissue, abnormal
growths, ulcers, and bleeding.
• If anything abnormal is seen in the colon, like a
polyp or inflamed tissue, the physician can
remove all or part of it using tiny instruments
passed
through the scope. That tissue (biopsy) is then sent
to a lab for testing. If there is bleeding in the colon,
the physician can pass a laser, heater probe, or
electrical probe, or inject special medicines through
the scope and use it to stop the bleeding.
26. INDICATIONS OF COLONOSCOPY
• Rectal bleeding with looser/more frequent +/- abdominal pain
related to bowel action
• Iron deficiency anemia (after biochemical confirmation +/-
negative coeliac serology) : oesophagogastroduodenoscopy &
colonoscopy
• Right iliac fossa mass if U/S suggest colonic origin
• Change in bowel habit associated with fever/elevated
inflammatory response
• Chronic diarrhoea (6 weeks) after sigmoidoscopy/rectal
biopsy & negative coeliac serology
• Follow-up of colorectal cancer & polyps
• Screening of patients with family history of colorectal cancer
• Assessment/removal of a lesion seen in radiological examination
• Assessment of ulcerative colitis/Crohn extent & activity
• Surveillance of IBD
• Surveillance of acromegaly/ureterosigmoidostomy
28. COMPLICATIONS OF COLONOSCOPY
Absolute :
Suspected perforation of intestine
Signs of peritonitis in toxic patient
Relative :
Severe acute colitis
Gross acute gastrointestinal bleeding
Poor bowel preparation
Recent surgical anastomosis
Partial or complete intestinal obstruction
Abdominal or iliac aneurysm
29. SIGMOIDOSCOPY
• To look at the inside of the large intestine from the rectum
through the last part of the colon : sigmoid or
descending colon
Indications :
• To find the cause of diarrhea, abdominal pain, or constipation
• To look for early signs of cancer in the descending colon and
rectum. With flexible sigmoidoscopy, the physician can see
bleeding, inflammation, abnormal growths, and ulcers in
the descending colon and rectum.
• Flexible sigmoidoscopy is not sufficient to detect polyps or
cancer in the ascending or transverse colon two-thirds of the
colon
32. ENDOSCOPIC ULTRASOUND (ECHOENDOSCOPE)
• Disadvantage of conventional endoscopy : limited
to mucosal surface
• Not possible to diagnose submucosal /
extraintestinal pathology
Types of echoendoscope:
• Radial echoendoscope : radially arranged U/S
probe & forward – viewing lens, diagnostic of
local tumour of esophagus & stomach
• Linear echoendoscope : side viewing scope which is
linearly arranged U/S probe, for sampling of tissues ;
eg : paraesophageal & celiac nodes
33. INDICATIONS FOR ENDOSCOPIC ULTRASOUND
Diagnostic
Staging of esophageal/gastric malignancy
Staging of hepatobiliary malignancy
Diagnosis of choledochal microlithiasis
Therapeutic
Biopsy of paraesophageal LN
Biopsy of submucosal upper GI lesions
Biopsy of pancreaticobiliary mass
Biopsy of portal lymphadenopathy
Biopsy of left adrenal & left liver massess
Transgastric drainage of pancreatic pseudocyst
Celiac plexus block
34. IMPROVED ENDOSCOPIC IMAGING
Chromoendoscopy, narrow band imaging & high
resolution magnification endoscopy
• Chromoendoscopy – topical application of stains / pigments to
improve tissue localisation, characterisation / diagnosis
• Agents that is used : methylene blue (vital), indigo carmine
(contrast) & India ink (tattooing), acetic acid & Lugol’s iodine
• Narrow band imaging – uses 2 discrete band of lights to
increase contrast image of tissue surface
• High resolution magnification endoscopy – to achieve near
cellular definition of mucosa for surveillance of neoplasia
35. Duodenal adenoma on
white light
Clearly delineate with
narrow band imaging
Chromoendoscopy with
indigo carmine
37. BRONCHOSCOPY
• A bronchoscope is a tube with a tiny
camera on the end which is inserted
through the nose (or mouth) into
the lungs. During a bronchoscopy
procedure, a scope will be inserted
through the nostril until it passes
through the throat into the trachea
and bronchi. A bronchoscope is used
to provide a view of the airways of the
lung. The scope also allows the doctor
to collect lung secretions and lung
tissue for biopsy for tissue
specimens.
39. CYSTOSCOPY
• Cystoscopy is a procedure that
uses a flexible fiber optic scope
inserted through the urethra into
the urinary bladder.
• The bladder is filled with water
and the interior of the bladder is
inspected.
• The image seen through the
cystoscope may also be viewed
on a color monitor and recorded
on videotape for later evaluation.
40. SUMMARY
• The definition of endoscopy and endoscope
• Upper & lower GI endoscopy
• The indication for diagnostic and therapeutic endoscopy/ colonoscopy/
endoscopic retrograde cholangiopancreatography
• The recognition and management of complications
• Briefly on other types of endoscopy
• Endoscopic ultrasound
• Respiratory
• Cystoscopy
41. References
• Bailey & Love’s H. B., & M. L. (2018). Short Practice of
Surgery(27th ed., Vol. 1). Boca Ratonca : CRC Press
• M., S. B. (2016). SRBs Manual of Surgery : Jaypee Brothers
Medical P.