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