Although an increasing number of ERCP and EUS procedures are being performed, there is currently no consensus on the use of a standard gastroscope in tandem with these procedures. Thus, the prevalence of missed luminal lesions when only using a non-forward-viewing endoscope is unclear. The purpose of the current study was to examine the prevalence of clinically significant incidental upper gastrointestinal tract lesions that were found using a standard forward-viewing gastroscope following an ERCP or EUS exam using a duodenoscope or linear echoendoscope.
We hypothesized prior to analyzing the data that linear EUS and ERCP would miss significant esophageal gastrointestinal lesions but not gastric or duodenal lesions. This was hypothesized because very little esophageal mucosa is seen while traversing the esophagus with a linear echoendoscope or duodenoscope.
After two missed gastric adenocarcinomas were presented at the hospital tumor board in patients who had previously undergone ERCPs by another gastroenterologist, the institution adopted as standard of care routine EGD at the time of all ERCP or EUS examinations.
All patients were screened for dysphagia prior to undergoing the procedure. All patients had undergone monitored anesthesia care with propofol sedation or general anesthesia. Patients were excluded from this analysis if: 1 they required an EGD for diagnostic purposes; 2 they had dysphagia; 3 there was a clinical suspicion of upper gastrointestinal tract lesions; 4 EUS was performed using a radial echoendoscope; 5 EUS exam was not a pancreaticobiliary exam; and 6 they had altered pancreaticobiliary anatomy.
All endoscopy reports recorded endoscopic lesions detected in the upper gastrointestinal tract. The data collected included age, gender, ethnicity, exam type, and indication for exam.
The oblique-viewing linear echoendoscope and side-viewing duodenoscope were passed in the usual fashion for the relevant EUS and ERCP exams.
Upper gastrointestinal luminal findings visualized during passage of the scopes were recorded separately for each procedure. Relevant histologic findings were recorded and correlated with endoscopic findings. The primary outcome of the study was to determine the proportion of clinically significant missed incidental lesions when using a side- or oblique-viewing endoscope as compared to the standard forward-viewing endoscope. Gastric erythema, Helicobacter pylori -negative gastritis, hiatal hernias or other anatomic abnormalities that did not affect management were not considered significant findings.
Data analysis was performed using SAS 9. The most common indications for the initial procedure were known or suspected choledocholithiasis, pancreatic mass, chronic pancreatitis, or evaluation of dilated pancreatic or bile ducts. Of the patients, 52 procedures were done with a duodenoscope followed by a gastroscope, 83 procedures were done with a curved linear echoendoscope followed by a gastroscope, and 33 patients were done using both a linear echoendoscope and a duodenoscope followed by a gastroscope.
Focal H. Two lesions, a duodenal polyp and an ampullary adenoma, were visualized with a side-viewing duodenoscope and not seen with the standard gastroscope. No upper gastrointestinal malignancies were diagnosed. While these endoscopes are required to traverse the upper gastrointestinal tract to obtain their images, it is unclear if the endoscopist should be performing a detailed exam of the upper gastrointestinal tract during the same procedure.
Our study helps answer this question as the literature to our knowledge is surprisingly sparse on this topic.
In our study we found that significant incidental upper gastrointestinal lesions is found when a formal exam is performed with a gastroscope. However, in the study, an EGD was performed before the EUS exam, and therefore it is not known if the clinically meaningful lesions would have been detected by an oblique-viewing echoendoscope without performing an EGD. Furthermore, no studies have evaluated the role of an EGD in detecting clinically meaningful lesions when performed either before or after an ERCP.
Another part of this technique involves biopsy, if necessary. This is done with a thin needle that extends from the endoscope into the pancreas. The ultrasound is able to continue during this process. The technique is called fine need aspiration. Endoscopic ultrasound is considered a very safe procedure but some problems can occur.
They are less common if the procedure is performed by an experienced physician with specialized training. The most common complaint from endoscopic ultrasound is sore throat from the insertion of the endoscope.
Your doctor may ask you to temporarily stop taking medicines that affect blood clotting or interact with sedatives. You typically receive sedatives during ERCP to help you relax and stay comfortable. Tell your doctor if you are, or may be, pregnant. If you are pregnant and need ERCP to treat a problem, the doctor performing the procedure may make changes to protect the fetus from x-rays.
Research has found that ERCP is generally safe during pregnancy. You will need to make plans for getting a ride home after ERCP. To see your upper GI tract clearly, you doctor will most likely ask you not to eat, drink, smoke, or chew gum during the 8 hours before ERCP. Doctors who have specialized training in ERCP perform this procedure at a hospital or an outpatient center. An intravenous IV needle will be placed in your arm to provide a sedative. Sedatives help you stay relaxed and comfortable during the procedure.
A health care professional will give you a liquid anesthetic to gargle or will spray anesthetic on the back of your throat. The anesthetic numbs your throat and helps prevent gagging during the procedure.
The health care staff will monitor your vital signs and keep you as comfortable as possible. There are several types of endoscopy. Those using natural body openings include esophagogastroduodenoscopy EGD which is often called upper endoscopy, gastroscopy, enteroscopy, endoscopic ultrasound EUS , endoscopic retrograde cholangiopancreatography ERCP , colonoscopy, and sigmoidoscopy.
Percutaneous endoscopic gastrostomy PEG is a procedure that utilizes endoscopy to help placement of a tube into the stomach; a small incision in the skin is also required. Endoscopies are usually performed under sedation to assure maximal patient comfort. Enteroscopy : A procedure that allows the visualization of a greater portion of the small bowel than is possible with EGD.
Enteroscopy can be achieved by using a long conventional endoscope, a wireless ingestible camera a capsule endoscopy , or a double-balloon endoscope inserted in the mouth or through the rectum. Endoscopic retrograde cholangiopancreatography ERCP : A procedure using a specific technique to study and treat problems of the ducts involving the liver, pancreas and gallbladder. This procedure utilizes a specialized endoscope with a side-mounted camera that can facilitate passage of a catheter into the bile and pancreatic ducts.
Endoscopic Ultrasound EUS : An examination with a special endoscope fitted with a small ultrasound device on the end, used to look inside the layers of the wall of the gastrointestinal tract and visualize the surrounding organs including the pancreas, liver, gallbladder, spleen and adrenal glands.
The scope is inserted in the mouth or anus in the same manner as a conventional endoscope. Percutaneous Endoscopic Gastrostomy PEG : A procedure through which a flexible feeding tube is placed with the assistance of an endoscope through a small incision in the abdominal wall into the stomach.
This procedure is performed in cases where oral ingestion of nourishment or medication is impossible. Colonoscopy is a common, safe test to examine the lining of the large bowel. During a colonoscopy, doctors who are trained in this procedure endoscopists can also see part of the small intestine small bowel and the end of the GI tract the rectum.
This procedure is often done under sedation to assure maximal patient comfort. During a colonoscopy, the endoscopist uses a flexible tube, about the width of your index finger, fitted with a miniature camera and light source. This device is connected to a video monitor that the doctor watches while performing the test. Various miniaturized tools can be inserted through the scope to help the doctor obtain samples biopsies of the colon and to perform maneuvers to diagnose or treat conditions.
Colonoscopy can detect and sometimes treat polyps, colorectal bleeding, fissures, strictures, fistulas, foreign bodies, Crohn's Disease, and colorectal cancer. Sigmoidoscopy, or "flexible sigmoidoscopy," lets a physician examine the lining of the rectum and a portion of the colon large intestine by inserting a flexible tube about the thickness of your finger into the anus and slowly advancing it into the rectum and lower part of the colon.
This procedure evaluates only the lower third of the colon. Sigmoidoscopy is often done without any sedation, although sedation can be used if necessary. Flexible sigmoidoscopy can detect and sometimes treat polyps, rectal bleeding, fissures, strictures, fistulas, foreign bodies, colorectal cancer, and benign and malignant lesions. Flexible sigmoidoscopy is not a substitute for total colonoscopy when it is indicated.
The finding of a new, abnormally growing polyp during sigmoidoscopy, for example, is an indication for a colonoscopy to search for additional polyps or cancer.
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