From WardWiki - Foundation Doctor Helper
Oesophogastroduodenoscopy is an endoscopic procedure to image the upper gastrointestinal tract from the oesophagus to the duodenum. It is invasive but justified for both diagnostic and therapeutic use. Its utility lies in the ability to obtain excellent views of the upper GI tract and perform interventions on it. These views allow prompt diagnosis of mucosal inflammation, ulceration and lesions. This is essential for surveillance of Barrett's oesophagus.
It can used to dilate and stent oesophageal strictures; obtain biopsies for oncology studies, and to remove foreign bodies. It is also invaluable in visualising and treating peptic and variceal bleeds.
Very little preparation is needed for OGD performed under sedation. Preoperative assessment is required for any patient undergoing general aneastheic, although this need not be extensive for young healthy adults. Patients must be nil by mouth for at least 6 hours prior to OGD and overnight starvation is usual. A patient will be returned to the ward if found not to be fasted. In patients who are meet preoperative requirements for ECG must have one, as IV buscopan is often given and can cause tachycardia. Prophylactic antibiotics are only given in unusual circumstances; a mechanical heart valve is classical.
The emergency preparation for OGD occurs when an emergency exists and no short cuts can be taken. The timely and careful resusitation of a critically patient should done alongside arranging senior support and transfer to the endoscopy room or theatre. Recognise that this is serious and not manageable by a foundation doctor alone.
Immediate management for all unwell patients
Assess the patency and protection of the airway. Take baseline observations, viewing them on a chart using an early warning system.
If evidence of airway compromise, contact anaesthetist and your seniour colleague.
If there is a raised or reduced respiratory rate, listen to the chest and give high flow oxygen via a non-rebeathe mask.
If there is a tachycardia, low blood pressure or evidence of dehydration establish IV access and give a fluid challenge.
Send of clotting screen if there is jaundice, history of alcohol excess or liver disease.
If there is pyrexia equal to or above 38 or less than or equal to 35 degrees, take blood cultures.
If SIRS is confirmed or sepsis suspected consider the Severe Sepsis Resuscitation Bundle, although sepsis is rare in upper GI bleeds. If patient meets these criteria and does not respond well to initial management contact a senior team member, and a member of critical care who can see the patient or give advice immediately.
Always cross match at least four units for a GI bleed in extremis. It is time consuming and distressing to attempt(pointlessly so) to rush the blood bank to dispense blood later on. Transfuse without hesitation when GI bleeding is obvious and the patient has a pulse greater than 120, systolic or diastolic hypotension that suggests Class III haemorrhage. Be cautious when other causes of tachycardia exist.
No risk scoring system calculated at admission or initial asessment has been shown to alter the outcome for patients admitted with acute upper GI bleeding. It is more important for foundation doctors to obtain help early on than attempt to use one to plan when an OGD will be needed, as this decision is made at senior level.
Note a urinary catheter is therapeutic only in cases where an empty bladder is desired (including transfer to theatre for surgery). It is important not to miss out resusitation and diagnostics steps in the first hour in an effort to set up equipment that measures a patient only hourly. Your initial fluid challenges will, by definition, not be affected by your promptly placed urinary catheter.
Continuing from the above, ensure patency of two wide bore cannulae; in practice at least two green cannulae needed. Secure these if patient is agitated with bandaging.
Nasogastric tube insertion is of uncertain value in unselected cases although may give symptomatic relief to these suffering from continuous haememesis.
Contrary to popular belief, there is no evidence of using proton pump inhibitors in unselected patients prior to endscopy, although starting a PPI infusion while waiting for endoscopy will probably do no harm.
Many trusts offer consent training and one must be familiar with the procedure prior to consenting for it. This article should serve as reminder to those who have consented previously. The benefits depend on the indication, not all will be true for each case. Any procedure for research purposes must be consented by a senior doctor.
Oesophogastroduodenoscopy +/- biopsy +/- dilation and insertion of stent +/- injection of point of bleeding +/- banding of varices
Diagnosis of stricture, removal of foreign body, removal of cause of bleeding, diagnosis
Bleeding, sepsis, failure to achieve goals, perforation of viscus requiring surgery, rebleeding, blockage of stent requiring retreatment, aspiration pneumonia.
Monitor for effects of sedation and nausea and confusion post analgesia. Most patients recover well and can go home the same evening. Unless stated in the operation notes, all patients can eat and drink as soon as is comfortable. If a CLO result comes back positive, prescribe a course of H. pylori eradication on the TTO.
Follow up with histology if any taken; a normal OGD needs no routine follow up.
Monitor patient for signs of bleeding post OGD. Hypotension is usually caused by rebleeding or by opioid analgesia (pethidine) or sedatives given periprocedure. Investigate carefully and inform senior if not responsive to immediate treatment.
Start a Hong Kong protocol infusion to reduce rebleeding.
Some centres start ciprofloxacin intravenously or as a syrup to prevent secondary infection post variceal bleeding.