Esophagogastroduodenoscopy (EGD), commonly known as upper endoscopy, is a vital diagnostic procedure in modern medicine. Gastroenterologists frequently utilize this endoscopic technique to visualize and assess the upper digestive tract, including the oropharynx, esophagus, stomach, and proximal duodenum. This article offers a comprehensive overview of EGD, emphasizing its diagnostic capabilities and the collaborative role of the healthcare team in ensuring optimal patient care for upper gastrointestinal disorders.
Objectives:
- Understand the specific indications for utilizing esophagogastroduodenoscopy in diagnosis.
- Detail the procedural technique involved in performing a thorough upper endoscopy.
- Identify and recognize potential complications associated with esophagogastroduodenoscopy.
- Discuss interprofessional strategies to enhance care coordination and communication for the safe and effective application of esophagogastroduodenoscopy, ultimately improving patient outcomes.
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Introduction to EGD Diagnosis
Esophagogastroduodenoscopy (EGD) stands as a cornerstone in the diagnostic toolkit for evaluating upper gastrointestinal (GI) conditions. This minimally invasive endoscopic procedure allows for direct visualization of the upper digestive system, encompassing the oropharynx, esophagus, stomach, and the initial segment of the duodenum. As one of the most frequently performed procedures by gastroenterologists, EGD plays a crucial role in both diagnosis and therapeutic intervention within the upper GI tract.
Anatomy and Physiology Relevant to EGD
Understanding the anatomy of the upper digestive tract is paramount for effective Egd Diagnosis and interpretation.
The Esophagus:
Positioned behind the trachea, the esophagus begins below the cricoid cartilage and terminates at the stomach’s cardiac orifice. In adults, the esophageal length is approximately 25 cm, with a diameter ranging from 4 to 6 mm. A key landmark during EGD is the Z-line, where the mucosal color transition from pale to reddish-pink marks the junction between the esophageal and gastric epithelium. Recognizing this transition is essential for identifying conditions like Barrett’s esophagus.
The Stomach:
Typically situated beneath the diaphragm, the stomach is approximately 40 cm from the incisors in adults. The gastric cardia denotes the area where the esophagus enters the stomach. The fundus, located above the esophagogastric junction, is best visualized in a retroflexed endoscopic view. The main portion of the stomach is the body. The incisura, along the lesser curvature, separates the body from the antrum. Endoscopically, the body-antrum transition is identified by the change from rugae to a flatter mucosa. The pylorus, a muscular opening, connects the stomach’s lower end to the duodenal bulb.
Image alt text: Diagram illustrating Esophagogastroduodenoscopy procedure, showing endoscope insertion through mouth into esophagus, stomach and duodenum for visual examination.
The Duodenum:
Extending from the pylorus to the duodenojejunal angle, the duodenum begins with the duodenal bulb, an expanded section immediately after the pylorus. The duodenum forms a C-shaped loop, turning posteriorly and to the right, then inferiorly (descending portion), followed by an anterior and leftward turn before connecting to the jejunum at the ligament of Treitz. Endoscopic examination meticulously follows these anatomical curves for a complete assessment.
Indications for EGD Diagnosis
EGD is indicated for a wide range of diagnostic and therapeutic purposes.
Diagnostic Indications:
- Persistent Upper Abdominal Pain: Especially when associated with alarming symptoms like unexplained weight loss or anorexia, EGD helps rule out structural or mucosal abnormalities.
- Dysphagia and Odynophagia: Difficulty swallowing (dysphagia) or painful swallowing (odynophagia) necessitate EGD to identify esophageal strictures, inflammation, or masses.
- Chronic Gastroesophageal Reflux Disease (GERD) Symptoms: In cases of intractable or chronic GERD symptoms unresponsive to medical management, EGD can detect complications like esophagitis or Barrett’s esophagus.
- Unexplained Irritability in Children: EGD is valuable in evaluating persistent unexplained irritability in children, potentially linked to upper GI issues.
- Persistent Vomiting or Hematemesis: Persistent vomiting of unknown cause or vomiting blood (hematemesis) warrants EGD to identify the source of bleeding or obstruction.
- Iron Deficiency Anemia: In cases of iron deficiency anemia suspected to be from chronic upper GI blood loss, particularly when colonoscopy is normal, EGD is crucial for source identification.
- Chronic Diarrhea or Malabsorption: EGD with duodenal biopsies can aid in diagnosing conditions causing chronic diarrhea or malabsorption, such as celiac disease.
- Caustic Ingestion Assessment: Evaluation of acute injury following caustic ingestion requires EGD to assess the extent of esophageal and gastric damage.
- Malignancy Surveillance: Patients with premalignant conditions like polyposis syndromes, history of caustic ingestion, or Barrett’s esophagus require regular EGD surveillance for early cancer detection.
Therapeutic Indications:
- Foreign Body Removal: EGD is the primary method for retrieving foreign bodies lodged in the upper GI tract.
- Stricture Dilation and Stenting: Esophageal strictures can be dilated or stented during EGD to improve swallowing.
- Esophageal Variceal Ligation: EGD allows for ligation of esophageal varices to prevent or treat variceal bleeding.
- Upper GI Bleeding Control: EGD is essential for identifying and controlling the source of upper GI bleeding through various hemostatic techniques.
- Feeding and Draining Tube Placement: EGD facilitates the placement of feeding tubes (PEG tubes) or drainage tubes.
- Achalasia Management: EGD can be used for botulinum toxin injection or balloon dilation in the management of achalasia.
Contraindications for EGD
While generally safe, EGD has specific contraindications.
Absolute Contraindications:
- Perforated Bowel: EGD is contraindicated in cases of known or suspected bowel perforation.
- Peritonitis: Active peritonitis is an absolute contraindication due to the risk of exacerbating infection.
- Toxic Megacolon in Unstable Patients: In unstable patients with toxic megacolon, EGD is contraindicated.
Relative Contraindications:
- Severe Neutropenia: Severe neutropenia increases the risk of infection post-EGD.
- Coagulopathy: Coagulopathy increases the risk of bleeding during and after EGD.
- Severe Thrombocytopenia or Impaired Platelet Function: Similar to coagulopathy, these conditions elevate bleeding risk.
- Increased Perforation Risk: Conditions increasing perforation risk, such as connective tissue disorders, recent bowel surgery, or bowel obstruction, are relative contraindications.
- Aneurysm of the Abdominal or Iliac Aorta: The procedure might pose a risk to patients with aneurysms.
Equipment Used in EGD
Specific equipment is required to perform EGD effectively.
Gastroscopes:
Standard gastroscopes are approximately 10 mm in diameter with a 2.8 mm instrument channel. Smaller diameter endoscopes (less than 6 mm) are used for pediatric patients under 10 kg. For significant upper GI bleeding, gastroscopes with larger operating channels (3.8 to 4.2 mm) are beneficial. High-definition gastroscopes with optical zoom are recommended for detailed mucosal examination to detect premalignant lesions in the stomach and duodenum.
Accessories:
Essential accessories include biopsy forceps (standard and jumbo) for tissue sampling. For foreign body retrieval, instruments like rat tooth forceps, alligator forceps, retrieval nets, polypectomy snares, overtubes, and foreign body protector hoods are necessary. Additional specialized equipment is required for therapeutic procedures.
Preparation for EGD
Proper patient preparation is crucial for a successful and safe EGD procedure.
Dietary Preparation:
Elective upper endoscopy typically requires fasting. Following ASA guidelines, patients should fast for at least 2 hours after clear liquids and 6 hours after light meals. In emergencies or when gastric emptying is impaired, the risk of pulmonary aspiration must be considered when deciding on sedation levels, the need for endotracheal intubation, or procedure delay.
Medications:
Most routine medications can be continued, usually taken with a small sip of water before EGD. However, diabetes medications may need adjustment due to fasting. ASGE guidelines dictate the management of antithrombotic agents and antibiotic prophylaxis for at-risk patients prior to endoscopy.
Sedation and Monitoring:
Sedation is standard for EGD to minimize discomfort and provide amnesia. Pre-procedural evaluation is necessary to assess sedation risks and manage pre-existing health conditions. Sedation options range from conscious sedation by the proceduralist to monitored anesthesia care by an anesthesiologist. Propofol intravenous sedation is commonly used for routine EGD. General anesthesia may be necessary for therapeutic procedures, foreign body removal, or in uncooperative patients, including young children. ASGE guidelines mandate continuous monitoring of vital signs and cardiopulmonary status during all sedated endoscopic procedures.
Informed Consent:
Informed consent must be obtained from patients, parents, or legal guardians before EGD and sedation administration, ensuring they understand the procedure’s risks and benefits.
EGD Technique: Step-by-Step
The EGD technique requires careful manipulation of the endoscope and systematic examination of the upper GI tract.
Endoscope Handling:
The endoscope is primarily held in the left hand, with the control section resting in the palm. The thumb controls up/down tip movement, while the index and middle fingers operate suction, air, and water valves. The right hand advances, withdraws, and rotates the endoscope and inserts instruments through the biopsy channel.
Esophageal Intubation:
Patients are positioned in the left lateral decubitus position with neck flexion. A bite block is placed, and the endoscope is inserted into the mouth, advancing to the tongue base under direct vision. The scope tip is gently angled downwards to visualize the vocal cords, epiglottis, piriform sinuses, and cricoarytenoid cartilages. The scope is then passed behind and to the right of the arytenoid cartilage towards the upper esophageal sphincter. The sphincter is traversed under direct visualization, often with gentle pressure and air insufflation.
Esophagus and Esophagogastric Junction Examination:
After esophageal intubation, the endoscope is advanced down the esophageal lumen, systematically examining the mucosa for inflammation, ulcerations, furrows, varices, narrowing, or strictures. The location of the esophagogastric junction and the Z-line (squamocolumnar junction) are noted. Proximal displacement of the Z-line suggests Barrett’s esophagus, requiring biopsies.
Stomach Examination:
Upon entering the stomach, residual secretions are suctioned, and air is insufflated to improve visualization. The endoscope is advanced along the lesser curvature towards the pylorus, often requiring torque to the right and filling the greater curvature for pyloric canal cannulation. The pylorus, with radiating folds, is identified. To pass through, the endoscope is positioned anterior to the pylorus with gentle pressure and air insufflation.
Duodenum Examination:
After pyloric passage, the endoscope enters the duodenal bulb, examined during insertion to avoid mucosal changes from instrument passage. After inspecting all bulb quadrants, the scope is advanced posteriorly, where the duodenum turns sharply right and downwards. Passing the superior flexure into the second duodenal portion requires dial and shaft torque, typically down and right followed by upward dial spin. The superior flexure is often examined on withdrawal. Straightening the endoscope by pulling back while maintaining lumen view advances it into the distal duodenum, reducing stomach loop. The duodenum distal to the bulb shows circular folds (valvulae conniventes). The ampulla of Vater is located in the second duodenal portion and examined during withdrawal.
Following duodenal, pyloric, and antral examination, the endoscope is retroflexed to visualize the gastric cardia and fundus. The endoscope is then returned to a neutral position. After complete stomach inspection and biopsies (if needed), the endoscope is withdrawn, suctioning air before exiting the stomach. The esophagus is re-examined during withdrawal. Diagnostic EGD typically lasts 5-10 minutes under optimal sedation.
Tissue sampling, including biopsies, brushings, and polypectomy, is obtained from suspicious lesions. Many gastroenterologists perform routine biopsies from designated sites as clinically significant disease can occur in normal-appearing mucosa. Specimens are sent for histological, cytological, or microbiological analysis.
Complications of EGD
Complications following EGD are infrequent, occurring in less than 2% of patients.
Sedation-Related Complications:
The most common and serious complications are cardiopulmonary, related to sedation. Over-sedation can lead to hypoxemia, hypoventilation, hypotension, airway obstruction, arrhythmias, and aspiration.
Endoscopy-Related Complications:
Diagnostic EGD complications include infection, bleeding, duodenal hematoma, and bowel perforation. Bleeding risk after biopsy is approximately 0.3%, presenting as intraluminal hemorrhage or hematoma. Duodenal hematoma is rare, more common in children. Bowel perforation occurs in less than 0.3% of cases, and infection is rarely reported. Complications typically manifest within the first 24 hours post-procedure. Bleeding presents as hematemesis or bloody gastrostomy tube output. Perforation is indicated by fever, tachycardia, abdominal pain, or discomfort. Abdominal X-rays can reveal extraluminal air in perforation cases. Conservative management with bowel rest and antibiotics is typical, though surgical repair may be necessary.
Clinical Significance of EGD in Diagnosis
Esophagogastroduodenoscopy has become indispensable in diagnosing and managing esophageal, gastric, and small bowel disorders. Its broad indications include evaluating dysphagia, GI bleeding, peptic ulcer disease, refractory GERD, esophageal strictures, celiac disease, and unexplained diarrhea. EGD allows for diagnostic biopsies and therapeutic interventions like hemostasis and stricture dilation. When performed correctly, EGD is generally safe and well-tolerated. Its availability and use have expanded in pediatrics, although pediatric EGD indications require careful clinical judgment to maximize benefits and minimize risks.
Enhancing Healthcare Team Outcomes in EGD Procedures
In pediatrics, EGD is ideally performed by a pediatric endoscopist with specialized expertise in GI procedures for this population. ASGE guidelines provide practice modifications for endoscopy in infants and children.
When a pediatric endoscopist isn’t available, adult-trained endoscopists should perform pediatric EGD in collaboration with a pediatrician and pediatric specialists. Pediatric-specific procedural and resuscitative equipment must be readily available. If sedation is required, personnel trained in pediatric life support and airway management should be present. In children with suspected caustic ingestion, EGD within 24 hours is recommended. Emergent foreign body removal is crucial for esophageal button batteries and multiple rare-earth neodymium magnets.
Review Questions
(Note: Review questions are available via the provided link at the beginning of the article.)
References
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- ASGE Standards of Practice Committee. Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016 Jan;83(1):3-16. [PubMed: 26621548]
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- ASGE Standards of Practice Committee. Early DS, Lightdale JR, Vargo JJ, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Muthusamy VR, Pasha SF, Saltzman JR, Shergill AK, Cash BD, DeWitt JM. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018 Feb;87(2):327-337. [PubMed: 29306520]
- ASGE Standards of Practice Committee. Lightdale JR, Acosta R, Shergill AK, Chandrasekhara V, Chathadi K, Early D, Evans JA, Fanelli RD, Fisher DA, Fonkalsrud L, Hwang JH, Kashab M, Muthusamy VR, Pasha S, Saltzman JR, Cash BD., American Society for Gastrointestinal Endoscopy. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc. 2014 May;79(5):699-710. [PubMed: 24593951]
Disclosures:
Rajni Ahlawat, Gilles Hoilat, and Albert Ross declare no relevant financial relationships with ineligible companies.
