1. EGD Learning Module for N123 CSUS Spring 2008 School of Nursing

2. What is GI Endoscopy? A therapeutic and diagnostic gastroenterological procedure that allows for direct visualization of the lumen of the GI tract.

3. The GI Endoscope Gastroscope: 103cm long 11mm diameter Colonoscope: 180cm long 13mm diameter Flexible Channel for biopsy, air, water, suction Not a sterile Procedure

4. Why isn’t this a sterile procedure? Click on correct answer.. A. It is a sterile procedure (trick question)! B. The GI tract is not sterile.B. The GI tract is not sterile. Continue->

5. A. Incorrect. It is not a sterile procedure because the GI tract is not sterile. The scope enters the body through the mouth, which is not a sterile area of the body. Back to question

6. B. Correct! It cannot be a sterile procedure because the scope enters the body through the mouth, which is not sterile at all. Back to question

7. What can Endoscopy do? Visualizes upper and lower GI tract Diagnostic treatmentDiagnostic treatment Therapeutic treatmentTherapeutic treatment Continue->

8. The GI Endoscopy Suite Continue->

9. Diagnostic Treatment In GI Endoscopy Therapy intended to confirm or rule out a diagnosis. GI Endoscopy does this by: Gross visualization during the procedure and/or Biopsy: taking a specimen (piece of tissue) to study the cells (Cytology) or tissue for disease (Hystopathology) Continue->

10. Therapeutic Treatment in GI Endoscopy: 1.Treat bleeding by Hemostasis: hem(=blood) + stasis(=standing still): “to stop bleeding” 2.Treat problems of nutrition or dysphagia (difficulty swallowing) by placement of a Gastrostomy or Jejunostomy Tube 3.Foreign body removal-removing something foreign to the body from the GI tract 4.Gastric or Colon polypectomy-removal of a polyp 5.Stricture Dilatation-tearing open a stricture in the esophagus Continue

11. Esophagogastroduodenoscopy EGD = Esophago (esophagus) Gastro (stomach) Duoden (duodenum) Oscopy (to examine) Continue

12. Most Common Indications for EGD Acute or Chronic GI Bleed Removal of ingested foreign object Dysphagia or odynophagia or dyspepsia Xray/CT Scan showing lesion Continue

13. Removal of foreign object back

14. Dysphagia or odynophagia or dyspepsia Difficulty swallowing (dysphagia), painful swallowing (odynophagia), or dyspepsia can cause malnutrition over time, and usually requires supplementing nutrition through a feeding tube. Continue

15. Feeding Tube PEG tube (Percutaneous Endoscopic Gastrostomy tube) or a PEJ tube (Percutaneous Endoscopic Jejunostomy tube) Back

16. Xray/CT Scan showing lesion back

17. Less Common Indications for EGD Suspected esophageal stenosis(narrowing) Suspected hiatal hernia Persistent esophageal reflux Obstructive lesions Caustic ingestion Chronic abdominal pain Persistent unexplained vomiting

18. Diagnostic Treatment: Biopsy

19. Therapeutic Treatments For Hemorrhage/Bleeding Gastrosomy or Jejunostomy Tube Placement Foreign body removal Gastric polypectomy, mucosal resection Stricture Dilatation Continue

20. GI Bleeding/Hemorrhage back

21. What causes GI Bleeding? Gastric, esophageal or duodenal ULCERS (80% of all peptic ulcers are duodenal) ulceration Continue

22. GI Bleeding visualized by Endoscopy If the GI bleed is active and profuse, it is difficult to find the site of the bleeding through all that blood! The body has formed a clot over the site of the previously bleeding ulcer. Continue

23. Other causes of GI Bleeding.. Esophageal Varices Mallory-Weiss Syndrome which causes a Mallory-Weiss TearMallory-Weiss Tear Erosive gastritis, esophagitis, duodenitis (think: erosive inflammation)Erosive gastritis, esophagitis, duodenitis AVMs (arteriovenous malformations)AVMs Tumor Continue

24. Esophageal Varices Dilated esophageal veins from portal HTN and cirrhosis. Once dilated, pressure builds up and bleeding occurs. Varices (bulging vein) Back

25. Mallory-Weiss Tear A tear in esophagus or gastroesopha- geal junction caused by severe retching, vomiting, or coughing and is usually associated with alcoholism. Back

26. Erosive Gastritis/Esophagitis Inflammation and erosion of the stomach (Gastritis) or esophagus (Esophagitis) Endoscopy View of erosive gastritis (also known as watermelon stomach) Back

27. Arteriovenous Malformations (AVMs) AVMs: dilated blood vessels in the submucosa - Also called angiodysplagias Back

28. Tumors Benign or Malignant 95% of all stomach cancers are adenocarcinoma Back

29. How does Endoscopy achieve Hemostasis? Hemostasis=Heme(blood)+stasis(stand still) Electrocoagulation/Electrocautery Injection Therapy Laser Therapy Ligation/Banding Clipping All of these therapies are wired through an endoscope, and come out at the tip to perform their function. Continue->

30. What is electrocoagulation? Heat is applied through direct heat (heater probe) or non-touch heat (argon plasma coagulation) to tissues. The heat coagulates the proteins in the tissue, thereby causing a burn (or seal) over the tissue. This effectively “seals” a bleeding vessel.heater probeargon plasma coagulation Back

31. Electrocoagulation/electrocautery Heater Probe: Probe that applies heat to the tissue Argon Plasma Coagulation (APC) The Probe comes out through the tip of the scope “Argon Plasma + Heat”is sprayed onto tissue, causing coagulation Back

32. Injection Therapy Injection Therapy: nonvariceal bleed hypertonic saline + epinephrine (vasoconstrictor), or just saline, is injected into the vessel that is bleeding Sclerotherapy: variceal bleed (varices) Chemical Injected into bleeding site or varix (varix is the singular form of varices) Back

33. Laser Therapy Photocoagulation-laser coagulates tissue Photovaporization-laser vaporizes tissue Laser can reach 1-4mm tissue depth Tissue layers Laser Endoscope Laser Beam Tissue Back

34. Ligation or Banding Rubber bands or O-rings ligate the varix the Band around a varix Back

35. Clipping Clipping involves actual titanium clips which are used to pinch the vessel and surrounding tissue closed. A clip Clips after deployment Back

36. Nursing Responsibilities Pre-procedure Consent Teaching/Reduce Anxiety Patent IV (large gauge > 20)Patent IV Oxygen Pre-medicate if indicated Good Oral Care prior to procedure NPO!!! (teaching is VERY important here)NPO!!! Remove dentures Continue->

37. Consent You must spell it out completely (not EGD!) it must read: Esophagogastroduodenoscopy You must include the possible adjunct procedures involved (ie. Treatment to bleeding site, procedural sedation, etc) on the consent form. If the MD has not discussed the procedure with the patient, can you obtain a signed consent? Answer Answer Back

38. No As an advocate for your patient, you must make sure the MD has discussed the procedure with the patient, AND the patient has no further questions for the MD, prior to obtaining the signature. Back

39. Teaching Teaching will not only inform your patient about what the procedure is, and what to expect, but it may also reduce anxiety, which most patients experience when they are about to participate in an unfamiliar procedure. In GI Endoscopy, patients will usually receive conscious sedation, which also needs to be explained to the patient. Back

40. Patent IV Patients should ALWAYS have a patent IV, but this needs to be confirmed prior to any procedure. Patients are given sedation and analgesia, as well as fluid resuscitation, blood products, and possible rescue medications, as well as the possibility of treatment for cardiac or respiratory arrest during the procedure. Make sure the IV is patent by flushing it with saline, if it is a saline lock. Back

41. Oxygen Patients receiving conscious sedation should always have appropriate O 2 monitoring. In addition, make sure there is Oxygen and equipment nearby and available. REMEMBER: Conscious sedation MAY affect respiration, ventilation and oxygenation. Back

42. Good Oral Care Good general practice- especially prior to procedure Back

43. NPO The stomach must be completely empty in order to: 1) visualize the interior appropriately 2) prevent aspiration of gastric contents Visualization is key to a successful endoscopic procedure. Back

44. Remove dentures Dentures should be removed because they may become loose during the procedure. Dentures should be marked clearly, and in a safe place at all times, to ensure that they do not get lost during a hospital admission. Back

45. Question #1 A 38 year old female is admitted to the hospital for weakness, melena, and an episode of hematemesis. She says she hasn’t eaten anything in almost two days, and is starving. The nurse prepares the client for an EGD and explains that she cannot have anything to eat or drink. The nurse knows the reason for this is because: Continue->

46. Choose all that apply: A)In order for the bleeding site to be visualized, the stomach must be empty B)If there is food or water in the client’s stomach, there is an increased risk of aspiration C)If the client eats or drinks, she is at greater risk for burn injury during the procedure Continue-><-Back to question

47. A. Correct! Visualization is the key to a successful endoscopy procedure! Back to AnswersBack to Answers_(there is more than one correct response)

48. B. Correct! The patient is at risk for aspirating stomach contents because: 1. The patient will be sedated. 2. The gag reflux may be stimulated, and may cause the patient to vomit any stomach contents. 3. The airway may not be protected. Back to AnswersBack to Answers-(there is more than one correct response)

49. C. Incorrect. There is no greater risk for burn injury (from use of electrocautery) because of food in stomach. Back to Answers

50. Question #2 Your client tells you she is scared and does not want to have the endoscopy procedure because she is afraid of surgery. The nurse knows the best way to reduce her anxiety is to: Continue

51. Choose all that apply… A) Apply Oxygen to prevent her from hyperventilating. B) Call the doctor, request anti-anxiety medication for the patient. C) Place a large bore IV in her arm and explain that it is important in case an emergency happens. D) Discuss the procedure in clear language and answer her questions to help reduce her anxiety. Continue

52. A. Incorrect. Oxygen will not prevent a person from hyperventilating, or reduce anxiety. Back to Answers

53. B. Incorrect. This may help eventually, but the patient does not appear to understand that an EGD is not surgery, it is a procedure. She may need further teaching, first. Back to Answers

54. C. Incorrect. Although it is important to have a patent IV, this may not serve to reduce a patients’ anxiety. Back to Answers

55. D. Correct! Discussing the procedure and answering her questions will help to reduce her anxiety about the procedure. Back to Answers

56. Complications Respiratory depression or arrest Perforation of esophagus, stomach or duodenum Hemorrhage related to trauma or perforation Pulmonary aspiration of blood, secretions or gastric contents Infection Sepsis Cardiac arrhythmia or arrest Vasovagal response Allergic reaction to topical anesthetic or IV meds Continue

57. Perforation One of the major complications of an EGD, although the incidence is rare, is a cut through the esophagus, stomach or duodenum. Usual signs and symptoms include neck, back, chest, shoulder, or abdominal pain, as well as tachycardia, diaphoresis, and hypotension. Back

58. Question #3 A client has just returned from an EGD to assess for a GI Bleed. The endoscopy found a large gastric ulcer which required electrocoagulation therapy. When assessing the client upon return from the procedure, he reports severe back and abdominal pain, and appears diaphoretic. The abdomen is distended, and he is tachycardic. Continue

59. The nurse knows that these assessment findings are most consistent with which potential complication of the GI procedure: A) Perforation B) Sepsis C) Infection D) Aspiration Click here for the correct answer

60. Perforation This is one of the major complications of an EGD, although the incidence is rare. It is a perforation of the submucosal layer of the lumen in the GI tract. Usual signs and symptoms include neck, back, chest, shoulder, or abdominal pain, as well as tachycardia, diaphoresis, and hypotension. Continue

61. You have just completed.. GI module for Upper Endoscopy (EGD)

62. Sources 1) Gastroenterological nursing: a core curriculum. Coordinated by the Society of Gastroenterological Nurses and Associates (SGNA), Core Curriculum Committee. (2003) SGNA, Inc. Illinois. (3rd ed.)