Endoscopy Procedures - PDF

 BRONCHOSCOPY is a procedure in which a hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or mouth to provide a view of the TRACHEOBRONCHIAL tree.  It can also be used to collect bronchial and/or lung secretions and to perform tissue biops...

 BRONCHOSCOPY is a procedure in which a hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or mouth to provide a view of the TRACHEOBRONCHIAL tree.  It can also be used to collect bronchial and/or lung secretions and to perform tissue biopsy.  The instrument used in BRONCHOSCOPY, a bronchoscope.  It is a slender, flexible tube less than 0.5 in (2.5cm) wide and approximately 2ft (0.3cm) long that uses FIBEROPTIC technology (very fine filaments that can bend and carry light)  There are two types of bronchoscope used in this technique. They are,. RIGID TUBE. FIBREOPTIC TUBE  During a BRONCHOSCOPY, the physician can visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles.  It is used to examine the mucosal surface of the airways for abnormalities that might be associated with a variety of lung diseases.  Its uses may be diagnostic are therapeutic.  BRONCHOSCOPY is usually performed in an endoscopy room, but may also be performed at the bedside.  The patient is placed on his back or sits upright.  A pulmonologist, a specialist trained to perform the procedure, sprays an anesthetic into the patients mouth or throat.  Then the bronchoscope is inserted into the patient’s mouth and passed into the throat.  The patient should fast for 6 to 12 hours prior to the procedure and refrain from drinking any liquids the day of the procedure.  Smoking should be avoided for 24 hours prior to the procedure  Patient should also avoid taking any aspirin or ibuprofen- type medications.  The BRONCHOSCOPY itself takes about 45-60 minutes.  After the BRONCHOSCOPY, the vital signs (heart rate, blood pressure, and breathing) are monitored.  No food or drink should be consumed for about 2 hours after the procedure or until the anesthesia wears off.  Stent therapy  Laser therapy  Argon beam coagulation  BRACHYTHERAPY  Rigid BRONCOSCOPY  Used to diagnose the disease of the lung, such as cancer or tuberculosis.  Congenital deformity of the lungs  Suspected tumor, obstruction, secretion, bleeding or foreign body in the airways.  Airway abnormalities such as tracheal STENOSES  Persistentcough, or HEMOPTYSIS, that includes blood in the sputum  Used to remove a foreign body in the lungs  To remove excessive secretions  Use of bronchoscope mildly irritates the lining of the airways.  It results in some swelling and inflammation, as well as hoarseness caused from abrading the vocal cords.  Components of colonoscope Control section An instrument channel A shaft The tip The connection section The connection line Tip deflection Two control knobs in the control section of colonoscope ○ The larger outer control knob is used for vertical movement of the tip (Figure ​A and B) ○ The smaller inner knob is used for lateral movement of the tip (Figure C and D). A: Up deflection; B: Down deflection; C: Left deflection; D: Right deflection; E: Push forward and pull back; F: Air insufflation (simple closure of hole in the air/water infusion button; pushing button not required); G: Example of air insufflation; H: Air suction (pushing the button above air/water infusion button); I: Example of water suction (because air is invisible). Procedure description Schematogram of large intestine ○ Potential difficult segments during the procedure: Red dotted circles rectosigmoid junction, sigmoidodescending, splenic flexure, hepatic flexure Green dotted box sigmoid colon Pre-intubation Patient on left lateral decubitus position with knees bent and pulled up ○ Inspection of the perianal region Skin tags, scarring, anal fistulae and fissures, hemorrhoids, and prolapse ○ Digital rectal examination with topical anesthetic jelly (usually lidocaine jelly) To prelubricate the anal canal To relax the sphincters. Anal canal Very short segment (~ 2-3 cm) from the anal verge to the dentate line @ introduction of the colonoscope, a red-out sign occurs -> Scope is opposed to the colon mucosa ○ Thus inflate air in the anus using air/water infusion valve button Retroflexion is done later once the scope has been withdrawn to the level of the distal rectum Rectum ~ 15 cm long from the dentate line to the RSJ Easy to advance the scope thru cuz ○ The rectum is attached to the retroperitoneal wall and has almost no mobility Houston’s valves (left-right-left alignment) ○ Progress thru using PF with left and right turns RSJ The 1st challenging area in the colonoscope intubation In most cases, the lumen open to the left axis (Figure G) ○ RSJ appears as an acute bend in the lumen Advancing with only the pushing action may cause a loop to form Only one way to remove a loop: PULL BACK the shaft Apply a left torque (anticlockwise rotation) with mild pushing (A) Alpha loop: withdrawal with clockwise rotation (B) “N” loop: withdrawal without clockwise rotation (A) (B) SC and SDJ Most common sites of iatrogenic perforation Highly variable length ( ~ 20 to 90 cm ) SC has many redundant folds obliterating the lumen ○ Apply adequate air insufflation to visualize the lumen SC and SDJ Use jiggling, shaking and RTS + continuous right torque ○ Use left and right turns + half-suction to avoid adhesion to the lumen ○ Manual abdominal compression by the assistant SC and SDJ If progress has been made up to these segments with minimal loop formation during intubation, the inserted length of the colonoscope should be ~ 40 cm The endoscopist should avoid excessive aeration of SC, which occurs in cases of acute angulation of the SDJ, making it difficult to advance the scope. DC DC is a long tube ringed with concentric haustra ○ It usually has a horizontal fluid level, located to the right of the DC lumen DC is normally traversed in a few seconds with a short “straight” advance and PF usually suffices to pass thru this area DC is attached to the retroperitoneal wall, has low mobility as does the AC SF The SF recognized by the splenic spot seen thru the colonic lumen The SF is the highest section of the colon, located just below the diaphragm ○ It is recommended to advance the colonoscope thru this segment with the up/down control knob set to a neutral state to avoid the walking-stick phenomenon ○ The examiner may change the examinee’s position and/or have an assistant provide abdominal compression The breath-holding technique in the non-sedated examinee may help cuz ○ It widens the angle of the SF by lowering the diaphragm TC Usually more triangular lumen than that of the DC ○ Much mobility, similar to the SC ○ Air suction is helpful in this area since the colonoscope advances relative to the air suction ○ If progression is difficult, the assistant should be instructed to perform abdominal compression on the umbilical area This will prevent loop formation by inhibiting the descent of the TC to the pelvis. HF The hepatic spot can be seen through the mucosa ○ The lumen of the AC of the next section is usually located on the right side. Applying a right turn in the anticipated direction of the lumen together and air suction If progression becomes difficult, shifting the examinee to a supine position may be helpful. AC More triangular in shape and thicker folds Attached to the retroperitoneal wall -> Low Mobility Advance by simple straight pushing CC From the ileocecal valve (ICV) to the cecal base Important to check the ICV and the appendix orifice to confirm the scope’s location in the lumen If progression difficult ○ Air suction ○ Alter the patient’s position ○ Assistant perform abd compression Terminal Ileum ICV seen on the left part of the scope ○ Usually closed, To pass thru u hv to deflect its tip ○ To open the entrance Repeated approach the ICV while using air suction Progression will give a red-out sign followed by the visualization of the TI TI has characteristic villi ○ Water-filling (T) ○ Indigocarmine-dye (U) ○ Narrow-band imaging mode COLONOSCOPY 1. What is it? 2. Indications 3. Contraindications 4. Preparation 5. Diagnostic Procedures 6. Theraputic Procedures  COLONOSCOPY- Introduction 1. Inserting flexible long colonoscope to different 5.Proper training and experience are parts of large bowel up-to cecum through anal necessary for correct diagnosis. orifice. While withdrawing this scope out, you have to look for any pathology. 6. The diagnostic spectrum of colonoscopy encompasses not only macroscopic assessment 2. Experienced examiner can now successfully reach of the condition of the mucosa, but also the the cecum in 98% of patients. possibility of collecting a targeted biopsy sample and, more recently, the use of dye 3.Difficulties can be posed by a mobile and spraying technique and magnification. elongated sigmoid colon or transverse colon as well as by postoperative intestinal fixations and other 7. Colonoscopy is a technically demanding adhesions. examination procedure with a high clinical yield combined with the capability of 4.Examination generally takes around 30 minutes. therapeutic intervention. Because of painful nature of this procedure you should try to finish the procedure as early as possible.  COLONOSCOPY- Indications  Constipation  Diarrhea  Abdominal pain  Bleeding per rectum, unexplained anemia, weight loss  Postpolypectomy surveillance  Prevention/aftercare colorectal carcinoma  Pathological thickening of the colon wall detected by other A Universal cord and plug imaging procedures B Instrument control head, C Insertion tube  Primary tumor search with metastasizing malignancy. Simbionix computer simulator  COLONOSCOPY- Contra Indications Contra Indications Complications and Risks  Perforated intestine  Risk of perforation  Acute diverticulitis  Injury to blood vessels causing  Deep ulcerations bleeding  Severe ischemic necroses  Infection  Fulminant colitis  Comparing diagnostic and therapeutic  Cardiopulmonary colonoscopy, more complications arise decompensation from therapeutic measures, such as polypectomies  COLONOSCOPY- Preparation  Emptying the contents of the  The day of the colonoscopy procedure — As colon is a key requirement for a on the previous day, clear liquid foods only successful colonoscopy. If the  Don't eat or drink anything two hours bowel prep isn't up to par, before the procedure polyps and lesions can be  Now you can give either PEG- Poly missed Ethylene Glycol or Sodium Picosulphate-  A few days before the Fleet enema colonoscopy procedure- Start  Dissolve one pocket of anyone of this in two eating a low-fiber diet Litres of fluid and ask patient to consume  The day before the colonoscopy  Patient will purge several times within few procedure - Don't eat solid hours so that the bowel will get cleaned. foods and have clear liquids.  Can be done under IV sedation of midazolam/fentanyl or propofol COLONOSCOPY- Preparation COLONOSCOPY- Preparation  COLONOSCOPY Five basic rules of colonoscopy  1. Do not advance the endoscope without a clear view of the lumen.  2. Do not advance the endoscope if there is any resistance.  3. When in doubt, pull back.  4. Use as little air as possible and as much air as necessary.  5. Pay attention to patient’s pain reaction.  COLONOSCOPY  Splenic flexure with luminal impression,  Triangular configuration shimmering of spleen. and evenly spaced haustration.  Relatively straight path, oval lumen, and  Ascending colon toward evenly spaced the 7-o’clock position. haustrations.  The ileocecal valve, seen as a yellowish,thickened  Lumen cannot be seen at fold, is on the lower edge of about the 7-o’clock the lumen position but can presumed, in part due to  Base of the cecum shadowing  Appendix orifice in the center  Roomy lumen  Terminal ileum: velvety  Valves of Houston mucosal surface and lacking  Typical submucosal haustrations vascular pattern  COLONOSCOPY Diagnostic Procedures DIVERTICULOSIS DIVERTICULITIS POLYPS POLYPOSIS CARCINOMA- COLON/RECTUM IBD- Crohn’s & Ulcerative Colitis Angiodysplasia & Radiation Colitis Pseudomembranous & Ischemic Colitis  COLONOSCOPY Therapeutic Procedures SNARE POLYPECTOMY Endoscopic Mucosectomy Steps in mucosal resection of broad-based polyps using piecemeal resection technique  SEMS- For Malignant Stricture Placement of metal stents combined with balloon dilation or bougienage Hemostasis in Colorectal Pathologies Injection Gold Probe Hemostasis in Colorectal Pathologies Coagulation of an angiodysplasia using APC (ERBE) Hemostasis in Colorectal Pathologies Endoscopic hemoclip application Removing Foreign Bodies  Removing Foreign Bodies Colonoscopic removal of Drug pouches- from a bodypacker  INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of : the duodenum (the first portion of the small intestine), the papilla of Vater (a small structure with openings leading to the bile ducts and the pancreatic duct), the bile ducts, and the gallbladder and the pancreatic duct.  USES Diagnostic Used when it is suspected a person’s bile or pancreatic ducts may be narrowed or blocked due to: tumors gallstones that form in the gallbladder and become stuck in the ducts inflammation due to trauma or illness, such as pancreatitis infection Dysfunction of valves in the ducts, called sphincters, scarring of the ducts (sclerosis), Pseudo-cysts—accumulations of fluid and tissue debris Therapeutic Sphincterotomy Stone Removal Stent Placement Balloon Dilation Tissue Sampling  PREPARATION OF PATIENT BEFORE ERCP The upper GI tract must be empty. Generally, no eating or drinking is allowed 8 hours before ERCP. Smoking and chewing gum are also prohibited during this time. Current medications may need to be adjusted or avoided. Most medications can be continued as usual. Removal of any dentures, jewelry, or contact lenses before having an ERCP.  Before ERCP, all of the patient’s previous abdominal imaging findings (from CT scans, magnetic resonance imaging [MRI], ultrasonography, and cholangiography or pancreatography) should be reviewed. Deep sedation is desirable during ERCP because a stable endoscopic position in the duodenum is important for proper cannulation, therapeutic intervention, and avoidance of complications.  PROCEDURE Patients receive a local anesthetic that is gargled or sprayed on the back of the throat & IV sedatives. patients lie on their back or side on an x-ray table Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the opening of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed.  A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones. When needed, the opening of the ampulla can be enlarged (sphincterotomy) with an electrified wire (sphincterotome) and access into the bile duct obtained so that gallstones may be removed or other therapy performed. FLUOROSCOPIC IMAGE SHOWING DILATATION OF THE PANCREATIC DUCT DURING ERCP INVESTIGATION. ENDOSCOPE IS VISIBLE. FLUOROSCOPIC IMAGE OF COMMON BILE DUCT STONE SEEN AT THE TIME OF ERCP. THE STONE IS IMPACTED IN THE DISTAL COMMON BILE DUCT. A NASOBILIARY TUBE HAS BEEN INSERTED.  Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be cannulated and stents be inserted. The pancreatic duct requires visualisation in cases of pancreatitis. In specific cases, a second camera can be inserted through the channel of the first endoscope. This is termed duodenoscope-assisted cholangiopancreatoscopy (DACP) or mother-daughter ERCP. The daughter scope can be used to administer direct electrohydraulic lithotripsy to break up stones, or to help in diagnosis by directly visualizing the duct.  AFTER THE PROCEDURE Patients are monitored in the endoscopy area for 1-2 hours until the effects of the sedatives have worn off & observed for complications. Eating or drinking is allowed if the throat is no longer numb and are able to swallow without choking. If a gallstone was removed or placed a stent during the test, the patient is made to stay in the hospital overnight.  AN EXAMPLE (BILE DUCT CANCER (CHOLANGIOCARCINOMA) Cholangiocarcinoma is a cancer that arises from the cells within the bile ducts; both inside and outside the liver. tumors arise along the bile ducts that enter the liver, the tumors are smaller than those which arise from within. COMPARISON OF RADIOGRAPHIC IMAGES SHOWING CHOLANGIOCARCINOMA; A, COMPUTED TOMOGRAPHY (CT) IMAGE; B, CHOLANGIOGRAM (ERCP) IMAGE. ARROWS DESIGNATE THE TUMOR A, B, POSITION OF THE ENDOSCOPE IN THE DUODENUM DURING ERCP A, TECHNIQUE OF TRANSHEPATIC PERCUTANEOUS CHOLANGIOGRAPHY; B, CORRESPONDING PERCUTANEOUS  COMPLICATIONS ERCP is a highly specialized procedure which requires a lot of experience and skill. The procedure is quite safe and is associated with a very low risk when it is performed by experienced physicians. The success rate in performing this procedure varies from 70% to 95% depending on the experience of the physician. Complications can occur in approximately one to five percent depending on the skill of the physician and the underlying disorder. Significant risks associated with ERCP include infection pancreatitis allergic reaction to sedatives excessive bleeding, called hemorrhage puncture of the GI tract or ducts tissue damage from radiation exposure death, in rare circumstances  CONTRAINDICATIONS Unstable cardiopulmonary, neurologic, or cardiovascular status; and existing bowel perforation. Structural abnormalities of the esophagus, stomach, or small intestine may be relative contraindications for ERCP. An altered surgical anatomy. ERCP with sphincterotomy or ampullectomy is relatively contraindicated in coagulopathic patients.  Endoscopy is a nonsurgical procedure used to examine a person's Gastrointestinal tract using an endoscope, a flexible tube with a light and camera attached to it  1958 Development of fibreoptic gastroscope  1968 Endoscopic retrograde pancreatography  1969 Colonoscopic polypectomy  1970 Endoscopic retrograde cholangiography  1974 Endoscopic sphincterotomy (with bile duct stone extraction)  1979 Percutaneous endoscopic gastrostomy  1980 Endoscopic injection sclerotherapy  1980 Endoscopic ultrasonography  1983 Electronic (charge coupled device) endoscope  1985 Endoscopic control of upper gastrointestinal bleeding  1990 Endoscopic variceal ligation  1996 Introduction of self-expanding metal stents  2008 Endomicroscopy delivers histological mucosal definition  UPPER GI ENDOSCOPY  ENTEROSCOPY  COLONOSCOPY ENDOSNCOPY PRINCIPLE  Endoscopy minimally invasive diagnostic medical procedure used to evaluate interior surface of an organ.  Endoscope may have rigid or flexible tube inserted into body. It has ability to looking inside the body using a variety of very small cameras attached to flexible or rigid tube. It facilitates direct viewing the interior of an organ is often very helpful in determining the cause of a problem. ENDOSCOPY PRINCIPLE(CONTD…)  An endoscope is a flexible tube equipped with lenses and a light source. Illumination is done by the help of a number of optical fibers.  Video endoscopy performed by attaching in microchip camera at the insertion tube, setup image is viewed on a video monitor. Distal Tip of Insertion Tube  ENDOSCOPY PIC FIBERSCOPES VIDEO ENDOSCOPE  Superior to Radiology  Except for motility disorders  Take Biopsies  Explain cause of pain  Reflux Oesophagitis  Ulcer disease  Oesophagus to jejunum  Malignancy 19/11/2024 9  Haemorrahage  Injection  Clips  Removal of foreign bodies  Dilation of strictures  Stenting  Feeding – PEG  Percutaneous Endoscopic Gastrostomy 19/11/2024 10  In the pyloric region  1st part of the duodenum  The gastric ulcer 19/11/2024 11  Small bowel pathologies  Angiodysplasia  Meckel’s diverticula  NSAID related enteropathy  Benign or malignant tumour  Push enteroscopy  Double balloon enteroscopy (DBE)  Single balloon enteroscopy (SBE)  Spiral enteroscopy  Capsule endoscopy  Indications:  GI bleeding of obscure origin  Chronic diarrhoea  Malabsorptive syndrome  Chronic abdominal pain  Therapeutic application:  Foreign body removal  Mucosal resection  Insertion of SEMS  Dilatation of stricture in Crohn’s disease  ERCP after Billroth II or Roux-en-Y reconstruction or after bariatric surgery  Described by Tada in 1977  Sonde enteroscopy  Working length of 250-400cm  Propelled by small bowel peristalsis  Lack of working channel and prolonged examination time  Performed with a dedicated enteroscope with an overtube  Method:  Overtube loaded onto the enteroscope  Enteroscope enter the proximal jejunum  Overtube pushed into the 3rd part of duodenum and held by assistant  Enteroscope proceed to advance into the jejunum  Depth of insertion: 40 to 100cm past ligament of Treitz  In contrast to DBE, balloon is not attached to the tip of the enteroscope  Stable positioning in the small bowel is achieved during withdrawal of the scope by angling the tip of the endoscope  Described by Dr Akerman  First performed in 2006  Applies the mechanical advantage of a screw to convert rotational force into linear one  Currently more than 2000 cases have been performed worldwide  Device:  Discovery SB overtube  Spirus Corporation  Overall length 118cm  Outer diameter 14.5mm  Accomodates endoscope