Oesophageal endoscopy

Darragh et ai, 2006. Gas chromatography on gastric aspirates, N = 172 Bile present in 92% (158/172) of patient samples. No difference in bile content between patients with Barrett s (60), oesophagitis (48) or controls N — 52). 12 patients without clinical information. All patients underwent endoscopy for GORD symptoms. 

Effective treatment of reflux disease has greatly reduced the need for anti-reflux surgery although the case for it remains in young people with persistent symptoms, and where responses to pharmacotherapy are poor. Endoscopic oesophageal dilatation with maintenance proton pump inhibitor treatment usually obviates the need for surgical reconstruction of the lower oesophagus in individuals with visible inflammation at endoscopy. 

Endoscopy shows whether or not oesophageal or gastric varices are present, and hence whether collateral vessels have formed, affecting blood flow through the liver. 

Direct treatment of varices by endoscopy is preferred. Band ligation, in which the varices are strangulated by application of small elastic bands has fewer complications than sclerotherapy, which involves injecting sclerosant into and around the varices but may lead to oesophagitis, stricture or embolisation of sclerosant. Either technique can control bleeding in about 90% of patients, and rebleeding is reduced if this direct treatment is combined with reduction of portal pressure (see below). 

Chung SC, Leong HT, Choi CY, Leung JW, Li AK. Palliation of malignant oesophageal obstruction by endoscopic alcohol injection. Endoscopy 1994 26(3) 275-7. 

Van Rnxteren B, Numans ME, Ponis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2000 CD002095 1-27. 

Tytgat GN (1990) Endoscopic review of esophageal cancer possibilities and limitations. Endoscopy 22 263-267 Watkinson AF, Ellul J, Entwisle K, et al. 0995a) Oesophageal carcinoma initial results of palliative treatment with covered self-expanding endoprostheses. Radiology 195 821-827... 

Negative endoscopy Duodenal ulcer Oesophagitis Gastric ulcer... 

A final abnormality which may be encountered at the level of the pharyngo-oesophageal junction is cricopharyngeal achalasia, sometimes referred to as a cricopharyngeal bar. This results from cricopharyngeal hypertrophy and is a not infrequent cause of a failed endoscopy. 

Irregularities of the oesophageal lumen secondary to ulcer deformities and scars are accurately depicted by high-quality contrast studies. Conversely erosions and shallow ulcers are easily overlooked therefore patients with GORD should be evaluated by endoscopy. Complicating strictures are readily managed at endoscopy by the use of hydrostatic balloons. 

At endoscopy oesophageal varices appear as axially running strings of blue-tinted sinuous structures, increasing in size aborally. Areas of diffuse redness and spots of haematin (Grade III) signify a 50% increased risk of bleeding. 

It is important to detect H. pylori infection because of its association with nonjunctional gastric adenocarcinoma, gastritis and duodenal ulceration, B-cell lymphoma, and reflux oesophagitis. There are a number of mechanisms for its detection. The urea breath test is the most accurate noninvasive test with an accuracy of 96% (Cohne et al. 1999). The rapid urease test or CLO test is performed at the time of endoscopy and has a 97% accuracy and an 80% sensitivity. This can indicate infection within minutes. Combining the CLO test with microscopy of tissue specimens, the detection rate comes close to 100%, emphasizing the importance of several biopsies from the gastric antrum (GuR et al. 1998). 

Fig. 4.1. Oesophageal web. Lateral view of the upper oesophagus demonstrating a tight web just below a prominent cricopharyngeal muscle impression. The web was not identified on endoscopy...

Fig. 4.10. Achalasia of the cardia. Typical appearances with mild dilatation of the oesophagus and Tat tail configuration of the lower oesophageal sphincter. This and the lack of any normal peristaltic activity in the lower oesophagus indicated the diagnosis immediately, although the patient had suffered dysphagia without diagnosis for three years and had undergone three endoscopies...

Fig. 4.26. Intramural pseudodiverticulosis. Typical and striking appearances of oesophageal pseudodiverticulosis that was not noted at endoscopy...

Preston SR, Clark GWB, Martin IG et al (2000) The effect of endoscopic ultrasound on the management of 100 consecutive cases of oesophageal and junctional carcinoma. Endoscopy 32 A4... 

The fact that some oesophageal stents are now removable both with and without endoscopy has brought certain advantages to practice. A stent which has displaced proximally above a tumour can be easily removed prior to the placement of a further stent. Stents which displace distally into the stomach, either spontaneously or after a period of chemo- and/ or radiotherapy can usually be pulled back into position endoscopically or completely removed. In the... 

Fig. 13.5. An 80 year old lady, 3 years after fundoplication presented with severe solid food dysphagia, weight loss and heartburn. Endoscopy revealed severe esophagitis. Upper G1 series showed a constant level of mucus and sedimented contrast material as a sign of delayed oesophageal clearance (white arrow). Small parts of the stomach are above the diaphragmatic hiatus (black arrow), indicating a partial migration of the fundoplication without disruption of the wrap itself. pH monitoring did not reveal reflux and the oesophagitis was suspected to be due to retention. Dilatation of the wrap was successful...

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