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Biopsies in the esophagus can be useful to determine whether there is BE, changes consistent with gastroesophageal reflux, and eosinophilic esophagitis. It is recommended that two to four biopsies be obtained from both the distal and proximal esophagus to maximize the likelihood of detecting esophageal eosinophilia [13]. In the stomach, biopsies are useful to distinguish benign fundic gland polyps associated with PPI usage from hyperplastic or adenomatous lesions and to determine if H. pylori infection or any premalignant changes are present. Duodenal biopsies should occur if celiac sprue is suspected in a patient presenting with a variety of symptoms, including abdominal pain, diarrhea, iron‐deficiency anemia, or weight loss. In order to obtain tissue biopsies, the biopsy forceps should be introduced through the working channel of the endoscope. The forceps should be opened and placed on the area of tissue targeted for sampling. The forceps should be closed in order to grasp the tissue and then withdrawn from the scope with the tissue sent for laboratory analysis.

Figure 5.11 Angulation and hooking of the endoscope tip to aid with duodenal intubation and visualization.

Routine biopsies may be more challenging in the esophagus given its tubular nature. Particular care should be exercised while pushing the forceps out into the narrow lumen. The scope tip may need to be angulated to bring the forceps closer to the target area of mucosa. It is sometimes helpful to apply suction in order to bring the esophageal wall into close proximity of the biopsy forceps so that tissue can be obtained.