Describe the anatomy of the oesophagus, stomach, and duodenum relevant to bleeding. Use Bailey and Love Short Practice of Surgery 28th Edition, Sabiston Textbook of Surgery 21st Edition, Shwartz's Principles of Surgery 11th Edition, and any anatomy textbooks that reliable as references, and for each part state what reference the information was extracted out of.

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Anatomy of the Oesophagus, Stomach, and Duodenum Relevant to Bleeding

1. OESOPHAGUS

General Anatomy and Divisions

The oesophagus is a muscular tube connecting the pharynx to the stomach. It begins at the level of the cricoid cartilage (C6 vertebra) and ends at the oesophagogastric junction (OGJ), which lies opposite the T11 thoracic vertebra. In the neck, it descends behind the trachea and anterior to the vertebral column. At the lower thoracic cavity, it traverses the diaphragmatic hiatus, clasped by the crura of the diaphragm, before joining the stomach.

For clinical purposes, the oesophagus is divided into cervical, thoracic, and abdominal segments - divisions that are relevant for cancer staging. The OGJ is anatomically defined as the point where the tubular oesophagus becomes the saccular stomach; endoscopically it corresponds to the top of the gastric folds.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1127-1129

Arterial Supply

The arterial supply of the oesophagus is segmental and derived from three levels:

Cervical oesophagus: supplied by the inferior thyroid artery (from the thyrocervical trunk).
Thoracic oesophagus: supplied segmentally by branches of the descending aorta (approximately five oesophageal arteries arising anteriorly), as well as by bronchial arteries. These form a vascular chain on the oesophagus that anastomoses superiorly with the inferior thyroid artery branches and inferiorly with the left phrenic and left gastric artery branches.
Abdominal oesophagus: supplied by the left gastric artery and the left inferior phrenic artery.

The anastomotic nature of this blood supply renders the oesophagus virtually immune to ischaemic infarction, which is why the stomach can be mobilised as a conduit for oesophageal replacement after oesophagectomy.

Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Blood Supply of the Oesophagus

Note: While a specific "oesophageal blood supply" section was not identified in Bailey & Love Chapter 66 by heading, Bailey & Love (28th Ed., p. 1170) describes the left gastric artery branches passing towards the cardia as part of the gastric blood supply discussion, and the gastroduodenal artery's relevance to bleeding is highlighted in the stomach chapter.

Venous Drainage - Critical for Variceal Bleeding

This is the most clinically relevant anatomical feature of the oesophagus with respect to bleeding.

Venous drainage begins via a dense submucosal venous plexus, which then drains into a perioesophageal (peri-adventitial) venous plexus.
From here, drainage is regionally divided:
- Cervical oesophagus: drains into the inferior thyroid vein via the brachiocephalic veins (systemic).
- Thoracic oesophagus: drains primarily into the azygos vein, and to a lesser extent the hemiazygos, intercostal, and bronchial veins (systemic).
- Abdominal oesophagus: drains into the left gastric (coronary) vein, which meets the oesophageal veins at the lesser curvature of the stomach and then drains into the portal vein (portal).

This creates a critical porto-systemic anastomosis at the level of the central diaphragmatic tendon (approximately vertebral level T8), where the portal venous system (via the left gastric/coronary vein) meets the systemic venous system (via the azygos and hemiazygos veins). When portal pressure rises (portal hypertension from any cause - cirrhosis, portal vein thrombosis, etc.), these submucosal venous channels at the lower oesophagus dilate to form oesophageal varices. The lower oesophagus is the most common site of variceal haemorrhage, which presents as acute large-volume haematemesis with high morbidity and significant mortality. Failure to control variceal bleeding with current medical management occurs in 10-20% of cases.

Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Blood Supply of the Oesophagus, lines 137-156
Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1224-1225 (Management of variceal bleeding)

Histological Layers

The oesophageal wall has four layers from inside outward: mucosa (lined by stratified squamous epithelium), submucosa, muscularis propria (inner circular and outer longitudinal), and adventitia (no serosa - this is relevant to surgical repair and the tendency for anastomotic leaks). The submucosal layer is particularly important as it contains the rich vascular and lymphatic plexuses relevant to both bleeding and cancer spread.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1129 (Fig. 66.3)

2. STOMACH

Gross Anatomy and Relations

The stomach is the most proximal abdominal digestive organ. Its key anatomical parts are:

Cardia: the part attached to the oesophagus, just below the OGJ. Just proximal is the physiologically demonstrable but anatomically indistinct lower oesophageal sphincter (LOS).
Fundus: the distensible superior portion, bounded superiorly by the diaphragm and laterally by the spleen. The angle of His marks where the fundus meets the left side of the GE junction.
Body (corpus): contains most of the parietal (acid-secreting) cells.
Antrum: the distal 25-30%, beginning at the angularis incisura.
Pylorus: connects the stomach to the first part of the duodenum; the circular muscle here forms a true anatomic sphincter.

Important relations: the left lateral segment of the liver covers the anterior stomach; the gastrohepatic (hepatogastric) ligament connects the liver to the lesser curve and contains the right and left gastric arteries. The gastrocolic ligament (omentum) attaches the greater curve to the transverse colon and contains the gastroepiploic vessels. The gastrosplenic ligament contains the short gastric arteries.

Schwartz's Principles of Surgery, 11th Edition, pp. 1127-1128
Sabiston Textbook of Surgery, 21st Edition, p. 1769

Arterial Supply

The stomach is the most richly vascularised portion of the alimentary tube, with an extensive intramural anastomotic network. The celiac axis provides the majority of the blood supply via four named arteries:

Left gastric artery - consistently the largest artery to the stomach; arises directly from the celiac trunk; divides into ascending and descending branches along the lesser curvature. It also gives branches towards the cardia and lower oesophagus. Importantly, in approximately 20% of cases it supplies an aberrant vessel to the left lobe of the liver (accessory or replaced left hepatic artery) travelling in the lesser omentum - inadvertent ligation of a replaced left hepatic artery may cause significant hepatic ischaemia.
Right gastric artery - arises from the proper hepatic artery near the pylorus; runs proximally along the lesser curvature to anastomose with the left gastric artery forming a lesser curvature arcade.
Left gastroepiploic artery - arises from the splenic artery; runs along the proximal greater curvature.
Right gastroepiploic artery - arises from the gastroduodenal artery (GDA) behind the first part of the duodenum; forms a greater curvature arcade with the left gastroepiploic artery. This arcade is often variably incomplete.

Additionally, the short gastric arteries (vasa brevia) arise from the terminal splenic artery to supply the fundus. Branches from the phrenic and splenic circulation may also supply the proximal stomach.

The extensive anastomotic connections mean the stomach survives ligation of up to three of four main arteries, provided the arcades along both curvatures remain intact - a principle used in oesophageal reconstruction (stomach pedicled on right gastric and right gastroepiploic vessels). Because of the rich anastomoses, angiographic control of bleeding gastric ulcers or tumours often requires embolisation of more than one feeding artery.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1170 (Arteries)
Schwartz's Principles of Surgery, 11th Edition, pp. 1127-1128 (Arterial and Venous Blood Supply)
Sabiston Textbook of Surgery, 21st Edition, p. 1769-1770 (Blood Supply)

Venous Drainage

The gastric veins generally parallel the arteries, all draining ultimately into the portal system:

Left gastric (coronary) vein and right gastric vein: drain the lesser curvature, typically joining the portal vein directly (the right gastric vein may join the portal vein or at the spleno-mesenteric confluence).
Left gastroepiploic vein: drains into the splenic vein.
Right gastroepiploic vein: drains into the superior mesenteric vein, often joining with superior right colic and anterior superior pancreaticoduodenal veins to form Henle's trunk (multiple anatomic variations exist), then to the superior mesenteric vein.
Short gastric veins: drain into the splenic vein.

The coronary (left gastric) vein is of particular clinical importance: it runs along the lesser curve towards the oesophagus and passes left to right to join the portal vein. In portal hypertension, this vein becomes markedly dilated and, via its connections with the oesophageal submucosal plexus, feeds oesophageal (and gastric) varices. Because of the rich venous interconnections, a transjugular intrahepatic portosystemic shunt (TIPSS) can effectively decompress oesophagogastric varices in portal hypertension.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1170 (Veins)
Schwartz's Principles of Surgery, 11th Edition, p. 1128
Sabiston Textbook of Surgery, 21st Edition, pp. 1769-1770

Wall Layers - Submucosa as the Haemostatic Layer

The stomach wall layers from outside inward are: serosa (peritoneum), muscularis propria (three layers: outer longitudinal, middle circular - which is the only complete layer, inner oblique), submucosa, and mucosa. The submucosa is the strongest structural layer (a collagen-rich connective tissue layer) and contains the rich anastomotic network of blood vessels and lymphatics, as well as the Meissner autonomic plexus. It is the principal layer providing haemostasis when vessels are ligated during surgery - in gastric resection this layer must be included in sutures to secure bleeding vessels.

Sabiston Textbook of Surgery, 21st Edition, p. 1771 (Gastric Morphology)

3. DUODENUM

Gross Anatomy and Parts

The duodenum is the first and shortest part of the small intestine, forming a C-shaped loop around the head of the pancreas. It is divided into four parts:

First part (superior/duodenal bulb, D1): passes from the pylorus to the right and slightly posteriorly; lies anterior to the gastroduodenal artery and portal vein. This is where the vast majority of duodenal ulcers occur (anterior wall: risk of perforation; posterior wall: risk of erosion into the GDA causing haemorrhage).
Second part (descending, D2): just to the right of midline, extends from the neck of the gallbladder to the lower border of L3; contains the major duodenal papilla (entry of bile and pancreatic ducts) and the minor duodenal papilla. The junction of the foregut (celiac axis supply) and midgut (superior mesenteric artery supply) occurs just below the major papilla - this is clinically relevant because ulcers in the proximal D2 bleed from the GDA territory while those at or beyond the papilla shift to SMA territory.
Third part (horizontal, D3): the longest section, crossing the IVC, aorta, and vertebral column; crossed anteriorly by the superior mesenteric artery and vein.
Fourth part (ascending, D4): passes upward to the left of the aorta, terminating at the duodenojejunal flexure (supported by the ligament of Treitz/suspensory muscle of duodenum).
Gray's Anatomy for Students, pp. 371-372

Arterial Supply - Critical for Posterior Duodenal Ulcer Haemorrhage

The duodenal blood supply comes from two arterial systems - the celiac axis superiorly and the superior mesenteric artery inferiorly - forming anterior and posterior pancreaticoduodenal arcades:

From the celiac axis (via the gastroduodenal artery, GDA):

The common hepatic artery arises from the celiac trunk, gives off the gastroduodenal artery (GDA) before continuing as the proper hepatic artery.
The GDA descends posterior to the first part of the duodenum (D1) and at the lower border of D1 gives rise to:
- The anterior superior pancreaticoduodenal artery - supplies the anterior aspect of the D1/D2 junction and pancreatic head.
- The posterior superior pancreaticoduodenal artery - supplies the posterior aspect.
- The right gastroepiploic artery (continuing the GDA along the greater curve).
- The supraduodenal artery (small branch to the superior aspect of D1).

From the superior mesenteric artery (SMA):

The inferior pancreaticoduodenal artery (a branch of the SMA) gives rise to:
- The anterior inferior pancreaticoduodenal artery.
- The posterior inferior pancreaticoduodenal artery.

The superior and inferior branches anastomose to form continuous anterior and posterior pancreaticoduodenal arcades, which supply both the duodenum and the head of the pancreas. This dual arcade is why the head of the pancreas cannot be resected without devascularising the duodenum unless a rim of pancreas containing the arcade is preserved (as in the Whipple procedure).

Clinical relevance to bleeding: The GDA travels inferiorly anterior to the neck of the pancreas and posterior to the duodenal bulb (D1). A posterior duodenal ulcer can erode directly into the GDA at this location, producing torrential haemorrhage - one of the most dangerous complications of peptic ulcer disease. Bailey and Love specifically states that the GDA "passes behind the first part of the duodenum, which is highly relevant with respect to a bleeding duodenal ulcer." Surgical control requires suture ligation of the GDA above and below the ulcer, with a transfixing suture through the floor of the ulcer to control the posterior superior pancreaticoduodenal artery branch. At the inferior border of the duodenum, the GDA gives rise to the right gastroepiploic artery and may continue to join the inferior pancreaticoduodenal artery.

Additionally, variations occur in 1 in 5 patients: the right hepatic artery may arise from the SMA (replaced right hepatic artery, 15-20% of patients), travelling posterior to the head of the pancreas toward the liver. Awareness of this on preoperative CT and intraoperatively is essential to avoid inadvertent ligation during surgery for duodenal bleeding.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1170 (Arteries, regarding GDA and its relevance to duodenal ulcer bleeding)
Schwartz's Principles of Surgery, 11th Edition, p. 1460 (Vascular and Lymphatic Anatomy, pancreas and duodenum)
Sabiston Textbook of Surgery, 21st Edition, p. 1770 (gastroduodenal artery)
Gray's Anatomy for Students, pp. 372-373 (Arterial supply to the duodenum)

Venous Drainage

The venous drainage of the duodenum parallels the arteries via anterior and posterior pancreaticoduodenal veins, draining ultimately into the portal venous system (superior mesenteric vein and splenic vein). The right gastroepiploic vein, related to the duodenum's superior surface, drains into the SMV often as part of Henle's trunk.

Sabiston Textbook of Surgery, 21st Edition, p. 1769-1770
Gray's Anatomy for Students, p. 372

Summary Table

Structure	Key Artery	Key Vein	Bleeding Relevance
Oesophagus (lower)	Left gastric a. (abdominal segment)	Left gastric v. → portal vein	Porto-systemic anastomosis → varices in portal hypertension
Oesophagus (thoracic)	Aortic branches	Azygos/hemiazygos v. (systemic)	Connects with portal via submucosal plexus
Stomach (lesser curve)	Left + right gastric aa.	Left gastric (coronary) v.	Coronary vein dilates in portal hypertension
Stomach (greater curve)	Right + left gastroepiploic aa.	Right gastroepiploic v. → SMV	Rich arcade; requires multi-vessel embolisation
Stomach (fundus)	Short gastric aa. (splenic a.)	Short gastric vv. → splenic v.	Isolated gastric varices in splenic vein thrombosis
Duodenum (D1 posterior)	GDA (posterior to D1 bulb)	Pancreaticoduodenal vv. → SMV	Posterior ulcer erosion into GDA = life-threatening bleed
Duodenum (D1-D3)	Pancreaticoduodenal arcades (GDA + SMA)	Follows arteries → portal	Foregut-midgut watershed at major papilla

Primary References Used:

Bailey and Love's Short Practice of Surgery, 28th Edition (9780367548117) - Chapter 66 (Oesophagus, pp. 1127-1131), Chapter 67 (Stomach and duodenum, p. 1170), Chapter 69 (Portal hypertension and varices, pp. 1224-1225)
Sabiston Textbook of Surgery, 21st Edition (9780443124341) - Chapter 86, pp. 1769-1771
Schwartz's Principles of Surgery, 11th Edition (9781259835346) - Chapter 26 (Stomach, pp. 1127-1128), Chapter 33 (Pancreas/duodenum, p. 1460)
Gray's Anatomy for Students (9780323934237) - pp. 371-373 (Duodenum)
Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Blood Supply of the Oesophagus (lines 118-156) - used as a supplementary anatomy reference for the detailed oesophageal vascular anatomy not covered in depth in the surgical texts

Explain the role of Oesophago-Gastro-Duodenoscopy (OGDS) in diagnosis and treatment. Use Bailey and Love Short Practice of Surgery 28th Edition, Sabiston Textbook of Surgery 21st Edition, and Shwartz's Principles of Surgery 11th Edition, and for each part state what reference the information was extracted out of.

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The Role of Oesophago-Gastro-Duodenoscopy (OGDS) in Diagnosis and Treatment

1. BACKGROUND AND INSTRUMENT

OGDS (also referred to as OGD or upper GI endoscopy) has become one of the most powerful diagnostic and therapeutic tools in surgical practice over the last five decades. The breakthrough was the discovery that images could be transmitted using flexible quartz fibres, first described in the late 1920s. In 1958, Larry Curtiss (a physics graduate student) and Basil Hirschowitz (a gastroenterology trainee) developed the first flexible fibreoptic gastroscope. The subsequent invention of the charge-coupled device (CCD) allowed digital image processing and transmission to television screens, giving birth to the modern video endoscope.

A standard diagnostic OGDS examines the pharynx, hypopharynx, laryngeal inlet, oesophagus, stomach, and part of the duodenum (typically to the second or third part). Rigid oesophagoscopy is now rarely used except for retrieval of large or sharp foreign objects; flexible endoscopy with an overtube is the preferred alternative.

Bailey and Love's Short Practice of Surgery, 28th Edition, Chapter 9 (Gastrointestinal Endoscopy), pp. 165-174

2. DIAGNOSTIC ROLES

2.1 General Indications

OGD is appropriate when a patient's symptoms are persistent despite appropriate empirical therapy, or when symptoms are associated with warning signs such as:

Intractable vomiting
Anaemia
Weight loss
Dysphagia
Bleeding

It is also part of the diagnostic work-up for patients with anaemia and symptoms of reflux disease or dyspepsia. OGD is appropriate in the setting of acute gastrointestinal haemorrhage of any aetiology.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 169 (Indications for OGD)

2.2 Peptic Ulcer Disease

Upper GI radiography with barium has largely been replaced by flexible upper endoscopy as the diagnostic method of choice for both gastric and duodenal ulcers. With single-contrast radiographic techniques, 50% of ulcers may be missed; even with double-contrast studies, 10-20% are still not detected. Endoscopy, by contrast, is the most reliable method for diagnosing gastric and duodenal ulcers. In addition to providing a visual diagnosis, it allows:

Tissue sampling to evaluate for malignancy
Testing for H. pylori infection (urease assay, histology, or culture)
Therapeutic intervention in the setting of bleeding or obstruction
Evaluation of other oesophageal, gastric, and duodenal pathologies

When a gastric ulcer is detected endoscopically, biopsy is generally recommended in all cases to rule out malignancy. Taking a single biopsy yields only 70% sensitivity for detecting gastric cancer; four specimens increase this to 95%, and seven specimens increase it to 98%. Biopsy specimens should be taken from all four quadrants of the ulcer where possible. Larger ulcers and those with irregular or heaped-up edges are more likely to harbour cancer.

Sabiston Textbook of Surgery, 21st Edition, p. 1786 (Flexible Upper Endoscopy)

2.3 Upper Gastrointestinal Bleeding - Diagnosis and Risk Stratification

OGDS is the most important diagnostic tool for acute upper GI haemorrhage. In the early hospital management of patients with acute upper GI bleeding, after resuscitation, upper endoscopy within 24 hours is indicated for all patients. For high-risk patients, endoscopy should be performed within 12 hours, after resuscitation and correction of coagulopathy.

Key endoscopic questions in acute upper GI bleeding include:

Is the patient bleeding from varices?
Is there active (arterial) bleeding?
Is there a visible vessel?
Is there a deep ulcer overlying a large vessel (e.g., posterior duodenal ulcer overlying the gastroduodenal artery)?

The Forrest classification (Table 98.2 in Sabiston, Table 67.5 in Bailey & Love's Rockall score) is used to stratify the endoscopic appearance of bleeding ulcers and predict rebleeding risk:

Forrest Class	Finding	Rebleeding Risk (%)
Ia	Active arterial spurting	~55 (Ia+Ib combined)
Ib	Oozing without visible vessel	-
IIa	Non-bleeding visible vessel	43
IIb	Adherent clot	22
IIc	Flat spot	10
III	Clean ulcer base	5

Patients with active bleeding (Ia/Ib) or a visible vessel (IIa) require endoscopic therapy. Patients with a clean ulcer base (Forrest III) are low risk and do not require further endoscopic intervention.

Sabiston Textbook of Surgery, 21st Edition, Table 98.2 and associated text, pp. 2185-2187
Bailey and Love's Short Practice of Surgery, 28th Edition, Table 67.5 (Rockall scoring system), p. 1188
Schwartz's Principles of Surgery, 11th Edition, p. 1180 (Massive Upper Gastrointestinal Bleeding)

In patients where blood obscures the source, a second endoscopy may be required to establish diagnosis, but routine second-look endoscopy is not recommended.

Sabiston Textbook of Surgery, 21st Edition, p. 2186

Upper GI barium studies are contraindicated in the setting of acute upper GI bleeding because they interfere with subsequent endoscopy, angiography, or surgery.

Sabiston Textbook of Surgery, 21st Edition, p. 2186

2.4 Variceal Bleeding

OGDS confirms the diagnosis of oesophageal or gastric varices in the context of portal hypertension. The lower oesophagus is the most common site of variceal haemorrhage, and confirmation of the source is required following initial resuscitation. Endoscopy serves as the primary diagnostic and therapeutic tool for both oesophageal and gastric variceal bleeding and should be done urgently (preferably within 12 hours of admission). Preprocedure erythromycin can be used to improve gastric visualisation.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1224-1226 (Management of variceal bleeding)
Sabiston Textbook of Surgery, 21st Edition, p. 1792 (Gastric Varices)
Sabiston Textbook of Surgery, 21st Edition, Chapter 88, p. 1878 (Endoscopic treatment of variceal bleeding)

2.5 Gastric Cancer

Flexible endoscopy is an essential tool for the diagnosis of gastric cancer. It allows:

Direct visualisation of the tumour
Tissue sampling for pathologic diagnosis
Documentation of tumour location and relation to the GE junction (Sievert classification for proximal lesions)
Treatment of patients with obstruction or bleeding

Current NCCN guidelines recommend harvesting six to eight biopsy specimens from different areas of the lesion to maximise diagnostic yield. Small lesions (<2 cm diameter) without ulceration can be resected endoscopically at the time of initial diagnostic endoscopy - this can be curative for early-stage cancers and provides a more complete specimen for pathologic analysis.

Sabiston Textbook of Surgery, 21st Edition, pp. 1801-1802 (Staging Workup - Endoscopy and biopsy)

2.6 Mallory-Weiss Tears

Upper endoscopy is both diagnostic and therapeutic for Mallory-Weiss tears (mucosal lacerations at the gastro-oesophageal junction caused by forceful vomiting, retching, coughing, or straining). Massive bleeding is more likely in patients with pre-existing portal hypertension.

Sabiston Textbook of Surgery, 21st Edition, p. 1791 (Mallory-Weiss Tear)

2.7 Atrophic Gastritis and Other Mucosal Lesions

On endoscopy, atrophic gastritis presents as a pale mucosa. The updated Sydney protocol requires biopsies from five specified sites in the stomach and has high diagnostic accuracy for both atrophic gastritis and H. pylori. These patients should undergo surveillance endoscopy after diagnosis because of increased risk of gastric neuroendocrine tumours and intestinal-type gastric adenocarcinoma.

Sabiston Textbook of Surgery, 21st Edition, p. 1790 (Atrophic Gastritis)

2.8 Oesophageal Diseases

Endoscopy is also essential in diagnosing oesophageal disease - achalasia (with the caution that the oesophagus may be fluid-filled and regurgitation can cause aspiration), malignant and benign strictures, Barrett's oesophagus, and oesophageal perforation. In patients with significant trismus or obstruction, an ultra-thin endoscope can be used via the oral or nasal route. In patients with suspected oesophageal perforation or during prolonged procedures, carbon dioxide should be used for insufflation, as it is absorbed more quickly than air.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1129-1130 (Endoscopy, Chapter 66)

2.9 Surveillance

In addition to its diagnostic role, OGD is commonly used in the surveillance of neoplasia in high-risk patient groups, including:

Genetic conditions such as familial adenomatous polyposis (FAP)
Premalignant conditions such as Barrett's oesophagus
Bailey and Love's Short Practice of Surgery, 28th Edition, p. 171

3. THERAPEUTIC ROLES

3.1 Overview of Therapeutic OGDS

Appropriate patient selection and monitoring are essential to minimise complications. The most common emergency therapeutic endoscopic procedure is control of upper gastrointestinal haemorrhage of any aetiology.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 171 (Therapeutic OGD)

3.2 Peptic Ulcer Haemorrhage

Therapeutic endoscopy achieves haemostasis in approximately 70% of cases of bleeding peptic ulcers, with the best evidence supporting a combination of adrenaline (epinephrine) injection with a second haemostatic technique such as heater probe thermal coagulation and/or endoclip application. This combination is the technique of choice for a peptic ulcer with active bleeding or high-risk stigmata of haemorrhage.

Epinephrine injection should not be used as monotherapy but can be used in combination with another method.
Other endoscopic treatment options include: haemostatic clips, electrocoagulation, argon plasma coagulation (APC), heater probe, and absolute ethanol injection.
High-risk bleeds (Forrest Ia, Ib, IIa) should be followed by 72 hours of intravenous proton pump inhibition to prevent rebleeding.
In patients where the source of bleeding cannot be identified or in those who rebleed after endoscopy, angiography with transcatheter embolisation may offer a valuable alternative to surgery.
Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1188-1189 (Medical and minimally interventional treatments)
Sabiston Textbook of Surgery, 21st Edition, p. 1787 (Complicated Peptic Ulcer Disease - Hemorrhage)
Schwartz's Principles of Surgery, 11th Edition, p. 1180 (Massive Upper Gastrointestinal Bleeding)

3.3 Oesophageal Variceal Haemorrhage

About 80-90% of acute variceal bleeding episodes are successfully controlled by endoscopic measures. The two main endoscopic options are:

Endoscopic band ligation (EBL): applies bands to the base of the varix. Band ligation is currently the modality of choice for initial control of variceal bleeding, as it is better than sclerotherapy in achieving initial control and is associated with fewer complications and reduced rebleeding. Literature also suggests that sclerotherapy (but not band ligation) may increase portal pressures.
Injection sclerotherapy: injection of a sclerosant into or around the varix. Used when band ligation technology is not available. A single treatment is usually sufficient.

Endoscopy is performed in a head-down position with good suction available. A double-channel endoscope with a bridge is essential to facilitate suction during injection and provide manoeuvrability of the needle. Only the source varix or varices should be treated.

Early endoscopy, preferably within 12 hours of admission, with an attempt at control of bleeding is recommended. Vasoactive drugs (octreotide, terlipressin) should be started early and continued concurrently.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1225-1226 (Endoscopic treatment)
Sabiston Textbook of Surgery, 21st Edition, p. 1878 (Endoscopy - variceal ligation)

3.4 Gastric Variceal Haemorrhage

For gastric varices, endoscopic options include:

Sclerotherapy
Band ligation (definitive for lesser curvature gastric varices)
Glue injection (cyanoacrylate) - recommended by the American Gastroenterological Association 2021 guidelines as first-line where definitive endoscopic therapy is favoured
Thrombin injection

EUS can be used to improve the accuracy of cyanoacrylate injection. A major problem with gastric varices after endoscopic treatment is rebleeding. When a gastrorenal shunt is present between gastric varices and the left renal vein, balloon-occluded retrograde transvenous obliteration (BRTO) can be performed. When endoscopic treatment fails, TIPS is the next step.

Sabiston Textbook of Surgery, 21st Edition, pp. 1792-1793 (Gastric Varices)

3.5 Mallory-Weiss Tears

Most patients with active bleeding from Mallory-Weiss tears can be treated with endoscopic methods: epinephrine injection, thermal coagulation, endoscopic band ligation, or endoscopic haemoclipping. Angiographic transarterial embolisation may be considered if endoscopic therapy fails. Surgery (laparoscopic or open oversewing of the tear under endoscopic guidance) is rarely necessary and is reserved for failure of endoscopic or angiographic approaches.

Sabiston Textbook of Surgery, 21st Edition, p. 1791 (Mallory-Weiss Tear)

3.6 Chronic Bleeding from Angioectasia / GAVE

Chronic blood loss from angioectasia (angiodysplasia) is most safely treated with argon plasma coagulation (APC), because of the controlled depth of burn compared with alternative thermal techniques. The characteristic watermelon stomach (gastric antral vascular ectasia, GAVE) appearance of parallel red stripes on the antral folds is readily treated with APC.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 171 (Fig. 9.6, therapeutic OGD section)

3.7 Haemostatic Powders

Haemostatic powders provide a further endoscopic method to arrest bleeding; these work best for diffuse bleeding or as salvage therapy when other methods have failed.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 171

3.8 Stricture Dilatation

Benign oesophageal and pyloric strictures may be dilated under direct vision with through-the-scope (TTS) balloon dilators or the more traditional guidewire-based systems such as Savary-Gilliard bougie dilators. More difficult benign strictures can be treated by insertion of a fully covered removable stent or a biodegradable stent.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 171

3.9 Achalasia

The non-relaxing lower oesophageal sphincter of achalasia can be treated by pneumatic dilatation with a 30-40 mm balloon. Endoscopic dissection techniques (per-oral endoscopic myotomy, POEM) are now employed with good follow-up results. An alternative in unfit patients is injection of botulinum toxin into the LOS, though this has a limited duration of benefit (3-6 months).

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 171

3.10 Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)

Improved endoscopic treatment has allowed resection of mucosal lesions previously subject to surgical intervention. Key applications include:

Barrett's oesophagus with high-grade dysplasia / early adenocarcinoma: Radiofrequency ablation (360° with balloon catheter or focal ablation with smaller probes) achieves destruction of Barrett's epithelium in low- and high-grade dysplasia, and has been shown to reduce risk of progression to cancer. Cryotherapy and APC can also be used for ablation.
Early gastric cancer: Small gastric lesions (<2 cm, without ulceration) can be resected endoscopically at the initial diagnostic endoscopy. This can be curative for early-stage disease.
Gastric neuroendocrine tumours: Small tumours <1 cm can be managed with endoscopic resection or active surveillance.
Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 171-172
Sabiston Textbook of Surgery, 21st Edition, pp. 1801-1802

3.11 Percutaneous Endoscopic Gastrostomy (PEG)

PEG insertion is one of the most important non-haemostatic endoscopic procedures. The stomach is insufflated under endoscopic vision, a direct percutaneous needle puncture is made at the point where the stomach abuts the abdominal wall, a wire is passed and caught with a snare, and the gastrostomy tube is then pulled through into position. Antibiotic prophylaxis (co-amoxiclav) reduces the risk of wound or stoma infection.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 171-172 (Fig. 9.8)

3.12 Foreign Body Removal

Large objects in the stomach can usually be removed endoscopically with an overtube technique. Recognised hazards include aspiration of the foreign body during removal and rupture of drug-containing bags in body packers.

Schwartz's Principles of Surgery, 11th Edition, p. 1182 (Foreign Bodies)

4. TIMING, PREPARATION, AND PRACTICAL CONSIDERATIONS

Timing in Acute Upper GI Bleeding

Scenario	Recommended Timing
All patients with acute UGIB	Within 24 hours
High-risk patients (haemodynamic instability, suspected varices)	Within 12 hours after resuscitation

A prokinetic agent (erythromycin) given before endoscopy improves mucosal visualisation by accelerating gastric emptying of blood and clots.

Sabiston Textbook of Surgery, 21st Edition, p. 1787
Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1224

Anticoagulated Patients

Diagnostic OGD, colonoscopy, enteroscopy, diagnostic EUS, and ERCP without sphincterotomy are all considered low-risk procedures, as is mucosal biopsy. High-risk procedures include polypectomy, sphincterotomy, stent placement, dilatation of strictures, PEG insertion, and EUS-guided fine-needle aspiration. In urgent UGIB in the anticoagulated patient, correction of the INR to approximately 1.5 is usually sufficient to allow both diagnostic and therapeutic endoscopy. Anticoagulation can often be resumed 24 hours after successful endoscopic therapy.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 169-170

Sedation

Most diagnostic endoscopies can be performed without sedation or with pharyngeal anaesthesia alone. Therapeutic procedures usually require conscious sedation (not anaesthesia). Medication-induced respiratory depression in elderly patients or those with comorbidities is the greatest cause of endoscopy-related mortality. Paediatric endoscopy requires a general anaesthetic.

Bailey and Love's Short Practice of Surgery, 28th Edition, p. 167

5. COMPLICATIONS OF OGDS

Diagnostic upper GI endoscopy is a safe procedure with minimal morbidity when appropriate patient selection and safe sedation are followed. The rate of serious complications is approximately 1 in 10,000. The majority of adverse events relate to sedation and patient comorbidity.

Specific complications include:

Cardiorespiratory complications related to sedation (greatest cause of mortality)
Aspiration (especially in patients with achalasia or obstruction)
Perforation - rare during diagnostic procedures (usually associated with inexperience); more common during therapeutic endoscopy, particularly oesophageal dilatation and EMR/ESD. Early diagnosis significantly improves outcome and can potentially be managed endoscopically with clips or endoscopic suturing.
Haemorrhage after dilatation, EMR/ESD, or EUS-guided procedures
Infection - diagnostic upper GI endoscopy has a bacteraemia rate of 4%; oesophageal variceal sclerotherapy carries 10-50%; oesophageal dilatation/prosthesis insertion 34-54%

Prompt management of perforation includes CT/water-soluble contrast studies, strict nil by mouth, IV fluids and antibiotics, and early review by an experienced upper GI surgeon.

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 167, 172-173 (Complications)

Summary by Source

Topic	Bailey & Love 28th Ed.	Sabiston 21st Ed.	Schwartz's 11th Ed.
Indications for OGD	Ch. 9, p. 169	-	-
Diagnostic endoscopy - peptic ulcer	-	p. 1786	p. 1180
Forrest classification & risk stratification	Table 67.5, p. 1188	Table 98.2, p. 2185	p. 1180
Haemostatic techniques - peptic ulcer	p. 1188-1189	p. 1787	p. 1180
Variceal band ligation vs sclerotherapy	pp. 1225-1226	p. 1878	-
Gastric variceal endoscopy	-	pp. 1792-1793	p. 1181
Mallory-Weiss endoscopy	-	p. 1791	p. 1180
APC for GAVE / angiodysplasia	p. 171	-	-
Barrett's ablation / EMR/ESD	pp. 171-172	pp. 1801-1802	-
Dieulafoy's lesion	-	-	p. 1181
PEG insertion	pp. 171-172	-	-
Complications	pp. 167, 172-173	-	-
Gastric cancer diagnosis & biopsy	-	pp. 1801-1802	p. 1145
Timing of endoscopy	p. 1224	p. 1787	p. 1180

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