The “eye” into the body
Scenario 1: Mr. Gao had a colonoscopy 8 years ago and found a polyp less than 1cm in size in his sigmoid colon. Due to his busy schedule, Mr. Gao did not undergo regular treatment as prescribed by the doctor and did not review it again in 8 years. Recently, Mr. Gao had another colonoscopy because of blood in his stool, and it was found that the small polyp had turned into a colon cancer with a diameter of more than 5cm, and almost blocked the whole intestinal cavity.
In modern society, people are under great pressure in life, employment and work, and these pressures can have adverse effects on the gastrointestinal tract. Many people have symptoms such as stomach pain, bloating, acid reflux, heartburn, abdominal pain, bloating, diarrhea and even constipation and blood in stool. The most common causes of these symptoms are gastritis, gastroduodenal ulcer, gastric cancer, esophageal cancer, and colitis, colon polyps, colon cancer, etc. The most common causes of these symptoms are gastritis, gastroduodenal ulcer, gastric cancer, esophageal cancer, and colon cancer. Among them, inflammation or polyps are benign lesions that can be treated well, while gastric cancer, esophageal cancer and colon cancer are malignant tumors that can be treated well only with early diagnosis and early treatment. The most accurate and intuitive way to diagnose these diseases early is to do gastroscopy and colonoscopy. These mirrors are like an “eye” that enters the body and can observe the lesions very visually. In the case of colon cancer, it is now believed that many colon cancers are caused by the malignant transformation of colon polyps. Therefore, as long as the colon polyps are detected early through colonoscopy, the nature of the colon polyps and whether there is early cancer will be determined, electrocoagulation will be performed in time for removal. This can achieve the effect of early treatment without the need of open surgery. If Mr. Gao mentioned above had undergone colonoscopic polyp removal 8 years ago, he could have completely avoided the occurrence of colon cancer. Currently, although Mr. Gao has undergone open surgery to remove the polyp, his survival prognosis will be greatly affected.
Not as painful as imagined
Scenario 2: Ms. Wang always felt uncomfortable in her upper abdomen recently and her appetite was not good, so after visiting the hospital, the doctor suggested her to have a gastroscopy. However, Ms. Wang was afraid because she heard from her friends that having a gastroscopy was as unpleasant as torture.
Currently, gastroscopy and colonoscopy are mostly used in Western countries as routine checkups for health checkups, outpatients or inpatients. However, in China, many people are reluctant to undergo gastroscopy and colonoscopy because they feel it is a very painful examination. In fact, with the advancement of painless gastroscopy and colonoscopy single-person operation technology, the operation time is significantly shortened, and most patients do not feel much pain during gastroscopy and colonoscopy. On the contrary, we found that many patients with gastrointestinal discomfort delayed to come for examination for a long time because they were afraid of gastroscopy, and after examination, they were often found to be in the middle or late stage of cancer, missing the best time for treatment.
Early diagnosis of stomach cancer depends on gastroscopy
Scenario 3: Mr. Li is 45 years old and was diagnosed with gastric ulcer many years ago. Over the years, he took some drugs on his own to relieve his symptoms when he had discomfort, so he almost did not have any re-examination. However, during a recent medical checkup, he unexpectedly found that he had advanced gastric cancer and liver metastasis.
In China, the incidence of gastric cancer ranks the first among digestive tract malignant tumors and the mortality rate ranks the third among systemic malignant tumors. “Bad habits + work pressure + genetic factors” have been clearly listed as high-risk triggers of gastric cancer, in addition to H. pylori infection, smoking and drinking, preference for salted and smoked food, family history of gastric cancer, pernicious anemia, etc. Some chronic benign gastric diseases such as gastric polyps, gastric ulcers and chronic atrophic gastritis may also turn into gastric cancer.
Studies have found that mental tension, high work pressure and irregular diet have increased the number of young gastric cancer patients. The number of young gastric cancer patients received by PKUH in recent years is also increasing, with the youngest patient being in his twenties. Due to the neglect of examination, most patients are already in the middle and late stage when they are diagnosed. The detection rate of early gastric cancer in China is not more than 10%, and Japan is also a country with a high incidence of gastric cancer, but due to the extensive gastroscopy screening in Japan, the detection rate of early gastric cancer can reach 50%-70% due to the routine gastroscopy examination every year above the age of 40. The 5-year survival rate of early gastric cancer can reach 95% after treatment, while the 5-year survival rate of mid- to late-stage gastric cancer is only 45%. As you can imagine, the effect of early diagnosis and early treatment of gastric cancer in Japan is much better than that in China.
Gastroscopy is the best screening method for early gastric cancer, and with the advancement of endoscopic technology, ultrasonic gastroscopy can be applied to determine the depth of lesions, and for early gastric cancer and precancerous lesions confined to the mucosal layer, gastric mucosal resection (EMR) or submucosal dissection (ESD) can be performed simultaneously under gastroscopy for minimally invasive treatment. This can save the patient from surgery and the treatment effect is the same as surgery.
Endoscopy can also stop bleeding
Scenario 4: Mr. Zhu, 34 years old, suddenly suffered from stomach discomfort after a full meal, vicious, vomiting and spitting out several mouthfuls of blood. An ambulance rushed him to the hospital emergency room, where doctors diagnosed a hemorrhagic gastric ulcer and promptly stopped his bleeding with an endoscope.
With the advancement of technology and equipment, gastroscopy and colonoscopy can not only examine the esophagus, stomach, duodenum and colon, but also serve as a means of treatment, such as microscopic hemostasis, polyp removal, foreign body removal, stricture dilation, stent placement, etc.
Upper gastrointestinal bleeding refers to bleeding from the gastrointestinal tract above the Trierz ligament in the esophagus, stomach and duodenum, and is often associated with vomiting blood, black stools or bloody stools. There are many causes of upper gastrointestinal bleeding, including peptic ulcer, esophageal varices, acute gastric mucosal lesions, gastroesophageal tumors, cardia mucosal tear syndrome and biliary and pancreatic diseases, among which upper gastrointestinal bleeding caused by peptic ulcer accounts for the first place. Once upper gastrointestinal bleeding occurs, as long as the situation allows, endoscopy should be performed in a timely manner to make a correct localization and qualitative diagnosis, and also to carry out hemostatic treatment under direct endoscopic view. Endoscopic hemostatic treatment includes injection of hemostatic drugs, tissue adhesive, electrocoagulation, ligature, metal clips, etc.
Gastroscopic dexterity to remove foreign body from upper gastrointestinal tract
Scenario 5: 5-year-old Ming Ming accidentally swallowed a button battery from a toy car while playing. Grandma said it was okay, the battery would be discharged eventually with food, and bought a lot of leeks for Ming Ming to eat. But Mingming’s mother was very worried and took Mingming to the hospital as a precaution. The hospital doctor used a gastroscope to quickly remove the battery from Ming’s stomach. The doctor said that it was lucky to get there in time, otherwise the battery could have damaged Ming’s digestive tract and even poisoning could have occurred.
A foreign body in the upper gastrointestinal tract is a pathological condition in which objects that cannot be digested remain in the esophagus and stomach and cannot be expelled from the body in time through the pylorus. Many people believe that the rate of natural elimination of foreign bodies from the digestive tract is high, especially in adults, and there are even many folk remedies. However, in recent years, many scholars believe that most foreign bodies in the digestive tract can be safely removed by gastroscopy, so it is advocated that all those who swallowed foreign bodies by mistake or intentionally should undergo emergency endoscopy and actively try to remove them if it is determined that there is no perforation.
According to the source of foreign body, it can be divided into exogenous foreign body (such as coins, pins, button batteries, fish spines, chicken bones, etc.), endogenous foreign body (such as roundworm mass, gastric persimmon stone, etc.), and medical foreign body (such as surgical residual sutures, hemostatic silver clips), etc. Foreign bodies are of different shapes, such as bamboo chopsticks and iron hooks, round coins, rings and buttons, irregular denture and toys, sharp blades and glass, etc. For larger and sharp foreign bodies, irregular hard foreign bodies and toxic foreign bodies, these foreign bodies are generally not easily discharged by themselves, and long stay easy to cause serious consequences such as gastrointestinal damage and poisoning. Button batteries should also be removed urgently, because too much time can cause damage or even perforation of the digestive tract due to the rupture of the battery shell and the leakage of a large amount of alkaline solution.
At present, 95% of foreign bodies in the upper gastrointestinal tract can be successfully removed by gastroscopy, making most patients free from the pain of surgical removal of foreign bodies. And in practice, it is also safe and effective to use adult gastroscopy to remove foreign bodies from the upper gastrointestinal tract of pediatric patients.
Endoscopic treatment of upper gastrointestinal stenosis
Scenario 6: Ms. Kim is 55 years old and has secondary esophageal stricture due to gastroesophageal reflux disease. Recently, Ms. Kim has always felt difficulty in swallowing and eating has become a painful task as a result. The gastroenterologist performed an esophageal dilatation with an endoscope and the results were satisfactory.
Patients with esophageal strictures often have difficulty swallowing or painful swallowing, which seriously affects the patient’s quality of life and can lead to complications such as malnutrition. Dilation of esophageal or cardia strictures can be performed through endoscopy by placing a balloon or metal dilator, and a stent can also be placed in the stricture site with the help of gastroscopy to maintain patency of the stricture site for a longer period of time.
The most common cause of esophageal stricture is benign ulcerative stricture secondary to gastroesophageal reflux. Most ulcerative strictures and many radiographic strictures are effectively dilated endoscopically with a success rate approaching 90% and can usually be performed on an outpatient basis.
The two most commonly used dilators are the guidewire-guided type, which allows for axial and spoke dilation, and the balloon type, which allows for spoke dilation only. The guidewire-guided dilator is easy to pass through the esophagus and is used for tighter strictures or when other dilators are not available; the balloon dilator can be used under direct endoscopic view for shorter strictures, anastomotic strictures, and cardia incontinence.
Stenoses secondary to malignant esophageal cancer often require endoscopic treatment. Patients with unresectable tumors or tracheoesophageal fistulas may require palliative dilatation, sometimes requiring placement of an esophageal stent. Stent placement begins with esophageal dilation followed by endoscopy to evaluate the location and length of the tumor. Under direct endoscopic view, a metal stent is placed to ensure that its distal end is 3-5 cm above the tumor or fistula.
Percutaneous endoscopic gastrostomy is preferred for enteral nutrition
Scenario 7: Ms. Qin’s mother needed enteral nutrition due to an oropharyngeal tumor, and her doctor recommended a percutaneous endoscopic gastrostomy to facilitate treatment. Ms. Qin was distressed by her mother and was reluctant to undergo further surgery. However, the doctor told her that this is actually a safe, effective and minimally invasive surgical treatment.
Many patients with normal gastrointestinal function but cannot eat through the mouth need enteral nutrition, and the most common method is to place nasogastric or nasojejunal nutrition tubes, which, although effective, also brings many difficulties and complications in clinical application. Currently, percutaneous endoscopic gastrostomy (PEG) can provide a safe, effective, and non-surgical way to establish long-term enteral nutrition access.PEG refers to the percutaneous puncture and placement of a gastrostomy tube under endoscopic guidance for gastrointestinal nutrition and other therapeutic purposes. PEG is now an alternative to surgical gastrostomy due to significantly lower complications and mortality than traditional surgical gastrostomy. It is very widely used in developed countries, while its use in China is extremely limited.
All patients who are expected to be unable to consume nutrients for more than 2 weeks or more should be given nutritional support. If the patient has normal gastrointestinal function and the expected duration of enteral nutrition support does not exceed 30 days, a nasogastric tube or nasoenteric tube can be placed for nutritional support. If the expected duration of enteral nutrition is greater than 30 days, gastrostomy should be considered. These patients can be those with severe neurological swallowing disorders or developmental disorders, traumatic or neoplastic obstruction of the oropharynx, or those with severe disease requiring prolonged tracheal intubation. The range of PEG indications for the population is now expanding and has been applied to patients with esophageal, head and neck cancer receiving adjuvant therapy. Patients with severe maxillofacial trauma can also benefit from PEG.
However, PEG is not indicated for patients with complete esophageal obstruction, coagulopathy, peritonitis, peritoneal dialysis, varices in the gastric wall, absence of the stomach and any patient who is unable to undergo gastroscopy.
Pancreatic pseudocysts can be treated with ultrasound endoscopy (EUS) guided puncture and drainage
A pancreatic pseudocyst is a cyst formed when blood and pancreatic fluid spill into the peri-pancreatic tissue and become encapsulated, and is called a pseudocyst because there are no epithelial cells within the cyst wall. About 75% of pseudocyst cases are caused by acute pancreatitis, about 20% of cases occur after pancreatic trauma, and 5% of cases are caused by pancreatic cancer. The majority of pseudocysts that occur after acute pancreatitis form 3 to 4 weeks after the onset of the disease. A small number of pseudocysts are asymptomatic and are detected only during ultrasound examination. In most cases, clinical symptoms are caused by the cyst compressing adjacent organs and tissues. Abdominal pain occurs in about 80% to 90% of cases. The pain is mostly in the upper abdomen, and the extent of pain is related to the location of the cyst, often radiating to the back.
Some pancreatic pseudocysts can subside on their own, but if the cyst does not subside on its own or continues to increase in size causing compression symptoms, or if secondary infection or even bleeding occurs, treatment is required. The traditional treatment is mainly surgical drainage, which is effective, but has more complications. In recent years, with the development of endoscopy and ultrasound endoscopy (EUS) technology, minimally invasive treatment of pancreatic pseudocysts has become possible. Endoscopic treatment of pancreatic pseudocysts is similar to surgical internal drainage surgery. Firstly, EUS examination can help diagnose pancreatic pseudocysts or other pancreatic cystic diseases and can accurately determine the relationship between the cyst and the gastrointestinal tract. If the shortest distance between the wall of the cyst and the wall of the gastrointestinal tract is <1 cm, the cyst can be punctured through the wall of the stomach or the wall of the duodenum under EUS guidance, and a guide wire can be placed into the cyst along the puncture needle tract. A stent tube can be placed along the guidewire, and the cyst fluid can flow into the gastrointestinal tract through the stent tube for the purpose of drainage.
EUS-guided gastrointestinal cyst puncture and drainage is safe and reliable and significantly reduces the complications associated with general endoscopic treatment of such diseases. Its main advantages are.
(1) accurate determination of the distance between the cyst wall and the stomach and duodenal wall and the presence of larger vessels between them, in order to select the best puncture site.
(2) The whole process of puncture and tube placement can be clearly displayed to avoid the puncture needle penetrating the cyst wall.
(3) It can observe the process of cyst shrinkage and disappearance, and thus determine the treatment effect.
When to do gastroscopy or colonoscopy
The indications for gastroscopy are as follows.
1.Where there are upper gastrointestinal symptoms, or barium meal X-ray examination fails to detect lesions, suspected esophageal, gastric and duodenal lesions (inflammation, ulcers, tumors, etc.) and clinical diagnosis cannot be confirmed.
2, upper gastrointestinal bleeding of unknown origin, confirmed by emergency gastroscopy.
3, diagnosed upper gastrointestinal lesions such as recurrent ulcers, atrophic gastritis and other precancerous lesions that require gastroscopic follow-up.
4, those who need endoscopy for treatment, such as microscopic hemostasis, polyp removal, stricture dilation, establishment of intestinal nutrition channel, stent placement, etc.
5, removal of foreign bodies from the upper gastrointestinal tract.
6, those with unexplained symptoms after upper gastrointestinal surgery (e.g., major gastric incision)
7, treatment of cardia incontinentia and other benign or malignant strictures.
For those who are over 30 years old and have lower gastrointestinal symptoms such as blood in stool and irregular stools; those who have a family history of colorectal cancer; those who have had colon cancer, polyps or have schistosomiasis or ulcerative colitis, colonoscopy should be performed regularly.
What preparations should be made before the examination
Patients should fast for 6 hours and abstain from smoking for 3 days before gastroscopy to reduce gastric juice secretion and pharyngeal irritation.
Those with gastric retention should be fasted for 3 days, given fluids, and the stomach should be lavaged before the procedure
application of 1% to 2% lidocaine solution to pharyngeal spray anesthesia before examination, or intravenous slow injection of imipramine, or intravenous general anesthesia by anesthesiologist if necessary.
The bowel should be prepared according to medical advice before colonoscopy in order to facilitate the smooth conduct of the examination.