Esophagogastroduodenoscopy Periprocedural Care

Updated: Feb 22, 2017
  • Author: Tony E Yusuf, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Periprocedural Care

Patient Education and Consent

Obtaining informed consent before esophagogastroduodenoscopy (EGD) is extremely important and is the responsibility of the endoscopist. [11]  Explain the indications, nature, and relevant details of the procedure to the patient. Risks, benefits, alternatives, and complications should also be presented to the patient. The consent form should be signed and dated by the patient and endoscopist and must be witnessed by other personnel and placed in the patient record.

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Preprocedural Planning

Obtain a complete history and perform a physical examination to determine whether EGD is appropriate. Document findings in the patient's medical record. Direct special attention to certain illnesses that might bear a direct effect on endoscopy, such as cardiovascular and pulmonary diseases. Obtain a history of drug allergies and previous abdominal surgeries.

Preprocedural testing in selected cases might include, but is not limited to, a complete blood count (CBC), blood crossmatching, coagulation studies, a chemistry panel, urinalysis, pregnancy testing, electrocardiography (ECG), and chest radiography. No data support routine laboratory testing prior to elective outpatient endoscopy. [12]  Preprocedural tests should be individualized and based on information obtained from the patient's history and physical examination and the indication for the procedure.

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Equipment

Endoscopes are available from several different manufacturers (eg, Olympus, Pentax, and Fujinon). The conventional endoscope consists of an umbilical cord, a control head (with wheels for up/down and left/right, an air/water button, and a suction button), an insertion tube 100 cm in length and 8-11 mm in external diameter, and a bending section at the tip (which allows up to 180° deflection for retroflexion of the endoscope).

The endoscope contains a lumen for insufflation of air and water, a working channel 2-3 mm in diameter (or larger, for therapeutic endoscopes) used for suctioning and passage of instruments, control wires for moving the tip of the endoscope, and an imaging system that is either fiberoptic (rare) or video (widely available). The endoscope, light source, and image source (either a video monitor or a direct view through the eyepiece) are essential equipment. Images and video can be recorded and printed, depending on the equipment used.

Flexible ultrathin fiberoptic and video endoscopes that can be used without sedation are also available for EGD. [13]  These endoscopes are inserted transnasally or perorally and have a working length of 925-1050 mm, an external diameter of 5.3-6 mm, and a working channel diameter of 2 mm.

Multiple instruments can be introduced through the working channel of the endoscope, including biopsy forceps, snares, sclerotherapy needles, heater probes, electrocautery probes, balloon-dilation devices, [14]  nets, and baskets. Guide wires can be placed, and when the endoscope is withdrawn, wire-guided bougie dilators can be passed. Devices can also be placed onto the end of the endoscope for banding of esophageal varices and endoscopic mucosal resection (EMR).

Some of the newer endoscopes provide high resolution and magnifying endoscopy and are used for the evaluation of certain upper GI diseases. [15, 16]  The upper gastrointestinal (GI) endoscope is also used to guide endoscopic treatment of gastroesophageal reflux disease (GERD), [17]  as with the Bard EndoCinch endoscopic suturing device and the NDO full-thickness plicator.

A potentially useful advance in video endoscopy is narrow-band imaging (NBI). [18, 19, 20]  NBI uses optical filters and high relative intensity of blue light for imaging and characterization of mucosal morphology, such as mucosal and superficial vascular patterns. NBI has been studied in patients with Barrett esophagus, early gastric tumors, and colorectal lesions and has had promising results.

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Patient Preparation

Anesthesia

In the United States, conscious sedation and topical anesthesia are commonly used for EGD. The use of monitored anesthesia care and propofol is gaining wide acceptance because of the short recovery time. [21]  However, in many other countries, EGD is performed with topical anesthesia only.

Topical anesthesia (eg, with Cetacaine [Cetylite Industries, Pennsauken, NJ] or lidocaine) has the advantages of requiring less time for the overall procedure, eliminating the risk of sedation, and decreasing the cost of the procedure by reducing or eliminating recovery time and nursing staff. [22]  The disadvantages are patient discomfort and problems in performing the procedure on a patient who may not be still.

With the cost-saving trends in medicine, EGD without sedation will likely become more commonplace in the United States. With the introduction of smaller-caliber endoscopes that can be passed through the nose, EGD without sedation may be more acceptable to patients.

When conscious sedation is being administered, the patient must be monitored throughout the procedure. Pulse oximetry, heart rate, and blood pressure are commonly monitored. [23]

ECG monitoring is recommended in patients with cardiopulmonary disease, in elderly patients, and during a prolonged procedure.

Agents that may be used in EGD include the following:

  • Benzodiazepines - Midazolam, diazepam
  • Opioids - Meperidine, fentanyl
  • Reversal agents - Flumazenil, naloxone

Midazolam is a sedative/hypnotic commonly used for sedation in endoscopic procedures. The peak effect of midazolam is 3-5 minutes, with a duration of action of 1-3 hours. Some of the major adverse effects include respiratory depression, hypotension, and paradoxical agitation. The typical starting dose is 0.5-2 mg intravenously (IV), which can be titrated to achieve a desirable level of sedation (usually in 1-mg increments). Lower doses of midazolam should be administered to elderly patients with cardiopulmonary problems to avoid serious complications.

Diazepam may be used instead of midazolam for sedation during endoscopic procedures, but many centers prefer midazolam to diazepam because of its amnestic effect and reduced tendency to cause phlebitis.

Meperidine is a narcotic analgesic that has mild sedative properties, slow onset of action, long duration, and long recovery time. When coadministered with benzodiazepines, potential complications include respiratory depression and sedation. The peak effect of meperidine is approximately 10 minutes, with a duration of action of 2-3 hours. Adverse effects include respiratory depression, hypotension, nausea, and vomiting. The typical starting dose is 15-50 mg IV, with subsequent individual doses not to exceed 25 mg.

Fentanyl is a mildly sedative narcotic analgesic that has a rapid onset of action and short recovery time. In many endoscopy centers, fentanyl is the preferred agent for outpatient endoscopic procedures. The peak effect is 5-8 minutes, and the duration of action is 1-3 hours. One of the major adverse effects is respiratory depression. The typical starting dose is 0.03-0.1 mg IV, with subsequent doses of 0.02-0.05 mg.

Flumazenil is typically used for reversal of benzodiazepine-induced sedation and respiratory depression. Flumazenil has a peak effect of 3-5 minutes and a duration of action of 1-2 hours. Potential adverse effects include resedation and seizures. The typical dose is 0.2-0.5 mg IV for reversal of sedation (up to 1 mg total) and 1-3 mg IV for benzodiazepine overdose.

Naloxone reverses opioid-induced analgesia, central nervous system (CNS) effects, and respiratory depression. Naloxone has a peak effect of 1-2 minutes and a duration of action of 1-3 hours. Adverse effects include pain, agitation, nausea, vomiting, arrhythmias, sudden death, pulmonary edema, and withdrawal syndrome in patients with opioid abuse. The typical dose is 0.04 mg IV for reversal of analgesia/sedation and 0.4 mg for narcotic overdose and respiratory arrest.

Other agents that have been tried include propofol and dexmedetomidine. In a study comparing propofol with dexmedetomidine in patients undergoing EGD under conscious sedation, Wu et al found that both agents offered a relatively satisfactory level of sedation without causing clinically notable adverse effects. [24]  Propofol was preferred by patients because of the deeper sedation and rapid recovery, and dexmedetomidine had minimal adverse effects on respiratory function.

Positioning

The patient is usually placed in the left lateral position for this procedure.

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Monitoring & Follow-up

After completion of a procedure performed with the patient under conscious sedation, transfer the patient to a recovery room for further monitoring by an endoscopy nurse.

Once the patient is alert and mobile (after ~1 hour), the patient may be allowed to leave the recovery room with an escort. Give the patient postprocedural instructions (eg, regarding diet and activity), and advise him or her to watch for signs and symptoms of GI bleeding, fever, and abdominal pain.

A follow-up appointment with the primary care physician and/or the endoscopist is usually arranged before the patient's discharge from the endoscopy unit.

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