Do’s

• Hold the endoscope in the left hand.
  • Left index finger controls either the suction valve or the air/water button.
  • The Left thumb controls the Big wheel. Individuals with large hands can reach the small wheels.
• Hold the insertion tube in the right hand
  • The right hand is used to advance and withdraw the insertion tube.
  • The right hand applies rotational torque to the insertion tube.
  • The right hand is used to advance accessories in the accessory channel. Ask your nursing colleague to hold the endoscope in position if necessary.
  • Although it is generally recommended to use torque instead of using the right and left deflection wheel sometimes this is necessary and is done using your right hand.
• Check your endoscope prior to inserting it in your patient.
  • Check that it is sucking fluid by inserting it in a bowl of sterile water and depressing the suction button (Red).
  • Check that it is blowing air by keeping the tip underwater and depressing partially/ covering the air/water button (Blue).
  • Check that it is flushing water by lifting the tip just above the level of water and fully depressing the air/water button.
  • Check that the lens is clear by pointing it to any written material (usually numbers on an endoscope) and looking at the screen to make sure you can read them.
  • Check that all locks are off including the variable stiffness in a colonoscope.

Dont’s

• Always handle the insertion tube carefully avoiding tight coiling, or accidental striking of the distal tip against hard surface.
• Avoid forcing deflection wheels. If they feel tight check that the locks have been unlocked.
• Never force instruments through the Accessory channel. This inevitably results in damage and prolonged / expensive repairs.
  • If an instrument is unable to pass through ensure that the endoscope is not in a tight loop or the tip has been deflected at a tight angle.
  • Check that the Biopsy forceps are closed and injection needles/ endoclip’s have been withdrawn back into their sheath.
  • Check that the diameter of the port is compatible with instrument being used.

An endoscope has 3 main sections

• The Insertion tube
• The Hand piece
• The Umbilical cord

The Insertion tube

• Flexible shaft: This is the part of the endoscope that transmits the push, pull and torque forces to the tip. It is susceptible to looping particularly during colonoscopy. Recent innovation with the now commonly available variable stiffness and the new overtube ShapeLock Endoscopic Guide (ShapeLock, USGI Medical, San Clemente, CA) has allowed endoscopist more control in preventing looping and reducing discomfort to the patient.
• Bending section: This allows manoeuvrability of the tip with movements up, down, left and right in response to turning the deflection wheels.



Image 2: Distal tip of an endoscope courtesy Pentax



Image 3: Components at Distal tip Courtesy Pentax

• Distal tip of an endoscope consists of :
  • Instrument / Suction channel. This is at 5 o’ clock position (endoscopic view) in a colonoscope and 7 o’ clock position in a gastroscope.
  • First  & second light guide which act as a light source.
  • Objective lens allows visualisation of the mucosa.
  • Air nozzle to insufflate air.
  • Water nozzle to clear the lens.
  • Water jet nozzle- water introduced with a syringe through the forward water jet connector comes to this port and gives a more powerful blast of water.

The Hand piece

• Up/down deflection wheels (Big wheel): This wheel moves the tip of an endoscope up or down. In the endoscopic view big wheel down results in the endoscope angulating upwards and vice versa. To further confuse you in actual 3 Dimension the endoscope is actually bending downwards but due to the way the optics and the visual image are organized it seems to be in the opposite direction.
• Up/down deflection lock: It is the knob with F written on it. To lock your wheel one needs to turn in the opposite direction of the arrow. This allows the endoscopist to lock his wheel in a particular position. This is usually in the setting of endoscopic therapy/ targeted biopsy.



Image 4: View of the deflection wheels and locks (side view)



Image 5: View of the deflection wheels and locks (Front view)

• Left/right deflection wheel (Small wheel): This moves the tip of an endoscope left or right. In endoscopic view small wheel down results in the endoscope angulating left and vice versa.
• Left/right deflection lock: It Locks the right and left deflection wheel.



Image 6: The Valves Courtesy Pentax

• Blue Air/Water valve: This is used to control the insufflations of air or flush water to clear the lens. Covering its opening or partial depression feeds air from the distal tip. Full depression flushes water to clear the lens.
• Red suction valve: When depressed this aspirates air or fluid through the distal tip. This is connected to the accessory channel. A biopsy cap needs to be in situ covering the accessory channel for the endoscope to generate the suction needed.

Top tip #1 Trainees have a tendency to use the index finger and the ring finger each to control both the buttons simultaneously. This results inadvertently in the opening of the blue air/ water valve being covered resulting in uncontrolled insufflations. The result is a distended bowel with tight angulations and a very uncomfortable patient. It is recommended that just the index finger is used alternating between the two valves to avoid this scenario.



Image 7: Accessory/ Biopsy channel and biopsy cap.

• Accessory/Biopsy channel opening: This allows passage of biopsy forceps and other instruments to undertake therapy. This is covered by the biopsy cap which creates an air tight seal necessary for the suction channel to operate. Therapeutic endoscopes such as on the image on the right may have 2 accessory channels. These allow multiple instrumentation and are useful in therapeutic settings eg GI bleed therapy.
• Remote Video buttons: There are 4 buttons numbered as such. These allow the endoscopist to remotely control freezing/capturing images, video or activating narrow band imaging. In our unit the settings are as follows:
  • Button 1: Freeze image
  • Button 2: Activate/ Turn off Narrow Band Imaging
  • Button 3: Start/ Stop video
  • Button 4: Unfreeze image



Image 8: Forward water jet connector (Opening just left of the video button 1) courtesy Olympus

• Forward water jet connector: This is rarely used and often forgotten but it is a useful adjunct when you want a water jet without removing the instrument in the accessory channel. This needs an irrigation tube to connect the syringe to it. The water jet comes out with force from the water jet nozzle in the distal tip.

The Umbilical cord

This is made of a flexible tube housing all the channels. The end of the cord is expanded to connect to the processor (PVE connector) and houses the air/water port, suction port, leak test port, light guide and the electrical contact.

Image 9: End of the umbilical cord and connection to the processor courtesy Olympus.

There are differences in PVE connector of the umbilicus with the Olympus and Pentax endoscopes. (See images 9 & 10). The main differences are the electrical pins with their soaking cap are on the right of the PVE connector in an Olympus scope while it is at the back of a Pentax scope. Secondly the water jet connector is at the PVE connector of a Pentax scope and in the hand piece of the Olympus scope. They both have ports for Air water and suction although these are organised slightly differently in both.

Image 10: End of the umbilical cord and connection to the processor courtesy Pentax

Indications:

1. To prevent post polypectomy bleeding (particularly with large stalked polyps) or for treatment of post polypectomy bleeding
2. Also used to prevent bleeding in gastric polypectomy

Steps:

1. The endoloop comes preloaded, attached to the end of the sheath
2. The loop will be protected in a plastic casing, from which it needs to be taken out
3. The handle has got a yellow bung, a thumb ring and a body (where index and middle fingers rest) of the handle.

Picture1: The handle of the endoloop

1. Pushing the yellow bung away from the handle (step1) will bring the loop inside the sheath

Picture2: Step1- ensheathing the loop before passing through the channel

1. Next the sheathed loop is fed through the accessory channel
2. Once polyp is located, loop is opened out of the sheath by pulling the yellow bung towards the handle ( Step2-reverse movement of step 1)

Picture3: Step2-Reverse movement of step 1- bringing the loop out of the sheath

1. The loop is then placed over the polyp or the polypectomy stalk
2. The loop is then tightened over the stalk – by closing the handle (i.e. the index and middle finger will close in to the thumb) Step3 – which moves a silicone stopper to close the loop. Don’t close too tightly; otherwise it might snare the polyp off.

Picture4: Step 3- tightening the loop

1. Once tight – check for blanching around the loop as a result of restricted blood flow
2. Lastly to fire/detach/deploy the loop- open the handle fully (Step 4- reverse movement of step 3)

Picture5: Step 4- Reverse of step3- firing/detaching the loop

1. Loop usually stays in for up to 7days and then falls off

Video link of how to use endoloop

• Easily ingested, painless procedure
• Progresses naturally through the GI tract via peristalsis
• Ambulatory examination
• Disposable video capsule

Discuss the components of a capsule endoscope?
It contains an imaging device and light-source on one-side and transmits images at a rate of 2 images per second generating more than 50,000 pictures over an 8-hour period.

1. Optical dome
2. Lens holder
3. Lens
4. Illuminating LEDs
5. Imager
6. Battery
7. RF Transmitter
8. Antenna
9. Dimensions 27X11 mm and weighs 3.7gm

How is capsule endoscopy performed?

• A patient fasts starting at midnight the day before the procedure. Some physicians use bowel prep as for colonoscopy.
• A sensor array is attached to the patient’s abdomen and the data recorder to a belt around the patient’s waist. The capsule transmits data to the Sensor Array which is secured to the patient’s abdomen. The Sensor Array is connected to the Data Recorder (which stores the data), worn on the belt.
  
• The patient is then asked to swallow the capsule.  The patient can resume daily activities once he or she has successfully swallowed the video capsule.
• After 8-hours the patient returns to the physician’s office to return the data recorder and the pill passes naturally with a bowel movement usually within 24 hours.
• Images are downloaded from the data recorder to the workstation for review and diagnosis.
• Patients are allowed to drink clear liquids after two hours and eat a light meal after four hours following the capsule ingestion
• It takes 30 to 60 minute reading time per study

Discuss the effectiveness of WCE over other methods of investigating small bowel?
Summary of Incremental Yield (IY) of WCE over other modalities for suspected or diagnosed Crohn’s disease.

Ref: Triester SL, et al Am J Gastroenterol 2006
Discuss the indications of WCE?

• Obscure GI bleed:  WCE considerably shortens the time to diagnosis and lead to definitive treatment in a relevant proportion of patients. WCE also spare a number of alternative investigations with low diagnostic yield
• Suspected Crohn’s disease
• Assessment of coeliac disease
• Screening and surveillance for polyps in familial polyposis syndromes

Discuss capsule retention?
Capsule retention is defined as having a capsule remain in the digestive tract for more than two weeks.
Retention has been reported at ~ 0.75% overall or up to 13% in patients with known strictures (ref- Signorelli C, et al. Digestive and Liver Disease 2006 )
The published incidence of capsule retention varies with the risk being related to the indication: (Ref- Lewis B, Endoscopy 2005)

• OGIB ~ 1.5%
• Known Crohn’s disease (CD) ~ 5%
• Suspected CD ~ 1.4%
• In healthy volunteers, during clinical trial, no incident of capsule retention occurred in 773 individuals

What are the causes of capsule retention?
Causes of retention cited in the literature include:

• NSAID strictures
• Crohn’s disease
• Small bowel tumors
• Radiation enteritis
• Surgical anastomotic strictures

Capsule retention has not been reported in “normal” anatomy or anatomical variants (e.g., colon or small bowel diverticulosis and appendiceal orifices).
How do you treat capsule retention?
Capsule retention is managed by medical (steroid may improve strictures), surgical, or endoscopic intervention (using a balloon enteroscope)
Can capsule retention be prevented?

• Current methods for identifying intestinal strictures lack sensitivity and specificity to evaluate GI tract patency.
• The majority of capsule retentions have occurred in patients with normal small bowel radiological studies. Conversely, results have suggested that functional patency may be present in patients with radiologically-documented strictures.

However, capsule retention can be prevented by using a patency capsule
Discuss patency capsule?
The patency capsule is a simple and convenient accessory to video capsules that is intended to verify functional patency of the GI tract in patients with known or suspected strictures prior to administration of the video capsule.
A patency capsule stays intact for minimum 30 hours post-ingestion. It subsequently disintegrates and is excreted. It emits electromagnetic waves at 64 KHz when sensing electromagnetic waves at 128 KHz.
Procedure:
Day 1: Patient swallows the patency capsule
Day 2: The patient’s abdomen is scanned using a hand held patency scanner. Patency is proven if the capsule is not detected by the patency scanner.

What are the contraindications of WCE?

• Patients with known or suspected GI obstruction, strictures or fistulas based on clinical presentation or pre-procedure testing
• Patients with cardiac pacemakers or other implanted electro-medical devices
• Patients with swallowing disorders

(Ref- Gastrointestinal Endoscopy 2006 )

Double balloon enteroscopy (DBE) is a new diagnostic and therapeutic modality originally described by Yamamoto et al in 2001 that allows high resolution visualisation, diagnostic and therapeutic interventions in all segments of the small intestine. It came almost the same time as Video capsule endoscopy and at one point was thought to be each other competitors. However with more widespread use of VCE it is expected that roughly 10% of those patients will need enteroscopy for further evaluation or imparting therapy.

The double balloon enteroscope comprises a 145 cm overtube back loaded on a 200 cm enteroscope and a latex balloon attached to each end.

(courtesy-http://www.fujinonendoscopy.com)

Technical details

• Once the system is passed into the proximal small bowel, the balloon of the overtube is inflated to anchor the position, so that the endoscope can be advanced. When the endoscope is advanced to its most distal point, the endoscope balloon is inflated to hold the insertion point. The overtube can be advanced after deflating the overtube balloon.  This serial inflation and deflation of balloons allow pleating of bowel on the back of the overtube and forward advancement of the enteroscope into a new segment of bowel. This process is repeated until advancing the endoscope any further becomes difficult.
• DBE can be used both from the mouth (anterograde approach) and anus (retrograde approach). The insertion route can be chosen according to the estimated location of the suspected lesions. Stable advancement of the enteroscope into the ileum from the anal approach is particularly challenging and failures occur in about 20% of patients
• The procedure can generally be performed under conscious sedation ( with midazolam/fentanyl) but general anaesthesia is preferrable.The entire small bowel can be visualized in 80 to 90 percent of cases (but requires significant experience of over 150 cases), with lesser degrees of visualization in patients who are obese and in operators with less experience with DBE (1).
• Screening is helpful in initial stages of learning and nice concentric circle with three turns normally ensures the tip is in sight of the target.
• Panenteroscopy is generally achieved by a combination of both the antegrade (oral) and retrograde (rectal) approach. In rare situations, panenteroscopy can be achieved via a single (oral or rectal) approach. Panenteroscopy is demonstrated by India ink injection at the most distal site during antegrade (or retrograde) DBE and by successful advancement of the enteroscope to the tattooed area during the opposite approach.
• The mean duration of the procedure varies from 90-120 minutes depending on the operator experience.

Indications
The main indications are

• Investigation of gastrointestinal bleeding and inflammatory bowel disease.
• Evaluation of abnormal capsule endoscopy or abnormal radiographic studies

Other indications for DBE include an evaluation of suspected small-bowel diarrhoea, abdominal pain, the removal of small-bowel polyps, treatment for angiodysplasias (APC) or small intestinal bleeding ( Endoclip) ,the retrieval of tissue samples/ stuck capsule  and accessing ampulla for ERCP in Roux-en-Y anastomoses, post bariatric surgery, small intestinal stricture dilatation/ stenting, tattooing to assist laparoscopic small bowel resection. Difficult colonoscopy is another indication when rectal approach is used.

One important point is if APC is used to treat any telangiectasia in small bowel – Argon flow is to be reduced to 1.5 litres/minute (normally 2 litres/minute) and energy reduced to A30 (normally A65 for Stomach/duodenum). Also avoid physical contact of the small bowel wall with the tip of APC catheter as suddenly the wall can be blown up with the gas. Also to inflate CO2 should be preferentially used.

Limitations
The limitations of DBE include the long procedural time and the patient discomfort and increased need for sedation.

Complications
Diagnostic DBE has an overall complication rate of 1.7% (perforation 0.3%, bleeding 0.8%, pancreatitis 0.3%). The cause of pancreatitis is uncertain.  Therapeutic DBE has a relatively high complication rate of 4.3% (polypectomy bleeding 3.3%, argon plasma coagulation perforation 1.2%, dilation perforation 2.9%) (2).

Single balloon enteroscopy

Single balloon enteroscopy (SBE) is similar to DBE except that SBE utilizes a single balloon on the overtube and a hyper flexible endoscope tip. Rather than the balloon at the tip of the endoscope fixing the endoscope when overtube is advanced- the intestine is fixed by hooking the flexible distal tip (J manoeuvre).

1. Insert the scope as deep as possible into the small bowel and fix the angulation of the scope.



2. Advance the overtube.



3. Inflate the balloon.



4. Withdraw the overtube and if possible, try to push the endoscope simultaneously.

(courtesy-http://www.olympus.com)

This decreases set-up time and also no assistant is needed. The single balloon enteroscope is also stiffer that may facilitate one-to-one advancement in the small bowel and improve success rates for ileal intubation from the anal approach. In the initial clinical experience using SBE, average depth of insertion (270 cm) and diagnostic yield (54%) were similar to those with DBE (3).Procedure time was somewhat shorter. There are no comparison studies between DBE and SBE with regard to complete enteroscopy rates.

Previously Enteroscopy was done either by Push Enteroscopy or Sonde enteroscopy
Push Enteroscopy
Push enteroscopy is an endoscopic procedure whereby a longer endoscope is inserted into the jejunum through the mouth to evaluate a larger segment of the small bowel. The diagnostic yield of push enteroscopy is approximately 40% to 65%.
Push enteroscopy is normally done with a paediatric colonoscope +/- overtube. The main disadvantage is the fact that small bowel is too long and being supported on a mobile mesentery, the endoscope tends to accentuate the natural curvature and makes complete examination almost impossible.

Sonde enteroscopy
Sonde enteroscopy involves the use of a long, flexible, fiberoptic instrument propelled through the small bowel by peristalsis; this procedure may allow for viewing the remainder of the small bowel. Sonde instruments rely on a balloon placed at the instrument’s tip. Peristalsis then advances the long flexible endoscope to the distal small bowel, and the endoscopic examination is performed during withdrawal. In contrast to push enteroscopy, this instrument has no biopsy or therapeutic capability.

References

1. Gross SA, Stark ME. Initial experience with double-balloon enteroscopy at a U.S. center. Gastrointest Endosc 2008; 67:890-897.
2. Mensink PB, Haringsma J, Kucharzik T, et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy 2007; 39:613-615.
3. Tsujikawa T, Saitoh Y, Andoh A, et al. Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences. Endoscopy 2008; 40:11-15.

1. When to use Adrenaline
2. How to set it up
3. How to actually use it once it is set up

When to use Adrenaline

1. Most commonly it is used as part of dual therapy (submucosal injection) to achieve haemostasis in ulcer bleeding, bleeding AVM, Dieulafoy lesion, MW tear, post polypectomy bleeding and post sphincterotomy bleeding.
2. Sometimes it is used to lift up the polyp base before snare polypectomy
3. It is not used in variceal bleeding.

How to set it up

Picture1: Adrenaline injection

1. Ten ml syringe filled with Adrenaline solution (1:10000 dilution, comes in 10ml ampoules)
2. Injector needle, primed with same solution. In most situations you probably will use a gold probe and use dual treatment with one device.

How to actually use it once it is set up

1. Inject adrenaline in four quadrants at the periphery of the lesion. This should be followed by injection at the centre of the lesion.
2. Assistant pushes the injection hub towards yellow injector stem when you say ‘advance needle’- don’t say ambiguous terms like needle out or needle in.


Picture2: Advance needle: injector hub is pushed towards the yellow stem

3. Inject in the submucosa and inject liberal amount (tamponade effect is probably as important as the vasoconstrictor effect) – 10-15ml should be the total amount. Studies show that at least 13 mls should be injected for optimum haemostasis.
4. After injection is given you say ‘needle back’ (don’t say needle out) and assistant withdraws the needle back in sheath by pulling the hub away from the yellow stem.


Picture3: Needle back: injector hub is pulled away from the yellow stem

5. Although at times when we inject adrenaline subcutaneously at times of giving local anaesthesia, we always aspirate before injecting to make sure we are not injecting in a blood vessel, we have not come across this practice but might not be a bad idea.
6. It should be followed by another modality of achieving haemostasis ( e.g. gold probe, endoclip etc)

Complications:

1. Cardiac tachyarrhythmia can occur particularly in the event of inadvertent intravascular injection
2. Local pressure necrosis (rarely)

Here is the link for Adrenalin injection video

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98

1. The basic principle of achalasia dilatation
2. The common devices used
3. How to actually do it
4. Aftercare

Choosing the correct patient

1. If you cannot pass the endoscope beyond the narrowing at GOJ , reconsider your diagnosis and consider pseudo-achalasia
2. A thorough endoscopic examination is important, with particular attention given to the GOJ, where malignancy can simulate achalasia (pseudoachalasia).
3. It is very important that your diagnosis of achalasia is quite firm  ideally with endoscopic, Barium swallow and manometry findings.
4. Quite high risk procedure (5% chance of perforation)- so discussion in the clinic with the patient is important while discussing the alternatives (Laparoscopic cardiomyotomy)
5. These patients are prone to aspirate particularly when regurgitation of old food is the predominant symptom.
6. The patient is advised to fast for at least 12 hours prior to the procedure +/- liquid diet for one or two days preceding the dilation
   

Procedure

Choice of balloon

1. A 30 mm balloon is used for a first dilatation. Subsequent dilatation may involve larger balloon- 35 and 40cm.
   This are quite big sized balloon compared to standard stricture dilatation balloons- the idea being to rupture the muscle fibres.
2. Inflate the  balloon before use to check for any leaks
3. We  describe the  OTW ( over the wire) achalasia balloon from Rigiflex™ II ( Boston Scientific)


Picture1: RigiflexII achalasia dilatation balloon: Courtesy Boston Scientific

4. Another frequently used balloon is Wilson-Cook


Picture2 and 3: Wilson-Cook achalasia dilatation balloon and the inflation and luminal port

5. Another alternative is reusable balloon (shown below)


Picture4 and 5: Reusable achalasia dilatation balloon with the pressure gauge: the endoscope goes through the top end of the yellow tube and comes out below the balloon

Positioning the balloon across the LOS

1. A guidewire is passed through the biopsy channel of the endoscope into the stomach and the scope is withdrawn to the GOJ.
2. Note the distance between the incisors and the GOJ along the length of the scope.
3. The endoscope is then removed (taking care to maintain the position of the guidewire in the stomach- push/pull technique).
4. As an aid in initial placement, a marker (such as a paper tape/ tippex) can be placed on the shaft of the dilating catheter to correspond to the previously noted distance from the incisors to the GOJ.
5. This distance should be measured from the middle of the balloon on the dilating catheter.
6. The balloon and tip of the shaft is lubricated and passed over the previously placed guide wire until the marker is in place at the incisors- that means the midpoint  of the balloon is now at GOJ.
   

Actual dilatation

1. Using fluoroscopy, the balloon is then gradually inflated with air, noting the position of the developing waist.
2. Inflation is achieved with a 50ml syringe attached to the balloon port with a 3 way stopcock ( one end to catheter, second to syringe and third port to the pressure gauge)
3. The balloon is inflated with air
4. Small adjustments usually have to be made in the position (deflating the balloon each time) to ensure that the waist occupies the centre of the balloon- balloon will slip downwards if you are too down and then you will have to exert a pull upwards and vice versa- called the cone effect
5. After a satisfactory position is obtained, the balloon is fully inflated (usually requiring about 120 mL of air).
6. The required pressure will be specified on the moulded junction- average 7-15 PSI
7. The balloon is kept inflated for 60 seconds, during which patients may be very  uncomfortable- give pethidine or fentanyl 2 minutes before the dilatation
8. After the 60 seconds are over, the balloon is rapidly deflated.
9. Sudden disappearance of the waist is very suspicious of rupture
10. Thereafter, perform another full inflation for 60 seconds and again note the pressure required to obliterate the waist. This is usually less than the initial pressure
11. Another alternative is reusable balloon-
    • The scope here is passed through the balloon and then the scope is introduced beyond GOJ- a J manoeuvre confirms part of the balloon beyond the GOJ ( see picture)
    • The side catheter containing the inflation port is attached straight to a inflation device with a pressure gauge ( see picture)
    • Pressure of 200mm kept for 2minutes and then release

Aftercare:

1. The patient is observed for the next five to six hours during which serious complications, such as perforation would be obvious
2. Routine post procedure CXR is advisable
3. Follow up in clinic to assess response

Here is the link for achalasia dilatation video

Acknowledgement/Bibliography:

1. Khan AA et al. Pneumatic balloon dilatation in achalasia: a prospective comparison of balloon distention time. Am J Gastroenterol 1998; 93:1064-1067
2. Kadakia SC et al.Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary achalasia. Am J Gastroenterol 1993; 88:34-38
3. Barkin JS et al.Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990; 36: 123-125
4. Product guide of the respective companies- Wilson-Cook and Boston Scientific

1. How to determine the location of the foreign body
2. How urgently the endoscopy needs to be done
3. How to use an overtube
4. How to grab the FB
5. When can you wait and watch
6. Food bolus obstruction

Location of the foreign body:

1. Two important questions-What is it and Where  is it ( Pharynx/Larynx/trachea/oesophagus etc)
2. Take history and get an x-ray of neck/CXR /AXR depending on the history and clinical suspicion
3. Remember -Bones may not show on x-ray
4. Get both coronal and sagittal views- if in doubt
5. Beware of airway compromise

How urgent is the need for an endoscopy?

1. Immediate if
   • Complete obstruction
   • Sharp – up to 35% perforate
   • Battery – burn within 2 hours and can perforate within 6 hours
2. Everything else within 24hours


Picture1: An overtube
How to use and overtube

3. Use overtube- prevents repeated intubation and protect airway and mucosa
4. Thoroughly lubricate the inside and the outside of the overtube
5. Pass the endoscope through the overtube- the thicker and corrugated end remains outside the oral cavity – then intubate and advance the gastroscope
6. Keep the tip of the overtube in the lower oesophagus while you find the foreign body as it immediately deflates the stomach and view will be compromised
7. Once FB is viewed and position located – do a J manoeuvre and advance the overtube – note the tip protruding through the GOJ- both overtube and the scope is black but scope has got white ring marking
8. Next withdraw the overtube just within the GOJ and inflate the stomach again
9. Find the foreign body and grasp it – use Roth net for battery, for razor blade use stent grabber- anything sharp – you need to grab it along its axis and not across
10. Pull the scope very close to GOJ
11. Advance the overtube OVER the scope to cover the sharp object – we find it more convenient than to pull the scope into the overtube
12. Immediately the whole field will look black
13. Withdraw the endoscope and FB together keeping the overtube in place
14. Can go back again if more FB is to be picked
15. Remove the overtube at the end

How to grab the FB

1. Tool kit- snare/triprongs/Roth net/Suction cap/biliary basket/Rat toothed forceps


Picture2: Capuchon hood

2. Capuchon hood is another device which can be used instead of overtube in selected cases- it is fitted at the tip of the endoscope and looks like a rubber skirt which invaginates itself once the scope is withdrawn into the GOJ and then covers the FB
3. Dry run outside the patient with similar objects- ensure the size of the FB is compatible with the holding size of your device
4. Move with pointed end trailing
5. If both ends pointed cover one with forceps
6. For razor blades rat toothed forceps ( stent grabbers) are probably best as with other devices you can catch it across which is problematic
7. If perforation- conservative management only in highly selected cases (endoclips or covered stents)- most require operation

When can you wait and watch

1. If the patient is
   • Asymptomatic
   • Blunt FB
   • Inert FB
   • Not>5cm
   • Healthy gut
2. Warn to report symptoms
3. Check X-Ray

Food bolus obstruction:

1. If complete obstruction with saliva drooling urgent OGD
2. Once visualised one can either
   • Pull- Forceps/snare/net/grasper
   • Push it down in to the stomach by using
     • Air insufflations
     • Gentle pressure
     • Fragment and gentle pressure
3. Success 97%
4. Remember to take oesophageal biopsy particularly if young male to exclude Eosinophilic oesophagitis
5. If narrowing is seen once the bolus is gone- e.g. benign stricture, web, schatzki’s ring or malignant stricture – that needs to be addressed then or later depending on the pathology.

Here is the link for foreign body extraction video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Alhaji M et al. Razor blade removal from the stomach utilizing a novel modification of the overtube. Endoscopy. 2009;41 Suppl 2:E166. Epub 2009 Jul 23.
2. Webb WA et al.Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology. 1988 Jan;94(1):204-16.
3. Stack LB et al. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. 1996 Aug;14(3):493-521.

1. Pre-cleaning inside the room
2. How to do leak testing
3. Actual wash and manual cleaning
4. Automated endoscopic reprocessor
5. Storage

Before you read this chapter make sure you have read parts of an endoscope and how to set up the endoscope.

1. Pre-cleaning inside the room
   • Ensure correct Personal Protection Equipments (PPE) are worn at all times of decontamination ( Gloves, Apron, Sleeve protectors and +/- Visor)
   • Suck the endozyme solution immediately by pressing the suction button
   • Wipe the outer surface of the scope with endozyme soaked sponge

   
   Picture1: Cleaning outside with the sponge soaked with endozyme

   • Switch off the air/water pump and disconnect  the water tube

   
   Picture2 and 3: The water valve is turned off: and is disconnected

   • Switch off the suction pump and remove the suction tube from the scope
   • Take the scope off the processor and lay on the tray with wheel upwards
   • Put the soaking cap on the PVE connector head

   
   Picture4 and 5: The PVE head: covered with the soaking cap

   • Put the sliding lock onto the Air/Water valve

   
   Picture6 and 7: The channel separator

   
   Picture8: Titbits for decontamination

   • Put the tubing to the additional port next to the water port and put a special  metal adaptor on the water port

   
   Picture9:Tubing fitted on forward water jet port

   • In this picture the metal cap on water port is not placed yet but in lower picture it is

   
   Picture10 and 11: The metal cap is on the water port: and being flushed in the room

   • Inject endozyme into the ports ( suction/biopsy/water/ additional)
   • Put the Air/Water valves in the metal container ( tea strainer)

   
   Picture12: Water/Air valve in the tea strainer

   • Take the tray with the dirty endoscope to the cleaning area after covering with the tray liner ( the red liner)
2. How to do leak testing
   • Beginning step in the decontamination area is leak testing
   • Connect the leak tester to the leak test port
   • Increase the pressure to the required amount ( the green zone)
   • Keeping the pressure high, manoeuvre the tip of the scope to look for evidence of leakage- immerse in next stage in water only if leak test is ok.

   
   Picture13 and 14:The leak testing tubing with the green nozzle: tip to be manoeuvred

   • Take the leak testing tubing off
3. Actual wash and manual cleaning
   • Fill the sink with 15 litres of water ( temp less than 35 degrees Celsius) and add 60ml of Endozyme solution
   • Soak the endoscope in the sink
   • Take the sliding plate off the air/water port
   • Clean the valves( suction and water/air valve) with the short brush ( purple here)- Put the valves back into the tea strainer and also the metal cap of the water port
   • Next clean the control wheels and the tip of the scope and also the rubber water jet valve ( next to the water port)
   • Clean the ports ( suction/biopsy/water/ additional ) with the long brush ( blue here) x 3 times
   • Put the channel separator back again and flush all  the channels with Endozyme mixed water of the sink
   • Transfer to clean water sink and flush the port again with clean water
4. Automated endoscope reprocessor
   • Connect the different colour coded tube to the different ports

   
   Picture15: The colour coded tubes in the AER

   • A typical sequence
     • Red- leak testing port
     • White- extra water port
     • Orange-Biopsy port
     • Blue- water port
     • Brown- suction port
     • Green/Yellow- additional
   • Ensure that the tubings are not going to be caught in the rotating sprinkler
   • Close the lid, select the cycle and enter the scope details and hit the start button
   • The paperwork
     • Place the endoscope and pre-manual clean and patient ID labels in appropriate section of the Traceability/Tracking Logbook
     • Record Manual cleaning details and Loading of endoscope in AER
5. Storage
   • Blow air through the different channels to make it dry- Some of the trusts stopped doing it as prions thrive in dry environment. After cleaning an endoscope can follow either of these three paths:
     • Used immediately or within three hours
     • Stored in UV cupboard and then it can be used within next three days
     • Hang the scope in a well ventilated cupboard removing all the valves, seals, soaking caps and angulation locks for storage

     
     Picture16: Drying cupboard
     Then it has to be disinfected again before use next morning by passing it through AER machine ( but decontamination i.e. manual cleaning is not needed)

With an Olympus scope

Picture17: The blue AW channel cleaning adapter, flushing catheter, enzymatic detergent ( First step)
1. Then clean the outside of the scope with the soaked sponge in side the cleaning solution ( First step)
2. Switch off the air pump.
3. Dip the tip of the endoscope into the enzymatic detergent and the black plastic end of the rubber tube to the biopsy port and dip the other end in the same pot of enzymatic detergent.
4. Then close the air/water port with the blue coloured  AW channel cleaning adapter and switch on the air pump again. Some trusts keep the air pump on until cleaning is finished.
5. The AW channel cleaning adapter  continually blows air then through the air/water channel. It is dangerous to accidentally use this valves when doing a procedure as it continuously blows air in and can distend and cause rupture in colon. So that it does not happen it comes attached with a card. And when you depress that valve then it flushes the air/water channel with water.
6. Keep pressing the suction button and that will suck the channel thoroughly with enzymatic cleaner. Then you should lift the insertion tube/tip from solution and suck air.
7. Then repeat the procedure again but this time dip both scope tip and the flushing catheter in clean water pot. It is said that the fluid should percolate for a total of 30 seconds.
8. Remember air/water channel and suction/biopsy channel are two different channel and are to be cleaned separately.


Picture18: The Electrical connector to be removed…

9. Next remove the water/air catheter and suction catheter after switching off the pump.
10. Take off the cover of the electric connector and immediately cover it with the water resistant soaking cap.
11. In the next step of leak testing the leak testing catheter is connected to the air vent of the soaking cap.


Picture19: …And end is covered with the soaking cap ( the air venting port takes the leak testing catheter in the next step)