clearing (NYU School of Medicine, New York City, USA).
Examination of the esophagus and stomach
The esophagus should be examined for any structural abnormalities including ulcerations, varices, strictures, rings, webs, and other findings. While routine endoscopy does not replace the information obtained during esophageal motility, a global assessment of motility can often be ascertained. In particular, patients with achalasia may be noted to have absent esophageal peristalsis, as well as a dilated esophagus and tight‐appearing GEJ that does not easily open with air insufflation. In patients with esophageal varices (EV), air should be insufflated in order to accurately stage varices, determine the number of columns present, the extent of esophagus involved, and the presence of any stigmata. The location of the GEJ should be noted in centimeters along with its appearance (regular versus irregular) and whether salmon‐colored mucosa is present in the tubular esophagus. The proximal extent of the gastric folds should be located. The diaphragmatic pinch can be identified by noting where the diaphragmatic crura “pinches” the esophagus or stomach. If a hiatal hernia is present, the size of the hernia should be measured from the top of the gastric folds to the diaphragmatic pinch, and a patulous hiatus documented on retroflexed view of the cardia.
After retroflexion is performed, the endoscope should be straightened and advanced to the antrum. Once the pylorus is visualized, the scope should traverse the pyloric channel to intubate the duodenum. The duodenal bulb should be carefully examined more than once as pathology can be missed particularly in the superior bulb and posterior wall. The scope is advanced past the duodenal bulb while typically dialing up and right on the angulation knobs to enter the second portion. The scope is often advanced deep into the second portion of the duodenum during a reduction maneuver that removes the loop of scope that forms in the stomach during insertion.
In a patient with acute upper GI hemorrhage, the bulb, first, and second portions should be examined multiple times to assure that no pathology is missed, particularly in the blind portion of the first part of the duodenum. A side‐viewing scope may be useful for examining the duodenum when a duodenal source is suspected and the standard endoscope fails to identify a source. With modern high‐resolution scopes, duodenal villi are easily visualized and trainees should be taught to routinely evaluate the villi. Evidence of blunted villi may be evident from celiac sprue. The ampulla should be identified if possible and inspected for any abnormalities, though a side‐viewing scope is usually required for a detailed examination of this area (see Chapter 8). In order to obtain optimal visualization of the duodenum, it is recommended that the endoscopist angle the tip of the endoscope down and withdraw in a hooked position to see the bulb, then angle up again to advance over the superior duodenal angle, and rotate 90° clockwise while angling the endoscope up and right to enter and view the descending duodenum (Figure 5.11).
Biopsies in the esophagus can be useful to determine whether there is BE, changes consistent with gastroesophageal reflux, and eosinophilic esophagitis. It is recommended that two to four biopsies be obtained from both the distal and proximal esophagus to maximize the likelihood of detecting esophageal eosinophilia [13]. In the stomach, biopsies are useful to distinguish benign fundic gland polyps associated with PPI usage from hyperplastic or adenomatous lesions and to determine if H. pylori infection or any premalignant changes are present. Duodenal biopsies should occur if celiac sprue is suspected in a patient presenting with a variety of symptoms, including abdominal pain, diarrhea, iron‐deficiency anemia, or weight loss. In order to obtain tissue biopsies, the biopsy forceps should be introduced through the working channel of the endoscope. The forceps should be opened and placed on the area of tissue targeted for sampling. The forceps should be closed in order to grasp the tissue and then withdrawn from the scope with the tissue sent for laboratory analysis.
Figure 5.11 Angulation and hooking of the endoscope tip to aid with duodenal intubation and visualization.
Routine biopsies may be more challenging in the esophagus given its tubular nature. Particular care should be exercised while pushing the forceps out into the narrow lumen. The scope tip may need to be angulated to bring the forceps closer to the target area of mucosa. It is sometimes helpful to apply suction in order to bring the esophageal wall into close proximity of the biopsy forceps so that tissue can be obtained.
Therapeutic endoscopy
Management of bleeding ulcers
For GI bleeding due to ulcer disease, it is important to note the appearance of the ulceration to guide whether endoscopic therapy and further hospitalization are needed. If an ulcer with a clean base is seen, the subsequent rate of rebleeding has been estimated to be less than 5%, while ulcerations with active bleeding and/or visible vessels have rebleeding rates over 50% [14]. The trainee should record the associated Forrest classification in the endoscopy report [15]. Injection of epinephrine in a 1:10,000 dilution using an injection needle around the base of the ulceration is not effective as solo therapy to decrease rebleeding rates, but can be used for initial hemostasis to improve visualization in the setting of active bleeding and in combination with either thermal coagulation therapy or hemoclips [16]. When using thermal therapy, the trainee should be taught how to apply either direct probe pressure on the vessel until coagulation is achieved or noncontact coagulation with argon plasma. If using hemoclips, these should be applied directly on or around the vessel and can be repeatedly applied until bleeding has stopped. The utilization of hemoclips may be more challenging in angulated areas such as the first portion of the duodenum.
Variceal ligation
In patients with active bleeding from EV, hemostasis can be achieved by band ligation. This is a local endoscopic therapy that involves placing a rubber band around the culprit EV. Band ligation is also performed in patients requiring primary or secondary prophylaxis for EV bleeding. This typically consists of repeated
