- Author: Dan C Cohen, MD; Chief Editor: Kurt E Roberts, MD more...
Esophagoscopy is a procedure in which a flexible endoscope is inserted through the mouth or, more rarely, through the nares and into the esophagus. The endoscope uses a charge-coupled device to display magnified images on a video screen. The procedure allows visualization of the esophageal mucosa from the upper esophageal sphincter all the way to the esophagogastric junction (EGJ).
This procedure is one of several procedures that fall under the category of upper endoscopy, including gastroscopy, esophagogastroduodenoscopy (EGD), and enteroscopy. Esophagoscopy alone is uncommon: It is generally performed as part of a more complete upper endoscopic procedure in which the esophagus, stomach, and portions of the small intestine are explored endoscopically.
In the United States, esophagoscopy is usually performed with moderate sedation, which is achieved by administering a narcotic and benzodiazepine in combination. In Europe and Asia, however, the procedure is commonly performed without sedation. Topical anesthesia is sometimes implemented to improve patient tolerance and comfort. Very rarely, general anesthesia is used in patients who are difficult to sedate or are at higher risk of airway compromise. The following topic focuses on transoral esophagoscopy. For information regarding transnasal esophagoscopy, see Transnasal Esophagoscopy.
Esophagoscopy is routinely performed in an outpatient setting, though inpatient and emergency department management of gastrointestinal diseases often require urgent inpatient upper endoscopy including but not limited to esophagoscopy. Moreover, certain conditions necessitate routine esophageal endoscopic surveillance and therapeutics. In such cases, a procedure may be limited to esophageal exploration alone. The indications for esophagoscopy are as follows:
Food bolus or foreign object impaction
Evaluation and management of odynophagia
Evaluation and management of esophageal cancer,  including placement of esophageal stents
Evaluation of the esophagus after abnormal imaging studies
Esophagoscopy is considered a safe procedure, with a complication risk of approximately 1 per 1000 procedures.[6, 7] Absolute contraindications include the following:
Failure to obtain consent
Possibility of perforation
Relative contraindications to esophagoscopy include the following:
Anticoagulation in the appropriate setting (ie, esophageal dilation)
Head and neck surgery
History of procedure intolerance
The American Society for Gastrointestinal Endoscopy (ASGE) recommends understanding of indications, limitations, contraindications, alternatives, principles of conscious sedation, and correct interpretation of endoscopic findings to achieve competency in performing upper endoscopic procedures.
Furthermore, ASGE has determined that a minimum of 100 upper endoscopic procedures are required for trainees to attain competency in diagnostic upper endoscopy.
Therapeutic upper endoscopy poses further challenges and complexities and therefore requires additional training. ASGE recommendations for the requirements to attain competency in therapeutic upper endoscopy are available through the society Web site (see American Society for Gastrointestinal Endoscopy).
Patient education and consent
Informed consent must be obtained prior to the procedure. The risks, benefits, complications, and alternative treatments must be reviewed with the patient.
Before the procedure, a full history should be obtained from the patient, and all previous and current medical records should be reviewed. A full physical examination should be performed, with special attention given to the oral cavity and pharynx. The thyroid and parathyroid glands should be palpated, and palpation for cervical and supraclavicular lymph nodes should be performed when esophageal cancer is suspected. The existence of poor dentition should be documented.
The patient is placed in the left lateral decubitus position. Moderate sedation is then accomplished by using a combination of narcotic and benzodiazepine, which are infused intravenously in incremental doses.
With the patient properly positioned and sedation accomplished, the scope is inserted into the oropharynx with visualization of the epiglottis and vocal cords. The scope is then advanced through the piriformis sinuses and into the esophageal lumen. Air insufflation is used to distend the esophageal lumen. Careful inspection of the esophagus is then accomplished and the findings are photodocumented.
The video below shows an example of pediatric esophagoscopy.
Diagnostic and therapeutic applications of esophagoscopy include the following:
Obtaining biopsies (see the first video below)
Banding esophageal varices (see the second, third, and fourth videos below)
Food bolus or foreign object retrieval using nets, baskets, forceps, and snares
Cauterization and endoscopic clip deployment
Dilations using balloon or savory dilators (see the fifth video below)
Deploying stents (see the sixth video below)
Resecting and/or ablating mucosal tissue (see the seventh, eighth, ninth, and 10th videos below)
Deploying and/or inserting instruments such as capsules and tubes
The videos below depict normal findings on esophagoscopy.
Once the procedure is completed, the endoscope is removed from the patient, and the patient is monitored postprocedurally for any possible complications and allowed to recover from sedation. If the procedure was performed in the outpatient setting, the patient is discharged from the endoscopy unit with an escort after approximately 1 hour.
Transnasal esophagoscopy is a procedure in which an ultrathin 4-mm flexible endoscope is introduced into the esophagus through the nares. It is a safe and well tolerated procedure that can be performed without sedation in an office-based setting. Transnasal esophagoscopy has been shown to have good results in visualizing the esophageal mucosa; however, its main limitation stems from the small channel caliber, through which it is not possible to pass many of the instruments necessary to perform therapeutic interventions.[8, 9]
Esophageal capsule endoscopy is a procedure in which a capsule the size and shape of a pill with a tiny camera is swallowed by the patient. Multiple images of the esophagus are then obtained for viewing. The procedure does not require sedation and is therefore safer for the patient than traditional esophagoscopy is.
Additionally, esophageal capsule endoscopy has been shown to yield improved patient tolerance and therefore may have implications with regards to patient willingness to proceed with endoscopic screening and surveillance. This has especially been studied in the setting of esophageal varices. Multiple studies have shown that esophageal capsule endoscopy is good at detecting esophageal varices.[9, 10, 11, 12, 13, 14] In a multicenter trial that evaluated 288 patients undergoing screening or surveillance for esophageal varices with both traditional upper endoscopy and esophageal capsule endoscopy, overall agreement for detecting varices was 85.8% between the two procedures.
Esophagoscopy is considered a safe procedure with a complication risk of approximately 1 per 1000 procedures. Mortality is in the range of 0.5-3 deaths per 10,000 procedures.[6, 7, 16] Common complications include the following:
Adverse reaction to medications
Aspiration, oversedation, hypoventilation, and airway obstruction account for more than 50% of major complications related to upper endoscopy.[17, 18]
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