tips and tricks of diagnostic endoscopy

2. Welcome to EFIAGES Course…
Dr. Basil Hirschowitz 1960
Father of Flexible Endoscopy
Prof Dr. B.Krishna Rau
Father of Endoscopy
In India

3. I
A
G
E
S
EFIAGES
FAGIE

6. Upper GI Endoscopy: Step by Step
 Recognize the landmarks
 Art of reaching each landmarks

7. Pre Endoscopic Ritual 1
Equipment check list:
 Endoscopy leak tested and disinfected and
ready
 Processor unit, monitor working
 Water bottle full and suction unit ready
 Check suction, air flow and water flow
 Mouth guard
 Accessories stand by

8. Pre Endoscopic Ritual 2
Patient check list:
 Know the indication
 Verify any contraindication
 Drug history and co morbidity
 Informed consent
 Fasting for 6 hours
 No denture or loose tooth

9. Success depends on Sound
Basics
 Ambidextrous
 Left hand on control head
 Right hand on endoscopy shaft
 Benefit of body movement
 Ergonomics during endoscopy

10. The Endoscopy room…

11. Endoscopy Room Lay Out
X2X1

13. Treat the monitor like a
clock!

14. Language of the Wheels/Buttons
•Big Wheel
•Small Wheel
•Towards you
•Away from you
•Superior button
•Suction
•Inferior Button
•Insufflation of air
•Instillation of water

15. Language of the Insertion tube
•Clock wise twist
•Anti-clock wise twist
Navigate using
•Wheel
•Shaft &
•your Body

16. Steps of Endoscopy
No & Position of Staffs: 1+ 4

18. Steps of Endoscopy.1
•Oropharynx
12 o clock
6 o clock
Glimpse of Epiglottis
Tongue
Uvula

19. Steps of Endoscopy 2
 Laryngopharynx
Cricopharynx : closed state
1
2
3
1. Vocal cord
2. Arytenoid fold
3. Piriform fossa

20. Dock and wait at 15cm
Sneak down cricopharynx as patient
swallows(not when he coughs or
struggles
Oops!

21. Steps of Endoscopy 3
•Entering esophagus

23. Navigate
straight
till U see
Z line at
40cm

24. Esophagus is empty! Peristalsis present

25. Steps of Endoscopy 4/5
Z line
NBI/ I scan/FICE image

26. Puddle of fluid greets you!
Enter the body of stomach
1st
,,,,,,,

27. Inspect/suction any residue and insufflate and orient yourself: remember the clock
Lesser curve : 12 o clock
Greater curve: 6 o clock
Anterior wall : 9 o clock
Posterior wall : 3 o clock
12
6
9 3

28. Steps of Endoscopy 6
Greater curve at 6 o clock position
Posterior wall at
3 O clock
Anterior wall
At 9 o clock
Enter along the long route
Exit along the short route
Lesser Curve at 12 o clock

29. Big wheel towards you
Clockwise twist of shaft
Push the scope
3 Times!

30. Proceed to pylorus…

31. Enter the pylorus when it is at the centre
and wide open and scope is straight

32. Enter the pylorus when it is
at the centre!
Pylorus

33. Steps of Endoscopy 9/10
D1 D2
Bulbar part Post bulbar part superior duodenal angle D2 Ampulla

34. See the bulbar part
Anterior wall: 9 o clock
Posterior wall: 3 o clock

35. Post Bulbar region
Superior Duodenal angle

36. Enter 2nd
part: do 3 maneuvers
Big wheel: towards U
Small wheel: away from U
Turn your body to right to face the monitor

37. 1. Big Wheel turn towards you
2. Small wheel turn away from
you/ or
Twist the shaft clock wise
3. Turn to face the monitor!

38. Pull back to shorten the scope
To 60cm at Incisor teeth

39. Return to stomach
Fall Back to Antrum
Enter along the long route
Exit along the short route

40. Long route Vs Short route
Entry
Exit
Along the greater curvature
Lesser curvature

41. Steps of Endoscopy 11/12
Incisura
Fundus
Antrum
Body of stomach
8
2
While staying in antrum ,
turn the Big wheel little bit towards you…
Incisura

42. Retreat and retroflex !
(big wheel fully towards U) to see
Incisura and then Fundus.

43. Big wheel fully towards you
& Pull back

44. Cardia/Crus
Big wheel fully towards you along with shaft movement & your body movement
360 degree panoramic view of cardia

45. J Maneuver
But do not pull the scope beyond 50cm
level

46. Do distensibility test of stomach.
Suck and remove the scope
Finally,

47. Abandon the procedure
 When patient is restless/ not co- operative
 Any indication of cardio respiratory distress
 Any indication of major complication
 Perforation/false passage/aspiration etc

48. Post endoscopic steps
 Endoscopy:
 Cleaning and disinfection
 Patient:
 Discuss the findings and their implications
 Give a written report
 Advice regarding further management

49. Patient instructions after
the procedure
•No solid foods for 30 minutes after the examination.
• Allow for after effects of sedation
(no driving, no hazardous work activities for 24 hours).
• Report any complications (pain, bleeding, fever).

50. Safety During Endoscopy
 Pre endoscopy check list
 Vigilance during endoscopy
 Administer Nasal O2
 ECG/Pulse Oximeter
 Need for anesthetist
 Access to Defibrillator/Resuscitation team
 Disinfected Endoscope and accessories
Safety of Patient Safety of Staffs Safety of Equipments

51. Endoscope Disinfection
protocol

52. Remember 3 things for life!
 Oral Cavity
 3 structures
 Tongue, Soft palate ,Glimpse of Epiglottis,
 Cricopharynx
 3 structures
 Vocal cord, arytenoid fold, piriform fossa
 Esophagus
 3 areas of narrowing
 15/25/40cm
 Stomach
 3 steps to reach pylorus
 Big wheel towards you, clock wise twist, Push/3 times
 Duodenum
 3 steps to enter D2
 Big wheel towards you, clock wise twist, turn body to right
 On J Maneuver
 3 structures
 Incisura, fundus, cardia