Transcript Nasopharyngolaryngoscopy for Family Physicians

EGD for Family Physicians
Scott M. Strayer, MD, MPH
Assistant Professor
University of Virginia Health System
Department of Family Medicine
Case Presentation
 A 47-year-old female presents with a long
standing history of heartburn and epigastric
tenderness. There is no family history of
stomach cancer, and she is tried on a 2-month
trial of PPI with significant relief, but fails an
attempt to stop the therapy.
Barrett’s Esophagus
Background
 Performed by about 4% of Family Physicians
(Source: American Academy of Family Physicians, Practice Profile II Survey, May 2000).
 EGD performed by primary care physicians
was associated with enhanced management
or improved diagnostic accuracy in 89% of
cases (Rodney WM et al: Esophagogastroduodensocopy by family physicians--Phase II: a national multisite study of 2500 procedures. Fam Pract Res J 13(2):121,
1993).
Background
 FP series showed an 83% correlation
between pathologic diagnoses of directed
biopsies and endoscopic diagnoses
including 4 cases of confirmed cancer (this
was comparable to subspecialist’s rates).
(Woodliff DM. The role of upper gastrointestinal endoscopy in primary care. J Fam Pract.
1979;8:715-9).
Complication Rates Among
FP’s
 In this same series, no complications
occurred in 1,783 EGD’s performed by 13
FP’s.
 Another series found one complication in
717 procedures
(Deutchman ME, Connor PD, Hahn RG, Rodney WM. Diagnostic and therapeutic
tools for the family physician's office of the 21st century. Fam Pract Res J.
992;12:147-55).
AAFP’s Position
1. Gastrointestinal endoscopy should be performed by
physicians with documented training and/or experience,
and demonstrated competence in the procedures.
2. Training in endoscopy includes clinical indications,
diagnostic problem solving, mechanical skills acquired
under direct supervision and prevention and management
of complications.
3. Endoscopic competence is determined and verified by
evaluation of performance under clinical conditions
rather than by an arbitrary number of procedures.
AAFP Position
4.
Endoscopic competence should be demonstrated by any
physician seeking privileges for the procedure.
5. Privileges should be granted for each specific
procedure for which training has been documented and
competence verified. The ability to perform any one
endoscopic procedure does not guarantee competency
to perform others.
6. Endoscopic privileges should be defined by the
institution granting privileges and reviewed
periodically with due consideration for performance
and continuing education.
Clinical Indications
 Cancer surveillance in high-risk patients (e.g.
Barrett’s esophagus, Menetrier’s disease, polyposis,
pernicious anemia).
 Esophageal stricture
 Gastric retention
 Chronic duodenitis
 Chronic esophagitis
 Chronic gastritis
 Symptomatic hiatal hernia
 Gastric ulcer monitoring
Clinical Indications
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Chronic peptic ulcer disease
Pyloroduodenal stenosis
Varices
Angiodysplasia in other bowel areas
Abdominal mass
Unexplained anemia
Gross or occult GI bleeding
X-ray abnormality on upper GI study
Clinical Indications
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Dyspepsia
Dysphagia/odynophagia
Early satiety
Epigastric pain
Food sticking
Meal-related heartburn
Severe indigestion
Chronic nausea or vomitting
Substernal or paraxiphoid pain
Reflux of food
Severe weight loss
Clinical Indications
 Not improving after 10 days of H2-blocker
or PPI therapy, or not resolving after 4-6
weeks of H2-blocker of PPI therapy, where
appropriate.
Contraindications
 History of bleeding disorder (platelet
dysfunction, hemophilia)
 History of bleeding esophageal varices
 Cardiopulmonary instability
 Suspected perforated viscus
 Uncooperative patient
Equipment
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Video gastroscope
Light source
Camera source
Color video
Video Monitor
Video recorder
Biopsy forceps
Williams oral introducer
Endoscopy table
Equipment
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Stool with wheels for endoscopist
Sphygmomanometer
Stethoscope
ECG machine or cardiac monitor
Pulse oximeter
IV fluids
Suction equipment and tubing
Specimen jars with formalin solution
Syringes and needles
Equipment
 Rubber gloves
 CLO test materials
 Anesthetic, sedative, and narcotic
medications
 Oxygen and delivery mask
 Crash cart supplies
 Cleaning supplies
Antibiotic Prophylaxis
 With or without biopsy, is not recommended
according to AHA guidelines (1997).
High Risk Patients
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Greater than 70 years old
Less than 12 years old
Agitated, uncooperative patient
History of angina
History of significant aortic stenosis
History of significant chronic obstructive pulmonary
disease
 History of cerebrovascular accident
 Presence of significant bleeding disorder or coagulopathy
 Barium administration within a few hours of procedure
Contraindications for VASC
Procedures
 Weight greater than 350 lbs.
 Significant COPD or pulmonary disease requiring
02
 Sleep apnea requiring CPAP
 Renal Failure on dialysis
 Hepatic failure
 Increased Goldman’s risk (i.e. MI within 6 months,
unstable angina, etc.)
Preparation
 Discontinue ASA/NSAIDS 7 days prior to
examination.
 NPO 7pm evening before procedure (at least
8 hours NPO).
 Examine oral cavity, remove dentures.
 Can use simethicone pre-procedure or as
needed.
Preparation
 Place the patient in the left lateral recumbent
position.
 Spray the back of the throat with 2% lidocaine or
swallow viscous lidocaine (30cc).
 Place Williams introducer in patient’s mouth over
the tongue and into the oral pharynx.
 Inser the lubricated tip of the endoscope down the
introducer, and slowly advance to the point of first
resistance (about 15-17 cm). This is the location of
the vocal cords and cricopharyngeus muscle.
Vocal Cords
Intubating the esophagus
 Ask the patient to swallow repeatedly until a
feeling of “give” is obtained; at this point,
the endoscope can then be passed naturally
into the esophagus.
 NOTE: NEVER USE FORCE AT ANY
TIME, Let the natural swallowing
mechanism advance the scope.
Esophagus
Where are We?
Visualizing the Esophagus
 Insufflate just enough air to dilate the
esophagus and visualize the mucosa.
 Gently advance down the esophagus. The
first landmark will be the bronchoaortic
constriction.
 Try to visualize on entering because mucosa
may be irritated by passage of the scope.
Landmarks
Squamocolumnar Junction
 Continue to the squamocolumnar junction
between the esophagus and the stomach,
which is approximately 40cm from the
patient’s teeth.
 Mucosal coloration changes from pale to
dark pink.
 This boundary is known as the Z line.
Squamocolumnar junction
Stomach
 After passing the GE-junction, the endoscope
will enter the stomach.
 The gastric lake and rugae become visible.
 Follow the rugae to the angularis, antrum and
pre-pyloric areas.
Gastric Rugae
Angularis and Closed Pylorus
Antrum and Pyloric Opening
Entering the Duodenum
 Guide the endoscope through the relaxed
pyloric sphincter and into the duodenal bulb.
 Ampulla of Vater may be visualized.
Duodenum
Retroflexion
 Withdraw past the pyloric sphincter into the
antrum. Turn the large wheel 180 degrees so
that the scope is looking back on itself.
Slowly withdraw so that the GE junction can
be clearly seen and examine the adjacent
cardia.
 Look for fixed or sliding hiatal hernia.
Retroflexion
GE Junction
Finishing the Procedure
 Straighten the endoscope by rotating the
wheel back to the original position. Slowly
withdraw the endoscope through the
esophagogastric junction and back through
the esophagus.
 Examine the vocal cords as the instrument is
withdrawn.
Sending the Patient Home
 The anesthesiologist or assistant should
complete the monitoring process. The
physician should reexamine the patient prior
to discharge from the facility. A 30-minute
observation period is generally sufficient,
especially if minimal sedation is used. No
food or drink for approximately 30 minutes
post-procedure due to local anaesthetic.