Gastrointestinal Procedures: Upper Endoscopy
Guest: Dr. Mark DeLegge – Gastroenterology-Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Mark DeLegge who is Director of the Digestive Disease Center here at the Medical University of South Carolina. Dr. DeLegge, one of the very common procedures that patients come, really, from all over the country to have performed here at the DDC is so-called, upper endoscopy. First of all, what does the term endoscopy mean?
Dr. Mark DeLegge: Linda, endoscopy means, frankly, to look inside the cavity. For gastroenterologists, the cavity would be, we will say, upper endoscopy, your mouth, esophagus, stomach and the very first part of your small intestine.
Dr. Linda Austin: So, about the upper half? Obviously, when you do it on the bottom half, it is called a?
Dr. Mark DeLegge: Colonoscopy.
Dr. Linda Austin: A colonoscopy. A lot of people are familiar with that. What are some of the most common symptoms that patients have that would make a gastroenterologist suggest an upper endoscopy?
Dr. Mark DeLegge: The most common symptoms are generally related to reflux disease, or heart burn. Patients typically come in complaining of chest pain or, perhaps, difficulty swallowing or even pain with swallowing. Some of the other indications can be for abdominal pain, what we call epigastric pain. What that means is, above the umbilicus and below the ribs. Typically when we hear that from a patient, we think of things such as ulcer disease, either an ulcer in the stomach or, perhaps, an ulcer in the first portion of the small intestine, or the duodenum.
Dr. Linda Austin: Now, when patients have chest pain, I mean, the first thing anybody thinks, of course, is heart. Do patients sometimes confuse pain that comes from the esophagus with heart attack, for example, or heart problems?
Dr. Mark DeLegge: Yes, absolutely. Frankly, sometimes it is very difficult for the patient to know whether this is heart pain, what we call angina, or whether this is pain from the esophagus. We call that non-cardiac chest pain, meaning, not from the heart. The two, sometimes, can be very close or on top of one another.
It is not uncommon for me to see a patient in my clinic who was referred to me for, perhaps, an upper endoscopy, doctor, see what you think about this procedure on my patient. After I take a history from the patient, I am more concerned about the fact that they may have heart disease, and not a disease of the esophagus or stomach. I may refer the patient to a cardiologist, first, for a stress test before we really get down to examining the esophagus.
Dr. Linda Austin: Because both kinds of pain can feel like they are just right under the sternum or breast bone and be quite uncomfortable.
Dr. Mark DeLegge: Absolutely. It is not uncommon, also, for pain in your chest, which could be, perhaps, some heartburn or spasm of the esophagus, or, perhaps, from some sort of ulceration in the esophagus to feel exactly like a heart attack. In fact, people will come to me with the pain radiating up into their neck and even into their left arm, the classic signs of a heart attack, when, in fact, it turns out to be a problem with the esophagus.
Dr. Linda Austin: Walk us through this, then, from the patient’s point of view. If a patient is going to have an upper endoscopy, is there a prep that they need to do? What happens?
Dr. Mark DeLegge: Generally there is no prep except that we like you to be NPO (nothing by mouth) for about eight hours. The rationale behind that is you do not want to have food or pill fragments sitting in the stomach that could interfere with someone’s ability to actually see the stomach or, perhaps, the esophagus or small intestine. So, we ask the patient not to eat or drink anything for a period of time. Now, I will tell you, many patients will come back and say, well, I am on blood pressure pills or, I am on pills for diabetes or, I am on pills for, perhaps, my heart. What we do with those patients is we allow them to take their pills with small sips of water so that we do not get into any difficulties with some other chronic disease.
So, let’s just say you were scheduled to see me at 8:00 a.m. for an upper endoscopy. I would tell you, Linda, after 12:00 midnight, tonight, please, do not eat or drink anything, come over here to the endoscopy suite and we will proceed with getting you admitted to the endoscopy suite and getting the procedure started.
Dr. Linda Austin: What is the next step, when the patient actually comes into the suite? What happens?
Dr. Mark DeLegge: After you are called out from the waiting room, you enter what we call a triage area or, perhaps, an admittance area. Frankly, what happens there is the nurse will go through with you all your medical problems, your medications, why you are there, remind you about important things. Following the endoscopy, one of the most important things is that, typically, you are sedated, meaning, we give you medications for this to make you very sleepy. We do not want you waking up and walking out and driving your car home. We kind of emphasize facts such as that. In addition to that, you will get an IV, an intravenous line, placed. The reason we do that is because we want to be able to give you medications for sedation and we have to have an IV to do that. We also hook you up to a blood pressure machine to read your pulse rate and your oxygen saturation, or how well you are breathing.
The physician will come into the room and talk to you, get a consent form signed and that consent form is very important. You must listen through that. It tells you why you are getting the procedure done, alternatives to the procedure, meaning, instead of the endoscopy. You will also hear about the risks, what could happen to you, potentially. You want to become fully aware, as the patient, why am I here, what is going to be happening, and what is the potential risk?
Dr. Linda Austin: I want to ask more about the risks, but let’s go through the whole procedure from the patient’s point of view first. After the patient has signed off, they have their IV going, what happens then?
Dr. Mark DeLegge: We bring you back to the actual procedure room. Again, in that room, we hook you up to blood pressure monitoring, pulse rate and, also, your oxygen saturation that we talked about. Then, once again, we will talk to you, let you know why you are having the procedure done, make sure you are the right patient that we are doing the procedure on as well as get a little history about you, meaning, what medications you are on, again, reiterating that point because it is very important. Ultimately what we will start off doing is putting a bite block which, basically, is a round circle of plastic that goes in between your teeth to protect your teeth and to keep you from biting on the instrument. After that, we will spray the back of your throat with a local anesthetic which, frankly, does not taste that great. It is supposed to taste like cherries or bananas but often it does not. That is to reduce your gag reflex so that when we are doing the procedure, you will not have the tendency to gag.
In addition to that, you will be sedated. You will be given some medication to make you very sleepy to the point that you are unaware that procedure is being done. From there, the upper endoscope, which is a long lighted tube, about the size of your pinky, is passed over your tongue, down into the esophagus. This is all done under direct visualization. We can see the images on a television screen. We will wander through your esophagus, into the stomach and down through the duodenum, which is the first part of the small intestine.
If I happen to see something down there that looks abnormal or perhaps I want to get a sample because I am looking for something that may not be visible to my eye, but would show up under a microscope, I will take a biopsy. That is done through a small piece of equipment that is passed through the endoscope. We take a biopsy and send it off to the laboratory. This is not something that the patient feels at all. In fact, it is painless. I think even if you were not sedated, it would be painless, but you are sedated for the whole procedure.
Dr. Linda Austin: You mentioned early on that reflux is one of the most common symptoms that brings patients in for endoscopy. What are you looking for in the reflux patient?
Dr. Mark DeLegge: Generally with reflux patients, we are looking for two things. One is, we look for ulcers or other erosions in the esophagus that tell us, yes, this is reflux disease. So, we are looking for actual damage to the esophagus. In addition to that, we are looking for a disease called Barrett’s esophagus, named after Dr. Barrett. That particular disease is present in people who have had reflux for a prolonged period of time. What we know about Barrett’s esophagus is that it is precancerous. So, what we do is take biopsies from that area to make sure that there is no cancer in what we are seeing, and diagnosing, as Barrett’s esophagus.
Dr. Linda Austin: And you can then treat it?
Dr. Mark DeLegge: Yes. Especially here at the Medical University of South Carolina, we have some new treatments for Barrett’s esophagus. Previously what we would do is just biopsy the area and if it showed something that was very precancerous, we might send you to the surgeon to have part of your esophagus removed, which, you can imagine, is a big time procedure.
We now have some newer procedures where we essentially ablate, or destroy, the tissue using a variety of instruments, which are all done endoscopically, and, frankly, the patient can go home the same day.
Dr. Linda Austin: So, in other words, you can do that at the time that you are doing that diagnostic look about. Is that right?
Dr. Mark DeLegge: If planned ahead, yes; all that can be done at one time. Sometimes I walk in and I will see a patient who has a new diagnosis of Barrett’s, meaning, I never knew they had it, I am just taking the biopsies now and we are not set up yet to do the other portion because it does require some elaborate equipment. I may have that patient come back, depending on what the biopsy reports show me.
Dr. Linda Austin: You mentioned, also, that ulcers can be another reason that patients come in for endoscopy. What do ulcers look like?
Dr. Mark DeLegge: Ulcers, essentially, look like punched out lesions on the lining of the esophagus. If you can imagine taking a piece of hamburger and taking your thumb and pushing it into the hamburger and then letting go, you would see a depression.
Dr. Linda Austin: Like a crater or a pit of some sort. Is that right?
Dr. Mark DeLegge: Absolutely. Sometimes those pits have a white base and that, basically, is where the tissue is healing. Sometimes you will actually see a blood vessel in the base. This is something that the patient can actually bleed from and have what we call an upper GI bleed where they are vomiting blood. With those ulcerations, we look for how many there are as well as how big they are because that tells us how bad the problem is, and we may also biopsy the area. The reason we biopsy is because some people with an ulcer in the esophagus, in that ulcer, can actually be hiding a cancer. We want to make sure that we are looking at is an ulcer from reflux disease and not an ulcer from something else, such a cancer.
Dr. Linda Austin: You mentioned earlier that there can be risks in having the procedure itself. What are those risks and how common are they?
Dr. Mark DeLegge: The risks with upper endoscopy are really pretty small, but here they are. As we are sedating you, if you have a reaction to the medication or perhaps you become overly sedated where you are not breathing well, that is a potential risk. When we do the upper endoscopy, if we are using instrumentation, like the biopsy forceps I talked about, you could potentially cause some bleeding that would not stop or even a whole in the esophagus, what we call a perforation. The risks here, however, are really very small. A perforation or bleeding, generally, is about 1 in every 30,000 to 40,000 patients. The reaction to the medication with sedation is typically about 1 in every 3,000 patients.
Dr. Linda Austin: So, it is quite a safe procedure?
Dr. Mark DeLegge: It is a very safe procedure.
Dr. Linda Austin: How long does the whole thing take, generally?
Dr. Mark DeLegge: Once you are sedated and the procedure has started, it is about a four to six minute procedure, depending on what you have to do, meaning, you are in there, you take a look, you biopsy and then you are out. We are talking about a relatively short piece of your intestine, or gut, your esophagus, your stomach and the very first portion of your small intestine. If your are in there, though, and see something very abnormal, something that you may have to remove with some more complicated therapy, then the procedure is going to take longer.
Dr. Linda Austin: Dr. DeLegge, thanks so much for talking to us today.
Dr. DeLegge: You are welcome.
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