GastroHep eBook

Home

News and Views

Reference

Advanced Digestive Endoscopy

Education

Links and Services

Conference Diary

PubMed

International GH Links

USA GH Links

National GH Links

National GI Societies

Other Useful Links

Showcase journal

Emails on Gastroenterology and Hepatology

View all the figures for this chapter.

This content is coming soon.

Email this page to a colleague

1. Overview

	A (very) brief history of endoscopy
	Professionalism and quality

2. Design and management of gastrointestinal endoscopy units

Synopsis
Introduction
Unit design
	Space planning
	Daily room volumes
	Procedure room size
	Preparation and recovery ratios
	Separate entrances
	Common space problems
	Physical infrastructure
	Intake and recovery areas
	Intake areas
	Managing clothes and valuables
	Recovery facilities
	Procedure room reprocessing and storage
	Standard procedure rooms
	Scope reprocessing and storage
	Patient flow issues
	Complex procedure rooms
	Storage of supplies and medications
	Travel carts for emergencies
Unit management
	Major areas of responsibility
	Staffing design
	Staffing emergencies
	Procedure schedules
	Relative time requirements
	Barriers to efficiency
	Purchasing
	Endoscopes
	How many endoscopes?
	Endoscope repair costs
	Databases
	Devices
	Endoscope reprocessing
	Coding and billing
	Accreditation
Outstanding issues and future trends
	Capsule endoscopy
	Colon screening technologies
	Endoscopy by non-specialists
	Growth of advanced endoscopy
Summary
References

3. Sedation, Analgesia, and Monitoring for Endoscopy

Synopsis
Introduction
	Moderate sedation
	Deep sedation/analgesia
Advances in monitoring during sedation
	Standard pulse oximetry
	CO2 monitoring
	Transcutaneous CO2 monitoring
	Capnography
	BIS monitoring
Topical anesthetics: are they worth the effort?
Titration vs. bolus administration of sedation and analgesia
Propofol
	Problems with propofol
	Specific training for use of propofol
	Contraindications of propofol
	Clinical trials of propofol
	Propofol or midazolam?
	Upper endoscopy
	ERCP
	Upper endoscopy and colonoscopy
	Propofol with or without midazolam
	Patient-controlled administration of propofol
	Nurse-administered propofol
	Gastroenterologist-administered propofol
Droperidol
	Complications
Outstanding issues and future trends
References

4. Endoscopic equipment

Synopsis
Gastrointestinal endoscopes
	Endoscope design
	Control section
	Insertion tube
	Connector section
	Imaging
	Light source/processors
	Endoscope equipment compatibility
	Endoscope categories
	Esophagogastroduodenoscope (gastroscope)
	Enteroscope
	Duodenoscope
	Choledochoscope
	Echoendoscopes
	Colonoscope
	Sigmoidoscope
	Wireless capsule endoscopy
Gastrointestinal endoscopic accessories
	Tissue sampling
	Biopsy forceps
	Single-bite cold-biopsy forceps
	Biopsy cup jaws
	Multi-bite forceps
	Other specialty forceps
	Monopolar hot biopsy forceps
	Reusable vs. disposable biopsy
	Cytology brushes
	Needle aspiration
	Polypectomy snares
	Retrieval devices
	Injection devices
	Injection needles
	Spray catheters
	ERCP catheters
	Hemostatic and ablation devices
	Contact and non-contact thermal devices
	Heater probe
	Laser fibers
	Argon plasma beam coagulator
	Mechanical hemostatic devices
	Band ligation
	Metallic clip application via flexible endoscopes
	Marking with clips
	Detachable loops
	Transparent cap
	Dilation devices
	Push-type fixed-diameter dilators
	Hurst and Maloney dilators
	Savary-type dilators
	American Dilation System dilators
	TTS fixed diameter dilators
	Threaded-tip stent retrievers
	Radial expanding balloon dilators
	TTS dilators
	Achalasia balloon dilators
Conclusion
Outstanding issues and future trends
References

5. Digital documentation in endoscopy

Synopsis
	Fiberoptic imaging
	Teaching attachments and photography
	Videoscopes
	Image capture
	Standardized image terminology
	Structured reporting
	The opportunities and challenges of the digital revolution
Digital imaging
	Imaging the gastrointestinal tract using a videoendoscope requires several steps
	Color models
	RGB
	CMYK
	HSB
Digitization of color
Color depth
Pixel density
File size
	What detail is needed?
	File compression
	Compression techniques
	Lossless compression
	Lossy compression
	Image file formats
	Color and black and white compression
	JPEG 2000 and beyond
DICOM standard
	Information Objects
	Patient name attributes
	DICOM conformance
	DICOM in endoscopy
	Expanding the scope of DICOM
How much compression is clinically acceptable?
	Studies of compression acceptability
	Vakil and Bourgeois
	Kim (personal communication)
	Developments in compression
Still pictures or live video?
	Video storage developments
What images should be recorded in practice?
	Lesion documentation
	Recording negative examinations
	Structured image documentation
	Costs of image documentation
Image enhancement
	Color manipulation
	Narrow band imaging and spectroscopy
Terminology standardization
	OMED standardized terminology
	Minimal standard terminology—MST
	Problems with MST
Outstanding issues and future trends
Acknowledgments
References

6. Principles of electrosurgery, laser, and argon plasma coagulation with particular regard to colonoscopy

Editor's note
Introduction
Relevant thermal effects in biological tissues
	Thermal devitalization
	Thermal coagulation
	Thermal desiccation
	Thermal carbonization
	Thermal vaporization
Generation of temperature in thermal tissue
	Heater probe
	High-frequency surgery
	General principles of high-frequency electric devices
	Electric arcs
Principles of high-frequency surgical coagulation
	Monopolar coagulation instruments
	Electro-hydro-thermo probes
	Bipolar coagulation instruments
Principles of high-frequency surgical cutting with particular regard to polypectomy
Technical aspects of polypectomy
	Polypectomy snares
	The polypectomy snare handle
	Polypectomy snare catheters
Safety aspects of high-frequency surgery
Argon plasma coagulation
	The principle of argon plasma coagulation
	Equipment for argon plasma coagulation
	Safety aspects of argon plasma coagulation
Laser
	Principle of Nd:YAG laser
	Specific characteristics of Nd:YAG lasers in flexible endoscopy
Safety aspects of Nd:YAG laser in flexible endoscopy
Summary
References

7. Infection control in endoscopy

Synopsis
Sterilization and disinfection
	Sterilization
	High-level disinfection
	What level of disinfection is required?
	Critical items
	Semi-critical items
	The practical problem
	Biocides
	The organisms
	The critical points in reprocessing
Risks of infections associated with endoscopic procedures
	Mechanisms of infection
	Clinical infections
	Infecting organisms
	Bacteria
	Vegetative bacteria
	Clostridium difficile
	Mycobacterium tuberculosis
	Atypical mycobacteria
	Serratia marcescens
	Helicobacter pylori
	Pseudomonas
	Viruses
	Human immunodeficiency virus (HIV)
	Hepatitis B
	Hepatitis C (HCV)
	Prions
	CJD
	What to do in practice about CJD?
	New variant CJD (vCJD)
	Other infections
	The endoscopic procedures
	Upper gastrointestinal endoscopy
	Lower gastrointestinal endoscopy
	Endoscopic retrograde cholangiopancreatography
	Percutaneous endoscopic gastrostomy
	Endoscopic ultrasound
	Mucosectomy
	Host factors
	Immune competence
	The degree of tissue damage
	Intrinsic sources of infection
	Damaged valves and implants
Antibiotic prophylaxis for endoscopic procedures
	Principles of prevention of bacterial endocarditis
	High risk cardiovascular conditions [43]
	Moderate risk cardiovascular conditions [43]
	Recommendations for antibiotic prophylaxis
	Who should receive antibiotics?
	Clinical problems where opinions diverge
	What antibiotic regimen?
Antibiotic prophylaxis for ERCP
	Prophylactic antibiotic regimens for ERCP
Principles of effective decontamination protocols
	Cleaning is essential
	Effectiveness of recommended protocols
	Endoscope structure
	Common features
	External features
	Common internal features
	Special internal features
	Cleaning equipment
	Cleaning fluids
	Rinsing
	Disinfectants
	Soaking time
	General maintenance
	Lubrication
	Recommendations
	Work areas
Reprocessing regimens
	Disinfect before and after procedures
	Manual cleaning
	Manual disinfection
	At the end of the list
	Endoscopic accessory equipment
	Cleaning accessories
	Disinfection
	Special accessory items
	Sclerotherapy needles
	Water bottles and connectors
	Dilators
Problem areas in endoscope reprocessing
	Rinsing water
	Poor quality water
	Infections from rinsing water
	Bacteria free water
	Water testing
	Recommendations for rinsing water
Variation in cleaning and disinfection regimens depending upon the supposed infective status of the patient
Compliance with cleaning and disinfection protocols
The investigation of possible endoscopy infection transmission incidents
	Common causes
	Golden rules for investigating potential infection incidents
	The investigation process
	Transmission of viral disease
Automatic flexible endoscope reprocessors (AFERs)
	Machine design and principles
	Contamination
	Water supply
	Alarm function
	Self-sterilization
	Fume containment
	Disinfectant supply
	Reprocessing time
	AFERs cannot guarantee to sterilize endoscopes
	Cost
	Plumbing pathway
	Rinse and dry cycle
	Regular bacteriological surveillance
Quality control in endoscope reprocessing
	Quality control measures
Microbiological surveillance in endoscopy
	Duodenoscopes
	Bronchoscopes
	Recommendations
	Testing procedures
	Interpretation of cultures
	Microbiological surveillance of AFERs
Outstanding issues and future trends
References

8. Risks, prevention, and management

Synopsis
Introduction
The contract with the patient; informed consent
	Responsibility
	Educational materials
	Humanity
What are 'risks' and 'complications'?
	Definitions
	Threshold for 'a complication'
	Severity
	Attribution
	Timing of unplanned events
	Direct and indirect events
	Data set for unplanned events
General issues of causation and management
	Technical and cognitive performance
	Fitness for procedures
	ASA score
	Other risk indices
	Prompt recognition and management
	Communication
	Distress
	Document
	Act promptly
	Specific unplanned events
	Failure to diagnose
	Perforation
	Risk factors
	Recognition
	Treatment
	Bleeding
	Risk factors
	Recognition
	Treatment
	Cardiopulmonary and sedation complications
	Infection
	Endocarditis
	Infections
	Instrumentation
	Allergic reactions
	IV site issues
	Miscellaneous and rare events
Preventing unplanned events
Outstanding issues and future trends
References

9. Pathology

Synopsis
Introduction
Gastroenterologist–pathologist communication
	Endoscopist communication responsibility
	Pathologist communication responsibility
	Question-orientated approach
	Common terminology
Endoscopic biopsy specimens
	Specimen handling and interpretation issues
	Orientation
	Fixation
	Number of biopsies per container
	Tissue processing
	Prep-induced artifact
	Endoscopy-induced artifacts
	Biopsy-induced artifacts
	Crush artifact
	Burn/cautery artifact
	Polypectomy
	Endoscopic mucosal resection
	Core biopsy
	Regular stains
Exfoliative and fine-needle cytology
	Specimen handling; staining and fixation
	Artifacts
	Cytological diagnosis
	Fine-needle aspiration
Organ system overview
	Esophagus
	Where and when to biopsy
	Gastroesophageal reflux disease
	Barrett's esophagus
	Infective esophagitis
	Candida
	Herpes simplex virus
	Cytomegalovirus
	Adenocarcinoma and squamous cell carcinoma
	Stomach
	Where and when to biopsy
	Inflammatory conditions; gastritis
	NSAIDS
	H.pylori gastritis
	Hypertrophic folds
	Polyps
	Mass lesions
	Small bowel
	Celiac sprue
	Infective enteropathies
	Whipple's disease
	Mycobacterium avium–intracellulare
	Giardia lamblia
	Polyps
	Mass lesions
	Colon
	Defining 'normal'
	Inflammatory colitides
	Normal colonoscopy
	Abnormal colonoscopy
	Inflammatory bowel disease
	Pseudomembranous colitis
	Ischemic colitis
	Polyps
	Adenomatous
	Hyperplastic
	Mass lesions

Special stains
	Histochemical stains
	Immunohistochemical stains
	In situ hybridization
	Flow cytometry
	Electron microscopy
	Cytogenetics
	Molecular pathology
Outstanding issues and future trends
References

10. Pediatric gastrointestinal endoscopy

Synopsis
Introduction
The endoscopy facility and personnel
	Endoscopy facility
	Equipment
	Endoscopes
	Endoscopy instruments
	Ancillary equipment
	Personnel
	The endoscopist
	Nursing and ancillary personnel
The pediatric patient and procedural preparation
	Patient preparation
	Psychological preparation
	Medical preparation
	Recommendations for fasting
	Bowel preparation
	Antibiotic prophylaxis
	Informed consent
Endoscopic procedures currently performed in pediatric patients
	Indications and limitations
	Patient sedation
	Endoscopic technique
	Esophagogastroduodenoscopy
	Colonoscopy
	Sigmoidoscopy
	Therapeutic endoscopy
	Other endoscopic modalities
	Small bowel enteroscopy
	Wireless capsule endoscopy
	Endoscopic ultrasonography
	Endoscopic retrograde cholangiopancreatography (ERCP)
Selected gastrointestinal pathologies in pediatric patients
	Eosinophilic esophagitis
	Food allergic enteropathy and colitis
	Foreign body ingestion
	Helicobacter pylori gastritis
	Polyps in the pediatric patient
	Lymphonodular hyperplasia
Outstanding issues and future directions
References

11. Training and credentialing in gastrointestinal endoscopy

Synopsis
General principles of endoscopy training
	Traditional standard means of instruction
	Teachers
	Environment
	Is self-teaching still acceptable?
	What to teach and how to teach it
	Defining competency and how to access it
	Linking diagnosis and therapy
	How competent?
	Varying rates of learning
	Outcomes
	Learning beyond the training period
Training and competency in specific endoscopic procedures
	Esophagogastroduodenoscopy (EGD)
	Published guidelines for training in EGD
	Defining competence for EGD
	Data on acquisition of competency in diagnostic EGD
	Competency and EGD outcome
	Therapeutic EGD techniques
	Standard upper GI endoscopy techniques
	Hemostasis techniques
	Simulation
	Bleeding team
	Retaining competence
	Other specialized therapeutic upper GI endoscopy techniques
	Flexible sigmoidoscopy
	Published guidelines for training in flexible sigmoidoscopy
	Colonoscopy
	Published guidelines for training in colonoscopy
	Defining competence for colonoscopy
	Technical components
	Cognitive objectives
	Minimum training requirements to achieve competency for colonoscopy
	The Cass study
	Conclusion
	Competency and colonoscopy outcome
	Acceptable outcomes
	Non-gastroenterologists
	Rate of skills acquisition for colonoscopy
	Cases per week
	Too many cases?
	Therapeutic colonoscopy (biopsy, polypectomy, hemostasis techniques, stricture dilation, stent deployment)
	Standard therapeutic techniques (integral to performance of diagnostic colonoscopy)
	Advanced therapeutic colonoscopy techniques
	Diagnostic and therapeutic ERCP
	Published guidelines for training in ERCP
	Non-technical training
	Defining competence for ERCP
	Technical success
	Varying case difficulty
	Judgement
	Minimum training requirements to achieve competency for ERCP
	Case numbers
	What is a case?
	Competency and ERCP outcome
	Improving after training
	Annual volume
	Competence affects complication rates
	Rate of acquisition of ERCP skills
	Therapeutic ERCP
	Rate of acquisition of therapeutic skills
	Diagnostic and therapeutic EUS
	Defining competency in EUS
	Learning curve for EUS
	Therapeutic EUS
	EUS training opportunities
Complementary methods for instructions in GI endoscopy
	Advances in didactic methods
	Self-instruction
	Group instruction
	Laboratory demonstrations
	Endoscopy simulators
	Static models
	Courses with static models
	Ex vivo artificial tissue models: the 'phantom' Tübingen models
	Ex vivo animal tissue simulators: EASIE and Erlangen models
	Live animals
	Computer simulation
	AccuTouch®
	GI Mentor™
	Current status of simulators
	Costs of simulators
	EUS models and simulators
	Use of training resources: summary
Endoscopy training 2010—a glimpse into the future
Credentialing and granting of privileges
	Credentialing
	Privileging
	Proctoring
	ASGE guidelines
Renewal of privileges and privileging in new procedures
	New procedures
Privileging for non-gastroenterologists and non-physician providers
The future of credentialing and privileging
	The use of new technology for credentialing
The role of endoscopic societies in training and credentialing
	Guidelines
	Society courses
	Materials
	Hands-on courses
	Research in training
	Influencing credentialing
Outstanding issues and future trends
References

12. Towards excellence and accountability

Synopsis
Introduction
Achieving competence—the goal of training
What experience is necessary in training? The fallacy of numbers
Beyond numbers: tools to measure competence
What level of competence is good enough? How is it recognized?
Endoscopic performance beyond training
Issues in measuring endoscopic performance
The report card agenda
Benchmarking
The quality of endoscopy units
Conclusion
Outstanding issues and future trends
References

Infection control in endoscopy: Commentary

Synopsis
Most endoscopists are not interested
Is the problem declining?
Newly recognized infections
Compliance with guidelines
What can be done to remedy this sorry state of affairs?
	Infection control staff
	Microbiological surveillance
	British practice
The role of industry
Manual cleaning is key
References

GastroHep.com is a Blackwell Publishing registered trademark
© 2010 Wiley-Blackwell and GastroHep.com and contributors
Privacy Statement
Disclaimer
About Us