Flexible Endoscopy

Stephanie H. Chang, Varun Puri, John A. Dumot

Key Points

  • Flexible endoscopy is the main tool for visual examination and biopsies of abnormalities in the upper gastrointestinal tract.
  • Proper patient selection with clear indications is a preprocedure quality indicator.
  • Important intraprocedure quality indicators include lesion recognition, proper sampling, and therapeutic interventions in the majority of procedures; only experienced physicians should perform high-risk interventions.

Flexible endoscopes have revolutionized the evaluation of the upper gastrointestinal tract with widespread use of esophagogastroduodenoscopy (EGD), which has become one of the most frequently performed endoscopic procedures. Early forms of the endoscope used flexible optic glass fiber bundles to bring the reflected light waves back to the eyepiece. The current video chip technology at the tip of the endoscope provides high-definition images. Integration of an accessory channel allows passage of a variety of forceps to take biopsies, balloons or wires to aid in dilation of strictures or esophageal stent placement, and a number of devices to ablate or resect large areas of mucosa. Common indications for EGD are listed in Table 1, and contraindications in Table 2. Specifically, the procedure results should have bearing on treatment decisions to justify the risk and cost of the procedure. Flexible endoscopy is well tolerated with low risk, especially when compared with rigid esophagoscopy, but these risks should not be minimized, especially when undertaking a therapeutic procedure.

Table 1: Diagnostic and Therapeutic Indications for Upper Endoscopy

  • Dysphagia or odynophagia
  • Long-standing or recurrent heartburn, regurgitation, or noncardiac chest pain
  • Dyspepsia with anorexia, weight loss, or age older than 45 years
  • Persistent nausea or vomiting of unknown cause
  • Iron-deficiency anemia or gastrointestinal bleeding
  • Small bowel mucosal biopsy or sampling of duodenal fluid
  • Caustic ingestion evaluation
  • Portal hypertension; screening or management of esophageal varices
  • Familial adenomatous polyposis syndromes
  • Treatment of gastrointestinal bleeding
  • Treatment of benign strictures with balloon or rigid dilators
  • Management of achalasia with balloon dilation or botulinum toxin injection or POEM
  • Foreign body removal
  • Feeding tube placement or replacement
  • Management of malignant strictures of the esophagus or duodenum with stents or ablation therapy
  • Mucosectomy or ablation therapy for early neoplasia of the esophagus, stomach, or duodenum
Table 2: Absolute and Relative Contraindications for Upper Endocscopy

Absolute Contraindications

  • Recent cardiac ablation with new onset hemoptysis (concern causing stroke if there is an esophageal-left atrial fistula)
  • Shock
  • Acute MI
  • Peritonitis
  • Fulminant colitis

Relative Contraindications

  • Severe neutropeniaߦ
  • Coagulopathy (INR > 1.4)
  • Severe thrombocytopenia (plt < 50,000) or impaired platelet function
  • Acute perforation
  • Obtunded patients
  • Cardiac arrythmias or recent MI

Preparation includes a fast from solid food for 8 hours and from clear liquids for 2 hours. Preprocedural issues include informed consent, assessment of the airway and cardiopulmonary status before sedation, and, in some patients, addressing antibiotic prophylaxis and anticoagulation (Table 3). Additionally, proton pump inhibitors (PPIs) should be given preprocedurally for suspected upper gastrointestinal (UGI) bleeds, and vasoactive agents often employed periprocedurally with UGI bleed in suspected varices. Informed consent should include a discussion of the procedure, as well as benefits, risks, limitations, and alternatives. Perforation is the most worrisome complication that can lead to further intervention including possible surgery, and must be highlighted in the preprocedural discussion. Other complications include sore throat, bleeding, infection, adverse reactions to sedation and topical analgesics, missed diagnosis and lesions, chest pain, and aspiration. The risk of complications increase with therapeutic interventions, such as dilations and polypectomy compared with diagnostic examinations with routine mucosal biopsies. Exceptions to the rule of informed consent include emergent situations when there is insufficient time to carry out the process, waiver by the patient knowingly and voluntarily, incompetence when consent should be obtained from a relative or guardian, and, rarely, through therapeutic privilege or legal mandate.

Table 3: Preparation for Flexible Endoscopy in the Upper Gastrointestinal Tract

Antibiotic* prophylaxis is recommended for special subgroups of patients with:

  • All patient with cirrhosis with acute upper gastrointestinal bleeding
  • Patients with established GI tract infections likely to include enterococcus AND the following high risk cardiac conditions:
    • Prosthetic heart valves
    • History of endocarditis
    • Cardiac transplant recipients who develop valvular disease
    • Patients with congenital heart disease (CHD)
    • Unrepaired cyanotic heart disease (includes palliative shunts)
    • Completely repaired CHD wih prosthetic material for the first 6 months after procedure
    • Repair CHD with residual defects at the site or adjacent to the site of a prosthetic device or patch
  • When undergoing any of the following:
    • Endoscopic retrograde cholangiopancreatography with biliary obstruction and incomplete drainage
    • Percutaneous endoscopic gastrostomy†

Anticoagulation medications such as warfarin (Coumadin) and antiplatelet medications should be individualized based on indications for the procedure, indications for the anticoagulation, and urgency of the procedure:

  • Low-risk procedures — no change in anticoagulation necessary
    • Diagnostic esophagogastroduodenoscopy with or without mucosal biopsy
    • Endoscopic retrograde cholangiopancreatography without sphincterotomy
    • Endoscopic ultrasonography without fine-needle aspiration
    • Enteroscopy
    • Enteral stent deployment
  • High-risk procedures
    • Polypectomy
    • Biliary sphincterotomy
    • Pneumatic or bougie dilation
    • Sclerotherapy and banding of varices
    • Ablation of mucosa or endoscopic mucosal resection
    • Endoscopic submucosal dissection
    • Percutaneous endoscopic gastrostomy
  • Low-risk for thromboembolic events
    • Mechanical bileaflet aortic valve prothesis
    • VTE > 12 months ago
  • Moderate-risk for thromboembolic events
    • Mechanical bileaflet aortic valve with atrial fibrillation, prior stroke or TIAs, hypertension, diabetes, congestive heart failure or age > 75
    • VTE within 3-12 months
    • Heterozygous factor V Leiden or prothrombin gene mutation
    • Recurrent VTE
    • Active cancer (treated with 6 months or palliative)
  • High-risk for thromboembolic events
    • Mitral valve prosthesis
    • Caged-ball or tilting disc aortic valve prosthesis
    • Stroke or TIA within 6 months
    • VTS within 3 months
    • Severe thrombophilia (protein C/protein S/or antithrombin deficiency, antiphospholipid antibodies)

For ALL low risk procedures: no change in anticoagulation necessary

For LOW embolic risk, HIGH procedure risk

  • Discontinue anticoagulation prior to procedure
  • Resume coumadin on the day of the procedure
  • Delay resuming NOAC until adequate hemostasis is achieved
  • Continue standard doses of aspirin and NSAIDs
  • Discontinue thienopyridines at least 5 days prior

For HIGH embolic risk, HIGH procedure risk

  • Same as prior above, but will need a therapeutic bridge when discontinuing anticoagulation

For patients with recent stents and/or acute coronary syndromes:

  • Defer elective procedures until the patient has received the minimal recommended course
  • If significant bleeding, consult cardiology before stopping APAs in patients with drug eluting stents < 1 year, bare metal stent < 30 days, or acute coronary syndrome < 90 days

GI: gastrointestinal; CHD: congenital heart disease; TIA: transient ischemic attacks; VTE: venous thromboembolism; NOAC: noval oral anticoagulant; NSAID: nonsteroidal anti-inflammatory drug;APA: antiplatelet agents

*Ampicillin and gentamicin are acceptable choices.

†First-generation cephalosporins have been shown to reduce skin infections.

From Khashab MA, Chithadi KV, Acosta RD, et al: Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 81:81-89, 2015 [1] ; and American Society for Gastrointestinal Endoscopy: The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 83:3-16, 2016 [2].

Intraprocedure quality indicators include a complete examination of the esophagus, the stomach including viewing with retroflexion, and the duodenum. Abnormalities should be photographed and documented. Biopsies should be obtained from all ulcers, as well as other abnormalities such as polyps, masses, and significant mucosal disturbances (i.e. Barrett’s esophagus or erosive gastritis). Exceptions are considered when the lesion is responsible for acute hemorrhage and a future examination is planned to document healing after medical therapy.

Postprocedural quality indicators include accurate detailed reporting so that information can be relayed to other medical providers in a timely fashion. Descriptions of lesions need to be detailed so that a subsequent endoscopist can locate the lesion. Other quality indicators include PPI for patients with peptic esophageal strictures, repeat endoscopy after treatment of UGI bleed, and PPI or H2 receptor anatagonist and H pylori testing in the setting of gastric/duodenal ulcers.

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Last updated: August 13, 2023