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Pocket Guide to Advanced Endoscopy in Gastroenterology
Adrian Săftoiu
Editor
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Pocket Guide to Advanced Endoscopy in Gastroenterology
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Adrian S
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ftoiu
Editor
Pocket Guide to Advanced Endoscopy in Gastroenterology
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This work contains media enhancements, which are displayed with a “play” icon. Material in the print book can be viewed on a mobile device by downloading the Springer Nature “More Media” app available in the major app stores. The media enhancements in the online version of the work can be accessed directly by authorized users.ISBN 978-3-031-42075-7 ISBN 978-3-031-42076-4 (eBook)https://doi.org/10.1007/978-3-031-42076-4
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.This Springer imprint is published by the registered company Springer Nature Switzerland AGThe registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Editor
Adrian S
ă
ftoiuDepartment of Gastroenterology and HepatologyElias Emergency University HospitalCarol Davila University of Medicine and PharmacyBucharest, Romania
Paper in this product is recyclable.
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Gastrointestinal endoscopy (GIE) has undergone a huge develop-ment during the last 30–40 years mainly due to improvements in technology combined with new creative innovations. Even though the endoscopic platform is unchanged the usefulness and func-tionality has undergone a breakthrough: The flexibility and han-dling of the endoscopes have markedly improved, resulting in an improvement in image quality that allows even the tiniest details to be visualized due to higher image resolution, new computer-ized image filters and new software allowing for structure enhancement and characterization, and development of new dedi-cated specialized endoscopes including the combination of image technology such as endoscopic ultrasound or confocal laser endo-microscopy. In addition to this, innovative micro-tools that can be introduced via the instrument channel or mounted on the endo-scope as well as new pharmaceutical products for application through the endoscope either the standard version or an EUS endoscope have further expanded the applicability in a variety of diseases within and outside the GI tract. These developments have paved the way for minimally invasive diagnostics and therapies and in many ways challenged or even replaced traditional surgery. GIE has become a cornerstone in modern gastroenterology both for diagnosis and for therapy for most GI diseases but also in many other conditions where the GI tract or adjacent organs or regions are involved.The present book is a pocket guide to advanced endoscopy in gastroenterology. The book is a condensed description of almost all conditions and diseases of the GI tract but at the same time
Foreword
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gives the reader a comprehensive overview of the role of endos-copy in upper GI tract diseases, lower GI tract diseases, pancre-atico-biliary diseases, and liver diseases. Furthermore, it covers all that is important to know regarding different types of endo-scopes, construction of an endoscopy unit, examination tech-niques, sedation, and monitoring of the patient. One of the key questions is of course whether the endoscopic procedure makes any diagnostic or therapeutic gain for the patient. This topic is nicely overviewed focusing on the clinical impact of GI endos-copy within gastroenterology, hepatology, surgery, and bariatrics.The book is enriched by more than 400 original images and accompanied by instructive videos. The work done by the authors is the result of many years of clinical experience mixed with firm scientific evidence within their fields of expertise. I believe that this book will not only become a reference guide for residents and trainees but also for specialists in gastroenterology, hepatology, pancreatology, and surgery, who want to get a good overview of endoscopy techniques.Peter VilmannDepartment of Clinical MedicineUniversity of CopenhagenCopenhagen, Denmark
Foreword
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Contents
Part I Introduction 1 The Future of Digestive Endoscopy
. . . . . . . . . . . . . . . 3Adrian S
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ftoiu
Part II Integrated Endoscopy Units 2 Infrastructure of the Endoscopy Unit
. . . . . . . . . . . . . 11Adrian S
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. . . . . . . . . . . . . . . . . . . 17Irina F. Cherciu Harbiyeli
. . . . . . . . . . . . . . . . . . . . 23Irina F. Cherciu Harbiyeli and Bogdan S. Ungureanu
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Vlad-Florin Iov
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nescu and Adrian S
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Part III Examination Techniques 6 Preparation Before Endoscopy
. . . . . . . . . . . . . . . . . . 37Irina F. Cherciu Harbiyeli and Mihaela Cali
ț
a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Maria Monalisa Filip and Daniela
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. . . . . . . . . . . . 51Sergiu Cazacu and Adrian S
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. . . . . . . . . . . 63Adrian S
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. . . . . . . . . . . . . . . . . . . . . . . . . 79Alina Constantin
. . . . . . . . . . . . . . . . . . . . 95Irina F. Cherciu Harbiyeli
Part IV Sedation and Monitoring 13 Superficial (“Conscious”) Sedation
. . . . . . . . . . . . . . . 109Andreea St
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nculescu and Alice Dr
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goescu
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Daniela Burtea and Anca Dimitriu
Part V Clinical Impact of Endoscopy 16 Clinical Impact of Endoscopy: Gastroenterology
. . . 127Dan Ionut Gheonea and Ion Rogoveanu
. . . . . . . . 131Larisa S
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a Gheorghe
. . . . . . . . . . . 135Valeriu Surlin and
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. . . . . . . . . . . . . . . . . 145Alina Constantin and C
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Part VI Upper Gastrointestinal Tract 20 Motility Disorders
ț
ianu Mihai
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Popa
. . . . . . . . . . . . . . . . . . . . . 175Ana-Maria Barbu and Sevasti
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a Iordache
. . . . . . . . . . . . . . . . . . . . 187Ana-Maria Barbu and Sevasti
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Dan Nicolae Florescu and Adrian S
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209Maria Monalisa Filip
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219Dan Nicolae Florescu
. . . . . . . . . . . . . . . . . 225Bogdan Silviu Ungureanu
Part VII Lower Gastrointestinal Tract 28 Inflammatory Bowel Diseases
ț
Gheonea and Petric
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. . . . . . . . . . . . . . . . . . . . . . 263Irina F. Cherciu Harbiyeli and Adrian S
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. . . . . . . . . . . . . . . . . . . . . . . 275Irina F. Cherciu Harbiyeli and Adrian S
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285Irina F. Cherciu Harbiyeli
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Irina F. Cherciu Harbiyeli
. . . . . . . . . . . . . . . . . . . . . . . . . . . 307Dan Nicolae Florescu
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a Iordache
. . . . . 353Sevasti
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a Iordache and Ana-Maria Barbu
Part VIII Pancreatico-Biliary Diseases 38 Acute Pancreatitis
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375Bogdan Silviu Ungureanu and Adrian S
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. . . . . . . . . . . . . . . . . . . . . . . . . . . 389Sergiu Cazacu and Adrian S
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. . . . . . . . . . . . . . . . . . . . . . . . 401Irina F. Cherciu Harbiyeli and Ioana Strea
ță
. . . . . . . . . . . . . . . . . . . . 409Irina Mihaela Cazacu and Adrian S
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. . . . . . . . . . . . . . 423Elena Codru
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a Gheorghe and Adrian S
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. . . . . . . . . . . . . . . . . . . . . . 431Vlad-Florin Iov
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nescu
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ftoiu and Irina Mihaela Cazacu
. . . . . . . . . . . . . . . . . . . . . . . . . . . 445Irina F. Cherciu Harbiyeli and Valeriu
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Part IX Liver Diseases 46 Liver Cirrhosis
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ndulescu and Elena Codru
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a Gheorghe
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473Irina Mihaela Cazacu and Adrian S
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Part IIntroduction
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
ă
ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
1
The Future of Digestive Endoscopy
Adrian S
ă
ftoiu
In medicine, predictions are extremely risky, especially for a min-imally invasive technique that has revolutionized gastroenterol-ogy in the last 50 years. Recently developed, a series of disruptive techniques seem to “threaten” flexible endoscopy, a technique defined in the current context of diagnosis and treatment of gas-troenterological and hepato-bilio-pancreatic diseases
1.1 Single-Use Endoscopes
• Types of single-use endoscopes: –Due to the issues generated by disinfection/sterilization, duodenoscopes were the first to be launched on the market, the cost of use being prohibitive for the time being.
A. S
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ftoiu (
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) Department of Gastroenterology and Hepatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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1.2 Miniaturization and Wireless Devices
–
Ultrathin endoscopes are already used in various clinical applications.Transnasal endoscopy.Cholangioscopy.Fistuloscopy.
–
Single-fiber endoscopes are under development, with min-iaturization increasing patient comfort and acceptability of intracavitary procedures.
–
Endoscopic videocapsule involves miniaturization and remote (“wireless”) transmission of images.
1.3 Endoscopic Robots
Different types of endoscopic robots are being evaluated, to improve standard diagnostic procedures or increase the precision of therapeutic interventions [2, 3]:
• Guided locomotion endorobots.• Capsules directed externally in magnetic field.• Externally coupled “tethered” capsules. –Pneumatically guided. –Guided by water jet. –Magnetically guided.• Endorobots with surgical instruments.• Operative instruments (dissectors, graspers, clips, electrodes, loops, needles, etc.).• Useful in repetitive, long procedures. –Endoscopic submucosal dissection. –Endoscopic gastroplasty.
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1.4 Endoscopic Surgery
Flexible endoscopy has gradually become a complementary tech-nique to laparoscopic/robotic surgery, with multiple clinical applications [4, 5]:
• “Third space” endoscopy procedures performed by penetrating the submucosal plane: –POEM (PerOral endoscopic myotomy) procedures for achalasia, with/without fundoplications (F-POEM). –Derivative procedures Z-POEM (Zencker diverticulum)/ G-POEM (refractory gastroparesis). –STER procedures (submucosal tunneling endoscopic resec-tion) for submucosal tumors.• Endoscopic procedures combined with laparoscopic ones such as CELS (combined endoscopic laparoscopic surgery): –Laparoscopic-assisted enteroscopy. –Laparoscopic-assisted polypectomy (difficult polyps). –Resections of submucosal tumors.• NOTES (natural orifice transluminal endoscopic surgery) endoscopic procedures that involve passing the endoscope into the peritoneal cavity: –Transgastric peritoneoscopies. –Transgastric/transvaginal appendicectomies.
–
Transvaginal cholecystectomies. –Transanal sigmoidectomies.• Procedures similar to digestive anastomoses. –EUS-guided drainage of pseudocysts/abscesses. –EUS-guided bilio-pancreatic drainages (choledoco- duodeno-, hepatico-gastro-, cholecysto-gastro-, pancreatico- gastro-). –EUS-guided gastrojejunal anastomoses (GJA). –EDGE procedures (EUS-directed transgastric Endoscopic retrograde cholangiopancreatography).
1 The Future of Digestive Endoscopy
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1.5 Molecular Endoscopy
• Early detection of premalignant/malignant lesions and assess-ment of prognosis by microscopic examination of the gastroin-testinal mucosa after topical/systemic application of contrast agents [6, 7]:
• Fluorescein is the only FDA-approved human fluorophore used in vivo in confocal laser endomicroscopy (CLE).• Alexa-fluor 488 or fluorescein isothiocyanate (FITC) are used to label molecular targets with emission at 488 nm (Fig. 1.1), and indocyanine green (ICG) with emission in the near- infrared spectrum (NIR) at 665–900 nm [8].• Clinical applications include: –Detection of high-grade dysplasia/early adenocarcinoma in Barrett’s esophagus. –Detection of intestinal metaplasia/early gastric adenocarci-noma. –Assessment of ulcerative colitis/Crohn’s disease. –Detection of colonic adenomas (including serrated adeno-mas) or early colonic adenocarcinoma. –Evaluation of prognosis in advanced cancer.
Fig. 1.1
Ex vivo
confocal laser endomicroscopy with anti-CD31 antibodies labeled with alexa fluor 488 (
a
—normal appearance of vessels regularly sur-rounding colonic crypts,
b
—colonic adenocarcinoma), compared to immuno-histochemical appearance (
c
—colonic adenocarcinoma, col. HE + CD31)
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1.6 Artificial Intelligence
Artificial intelligence techniques using neural networks have recently been used in the field of digestive endoscopy, especially after the introduction of “deep learning” techniques using convo-lutional neural networks (Fig. 1.2) [9]:
• Computer-aided detection systems (computer-aided detec-tion—CADe). –Detection of digestive bleeding. –Detection of diminutive colonic polyps [10].
–Early digestive cancer detection.• Computer-aided characterization/diagnosis/prognosis systems (computer-aided diagnosis—CADx). –Differentiation of neoplastic/hyperplastic polyps based on NBI/i-SCAN appearance (see Chap. 6). –Early diagnosis and delimitation of eso-gastroduodenal/ colorectal cancers. –Diagnosis of inflammation in ulcerative colitis/Crohn’s dis-ease to assess remission. –Differentiation of focal pancreatic tumors according to EUS appearance.
Fig. 1.2
Deep learning model for the use of convolutional neural networks for computer-assisted diagnosis
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References
1. McGoran JJ, McAlindon ME, Iyer PG, Haidry R, Lovat LB, Sami SS. Miniature gastrointestinal endoscopy: now and the future. World J Gastroenterol. 2019;25:4051–60.2. Boskoski I, Costamagna G. Endoscopy robotics: current and future appli-cations. Digestive Endoscopy. 2019;31:119–24.3. Martin JW, Scaglioni B, Norton JC, et al. Enabling the future of colonos-copy with intelligent and autonomous magnetic manipulation. Nat Mach Intell. 2020;2:595–606.4. Surlin V, S
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ftoiu A, Rimba
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M, Vilmann P. Notes—“state of the art” surgical gastroenterology: the beginning of the voyage. Hepatogastroenterology. 2010;57:54–61.5. Arezzo A, Zornig C, Mofid H, et al. The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report. Surg Endosc. 2013;27:3073–84.6. Karstensen JG, Klausen PH, Saftoiu A, Vilmann P. Molecular confocal laser endomicroscopy: a novel technique for in vivo cellular characteriza-tion of gastrointestinal lesions. World J Gastroenterol. 2014;20: 7794–800.7. Ahmed S, Galle PR, Neumann H. Molecular endoscopic imaging: the future is bright. Ther Adv Gastrointest Endosc. 2019;12:1–15.8. Ciocâlteu A, S
ă
ftoiu A, Câr
ţ
ân
ă
T, et al. Evaluation of new morphometric parameters of neoangiogenesis in human colorectal cancer using confo-cal laser endomicroscopy (CLE) and targeted panendothelial markers. PLoS One. 2014;9:e91084.9. S
ă
ftoiu A, Vilmann P, Gorunescu F, et al. Efficacy of an artificial neural network-based approach to endoscopic ultrasound elastography in diag-nosis of focal pancreatic masses. Clin Gastroenterol Hepatol. 2012; 10:84–90.e1.10. Mori Y, Kudo S. Detecting colorectal polyps via machine learning. Nat Biomed Eng. 2018;2:713–4.
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Part IIIntegrated Endoscopy Units
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
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ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
2
Infrastructure of the Endoscopy Unit
Adrian S
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ftoiu
2.1 Estimated Flow
Modern endoscopy units have a complex infrastructure and allow multidisciplinary team activities [1–5]
• 1000–1500 patients for each room.• At least 2–4 examination rooms +1–2 interventional rooms (EUS/ERCP, etc.).• Flexibility to adapt to emergencies.• Possibility of extension with two more rooms (for screening/ polypectomies, etc.) (Fig. 2.1).
A. S
ă
ftoiu (
*
) Department of Gastroenterology and Hepatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Fig. 2.1
Flows in the endoscopy unit
2.2 Functional Circuits
• Waiting room.• Patient preparation room.• Pre-procedure consultation office.• Endoscopy examination room. –O
2
, CO
2
, compressed air (suction). –Blood pressure (BP), heart rate, O
2
saturation (continuous monitoring).• Post anesthesia room—refresh. –Minimum three beds for a room.• High-grade disinfection of endoscopes + sterilization of con-sumables (preferably single use). –Automatic washing machines, –In-out circuits, dirty-clean,• Separate storage room + transport with dedicated tanks (Fig. 2.2).
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Fig. 2.2
The disposition of endoscopy equipment
2.3 Other Rooms
• Doctors’ offices + nurse’s office.• Registration offices/technical support + IT.
2.4 Equipment
• High-definition (HD) endoscopy towers. –Dx and Tx gastroscope. –Colonoscope. –Linear/radial echoendoscope. –Tx duodenoscope (ERCP). –Pediatric enteroscope/colonoscope.• Digital radiology equipment. –For EUS/ERCP/dilation, etc. –Mobile radiology table.
2 Infrastructure of the Endoscopy Unit
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1234567891012345X6789201234567893012345678• Emergency equipment. –Intubation kit (laryngoscope, etc.). –Ambu bag, O
2
masks. –Anesthesia machine.
2.5 Usual Consumables
• Hemostasis (needles, monopolar and bipolar coagulation probes, clips, endo loops, OTSC clips, etc.)• Polypectomy (different size, oval and hexagonal loops, mono- and multifilament, etc.)• EUS consumables (FNA/FNB needles, plastic and metal stents, guide wires, etc.)• ERCP consumables (sphincterotomies, guide wires, extraction baskets and balloons, dilation balloons, plastic and metal stents, dilators, etc.)• Video endoscopy capsule.
2.6 Staff
• Two full-time doctors/each room.• Three nurses for one doctor (3:1).• An IT technician.• An anesthesiologist/unit. –Anesthesia nurses for NAPS.• Reception and technical secretary.
References
1. Burton D, Ott BJ, Gostout CJ, DiMagno EP. Approach to designing a gastrointestinal endoscopy unit. Gastrointest Endosc Clin N Am. 1993;3: 525–40.2. Mulder CJJ, Jacobs MAJM, Leicester RJ, et al. Guidelines for designing a digestive disease endoscopy unit: Report of the World Endoscopy Organization. Dig Endosc. 2013;25:365–75.
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3. Valori R, Cortas G, de Lange T, et al. Performance measures for endos-copy services: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy. 2018;50:1186–204.4. Lennard-Jones JE, Williams CB, Axon A, et al. Provision of gastrointesti-nal endoscopy and related services for a district general hospital. Working party of the Clinical Services Committee of the British Society of Gastroenterology. Gut. 1991;32:95–105.5. Lennard-Jones JE. Staffing of a combined general medical service and gastroenterology unit in a district general hospital. Gut. 1989;30:546–5.
2 Infrastructure of the Endoscopy Unit
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
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ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
3
Deconstructing the Endoscope
Irina F. Cherciu Harbiyeli
3.1 Anatomy of the Endoscopy System
• Endoscope.• Video processor.• Light source.• Video recorder.• Suction system.• Electrosurgical generator unit.• Trolley with hanger + monitor.
The endoscope
is a flexible instrument facilitating the illumi-nation and visualization of the lumen of hollow organs. It incor-porates the following:
–
A proximal end (control section).
–
An insertion tube.
–
A distal end (tip).
I. F. Cherciu Harbiyeli (
*
) Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy of Craiova, Craiova, Romania
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• Includes the control unit.• Held in the left hand of the endoscopist (Figs. 3.1 and 3.2).
• Used to maneuver the endoscope and introduce accessories.• The twin dials help maneuver the tip. –Larger dial (deflects the tip up/down).
–
Small dial (left/right lateral control).
–
Ultra-thin specialized endoscopes may have only a single dial (up/down angulation). –Duodenoscopes (utilized for ERCP) and linear echoendo-scopes carry a supplementary dial for maneuvering the ele-vator.
Fig. 3.1
The proximal end of the endoscope: 1—large dial (up/down con-trol), 2—small dial (left/right control), 3—small wheel lock lever, 4—large wheel locking lever, 5 and 6—buttons for storing images, other functions
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Fig. 3.2
The proximal end of the endoscope: 1—small wheel lock lever, 2—small dial (left/right control), 3—large dial (up/down control), 4—button with dual air/water insufflation function, 5—suction button, 6 and 7—buttons to record/store images; other functions
• An additional rotatable dial might be incorporate in colono-scope for controlling the variable-stiffness function of the insertion tube.• Front openings accommodate specially designed buttons. –Suction button.
–
Button with dual functions of air/water insufflation. –Buttons to save images, switch the NBI/i-SCAN mode, etc.
• Contains multiple layers of polymers that confer durability along with flexibility.• It accommodates a “working channel” of variable diameters, which permits the passage of endoscopic accessories.• Involved in applying suction and insufflation.
3 Deconstructing the Endoscope
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• Guides a jet of water toward a target within the lumen, the “power wash” function is used for cleaning debris.• Angulation wires. –Run along the length of the insertion tube.
–
Are connected to the up-down and right-left control dials. –Allow to flex
−
/retroflex the tip of the endoscope.• Spiral metal bands.
–
Facilitate the ability to torque.• Certain endoscopes conceal devices to create variable stiffness of the insertion tube.
–
The rigidity does not extend to the distal 15–20 cm.• The art and science behind designing the insertion tube resides in obtaining the optimum combination between flexibility, elasticity, column strength, and torquing ability.
• The widest opening is a port of the working channel for pas-sage of various endoscopic accessories.• Allows the air/water insufflation/aspiration.• The objective lens might be forward-viewing, oblique, or side- facing.• The “light source” dispatches light into the field of view.• The charge-coupled device (CCD) unit: –Sets up an integrated system with the objective lens.
–
Allows transmission of images directly into the image pro-cessor through an “umbilical cord” (connector).
• Electronic images are sent to a video monitor.• Real-time automatic detection systems are available for increasing adenoma detection rates.• High-magnification endoscopes perform optical zoom.• Digital magnification enlarges the image on the display, reduces pixel density and therefore decreases the image quality.• Details regarding enhanced imaging techniques in Part 3, Chap. 7.
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• Additional imaging devices (Fuse® Full Spectrum Endoscopy® platform, EndoChoice Inc., Alpharetta, GA, USA) or cameras with extra wide view (Extra-Wide-Angle-View Olympus colo-noscope, Tokyo, Japan), with angles between 170 and 330° to allow visualization of mucosa behind the folds.• Accessories that can flatten the haustral folds for inspection (attached to the tip of the endoscope or passed through the working channel). –NaviAid G-EYE colonoscope (Smart Medical Systems Ltd., Ra’anana, Israel)—permanently integrated balloon system for straightening colon folds, centralizing the image, and reducing bowel slippage.
–
Endocuff (Arc Medical Design Ltd., Leeds, United Kingdom)—accessory mounted on the distal tip of the endoscope with multiple soft fingerlike projections that can flatten the haustral folds.
–
Third Eye Retroscope (Avantis Medical Systems, Sunnyvale, CA, USA)—a retroflexed video camera system passed through the working channel of the endoscope, func-tioning as a rear-view mirror.
• The ideal endoscope: –A single-use, super-flexible, multidimensional, self- propelled tool for a pain free procedure and with no seda-tion.
–
Enables an elective increase in rigidity to allow a stable position during therapeutic maneuvers. –Has a small caliber and adequate size working channels to easily employ/exchange all of the endoscopic accessories.
3 Deconstructing the Endoscope
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• Improving real-time image processing programs to assist in lesion detection and characterization through artificial intelli-gence techniques.• Dedicated endoscopy robotic platforms to additionally boost the 3D imaging of intraluminal and transmural advanced pro-cedures [5].
References
1. Kurniawan N, Keuchel M. Flexible gastro-intestinal endoscopy—clinical challenges and technical achievements. Comput Struct Biotechnol J. 2017;15:168–79.2. Kochman M, Swain P. Deconstruction of the endoscope. Gastrointest Endosc. 2007;66:677–8.3. Gkolfakis P, Tziatzios G, Dimitriadis GD, Triantafyllou K. New endo-scopes and add-on devices to improve colonoscopy performance. World J Gastroenterol. 2017;23:3784–96.4. Varadarajulu S, et al. GI endoscopes—report on emerging technology. Gastrointest EndoscGastrointest Endosc. 2011;74:1–6.5. Gralnek IM. Emerging technologies in colonoscopy. Dig Endosc. 2015;27:223–31.
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4
Types of Flexible Endoscopy
Irina F. Cherciu Harbiyeli and Bogdan S. Ungureanu
4.1 Gastroscope [1]
• Diagnostic and therapeutic endoscopes (with enlarged/dual working channels).•
Narrow-caliber/ultra-slim endoscopes.
–A diameter ranging from 4.9 to 6 mm (can be introduced transnasally/transorally). –The accessory channel is relatively narrow (2 mm).
4.2 Colonoscope [1, 2]
• Designed to minimize loop formation (Fig. 4.1). –The distal end is rather soft and flexible to permit the nego-tiation of angulations/curves. –The proximal end is comparatively stiffer and slighter flex-ible to decrease loop formation. –Due to elasticity, it straightens when pulled back.
I. F. Cherciu Harbiyeli (
*
) · B. S. Ungureanu Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy of Craiova, Craiova, Romania© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
ă
ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
, https://doi.org/10.1007/978-3-031-42076-4_4
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Fig. 4.1
Standard colonoscope, with fixed stiffness
• The variable-stiffness colonoscope. –Used to stiffen the proximal 40–50 cm. –Improves cecal intubation rates with less discomfort.
• Characteristics. –Forward-viewing endoscope, considerably longer. –Comprises devices (“overtube,” inflatable balloons) designed for the intubation of the jejunum/ileum. –Performed anterograde/oral or retrograde/anal.•
Balloon-assisted enteroscope
utilizes an overtube with a sin-gle- or double-balloon system mounted at the distal end: –Examination of the small intestine on large portions. –The balloons anchor alternately the endoscope and the over-tube to facilitate the pleating of the bowel.•
Spiral enteroscope.
–Do not engage balloons, but an overtube with external spi-rals that folds the small bowel as it rotates.
I. F. Cherciu Harbiyeli and B. S. Ungureanu
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•
Push enteroscopy.
–Do not rely on balloons or overtubes. –Assessment limited to the upper GI tract. –Adult/pediatric colonoscopies/enteroscopes.
• Specialized endoscopes used primarily for ERCP (Figs. 4.2 and 4.3).• Side-viewing for looking at the major duodenal papilla en face.• A lever is used to maneuver the elevator, hence: –The doctor may angle the accessories. –It facilitates access to the bile/pancreatic duct, which is helpful for cannulation of the papilla.• Cholangioscopes (SpyGlass Direct Visualization System, Boston Scientific Corp, Natick, MA, USA) are devices that can be passed throw the working channel of the duodenoscope into the biliary/pancreatic duct for real-time visualization and sam-pling of the mucosa, for the treatment of lithiasis and strictures.
Fig. 4.2
Details of a side-viewing duodenoscope, with elevator used for the angulation of accessories inserted through the papilla
4 Types of Flexible Endoscopy
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Fig. 4.3
Side-viewing duodenoscope, dedicated to ERCP
I. F. Cherciu Harbiyeli and B. S. Ungureanu
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• Allows the examination of the GI wall and extra-luminal struc-tures, combining ultrasound with endoscopy.•
The ultrasound transducer
at the tip (Fig. 4.4): –Differentiates echoendoscopes from the standard endo-scopes. –Contains piezoelectric crystals
→
convert electrical energy into sound waves
→
travel through the wall of the GI tract
→
get reflected back to the transducer
→
reconverts it to electric signals
→
processed for creating an EUS image.• Scanning frequencies: 5–12 or 20 MHz (miniprobes). –Higher frequencies enhance the resolution and reduce depth of penetration. –Lower frequencies utilized for imaging distant structures.• Doppler signal assessment allows the identification and avoid-ance of vascular structures.•
Curvilinear echoendoscope.
–Produces an image parallel to the insertion tube. –Visualizes structures in the 100–180° range. –Allows real-time visualization of EUS needles. –Can be used for diverse guided/assisted EUS interventions (Fig. 4.5).•
Radial echoendoscope.
–Produces an image that is perpendicular to the insertion tube. –Provides an ultrasonographic 360° view. –Cannot be used for therapeutic procedures.
Fig. 4.4
Side-viewing echoendoscope, dedicated EUS-FNA
4 Types of Flexible Endoscopy
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Fig. 4.5
Linear echoendoscope, dedicated EUS-FNA, with elevator used for the angulation of the accessories introduced through the biopsy channel
• Made of: –A clear plastic dome. –Compact lens system. –Illumination white LED. –High-resolution CCD (to capture images). –Battery. –Antenna.• Activated after removal from the magnetic holder.• Can be swallowed or endoscopically positioned in the stom-ach/small intestine (proximal).• Disposable and designed to be excreted.• The endoscopist/endoscopy nurse can: –Review all the images in multiple/single frames, inspecting for mucosal lesions. –Calculate the transit time of the capsule (see more about capsule endoscopy in Chap. 5).
References
1. Kohli DR, Baillie J. How endoscopes work. In: Chandrasekhara V, Elmunzer BJ, Khashab MA, Muthusamy VR, editors. Clinical gastroin-testinal endoscopy. 3rd ed. Amsterdam: Elsevier; 2018. p. 24–31.e2.2. Kurniawan N, Keuchel M. Flexible gastro-intestinal endoscopy—clinical challenges and technical achievements. Comput Struct Biotechnol J. 2017;15:168–79.3. ASGE Technology Committee, Komanduri S, Thosani N, Abu Dayyeh BK, et al. Cholangiopancreatoscopy. Gastrointest Endosc. 2016;84:209–21.
I. F. Cherciu Harbiyeli and B. S. Ungureanu
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29
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
ă
ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
5
Capsule Endoscopy
Vlad-Florin Iov
ă
nescu and Adrian S
ă
ftoiu
5.1 General Principle
• Diagnostic method that allows endoluminal evaluation of the gastrointestinal tract by recording sequential images captured by a pill-like device that is swallowed and moves with peristalsis.• The capsule endoscopy consists of a miniature video camera, a light source (LEDs), a transmitter, and a battery incorporated in a plastic housing measuring an average of 2–3 cm.• Two types of capsules available: –Capsules that record the images onto the internal memory.The capsule has to be retrieved from the stool. –Capsules that transmit the signal wirelessly to a series of sensors applied to the patient’s body which are connected to a device that allows live-image viewing and storage.
V.-F. Iov
ă
nescu (
*
) University of Medicine and Pharmacy of Craiova, Craiova, Romaniae-mail: vlad.iovanescu@umfcv.ro A. S
ă
ftoiu Department of Gastroenterology and Hepatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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30
• Dedicated software is used for analyzing the retrieved images.
–
Software postprocessing allow image enhancement such as red spot detection (for easier identification of hemorrhagic lesions/active bleeding).• Non-most commonly used for assessing small bowel pathology.• Different systems also available for visualization of esopha-gus, stomach, and colon. –Esophagus and stomach capsules usually indicated when a patient refuses to undergo upper gastrointestinal endoscopy.
–
Colon capsules used in patients with an incomplete colo-noscopy due to inadequate bowel preparation and when complete colonoscopy is not technically feasible [1].
5.2 Preparation
• Fasting is recommended 12 h before the examination.• Preparation with 2 L polyethyleneglycol (PEG) solutions prior to capsule ingestion is recommended by European guidelines [2].• Optimal timing is not established.• Use of antifoaming agents (e.g., simethicone) is advised.• Prokinetics are not routinely recommended; however, may be used in particular cases (e.g., diabetic neuropathy) if the capsule fails to progress beyond the stomach for 30–60 min as observed by real-time viewing.
5.3 Indications
• Obscure gastrointestinal bleeding. –Most sources located in small bowel. –Ideally during/in the first 24–72 h after the bleeding onset to have a higher chance of identifying the source.• Occult gastrointestinal bleeding.• Unexplained iron-deficiency anemia.
–
Performed after no source has been identified by upper and lower gastrointestinal endoscopy.
V.-F. Iov
ă
nescu and A. S
ă
ftoiu
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31
• Malabsorption syndrome.• Evaluation of chronic diarrhea.• Surveillance of gastrointestinal polyposis syndromes.
–
Particularly in familial adenomatous polyposis and Peutz–Jeghers syndrome.• Diagnosis of suspected small bowel Crohn’s disease. –Recommended as the initial diagnostic method in the absence of obstructive symptoms or previously known ste-nosis [3]. –CT/MRI enterography are the first diagnostic modalities if obstructive symptoms are present or there is a previously known stenosis.• Evaluation of the location/extent/flare of a previously diag-nosed small bowel Crohn’s disease. –Indicated only when CT/MRI enterography results are inconclusive and only if it impacts management.
–
Should be preceded by administration of a patency capsule to ensure safe passage of the capsule endoscopy.
5.4 Advantages and Disadvantages
• Advantages –Noninvasive technique.
–
No need for patient sedation. –No need for hospital admission (usually performed as an outpatient procedure).• Disadvantages
5 Capsule Endoscopy
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–Does not allow tissue sampling and therapeutic maneuvers.
–
Impossibility of exact lesion localization.
–
Low-quality image in case of poor bowel preparation because it lacks possibility of aspiration and lavage.
–
Expensive
5.5 Complications
• Tracheobronchial aspiration –Extremely rare.
–
In patients with impaired deglutition. –The capsule can be introduced with the endoscope into the duodenum.• Intestinal perforation• Capsule retention –Most important complication (1.4%) [4].
–
Increased risk in patients with small bowel obstruction (ste-nosing Crohn’s disease, small bowel tumors, history of abdominal or pelvic radiotherapy).
–
Suspected if the capsule is not eliminated in stool after 14 days.
–
In case of prolonged retention or presence of obstructive symptoms, endoscopic or surgical retrieval is necessary. –Patency capsules can be used in cases of suspected obstruc-tion to minimize the risk of retention.Traceable capsule that dissolves itself if not eliminated in a certain time limit.
References
1. Hale MF, Sidhu R, McAlindon ME. Capsule endoscopy: current practice and future directions. World J Gastroenterol. 2014;20(24):7752–9. https://doi.org/10.3748/wjg.v20.i24.7752.2. Rondonotti E, Spada C, Adler S, May A, Despott EJ, Koulaouzidis A, Panter S, Domagk D, Fernandez-Urien I, Rahmi G, Riccioni ME, van Hooft JE, Hassan C, Pennazio M. Small-bowel capsule endoscopy and
V.-F. Iov
ă
nescu and A. S
ă
ftoiu
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device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy. 2018;50(4):423–46. https://doi.org/10.1055/a- 0576- 0566.
3. Akpunonu B, Hummell J, Akpunonu JD, Ud DS. Capsule endoscopy in gastrointestinal disease: Evaluation, diagnosis, and treatment. Cleve Clin J Med. 2022;89(4):200–11. https://doi.org/10.3949/ccjm.89a.20061.4. Wang YC, Pan J, Liu YW, Sun FY, Qian YY, Jiang X, Zou WB, Xia J, Jiang B, Ru N, Zhu JH, Linghu EQ, Li ZS, Liao Z. Adverse events of video capsule endoscopy over the past two decades: a systematic review and proportion meta-analysis. BMC Gastroenterol. 2020;20(1):364. https://doi.org/10.1186/s12876- 020- 01491- w.
5 Capsule Endoscopy
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Part IIIExamination Techniques
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
ă
ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
6
Preparation Before Endoscopy
Irina F. Cherciu Harbiyeli and Mihaela Cali
ț
a
6.1 General Preparation [1, 2]
• Patients history (allergies, heart/lung disease).• The treatment for chronic diseases (heart, etc.) will not be interrupted, will be administered in the morning with a small amount of fluid.
–
Exceptions: anticoagulants and antiplatelets drugs will be discontinued according to the recommendations, in case of procedures with risk of bleeding (see Chap. 11).• For patients with diabetes: –Oral antidiabetic medication will not be administered pre-procedurally. –The insulin will be administered as follows: half of the morning dose at the usual time and the other half together with the first post-procedural meal.• Submitting all medical documents that could guide the diagno-sis and further therapy.
I. F. Cherciu Harbiyeli (
*
) · M. Cali
ț
a Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy Craiova, Craiova, Romania
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38
• Informed consent is essential! –Provides information on the nature of a proposed procedure or specific treatment for which the procedure is suggested, with risks, benefits, possible complications, and reasonable alternatives.
–
Must be obtained within a predefined time and in a favor-able environment.
–
It is necessary for the document to cover the separate endo-scopic procedure, respectively, the sedation.The endoscopist will document in the final result the pre-procedural consent.
–
The recognized exceptions to the informed consent process include the following:Emergency.The possibility that the information may harm the patient.Legal waiver and power of attorney. –All informed refusals must be documented!• Creating the venous approach by mounting a catheter in a peripheral vein in patients undergoing deep sedation investiga-tion (see Chaps. 13, 14, and 15).
• Fasting 6–8 h before the procedure + liquid rest for at least 2 h.
–
Exceptions: patients with diabetes and gastrointestinal ste-nosis, in whom rest may be prolonged.• Removal of denture prosthesis to prevent migration into the trachea!• When biliary obstruction is suspected, appropriate antibiotic therapy is recommended prior to ERCP procedures (see Chap. 12).• Corticosteroid prophylaxis may be considered in patients with a history of anaphylactic reactions to the contrast agent, prior to the EUS procedure.
I. F. Cherciu Harbiyeli and M. Cali
ț
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• Instructions regarding the preparation for colonoscopy.
–
As detailed as possible (provided verbally and in writing), increasing the degree of adherence of patients proportionally.• Dietary changes.
–
On the day before preparation, a diet low in vegetable fiber is recommended (Table 6.1).• Additional medication changes: –Iron medication should be stopped 7 days before the colo-noscopic examination.
–
It is recommended to avoid agents with constipating effect, medicinal charcoal, laxative oils, etc.
–
Oral simethicone can be added to the colonoscopy prepara-tion scheme. –The use of prokinetic agents is not recommended.• Required before performing colonoscopy: –Preparation of the intestine by ingesting a purgative solu-tion in order to eliminate the intestinal contents. –The most commonly used purgative solution in RO is the electrolytic solution with polyethylene glycol (PEG):The first dose will be administered in the afternoon of the day before the investigation.The second dose will be completed approximately 2–3 h before the investigation (split dose).
Table 6.1
Recommendations regarding the low-fiber dietCategoryAllowed foodsFoods to avoidType of foodDairy products, white bread, white rice, chicken, turkey, fish, eggs, fruit juice without pulp, strained soups, fruits without peel and seeds (apples, cantaloupe melons, peaches), vegetables (carrots, mushrooms, potatoes, asparagus) thermally preparedFresh or dehydrated fruits and vegetables, any whole grain, red meat, nuts, seeds, granola, etc.
6 Preparation Before Endoscopy
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–
Osmotic laxatives with nonabsorbable carbohydrates (man-nitol, lactulose, sorbitol)/oral sodium phosphate.• Preparation in particular cases: –Patients with constipation do not require any specific prepa-ration.
–
Pregnant/lactating women: if colonoscopy is absolutely necessary, PEG-based protocols may be considered. For sigmoidoscopy, water enemas are preferred. –Patients with inflammatory bowel disease: PEG-based pro-tocols will be used.
Table 6.2
Validated purgative solutions for colonoscopy/enteroscopy prepa-rationProductCharacteristicsNot recommended for patients with:PEGIzo-osmotic agentSafe and effectiveThe 4 L of liquid can be difficult to ingest, even in two dosesCongestive heart failure (NYHA class III or IV)Low volume PEG and adjuvantsHypo-osmotic agentSimilar to PEG regarding safety and efficacy2 L PEG plus ascorbate/ ascorbic acid/citrate/ bisacodil administered in two dosesSevere renal impairment (creatinine clearance <30 mL/min)Congestive heart failure (NYHA class III or IV)Unstable anginaAcute myocardial infarction PhenylketonuriaGlucose-6-phosphate dehydrogenase deficiencyMagnesium salts (Mg citrate and picosulfate)Hyper-osmotic agentSimilar to PEG regarding safety and efficacy2 L of liquid administered in two dosesCongestive heart failureSevere renal failureHypermagnesemiaRhabdomyolysisTrisulfate solutions (Na, Mg, and K sulphate)Hyper-osmotic agentSimilar to PEG regarding safety and efficacy2.5 L liquid administered in two dosesCongestive heart failureSevere renal failureAscites
I. F. Cherciu Harbiyeli and M. Cali
ț
a
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41
• Inadequate preparation: –Makes colonoscopic screening inefficient.Decreases the detection rate of polyps and adenomas.Cecal intubation failure.
–
Requires to repeat colonoscopy in maximum 1 year. –Colonoscopy can be rescheduled on the same day or the next day, after additional preparation (with laxative or enema), individualized according to the possible reasons for the initial failure.
References
1. Haycock A, Cohen J, Saunders BP, Cotton PB, Williams CB. Cotton and Williams’ practical gastrointestinal endoscopy: the fundamentals, vol. 3. 7th ed. Chichester: Wiley Blackwell; 2014. p. 19–32.2. Zuckerman MJ, Shen B, Harrison ME, Baron TH, Adler DG, Davila RE, et al. Informed consent for GI endoscopy. Gastrointest Endosc. 2007;66:213–8.3. Standards of Practice Committee, Faigel DO, Eisen GM, Baron TH, Dominitz JA, Goldstein JL, et al. Preparation of patients for GI endos-copy. Gastrointest Endosc. 2003;57:446–50.4. Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline—Update 2019. Endoscopy. 2019;51: 775–94.5. ASGE Standards of Practice Committee, Saltzman JR, Cash BD, Pasha SF, Early DS, Muthusamy VR, Khashab MA, et al. Bowel preparation before colonoscopy. Gastrointest Endosc. 2015;81:781–94.
6 Preparation Before Endoscopy
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
ă
ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
7
Enhanced Imaging
Maria Monalisa Filip and Daniela
Ș
tef
ă
nescu
7.1 Definition
Advanced imaging techniques improve the examinations quality through enhancement of fine structural mucosal visualization and microvascular detail (pit pattern and vessel pattern).
7.2 High-Definition Endoscopy (HD)
• Resolutions from 850,000 to more than 1 million pixels. –Discriminates details on mucosal surface. –HD video imaging can be displayed on computer monitor formats (Fig. 7.1).
M. M. Filip (
*
) · D.
Ș
tef
ă
nescu Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Craiova, Romania
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44
a b
Fig. 7.1
High-definition (HD) endoscopy in white light mode (
a
) and enhanced visualization (I-scan 2) (
b
): portal-hypertensive gastropathy
7.3 Magnification Endoscopy
• Enlarge the image by performing optical zoom. –Images can be optically zoomed up to 150 times without losing image quality.
7.3.1 Magnification Chromoendoscopy
• Uses dye agents to visualize mucosal surface (absorptive, con-trast, or reactive staining agents). –The dyes may be applied on the whole surface or on a small area.
–
Enhance mucosal visualization (i.e., microvascular net-works).
–
Can distinguish among different types of epithelium.
–
Abnormal mucosa may stain positively or negatively. –Chromoendoscopy with magnification allows a detailed mucosal surface analysis (Fig. 7.2).
M. M. Filip and D.
Ș
tef
ă
nescu
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45
a b
Fig. 7.2
“Virtual” chromoendoscopy (
a
), with magnification (
b
), both in optical enhancement (OE) mode: tubular adenomatous colonic polyp
7.4 Narrowed-Spectrum Technologies
• Image enhancement techniques rely on using only a narrowed part of the available spectral bandwidth, mainly corresponding to “blue light” –It is accomplished through optical or digital filtering, being termed “virtual chromoendoscopy”.
–
It improves the visualization of the mucosal pattern and the mucosal and submucosal vessels, by using the characteris-tics of the light spectrum.
7.4.1 Narrow Band Imaging (NBI)
• Uses narrow band optical filters that illuminate the tissue with blue (415 nm) and green (540 nm) light (Olympus Medical Systems, Tokyo, Japan) (Fig. 7.3) –The longer the wavelength of light used, the deeper the pen-etration into tissue.
–
Superficial blood vessels appear brown. –Blood vessels from deep mucosa and submucosa appear cyan.
7 Enhanced Imaging
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480
Lenvatinib:
noninferior to sorafenib; for Child–Pugh A only. –
Second line.
Regorafenib.Cabozantinib.Ramucirumab (if AFP > 400 in Child–Pugh A).Pembrolizumab (FDA approved for Child–Pugh A).Nivolumab + ipilimumab (Child–Pugh A only).
References
1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49.2. Casciato DA, Territo MC. Manual of clinical oncology. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.3. DeVita VT, Lawrence TS, Rosenberg SA. Cancer: principles & practice of oncology: primer of the molecular biology of cancer. Lippincott Williams & Wilkins; 2012.4. Benson AB, D’Angelica MI, Abbott DE, Anaya DA, Anders R, Are C, et al. Hepatobiliary cancers, version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2021;19(5):541–65.5. Girotra M, Soota K, Dhaliwal AS, Abraham RR, Garcia-Saenz-de-Sicilia M, Tharian B. Utility of endoscopic ultrasound and endoscopy in diagno-sis and management of hepatocellular carcinoma and its complications: what does endoscopic ultrasonography offer above and beyond conven-tional cross-sectional imaging? World J Gastrointest Endosc. 2018;10(2):56.6. Vogel A, Cervantes A, Chau I, Daniele B, Llovet J, Meyer T, et al. Hepatocellular carcinoma: ESMO clinical practice guidelines for diagno-sis, treatment and follow-up. Ann Oncol. 2018;29:iv238–iv55.
I. M. Cazacu and A. S
ă
ftoiu
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481
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. S
ă
ftoiu (ed.),
Pocket Guide to Advanced Endoscopy in Gastroenterology
48
Vascular Liver Disorders
Elena Codru
ț
a Gheorghe
48.1 Definition and Classification
The liver has a dual blood supply, hepatic artery and the portal vein. The hepatic veins drain the blood from the liver. Due to this fact, vascular disorders of the liver are rare, the causes being:•
Ischemia
(hepatic infarction, ischemic colangiopathy),•
Insufficient venous drainage
(congestive hepatopathy, Budd–Chiari syndrome, sinusoidal obstruction syndrome),•
Specific vascular lesions
(hepatic artery occlusion, hepatic artery aneurysm, portal vein thrombosis, congenital vascular malformations, schistosomiasis, sarcoidosis).
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1007/978- 3- 031- 42076- 4_48. The
videos can be accessed individually by clicking the DOI link in the accompa-nying figure caption or by scanning this link with the SN More Media App.E. C. Gheorghe (
*
) University of Medicine and Pharmacy Craiova, Craiova, Romania
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482
48.1.1 Portal Vein Thrombosis
48.1.1.1 Epidemiology
• The incidence in non-cirrhotic patients is between 5-10%, in cirrhotic patients increases up to 64%.• Prevalence <1% in patients with compensated cirrhosis.
48.1.1.2 Etiopathogeny
• Portal vein thrombosis (PVT) represents the partial or total obstruction of the portal vein flow due to the presence of a thrombus in the vascular lumen.• The natural history depends on the size, extent, and degree of thrombosis, as well as comorbidities.• The causes are multifactorial, but in a third of cases they remain unknown: –In newborns, umbilical cord infection, –In children, appendicitis, –In adults:Surgery (splenectomy, gastrectomy, colectomy, chole-cystectomy),Hypercoagulability (myeloproliferative diseases, C or S protein deficiency, factor V Leiden mutation, preg-nancy),Cancer (hepatocellular carcinoma, pancreatic, renal, adrenal),Cirrhosis,Trauma.
48.1.1.3 Diagnosis
• Signs and symptoms. –Most often, asymptomatic, –Rarely, may manifest acutely with acute or progressive abdominal or lumbar pain, abdominal distension due to ileus but with no signs of intestinal obstruction,
E. C. Gheorghe
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–More frequently, it occurs secondary to portal hypertension with splenomegaly and variceal hemorrhage, less often ascites (when cirrhosis is also present),• PVT should be suspected: –Acute PVT in patients with abdominal pain of more than 24 h, –Chronic PVT in patients with portal hypertension manifes-tations in the absence of cirrhosis or slightly altered liver tests + risk factors,• Laboratory tests. –Inflammatory response in the absence of sepsis in acute PVT, –Liver tests are generally normal or slightly altered,• Imaging tests. –Color Doppler ultrasound is usually diagnostic – reduced or absent portal vein flow +/
−
thrombus. –MRI and CT scan – can be used for more complex cases, to assess thrombus extension. –Angiography – can guide surgery for intrahepatic transjug-ular portosystemic shunt (TIPS).
48.1.1.4 The Role of Endoscopy
•
Upper gastrointestinal endoscopy
–Allows the evaluation of segmental portal hypertension: esophageal, gastric, ectopic varices + portal hypertensive gastropathy,•
Endoscopic ultrasound
–Allows the assessment of the portal vein, the splenomesen-teric confluence, and the superior mesenteric vein + splenic vein, –Color Doppler examination (Fig. 48.1; Video 48.1a),
–Evaluation with contrast substance in low mechanical index mode (Fig. 48.2; Video 48.1b), –Assessment of collateral circulation as an indirect sign of deep venous thrombosis,
48 Vascular Liver Disorders
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Fig. 48.1
Benign thrombosis of the superior mesenteric vein visualized in power Doppler mode. (
▶
Fig. 48.2
With turbulent flow in the portal vein (hepatic hilum), visualized with contrast substance in specific harmonic mode with low mechanical index. (
▶
–Allows performing fine-needle aspiration/biopsy (EUS-FNA/FNB) when malignancy is suspected, –Differential diagnosis between benign and malignant thrombosis (Fig. 48.3a, b; Video 48.2).
E. C. Gheorghe
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Fig. 48.3
Malignant thrombosis of the portal vein expanding the lumen, visualized in color Doppler mode (
a
), with EUS-FNA which confirmed the diagnosis of primitive hepatocellular carcinoma with direct invasion of the portal vein (
b
). (
▶
48.1.1.5 Treatment
• For acute cases (especially with proven hypercoagulability) thrombolysis is recommended.• Long-term anticoagulant treatment (for patients with hyperco-agulability, patients with cirrhosis + symptomatic acute PVT).• Management of portal hypertension and its complications (octreotide i.v. and endoscopic band ligation to control variceal bleeding, beta-blockers to prevent variceal rebleeding).
References
1. DeLeve LD, Valla DC, Garcia-Tsao G, American Association for the Study Liver Diseases. Vascular disorders of the liver. Hepatology. 2009;49(5):1729–64.2. Sanyal AJ. Epidemiology and pathogenesis of portal vein thrombosis in adults. In: Post TW, editor. UpToDate. Waltham, MA: UpToDate; 2023.3. Basit SA, Stone CD, Gish R. Portal vein thrombosis. Clin Liver Dise. 2015;19(1):199–221.
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