Flexible endoscopy: upper gastrointestinal tract

image of Flexible endoscopy: upper gastrointestinal tract
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Upper gastrointestinal (GI) endoscopy is one of the most common endoscopic procedures performed in companion animal practice, and encompasses examination of the oesophagus, stomach and proximal small intestine. It is possible to examine the oesophagus with a rigid endoscope (which may also be useful for foreign body removal) but a flexible endoscope is preferred for diagnostic investigation of the oesophagus, and is essential to be able to examine the stomach completely and to intubate the small intestine. And whilst early flexible endoscopes were only able to permit observation of the GI tract, modern gastroscopes can now also be used for sampling tissues and liquids and even for some therapeutic procedures. This chapters describes the Role of endoscopy in investigating GI disease; the Indications; the Contradictions; the Instrumentation; Patient preparation; Premedication and anaesthesia; Patient positioning; Procedure; Rigid oesophagoscopy; Normal findings; Pathological conditions; Foreign body removal; Oesophageal stricture; Percutaneous endoscopic gastrostomy tube placement; Jejunostomy tube placement; and Complications of upper GI endoscopy.

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4.3 Upper GI endoscopy reporting proforma. This standard form was developed by the WSAVA Gastrointestinal Standardization Group (Drs Washabau, Willard, Hall, Jergens, Day, Mansell, Wilcox, Minami, Guilford and Blizer) with sponsorship from Hill’s Pet Nutrition).
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4.10 Mass of grass in the stomach of a poorly prepared patient obscures examination of the stomach.
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4.11 The patient is placed in left lateral recumbency for routine upper GI endoscopy. Note the ET tube is securely fastened and a gag and pulse oximeter are being used.
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4.12 The view on entering the stomach is of the junction of the fundus and body. Note the parallel rugal folds on the greater curvature running towards the antrum beneath the angle of the lesser curvature. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.14 Orientation in the stomach. In order to reach the pylorus there are a number of landmarks that can be used: the angularis incisura divides the antrum (below) from the fundus and cardia (above), through which the insertion tube can be seen entering the stomach. Approximate position of the endoscope in the stomach. Passage of the tip of the insertion tube around the angularis incisura to enter the antrum. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.15 Ring of peristalsis migrating down the antrum towards the pylorus.
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4.16 Distension of the fundus allows the insertion tube to form a loop, which tends to direct the tip up towards the cardia. Advancement of the insertion tube further distends the gastric wall and compounds the problem. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.17 The normal pylorus of a cat.
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4.18 Retroflexion allows visualization of the cardia and fundus. Withdrawal of the retroflexed endoscope allows closer vision of the cardia, and rotation on its long axis allows visualization of the whole area. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.19 Brush cytology showing gastric spiral organisms. (Reproduced from )
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4.20 Gastric biopsy. A rugal fold is grasped by the biopsy forceps and avulsed. Site of a gastric biopsy. (Reproduced from )
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4.21 Techniques to enhance the size and quality of duodenal biopsy specimens. Samples should be taken: from the distal duodenal flexure, from the ‘back’ of a peristaltic wave and after deflation of the duodenum so that folds develop. The forceps should be placed on the wall of the descending duodenum and the endoscope tip deflected into the wall, whilst pushing the mucosa away with the forceps to allow the biopsy site to be viewed. The open cups should be pushed along the wall to scoop up a larger piece of mucosa. ‘Swing-jaw’ forceps should be used (see also Chapter 3). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.22 Rigid colonoscope suitable for aiding the removal of oesophageal foreign bodies. Note the obturator to facilitate atraumatic insertion, and rubber bulb for insufflation once the viewing window has been sealed.
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4.23 Endoscopic appearance of the normal oesophagus. Indentation of the trachea into the oesophagus in the cranial thorax. In cats the distal oesophagus has numerous annular folds of mucosa. Submucosal vessels are not visible in normal dogs, but are sometimes seen in puppies and cats. Normal lower oesophageal sphincter. ‘Z-line’ demarcation between the paler oesophageal mucosa and the redder gastric mucosa at the open lower oesophageal sphincter.
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4.24 Endoscopic appearance of normal stomach. Parallel rugal folds running towards antrum. Lymphoid follicles are darker spots on the rugal folds.
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4.25 Endoscopic appearance of a normal descending duodenum in a cat and a dog. Note the paler duodenal mucosa in cats.
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4.26 Landmarks in normal canine duodenum. The major duodenal papilla in the duodenum of the dog is the site of entry of the common bile duct and major pancreatic duct. Peyer’s patches (lymphoid aggregates) in the duodenum appear as pale round depressions along the antimesenteric border of the descending duodenum. The minor duodenal papilla (m) is seen in some but not all dogs distal to the major duodenal papilla (M) and approximately 100 degrees clockwise from it.
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4.28 Examples of oesophageal lesions. Megaoesophagus. Severe oesophagitis following reflux under anaesthesia for ovariohysterectomy. Spontaneous reflux oesophagitis. Oesophageal stricture. Submucosal leiomyoma in a dog. (Courtesy of EJ O’Neill) Squamous cell carcinoma in an old cat. (Courtesy of SMA Caney) Hiatal hernia with bulging of the oesophageal wall into the oesophageal lumen. Oesophageal diverticulum filled with fluid. Fish hook lodged at the gastro-oesophageal junction.
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4.30 Examples of gastric lesions. Gastritis showing submucosal haemorrhage. Multiple minor gastric ulcers (erosions) associated with chronic gastritis. Ulcer on the lesser curvature following non-steroidal anti-inflammatory drug administration. Hair and debris are stuck in the ulcer; the fresh blood seen is from an adjacent biopsy site. Hypertrophic pylorogastropathy. Note the multiple thickened mucosal folds around the pylorus, which is not visible. Gastric carcinoma. A large ulcerated mass is visible
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4.32 Examples of duodenal lesions. Inflammatory bowel disease: lymphoplasmacytic enteritis. Note the increased granularity. Inflammatory bowel disease: eosinophilic enteritis. Note the increased irregularity and ulcerated areas. Inflammatory bowel disease: bleeding associated with eosinophilic enteritis. Alimentary lymphosarcoma. Biopsy is required to confirm the cause of this ulcerated proliferative tissue. Adenocarcinoma: an annular ulcerated mass is visible (arrowed). Lymphangiectasia. Note the multiple dilated lacteals containing white lymph. Isolated Toxocara worm in duodenum of a cat. Swallowed hair is also visible. Segmented tapeworm in the duodenum of a dog.
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4.33 Gastric foreign bodies. Rubber ball in stomach. Despite being swallowed, the ball was too large to be retrieved endoscopically and a gastrotomy was performed. Coin. Note that it has fallen down to the cardia. Sock. Peach stone. Stone.
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4.34 A bone stuck in the oesophagus has caused severe oesophagitis.
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4.35 An oesophageal stricture. The open biopsy forceps are used as an internal measure; the cups span 4–5 mm, indicating how narrow strictures can be. Balloon dilation of the stricture. Dilation of the stricture seen in Figure 4.28 d has led to a mucosal tear and only partial dilation of the remainder of the stricture. The induced oesophagitis is likely to cause healing by further stricture formation.
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4.36 The principle of placing a PEG tube. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.37 PEG tube kit (Mila International Inc.).
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4.39 Mushroom tip catheter. PEG tube showing mushroom tip and centimetre markers (Cooks Medical Supplies). PEG tube showing wide openings for food (Cooks Medical Supplies). PEG tube (Mila International Inc). The foam in the mushroom tip becomes rigid when the feeding adaptor is fitted as it forces air down a small tube in the wall of the main feeding tube into the mushroom. A large central hole for feeding is visible.
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4.40 Revised (kit) PEG tube. A wire loop is swaged on to the hard conical end of the tube, which acts as its own dilator; the mushroom tip is at the other end.
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4.41 Placing the line to insert a PEG tube. A needle is inserted through the flank into the inflated stomach. (Courtesy of D Holden) The needle entering the stomach viewed endoscopically. The wire is now inserted. The wire loop inserted through the needle is grasped by basket forceps and pulled out through the mouth.
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4.42 Fitting the pipette tip on to a PEG tube. The end of the PEG tube and pipette tip. The flared tip of the PEG tube is cut off and the pipette tip is threaded on to the wire exiting the mouth. The wire is then fixed to the tube by a transfixion knot. A needle pushed through the tube aids placement of the transfixing wire. After securely attaching the wire to the PEG tube, the pipette tip is slid over the join to act as a dilator for when the tube is pulled out through the body wall.
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4.43 Pulling the PEG tube through the body wall.
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4.44 Wire loop for inserting PEG tube. The mushroom tip of the PEG tube is looped through the swaged-on wire loop to join it to the wire loop passing out of the mouth. The wire loops are interlocked. Pulling the wires tight produces a knotless connection.
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4.45 Endoscopic appearance of a fitted PEG tube. Cooks Medical Supplies tube. Mila International Inc. tube.
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4.46 Fixing the PEG tube. A feeding adaptor is placed on the end of the PEG tube, which is attached to the body wall by a Chinese finger-trap suture. The PEG tube is covered lightly with a stretch netting dressing. (Courtesy of A Harvey)
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4.47 Low-profile gastrostomy tube. The different sizes of stalk are to accommodate differences in the thickness of the body wall. The conical mushroom is lodged in the stomach, whilst the feeding port is flush to the skin. Stretching the device with a stylet allows it to be inserted through the stoma when the PEG tube is finally removed, producing a permanent gastrostomy.
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4.48 Removal of a PEG tube. Basket forceps are used to grasp the mushroom tip of the PEG tube as it is cut off outside the patient.
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4.49 Acid burns caused by a leaking PEG tube.
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4.50 Endoscopic appearance of massive GI bleeding. A large blood clot is seen in the gastric lumen, following bleeding from biopsy of a gastric ulcer. A stream of blood is seen in the duodenum after biopsy of a more distal duodenal mass.
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