L-5
Endoscopic procedures
ENDOSCOPY



The use of fiber-optic scopes for the
purpose of examination, diagnosis,
and treatment.
Began as a diagnostic tool.
Now most scopes are equipped w/
various gizmos for: biopsy,
cauterization, and a wide variety of
instruments for advanced surgical
procedures.
2
COMPLICATIONS / RISKS









Risk depends on the nature of the procedure
and the anesthesia involved.
There are possible 7 risks of any
endoscopy.
1) Perforation.
2) Aspiration.
3) Adverse drug reaction.
4) Cardiovascular problems, arrhythmias.
5) Bleeding.
6) Infection.
7) Reaction to contrast material.
3
BRONCHOSCOPY






Examination of the trachea and main
stem bronchi.
Primary purpose is to diagnose
malignancy.
Also used to remove foreign bodies.
Can do biopsies, washings, and brush
biopsies.
Can culture for pathogens: Pneumocystis
carinii, Legionella.
Done under conscious sedation w/ topical
anesthetic, or general anesthesia.
4
LARYNX
5
BRONCHOSCOPY
6
GASTROINTESTINAL
ENDODOSCOPY







ESOPHAGOSCOPY- esophagus only.
GASTROSCOPY- esophagus and stomach.
ESOPHAGOGASTRODUODENOSCOPYesophagus, stomach, & duodenum.
PROCTOSCOPY- anus & rectum.
SIGMOIDOSCOPY- rectum and sigmoid
colon.
COLONOSCOPY- rectum and entire colon.
Usually done under conscious sedation,
occasionally general
7
GASTROINTESTINAL
ENDODOSCOPY




USES
DIAGNOSIS / DETECTION OF:
malignancy, ulcers, bleeding,
inflammation, etc.
Removal of foreign bodies.
Biopsy of polyps, lesions suspicious for
malignancy, etc.
Control of bleeding via cautery, ligation.
8
ESOPHAGUS
IMAGES COMPLIMENTS OF :http://www.gicare.com/pated/ei00001.htm
9
Barretts Esophagus
10
Esophageal Varicies
11
Gasric hypylori inflammation
12
Duodenal Ascariasis
13
Foreign body Duodenum
14
EUS LIV. Metastasis
15
Colonic Diverticuli
16
LOWER ESOPHAGEAL SPHINCTER
CLOSED
OPEN
17
REFLUX – (GERD)
18
ESOPHAGEAL VARICES
19
ESOPHAGEAL POLYP
20
CANCER OF THE ESOPHAGUS
21
ESOPHAGEAL MONILIASIS
22
NORMAL STOMACH
FUNDUS
ANTRUM
PYLORIS
23
HEMORRHAGIC GASTRITIS
24
GASTRIC ULCER
25
FOREIGN BODY - STOMACH
26
FOREIGN BODY - STOMACH
PEARL EAR-RING
27
STOMACH CANCER
28
POLYPS - STOMACH
29
NORMAL DUODENUM
30
AMPULLA OF VATER
31
DUODENAL ULCERS
32
DUODENAL STRICTURE
33
E.R.C.P.




Endoscopic Retrograde
Cholangiopancreatography.
Endoscope passed to the duodenum, w/
cannulation of the Ampulla of Vater.
Dye is injected and films taken.
Used to evaluate the patency and
integrity of the common bile duct, R/O
obstruction, such as w/ stones.
34
E.R.C.P.

Helpful in the post-cholecystectomy
patient who has a post-op complication:
stone obstructing the CBD, stricture, etc.
35
E.R.C.P.
36
E.R.C.P.
37
NORMAL JEJUNUM
38
CELIAC SPRUE
39
COLONOSCOPY




USES
Evaluation of rectal bleeding, abdominal pain,
etc.- cancer, polyps, inflammatory bowel
disease.
Biopsy of suspicious lesions, polyps,
inflammation.
Control of bleeding, banding of hemorrhoids.
Also used as a screening tool for early diagnosis
of colon cancer, along w/ rectal exam and test
for fecal occult blood.
40
NORMAL COLON
41
INTERNAL HEMORRHOIDS
42
DIVRTICULOSIS
43
DIVERTICULITIS
44
ADENOMATOUS POLYP
45
CROHN’S DISEASE - COLON
46
CROHN’S DISEASE - ILEUM
47
ULCERATIVE COLITIS
48
CANCEROUS COLON POLYP
49
CANCER - RECTOSIGMOID
50
LAPAROSCOPY




Endoscopy of the abdomen (and pelvis).
Wide variety of uses, too numerous to
mention, but examples would be:
diagnosis and treatment of gynecologic
pathology – endometriosis, ectopic
pregnancy, infertility, and much more;
Cholecystectomy; appendicitis, etc.
Has greatly reduced the hospital stay,
cost, pain, and recovery period as
compared to “open” procedures
(laparotomy).
51
LAPAROSCOPY



The abdomen is insufflated w/ CO2 in order to
“lift” (distend) the abdominal wall up off the
abdominal contents, to allow for visualization,
room to work in, etc.
Post-op, these patients experience right
shoulder pain as the CO2 lodges under the right
hemi-diaphragm, which is innervated by C-3-45.
Because of the CO2, general anesthesia is
generally used, as patients are unable to
ventilate w/ large volume of CO2 on board.
52
LAPAROSCOPY – ECTOPIC
PREGNANCY
53
LAPAROSCOPY – ECTOPIC
PREGNANCY
54
LAPAROSCOPY – GALL BLADDER
55
LAPAROSCOPIC
CHOLECYSTECTOMY
1
2
3
56
HYSTEROSCOPY - FIBROID
57
HYSTEROSCOPIC MYOMECTOMY
58
ARTHROSCOPY




Evaluation of joint pathology.
Most commonly used in the knee –
torn menisci, ACL’s, etc.
Used both as a diagnostic tool and
for surgical repair.
Depending on the joint, can be done
under general anesthesia, or w/
regional block and sedation.
59
NORMAL KNEE ANATOMY
60
ARTHROSCOPY – TORN MENISCUS
(MF)
61
ARTHROSCOPY – NORMAL ACL
62
CYSTOSCOPY




Evaluation of the bladder, and urethra.
For diagnosis and treatment of urethral
and bladder pathology, as well as for
TURP’s.
Can also evaluate the ureteral orifices,
and can cannulate the orifice and inject
dye into the ureter, a “retro-grade”
pyelogram.
Topical anesthesia can be used, but if
extensive diagnostic or therapeutic
procedures are done, sedation or regional
block can be used.
63
DIAGNOSTIC PROCEDURES RELATED
TO THE CHILDBEARING YEARS
CHAPTER 28
TESTS OF TUBAL PATENCY


1) THE HSG – HYSTEROSALPINGOGRAM –
X-Ray study w/ dye injected thru the cervix –
detects tubal occlusion, also looks at the
anatomy/contour etc. of the uterine cavity (ies).
2) LAPAROSCOPY W/ TUBAL DYE STUDY –
If needed to look for intra-abdominal pathology
as the problem, such as endometriosis, etc
65
IF EVERYTHING IS NORMAL…



Would typically proceed w/ laparoscopy.
Looking for: tubal patency (dye study),
presence of adhesions (old PID), and
endometriosis, which is a common finding in
patients w/ otherwise unexplained infertility to
this point.
Some physicians would also do a hysteroscopylooking inside the uterine cavity to look for
anatomic malformations, intracavitary / submucous firoids, adhesions (Asherman’s
Syndrome), etc.
66
TESTS DURING PREGNANCY
TO DETECT CHROMOSOMAL, GENETIC,
AND/OR STRUCTURAL
ABNORMALITIES
 DONE IN PATIENTS W/:
 1) Advanced Maternal Age Risk - > age
35. Risk of chromosomal abnormalities
increases with increasing maternal age.
 2) Family or personal history of genetic or
chromosomal abnormalities.
67
Ultrasonography
Obstetrics
CRL: Crown Rump Length

Earliest
detection at 45 weeks
69

11-12
week fetus
shows
division of
hemispher
es and
choroid
plexus
70
Fetal Spine
71
Liver/Lung Interface
72
Study of intracranial features including the
cerebellum and corpus callosum.
73
Umbilical Cord
74
3D imaging of placenta
75
3D Imaging of eyeball sockets at 12
weeks
76
Diagnosis of fetal malformation.







Hydrocephalus
Anencephaly
Myelomeningocoele
Achondroplasia,
Spina bifida,
Cleft lips/ palate and
Congenital cardiac abnormalities
77





placenta previa
diabetes,
fetal hydrops,
Rh isoimmunization and
severe intrauterine growth retardation
78
ULTRASOUND




3 “levels” of ultrasound.
Level I – the basics – how many babies, how much
fluid, where’s the placenta, gestational age, is the
heart beating, etc.
Level II – all the above plus a cursory evaluation
for structural abnormalities – how many kidneys,
does the heart have 4 chambers, etc.
Level III – targets specific areas, looking for the
“usual’ signs of Downs, specific cardiac defects,
neurologic defects, etc – usually done in response
to something not being normal, elevated AFP, etc.
79
AMNIOCENTESIS





Removal of amniotic fluid for evaluation for:
1) Karyotype – the chromosome analysis; looks
for Downs, other trisomies, etc.
2) Biochemical defects – numerous metabolic
disorders such as the glycogen storage diseases
(galactosemia, Tay Sach’s, etc), and can also test
for genetic “markers” for things such as
Huntington’s Chorea, muscular dystrophy, etc.
Typically done under ultrasound guidance at 1618 weeks, sometimes combined w/ a Level III
scan.
Karyotype can take up to 2 weeks for results.
80
CHORIONIC VILLUS SAMPLING






The CVS.
Trans-cervical sampling of the chorionic
villi, part of the placenta of fetal origin.
Since there is no fluid, is limited to
chromosomal and genetic analysis.
Done at 10-12 weeks.
Risk of amnio = 1/200.
Risk of CVS = 1/100, but get earlier
results.
81
AMNIOCENTESIS FOR Rh DISEASE




Rh Disease = Isoimmune Erythroblastosis
Fetalis = Hemolytic Disease of the
Newborn.
The gist of it is that the mother’s anti-Rh
antibodies results in hemolysis of fetal
RBC’s.
This results in excess bilirubin, which can
be detected in the amniotic fluid.
In a nutshell, when hemolysis is severe
enough, can decide to do an intrauterine
transfusion or delivery, depending on
gestational age.
82
ASSESSMENT OF FETAL MATURITY


When deciding to deliver a baby,
especially if it is pre-term, it is
useful to know if the baby’s lungs
are mature.
Ventilation depends on the ability of
the alveoli to remain open, which is
dependent on surface tension,
which is dependent on surfactant.
83
ASSESSMENT OF FETAL MATURITY





There are 3 chemicals values which, when
present in the amniotic fluid, predict the
presence of adequate surfactant and
pulmonary maturity, so that delivery can
proceed without having to worry about
delivering a baby unable to breath /
oxygenate.
These 3 chemical values are:
1) The L/S ratio- lecithin and
sphingomyelin.
2) S/A ratio- surfactant and albumin.
3) PG- phosphatidylglycerol.
84
TESTS OF FETAL WELL-BEING





Fetal well-being, in a nutshell, means the
degree to which a fetus is receiving
oxygen from the placenta.
3 tests are commonly done to assess this:
1) THE NST- the non-stress test.
2) THE CST-contraction stress test (your
text calls it the contraction stress test).
3) THE BIOPHYSICAL PROFILE.
85
THE NST





The stress that is missing in the non-stress
test is the stress of uterine contractions.
The healthy fetus (and placenta) will
ordinarily show variation in the fetal heart
rate (FHR).
The NST looks for this variation, which is
often associated w/ fetal movement.
The results are read as reactive, nonreactive, and equivocal.
Reactive is reassuring, non-reactive is not.
86
NON-STRESS TEST
87
THE CST



During a contraction, blood flow to the placenta
(utero-pacental blood flow) is greatly
decreased. Normally, there is enough “placental
and fetal reserve” to compensate for this lack
of perfusion.
Pregnancies in which placental function is
diminished do not have this reserve.
When diminished reserve is present, the fetal
heart rate will slow during a contraction, which
indicates a fetus that is now or is soon to be
compromised, and one that will not likely
withstand the stress of labor.
88
THE CST

If the CST is positive (non-reassuring), delivery
is generally considered, often by C-section.
89
THE BIOPHYSICAL PROFILE








An ultrasonic evaluation of:
1) Fetal movement.
2) Amniotic fluid volume.
3) Fetal muscle tone.
4) Fetal breathing activity, and
5) The NST.
Each parameter is given a score of 0, 1,
or 2.
10 is good, below 6 or so is bad.
90