Major parts of an endoscope gastritis

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Major parts of an endoscope gastritis Powered By Docstoc
					                                Gastrointestinal Endoscopy Basics                                      Pg. 1
                                      Jeffrey K. Saur, DVM, DABVP


In-Hospital Basic Training Opportunities
Flexible Gastrointestinal Endoscopy
Canine and Feline

Syllabus

Major parts of an endoscope
    Insertion tube
         Tube
         Bending section
         Distal tip
              Image guide objective lens
              Insufflation channel
              Accessory channel
              Irrigation channel
              Light guide objective lenses
    Handpiece
         Suction valve
         Air/water valve
         Accessory channel opening
         Up/down deflection knob
         Up/down deflection lock
         Left/right deflection knob
         Left/right deflection lock
         Eyepiece with ocular lens
         Diopter adjustment ring
    Umbilical cord
         Light guide connector
         Connector to suction pump
         Connector to air pump for insufflation
         Connector to water bottle for irrigation
         Pressure compensation valve: Remove cap and placard for use and routine cleaning
Care of the endoscope
    Always handle the insertion tube carefully; avoid sharp bends, tight coiling, or accidental striking of
           the tube against hard surfaces
    The fingers should never manipulate the distal deflecting portion of the endoscope; the control knobs
           should be used to check the range of motion of the deflecting tip.
    Excessive force on the control knobs should always be avoided (make sure deflecting locks are off).
    Always use an oral speculum when passing the endoscope through the oral cavity of an anesthetized
           patient
    Never force instruments or pass foreign objects through the accessory channel.
    Pressure compensation valve: Remove red cap and placard from scope
         Red cap should be on scope ONLY
              For ethylene oxide sterilization
              Transportation/shipping (altitude changes of >2500 ft)
Holding the endoscope
    Hold in left hand
         Left index finger controls suction valve
         Left index or middle finger can control air/water valve
         Left thumb controls up/down deflection knob
    Right hand
         Controls left/right deflection knob
         Inserts channel accessories
         Advances insertion tube
         Applies rotational torque to insertional tube
                               Gastrointestinal Endoscopy Basics                                       Pg. 2
                                      Jeffrey K. Saur, DVM, DABVP


Accessory channel and instruments
     “Disposable” instruments that are not compatible with endoscope may damage the accessory channel
     Instrument diameter should not exceed that recommended by the manufacturer
     Instruments should never be forced through the channel when resistance is felt
     Foreign objects should not be removed through the instrument channel: Instead, the entire endoscope
            should be removed from the patient once the object has been firmly grasped
     Before passing instruments through the deflected tip, the manufacturer’s recommendations should be
            reviewed.
Irrigation: Fill the irrigation bottle 2/3 full with de-ionized or distilled water
     The use of de-ionized or distilled water will reduce the incidence of mineral deposits clogging the
            irrigation channel
Cleaning, disinfection and sterilization
     A pressure check is done immediately after use to ensure that no leaks have developed.
          If a leak has occurred, DO NOT CLEAN THE ENDOSCOPE.
          Call Karl Stroz immediately.
     Avoid applying cleaning solutions to ocular lens and to diopter adjustment ring
     Next, organic material should be mechanically removed from all surfaces of the endoscope and other
            surfaces.
          All external surfaces should be wiped down with gauzes soaked in cleaning solution
          Remove suction valve and replace with cap.
          Cleaning solution is suctioned through the accessory channel to remove debris and soften any
                 adherent debris.
          Cleaning brushes should then be passed through all channels several times to remove adherent
                 debris before it has the opportunity to dry.
                Passing the cleaning brush through the channel rapidly may cause damage
                A back-and-forth scrubbing motion within the channel may cause damage
          The balance of the cleaning solution is then suctioned through the accessory channel
          A final rinse of de-ionized or distilled water is suctioned through the channel.
          All external surfaces are rinsed or wiped with de-ionized or distilled water.
          A final wiping down is done with 70% isopropyl alcohol-soaked gauze.
     Drying the endoscope
          Empty the irrigation bottle, and reattach
          Place cleaning cap on air/water valve
          Turn on air pump. This will expel the residual water from the irrigation channel.
          Then turn-on suction pump to air-dry the accessory channel
          Wipe down all external surfaces with clean, dry gauze.
          The air pump and suction should be left on 10 minutes before hanging scope for storage (longer if
                 endoscope is stored in the case).
     Instruments
          The instruments should be rinsed well with warm water to remove debris.
          Place them next in an ultrasonic cleaner with cleaning solution
          Rinse the instruments with water
          Apply instrument milk, hang, and allow drying.
          Cold sterilization or ethylene oxide sterilization may be used.
                Autoclaving may be used if all parts are autoclave-safe
     A commercially available enzymatic cleaning solution designed for endoscopes and accessories is
            highly recommended
          Detergezyme (item # MX4500)
                Available through
                     Med-Vet International
                     (847) 680-3050
          Does Karl Storz recommend the use of other solutions, such as dilute betadine, Nolvasan®, dish
                 soap, or Cidex?
     All lens surfaces and light guide surfaces should be wiped with 70% alcohol to remove residual
            cleanser film that may compromise light and image transmission
                                Gastrointestinal Endoscopy Basics                                      Pg. 3
                                      Jeffrey K. Saur, DVM, DABVP


First of all, do no harm
     If too much air is insufflated, especially in small dogs and cats, the stomach may become quite
            distended, causing significant compromise of respiratory capacity.
          In extreme cases, venous return from the abdomen may also be compromised.
     When an examination is finished, suction as much air as possible from the stomach.
     During withdrawal, any fluid observed in the esophagus should be suctioned.
                                Gastrointestinal Endoscopy Basics                                        Pg. 4
                                      Jeffrey K. Saur, DVM, DABVP


Esophagogastroduodenoscopy (also referred to as gastroduodenoscopy, or endoscopy)
    When possible, patients should be fasted for at least 12 hours prior to the procedure.
        At least 24 hours should pass from the completion of any barium series.
             Residual barium should NOT be suctioned through the accessory channel. Barium is very
                    adherent, and is difficult to remove.
    Known esophageal or gastrointestinal perforation is a contra-indication for
          esophagogastroduodenoscopy.
    Positioning of the patient and the scope
        The classic position for the patient undergoing endoscopy is left lateral recumbency.
    An oral speculum should ALWAYS be used for esophagogastroduodenoscopy
    The endotracheal tube should be tied in firmly either behind the patient’s head, or to the lower jaw (do
          not entrap the tongue in the tie)
    A long, flat surface in front of the patient is best. This allows the endoscope to be kept straight, which
          allows for better control, orientation, advancement and application of torque to the endoscope.
Esophagoscopy
    Esophagoscopy is the method of choice for diagnosing disorders of the mucosa or causes of
          obstruction of the lumen, including esophagitis, stricture, foreign bodies, and neoplasia.
        Other disorders for which esophagoscopy is valuable are esophageal diverticulum, vascular ring
               anomaly, gastroesophageal intussusception, megaesophagus, hiatal hernias, and
               periesophageal compression.
    Terminology
        Dysphagia: Difficulty in swallowing
        Odynophagia: Pain on swallowing
        Ptyalism: Excessive salivation
    The scope is passed dorsally over the larynx, avoiding the piriform recesses laterally.
    Conditions:
        Megaesophagus
             Congenital megaesophagus: Occurs in several canine breeds, as well as Siamese cats
             Adult-onset megaesophagus
                  Idiopathic
                  Secondary to myasthenia gravis, polymyositis, peripheral neuropathies, CNS disease,
                         dysautonomia, lead toxicity, hypothyroidism, or hypoadrenocorticism.
             General anesthesia makes the esophagus flaccid and dilated
             Esophagoscopy may be normal in animals with mild hypomotility
             A dilated esophagus without any insufflation is suspect. The presence of pooled fluid, froth,
                    and/or food is more consistent with a diagnosis of megaesophagus.
        Esophageal diverticula: Large, circumscribed saculations of the esophageal wall, often containing
               fluid and/or ingesta.
        Vascular ring anomalies
             A persistent right aortic arch accounts for 95% of vascular ring malformations
             A stricture is present at the base of the heart, with dilation of the esophagus proximal, and
                    normal esophageal diameters distal to the stricture.
             Pulsations are present at the level of the stricture
        Esophagitis
             The common causes of esophagitis include injury from gastroesophageal reflux during
                    general anesthesia, esophageal foreign bodies, hiatal hernia, gastric emptying disorders,
                    persistent vomiting, indwelling nasogastric tubes, ingestion of caustic irritants, and
                    thermal injury from ingestion of overheated food (microwaved).
             Esophagitis caused by gastroesophageal reflux is related to the duration of mucosal contact
                    with refluxed gastric acid, pepsin, bile salts and trypsin.
                  Clinical signs from esophagitis secondary to anesthesia are usually seen 2-4 days post
                         anesthesia.
             Lesions observed on esophagoscopy include mucosal erythema, hemorrhage, friability,
                    irregularity, erosions, ulcers, pseudomembranes, indistensibility, and stricture.
        Esophageal stricture
                                Gastrointestinal Endoscopy Basics                                       Pg. 5
                                      Jeffrey K. Saur, DVM, DABVP


             Visualized as a circumferential smooth ridge or ring of fibrous tissue
             Balloon dilation is the treatment of choice.
             Referral to a facility that is prepared to handle an esophageal perforation is recommended
                     even though balloon dilation itself is a straightforward procedure.
        Esophageal perforation
             May occur during endoscopic removal of a foreign body, or stricture dilation.
             Clinical signs from esophageal stricture secondary to anesthesia are usually seen around 10
                     days post anesthesia.
             Clinical signs include anorexia, depression, odynophagia, fever, pain, cough, and/or dyspnea.
             Thoracic radiographs may demonstrate mediastinitis, pneumomediastinum, pneumothorax,
                     soft-tissue emphysema, and pleural effusions.
             Endoscopy should NOT be performed in cases of known esophageal perforation
        Esophageal fistulas are congenital or acquired communications between the esophagus and the
               tracheobronchial tree, mediastinum, or pleural space.
        Hiatal hernias and gastroesophageal intussusception
             A sliding hiatal hernia is a protrusion of the abdominal segment of the esophagus and cardia
                     region of the stomach through the esophageal hiatus into the thorax.
             A paraesophageal hiatal hernia occurs when a portion of the stomach (fundus) herniates
                     through the hiatus into the caudal mediastinum along the caudal thoracic esophagus.
             A gastroesophageal intussusception is an invagination of the stomach into the lumen of the
                     caudal esophagus.
                  To reduce the intussusception, apply digital pressure to the cervical esophagus and
                          maximally insufflate. The endoscope may be used to gently push the
                          intussusception caudally.
                  Monitor for respiratory compromise.
        Esophageal neoplasia
             Primary esophageal neoplasia is rare.
             Multiple biopsies from the same location should be obtained, especially if the surface is
                     inflamed or necrotic.
             Firm masses may be biopsied by first stabbing repeatedly with a retractable
                     injection/aspiration needle, then grasping with the biopsy forceps.
        Esophageal foreign bodies
             See foreign body section
Gastroscopy
    Gastroscopy is a valuable tool for diagnosing primary gastric disorders including chronic gastritis,
          superficial gastric erosions, gastric foreign bodies, gastric motility disorders, ulcers, and
          neoplasia.
    Gastroscopy should be considered anytime there is hematemesis
    Preparation
        See notes at start of esophagogastroduodenoscopy
        Atropine and other anticholinergic drugs are not used unless they are required to maintain heart
               rate.
        Opioid drugs should not be used as they may increase pyloric tone.
    Anatomical terms
        Cardia
        Fundus
        Body
        Angularis (incisura angularis)
        Antrum
        Pylorus
        Greater curvature
        Lesser curvature
    During the initial examination, note any fluid or ingesta present, the ease with which the gastric walls
          distend with insufflation, and the gross appearance of the rugal folds and mucosa.
        Green or yellowish fluid may indicate reflux of intestinal contents into the stomach.
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                                      Jeffrey K. Saur, DVM, DABVP


            To remove fluid, position the endoscope tip parallel to the fluid and gastric wall, and suction
                   fluid.
                  Avoid suctioning fluid with particulate matter. Debris can lodge in the accessory
                         channel, clogging, and potentially damaging the channel.
       A retroflex view should be attempted/obtained to fully evaluate the cardia for lesions.
       To access the antrum, counterclockwise rotation on the up/down knob is used as the scope is
              advanced along the greater curvature.
       To access the pylorus, the pyloric opening is kept centered in the field of vision as the scope is
              advanced.
            Gentle, continuous pressure is applied to advance the scope through the pylorus.
            Once passed, clockwise rotation of both directional knobs may help advance the scope into
                   the proximal duodenum.
            If this fails, a biopsy forcep may be passed through the pylorus, and then the scope advanced
                   over the forcep into the duodenum.
            Monitor the patient as stretching and displacement of the gastric body and pylorus may elicit
                   vagal stimulation resulting in a bradycardia.
   Biopsy techniques
       The stomach should be only moderately insufflated, allowing for grasping of prominent rugal
              folds.
       The biopsy forceps are advanced towards the mucosa at an angle of 45o to perpendicular to the
              mucosa.
       The biopsy forceps are advanced to a fold, opened, advanced, and closed.
       The forcep is withdrawn steadily, with the biopsy sample shearing-off as it enters the accessory
              channel. Only in cases of significant disease will the forceps “bite off” tissue.
       Biopsies of ulcers and erosions should be obtained from the margins. This reduces the amount of
              inflammatory or necrotic tissue obtained, reduces the possibility of a perforation, and
              maximizes the diagnostic tissue.
       Masses should be biopsied repeatedly and deeply. Chose a site that can be approached easily.
              Then, biopsy the same site repeated, digging into the mass.
   Conditions and diagnoses: In general, let the pathologist make the diagnosis.
       Gastritis: Mucosal erythema, mucosal irregularity, friability, hemorrhage, erosions,
       Helicobacter-associated gastritis: Pathologists will find this. Don’t sacrifice a biopsy for culture
              or for a urea slat test.
       Erosions and hemorrhages
            Erosions: A shallow defect in the mucosa that does not extend into the submucosa.
            Hemorrhage: Discrete petecchiae or bright-red streaks not associated with visible breaks in
                   the mucosa.
            Associated with: stress lesions, critical illness, localized gastric trauma, ingestion of
                   corrosives, radiation, drugs (especially NSAIDs), discrete ischemia, mast cell tumors,
                   and idiopathic chronic erosions.
       Ulcers: An erosion that has breached the muscularis mucosa.
       Gastric polyps
       Gastric neoplasia:
            Adenocarcinoma is the most common gastric tumor in the dog.
            Lymphosarcoma is the most common gastric tumor in the cat.
Duodenoscopy
   Regions:
       Proximal duodenum
       Proximal flexure
       Descending duodenum
       Major duodenal papilla
       Minor duodenal papilla (in dogs)
       Caudal or colic flexure
       Ascending duodenum
   Descriptors
                                Gastrointestinal Endoscopy Basics                                       Pg. 7
                                      Jeffrey K. Saur, DVM, DABVP


         Cobblestone
         Erosion
         Erythema
         Fibrinous
         Fissures
         Grainy
         Granular
         Irregularity
         Proliferative
         Roughened
         Shaggy
         Swollen villi
         Velvety
         White discoloration
     Biopsy procedures
         Do not biopsy the major or minor duodenal papillae
         The biopsy forcep is opened, advanced to a specific target, closed, and retracted.
         The biopsy forcep is passed (blindly) until resistance is felt, retracted slightly, opened, advanced,
                closed, and retracted.
         The biopsy forcep is opened, advanced (blindly) against the mucosa until resistance is felt, closed,
                and retracted. Strips are often obtained in this manner. Depending on technique, a strip may
                break off, but can be retrieved by advancing the scope until it is visualized, then grasped
                with the biopsy forcep, and retracted.
     Conditions
         Inflammatory bowel disease
         Lymphangiectasia
               Swollen villi
               White discoloration
               Give 1-2 tablespoons of corn oil the night before the procedure to increase microscopic and
                     macroscopic lesions.
         Intestinal parasites
         Neoplasia: Lymphosarcoma, adenocarcinoma, mast cell tumors, leiomyoma, leiomyosarcoma,
                fibrosarcoma, ganglioneuroma, and carcinoid tumors.
         Protein losing enteropathies: A special consideration needs to be taken with those patients having
                low total protein and/or low albumin. Some of these patients will have inapparent pleural
                effusion that can compromise anesthesia. Thoracic radiographs should be taken prior to
                anesthesia to assess for the presence of a pleural effusion.
Gastroduodenoscopy
     This is the primary upper gastrointestinal endoscopy procedure. When generalized disease is
           suspected, the endoscope is rapidly advanced as far distally into the duodenum as possible.
           Inspection and biopsies are performed during withdrawal. By minimizing gastric manipulation
           and insufflation, the pylorus is more easily entered, thus reducing procedure time.
Ileoscopy, colonoscopy and colonoileoscopy
     Colonoscopy
         Used to diagnose inflammatory disorders, neoplasia, and fungal infections.
         Preparation
               The patient is withheld from food for 36 hours.
               The patient receives a combination of oral lavage and cathartic solutions, and enemas (see
                     attached colonoscopy preparation form).
               The patient is positioned in left lateral recumbency
         A digital rectal exam is performed to detect any distal lesions.
         The endoscope is then introduced into the rectum, using the digit to guide the scope tip past any
                folds in the rectum.
         The endoscope is advanced to the ileocolic junction.
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                                     Jeffrey K. Saur, DVM, DABVP


              The feline cecum is a blind pouch. If advancing the endoscopy is not improving visualization,
                     retract the scope and insufflate. The scope may already be in the cecum. A biopsy
                     forcep may be advanced to push the mucosa away from the endoscope to allow for
                     better visualization and recognition of the ileocolic valve.
    Ileoscopy
         Preparation is necessarily the same as it is for colonoscopy.
         Unless the approach angle to the ileocolic valve is straight, advancing the endoscope into the
                ileum can be difficult.
         Placing the patient in dorsal recumbency may help. Once the endoscope has been successfully
                passed into the ileum, the patient is returned to left lateral recumbency.
         The biopsy forcep may be passed through the valve, and then the endoscope advanced over it.
    Biopsies with colonoileoscopy
         Biopsies are obtained during withdrawal of the endoscope.
         Only moderate insufflation should be used.
         About 4-6 biopsies of the ileum should be obtained when possible.
         At least two biopsies should be obtained from each region: cecum, ascending colon, transverse
                colon, high descending colon, and lower descending colon.
         Multiple biopsies of specific lesions should be obtained and submitted in a separate container.
         When indicated, consider submitting a biopsy sample for Salmonella culturing, which can be an
                intracellular organism missed during fecal cultures.
    Post colonoileoscopy
         Suction excess air
         Theoretically antibiotics are not needed.
         Analgesics also are not needed.
    Conditions
         Colitis
         Strictures and obstructions
              Extramural obstruction: Smooth, normal appearing mucosa at level of obstruction
              Intramural obstruction: Similar to extramural, but often with some mucosal changes
              Mucosal disease is evident by irregular, roughened, highly inflamed mucosa.
         Neoplasia
Approach based on clinical signs
    When vomiting is the chief presenting complaint, biopsies obtained by gastroduodenoscopy is
          indicated.
         Cats, though, may present with vomiting due to lesions anywhere in the small intestine,
                ileocecocolilc area, or proximal colon.
              Diarrhea may or may not be present.
    When chronic small bowel diarrhea and/or weight loss occurs, especially with panhypoproteinemia,
          biopsies should be obtained by gastroduodenoscopy and ileoscopy.
    When chronic, nonspecific diarrhea is present, biopsies should be obtained by gastroduodenoscopy and
          ileocolonoscopy.
    When hematochezia, chronic vomiting (especially cats), dyschezia, tenesmus, and constipation are
          present, colonoscopy is indicated.
Foreign bodies
    Esophageal foreign bodies
         Most esophageal foreign bodies lodge at the thoracic inlet, the base of the heart, or at the lower
                esophageal sphincter.
         Clinical signs associated with an esophageal foreign body include salivation (which may include
                blood), regurgitation, odynophagia, dysphagia, retching, and anorexia.
    Gastric foreign bodies
         The most common clinical sign associated with a gastric foreign body is vomiting, which may be
                intermittent. Inappetence, anorexia, malaise, and abdominal tenderness may also be seen.
    General approach
         Obtain thorough radiographs. These may include cervical, thoracic and abdominal radiographs to
                evaluate for multiple foreign bodies.
                           Gastrointestinal Endoscopy Basics                                      Pg. 9
                                 Jeffrey K. Saur, DVM, DABVP


          Thoracic radiographs should be evaluated for evidence of an esophageal perforation.
                Pneumomediastinum, pneumothorax, subcutaneous emphysema, and/or pleural
                effusions may be seen.
          Abdominal radiographs should also be evaluated for signs of a perforation. Evidence of free
                air or a peritoneal effusion may indicate a perforation, and surgery should be
                considered.
          Wood and most plastic foreign bodies are radiolucent, and will not be evident on radiographs.
                An air gastrogram may make these more evident, whereas a barium series may mask the
                foreign body, and subsequently interfere with an endoscopic inspection.
When the history indicates, gastric and duodenal biopsies should also be obtained after a foreign body
      is removed. A prime example is when chronic vomiting was present prior to a known time of
      foreign body ingestion.
Esophageal foreign bodies should be removed as soon as possible.
Gastric foreign bodies should be removed if they are causing clinical signs, are unlikely to pass, are
      long and/or sharp, or are composed of toxic materials.
    Gastric foreign bodies that are best removed surgically include corncobs, rocks over 1-2 cm in
           diameter, balls, heavy objects, large pieces of cloth.
Complications of endoscopic foreign body retrieval include perforation, lacerations, worsened
      impaction, pyothorax, pneumothorax, pneumomediastinum, and peritonitis.
Equipment
    Very basic
          Alligator grasping forcep
          Snare
          Wire basket
          Overtube
          Bolt grabber
    Additional retrieval equipment: Two- or three-prong grasper
Esophageal foreign bodies
    The patient is placed in left lateral recumbency. This positions the esophagus above the aorta.
    A foreign body should be retrieved, or pushed into the stomach. Some foreign bodies may only be
           pushed to the distal esophagus, but this then allows for a surgical approach through a
           gastrotomy to grasp and retrieve the foreign body through the lower esophageal sphincter.
          All of these methods are preferable to esophageal surgery.
    When lodged kibble is unexpectedly encountered, copious lavaging and patience may reduce the
           kibble to mush, and minimize any mucosal damage.
    A foreign body may be partially embedded in the mucosa. An overtube may help dilate the
           esophagus and aid in the removal of the foreign body.
    Fishhooks: Overtubes are very helpful.
          The fishhook may be drawn inside the overtube, or the prongs pulled tight against the
                overtube, which then allows for safe withdrawal of the fishhook.
          The overtube may be aligned snuggly against a lodged fishhook, and then forcefully thrust
                caudally to dislodge it.
          A deeply embedded fishhook may be retrieved through a combination of thoracotomy and
                endoscopy. The penetrating barb may be snipped off surgically, and the balance of the
                fishhook retrieved endoscopically. This eliminates the need of a full-thickness
                esophageal incision.
    Bolt grabbers (obtainable at auto parts and hardware stores) may be passed next to the endoscope
           to grasp large objects
          Make sure to file down any sharp edges on the grabbers to prevent injury to the patient and
                tears to the endoscope.
          The bolt grabber may also be advanced through a separate overtube.
    When perforation is possible, follow-up thoracic radiographs should be taken at 12 and 24 hours
           post-procedure to evaluate for pneumomediastinum, pneumothorax, and/or subcutaneous
           emphysema.
Gastric foreign bodies
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                                   Jeffrey K. Saur, DVM, DABVP


   No matter how long the foreign body has been present in the stomach, radiographs should be
         obtained immediately prior to anesthesia to insure that the foreign body hasn’t finally passed
         out of the stomach.
   Linear foreign bodies that extend through the pylorus may be gently tugged on. If resistance is
         felt, the patient should be taken to surgery.
   Pennies minted since 1982 contain a toxic level of zinc, which is rapidly freed by the action of
         stomach acid. Immediate removal by induced vomiting, endoscopy or surgery is essential.
       A penny, nickel and dime should be placed next to the patient and a radiograph taken. This
               can aid in determining which coin(s) might be in the stomach. A folded towel may be
               placed under the coins to approximate the thickness of the body wall and fat. This may
               help in maintaining the same degree of magnification that occurs based on the distance
               between the subject and the film plate.
       A lot of nuts and bolts are zinc-coated, and should also be removed immediately.
   Bolt grabbers (obtainable at auto parts and hardware stores) may be passed next to the endoscope
         to grasp large objects
       Make sure to file down any sharp edges on the grabbers to prevent injury to the patient and
               tears to the endoscope.
       The bolt grabber may also be advanced through a separate overtube.
   Once a foreign body has been retrieved, the entire stomach and duodenum should be inspected for
         any remaining foreign material for the procedure to be considered completed.
Duodenal foreign bodies
   Linear foreign bodies may be gently tugged on. If resistance is felt, immediately proceed to
         surgery.
   A lot of duodenal foreign bodies have the aggravating habit of advancing distally at the approach
         of the endoscope. This is partially due to the air insufflation. This expands the lumen, which
         then frees the foreign body and allows the air to push it or peristalsis to carry it distally, until
         it is out of reach.
   Those duodenal foreign bodies that stay put are often so firmly lodged that surgery must be used
         to retrieve them.
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                                       Jeffrey K. Saur, DVM, DABVP



                         COLONOSCOPY PREPARATION
                                        (Or, Things Are Looking Up)

The following is a recommended procedure and timetable for preparing a patient for colonoscopy.

Oral lavage
   Two days prior to procedure
         Confine
         Start fast (water OK) in evening after highly-digestible meal (I/D, A/D)
         Open magnesium citrate, pour in pan, and allow de-fizzing overnight
   One day prior to procedure
         Have owner drop-off pet first thing in the morning
Water OK at all times during preparation, but DO NOT FEED
         HOSPITALIZE UNTIL AFTER PROCEDURE IS DONE
                   The lavage solution should produce a copious, unpredictable diarrhea that can ruin a
                        client’s house, carpets, and a good client-Veterinarian relationship
         Give Reglan 0.1 mg/LB IM at admission
         15 minutes later, administer
                   Magnesium citrate 10 - 15 cc/LB PO
                             Dogs: May need to stomach tube
                             Cats: Nasogastric tubes work well
                                  Place cat in cat bag, apply cat muzzle
                                  Place 2-3 drops ophthalmic topical anesthetic down left nostril
                                  Apply light layer of lubricant to 3 1/2 or 5 fr red-rubber feeding tube
                                                Lidocaine jelly works best
                                                K-Y Jelly OK
                                  Slowly advance feeding tube through nostril while firmly holding the cat’s
                                      head with other hand (1-2 technicians holding cat down in bag)
                                  When full length of feeding tube is in, slowly flush tube with 3 - 6 cc NaCl
                                      to make sure you’re in the esophagus, not the trachea.
                                  Slowly administer fluid through nasal tube
                                  Pinch off tube, then gently and slowly remove tube
                                  Unmask and unbag the (probably upset) cat
                   Take dogs for frequent walks throughout day
                   Make sure cats have ample litter box and litter
         In late afternoon, repeat Reglan IM
                   15 minutes later, Use Go-Lytely at 10 – 15 cc/LB PO
   Day of procedure
         Dogs
              Give gentle, warm water enema of 10 - 15 cc / LB first thing in the morning
              Repeat in 2 hours
         Cats:
              Give gentle, warm water enema of 9 cc / LB first thing in the morning
              Repeat in 2 hours
         If patient appears to have “cleaned itself out”, place in clean cage and wait for time of procedure
Colonoscopies generally are done between noon and closing
Anesthetic protocol as indicated by the patient’s overall health status
         NO NITROUS
         Narcotics should be avoided as they may cause intestinal spasms and make it more difficult to
                enter the ileum
                                 Gastrointestinal Endoscopy Basics                                        Pg. 12
                                       Jeffrey K. Saur, DVM, DABVP



                          COLONOSCOPY PREPARATION

Enemas
 I recommend doing two enemas the morning of the procedure after having done the usual oral lavage
preparation the day before, especially if little or no diarrhea has been produced, or if feces are still evident
on rectal:
          Enema: Warm water only
               Lactulose may also be used : 1 part per two parts water
          Pass large French feeding tube to level of last rib
          Administer prescribed amount of enema mixture rectally
          Return to cage, or take dogs for walks
                   I find it helpful to hold the cat’s tail firmly over the rectum and between its rear legs
                       until the cat is placed safely back in its cage (small dogs as well)
In general, I have found using only an enema as preparation inadequate in that there is usually fresh ingesta
entering the upper colon during the colonoscopy.

Hints on using the Go-Lytely lavage solution

This is available by prescription in a powdered form in a 4 liter container. Obviously our little patients are
not going to require the whole jug. I recommend making up an appropriate amount in a separate jar (like
500cc for a cat) and preserving the balance for future procedures.

    If you have a gram scale,
         Weigh the powdered contents
         Record total weight of powder, and the amount to make 500cc when combined with water, which
              will be 1/8th of the total weight of the powder
             Record amount in grams to make 500cc on jug
         Return balance to jug and store
         Mix appropriate number of 500cc aliquots for the job in a separate container

    If you don’t have a gram scale
         Pour powder into clean, very dry 60cc syringe or appropriately sized measuring cup
         Record total volume of powder, and the amount to make 500cc when combined with water, which
              will be 1/8th of the total volume of the powder
             Record amount to make 500cc in units of measure on jug (cc, Tbsp, cups, etc.)
         Return balance to jug and store
         Mix appropriate number of 500cc aliquots for the job in a separate container
                               Gastrointestinal Endoscopy Basics                                       Pg. 13
                                     Jeffrey K. Saur, DVM, DABVP


References

Chamness JJ: Endoscopic instrumentation. In Tams TR, editor: Small Animal Endoscopy (2nd ed.): Mosby,
    Inc., St. Louis. pp 1-16. 1999.

Leib MS: Esophageal strictures. Proceedings of the 18th Annual ACVIM Forum. pp 557-559. 2000.

Moore LE: The pros and cons of endoscopy. Proceedings of the 20th Annual ACVIM Forum. pp 533-534.
    2002

Sherding RG, Johnson SE & Tams TR: Esophagoscopy. In Tams TR, editor: Small Animal Endoscopy (2nd
     ed.): Mosby, Inc., St. Louis. pp 39-96. 1999.

Tams TR: Endoscopic examination of the small intestine. In Tams TR, editor: Small Animal Endoscopy
     (2nd ed.): Mosby, Inc., St. Louis. pp 173-215. 1999.

Tams TR: Endoscopic removal of gastrointestinal foreign bodies. In Tams TR, editor: Small Animal
     Endoscopy (2nd ed.): Mosby, Inc., St. Louis. pp 247-295. 1999.

Tams TR: Gastrointestinal endoscopy: Instrumentation, handling technique, and maintenance. In Tams TR,
     editor: Small Animal Endoscopy (2nd ed.): Mosby, Inc., St. Louis. pp 25-38. 1999.

Tams TR: Gastroscopy. In Tams TR, editor: Small Animal Endoscopy (2nd ed.): Mosby, Inc., St. Louis. pp
     97-172. 1999.

Willard MD: Colonoscopy. In Tams TR, editor: Small Animal Endoscopy (2nd ed.): Mosby, Inc., St. Louis.
     pp 217-245. 1999.

Willard MD: Rare esophageal diseases that are not rare if you look for them: Proceedings of the 18th
     Annual ACVIM Forum. pp 33-35. 2000.

Zoran D: Protein-losing enteropathies. Proceedings of the 75th Annual Western Veterinary Conference.
     Vet-122. 2003.

				
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Description: Major parts of an endoscope gastritis