Principles of gastrointestinal

endoscopy
Tatiana Martin
Kat Schwab
Sukhpal Singh
Abstract
Endoscopes, both rigid and exible, are used in many surgical specialties.
They allow for minimally invasive investigations of symptoms, diagnosis
of pathology and application of directed therapies. Although the ability to
see inside the human body has challenged pioneers of medical science for
centuries, it is only in the last 100 years that technology has evolved to
produce the advances in computers, breoptics and mechanics required
for endoscopy.
This article provides an overview of rigid and exible endoluminal
endoscopy, focussing on the common examinations of the GI tract,
namely oesophagogastroduodenoscopy (OGD), sigmoidoscopy and colo-
noscopy. Laparoscopy, the most common form of rigid endoscopy, is dis-
cussed elsewhere in this series.
Keywords Colonoscopy; complications; endoscopy; exible endoscopy;
history of endoscopy; oesophagogastroduodenoscopy; procedure; proc-
toscopy; rigid endoscopy; sigmoidoscopy
What is endoscopy?
The word endoscopy comes from the Greek Endon inside and
Skopeo to look at, therefore an endoscope is dened as an
instrument that can be introduced into the body to view its in-
ternal parts. Endoscopy can be subdivided into rigid and exible.
This article discusses the basics of gastrointestinal (GI) exible
and rigid endoscopy.
A brief history of endoscopy
The rst endoscope came from Bozzini, a German urologist in
1806. He used concave mirrors and candlelight to allow exami-
nation of the bladder through a hollow tube, called the Licht-
leiter (light conductor). Nitze later improved on Bozzinis work
with the addition of an electric light. The rst laparoscopy was
performed in 1901 on a dog, by George Kelling who realized the
importance of insufating air into the abdomen and coined the
term coelioscopy. Human laparoscopy was rst performed in
1910 by a Swedish surgeon called Jacobaeus. Technological ad-
vances in the post-war period of the 1950s saw the birth of
breoptics and Hopkins breoptic endoscope allowing exible
scopes suitable for use in the GI tract. Endoscopy was trans-
formed in the 1980s by the invention of the video computer chip
that enabled the image from the endoscope to be magnied and
then displayed on a television screen. The advent of wireless
technology revolutionized our ability to visualize the small
bowel by way of capsule endoscopy, which allows 360-degree
views as well as measurement of pH, temperature and pres-
sure. Further innovations in instrumentation and technology are
already being made, from high-denition and three-dimensional
images, to single port access surgery and the use of robotics.
Current types of endoscopy are listed in Table 1.
The exible endoscope
Although there are many different applications for the exible
endoscope, the basic equipment is similar between all types of
scopes. The main equipment includes the endoscope, stack and
instrumental tools.
Endoscope:
breoptic system to conduct light from a source through
the scope to its tip
chip camera positioned at tip and connector system to
relay image back to screen
plumbing systems with independent channels to allow
irrigation of tip, suction and insufation
working channel for passage of instruments
control body (Figure 1) that houses the outlets for the
plumbing systems, ports for access to the working chan-
nel(s) and the control knobs which allow rotation of the
distal tip in two planes.
Stack (Figure 2):
light source
insufator system
suction unit and water reservoir
electrosurgical unit, including argon plasma system
image recorder (video/digital recorder; photo-capture and
printer).
Instruments/extras:
biopsy forceps
snares
injecting needles
electrosurgical probes
dilating and stenting kits
banding devices for variceal treatment & EMR (endoscopic
mucosal resection).
Gastrointestinal exible endoscopy
Joint Advisory Group on GI endoscopy (JAG)
JAG ensures the quality and safety of patient care by dening
and maintaining the standards by which endoscopy is practised
in the UK www.thejag.org.uk. JAG provides nationwide training
for doctors and nurses through regional training and mentored
assessment programmes, as well as running centralized basic
and advanced skills courses. To practise independently as an
endoscopist, JAG certication is needed and course attendance
compulsory, although for surgical trainees this is not expected
Tatiana Martin MBBS BSc MRCS is an ST3 in General Surgery at The Royal
London Hospital, London, UK. Conicts of interest: none declared.
Kat Schwab MBBS(Hons) BSc(Hons) MRCS is a Surgical Specialist Registrar
and MATTU Research Fellow at Royal Surrey County Hospital, Surrey,
UK. Conicts of interest: none declared.
Sukhpal Singh FRCS is a Consultant Upper Gastrointestinal and General
Surgeon at Frimley Park Hospital, Surrey, UK. Conicts of interest: none
declared.
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SURGERY 32:3 139 2013 Elsevier Ltd. All rights reserved.
Types of endoscopy
Flexible endoscopy
Body system Name of endoscopy What is visualized/accessed
Gastrointestinal (GI) tract Oesophagogastroduodenoscopy (OGD) Oesophagus, stomach and duodenum
Enteroscopy Small intestine
Colonoscopy Large intestine (and terminal ileum)
Sigmoidoscopy Sigmoid colon, rectum
Endoscopic ultrasound (EUS) Upper GI tract and biliary tree
Biliary tree, hepatic ducts Endoscopic retrograde
cholangiopancreatography (ERCP)
Pancreas, common bile duct, hepatic ducts,
gallbladder
Choledocoscopy e intraoperative or peroral
(Spyglass for example)
Access to bile ducts for biopsy and lithotripsy
Respiratory tract Bronchoscopy/endobronchial ultrasound Trachea, large and small bronchi
Ear, nose and throat Rhinoscopy Nose
Laryngoscopy Throat
Urological Cystoscopy Bladder, urethra
Ureteroscopy Ureters
Gynaecological Hysteroscopy Uterus
Falloscopy Fallopian tubes
Rigid endoscopy
Type of procedure Speciality Example of use
Laparoscopy All subspecialities Diagnostic
Upper gastrointestinal surgery Bariatric procedures
Nissen fundoplication
Cholecystectomy
Splenectomy
Lower gastrointestinal surgery Appendicectomy
Colectomy
Gynaecology Hysterectomy
Salpingo-oophorectomy
Bladder neck repair (incontinence)
Thoracoscopy Vascular surgery Cervical sympathectomy
Thoracic surgery Video-assisted thoracoscopic surgery (VATS)
Extraperitoneal
laparoscopy
General surgery Hernia repair (inguinal, femoral, obturator)
Endocrine surgery Thyroidectomy/parathyroidectomy
Vascular surgery Subfascial endoscopic perforator surgery
(SEPS)
Urology Adrenalectomy
Nephrectomy
Prostatectomy
Endoluminal Lower gastrointestinal surgery Rigid sigmoidoscopy/proctoscopy
Head and neck surgery Rigid nasendoscopy/laryngoscopy/
oesophagoscopy
Urology Cystoscopy/ureteroscopy
Trans-urethral resection of the prostate
(TURP)
Gynaecology Hysteroscopy
Arthroscopy Orthopaedic surgery Diagnostic
Removal of intra-articular loose bodies
Trimming cartilage
Anterior cruciate ligament reconstruction
Table 1
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until after the fth year of registrar training. JAG also provides
guidance on the set up and running of endoscopy units, to ensure
universal standards are met.
Endoscopy units
Gastrointestinal exible endoscopies are usually performed in dedi-
cated endoscopy day units with specially trained staff. The units
consist of a reception and waiting area for patients, with easily
accessible toilet facilities, individual private treatment rooms for the
provisionof theendoscopy, astep-down/recoveryarea, cleaningand
sterilizing facilities for the turnaround of the scopes and adminis-
tration ofces. The most commonly performed gastrointestinal en-
doscopies are oesophagogastroduodenoscopy and colonoscopy.
Sedation and monitoring
Patient tolerance of endoscopic procedures may be improved
with sedation and locally administered analgesic agents. National
guidelines exist with evidence-based recommendations, sum-
marized as follows:
safe secure intravenous (IV) access (non-buttery) to be
used and remain until post-recovery
continuous non-invasive blood pressure and pulse oxim-
etry monitoring
continuous peri-procedural oxygenation of patient
benzodiazepine and opioid IV to be used as sedative and
analgesic
appropriate dose for age and physiological condition of
patient, given as small aliquots and titrated
good communication with nursing staff regarding dosage
and vital signs
awareness of cardiopulmonary complications of drugs and
their management (head down and IV uids for low blood
pressure, over-sedation and respiratory depression
requiring reversal agents and appropriate resuscitation)
clear thorough documentation of entire procedure not just
endoscopic ndings.
Consent
Before undergoing an endoscopy, patients should have under-
gone the process of giving informed consent e adequate
procedural information given, risks and complications explained,
co-morbidities and possible use of sedation addressed with
ample opportunity for questions to be answered. Consent is
usually supported with information leaets.
Upper gastrointestinal tract endoscopy
Indications
Diagnostic
to investigate causes of anaemia, upper GI haemorrhage,
persistent vomiting
to investigate upper GI symptoms including dyspepsia,
reux, dysphagia (difculty in swallowing) and odyno-
phagia (pain on swallowing)
Surveillance
review of peptic ulcer healing
Barretts Oesophagus
post-surgery
Biopsying
CLO test for Helicobacter pylori
duodenal biopsy for coeliac disease
mucosal biopsy for pathology
Therapeutic
intervention of upper GI bleeding e including adrenaline
injection, clips, gold probe
variceal treatment e including injecting, banding and glue
polyp snaring
removal of foreign bodies
dilatation of strictures or achalasia
stenting
Specialist endoscopic procedures
EUS (endoscopic ultrasound assessment of organs), EUS
guided FNA (ne needle aspiration), EUS guided coeliac
axis block
endoscopic retrograde cholangiopancreatography
(ERCP) e utilizing a side-viewing scope and uoroscopy
to access the bile and pancreatic ducts
percutaneous endoscopic gastrostomy (PEG) insertion,
guidance of enteral feeding tubes under direct vision
endoscopic or EUS-guided drainage (e.g. pancreatic
pseudocysts)
radiofrequency ablation of dysplastic Barretts
Oesophagus
EMR, submucosal dissection and PerOral Endoscopic
Myotomy (POEM).
The procedure
Patients are kept nil by mouth for 4e6 hours before the proce-
dure. Local anaesthetic spray is administered to the oropharynx
to reduce the gag reex and intravenous sedation may be
administered. The patient lies on their left side with monitoring
attached and a mouth guard is placed between their teeth to
prevent scope damage. The endoscopist, after checking that the
scope has been connected to the stack correctly (light, suction,
insufation and irrigation), gently passes the scope over the
tongue and manoeuvres through the pharynx to intubate the
oesophagus. The scope is passed through the oesophagus and
stomach through to duodenum under direct vision, noting pa-
thology as seen. Retroexion or J-manoeuvre allows for full
Rigid sigmoidoscope
Proctoscope
Light source
and eyepiece
Proctoscope light
connector
Manual insufflator
Figure 1
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vision of the fundus of the stomach and the gastro-oesophageal
junction (GOJ). Any extra instrumentation such as biopsy can
be performed and photographs may be taken as evidence of
ndings. Any insufated gas can be removed by suctioning on
withdrawal of the scope.
Risks/complications of oesophagogastroduodenoscopy (OGD)
The risk of complications is quoted as approximately 1 in 1000,
increased in therapeutic procedures.
The main risks in order of most common are:
cardiopulmonary problems (aspiration, respiratory
depression, hypotension, arrhythmias)
perforation
bleeding
injury to teeth.
Lower gastrointestinal exible endoscopy
Indications
Diagnostic
investigation of change of bowel habit, especially diar-
rhoea and increased frequency of stool
investigate anaemia (usually in conjunction with OGD)
investigate symptoms including abdominal pain, bloat-
ing, weight loss and unexplained rectal bleeding
Surveillance
inammatory bowel disease
polyposis
post-cancer surgery
Biopsying
terminal ileum biopsies for Crohns disease
biopsying pathology visualized on radiological imaging
Light source and
insufflation system
Electrosurgical unit
Monitor
Image recording systems,
photo-capture and printer
Suction unit and
water reservoir
Stack systems and extras for flexible endoscopy
Figure 2
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tattooing lesions for laparoscopic resection
Therapeutic
snaring polyps
APC or laser therapy to vascular anomalies
haemorrhage control
stenting
Screening for cancer
positive faecal occult blood results (FOBs) in the na-
tional screening programme
strong family history
familial polyposis syndrome.
The procedure
Bowel preparation is required before lower GI endoscopy to
ensure clear vision of all colonic mucosa. This consists of 2e3
days of a low-bre diet prior to colonoscopy and prescribed oral
laxatives to clear the colon the day before (for colonoscopy) or
enemas on the day (for exible sigmoidoscopy). Care needs to be
taken with preparation in patients with signicant renal or car-
diovascular comorbidities due to the osmotic laxative effects. If
there are concerns, a patient can be admitted for administration
of the preparation and supplemental intravenous uid. Intrave-
nous analgesia and sedation are given before the procedure to
help the patient tolerate the colonoscopy. This is not usually
required for exible sigmoidoscopy.
Adigital rectal examination is performed rst to check sphincter
tone, assess bowel preparation, lubricate the anus and ensure no
anal lesions have been missed. The colonoscope is then inserted
into the anus and guided through the rectum and colon (sigmoid,
descending, transverse and ascending) to the caecumand possibly
terminal ileum. Sigmoidoscopy will visualize the left colon. Insuf-
ation is required to visualize the lumen. Looping of the colono-
scope inthe non-xedcolonmayresult indiscomfort for the patient
and lack of forward progress. Methods to resolve formation of the
loop and prevent recurrence can include torque application to the
scope, xation of scope tip and withdrawal to straighten the scope,
stiffening of the scope, repositioning of the patient and pressure
applied by an assistant to the patients abdomen. To try to ensure
that no pathology is missed, slow withdrawal of the scope is
advised. Polyps can be snared, biopsies andphotographs takenand
interventions performed throughout the procedure.
Risks/complications of lower GI endoscopy
Cardiopulmonary problems (as listed for OGD).
Dehydration from bowel preparation.
Perforation (risk increases with biopsy and polypectomy)
0.2%.
Bleeding 1.5%.
Rigid endoscopy
Rigid endoscopes allow access to shallow and easily accessible
cavities, suchas inthe headandpelvis for diagnostic andtherapeutic
purposes, or with surgical incisions for minimally invasive cavity
work, such as the chest, abdomen or joints. Surgical applications of
rigid endoscopy are discussed further in a chapter on laparoscopy.
We will look briey here on GI rigid endoscopies as an example.
Rigid sigmoidoscopy and proctoscopy are routinely performed
in OPD clinics and can be easily utilized in inpatient settings and
intra-operatively. They both require a simple light source and
sigmoidoscopy also uses gentle manual insufation to aid visu-
alization of the rectum and distal sigmoid up to 25 cm. The
advantage of these procedures is that they can provide rapid
diagnosis, and in some cases treatment, without the need for
bowel preparation or sedation.
Proctoscopy
Used for:
Diagnosis
benign anorectal disorders, such as haemorrhoids, s-
sures, stulae
carcinoma of anal canal or rectum
rectal polyps
other anorectal problems
Treatment
banding or injection of sclerosing agent to haemorrhoids
rectal washout intra-operatively on anterior resection or
faecal impaction relief.
Rigid sigmoidoscopy
Used for:
Diagnosis
mass lesions and mucosal abnormalities
bleeding from lower GI source
inammatory rectal disease
biopsy
Treatment
conservative treatment of sigmoid volvulus
Intra-operatively
assess the true height of a rectal cancer
inspect anastomosis.
The procedure
In the clinic setting, the examination is explained to the patient and
any questions are answered appropriately. It is essential to clarify
understanding and ensure that verbal consent is obtained. The
patient is placed on the examining couch, in the left lateral position
with buttocks exposed. Digital rectal exam (DRE) is then per-
formed, which allows lubrication of the anus, assessment of anal
tone andquality, improvedcomfort for the patient and palpationof
any lesions or abnormalities in anal canal or distal rectum. Most
scopes are disposable and familiarity with themis necessary to aid
positioning of the obturator, reusable light sources andinsufation
connectors. The scope is lubricated and then gently inserted
through the anal canal before being rotated back 60

into the
rectum. It is not insertedany further without direct visualizationso
as to avoid inadvertent injury or bleeding. The obturator is then
removed and disposed of, the light source attached and the
eyepiece closed. Gentle insufation while looking through the
eyepiece allows visualization of the rectum as the scope is guided
forward through the valves of Houston (transverse folds of the
rectum). There is a distance gauge on the outside of the scope for
documentation of depth visualized or recording of where in the
rectum an abnormality has been observed. Biopsy forceps and
other instruments can be passed down the lumen as required.
Proctoscopy is approached in a similar manner and may be
performed after rigid sigmoidoscopy or alone after DRE for
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inspection of the anal canal and distal rectum. Be aware that the
connectors on your light source may need to be changed. The
obturator is easily reinserted for re-entry into the anal canal,
which is useful for detailed assessment of haemorrhoidal disease
and its descent. Therapeutic instruments such as Gabriel syringes
or banding devices can easily be passed through the lumen for
haemorrhoidal treatment.
Future developments in endoscopy
Imaging
High denition (HD) endoscopes e standard endoscopes
use less than 200,000 pixels to construct an image which
can limit detailed inspection of mucosa, however high-
resolution endoscopes (>850,000 pixels) are now
commercially available, which improves assessment of
structures and pathology, allowing endoscopists to make
more accurate in vivo diagnoses.
Narrow band imaging-lter enhances the quality of ne
structures and capillary network of the mucosal surfaces.
Light-induced uorescence endoscopy (LIFE) e involves
passing of small probes through the endoscope to emit light
and stimulate certain moleculesduorophores, the re-
ected light is detected by miniature charge-coupled devices
(CCDs). Normal mucosa appears as a bright green back-
ground, however regions of increased haemoglobin (e.g.
ulcerated or thickened mucosa in at/depressed tumours)
appear dark green while elevated tumours appear magenta.
This technique aims for early identication of pre-malignant
and malignant lesions that have minimal morphological
features on regular endoscopy
Photon endomicroscopy e utilizes uorescence generated
by photons to construct an optical sectional image of tissue
endoscopically which is comparable to a traditional H&E-
stained biopsy. The limitation of this, however, is the
requirement of a trained specialist or histopathologist to
interpret the images
Endoscopes/endoscopic assistance
Endoscopes with full angulation ability up to 360

.
Self-propelling endoscopes e scopes with gas propulsion
systems to pull themselves around the colon.
Guiding systems e providing computer-generated scope
positioning to allow endoscopists improved awareness of
anatomical position of scope and information of direction
of loop formation.
Contrast EUS and EUS elastography may be able to
distinguish between benign conditions such as chronic
pancreatitis and malignancy. If developed further, the
quantication of contrast to assess tumour characteristics
may even predict response to chemotherapy.
Development of smaller and smaller endoscopes (e.g.
scanning bre endoscope [SFE]) that incorporate an optical
design to allow a large eld of view despite their narrow
calibre as well as great exibility. This is of particular use in
the visualization of biliary and pancreatic ducts.
Three-dimensional high-denition laparoscopes are
already on the market, with particular utilization in robotic
surgery, and further potential for application to exible
endoscopic procedures.
Therapeutic tools
Advances in stents e shapes, materials including biode-
gradable, deployment systems, possible drug impregnation
for targeted delivery.
Dyes may be used to enhance contrast
Future techniques not yet fully in practice
Full-thickness mucosal resection of tumours.
NOTES e natural orice transluminal endoscopic surgery
e the ability to reach intra-abdominal organs endoscopi-
cally through the mucosal wall of the GI tract (such as
stomach) and vaginal vault, with operating tools manipu-
lated through the work channels of an endoscope. There
has been reported success with appendicectomy and cho-
lecystectomy. The aim is to improve patient recovery,
reduce anaesthesia requirements and possibly allow day
surgery with minimal perioperative requirements.
Further development of capsule endoscopy to incorporate
computer-assisted diagnosis that would improve the la-
bour intensity of reporting. Other advances currently being
explored include local delivery of drugs in the small bowel
and biopsy using capsule endoscopy.
Integration of biological markers such as antibodies or
peptides, as well as uorescence, to target specic markers
on tumours (e.g. HER2 antibodies). A
FURTHER READING
ASGE. Complications of upper GI endoscopy. Gastrointest Endosc 2002;
55: 784e93.
Bergman J, Tytgat G. New developments in the endoscopic surveillance of
Barretts oesophagus. Gut 2005; 54: i38e42. http://dx.doi.org/10.
1136/gut.2004.041590.
Bozzini PH. Lichtleiter, eine Erndung zur Anschauung innerer Teile und
Krankheiten. J Prak Heilk 1806; 24: 107.
Green J. Complications of gastrointestinal endoscopy. Available at: http://
www.bsg.org.uk/pdf_word_docs/complications.pdf.
Guelrud M, Herrera I, Essenfeld H, et al. Enhanced magnication endos-
copy: a new technique to identify specialized intestinal metaplasia in
Barretts esophagus. Gastrointest Endosc 2001; 53: 559e65.
Hart R, Classen M. Complications of diagnostic gastrointestinal endos-
copy. Endoscopy 1990 Sep; 22: 229e33.
Haycock A, Oppong KW. The future developments in endoscopy. Frontline
Gastroenterol 2012; 3: i19e23. Also available at: http://fg.bmj.com/
content/3/Suppl_1/i19.full.html#ref-list-1.
Majumdar SK. A short history of gastrointestinal endoscopy. Bull Indian
Inst Hist Med Hyderabad 1993; 23: 67e86.
Sivak MV. Gastrointestinal endoscopy: past and future. Gut 2006; 55:
1061e4.
Standards of Practice Committee of the American Society for Gastro-
intestinal, Lichtenstein DR, Jagannath S, Baron TH, et al. Sedation
and anesthesia in GI endoscopy. Gastrointest Endosc 2008 Nov; 68:
815e26.
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