Читать книгу Successful Training in Gastrointestinal Endoscopy - Группа авторов - Страница 94

The esophagus should be examined for any structural abnormalities including ulcerations, varices, strictures, rings, webs, and other findings. While routine endoscopy does not replace the information obtained during esophageal motility, a global assessment of motility can often be ascertained. In particular, patients with achalasia may be noted to have absent esophageal peristalsis, as well as a dilated esophagus and tight‐appearing GEJ that does not easily open with air insufflation. In patients with esophageal varices (EV), air should be insufflated in order to accurately stage varices, determine the number of columns present, the extent of esophagus involved, and the presence of any stigmata. The location of the GEJ should be noted in centimeters along with its appearance (regular versus irregular) and whether salmon‐colored mucosa is present in the tubular esophagus. The proximal extent of the gastric folds should be located. The diaphragmatic pinch can be identified by noting where the diaphragmatic crura “pinches” the esophagus or stomach. If a hiatal hernia is present, the size of the hernia should be measured from the top of the gastric folds to the diaphragmatic pinch, and a patulous hiatus documented on retroflexed view of the cardia.

Any fluid present upon entrance into the stomach should be suctioned if possible to avoid potential aspiration or reflux. Adequate examination of the stomach requires extensive air insufflation and up‐close inspection of each segment. Retroflexion is necessary for complete visualization of the fundus and cardia (Video 5.3). Commonly missed lesions in the stomach include varices in the fundus and Dieulafoy's lesions near the cardia when endoscopy is performed after bleeding has ceased. Subtle mucosal abnormalities in early gastric cancer are also commonly missed.

To perform retroflexion, the tip of the endoscope should be in the antrum and the stomach insufflated with air; by angulating the tip 180° and gently advancing the endoscope, views of the fundus and cardia can be obtained. In this position, the shaft should then be rotated 180° in both directions. With the instrument retroflexed, the endoscope should be withdrawn to obtain close‐up views of the fundus and cardia (Video 5.2).