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The trainee should be instructed not to point the endoscope tip at the patient until adequate sedation has been administered, as the light from the endoscope may distract the patient and result in the need for additional medications for moderate sedation. Some physicians place a washcloth over the patients' eyes in order to prevent the distraction from visualization of the endoscopy equipment, especially if the patient is undergoing the procedure without sedation. When it is time to start the procedure, the endoscopist should stand acing the patient with the endoscope held directed toward the patient's mouth. The patient's head should be flexed with the chin toward the chest, to facilitate esophageal intubation.

The trainee should be instructed to hold the control head of the endoscope in his/her left hand, using the thumb and third or fourth finger to control the up/down and left/right angulation knobs (Figure 5.9). The forefinger and thirrd finger can be applied to the suction and air/water buttons as needed. The trainee should be encouraged to learn to use the left hand to control both knobs and buttons rather than taking the right hand away from the endoscope to help control the knobs, as this technique may lead to loss of endoscope position and increased loop formation particularly during colonoscopy.

Figure 5.7 White light HRE view of (a) esophageal squamous cell carcinoma (SCC) (University of Amsterdam, Amsterdam, Netherlands), (b) a gastric inlet patch upon slow withdrawal of the endoscope from the esophagus (Mount Sinai School of Medicine, New York City, USA), (c) multiple tiny white plaques suggesting candidiasis that actually represent eosinophilic esophageal microabscesses (NYU School of Medicine, New York City, USA), (d) smooth benign esophageal stricture (Mayo Clinic, Jacksonville, USA), (e) white, curd‐like exudate of Candidal esophagitis (endoscopic appearance is sufficient to make this diagnosis) (Mayo Clinic, Jacksonville, USA), (f) Nissen‐type fundoplication with intact wrap (Mayo Clinic, Jacksonville, USA), (g) early gastric carcinoma in a background of intestinal metaplasia and atrophy (University of Amsterdam, Amsterdam, Netherlands), (h) benign appearing gastric ulcer with smooth regular borders (Institut Arnault Tzanck, Saint‐Laurent‐du‐Var, France), (i) Brunner's gland hyperplasia of the duodenal bulb (Institut Arnault Tzanck, Saint‐Laurent‐du‐Var, France), (j) arteriovenous malformation (Mayo Clinic, Jacksonville, USA), (k) bile duct adenoma with high‐grade dysplasia (note yellow‐colored bile) (Mayo Clinic, Jacksonville, USA), and (l) complete villous atrophy (Institut Arnault Tzanck, Saint‐Laurent‐du‐Var, France).

(Contributed with permission from Advanced Digestive Endoscopy: Comprehensive Atlas of High‐Resolution Endoscopy and Narrowband Imaging. Edited by J. Cohen. Blackwell Publishing. 2007: pp. 170, 208, 207, 206, 178, 239, 229, 223, 246, 260, 256, 259.)