endoscopy review

Endoscopy review

Joan Miller, RN Nikolas Kazmer, MD

A routine physical examination in- cludes endoscopy of the eyegrounds, ear canals, and vagina. When disease is suspected in certain areas of the alimentary tract, esophagoscopy, gastroscopy, peritoneoscopy, cholangioscopy, cystoscopy, sigmoidoscopy and coloscopy of the left colon should be considered part of the physical examination. The fear of injury to the patient and the fear of discomfort for the patient are not founded. More harm is done to the patient when a correct diagnosis is not made. The

radiological diagnosis is not always correct in abdominal problems and even a carefully performed explora- tion may not reveal gross abnormal- ity in certain instances.

Esophagoscopy is reasonably accurate in determining the level of the esophagogastric junction, the degree of esophagitis and the amount of gastric juice reflux in patients with suggestive symptoms but negative x- ray findings in esophageal hiatus hernia. Ulcerations, neoplasms and foreign bodies of the esophagus can be detected with ease.

Gastroscopy and gastrophotography are of great value in detecting causes

College of Nursing in Detroit, and i s (I member radiologic examination. C a m s for of the Western Michigan chapter of AORN. hemorrhage may include acute gas-

chronic superficial ulcers, lacerations of the cardia (Mallmy-Weiss Syn-

plasms in early stages.

Joan Miller, RN, is operating room inservice in-

stroctor at Leila Y. Post Montgomery Hospital in Battle Creek, Mich. She i s a graduate of Mercy Of hemorrhage not apparent by the

Nikolas Kazmer, MD, FICS, FACG, i s chief of surgery at Kelsey Memorial Hospital, Lakeview,

Mich. H e is a graduate of the Medical Faculty

of the University of Latvia, Riga. Dr. Kazmer prepared this speech and Ms Mil ler

tritis, acute stress ulcer and erosions,

b m e ) and gastric V d C f 3 S and n e organized the contents for publication.

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Peritoneoscopy permits viewing of the parietal and exposed visceral peri- toneal surfaces, the anterior and the inferior aspects of the liver surface, gall bladder, stomach, spleen and in- testines. It also permits biopsy under direct vision. It is a reliable procedure in establishing diagnosis of abdominal carcinomatosis, tuberculous, perito- nitis and metastatic liver disease. In women, the internal genitalia can be studied well by tipping the patient up so the small bowel and omentum roll back away from the pelvis.

Cholangioscopy permits survey of the form and position of the bile ducts, changes of the mucosa, size and form of the papilla and the amount, size and position of stones or debris. It also demonstrates neoplasms of the extrabiliary tract in early stages.

Cystoscopy may be important in differential diagnosis not only in the diseases of the urinary tract but also in abdominal disorders. Ureteral in- juries may occur as a complication of either gynecological operations or colon surgery for carcinoma or di- verticulitis when the disease process has altered the normal anatomy. Rarely, the right ureter may be dam- aged during appendectomy for retro- cecal appendicitis. If ureteral cath- eters are not inserted prior to gynecological operations or colon resection it is advisable to perform cystoscopy during or immediately after surgery, injecting a sterile indigo carmine solution intravenously, especially if dissection has been difficult, and to observe the excretion of the dye from the orifices of both ureters.

Proctosigmoidoscopy is useful in demonstrating rectal inflammatory

disease, internal hemorrhoids, chronic nonspecific ulcerative colitis, n e e plasm, polyps, Hirschsrpungs’ disease, bacillary dysentary and ame- biasis. The left colon can be viewed through the gastroscope prior to surgery. During surgery, coloscopy can be performed through a separate colotomy opening using sterile sig- moidoscopes.

Esophagoscopy and gastroscopy: Phil- lip Bozzini, a general practitioner and obstetrical helper in Frankfurt, Ger- many, is credited for developing in 1807 a “Light leader” for inspection of body cavities, as well as oral cavities and the bowel. His source of light was very primitive-a candle. The light was directed by reflecting lens through a tube or tubes so ar- ranged that a field “around a corner” could be inspected. Laryngeal mirrors were developed next, which permitted the viewing of the inlet of the esophagus. (Schmerz et Hacker) Then Val- tonini constructed the first speculum in 1816. Starck, Semeleder and others further developed tubes which could telescope into each other. By 1868 dilators for the esophagus were made available.

It seems that Bevan was the first who reported an esophageal diverti- culum during endoscopy. Mikulicz, together with the instrument manu- facturer Leiter, produced a rigid tube esophagoscope with a glowing plati- num sling as the light source. Miku- licz remains in history as the father of endoscopy of the gastrointestinal tract after he reported in 1881 the basic principles of esophagoscopy and gastroscopy. While Mikulicz worked on endoscopes with an inner light source, Von Hacker attempted to move the light source outside the

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scope in order to provide a wider and better field for inspection and thera- peutic work. At the same time, Leiter and Nitzsche attempted to employ the principles of cystoscopy for inspection of the esophagus. Unfortun- ately, this work was without valuable progress.

Von Hacker and his pupil, Lotheis- sen, made great contributions for the development of instruments of modern endoscopy. The invention of the bronchoscope by G. Killian instilled Brunings with the idea of construc- tion of a universal endoscope. This dream was never fulfilled. Further modifications of esophagoscopes were elaborated by Kahler, Hasslinger, Starck, Scheiber and others. The rigid and straight esophagoscopes required considerable examiner’s skill and the procedure was painful and relatively dangerous. Hirchowitz revolutionized the esophagoscope development in the United States. In 1963 the first flexible esophagofiberscope was placed on the market. This revision made the esophagoscope safer and much easier to use. Utilization of the instrument is simple. The head of the fiberscope can be bent to a desired angle up to 90 degrees. The camera can be attached to the fiberscope with ease and photographs can be taken while the esophagus is inspected. Aspira- tion, insufflation, ar,d fluid feeding can be controlled automatically while biopsy is being accomplished.

Gastric endoscopy and photography: Gastroscopy and gastrophotography are of great value in detecting causes of hemorrhage, gastric ulcers, foreign bodies and neoplasms not apparent by radiologic examination.

Stomach cancer ranked fifth be- hind lung, breast, colon and pancre-

atic cancer in the United States last year. It is very important to diagnose neoplasms in their early stages. Five years survival after surgery for localized gastric cancer in the United States is 40 percent while it is only 12 percent when the regional lymph nodes are involved.

In 1868 Kussmaul tried to look inside the stomach of a sword swal- lower. He used a straight tube 13mm in diameter and an external source of light reflected by a system of mirrors. Mikulicz, following the principles of the cystoscope developed by Nitz- sche, attached the source of light a t the tip of the gastrowope and was able to see, for the first time, the ac- tion of the pylorus and observe carcinoma of the stomach in 1881. Great progress has been made during the past 100 years, mainly since the intro- duction of the flexible gastrowope by Schindler in 1932 and most recently with the development of several types of fikrscopes. Illumination is achieved with either small electric bulbs inside the stomach or a powerful external source of light transmitted into the stomach by means of bundles of fiber- glass.

The first black and white intragastric photographs were taken by Lange and Meltzing in 1898. The poor quality of the photographic emulsion available a t that time discouraged its further use. In recent years, photography of the stomach was done by attach- ing an external camera to a gastroscope. There were technical phote graphic difficulties and this technique did not gain popularity,

The fact that the Japanese people are six times more susceptible to gastric cancer than the Americans led to perfection of diagnostic procedures

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including development of gastro- scopes and gastrocameras. In 1950 a successful intragastric camera was developed by Dr.s T. Uji and T. Haya- shida of the University of Japan. The camera was introduced in the United States by Dr Yoshio Hara of the Nii- gata Cancer Research Center working on exchange a t the University of Wisconsin Cancer Research Hospital.

The fiberscope has a wide applica- tion in the diagnosis of gastric disease. It is easy to pass and it is a safe procedure. However, possible complications of gastroscopy and photography should be mentioned. These complications may be subdivided into three groups:

1. Complications of preexamination

2. Accidents during the procedure.

3. Postexamination complications.

The drugs used to produce sedation also produce depression of the baso- motor and respiratory systems. The belladonna derivates, such as atro- pine or scopolamine, used to reduce secretions and to minimize potentially hazardous vagal reflexes, have also undersirable side effects. They may produce tachycardia, heart irregular- ities and mental confusion. A small percentage of patients may react ad- versely to extremely small quantities of topical anesthetic agents used for spraying of the throat. Initial excite- ment is followed by confusion pro- gressing to coma, convulsions and failure of respiration and circulation. One should always be ready for ad- ministration of oxygen, artificial res- spiration, intravenous barbiturates, intravenous vasopressors, antihista- mines, and cortisone preparations and

medications.

external cardiac massage when local anesthetics are used.

One using a faulty technique may perforate the esophagus during in- troduction of the instrument. The stomach may also be perforated by air distention, especially if a sealed off perforated gastric ulcer is present.

Saliva may be inhaled into the trachea while the camera is removed. The patient should stop breathing until he or she sits up. No fluids or foods should be permitted for one hour after the examination because aspiration of food particles may occur due to temporary drug induced par- alysis of the pharynx.

Endoscopy should not be used alone. X-ray examination is the most important diagnostic method for establishing a diagnosis of stomach disorders. Gastroscopy and gastrophotography are necessary when the x-ray films are normal or inconclusive and the patient’s symptoms persist. Experience shows that the combina- tion of endoscopy and radiology provides the correct diagnosis in 90 percent of upper gastrointestinal tract diseases.

The gastroscopy examination with gastrocamera photography is a relatively accurate technique in the diagnosis and management of patients with gastric ulcers as well as marginal ulcers after partial gastric resection. Statistically the gastrocamera has demonstrated a larger number of ulcers than had simultaneously performed x-ray examinations. This may be due to demonstration of superficial shallow ulcers and to the cover- age of more stomach surface, including areas such as the cardia and the fundus where x-ray and gastroscopy have some limitations. Statistically,

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gastrophotography is superior to gastroscopy. This may be, in part, due to the 80 degree angle of view of the conventional gastroscope ,

Gastroscopy with gastrophotography is a reliable procedure in diagnosis of gastric cancer. The diagnosis is difficult if the lesion is rather small, respectively so small that it can hardly be detected by x-ray or endoscopic examination. In these instances, the cystological or histological examination plays a definite role in the correct diagnosis. There is a tendency to over diagnose malignancy in chronic ulcers. The differentiation between benign and malignant ulcers may be aided by examination of gastric washings for malignancy cells with an accuracy of 81 percent or by biopsy. The gastric cystology offers only one percent false positive findings, but the incidence of false negative findings is higher, varying from 0 to 20 percent.

The diagnosis of gastritis, with the exception of hypertrophic gastritis and marked gastric atrophy, is rarely made by x-ray. Gastroscopy is the principle method of diagnosis of this entity. The procedure is also useful for the detection of other forms of gastric lesions, such as polyps, leio- myomas or phytobezoars.

The first instrument, as well as the most modern ones, was designed either for gastroscopy or for blind endogastric photography. If gastroscopy and p h y o g r a p h y were performed it was necessary to pass the instrument twice. The new fiber scope with gastrocamera is an im- proved diagnostic instrument with, for the first time, a fiberscope attached to the intragastric camera. Gastroscopy with this instrument is

superior to the conventional gastroscope for a number of reasons. The patient can be examined anywhere with very little discomfort allowing adequate time for thorough viewing and photography. There are no blind spots when the tip of the gastroscope is reflected downward and upward while observing and photographing all quadrants of the stomach. Ehdos- copy and radiology combined provide the correct diagnosis in 90 percent of instances of upper gastrointestinal tract disease. Gastrophotog- raphy provides a permanent record of the lesion, and the gastrocamera films can be compared with the x-rays and surgical specimens, which is of great interest and benefit to a radiol- ogist and surgeon,

Leiomyomata of the stomach does not give distant metastases, but they may occur locally. Repeated follow up gastroscopy is as important in those instances as it is in following the medical management of gastric ulcer. The size of the tumor encountered in endoscopy or in surgery has no direct relationship to the curability. Microscopic diagnosis is essential. A small gastric carcinoma may be in- curable but a large sarcoma may be treated successfully. The most important feature in management of neoplasms of the stomach is the recog- nition of the true nature of the lesion. Occasionally we cannot judge a t the operating table the nature of the growth which may appear inoperable or which may appear innocent. If the lesion appears inoperable, one should always obtain a specimen for microscopic examination leading to a diagnosis.

The main object is to obtain a correct diagnosis, which is not always easy. The primary diagnostic tool is

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the x-ray examination, proving or dis- proving the clinical impression, which is one of the most important points in the chain of diagnosis. Cystologic and endoscopic examinations add greatly to the accuracy of the diagnosis and management of gastric disorders.

Clinical examples: In over 100 gastric endoscopy and photography examinations performed a t our hospital, gastric carcinoma could not be ruled out by the x-ray examination in two female patients, 88 and 67 years of age and two male patients 70 and 82 years of age. The benign nature of the lesions was demonstrated on gastroscopy and gastrophotography.

Prepyloric ulcer was demonstrated on x-ray examination in a 65 year old female patient. Endoscopy findings were highly suggestive of malignancy. Gastric washings and cystology dem- dnstrated cells suspicious of malignancy. Gastric resection was done and the diagnosis of malignancy was confirmed.

X-ray and gastroscopy findings were highly suggestive of a gastric malignancy in a 63 year old male patient with previously diagnosed Hodgkin’s disease. This patient re- fused surgery and he died one month later.

There was radiological evidence of duodenal ulcer in a 71 year old male patient. Submucosal lesion and possible malignancy were seen on gastrophotography film strips. This patient had also increased acidity with no malignant cells in gastric washings. The deeply pene t ra t ing duodenal ulcer and two small amas of mucosal hemorrhage were encountered at laparotomy when subtotal gastric resection was done.

Carcinoma of the stomach was suspected on x-ray examination in a 40 year old male patient. Gastroscopy was done before considering surgery. There was no evidence of gastric malignancy. The defect seen in the stomach radiologically was due to food ingested secretly by the patient prior to x-ray examination.

Relatively large peptic ulcers of the stomach and duodenum can be demonstrated by x-ray examination as well as by gastroscopy but x-ray diagnosis cannot be made in shallow or small superficial ulcerations and sometimes even in larger ulcers. In all instances gastric washings are considered important. A small ulcer not detected on x-ray examination but demonstrated in gastric endoscopy was found in a patient who had repeated episodes of severe hemorrhage.

Various forms of gastritis were noted in 20 patients. Localized mucosal hemorrhage was demonstrated in three instances.

Esophageal hiatus hernia was proven in six instances with no x-ray evidence of the hernia. The degree of esophagitis and esophageal hiatus hernia was determined in a patient with suggestive symptoms but x-ray findings that were negative.

There are certain diagnostic problems when new symptoms develop in patients with previous surgical procedures involving the stomach or its opening. X-ray examination may be of some value but endoscopy combined with photography offers a correct diagnosis in these cases.

Endoscopy is a valuable diagnostic tool which should be utilized to its fullest extent in order to give quality patient care.

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endoscopy review

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