Endoscopy and biopsy

Question 1

Upper GI endoscopy: diagnostic indications

Answer 1

Haematemesis/melaena
Dysphagia
Dyspepsia (>55yrs old + alarm symptoms or treatment refractory)
Duodenal biopsy
Persistent vomiting
Iron deficiency (cancer)

Question 2

Upper GI endoscopy: therapeutic indications

Answer 2

Treatment of bleeding lesions
Variceal banding and sclerotherapy
Argon plasma coagulation for suspected vascular abnormality
Stent insertion, laser therapy
Stricture dilatation, polyp resection

Question 3

Upper GI endoscopy: pre-procedure

Answer 3

Stop PPIs 2wks pre-op if possible (pathology masking).
Nil by mouth for 6h before.
Don’t drive for 24h if sedation is used.

Question 4

Upper GI endoscopy: procedure

Answer 4

Sedation optional, e.g. midazolam 1-5mg slowly IV (to remain conscious; if deeper sedation is needed, propofol via an anaesthetist (narrow therapeutic range)); nasal prong O2 (e.g. 2L/min; monitor respirations and oximetry).
The pharynx may be sprayed with local anaesthetic before the endoscope is passed.
Continuous suction must be available to prevent aspiration.

Question 5

Upper GI endoscopy: complications

Answer 5

Sore throat
Amnesia from sedation
Perforation (<0.1%)
Bleeding (if on aspirin, clopidogrel, warfarin, or DOACs, these need stopping only if therapeutic procedure).

Question 6

Upper GI endoscopy: duodenal biopsy

Answer 6

The gold standard test for coeliac disease.

Also useful in unusual causes of malabsorption, e.g. giardiasis, lymphoma, Whipple’s disease.

Question 7

Sigmoidoscopy

Answer 7

Views the rectum and distal colon (to ~splenic flexure).
Flexible sigmoidoscopy has largely displaced rigid sigmoidoscopy for diagnosis of distal colonic pathology, but ~25% of cancers are still out of reach. It can be used therapeutically, e.g. for decompression of sigmoid volvulus.

Question 8

Sigmoidoscopy: preparation

Answer 8

Phosphate enema PR.

Question 9

Sigmoidoscopy: procedure

Answer 9

Learn from an expert.
Do PR exam first.
Do biopsies- macroscopic appearances may be normal, e.g. IBD, amyloidosis, microscopic colitis.

Question 10

Colonoscopy: diagnostic indications

Answer 10

Rectal bleeding- when settled, if acute
Iron deficiency anaemia (bleeding cancer)
Persistent diarrhoea
Positive faecal occult blood test
Assessment or suspicion of IBD
Colon cancer surveillance

Question 11

Colonoscopy: therapeutic indications

Answer 11

Haemostasis (e.g. by clipping vessel)
Bleeding angiodysplasia lesion (argon beamer photocoagulation)
Colonic stent deployment (cancer)
Volvulus decompression (flexi sig)
Pseudo-obstruction
Polypectomy

Question 12

Colonoscopy: preparation

Answer 12

Stop iron 1wk prior

Discuss with local endoscopy unit bowel preparation and diet required.

Question 13

Colonoscopy: procedure

Answer 13

Do PR first.

Sedation and analgesia are given before colonoscope is passed and guided around the colon.

Question 14

Colonoscopy: complications

Answer 14

Abdominal discomfort
Incomplete examination
Haemorrhage after biopsy or polypectomy
Perforation (<0.1%)
Post-procedure: no alcohol, and no operating machinery for 24h.

Question 15

Video capsule endoscopy (VCE)

Answer 15

To evaluate obscure GI bleeding and to detect small bowel pathology.
Use small bowel imaging (e.g. contrast) or latency capsule test ahead of VCE if patient has abdominal pain or symptoms suggesting small bowel obstruction.

Question 16

Video capsule endoscopy: preparation

Answer 16

Clear fluids only the evening before then nil by mouth from morning until 4h after capsule swallowed.

Question 17

Video capsule endoscopy: procedure

Answer 17

Capsule is swallowed- this transmits video wirelessly to capture device worn by patient. Normal activity can take place for the day.

Question 18

Video capsule endoscopy: complications

Answer 18

Capsule retention in 1% (endoscopic or surgical removal is needed)- avoid MRI for 2wks after unless AXR confirms capsule has cleared.
Obstruction.
Incomplete exam (e.g. slow transit, achalasia).

Question 19

Video capsule endoscopy: problems

Answer 19

No therapeutic options
Poor localisation of lesions
May miss more subtle lesions

Question 20

Liver biopsy: route

Answer 20

Percutaneous if INR in range else trans jugular with FFP

Question 21

Liver biopsy: indications

Answer 21

Raised LFTs of unknown aetiology.
Assessment of fibrosis in chronic liver disease (this indication being replaced by ultrasound based elastography).
Suspected cirrhosis.
Suspected hepatic lesions/cancer.

Question 22

Liver biopsy: pre-op

Answer 22

Nil by mouth for 8h.

Are INR <1.5 and platelets >50x10^9/L? Give analgesia.

Question 23

Liver biopsy: procedure

Answer 23

Sedation may be given.
Do under US/CT guidance.
The liver borders are percussed and where there is dullness in the mid-axillary line in expiration, lidocaine 2% is infiltrated own to the liver capsule.
Breathing is rehearsed and a needle biopsy is taken with the breath held in expiration.
Afterwards lie on the right side for 2h, then in bed for 4h.
Check pulse and BP every 15 mins for 1h, every 30 mins for 2h, then hourly until discharge 4h post-biopsy.

Question 24

Liver biopsy: complications

Answer 24

Local pain
Pneumothorax
Bleeding (<0.5%)
Death (<0.1%)