Esophagogastro‐Duodenoscopy (EGD)

The Esophagus

The cervical segment of the esophagus begins at the upper esophageal sphincter, which is 15 cm from the incisors and is 6 mm long ( Figure 40-1-1 ). The thoracic segment of the esophagus is approximately 19 cm long. Its lumen is open during inspiration and closed during expiration. The imprint of the arch of the aorta is sometimes apparent at 25 cm from the incisors on the left. How to describe where a lesion is in terms of anterior, posterior, right, left, is very important and is shown in Figure 40-1-2 . The transition between the esophagus and gastric epithelium (Z line) is identified by the change in color of the mucosa from pale pink to reddish-pink.

The Stomach

The stomach extends from the cardia to the pylorus ( Figure 40-1-3 ). The fundus is the portion of the stomach above the horizontal line that passes through the cardia and that is visible in a retroflexed endoscopic view. The body is the remainder of the upper part of the stomach and is delimited at its lower edge by the line that passes through the angular notch. Endoscopically, the transition from the body to the antrum is seen as a transition from rugae to flat mucosa ( Figure 40-1-4 ). The pylorus is a circular orifice, which leads to the first part of the duodenum.

When the patient is in the lateral left decubitus position, the greater curvature is at the bottom, the lesser curvature at the top, the posterior stomach wall on the right, and the anterior stomach wall is on the left ( Figure 40-1-4 ). The anterior wall can be visualized with transillumination, a technique used for PEG insertion. A normal stomach distends fully with insufflation, with the rugae flattening out ( Figure 40-1-5 ).

The Duodenum

The duodenum extends from the pylorus to the duodeno-jejunal angle. The duodenal bulb extends from the pylorus to the genu superius. The second portion (D2) extends from the genu superius to the genu inferius. The ampulla of Vater is usually found in a horizontal fold in the middle of the second portion of the duodenum ( Figure 40-1-6 ). The accessory papilla is a small protuberance, which is usually found just superior and proximal to the ampulla of Vater.

Postoperative Endoscopy of the Stomach and Duodenum

Common post-surgical anatomy includes a Billroth I ( Figure 40-1-7 ), where only one lumen is present. In a Polya or Billroth II ( Figure 40-1-7 ), two gastrojejunal orifices are visible. The afferent limb leads to the duodenum, while the efferent limb leads to the colon.

Dyspepsia

Age ≥50 with new onset dyspepsia:

• Should undergo EGD regardless of whether they have alarm symptoms.

Age <50 with dyspepsia:

• Patients with alarm symptoms should undergo EGD

• Those without alarm symptoms should undergo an initial test-and-treat approach for H. pylori

• Patients who are H. pylori -negative should be offered a short trial of proton pump inhibitors (PPI) therapy

• Patients who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy.

Dysphagia or Odynophagia

Unless there is a clear history pointing to a neurological cause or ENT origin for dysphagia, all patients should undergo urgent EGD as their first investigation ( Figure 40-1-8 ). Note, patients with GERD can present with atypical symptoms including laryngitis, chronic cough or bronchospasm.

Gastroesophageal Reflux

• Gastroesophageal reflux (GERD) can be diagnosed on the basis of typical symptoms without the need for EGD

• In patients with uncomplicated GERD an initial trial of empiric medical therapy is appropriate

• EGD should be performed if patients have alarm symptoms or symptoms suggesting complicated GERD or in patients who fail to respond to empiric medical therapy.