Anke Tillman March 2019
An Upper endoscopy examines the lining of the upper part of the gastrointestinal tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine). A thin, flexible tube, the endoscope, is used which has it’s own lens and light source, and shows the images on a video monitor. Pictures are taken usually from every part of the GI tract and placed, with a brief description of findings, in the EGD report. The endoscope is also able to take small tissue samples, biopsies, that will be sent to the lab and results will be listed in a pathology report which usually will be finalized 7 to 10 days after the procedure. EGD is also referred to as upper endoscopy, upper GI endoscopy, esophagogastroduodenoscopy (EGD) or panendoscopy. Usually in the case of infants and toddlers, an EGD is performed under general anesthesia. In some cases it will be useful to add an sigmoidiscopy to be done right after the EGD, to make the most use of the general anesthesia applied. A sigmoidoscopy is an examination of the large intestine from the rectum through the nearest part of the colon, the sig-moid colon, also carried out by a flexible scope with a light source and a camera, and able to obtain biopsies.
The fact in question is, what kind of results may we expect. What testing should be done, what findings can be detected.
FREQUENT QUESTIONS AND ANSWERS:
Q: Does the scope show reflux?
No. this is impossible. The patient fasts before the scope, so the stomach will be empty, and there is no regurgitation that possibly would happen right in the instant the scope is inserted into the esophagus. Evidence of reflux being present in the patient will be revealed though, by visible inflammation or ulceration of the esophageal lining. However, the absence of these does not rule out esophageal reflux.
Q: Does the scope show allergies?
No. It is also impossible to rule out allergies with a scope. The scope will obtain biopsies, and later in the pathology report there may or may not be eosinophilic cells, which may lead to the conclusion that this is an EGID, and EGIDs are associated with allergies. This would be up to further diagnosis in relation of number of eosinophils and clinical presentation. The absence of eosinophils in an pathology report though, does not rule out food allergies.
Q: Does the scope show celiac?
Not celiac itself, but damage to the intestinal mucosa from celiac. Biopsies are collected and examined to check for damage to the gut lining and lymphocytes, which is typical of celiac disease. Be advised that these changes usually only occur if a patient has been exposed to gluten for weeks before the examination. If your child never has been exposed to gluten in his/her diet, these changes would not be present, even if the child did indeed have celiac disease.
Q: Does the scope show esophageal thrush?
Yes, it does. Thrush shows as a white plaque laying on the superficial mucosa of the esophagus, sometimes it looks like strings. Its very distinctive, but even if it does not present with this obvious plaque, the path report will confirm if it truly is a fungal infection (thrush).
Q: Do we have to stop meds for the scope?
Since the number one reason for infants and toddler to undergo a scope is reflux, is not very helpful, and, in some cases, not even doable to stop PPI medication for the scope. Some provider do request stopping the PPI in order to see the “ true picture”. That should not be. The things that are checked for with the scope are anatomy and histology. Both do not change from recent PPI medication. The inflammation that does occur from untreated GERD will take weeks to month to develop. So only long term changes in mucosa will be visible in the scope and and pathology report. Still, the answer to the initial question can not be no in general, since in some cases it may be required to stop the PPI before the scope, one would be the biopsies for H. pylori. If H. pylori needs to be ruled out, the PPI medication needs to be stopped 7 days prior the scope, in order to avoid a false negative result.
Q: Does the scope show EoE?
No, EoE does not show visually in the esophagus. Only long term effects such as furrowing or rings will be visible. But still, they need confirmation from biopsies in order to be diagnose Eoe. Biopsies are collected throughout the GI tract and examined under the microscope to check for a certain type of white blood cells, eosinophils. Not every case when eosinophils are found is automatically a confirmed case of EoE. In order to be diagnosed, certain criteria have to be met. While it is not uncommon to find scattered eosinophils in the GI system, for an EoE diagnosis the patient needs to have been on a sufficient dosage of PPI at least 6 weeks prior the biopsies. This is crucial to rule out eosinophilia that may be brought on by untreated GERD. Furthermore, in EoE the eosinophils do appear in a certain pattern, as they tend to build clusters, or hotspots. So, it needs a professional interpretation of pathology report in combination with considering clinical presentation and symptom correlation in order to diagnose EoE. In some cases eosinophils may also be found in gastric or duodenal mucosa, or in rectum during an sigmoidoscopy. Then, an EGID (Eosinophilic Gastrointestinal Disease) may be diagnosed, but similar criteria like explained for EoE diagnosis will apply. The best provider for diagnosing and treating cases with eosinophila are EGID departments incorporated in GI departments of children´s Hospitals, as usually a GI doctor works in a team with an allergist and nutritionist.
Q: Does the scope show a hiatal hernia?
Yes, it does. But the performing doctor needs to apply a certain maneuver to retroflex the scope inside the stomach, looking upwards to the LES from underneath. Then, a hernia if present, does show, also if the LES has problems closing properly around the scope this will be visible. If the retroflex maneuver has been carried out, the doctor usually takes one picture of it and this is included with the pictures in the EGD report. The picture is distinctive from the others, as it is the only one that shows the black tube, when the camera that is connected is pointing upwards, the scope takes a picture of itself, like a snake would see, looking at her back.
Q: Does the scope show malabsorption?
Yes, it does. Biopsies from the small intestine should be checked for disaccharidase enzymes. These are: Lactase, Maltase, Sucrase and Trehalase. In very rare cases we see one of these missing, which would be genetic and result in a malabsorption of the specific sugar, such as fructose, when Sucrase is missing. In infants and toddler with GERD, if we see abnormal results, we usually see all 4 of these enzymes lower than reference range (but not almost zero as in genetic caused malabsorption) . Then, we don´t have a congenital deficiency, rather, it is acquired and transient, due to inflammation of the wall of the small intestines.
Q: What should I walk away with after the procedure?
You will meet the performing doctor again right after the procedure in the recovery room. At this point he should give you a brief explanation of the findings, in combination with the printed EGD report. This is usally between 1 to 5 letter size documents, with a description of the procedure and findings, as well as photos. Do not accept any less than this, do not accept a doctor commenting to you in the hallway like “the scope was “all normal” or a nurse telling you this. Arrange a follow up appointment 7 to 10 days after the procedure, when the pathology report from the lab is in, and discuss everything with your doctor, going through and reviewing the path report, biopsy by biopsy, and have him explain what everything means. Then, establish a new treatment plan, one that makes sure to incorporate the conclusions of the results from this procedure.
Here is a table with all tests and documents you need from your EGD, in order to get the most possible results out of this procedure.
|conditions||diagnosed by||documented in|
|overall visual impression, including ulcers, furrowing, rings, polyps, severe inflammation||performing provider||EGD report|
|retroflex maneuver to rule out hiatal hernia
|picture in EGD report|
|Pathology results of biopsies, changes in histology including inflammation, fungus infections and findings of eosinophils, H. pylori, celiac||pathology lab||pathology report|
|Disaccharadise enzymes to rule out malabsorption / inflammation of small intestines||pathology lab||Disaccharidase pathology report sheet (usually separate)|