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Flexible endoscopy: upper gastrointestinal tract

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Abstract

Upper gastrointestinal endoscopy is one of the most common flexible endoscopic procedures. This chapter covers indications and contraindications, instrumentation, patient preparation and management, procedure, capsule endoscopy, normal and pathological findings, and complications. A number of therapeutic procedures are described, including placement of PEG and jejunostomy tubes. The chapter also includes four video clips.

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Figures

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5.3 Upper GI endoscopy reporting proforma. This standardized form was developed by the WSAVA Gastrointestinal Standardization Group, with sponsorship from Hill’s Pet Nutrition. (continues) ( )
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5.9 Inadequate preparation for gastroscopy. (a) Mass of grass in the stomach of a poorly prepared dog obscuring visualization of the gastric mucosa. (b) Mat of grass removed from the stomach of a dog before gastroscopy could proceed. (c) Food in the stomach of a dog that had inadvertently been fed. (d) Partially digested food retained in the stomach of a dog due to delayed gastric emptying secondary to chronic inflammatory enteropathy.
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5.10 Patient positioning. (a) The anaesthetized dog is placed in left lateral recumbency for routine upper GI endoscopy; air fills the antrum, making pyloric intubation possible. A pulse oximeter is placed on the tongue. (b) The anaesthetized cat is also placed in left lateral recumbency for routine upper GI endoscopy. Note that the endotracheal tube is fastened around the back of the head, and a chopped down needle cap is being used to maintain safe access into the oral cavity. A spring-loaded gag should not be used in cats as it may cause ischaemic brain damage and cortical blindness post procedure.
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5.11 Ventrodorsal diagrammatic representation of the regions of the stomach. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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5.12 Passage of the endoscope into the stomach. (a) On entering the stomach, the view is of the greater curvature at the junction of the fundus and body. Slight redirection of the endoscope tip (in the direction of the arrow) produces a view along the gastric body towards the antrum. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (b) Parallel rugal folds running along the greater curvature. The entrance to the antrum is visible at the far end of the gastric body. (b, Reproduced from the )
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5.14 Orientation in the stomach. In order to reach the pylorus there are a number of landmarks that can be used. (a) The angle of the lesser curvature (angularis incisura) divides the antrum (below) from the fundus and cardia (above), through which the insertion tube can be seen entering the stomach. In this image, bile can be seen bubbling back from through the pylorus. (b) Diagram showing the position of the endoscope tip in the stomach in order to achieve a view of the angularis incisura with the cardia above and antrum below. (c) Entrance below the lesser curvature into the antrum, which has no rugal folds. (d) The insertion tube has been passed along the greater curvature and retroflexed to view the angularis incisura (arrowed) dividing the antrum (A) from the fundus and cardia (C). (e) Diagram showing the insertion tube entering at the cardia, passing along the greater curvature into the antrum showing the pylorus in the distance. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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5.15 (a) Circular wave of peristalsis migrating down the antrum towards the pylorus. (b) As the circular wave of peristalsis reaches the end of the antrum, the pylorus (arrowed) comes into view.
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5.16 (a) Diagram demonstrating the effects of overinflation of the stomach during gastroscopy. Distension of the gastric body and fundus allows the insertion tube to form an expanding loop, which tends to direct the tip up towards the cardia. Attempts to advance the gastroscope distend the greater curvature further, compounding the problem. (b) This stomach has been overinflated and, in the retroflexed view, the angularis incisura is narrowed compared with the appearance in Figure 5.14a , and the pylorus is no longer directly visible, such that the insertion tube turns back towards the cardia. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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5.17 (a) The normal pylorus of a cat. (b) The normal pylorus of a dog; a few mucosal folds are slightly obscuring the entrance to the pylorus.
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5.18 (a) Insufflation of the stomach to flatten all the rugal folds ensures that no lesions remain hidden. (b) Complete flattening of the rugae enables a small gastric ulcer to be found or, as here, the full extent of a larger lesion to be seen.
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5.19 (a) Retroflexion of the endoscope allows visualization of the cardia and fundus, and (b) simultaneous rotation about the long axis of the endoscope allows examination of the whole area. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (c) The ‘J’ manoeuvre, showing the retroflexed insertion tube entering at the cardia with the blind-ended fundus beyond; the lesser curvature lies at the bottom of the image.
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5.20 Brush cytology showing gastric spiral organisms. (Reproduced from the )
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5.21 Gastric biopsy. (a) Biopsy of the lesser curvature. The sites of previous biopsies are indicated by the small areas of bleeding, with blood trickling down. (b) The edge of a rugal fold is grasped by biopsy forceps and a sample of tissue is avulsed. (c) Site of a gastric biopsy. (c, Reproduced from the )
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5.22 Techniques to enhance the size and quality of duodenal biopsy specimens. (a) Samples should be taken (i) from the distal duodenal flexure, (ii) from the ‘back’ of a peristaltic wave and (iii) after deflation of the duodenum so that folds develop. (b) The forceps are placed on the wall of the descending duodenum and the endoscope tip is then deflected into the wall while pushing the mucosa away with the forceps to allow the biopsy site to be viewed. (c) The open cups should be pushed along the wall to scoop up a larger piece of mucosa. Swing-jaw forceps should be used (see Chapter 3, Figure 3.20). Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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5.23 Capsule endoscopy. Alicam video-endoscopy capsule (see Video 5.2 for a detailed video sequence). (Courtesy of Infiniti Medical LLC, Redwood City, CA, USA)
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5.24 Endoscopic appearance of the normal stomach. (a) Rugal folds on the greater curvature. A small amount of bile-stained fluid is present and should be aspirated during examination of the stomach. (b) Lymphoid follicles may be seen in the mucosa as darker spots; these have been associated with infection. (c) Transient patches of hyperaemia are sometimes seen as here on the angularis incisura. (d) In this image, there is a sharp line of demarcation of redness between the gastric body and antrum; the significance of this finding is unknown.
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5.25 Endoscopic appearance of the normal descending duodenum in (a) a cat and (b) a dog. Note the paler duodenal mucosa in the cat and the presence of hair and an incidental roundworm.
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5.26 Landmarks in the normal canine duodenum. (a) The major duodenal papilla in the duodenum of the dog is the site of entry of the common bile duct and major pancreatic duct. (b) A minor duodenal papilla (m) is seen in some but not all dogs distal to the major papilla (M) and approximately 90 degrees clockwise from it. The distal duodenal flexure is seen in the distance. (c) Peyer’s patches (lymphoid tissue) in the canine duodenum appear as a line of pale oval depressions along the antimesenteric border of the descending duodenum. White spots probably represent follicles within the lymphoid tissue.
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5.28 Endoscopic appearance of gastritis. (a) Subtle irregularities in the mucosa of the rugal folds, consistent with chronic gastritis. (b) ‘Paintbrush’ haemorrhages in the antrum. (c) Multiple superficial gastric ulcers associated with chronic gastritis, showing small amounts of changed (brown) blood. (d) Severe diffuse ulceration with significant bleeding in chronic gastritis; fresh blood is dripping down. (a, b, d, Reproduced from the )
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5.29 Endoscopic appearance of NSAID-induced gastric ulcers. (a) Multiple ulcers following NSAID administration. (b) A single large ulcer. NSAIDs = non-steroidal anti-inflammatory drugs.
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5.30 Endoscopic appearance of antral lesions. Polypoid lesions sometimes bleed and are biopsied as a precaution, but are usually benign, whereas hypertrophic mucosa may obstruct the pylorus. (a) Two small polyps in the antrum of a dog either side of the pylorus. (b) One of these polyps appears very vascular, and another, very small polyp is just below it (arrowed). (c) Biopsy sample being taken from the vascular polyp shown in (b). (d) Hypertrophic pylorogastropathy. (d, Reproduced from the )
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5.31 Endoscopic appearance of mass lesions in the canine stomach. (a) Diffuse gastric carcinoma infiltrating the whole of the lesser curvature, which is completely ulcerated. (b) Bleeding from a gastric carcinoma. (c) Gastric carcinoma with a large deep ulcer (arrowed). (d) Gastric leiomyoma in the antrum.
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5.33 Endoscopic appearance of inflammatory duodenal lesions. (a) Lymphoplasmacytic enteritis. (b) Spontaneous bleeding associated with eosinophilic enteritis. (c) Ulceration associated with eosinophilic enteritis. (d) Stripping of the mucosa during insertion of the endoscope, suggestive of very friable, inflamed tissue.
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5.34 Endoscopic appearance of ulcerative duodenal lesions. (a) Benign chronic deep ulcer in the proximal duodenum of a dog caused by treatment with NSAIDs. The major duodenal papilla is seen distal to the ulcer. (b) Alimentary lymphoma in a dog. (c) Small cell alimentary lymphoma in a cat with spontaneous bleeding highlighting the preserved villous structure. (d) Intestinal adenocarcinoma in a dog. NSAIDs = non-steroidal anti-inflammatory drugs. (c, Courtesy of Claudia Gil Morales)
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5.35 Endoscopic appearance of miscellaneous duodenal lesions. (a) Lymphangiectasia in a dog. Note the multiple dilated lacteals containing white lymph. (b) Crypt abscessation in a dog with a protein-losing enteropathy; the white spots could be mistaken for lymphangiectasia. (c) Isolated roundworm in the duodenum of a dog. (d) Segmented tapeworm in the duodenum of a cat.
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5.36 Gastric foreign bodies in dogs. (a) Rubber ball in the stomach. Despite being swallowed, the ball was too large to be retrieved endoscopically and a gastrotomy was performed. (b) Coin. Note that it has fallen down to the cardia. (c) Sock. (d) Peach stone. (e) Stone. (f) Gold ring with paper tissue stuck to it. (g) Fishhook and (h) peach stone in the stomach of the same dog.
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5.37 The principle of placing a PEG tube. A wire loop is passed through a large-bore needle inserted into the stomach after endoscopic insufflation. Endoscopic forceps are used to snare the wire and pull it out through the mouth, where it is then attached to the gastrostomy tube. The wire and gastrostomy tube are then pulled back into the stomach and out through the body wall until the mushroom tip of the gastrostomy tube lies against the gastric mucosa. PEG = percutaneous endoscopic gastrostomy. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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5.38 (a) PEG tube kit (Mila International Inc.) (b) PEG tube. A wire loop is swaged on to the hard conical end of the tube, which acts as a dilator as it is pulled through the body wall; the mushroom tip is at the other end. PEG = percutaneous endoscopic gastrostomy.
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5.40 (a) PEG tube showing the mushroom tip and centimetre markers (Cooks Medical Supplies). (b) PEG tube showing wide openings for food (Cooks Medical Supplies). (c) 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 lumen in the wall of the main feeding tube into the mushroom. A large central hole for feeding is visible. PEG = percutaneous endoscopic gastrostomy.
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5.41 (a) A site on the left flank has been clipped and surgically prepared. The light from the endoscope in the inflated stomach transilluminates the site where the PEG tube will be placed. (b) A gloved finger is pushed into the prepared site to indicate where the PEG tube will be inserted. (c) Endoscopic view of the indentation caused by the gloved finger in Figure 5.41b . (d) A large-bore needle is pushed through the body wall. (e) The needle is seen emerging into the gastric lumen and a wire loop is then passed through it. (f) The wire is grasped by basket forceps as it emerges into the stomach through the needle. (g) As it is pulled out through the mouth by withdrawal of the endoscope and basket forceps, the wire is fed into the stomach through the body and gastric walls via the needle from a spool. PEG = percutaneous endoscopic gastrostomy.
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5.42 Attaching the wire loop to the PEG tube. (a) The swaged-on wire loop is passed through the wire loop that has been pulled out of the mouth, and then the mushroom tip of the PEG tube is passed through it. (b) The wire loops are interlocked as the PEG tube is straightened. (c) Pulling the wire loops tight produces a knotless connection. PEG = percutaneous endoscopic gastrostomy.
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5.43 PEG tube placement. (a) As the wire is pulled back the conical tip of the gastrostomy tube reaches the body wall. (b) With the aid of a very small skin incision the conical tip of the tube is pulled through the body wall. (c) The tube is pulled through the body wall until the mushroom lies in the stomach adjacent to the gastric mucosa. (d) Endoscopic appearance of fitted PEG tube. PEG = percutaneous endoscopic gastrostomy. (d, Courtesy of Mila International Inc.)
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5.44 Fixing the PEG tube. (a) The tube is fixed with a Chinese finger-trap suture. (b) A feeding adaptor is placed on the end of the PEG tube. (c) The PEG tube is covered lightly with a stretch netting dressing. PEG = percutaneous endoscopic gastrostomy. (c, Courtesy of A Harvey)
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5.45 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; the mushroom tip is then retrieved endoscopically. PEG = percutaneous endoscopic gastrostomy.
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5.46 Burns on the skin caused by gastric acid leaking from a PEG tube when the owner left it uncapped. PEG = percutaneous endoscopic gastrostomy.

Supplements

Upper GI endoscopy.

Upper GI endoscopy.

Capsule endoscopy.

Video sequence recorded from an Alicam® videoendoscopy capsule, showing a bleeding gastric polyp.

Upper GI endoscopy of a dog with a gastric carcinoma.

Upper GI endoscopy of a dog with a gastric carcinoma.

Placement of a percutaneous endoscopic gastrostomy (PEG) tube in a cat.

Placement of a PEG tube in a cat: severe oesophagitis (5s); identifying the PEG tube site (40s); insertion of a needle into the stomach (1m 10s); passage of a wire loop into the stomach (1m 30s); grabbing and pulling the wire loop out of the mouth (2m); positioning of the PEG tube mushroom (3m 10s).

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