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After retroflexion is performed, the endoscope should be straightened and advanced to the antrum. Once the pylorus is visualized, the scope should traverse the pyloric channel to intubate the duodenum. The duodenal bulb should be carefully examined more than once as pathology can be missed particularly in the superior bulb and posterior wall. The scope is advanced past the duodenal bulb while typically dialing up and right on the angulation knobs to enter the second portion. The scope is often advanced deep into the second portion of the duodenum during a reduction maneuver that removes the loop of scope that forms in the stomach during insertion.

In a patient with acute upper GI hemorrhage, the bulb, first, and second portions should be examined multiple times to assure that no pathology is missed, particularly in the blind portion of the first part of the duodenum. A side‐viewing scope may be useful for examining the duodenum when a duodenal source is suspected and the standard endoscope fails to identify a source. With modern high‐resolution scopes, duodenal villi are easily visualized and trainees should be taught to routinely evaluate the villi. Evidence of blunted villi may be evident from celiac sprue. The ampulla should be identified if possible and inspected for any abnormalities, though a side‐viewing scope is usually required for a detailed examination of this area (see Chapter 8). In order to obtain optimal visualization of the duodenum, it is recommended that the endoscopist angle the tip of the endoscope down and withdraw in a hooked position to see the bulb, then angle up again to advance over the superior duodenal angle, and rotate 90° clockwise while angling the endoscope up and right to enter and view the descending duodenum (Figure 5.11).