EGD
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EGD esophagogastroduodenoscopy procedure indications technique 2024
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Esophagogastroduodenoscopy (EGD)
EGD (upper endoscopy, gastroscopy) is a flexible endoscopic procedure that directly visualizes the oropharynx, esophagus, stomach, and duodenum (with extension into the proximal jejunum when needed). It is both a diagnostic and therapeutic tool and is one of the most commonly performed procedures in gastroenterology.
Anatomy Examined
- Upper esophageal sphincter (UES) and proximal esophagus
- Mid and distal esophagus, including the Z-line / ora serrata (~39 cm from incisors) — the squamocolumnar junction
- Gastroesophageal (GE) junction and cardia
- Gastric fundus, body, antrum, and pylorus
- Duodenal bulb and descending (second) duodenum; ampulla of Vater (tangential view)
Indications
Symptoms
- Dyspepsia / epigastric pain
- Dysphagia or odynophagia
- Persistent GERD / heartburn refractory to PPIs or H₂ blockers
- Noncardiac chest pain
- Chronic nausea/vomiting
- Early satiety
- Sensation of food sticking or foreign body
- Unexplained significant weight loss
Signs
- Unexplained anemia (iron-deficiency)
- Gross or occult GI bleeding / hematemesis
- Radiographic upper GI abnormality
- Palpable abdominal mass
Surveillance / Preexisting Conditions
- Barrett's esophagus surveillance
- Gastric polyposis, pernicious anemia
- Known esophageal stricture, esophagitis, gastritis, duodenal ulcer
- Symptomatic hiatal hernia
- Portal hypertension (variceal screening)
- Pre-transplant or pre-major surgery assessment in high-risk patients
- Caustic ingestion assessment
Therapeutic Indications
- GI bleeding control: electrocoagulation, heater probe, injection (epinephrine), laser
- Variceal management: band ligation, sclerotherapy
- Foreign body removal
- Stricture dilation: balloon (TTS) or bougie dilators
- Achalasia management: botulinum toxin, pneumatic dilation, POEM (per-oral endoscopic myotomy)
- Lesion removal: gastric polyps, duodenal adenomas, early mucosal neoplasia (EMR/ESD)
- PEG/PEJ tube placement (percutaneous endoscopic gastrostomy/jejunostomy)
- Palliative stenting for obstructing esophageal/gastric cancers
Contraindications
Absolute
- Suspected perforated viscus
- Cardiopulmonary instability
- Recent myocardial infarction
- Uncontrolled bleeding disorder (hemophilia, severe platelet dysfunction)
- Uncooperative patient
- Absence of informed consent
Relative
- Anticoagulation (diagnostic EGD is low-risk and generally safe; therapeutic procedures [dilation, polypectomy, PEG] require normalization of coagulation or bridging)
- Functionally symptomatic patients without alarm features (may not be warranted)
- Medically unstable / hospice/palliative care patients
- Benign asymptomatic radiographic findings (e.g., uncomplicated sliding hiatal hernia)
Equipment
The standard video esophagogastroscope has:
- Insertion tube ~100 cm long, 7.8–11 mm diameter
- Bending section allowing up to 180° deflection (for retroflexion)
- Channels for air/water insufflation, suction, and working instruments (2–3 mm; larger in therapeutic scopes)
- CCD imaging chip providing 30,000–850,000 pixels; high-resolution scopes can discriminate objects 10–70 μm in diameter vs. 125–165 μm with the naked eye
- Control knobs: up/down (large dial), left/right (small dial)
Ultrathin scopes (5.3–6 mm OD) allow unsedated transnasal EGD.
Accessories passed through the working channel include biopsy forceps, snares, sclerotherapy needles, heater probes, electrocautery probes, balloon dilators, variceal band ligators, and guidewires.
Technique
Preparation: NPO ≥6 hours. Informed consent. IV access. Monitoring: pulse oximetry, BP, ECG.
Sedation: Conscious/moderate sedation (midazolam + fentanyl or meperidine) is standard in the US. Topical pharyngeal anesthesia alone is common in Europe/Asia. Propofol (anesthesia-assisted) is used for complex cases or difficult-to-sedate patients.
Procedure steps:
- Patient positioned left lateral decubitus; mouth guard placed
- Scope introduced perorally (or transnasally for ultrathin scope) under direct vision — inspect oropharynx, epiglottis, vocal cords before entering esophagus
- UES traversed; esophagus examined (proximal esophagus best viewed on withdrawal)
- Z-line identified at ~39 cm
- Scope advanced into stomach with left-anterior angulation; air insufflated
- Retroflexion performed in antrum (180° up-deflection) to view cardia, fundus, GE junction, and hiatal hernia
- Antrum and pylorus examined; scope advanced through pylorus into duodenal bulb
- Right-turn maneuver to enter descending duodenum; Kerckring folds appear; ampulla visualized tangentially
- Withdrawal phase: careful re-examination of duodenum, stomach (re-inflate to flatten folds and detect small lesions), and esophagus; UES and larynx checked
- Air/CO₂ aspirated before full withdrawal
- Biopsies, CLO test (H. pylori rapid urease), or therapeutic interventions performed as indicated
H. pylori Testing via EGD
The CLO (Campylobacter-like organism) test is a rapid urease test performed on gastric biopsy specimens. Single biopsy sensitivity ~95%; two biopsies approach 100%. H. pylori distribution is patchy, so multiple samples are preferred. Histologic analysis can be sent if CLO test is negative but suspicion remains high.
Complications
Overall complication rate is very low: ~0.13–0.14% for diagnostic EGD. 60% of adverse events are cardiopulmonary complications from conscious sedation rather than mechanical complications.
| Complication | Notes |
|---|---|
| Perforation | Rare in diagnostic EGD; risk rises sharply with therapeutic procedures |
| Bleeding | From trauma or biopsy |
| Infection | Including aspiration |
| Cardiopulmonary | From sedation — most common category |
| Inadequate interpretation | Operator-dependent |
Perforation risk by therapeutic procedure:
- Esophageal dilation: 0.5%
- Dilation for achalasia: 1.7%
- Endoscopic thermal therapy: 1–2%
- Variceal sclerotherapy: 1–6%
- Laser therapy: 5%
- Photodynamic therapy: 4.6%
- Esophageal stent placement: 5–25%
Documentation
The EGD report should include: indication (symptoms/signs), sedation agents and doses, all endoscopic findings, biopsy sites and number, final diagnoses, and treatment plan.
Sources: Pfenninger and Fowler's Procedures for Primary Care, 3e | Yamada's Textbook of Gastroenterology, 7e | Sleisenger and Fordtran's GI and Liver Disease
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