Gastroenterological EndoscopyEdited by M.Classen, M.D.; G.NJ.Tytgat, M.D.; and CJ.Lightdale, M.D.
Contr ibutors :
A.T.R.AxonJ.BaillieH.BarrK. F. Binmoel lerA. BitounP. BornY.BouhnikLJ. BrandtA. K. BurroughsLBuscailO.CassS. C.S.ChungJ.F.ColombelG. CostamagnaP. B. CottonM.CremerO.W.CummingsLDagherC.E.DevereauxS. EdmundowiczA. ElewautC.E11
1721 I l lustrat ions171 Tables
J.EscourrouH.FeussnerE. L. FogelV.LFoxE. FrimbergerR.FujitaLGossnerG.B.HaberW. HeldweinB.I.HirschowitzJ. HochbergerH.InoueD.M.JensenS.JonnalagaddaA. M. KassemK. KawaiR.A.KozarekS.KudoJ. C. LappasJ.Y.W.LauP.W.R.LeeS.D.Lee
G.LehmanM. LemannB.S.LewisJ. R. LightdaleR. LigrestiG. A. MachicadoJ.MaissN.MarconP. D. MauldinV. MaunouryH.MessmannI.M.ModlinG. M. NaylorP. NearyH.NeuhausM. NeumannH. NiwaH.J.NordS. O'MahonyD.G.OrmondeJ. L PonskyD.Rex
J. E. RichterR.H.RiddellJ. F. RiemannT. RoschW.RoschJ.SalcedoG.S.SandhaB. SaundersJ. Scho lmerichJ. A. ShadS.ShermanS.ShimizuJ.J.Y.SungC. SurawitzC. P. SwainA. Van GossumJ.D.WayeR.WinklerJ.WuQ. ZhangG. Zuccaro
ThiemeStuttgart • New York
Contents
The Impact of Endoscopy
Edited by M. Classen, CJ. Lightdale, and C.N.J. Tytgat
1 The History of Endoscopy: The American PerspectiveBasil J. Hirschowitz, Irvin M. Modlin 2
Introduction 2A Short History of Endoscopy 2
Open Tubes 5Proctosigmoidoscopy (Sigmoidoscopy) 5The Last 40 Years 5
Esophagus 9Barrett's Esophagus 9Esophageal Cancer 9
Stomach and Duodenum 10Small Bowel 12Colon 12Pancreas and Biliary Tract 13Minimally Invasive Surgery 13Conclusions 15The Future of Endoscopy 16
The History of Gastrointestinal Endoscopy—the European PerspectiveAndre Elewaut and Michel Cremer 17
The Pioneers 17The Semiflexible Gastroscope: Demonstration of theClinical Value of Gastroscopy 20The Origins of Esophagoscopy 22The Vigorous Diagnostic Approach 24Gastrocamera 24Fiberoptic Endoscopes (1957-83): Full-Scale Endoscopy . 24Forward-Viewing Endoscopy: the Panendoscope 25Advent of Therapeutic Endoscopy 27Endoscopic Retrograde Cholangiopancreatography 27The Flexible Fiberoptic Sigmoidoscope/Colonoscope 28Video Endoscopy 29Laparoscopy : 29Enteroscopy 29Endoscopy Societies 30Recent Developments and Future Prospects 30
The History of Endoscopy: the Japanese PerspectiveK. Kawai, H. Niwa, R. Fujita, S. Shimizu 32
Development of Modern Endoscopy of the UpperGastrointestinal Tract 32Endoscopy of the Colon 34
Sigmoidoscope Photography 34Colonocamera 34Colonofiberscope (Colonoscope, Coloscope) 35Magnified Observation 37Depressed-Type "Early" Colorectal Carcinoma 37
Endoscopic Retrograde Cholangiopancreatographyand Related Therapeutic Procedures 38
Ulcerative Colitis and Crohn's Disease 38References 41
2 Research, Outcomes, and Justification in EndoscopyPeter B. Cotton, Patrick Mauldin 46
Introduction 46Why Do We Need Evaluation? 46What Do We Need to Know? 46Evaluation of Diagnostic Endoscopy Procedures 47Staging Information 47Screening and Surveillance 47Therapeutic Endoscopy 48A Clinical Intervention Model 48Economic Evaluations of Interventions 49Who Determines What Is "Better"? 49Evaluation in Practice: Documentation and Trials 50
Randomized Controlled Trials 50Disciplined Cohort Studies 50References 51
3 Quality Assurance in Gastrointestinal EndoscopyCM. Naylor, A.T.R. Axon, S. O'Mahony 53
What Is Quality Assurance? 53Quality Indicators 53Quality Assurance in Endoscopy—Why Bother? 53What Data to Collect? 54
Core Quality Indicators 55Beyond the Core Quality Indicators 56
Quality Assurance vs. Continuous Quality Improvement . 57Computers in Quality Assurance 57Endoscopy Training and Quality Assurance 58Setting Up a Quality Assurance Program 58Does Quality Assurance Work? 59Our Experience in Setting Up a Program 59The Future of Quality Assurance 60
References 60
4 New Technology for Diagnostic and TherapeuticEndoscopyC. Paul Swain 62
Introduction 62Biopsy Methods 62
Polyp Cutting and Retrieval 63Needle Biopsies 63
Bleeding 63New Instruments for Flexible Endoscopic Surgery 63
Sewing and Stapling Devices 63Sewing Machines 64
Transgastric Surgery 64Transanal Endoscopic Microsurgery 65Overtubes 65Costs 65New Technologies 66Design Problems at Flexible Endoscopy 67
References 69
The Patient and Endoscopy
Edited by M. Classen, CJ. Lightdale, and C.N.J. Tytgat
5 Informed Consent for Gastroenterological EndoscopyM. Classen 72
Patients' Rights 72Obtaining Consent 72How Should Informed Consent Be Obtained in EverydayPractice? 73Who Is Responsible for Obtaining Informed Consentfrom an Individual Patient? 73Open-Access Gastrointestinal Endoscopy 73Tape Recording and Videotaping 74Patient's Arrival at the Endoscopy Unit .. 74A Standard Patient Information Pamphlet 75Practical Problems When Obtaining Consent ." 79
References 79
6 Procedural Sedation for EndoscopyJenifer R. Lightdale and Charles J. Lightdale 80
Sedation: When to Use It 80Level of Sedation 81General Anesthesia 81Patient Assessment for Sedation 82Pharmacological Options for Endoscopy 82Topical Agents 83Benzodiazepines 83
Diazepam 83Midazolam 83
Opioids 83Meperidine 84Fentanyl 84
Adjuvant Agents 84Other Agents 84
Droperidol 84Propofol 84Nitrous Oxide 85
Antagonists 85Flumazenil 85Naloxone 85
Risks of Procedures 85Antibiotic Prophylaxis 86Preprocedural Fasting 87Care and Monitoring of the Patient during Endoscopy . . . 87
Supplemental Oxygenation 87Electronic Monitoring 87Monitoring Patient Oxygenation 87Monitoring Patient Hypercarbia 88Monitoring Patient Cardiovascular Status 88References 88
7 The Endoscopy SuiteG.N.]. Tytgat 91
Guidelines for Planning an Endoscopy Unit 91The Endoscopic Examination Room 92Endoscopic Ultrasound and Laser Treatment Room,Radiography Room 93Preparation and Recovery Room 93Cleaning and Disinfection Area 93Staffing 93Overall Requirements for Proper Patient Care 93
References 94
8 Cleaning and Disinfecting Instruments and Accesso-riesG.N.J. Tytgat 95
Endoscopy-Related Infections 95Hazards to Endoscopic Personnel 95General Principles 95
Medical Devices 95Levels of Disinfection 95Disinfectant Products 96
Treatment of Endoscopes 97Manual Disinfection Procedures for Endoscopes 97Automatic Procedures (Washer-Disinfectors) 98
Treating Small Items of Equipment and Accessories 99Cleaning '. 99Rinsing 99Drying 99Sterilization 99
Miscellaneous Requirements 99Staff 99Facilities 99Traceability 99
Conclusion 100References 100
Teaching and Learning
Edited by M. Classen. CJ. Lightdale and C.N.J. Tytgat
9 Training and Education in Gastrointestinal EndoscopyJ. Hochberger, J. Maiss, O. Cass, T. Rb'sch, D. Mentges,K.E. Grund, and E.G. Hahn 102
Introduction 102Studies on Training and Guidelines 102Training Simulators 103
Plastic Dummies and Other Static Models 103Computer Simulators 103Endoscopy Training in Anesthetized Animals 104Animal Part Simulators 104
Practical Training in Gastrointestinal Endoscopy 106
Clinical Education 106Endoscopy Training Courses with Static Models andComputer Simulators in 1-Day and Weekend Courses . 106Training in Interventional Endoscopy 106Educational Approaches in GastrointestinalEndoscopy 107Prospects for Introducing and Providing Training inNew Interventional Techniques 107Simulators for Quality Control and as Teaching Toolsin Continuing Education 107
Conclusions 108References 108
Diagnostic Procedures and Techniques
Edited by M. Classen
10 Upper Gastrointestinal EndoscopyJ. Escourrou 113
Introduction 113Indications and Contraindications 113
Does Negative Endoscopy Imply Overuse? 114Contraindications 115
Instruments 115General Characteristics of Standard Gastroscopes 115Specific Upper Gastrointestinal Endoscopes 115Biopsy and Cytology Devices 116
Examination Technique 118Preparation of the Patient 118Intubation of the Hypopharynx 118Esophagus 119Stomach 120Duodenum 121Completing the Examination 121
Complications 122Conclusions 122
References 123
11 Enteroscopy TechniquesA. Van Gossum 124
Introduction 124Push Enteroscopy 124
Instruments 124Sedation 124Intubation and Advancement Technique 124Diagnostic and Therapeutic Modalities 126Depth of Insertion 127
Sonde Enteroscopy , 128Instruments 128Sedation 128Technique of Intubation and Advancement 128
Wireless Capsule Enteroscopy 129Intraoperative Enteroscopy 129Endoscopic Aspects of Small-Bowel Lesions 130
Vascular Abnormalities 130Tumors 131Ulcerative Lesions 131Diverticula 132Miscellaneous Indications 132References 134
12 Colonoscopy: Basic Instrumentation and TechniqueBrian P. Saunders 135
Introduction 135Indications 135Contraindications 136Bowel Preparation 136Sedation • 137Equipment for Colonoscopy 138
Antispasmodics 138Colonoscopes 138High Resolution and Magnification 139Carbon Dioxide versus Air Insufflation 140Accessories 140
Imaging during Colonoscopy 141Fluoroscopy 141Magnetic Endoscope Imaging 141
Colonoscope Insertion: Technique 143General Principles 143Instrument Handling 143Ancillary Techniques for Colonoscope Insertion 144Anus and Rectum 144Sigmoid Colon 145Descending Colon and Splenic Flexure 147Transverse Colon and Hepatic Flexure 147Ascending Colon, Cecum and Terminal Ileum 148Is Total Colonoscopy Achievable in All Patients? 149
Examination Technique during Withdrawal 150Complications 150
References 150
13 Endoscopic Retrograde CholangiopancreatographyGregory B. Haber, Gurpal S. Sandha 152
Historical Background 152Indications 152Equipment 152
Endoscopes 152Cannulating Devices 152
Technique 154Patient Preparation and Sedation 154Contrast Agents 154
Procedure 155Oropharyngeal Intubation 155Passing the Pylorus 155Advancing to the Papilla 155The Papilla of Vater 155Selective Cannulation 155Cannulating the Common Bile Duct 156Obtaining a Cholangiogram 157Cannulating the Pancreatic Duct 157Cannulating the Minor Papilla 157Challenging Scenarios 158
Complications 160Pancreatitis 160
Future Directions 160References : 160
14 Peroral CholangioscopyJ.F. Riemann 162
Introduction 162Instruments and Technique 162Limitations 163Complications 163Clinical Applications and Results 164
Suspected Malignant Biliary Lesions 164Bile Duct Stones 164
Conclusions 165References 166
15 Percutaneous Transhepatic Cholangiography andCholangioscopyHorst Neuhaus 167
Introduction .\ 167Indications 167Contraindications 168
Equipment 168Accessories for Establishing a Transhepatic Tract 168Cholangioscopes 168Lithotriptors 168
Patient Preparation 169Procedures 169
Percutaneous Transhepatic Cholangiography 169Percutaneous Transhepatic CholangiographicDrainage 169Percutaneous Transhepatic Cholangioplasty andBiliary Stent Placement 170Percutaneous Cholangioscopy 171Percutaneous Stone Removal 171
Postprocedural Care of the Transhepatic Tract 173Results 173
PTC, PTCD, Cholangioplasty, and Stent Placement 173Diagnostic Percutaneous TranshepaticCholangioscopy 174Therapeutic Percutaneous TranshepaticCholangioscopy 176
Complications and Management 176Conclusions 177
References 177
16 Tissue Sampling TechniquesWolfgang Rosch 179
Introduction 179Biopsy 179Esophagus 182Stomach 184Duodenum and Small Intestine 185Colon 185Pancreatic and Biliary Ducts 186Cytology 186Sampling of Body Fluids 187
Summary 187References 187
17 The Contribution of Histopathology to EndoscopyRobert H. Riddell 189
Role of Pathology when Polyps and Other Tumors AreEncountered 189Role of Pathology when Features of Inflammation orMetaplasia Are Present 191
Gastroesophageal Reflux Disease and Barrett'sEsophagus, Esophageal Infections, and Other RareDiseases 191Stomach and Duodenum 192Terminal Ileum and Large Bowel 193
Role of Pathology When No Endoscopic AbnormalitiesAre Present '. 196Conclusions 196
References 197
18 Endoscopic UltrasonographyT. Rosch and AM. Kassem 199
Available Instruments and Scanning Principles 199Basics of EUS-Guided Puncture Techniques 200Clinical Background and Prerequisites of EUS andEUS-Guided Fine-Needle Puncture 203Examination Technique and Normal Findings 204
Preparation, Sedation, and Complications 204Upper Gastrointestinal Tract 204
Pancreas and Biliary Tract 204Colorectum 207
Pathological Findings: General Principles 208Tumor Staging in the Gastrointestinal Tract 208Submucosal Lesions 208Tumor Diagnosis and Stagingin the Pancreaticobiliary Tract 210Benign Lesions and Differential Diagnosis 211Fine-Needle Puncture: Accuracy, Pitfalls,and Limitations 213
EUS in the Clinical Setting 214Outlook: New Techniques and EUS-Guided Interven-tions 215
References 216
19 Laparoscopic Investigation and CombinedLaparoscopic and Endoscopic ProceduresEckart Frimberger and Hubertus Feussner 221
Laparoscopic Investigation 221Introduction 221Indication 221Contraindications 222Side Effects and Complications 222Examinations Before Laparoscopy 222Equipment 223Preparation of the Patient and Medication 223Pneumoperitoneum 224Insertion of the Cannula 224Minilaparoscopy 225Inspection of the Abdominal Cavity and Biopsy 225
Extended Diagnostic Laparoscopy 225Technical Performance of the EDL Examination 225Indications and Results 228Complications of Extended Diagnostic Laparoscopy .. 230
Combined Laparoscopic-Endoscopic Procedures (LEP) .. 231Introduction 231Indications., 232Contraindications 232General Aspects 232Equipment 232Special Preoperative Assessment 232Preparation of the Patient 232Positioning of the Patient, Anesthesia, Position of theLaparoscopist and Endoscopist, Arrangement of theEquipment 233General Technical Aspects 233LEP Variants 233Results 235Discussion 236References 238
20 Proctological InvestigationsP. Neary, P.W.R. Lee 241
Introduction 241Outpatient Appraisal 241
History 241Examination 241
Endoscopic Techniques 242Proctoscopy 242Rigid Sigmoidoscopy 243Flexible Sigmoidoscopy 244
Anorectal Ultrasonography 245Endoanal Ultrasound (Endoluminal Ultrasound) 245Endorectal Ultrasound 246
Contents XV
Anorectal Physiology 247Anorectal Manometry 247
Nerve Stimulation Techniques 248Pudendal Nerve Terminal Motor Latency (PNTML)Testing 248Spinal Nerve Latency 248
Radiography 249Defecography 249Magnetic Resonance Imaging and ComputedTomography 249
Examination under Anesthesia 250Conclusions 251
References 251
21 Liver BiopsyA.K. Burroughs 252
Introduction 252Indications 252Percutaneous Liver Biopsy 252
Menghini Technique 253Tru-Cut Needle Biopsy 253Plugged Percutaneous Liver Biopsy 254Fine-Needle Aspiration Biopsy of the Liver 254Ultrasound-Guided Liver Biopsy 256
Transvenous (Jugular) Approach 256Laparoscopic Biopsy of the Liver 258Acknowledgments 258
References 258
Therapeutic Procedures
Edited by Meinhard Classen
22 Hemostasis: Injection Sclerotherapy, Banding,Mechanical Methods, Heater Probe, and OtherMethodsJames Y.W. Lau and S.C. Sydney Chung 262
Nonvariceal Hemorrhage 262Injection Therapy 262Diluted Epinephrine 262Techniques of Injection Therapy 262Sclerosants 262Thrombin and Fibrin Sealant 262Contact Thermal Device: Heater Probe 264Endoscopic Clips 265Single or Combination Treatment 266Limits of Endoscopic Therapy 266
Variceal Hemorrhage 267Endoscopic Injection Sclerotherapy 267Band Ligation 267Band Ligation Versus EIS 268Combining Band Ligation and Sclerotherapy 268Prophylactic Treatment of Esophageal Varices 268Tissue Adhesives 269Gastric Varices 271Endoloops and Detachable Mini-Snares 271Summary 272References 272
23 Principles, Technical Guidelines, and Results ofArterial Hemostasis with Coagulation ProbesDennis M.Jensen and Gustavo A. Machicado 274
Introduction 274Principles of Arterial Hemostasis with CoagulationProbes 274Technical Parameters and Guidelines for EndoscopicTreatments 275
Bipolar or Multipolar Electrocoagulation 275Technical Guidelines for the Heater Probe 275Combination Injection and Thermal Coagulationfor Ulcer Hemostasis 277Monopolar Electrocoagulation: Technical Guidelines . 278
Randomized Prospective Trials for Ulcer Hemorrhage .. 278Clinical Results for Monopolar Electrocoagulation 278Bipolar Electrocoagulation 279Heater Probe 279
Comparisons of Injection Versus ThermalHemostasis for Ulcers 280Clinical Results of Combination Therapy forUlcer Hemostasis 280
Bipolar Coagulation for Hemostasis of Mallory-WeissTears 281Bipolar Coagulation for Hemostasis of Dieulafoy'sLesions 281Hemostasis of Bleeding Upper Gastrointestinal Tumors. 282Hemostasis of Upper Gastrointestinal Angiomas withContact Probes 282
References 282
24 Laser ApplicationHugh Ban 284
Physics and Principles of Laser Therapy 284Interaction of Laser Light with Tissue 284Types of Laser 285Endoscopic Laser Therapy 285
Hemostasis 285Palliation of Malignant Dysphagia 285Ampullary and Duodenal Neoplasia 287Colorectal Cancer 287Early Gastrointestinal Cancer and Precancer 287
Conclusions 289References 289
25 Argon Plasma CoagulationGuido Costamagna 290
Principles and Equipment 290Technique 293Indications 294
Barrett's Esophagus 294Zenker's Diverticulum 294Treatment of Small Gastrointestinal Carcinoma 295Debulking of Gastrointestinal Carcinoma andRecanalization of Obstructed Metal Stent's 295Eradication of Sessile Polyps 296Nonvariceal Gastrointestinal Bleeding 296Esophageal Varices 300Radiation Proctosigmoiditis 300References 300
26 Colonoscopic PolypectomyJerome D. Waye 302
Principles of Colonoscopic Polypectomy 302Heat Sealing of Blood Vessels 302Type of Current 302Electrosurgical Unit 302Coaptive Coagulation 302
Types of Polyp 303Chromoendoscopy 303Endoscopic Accessories 304
Electrosurgical Units 304Injector Needles 304Colonoscope 304Hot Biopsy Forceps 304Heater Probe and BICAP 304Argon Plasma Coagulator 304Detachable Loop 304Clips 306Snares 306
Preparation Phase 306Colon Cleansing 306Carbon Dioxide 306Precolonoscopic Laboratory Testing 306Aspirin and Anticoagulants 306
Polypectomy Technique 307Polyp Position 307Small Polyps 307Snare Catheter Placement 307Pedunculated Polyps 307Sessile Polyps 308
Treatment of Polyp Base after Removal 308Methods for Safer Polypectomy 309
Marking the Snare Handle 309Submucosal Injection for Polypectomy 309Volume of Injected Fluid 310Malignant Polyps 310Tumor Tracking 311Air Aspiration 311The Tip of the Snare 311Stopping at the Line 311Tent the Polyp away from the Base 312Piecemeal Polypectomy 312
Problems 312Polyp Position 312When to Remove Polyps 313Positional Changes and Abdominal Pressure 313Rotatable Snares 313Mini-Snares 313Gastroscope for Better Tip Deflection 313New Colonoscopes 314Clamshell Polyps 314Follow-Up Interval 314Retroversion 314Polyp Size 314Bleeding during Polypectomy 314
Polyps Too Difficult to Remove 315Flat Polyps 315Extremely Difficult Colonoscopy 315Laparoscopy and Polypectomy 315
Location of Lesions 315Endoscopic Follow-Up 315Healing of Polypectomy Site 315Invalidity of Shaft Measurement 315Endoscopic Landmarks 315Clips 315
Barium Enema 316Magnetic Imaging 316Intraoperative Colonoscopy 316Marker Injections into the Colon Wall 316
Complications 317Perforation 317Postpolypectomy Coagulation Syndrome (Serositis,Transmural Burn, Postpolypectomy Syndrome) 318Postpolypectomy Hemorrhage 318Hot Biopsy Forceps 318
Results 319Checklist of Practice Points 319
References 319
27 Endoscopic Mucosal Resection for GastrointestinalMucosal CancersHaruhiro Inoue 322
Development of Endoscopic Mucosal Resection 322Diagnosing Esophageal, Gastric, and Colonic Cancer 322
Detecting Early-Stage Esophageal Cancer 322Diagnosing Early-Stage Gastric Cancer 323Diagnosing Early-Stage Colon Cancer 323
Treatment of Early-Stage Cancers in the Esophagus,Stomach, and Colon 324
Principle 324Technique 324Histopathological Assessment 326
Healing of Lesions after EMR 327Clinical Results 328Prevention and Treatment of Complications 329
Perforation 329Bleeding from the Ulcer Bed 332
Conclusions 333References 333
28 Photodynamic TherapyI. Gossner and C. Ell 334
Introduction 334Principles of Photodynamic Treatment: Photochemistryand Photobiology 334
Type I and Type II Photochemistry 334Equipment 335
Photosensitizers 335Light Sources 335Light Application Systems 336Dosimetry 337
Indications 337Curative Treatment 337Palliative Treatment 338
Contraindications 338Patient Preparation 338Pretherapeutic Staging 339Procedure 340Results 340
Barrett's Esophagus 340Esophagus 341Stomach 341
Complications 342Aftercare 342Conclusion 343
References 343
29 Endoscopic Papillotomy (EPT) and EndoscopicSphincterotomy (ES; EST)M. Classen, Z. Zhang 345
Introduction 345Indications 345
Main Duodenal Papilla and Minor Papilla 345Bile Ducts 345Pancreas 349
Admission, Premedication, and Instruments 350Circumstances of Admission (In-Patient or Outpatient) 350Preparation 350Instruments 350
Methods of Endoscopic Papillotomy 354Biliary Papillotomy 354Precut Papillotomy 354Needle-Knife Papillotomy 354Fistulotomy, Papillectomy (Ampullectomy) 356Pancreatic Duct Papillotomy 356Minor Papilla Papillotomy 357Juxtapapillary Diverticula 357Billroth II Gastrectomy 357Rendezvous Technique 358
Complications of EPT 359Short-term Complications 359Long-Term Complications 362
Results and Outcome 363Technical Success 363EPT in Individual Indications 364
Alternatives to EPT 367References 367
30 Intestinal Tract StentingR.A. Kozarek 372
Introduction 372Indications and Contraindications 372Equipment 373
Dilation Devices 373Prosthetic Devices 373
Procedure and Placement Methods 375Bougienage 375Esophageal Prostheses 375Nonesophageal Stents 379
Management of Complications 381Clinical Results and Outcomes 382
Bougienage 382Esophageal Prostheses 382Stent Placement 382
Alternatives 384Conclusions 384
References 384
31 Biliary and Pancreatic StentingKenneth F. Binmoeller, Christopher E. Devereaux, andJavaidA. Shad 387
Introduction " 387Biliary Stents 387
Plastic Stents 387Expandable Metal Stents 389
Pancreatic Stents 391Stent Retrieval and Exchange 392
Retrieving the Migrated Stent 393Complications of Stent Placement 393
Stent-Related Pancreatic Ductal Changes 393
Biliary Indications 394Benign Strictures 394Primary Sclerosing Cholangitis 394Biliary Duct Leaks 394Post-Transplant Biliary Complications 394Cholelithiasis and Choledocholithiasis 394Pregnancy 394Cholecystitis 395Preoperative Biliary Stenting 395Malignant Strictures 395Brachytherapy 395
Pancreatic Indications 395Pancreatic Ductal Strictures 395Pancreatic Ductal Stones 395Pseudocyst 396Pancreatic Duct Leaks 396Pancreas Divisum 396
Conclusion 397References 397
32 Intestinal DecompressionDonald G. Ormonde and Norman E. Marcon 400
Acute Colonic Pseudo-Obstruction 400Presentation 400Diagnosis 400Pathophysiology 401Causes 402Natural History and Sequelae 403Summary 409Treatment 403
Balloon Dilation of Colonic and Ileocolonic Stricturesfor Colonic Decompression 409
Benign Strictures 409Malignant Strictures 411
Conclusions 412References .\ 412
33 Approach to Gastrointestinal Foreign BodiesJeffrey L Ponsky 414
Approach to the Patient with Foreign-Body Ingestion . . 4 1 4Food Bolus Impaction 414Coins 417Sharp Objects 418Batteries 420Bezoars 420Unusual Foreign Bodies 421Rectal and Colonic Foreign Bodies 422Conclusion 423
References 423
34 LithotripsyP. Born 424
Introduction 424Indications 424
Choledocholithiasis 424Pancreatolithiasis 425
Equipment and Techniques j 425Endoscopes 425Papillotomes . \ . , 425Wires 425Baskets 425Balloons 426Percutaneous Access 426
XVIII Contents
Endoscopic Access 426Mechanical Lithotripsy 428Electrohydraulic Lithotripsy 429Laser Lithotripsy 429Extracorporeal Shock-Wave Lithotripsy 429
Contraindications 431Results in Choledocholithiasis 431
Mechanical Lithotripsy 431Electrohydraulic Lithotripsy 432Laser Lithotripsy 432Extracorporeal Shock-Wave Lithotripsy 432
Complications 433Extracorporeal Shock-Wave Lithotripsy 433Laser Lithotripsy 433Electrohydraulic Lithotripsy 434Mechanical Lithotripsy 434
Results in Pancreatic Stones 434Extracorporeal Shock-Wave Lithotripsy 434Laser Lithotripsy 435
Alternatives 435Surgery 435Stent Therapy 436
Summary 436References 436
35 Percutaneous Endoscopic Gastrostomyand JejunostomySreeni Jonnalagadda, Steven A. Edmundowicz 439
Introduction 439Indications 439Contraindications 439Patient Preparation 440Procedure 440
Optimal PEG Site 440Pull-Type (Ponsky-Gauderer) Gastrostomy [2] 442Push-Type (Sacks-Vine) Gastrostomy [3] 445Introducer-Type (Russell) Gastrostomy [4] 445Post Procedure 446Endoscopically Placed Gastrojejunostomy 446Direct Percutaneous Endoscopic Jejunostomy 446
Complications 448Replacement/Removal of PEG 449Conclusion 450
References 450
Upper Intestinal Diseases
Edited by G.N.J. Tytgat
36 Esophageal DiseasesJoel E. Richter and Gregory Zuccaro 452
General Anatomy 452Squamocolumnar (Mucosal) Junction 452Esophagogastric (Muscular) Junction 452Lower Esophageal Sphincter (LES) 453
Hiatal Hernia 454Sliding Hiatal Hernia 454Paraesophageal Hernia 454
Gastroesophageal Reflux Disease 457Esophagitis 457Esophagitis Grading Systems 458Sentinel Fold 458Miscellaneous Findings in GERD 458
Peptic Esophageal Strictures 460Lower Esophageal (Schatzki) Ring 462Ringed Esophagus 463Barrett's Esophagus 464Postfundoplication Endoscopic Examination 465Esophageal Motility Disorders 466
Achalasia 466Scleroderma 467
Infections of the Esophagus 468Candida Esophagitis 468Herpetic Esophagitis 469Cytomegalovirus Esophagitis 469Human Immunodeficiency Virus Esophagitis 470Miscellaneous Infections - 470
Pill-Induced Esophageal Injury 470Corrosive Esophagitis 472Radiation-Induced Esophagitis 472Skin Diseases Associated with Esophagitis 473Esophageal Diverticula 473
Zenker's Diverticulum 473Mid-Thoracic Traction Diverticulum 474Epiphrenic Diverticulum 474
Esophageal Varices 475Endoscopic Grading Classifications 475Other Methods of Assessing Esophageal Varices 477
Tumors of the Esophagus 478Clinical Presentation 478Structural Evaluation 478
Benign Tumor's of the Esophagus 479Smooth-Muscle Tumor 479Benign Tumors of the Superficial Layer of theEsophageal Wall 479Benign Tumors of the Submucosal Layer 480
Malignant Tumors of the Esophagus 481Endoscopic Surveillance for Cancer 481Endoscopic Approach to Esophageal Cancer 483References 484
37 Gastric DiseasesG.N.J. Tytgat 488
Normal Stomach—Anatomical Variants—Mucosal Prolapse and Tearing 488
Normal Stomach 488Hiatal Hernia 488Paraesophageal Hernia 488Mixed Axial and Paraesophageal Herniation 488Upside-Down Stomach 489Gastric Diverticula 491Gastroesophageal Prolapse 491Mallory-Weiss Tears j 491
Gastritis 491Endoscopic Aspects 491Histological Aspects 493Infectious Forms of Gastritis 496Autoimmune Gastritis 498Drug-Induced Gastric Mucosal Damage 499Hypertrophic-Hyperplastic Gastritis 500
Granulomatous Gastritis 502Enterogastric or Biliary Reflux Gastritis 502Physical-Chemical and Caustic Gastritides 502Stress-Induced Gastritis 503Inflammatory Vascular Disorders and Ischemia 503Miscellaneous Idiopathic Conditions 504
Vascular Disorders 505Gastric Ulcer 507Gastric Polyps 509
Epithelial Lesions 509Subepithelial Polypoid Lesions 511
Gastric Cancer 513Early Gastric Cancer 513Advanced Gastric Cancer 515Malignant Nonepithelial Tumors 517
Postoperative Stomach 519References 521
38 Duodenal and Small-Intestinal DiseasesBlair S. Lewis 524
Small-Bowel Tumors 524Stromal Tumors 526Adenoma and Adenocarcinoma 526Inflammatory Polyps 526Lipomas 526Carcinoid 528Lymphoma 528Kaposi's Sarcoma 528Metastatic Disease 528
Ulcerative and Erosive Diseases of the Small Bowel 529Crohn's Disease 529Zollinger-Ellison Syndrome 529
Infections 529Medication Effects 529Vasculitis 530Radiation Injury 530Mesenteric Ischemia 530Graft-versus-Host Disease (GVHD) 531
Congenital Lesions 531Diverticula and Duplication Cysts 531Meckel's Diverticulum 531Duplication Cysts 531
Vascular Anomalies 532Malabsorption 535
Celiac Disease 535Whipple's Disease 535Amyloid 536References 536
39 Upper Gastrointestinal Bleeding DiseasesJustin C.Y. Wu and Joseph J. Y. Sung 538
Introduction 538Peptic Ulcer 538Gastric and Duodenal Erosion and Hemorrhage 539Esophageal and Gastric Varices 540Portal Hypertensive Gastropathy 543Mallory-Weiss Syndrome 544Esophagitis and Esophageal Ulcers 544Dieulafoy's Lesion 545Gastric Antral Vascular Ectasia 545Aortoenteric Fistulas 545Upper Gastrointestinal Tumors 546
References 546
flower Intestinal Diseases
Edited by C.N.J. Tytgat
40 Colorectal DisordersDouglas K. Rex, John C. Lappas, Oscar W. Cummings 550
Colorectal Cancer 550Inherited Syndromes 554Colonic Polyps 556Malignant Polyps 561Ischemic Colitis 562Pseudomembranous Colitis 563Bacterial Colitis 564Colonic Tuberculosis and Viral Infections 565Anorectal Disorders 565
Internal Hemorrhoids 565External Hemorrhoids 565Anal Fissure 566Perianal Fistula and Abscess 566Diverticular Disease 567Diverticular Bleeding 567Diverticulitis 567
Miscellaneous Conditions 569Microscopic Colitis 569Melanosis Coli 570Pneumatosis Cystoides Intestinalis 570Solitary Rectal Ulcer Syndrome 571Colitis Cystica Profunda 572Stercoral Ulcers 572
Miscellaneous Mass Lesions 572References 573
41 Inflammatory Bowel DiseasesYoram Bouhnik, Marc Lemann, Vincent Maunoury,Alain Bitoun, and Jean-Frederic Colombel 575
Technical Aspects of Ileocolonoscopy 575Diagnosis 575
Basic Endoscopic Lesions in InflammatoryBowel Disease 575Diagnosis of IBD by Endoscopy 581Differential Diagnosis between IBD and Other Causesof Colitis 582
Specific Indications for Endoscopy in IBD 587Acute Severe Colitis 587Cancer Diagnosis and Screening 588Follow-Up of Medically Treated Patients 590Postsurgical Follow-Up 590Complications • 591
Other Endoscopic Techniques in IBD 592Upper Endoscopy in Crohn's Disease .\ 592Enteroscopy 592Peroperative Endoscopy in Crohn's Disease 592Endoscopic Retrograde Cholangiopancreatography
(ERCP) 593
XX Contents
Endoscopic Ultrasonography 593New Techniques 593References 594
42 Lower Intestinal Bleeding DisordersJ. Scholmerich and H. Messmann 598
Definition 598General Aspects of Lower Gastrointestinal Bleeding 598Clinical Aspects 598
History 598Physical Examination 598Laboratory Studies 599
Technical Diagnosis 599Endoscopy 599
Nuclear Scintigraphy 599Visceral Angiography 600Differential Diagnosis 601
Diverticular Disease 601Acute and Chronic Colitis 602
Inflammatory Bowel Disease 602Ischemic Colitis and Vascular Disorders 602Infectious Colitis 602Radiation Colitis 604
Colonic Neoplasia 604Postpolypectomy Hemorrhage 605Angiodysplasia and Other Vascular Malformations 606Anorectal Diseases 607Small-Intestinal Hemorrhage 608Lower Gastrointestinal Bleeding in HIV-InfectedPatients 608Rare Causes 608Impact of Endoscopy and Other Related Methods OnOutcome 610
References 610
Biliopancreatic, Hepatic, and Peritoneal Diseases
Edited by G.N.J. Tytgat and CJ. Lightdale
43 Biliary Tract DiseasesJohn Baillie 614
Introduction 614Procedures 614
General Indications for ERCP and EUS 614Patient Preparation 614Antibiotic Coverage 614Contrast Allergy 614Difficult Anatomy 615
The Normal Cholangiogram 615Cholelithiasis 616Choledocholithiasis 617
Background 617ERCP, EUS, or MRCP to DiagnoseCholedocholithiasis? 617Endoscopic Management 618
Gallbladder Lesions 623Biliary Malignancy 623
Malignancy Affecting the Biliary Tree 623A Potpourri of Imaging Techniques 623 45EUS or ERCP in the Diagnosis of Biliary Malignancy .. 624Tissue Sampling 624Staging of Bile Duct Tumors 625Biliary Stenting 625
Miscellaneous Conditions in the Biliary Tree 626Primary Sclerosing Cholangitis 626Choledochal Cysts 627Sphincter of Oddi Dysfunction 629Biliary Parasites 630Some Recent Developments 630References 631
44 Pancreatic DiseasesEvan L. Fogel, Stuart Sherman, Glen A. Lehman 634
Introduction 634Developmental Anomalies of the Pancreas 634
Pancreas Divisum: Diagnosis and Therapy 634Annular Pancreas 642Pancreatic Agenesis '. 642Anomalous Pancreaticobiliary Ductal Junction 643
Acute Pancreatitis 643Acute Gallstone Pancreatitis 643Acute Recurrent Pancreatitis of Known or UnknownCause 645Unresolving Acute Pancreatitis 647
Chronic Pancreatitis 647Pancreatic Strictures 647Pancreatic Ductal Stones 650Pancreatic Pseudocysts and Fistulas 654Biliary Obstruction in Chronic Pancreatitis 656Sphincter of Oddi Dysfunction 657
Pancreatic Neoplasms 657Conclusions 660
References 660
Diseases of the Liver and PeritoneumH. Juergen Nord 664
Introduction 664Diseases of the Liver and Biliary System 664
Normal Findings 664Fatty Liver 665Acute and Chronic Hepatitis 666
Focal Liver Lesions 670Benign Focal Lesions 670Focal Malignant Lesions 672
Peritoneal Disorders 675Primary Peritoneal Disease •...- 675Metastatic Disease 676Infectious Diseases 676Ascites of Unknown Cause / 677Perihepatitis 677Chronic and Acute Pain Syndromes 677References 678
Contents XXI
Proctologic Diseases
Edited by CJ. Lightdale
46 Clinical ProctologyRainer Winkler 682
Proctological Diagnosis 682General 682Examination Procedure 682History 682Preparation 682Position 682Inspection 682Digital Examination 683Rectoscopy 683
Proctoscopy 684Supplementary Instrumentarium and AdditionalExaminations 685
Anal Disorders 685General 685Hemorrhoid Complex 685Anal and Perianal Fistulas and Abscesses 690Anal and Perianal Tumors 693Ulcerous Lesions 696Miscellaneous 697References 699
Infectious Diseases of the Gastrointestinal Tract
Edited by CJ. Lightdale
47 Infectious Diseases of the Gastrointestinal TractScott Lee and Christina M. Surawicz 702
Introduction 702Pathophysiology 702Clinical Features 702
History and Physical 702Diagnostic Testing 703Differentiating Infectious Colitis from InflammatoryBowel Disease 703Treatment 704
Specific Organisms 704Viruses 704Bacteria 705Parasitic Diseases 706References 708
48 Intestinal Abnormalities in AIDSRosario Ligresti, Lawrence J. Brandt 710
Introduction 710Diarrhea 710
Pathogens 711Diagnostic Yield 711
Specific Pathogens and Endoscopic Appearance 712
Cytomegalovirus 712Mycobacterium avium-intracellulare 712Microsporidia/Cryptosporidium parvum 712HIV Enteropathy 712
Dysphagia and Odynophagia 712Etiology 712Candida Esophagitis 713Cytomegalovirus 713Herpes Simplex Virus 713Idiopathic (Aphthous) Ulcers 713Other 713
Abdominal Pain 714Gastric Diseases .. /• 714MAI i 715
Right Upper Quadrant Abdominal Pain 715Acalculous Cholecystitis 715AIDS Cholangiopathy 715Pancreatitis 716
Gastrointestinal Bleeding 716Lower Gastrointestinal Bleeding 716-Upper Gastrointestinal Bleeding 716
AIDS and the Endoscopist 717Conclusions 717
References 717
Pediatric Endoscopy
Edited by CJ. Lightdale
49 Pediatric EndoscopyVictor LFox 720
Introduction 720Patient Preparation 721
Emotional Preparation 721Dietary Restrictions 721Sedation 721Antibiotic Prophylaxis 723Contraindications 723
Equipment 723Upper Gastrointestinal Endoscopy 723
Indications and Specific Diagnostic and TherapeuticApplications 724
Colonoscopy V. 732Sedation 732Bowel Preparation 732Equipment 732Basic Technique 733
XXII Contents
Polypectomy 733Indications and Contraindications 733Specific Diagnostic and Therapeutic Applications 733
Endoscopic Retrograde Cholangiopancreatography 738Introduction 738Equipment 738Patient Preparation and Sedation 738Basic Technique 739
Role of the Pediatric Endoscopist 739Contraindications 739Diagnostic and Therapeutic Indications 739Biliary Conditions 739Pancreatic Conditions 744
Gastrointestinal Endosonography 747References 748
Terminology and Endoscopic Reporting
Edited by M. Classen
50 Reporting Terminology and Image Documentation inEndoscopyThomas Rosch and Walter Heldwein 754
Written Reports 754Terminology 754
Index 761
Specific Requirements for Software-ImplementedTerminology 754
Image Documentation 756Still Images and Video Sequences 756Towards an Image Documentation Standard 757References 759