(BQ) Part 2 book “Practical pediatric gastrointestinal endoscopy” has contents: Polypectomy, endoscopic application of mitomycin C for intractable strictures, endoscopic retrograde cholangio-pancreatography in children, endoscopic pancreatic cysto-gastrostomy,… and other contents.
8 Polypectomy George Gershman KEY POINTS • Knowledge of the principles of electro-surgery is an essential component of safe polypectomy technique • Knowledge of snare designs and choosing the appropriate snare are essential parts of a successful polypectomy • Navigation of the scope to an optimal position and a clean environment create an optimal condition for a safe polypectomy Basic principles of electrosurgery The cornerstone of electric cutting and coagulation of living tissue is the heating of the restricted area by radio-frequency alternating current (RF) without stimulation of nerves and muscles When current alternates up to a million times per second it does not stimulate muscle and nerve membranes long enough to induce depolarization before the next alternation occurs Cutting is produced by rapid and strong heating, which creates evaporation of intra-and extracellular fluids Coagulation is initiated when the speed and degree of tissue heating is slower and less intense, leading to cellular desiccation Specific effects of different types of RF currents and heat-related tissue destruction are illustrated in Figures 8.1 and 8.2 Several factors regulate the degree of tissue heating: • The size and the shape of the polyp dictates the choice of the proper technique • Short distances (less than cm) between the tip of the snare and a polyp, minimal opening of the metal loop and simultaneous advancement of the snare toward the polyp, along with tightening of the loop are the key elements of the technique • Polypectomy of a large polyp requires additional training in the piece-meal technique • Voltage (V) is the force required to push current through the tissue The higher the voltage, the deeper the thermal tissue destruction • Tissue resistance (R) or impedance (for alternating current) is the force generated by tissue to resist electrical flow It is directly proportional to the amount of tissue electrolytes Resistance increases dramatically during tissue heating and desiccation Normal tissue resistance is not uniform; it is lowest along blood vessels and highest at the level of the skin • Time (T) is an essential factor of energy (E) regulation, which can be expressed as: E (in joules) = P ( power in watts) × T Tissue heating increases with time, although the process is quite complex: Practical Pediatric Gastrointestinal Endoscopy, Second Edition George Gershman, Mike Thomson, Marvin Ament © 2012 Blackwell Publishing Ltd Published 2012 by Blackwell Publishing Ltd Polypectomy 133 Alternating RF Current Uninterrupted highpower, low-voltage current Interrupted high-voltage spikes of RF current lasting 20% of the cycle Combination of both currents Sparks between tissue and active electrode Deep penetration of current across the tissue, causing desiccation Relatively greater “cut” than “coagulating” tissue effects Quick tissue heating up to 500ºC and above produces vaporization Coagulating current ** Blended current Cutting current * * Low-voltage current penetrates less through desiccation tissue and has limited ability to induce deep tissue heating ** Spikes of high-voltage coagulating current allow a deeper spread through desiccated tissue and induce more tissue destruction Alternative RF current Figure 8.1 Different types of alternating RF currents and specific tissue response Tissue resistance Heat Above 41.5ºC • devitalization – irreversible death of the tissue Above 60ºC Coagulation and moderate desiccation • contraction of collagen • hemostasis of small vessels • formation of adhesive derivatives of glucose 100ºC Fast desiccation • hemostasis of bigger vessels secondary to glue effect of desiccated glucose • tissue sticking to the active electrode Above 200ºC Cabonization • tissue may become an electric insulator Above 500ºC • tissue vaporization cutting • smoke production Figure 8.2 Temperature-related tissue destruction always induced by RF current • Heating produces water loss and increases resistance • Increasing resistance shifts the distribution of current from the lowest resistance pathway • Fluctuation of the resistance affects the power output produced by the generator • Some of the released heat is removed from high-temperature areas by blood flow The cooling effect of bloodflow explains why the same energy applied to the tissue generates less destruction if delivered slowly 134 Basic Pediatric Endoscopy Techniques • Current density is a measure of RF current (I) which flows through a specific cross-section area (a): Ι Ι = a πτ The amount of heat generated in tissue is directly proportional to power density (P) expressed as a square value of current density multiplied by resistance: Ι Ι2 Ρ =⎛ ⎞ ℜ= ×ℜ ⎝ a⎠ πτ This important equation implies that power density is an inverted relationship with the square of the cross-sectional area (πr2) It means that even a small tightening of the loop produces a profound effect on tissue heating This can be illustrated by the polypectomy of a one centimeter polyp If a snare decreases the diameter of a polyp in half, the cross-sectional area at the level of the loop will be only 0.2 cm2 It is times less than a cross-sectional area at the base of a polyp and about 500 times less than a cross-sectional area of skin under a 10 cm × 10 cm plate of the “return” electrode If 0.2 A electric current is applied through the snare it produces a current density of A /cm2, 0.25 A/cm2 and 0.002 A/cm2 at the level of the loop, polyp bases and skin level respectively The fall of the power density, i.e power actually delivered to the tissue and generated heat, is even more dramatic: from A/cm2 × R at the level of the loop, to 0.06 A/cm2 × R and 0.000004 A/cm2 × R at the base of the polyp and skin under the “return” electrode respectively Narrowing of a crosssectional area by a closing snare produces the most significant effect on heat production compared with increasing the power setting and time of electric current application It also allows one to perform a polypectomy at a lower power using a coagulating mode safely The law of current density is vital for polypectomy Narrowing of a cross-sectional area is the most important safety technique, which produces a coagulation of the core vessels of the polyps before cutting, restricts the area of maximal tissue heating around the loop, and limits tissue destruction of the deep bowel wall layers Snare loops Commercially available snares vary by size, configuration of the loop, design, and mechanical characteristics of the handles and wire thickness Reusable snares often lose their mechanical properties and can peel and break at the tip Disposable snares are more durable and predictable The thickness of the wire loop and handle “behavior” can significantly affect the results of polypectomy Snares with thick wire loops have two important advantages: A decreased risk of snapping a polyp without adequate coagulation and A large surface contact with tissue resulting in better coagulation A standard snare with an opening diameter of 2.5 cm can be used for different size polyps A special small or “mini” snare (1 cm loop) has been designed for polyps less than cm It is important for endoscopists to find an “optimal” snare for routine practice in order to avoid any unexpected “surprises” during cutting or coagulation A chosen snare should be fully open and then closed to the point when just the tip of a wire loop is outside of outer sheath Marking of the so-called closing point on the handle of the snare (Figure 8.3) serves two important safety features: Figure 8.3 Snare preparation before polypectomy: marking of so-called closing point on the handle of the snare Polypectomy 135 Safety Routine 15mm Figure 8.4 Squeezing pressure A 15 mm retraction of the wire into the plastic sheath provide an optimal narrowing of the polyp base or the stalk for adequate constriction of the blood vessels and generation of an appropriate power density Protects from premature cutting of a small sessile or pedunculated polyp without adequate coagulation and Alerts the endoscopist of a partial polyp’s head entrapment or underestimation of the stalk size It is very important to check how far the tip of a wire loop is retracted into the outer plastic sheath when a snare is fully closed The distance of 15 mm reassures an adequate squeezing pressure (Figure 8.4) If the stalk of a large polyp is not squeezed adequately, it compromises the coagulation of core vessels for two reasons: • Blood vessels remain open and bloodflow continues producing a cooling effect but more importantly • A cross-sectional area is not narrow enough to concentrate the current flow to an appropriate power density to coagulate core vessels Closure of a snare loop with excessive pressure can induce premature cutting before coagulation Both conditions could lead to significant bleeding The Routine Polypectomy Polypectomy is the most common therapeutic procedure in pediatric GI Endoscopy It can be simple or more complex depending on the size or location of the polyp and personal experience No matter how easy the procedure appears to the endoscopist, it is always wise to follow a simple rule: safety before action It is always useful to routinely inspect the snare and generator as well as prepare the hemostatic equipment such as detachable loops, metal clips, and needle for epinephrine injection The polypectomy snare should be checked for smooth opening, thickness of the wire (a thin snare predisposes to a premature cut of a small polyp before appropriate coagulation), adequate squeezing pressure, and closing point It is extremely important to test the generator to find a minimal power setting, which is necessary to induce whitening and swelling of the tissue inside a wire loop It should be done at least once by adjusting the power output according to the effect of short (2–3 seconds) burst of coagulating current until a visible effect is achieved The generator setting should be inspected routinely before the procedure to avoid an accidentally high power setting A foot pedal should be conveniently positioned in front of the endoscopist A teaching session with the assistant or technician is important for safe and optimal manipulations with a snare during opening or closure Safety conditions and techniques A good bowel preparation is essential not only for optimal viewing and positioning of the loop around a polyp stalk or base, but also to avoid an accidental burning or coagulation of normal mucosa A large amount of liquid or solid stool increases the chance of missing a small or even a good size polyp An obscure view often leads to excessive use of air and bowel stretching, which makes the bowel wall thinner Sudden patient irritability, unexpected waking or movements complicate the polypectomy, especially during a snare closure and should be prevented by adequate sedation The technique of polypectomy consists of three important elements: Navigation of the scope to an optimal position, angle and distance to a polyp; Placement of a wire loop around a polyp, and Cutting 136 Basic Pediatric Endoscopy Techniques A six o’clock position is an ideal for polypectomy The location of a polyp between and or and o’clock is suboptimal Polypectomy is very difficult and somewhat unsafe if a polyp is located on the upper aspect of a lumen between and o’clock An ideal o’clock position could be created by clock- or counterclockwise rotation of the shaft and downward deflection of the tip Careful assessment of the stalk size and location of a polyp is obligatory before polypectomy It can be done by rotation, advancement of a scope beyond a polyp and pulling the shaft backwards Once an optimal position and clear view of the polyp is achieved, the scope is moved toward the polyp base An ideal distance from the tip of the scope to the polyp is 1–2 cm unless the polyp is hiding beyond a fold In this case, the tip should be positioned just above the fold and pressed down to reveal the polyp The same effect can be achieved by a closed snare All manipulations with a snare should be done slowly It is opened just enough to embrace a polyp Full opening of a snare makes the wire loop floppy and less controllable Snaring a sessile polyp at the o’clock position is easy if the wire loop is horizontal to the polyp Simple downward tip deflection is necessary to encircle the polyp If an opened wire loop creates an angle at the base of the polyp, the shaft of the scope should be rotated toward a polyp until it is captured The technique is modified if a sessile polyp is located between and o’clock or and o’clock and previous attempts to establish an ideal o’clock position have failed The shaft is slightly rotated away from the polyp The snare is opened more than usual making it less rigid and advanced toward the polyp (Figure 8.5) Once the polyp is inside the loop, the scope is rotated slowly toward the polyp to align the plane of the snare with the axis of a bowel lumen Then, the snare is closed slowly and moved forward until it reaches the base of the polyp At this moment, the snare should be completely closed (Figure 8.6) Occasionally, a backward snaring is more effective, especially if the polyp is more than 1.5 cm in length An open loop is pointed down towards the area where a polyp head touches the bowel wall When the snare is advanced, tissue resistance creates a bowing effect and induces a loop opening As a result, the loop slides between the mucosa and the polyp head An additional clockwise rotation of the tip using both knobs swings a Figure 8.5 The snare is placed around the polyp Figure 8.6 The snare is closed tight but not enough to amputate the polyp wire loop under the polyp head If the position of the snare is satisfactory, the snare is slowly closed tight enough for polypectomy If a polyp is facing away from the tip, the snare is advanced and opened slowly until the tip of the wire is beyond the polyp’s head The tip of the scope is deflected down slightly to move the wire loop below the polyp After this, the snare is pulled back until the head of the polyp is inside the loop and the wire is just under the polyp head The snare is closed slowly and advanced toward to the polyp to prevent sliding of the wire along the stalk Advancement of the snare towards the polyp during wire loop closure is a key element to polyp snaring It secures a polyp within the loop and allows precise navigation of the snare Capturing a small polyp with a standard snare may be challenging A slight decompression of the bowel may elevate the polyp above a wire loop and facilitate a capture The technique of polypectomy is different when applied to small polyps less than mm, broadbase polyps more than 15 mm, or pedunculated polyps more than 20 mm Diminutive or small Polypectomy sessile polyps less than mm can be removed safely by cold biopsy forceps (hot biopsy forceps should be avoided as these may be associate with perforation) Two helpful hints: If a polyp is located on the edge of a fold, position the tip of the colonoscope within a distance of cm from the polyp, open the forceps and place the open cusps perpendicular to the fold just above the polyp and close it Avoid pushing the forceps up against mucosa as it will stretch tissue and result in suboptimal sampling If a small polyp is between the folds, try to position the snare with cusps opened horizontally and just enough to outline the polyp Advance the forceps forward slightly to cover the polyp and close the forceps slowly An alternative technique consists of • Opening the forceps with cusps vertical to the folds • Positioning the lower cusp just below the polyp to avoid grasping normal mucosa • Closing a snare A large sessile polyp is rare in children except in patients with Peutz-Jegher’s syndrome Polyps more than 2.5–3 cm are usually located in the small intestine, primarily in the jejunum If the size of a polyp is between 10 and 15 mm a single cut polypectomy may be safe if advancement of a snare with the captured polyp does not produce synchronous movements of the underlying wall This indicates that the submucosa and muscularis propria are not trapped within the wire loop Piece-meal technique entails piece-by-piece removal of a large broad-base polyp more than 15 mm A submucosal injection of saline, hypertonic saline, or epinephrine (1:10 000) solution before polypectomy decreases the risk of the transmural burns Injection at the site proximal to the polyp is performed first if possible, followed by injection at the distal edge and both sides of a polyp Injection of to10 cc of a chosen solution in three to four sites is usually adequate to create a liquid “cushion” under the polyp The needle should be oriented tangentially to minimize a risk of transmural injection Once again, a broad-base polyp more than 15 mm should be removed in pieces to minimize the risk of perforation The risk of bleeding is not high as blood vessels in such polyps are much smaller than in large pedunculated polyps 137 The piece-meal technique consists of placement of a wire loop diagonally across a polyp and removing the polyp in few pieces The remaining central area is cut at the end Excessive closing pressure should be avoided because it may compromise initiation of cutting, due to lack of electrical arc from the active electrode to the tissue In addition, decreased wire-tissue contact area increases the current density, which may induce excessive desiccation and cease current flow Polypectomy of pedunculated polyps more than cm may be challenging Attention should be paid to proper positioning of the wire loop at the narrowest portion of the stalk right below a polyp head Thick blood vessels in the middle of the stalk require slow desiccation for complete coagulation and hemostasis before the final cut Occlusion of a thick stock with Endo-loop® just before manipulations with the snare is effective way to prevent immediate and delayed bleeding after polypectomy Clipping devices should be available for immediate action Do remember that epinephrine injection will only cause vasospasm and apparent hemostasis for 20 minutes or so It is quite difficult to avoid direct contact of a large pedunculated polyp with normal mucosa during polypectomy However, attempts should be made to keep a snared polyp close to the center of the bowel lumen to minimize thermal destruction of adjacent tissue Careful inspection of a long stalk should precede any manipulations with the snare The location of the polyp base and position of the long stalk are crucial for optimal approach to the polyp The snare is advanced forward to the lowest point of the polyp head and opened slowly until the loop is big enough to embrace the polyp Further manipulation with the snare should be coordinated with either right or left torque of the shaft toward the o’clock direction Backward snaring may be useful A reduction of a polyp size by piece-meal technique with prior injection of epinephrine solution (1:10 000) into the stalk below the polypectomy site is the last option to complete the procedure After successful capture and adequate tightening of the wire loop, a polyp less than 10 mm is removed using a low power coagulating current (15–18 W) continuously for 2–3 seconds and slow closure of a snare after whitening and tissue swelling has occurred A modified technique is applied to sessile polyps less than 15 mm or large pedunculated polyps with a small pseudo stalk Injection of saline or epinephrine (1:10 000) 138 Basic Pediatric Endoscopy Techniques solution underneath the polyp head protects deep tissue from desiccation and decreases mobility of the polyp This simplifies the placement of the wire loop without trapping a part of the polyp head A slightly longer duration of coagulation (2–3 cycles) may be necessary for adequate coagulation of blood vessels A blended current up to 20–25 W may be reasonable for the polypectomy of a broad-base polyp using a piece-meal technique Lower power setting (10 to 15 watts) is preferable for polypectomy of the polyps in the right side colon or the small bowel Different electro-surgical generators have two different setting systems – a dial type with a scale from 0–10 Usually, a setting point between ½ and are equivalent to a low power of 15–20 W; – a numeric type system when displayed numbers represent current power in watts An endoscopist should become familiar with the particular electrosurgical generator available to his or her practice to avoid an application of excessively high power above 30 W, which could lead to a transmural tissue necrosis A polypectomy can be performed during colonic intubation or the withdrawal phase of a colonoscopy The decision is made based on size of the polyp It is wise to remove a small sessile or pedunculated polyp as soon as it is discovered to eliminate the chance of missing this polyp later on Removal of a large polyp is more convenient after the entire colon has been inspected, except in the case when the position of a polyp is ideal for polypectomy Careful examination of the colon, especially behind the folds, can be accomplished by circumferential rotation of the tip and the shaft, aspiration of excessive fluid and repeat insertion of the scope for a few segments if the bowel quickly slipped away from the tip After polypectomy, polyps less than 10 mm can be easily sucked into a biopsy channel and eventually into a filtered polyp suction trap Water irrigation and proper orientation of a suction nostril at the tip of a scope facilitates the recovery process During polypectomy, attention should be paid to observing the direction in which the polyp falls The first place to look for a hidden polyp is in a pool of fluid If the polyp is not discovered, flush some water and watch where it flows: backflow indicates that the polyp is distal to the tip of a scope Figure 8.7 APC is useful tool of hemostasis Bleeding after polypectomy can be successfully controlled by argon plasma probe Nylon polyp retrieval nets or metal baskets can be used for removal of multiple polyps Grasping of a large polyp using the snare is the most reliable way to bring it to the rectum Manual assistance for the recovery of a specimen may be necessary to squeeze a large polyp more than cm through the anus Complications Three types of complications can occur after polypectomy The most common one is bleeding In contrast to adults, a delayed bleeding within weeks after the procedure is quite rare Immediate onset of bleeding is more common, although the incidence of this complication is less than 1% in infants and children This may reflect a smaller size, the number of polyps and the absence of co-morbid conditions such as hypertension, atherosclerosis etc A slow oozing from the polpypectomy site is easy to control by injection of epinephrine solution (1:10 000) or bipolar or argon plasma coagulation (Figure 8.7) The risk of arterial bleeding always exists immediately after polypectomy of a large pedunculated polyp due to incomplete coagulation of thick vessels Endoscopic hemostasis should be prompt before a large amount of blood and clots make the bleeding vessel invisible A temporary hemostasis can be achieved almost immediately by resnaring and tightening of the stalk After a few minutes, the wire loop should be replaced by the Endo loop® for permanent hemostasis In addition, injection of epinephrine below the Endo loop® can augment a hemostatic effect Polypectomy FURTHER READING Cappell MS, Abdullah M (2000) Management of gastrointestinal bleeding induced by gastrointestinal endoscopy Gastrointestinal Endoscopy Clinics of North America, 29, 125–167 Charotini I, Theodoropaulou A, Vardas E, et al (2007) Combination of adrenaline injection and detachable snare application as haemostatic preventive measure before polypectomy of large polyps in children Digestive Diseases and Sciences, 52, 338–339 Cotton PB, Williams C, Hawes RH, et al (2008) Practical Gastrointestinal Endoscopy The Fundamentals (6th edn) pp 182–201, Blackwell Publishing, Oxford Gershman G, Ament ME (2007) Practical Pediatric Gastrointestinal Endoscopy Blackwell Publishing, Oxford, UK 139 Mougenot JF, Vargas J (2006) Colonoscopic polypectomy and endoscopic mucosal resection In: Winter HS, Murphy MS, Mougenot JF, et al, (eds) Pediatric Gastrointestinal Endoscopy pp 163–181, BC Decker, Hamilton, Ontario Tappero G, Gaia E, DeFiuli P, et al (1992) Cold snare excision of small colorectal polyps Gastrointestinal Endoscopy, 38, 310–313 Waye JD (1997) New methods of polypectomy Gastrointestinal Endoscopy Clinics of North America, 7, 413–422 Way JD (2001) Endoscopic mucosal resection of colon polyps Gastrointestinal Endoscopy Clinics of North America, 11, 537–548 Chromoendoscopy Alberto Ravelli, MD KEY POINTS • Chromoendoscopy facilitates the optimal mucosal sampling, for example, in children with Barrett’s esophagus, celiac sprue, polyposis syndromes and long history of inflammatory bowel disease • Interpretation of the stained mucosa is required the knowledge of a positive or negative techniques of chromoendoscopy • It is an essential part of enhanced magnification endoscopy or magnification chromoendoscopy • Technique of mucosal staining is simple and adds only few minutes to the routine endoscopic procedure Indications Esophageal disorders One potential indication of chromoendoscopy in the pediatric esophagus is intestinal metaplasia, i.e Barrett’s esophagus If this condition is suspected, the main aim of chromoendoscopy is to help increase the diagnostic yield of endoscopic biopsies Positive staining with methylene blue could also be used to identify endoscopically invisible intestinal metaplasia of the cardia region which may exist in patients with GERD However, it is questionable if methylene blue staining should be applied to all patients with longstanding GERD who undergo upper endoscopy, since intestinal metaplasia can also be found in asymptomatic individuals and the advantage of methylene blue staining over random biopsy is controversial In adult patients with short-segment Barrett’s esophagus, the sensitivity of methylene blue staining for the detection of intestinal metaplasia varies from 60 to 98%, but is generally higher than that of random biopsies Abnormal methylene blue staining can also be helpful in delineating dysplastic or malignant areas for endoscopic treatment such as mucosal resection or photodynamic therapy If mucosectomy is planned, a minimum amount of methylene blue injected with saline into the underlying submucosa which stain it blue, thereby facilitating an accurate removal of the mucosal lesion In patients who have undergone mucosal ablation, chromoendoscopy could also help distinguish the regenerating squamous epithelium from residual Barrett’s mucosa Lugol’s solution has also been used in follow-up endoscopic examination of young patients who have been treated for Barrett’s esophagus or dysplasia, in order to promptly detect remnants of unstained Barrett’s epithelium Studies in adults have shown that chromoendoscopy with Lugol’s solution is superior to conventional endoscopy for the detection of severe dysplasia and early squamous cell carcinoma of the esophagus In a Chinese population with a high esophageal cancer rate, chromoendoscopy with Lugol’s solution showed a sensitivity of 62 to 96% and a specificity of 63% However, esopha- Practical Pediatric Gastrointestinal Endoscopy, Second Edition George Gershman, Mike Thomson, Marvin Ament © 2012 Blackwell Publishing Ltd Published 2012 by Blackwell Publishing Ltd Chromoendoscopy geal dysplasia and cancer are extremely uncommon in pediatric patients and it should be kept in mind that Lugol’s solution can also stain an inflamed esophageal mucosa, namely reflux esophagitis Other staining techniques such as indigo carmine and acetic acid have been proposed in association with magnification endoscopy to detect Barrett’s esophagus and dysplasia Staining with toluidine blue has been reported to have a very high (98%) sensitivity for Barrett’s esophagus, but cannot distinguish between gastric and intestinal metaplasia Although studies in adults have shown promising results, so far there are insufficient data supporting a routine use of chromoendoscopy for detecting Barrett’s esophagus and dysplasia in children Helicobacter pylori infection and related disorders To date, there are no clear-cut indications for the use of chromoendoscopy to detect specific gastric disorders in clinical practice At least two reactive dyes, however, deserve attention and may prove useful in the near future Congo red stains acidsecreting mucosa and has been used in adult patients to detect gastric atrophy, which appears as an area of negative staining on the dark blue/ black background of the normal mucosa of the gastric fundus and body Phenol red turns from yellow to red in the presence of alkaline pH, such as that related to the hydrolysis of urea by ureaseproducing H pylori, and has been used to map the extent of H pylori colonization in the stomach Both these staining techniques could, therefore, find an application in pediatric patients with long-standing or refractory Helicobacter pylori infection Celiac Disease Gluten-sensitive enteropathy (celiac disease) usually result in endoscopically visible changes of the duodenal mucosa, including a “mosaic” pattern, loss or indentation (scalloping) of Kerckring’s folds and a visible vascular pattern Chromoendoscopy with methylene blue emphasizes the mosaic pattern, although it does not seem to increase the diagnostic yield of endoscopy, at least when performed by experienced gastroenterologists In one study, indigo carmine scattering combined with magnification endoscopy proved superior to standard endoscopy for 141 the detection of small bowel enteropathy, mainly because it was able to distinguish between total and partial villous atrophy However, since the diagnosis of celiac disease is established by histology and not by endoscopy, duodenal biopsies should be taken whenever celiac disease is suspected, irrespective of the endoscopic appearance of the duodenal mucosa Therefore, the major contribution of chromoendoscopy in celiac disease is to allow for better targeting – and consequently some sparing – of duodenal biopsies Polyposis syndromes Chromoendoscopy may be very useful to detect smaller lesions in the duodenum of patients with familial adenomatous polyposis (FAP) Small flat duodenal adenomas may, in fact, go unnoticed during standard endoscopy and even capsule endoscopy, but can be identified as negativestaining lesions when an absorptive dye such as methylene blue is sprayed onto the mucosa In colonic polyposis, the main aim of chromoendoscopy is the same as in the duodenum, i.e to increase the detection rate by facilitating the identification of small flat polyps, especially adenomas The preferred dye for the detection of colonic polyps is indigo carmine, a contrast stain that pools in areas of mucosal irregularity and often gives a three-dimensional effect, which is particularly useful for the detection of small protruding lesions Needless to say, magnification endoscopy and high-resolution endoscopy can add to the accuracy of the technique In adult studies, leftsided or total colonic indigo carmine staining significantly increased the detection rate of small flat or depressed adenomas Chromoendoscopy can also help distinguish between hyperplastic and adenomatous polyps, as they produce different staining patterns In a recent multicenter study, more than 90% of colonic polyps were correctly classified according to the staining pattern, and for adenomatous polyposis, the sensitivity and specificity were 82% and the negative predictive value was 88% Inflammatory Bowel Disease In inflammatory bowel disease (IBD), the greatest potential for chromoendoscopy is the ability to detect dysplasia or cancer early in patients with long-standing ulcerative colitis Colonic dysplasia and colitis-related colon cancer may also, occasionally, be a problem in pediatric patients, as in 232 Advanced Pediatric Endoscopy Techniques Summary The most promising results seem to accrue in the mid-term with the suturing devices which attain full-thickness plications, increase the intra-abdominal portion of the esophagus (most likely by plication tags inserting through the diaphragmatic crura as well as the full thickness of the oesophageal wall i.e., actual change in anatomy), and raised intra-sphincteric length and resting pressure Endo-ultrasound may provide a more controled and sophisticated approach to this technology in the future FURTHER READING Figure 18.16 Injection of liquid polymer into the oesophageal mucosa The Enteryx® procedure 26 (77%) EndoCinch®-treated patients and in 20 of 23 patients treated by Enteryx® (87%, p = 0.365) Approximately 25% of the patients in both groups required retreatment in an attempt to achieve symptom control To date, an estimated 800 patients have been treated with the Enteryx® device, which was approved in 2003 by the FDA To date, there are no published records of its use in pediatrics However, the FDA & Boston Scientific notified healthcare professionals and patients about serious adverse events, including death, occurring in patients treated with the Enteryx® device Based upon reports filed with the FDA, patients suffered leakage, swelling, and ulcers in the esophagus One elderly patient died after some of the polymer had been injected into the woman’s aorta, which ruptured, causing her to bleed to death On September 23, 2005, Boston Scientific ordered a recall of all Enteryx® Procedure Kits and Enteryx® Injector Single Packs from commercial distribution The company’s recall notice stated some doctors accidentally punctured the wall of the esophagus while injecting the substance, causing adverse events Additionally, Boston Scientific Corp recently suspended sales of its Enteryx® device after more than two dozen reports of problems The notice was posted on the company’s Website, during the week of September 19, 2005 Cadiere GB, Rajan A, Germay O, et al (2008) Endoluminal fundoplication by a transoral device for the treatment of GERD: A feasibility study Surgical Endoscopy, 22, 333–342 Cadiere GB, Van Sante N, Graves JE, et al (2009) Two-year results of a feasibility study on antireflux transoral incisionless fundoplication (TIF) using EsophyX Surgical Endoscopy, 23, 957–964 Cohen LB, Johnson DA, Ganz RA, et al (2005) Enteryx implantation for GERD: expanded multicenter trial results and interim postapproval follow-up to 24 months Gastrointestinal Endoscopy, 61, 650–658 FDA (2005) FDA preliminary public health notification Internet Communication Festen C (1981) Paraesophageal hernia: a major complication of Nissen’s fundoplication Journal of Pediatric Surgery, 16, 496–499 Filipi CJ, Lehman GA, Rothstein RI, et al (2001) Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial Gastrointestinal Endoscopy, 53, 416–422 Gotley DC, Smithers BM, Rhodes M, et al (1996) Laparoscopic Nissen fundoplication – 200 consecutive cases Gut, 38, 487–491 Hyams JS, Ricci A Jr, Leichtner AM (1988) Clinical and laboratory correlates of esophagitis in young children Journal of Pediatric Gastroenterol ogy & Nutrition, 7, 52–56 Islam S, Geiger JD, Coran AG, et al (2004) Use of radiofrequency ablation of the lower esophageal sphincter to treat recurrent gastroesophageal reflux disease Journal of Pediatric Surgery, 39, 282–286 Jobe BA, O’Rourke RW, McMahon BP, et al (2008) Transoral endoscopic fundoplication in the Endoscopic approaches to the treatment of GERD treatment of gastroesophageal reflux disease: the anatomic and physiologic basis for reconstruction of the esophagogastric junction using a novel device Annals of Surgery, 248, 69–76 Liu DC, Somme S, Mavrelis PG, et al (2005) Stretta as the initial antireflux procedure in children Journal of Pediatric Surgery, 40, 148–151 Liu JJ, Glickman JN, Carr-Locke DL, et al (2004) Gastroesophageal junction smooth muscle remodeling after endoluminal gastroplication American Journal of Gastroenterology, 99, 1895–1901 Mahmood Z, McMahon BP, Arfin Q, et al (2003) Endocinch therapy for gastro-oesophageal reflux disease: a one- year prospective followup Gut, 52, 34–39 Mahmood, Z Byrne PJ, McMahon BP, et al (2006) Comparison of transesophageal endoscopic plication (TEP) with laparoscopic Nissen fundoplication (LNF) in the treatment of uncomplicated reflux disease American Journal of Gastroenterology, 101, 431–436 Martin AJ, Pratt N, Kennedy JD, et al (2002) Natural history and familial relationships of infant spilling to years of age Pediatrics, 109, 1061–1067 Mattioli G, Repetto P, Carlini C, et al (2002) Laparoscopic vs open approach for the treatment of gastroesophageal reflux in children Surgical Endoscopy, 16, 750–752 Park P, Kjellin T, Kadirkamanathan S (2001) Results of endoscopic gastroplasty for gastrooesophageal reflux disease Gastrointestinal Endoscopy, [Abstract] Pleskow D, Rothstein R, Lo S, et al (2004) Endoscopic full-thickness plication for the treatment of GERD: a multicenter trial Gastrointestinal Endoscopy, 59, 163–171 Raijman I, Ben-Menachem T, Reddy G (2001) Symptomatic response to endoluminal gastroplication (ELGP) in patients with gastroesophageal reflux disease (GERD): a multicentre experience Gastrointestinal Endoscopy, [Abstract] Repici A, Fumagalli U, Malesci A, et al (2009) Endoluminal fundoplication (ELF) for GERD using EsophyX: a 12-month follow-up in a single-center experience J Gastrointestinal Surgery, (ePub ahead of print) Richards WO, Scholz S, Khaitan L, et al (2001) Initial experience with the stretta procedure for the treatment of gastroesophageal reflux disease Journal of Laparoendoscopic & Advanced Surgical Techniques, 11, 267–273 233 Richards WO, Houston HL, Torquati A, et al Paradigm shift in the management of gastroesophageal reflux disease Annals of Surgery, 237, 638–647 Rudolph CD, Mazur LA, Liptak GP, et al (2001) Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition Journal of Pediatric Gastroenterology & Nutrition, 32(Suppl 2), S1–S31 Shepherd RW, Wren J, Evans S, et al (1987) Gastroesophageal reflux in children Clinical profile, course and outcome with active therapy in 126 cases Clinical Pediatrics (Philadelphia), 26, 55–60 Swain CP, Kadirkamanathan SS, Gong F, et al (1994) Knot tying at flexible endoscopy Gastrointestinal Endoscopy, 40, 722–729 Swain P, Park PO, Mills T (2003) Bard EndoCinch: the device, the technique, and pre-clinical studies Gastrointestinal Endoscopy Clinics of North America, 13, 75–88 Swain P, Park PO (2004) Endoscopic suturing Best Practice and Research in Clinical Gastroenterology, 18, 37–47 Thiny MT, Shaheen NJ (2002) Is Stretta ready for primetime? Gastroenterology, 123, 643– 644 Thomson, M (1997) Disorders of the oesophagus and stomach in infants Baillieres Clinical Gastroenterology, 11, 547–571 Thomson M, Frischer-Ravens A, Hall S, et al (2004) Endoluminal gastroplication in children with significant gastro-oesophageal reflux disease Gut, 53, 1745–1750 Thomson M, Antao B, Hall S, et al (2008) Mediumterm outcome of endoluminal gastroplication with the Endocinch device in children Journal of Pediatric Gastroenterology & Nutrition, 46, 172–177 Thomson M, Lobontiu A, Stewart R, et al Transoral incisionless fundoplication for the treatment of pediatric gastroesophageal reflux disease: a feasibility study (in preparation) Torquati A, Houston HL, Kaiser J, et al (2004) Long-term follow-up study of the Stretta procedure for the treatment of gastroesophageal reflux disease Surgical Endoscopy, 18, 1475–1479 Veit F, Schwagten K, Auldist AW, et al (1995) Trends in the use of fundoplication in children with gastro-oesophageal reflux Journal of Paediatric Child Health, 31, 121–126 234 Advanced Pediatric Endoscopy Techniques Velanovich V, Ben-Menachem T, Goel S (2002) Case-control comparison of endoscopic gastroplication with laparoscopic fundoplication in the management of gastroesophageal reflux disease: early symptomatic outcomes Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 12, 219–223 Watson DI (2008) Endoscopic antireflux surgery: are we there yet? World Journal of Surgery, 32, 1578–1580 Youd P, Emmanuel A, Sivanesan S, et al Cessation of proton pump inhibitors following transoral incisionless fundoplication is associated with reduced proximal extent of refluxate Endoscopy (submitted) Index Notes: Pages numbers in italics refer to Figures; those in bold to Tables abdominal pain colon perforation, 121 recurrent, 59–60 aberrant crypt foci (ACF), 172–3 AC line, 51, 51 accessories disinfection, endoscopic retrograde cholangiopancreatography, 189, 189–90 reprocessing, 28 acetic acid, 144 achalasia, pneumatic dilatation, 83–4 acriflavine hydrochloride (AH), 207–8 acute pancreatitis ERCP, 194–5, 195 post-double-balloon enteroscopy, 218 trauma-related, 199 additive primary colors, 18 adenoma-carcinoma concept, 171 adenomatous polyposis coli (APC) gene, 126 adherent clot, 58, 58 adverse effects, sedation, 32 air insufflation, 11 excessive, 42 air/water valve, 13, 42, 43 airway equipment, 32 alcohol flush, 5, 28 alfentanil, 36 allergic proctocolitis, 123–4, 124 allergies, 36 Alpha loop, 117–18 American College of Gastroenterology Barrett’s esophagus definition, 61 American Society for Gastrointestinal Endoscopy (ASGE) colonoscopy bacteremia risk, 121 American Society of Anesthesiologists (ASA) levels of sedation, 30–31 physical status classification, 33, 37 ampulla, 109 anal canal, 109, 110 anal papillae, 109, 110 analgesics, 36 ancillary support staff, angiodysplasia, colon, 129, 128 anomalous pancreatobiliary junction (APJ; common channel), 191–2, 192, 196 antifibrotic agents, 166 antrum, 50 biopsy, 55 anxiolysis (minimal sedation), 30, 35–6 aorta-esophageal fistula, 87 aphthous ulcer, 123, 123 apnea, 32, 34 appendiceal orifice, 113, 113 argon plasma coagulation (APC), 93, 182 aryepiglottic fold, 46 arytenoid cartilage, 46 ascending colon, 109, 112–13, 113, 118 aspirin, 58 attenuated familial adenomatous polyposis (AFAP), 126–7 auto-fluorescence colonoscopy, 179–80 automated reprocessors, 28 autosomal recessive MYH-associated polyposis (MAP), 126 azathioprine, 178 back-washed ileitis, 122 bacteremia, 56 “bagel” shaped lesion, 69, 69 balloon dilatation, 82, 157 balloon dilators, 82–3, 165–6 Barrett’s esophagus (BE), 61–2 chromoendoscopy, 140, 145, 146 definitions, 61–2 epithelial types, 62 intestinal metaplasia, 62 tongue-like lesions, 62, 62 bedside endoscopy, 4–5 bedside precleaning, 26 benzodiazepines, 35–6 bile ducts, 191 bile leaks, 194, 194 biliary anastomosis strictures, 216–18 biliary atresia (BA), 191, 192 biliary endoscopic sphincterotomy, 196 Practical Pediatric Gastrointestinal Endoscopy, Second Edition George Gershman, Mike Thomson, Marvin Ament © 2012 Blackwell Publishing Ltd Published 2012 by Blackwell Publishing Ltd 236 Index biliary rhabdomiosarcoma, 193, 193 biodegradable stents, 159, 159–60 advantages/disadvantages, 162 pediatric experience, 160–162, 161 stenosis development, 161–2 biopsy duodenum, 54–5 eosinophilic esophagitis, 64 esophageal, 54 gastric, 54–5 infectious esophagitis, 65 technique, 54–6 tissue mounting technique, 55–6 biopsy specimens, confocal laser endomicroscopy, 208 bipolar thermal devices, 92 bite guards, 41–2, 44–5 black & white CCD system see RGB sequential endoscopy system bleeding endoscopic retrograde cholangiopancreatography, 191 esophagogastroduodenoscopy-induced, 56 lower tract, 59 obscure, 220 polypectomy-induced, 138, 138 post-colonoscopy, 121 post-double-balloon enteroscopy, 218 post-endoscopic mucosal resection, 182–3 treatment plan development, 57–8 upper tract, 57–9, 59, 88 bleeding disorders, colonoscopy, 121 blind screen, 42 bloom, 14 blue rubber nevus syndrome, 217, 217 Bougie-type dilators, 166 boungienage, 157 bowel preparation colonoscopy, 105–7 polypectomy, 135 bradycardia, 34 British Society of Gastroenterology Barrett’s esophagus definition, 62 epinephrine injection therapy guidelines, 90 buried bumper syndrome, 98, 99 Burkitt’s lymphoma, 70, 71 Buscopan (hyoscine N-butylbromide), 144, 207 N-butyl-2-cyanoacrylate injection, 151–5 Candida esophagitis, 65, 65 carrying cases, 28 cascade stomach, 49 caustic ingestion, 65–6, 66, 166 esophageal stenting, 160 fibrosing gastropathy, 66, 66 CCD see charge-coupled device (CCD) Cdx homeobox gene, 62 cecal patch, 122, 122 cecum, 109, 113, 119 celiac disease, 70–72 active phase, 71–2 chromoendoscopy, 141, 145–7, 146 “cobblestone” appearance, 145 confocal laser endomicroscopy, 208–9, 209 endoscopic signs, 71, 71 immersion chromoendoscopy, 145–7, 147 jejunal capsule biopsy, 70–71 “sticky” villi, 209, 209 celiac spruce see celiac disease cervical esophagus, 48 foreign bodies, 85, 85 pressure necrosis, 85, 85 charge-coupled device (CCD), 14, 14–15 color-chip see color-chip endoscopy image reading, 14, 15–16 image reproduction, 14 image sensor, 8, 11, 11, 15 interline transfer, 16 light sensitivity, 17, 17 light source strobing, 15 line transfer, 15 output signal, 15 photosites, 14, 14 types, 15–16 unit, 11 charge packets, 15 cherry red spots (“red wale” marks), 89, 89 children GI bleeding, 59 see also specific topics choledochal cysts (CC), 191–3, 192 choledococele, 192–3, 193 choledocolithiasis, 193–4 chromoendoscopy, 140–148, 209 application technique, 142–4 celiac disease, 145–7, 146 equipment, 142, 142 esophageal disorders, 140–141 familial adenomatous polyposis, 141 Helicobacter pylori infection, 141 hyperplastic vs adenomatous polyps, 141, 147, 147, 148 indications, 140–142 inflammatory bowel disease, 141–2, 148, 148 lesion recognition, 145–8 mucosa preparation, 144 polyposis syndromes, 141, 147, 147, 148 sedation, 144 stain types, 142–4, 143 staining technique, 144, 145 ulcerative colitis, 145 see also individual stains citric acid magnesium, 106 cleaning attachments, 26, 27 clips, hemostatic, 91, 91–2 coagulation argon plasma, 93, 182 electrosurgery, 132 thermal, 92–4 Index coins, 85, 85–7, 86 treatment algorithm, 86 colitis allergic, 124, 124 collagenous, 210–211 colon cancer, 141–2 Crohn’s disease, 122–3 ulcerative see ulcerative colitis collagenous colitis, 210–211 collagenous gastritis, 67, 67 colon adenocarcinoma, 127, 127 anomalies, 109 ascending, 109, 112–13, 113, 118 confocal laser endomicroscopy, 209, 210 crypt pattern, 209, 210 descending, 109, 111, 111, 112 dysplasia, 141–2 embryology, 108–9 endoscopic anatomy, 109–13 hidden lumen, 115–17, 116 intubation, 138 lymphoid aggregates, 124, 124 perforated, 120 sigmoid see sigmoid colon transverse, 112, 112, 118 ultraviolet light use, 180 vascular malformations, 127, 128 colonic chromoscopy, 183–4 colonic interposition, 157 colonoscopy/colonoscopes, 104–31 auto-fluorescence, 179–80 bleeding disorders, 121 bowel cleaning, 105–7 common pathology, 121–5 complications, 120, 119–121 contraindications, 104, 106 corkscrew technique, 116 degrees of deflection, 13 early precancerous lesion detection, 170–171 equipment, 107, 107–8 handling, 114 handling mistakes, 114 hidden lumen, endoscopic clues, 115–17, 116 historical aspects, 170 indications, 104, 105 infection risk, 121 informed consent, 108 insertion technique, 114–15 one person-single handed approach, 114 pain control, 108 patient positioning, 108, 114–15 pre procedure preparation, 108 pre procedure rectal exam, 115 preparation, 105–7 rare pathology, 125–9 three-finger rotation technique, 114 torque steering technique, 113–14 twisted lumen, 116 237 two persons-single handed approach, 114 withdrawal phase, 119, 138 color-chip endoscopy, 16, 18, 21 advantages/disadvantages, 24 motion reproduction, 21–2 narrow-band imaging, 22, 23 RGB sequential endoscope vs., 21–2, 24 color-chip video imaging, 18, 20–21, 21 color imaging display, 19–20, 20 color imaging systems, 18 color perception, 17 color sources juxtaposition, 20 color video theory, 18, 19 colorectal cancer (CRC), 127 colitis-related, 141–2 exophytic lesion polypectomy, 171 flat lesions, 171, 172 morphology, 171 pathogenesis, 171–3 screening, 170–171 columns of Morgani, 109–10, 110 common channel (anomalous pancreatobiliary junction), 191–2, 192, 196 computer-controlled thermal probes (heater probes), 92–3 confocal endomicroscopy, 178–9, 179 confocal laser endomicroscopy (CLE), 206–12, 207 benefits, 206–12 biopsy specimens, 208 contrast agents, 207–8 image acquisition, 208 image depth adjustment, 207 lower GI tract, 209–11 upper GI tract, 208–9 as “virtual biopsy,” 207 confocal microscope, 207 congenital heart disease, 33 Congo red, 143, 144 Helicobacter pylori infection, 141, 145 conscious sedation (moderate sedation and analgesia), 30–31 corkscrew maneuver, 75 corrosive esophagitis, 160 CRE™ Wire guided Balloon Dilator, 82 cricoarytenoid cartilage, 46, 46 Crohn’s disease colitis, 122–3 colonoscopy, 122–3 confocal laser endomicroscopy, 210 crypt abscesses, 68 intra-operative enteroscopy, 220 mucosal bridges, 123, 124 noncaseating granulomas, 68 skip lesions, 68, 122–3 ulcers, 123, 123 upper GI tract involvement, 68 crypt abscesses, 68 crystal violet (CV), 174, 175–6, 176 238 Index current density, 134 custom-made stents, 162 cytomegalovirus (CMV) esophagitis, 65 gastritis, 67, 67 Menetrier’s disease, 67 deep sedation, 31, 95, 108 dentate (pectinate) line, 109, 110 desaturation, 32 descending colon, 109, 111, 111, 112 dexmedetomidine, 37 diagnostic upper gastrointestinal endoscopy, 41–81 biopsy technique, 54–6 indications, 56, 56–7 pathology, 56–7 diaphragmatic notch (third physiological narrowing), 48 digitized endoscopic images, dilators, 82–3, 165–6 disc battery, 87, 87 disinfectants, 27–8 disinfection, 4, 5, 26–8 high-level, 26–8 documentation, 4, double-balloon enteroscopy (DBE), 213 carbon dioxide insufflation, 218 complications, 216, 218, 220 indications, 216, 216 learning curve, 218–20 pediatric experience, 216–18 polyps, 215, 215, 217 system configuration, 214, 214 tattooing, 215, 215 technique, 214–16, 215 training issues, 218–20 wireless capsule endoscopy vs., 214 “doughnut” shaped lesion, 69, 69 DPEJ technique, 99 drain cleaner ingestion, 161, 161–2 duodenal bulb, 50, 50, 51 biopsy, 55 bleeding ulcers, 50, 58, 59 blind zone, 50 gastric metaplasia, 142 duodenal duplications, 197, 197, 198, 198 duodenal papilla, 52, 52, 53 duodenal ulcers bleeding, 58–9, 59 kissing, 66 duodenal villi, 55, 208 duodenoscopes, 189, 189–90 duodenum biopsy, 54–5 distal, 75 exploration, 47–50 fourth portion, 53 intubation, 50–51 lumen “crescent,” 52 lumen marsupialization, 197, 198 scope retro-flexion, 52, 52 transitional zone, 51, 51 dysplasia, 178 ectopic pancreas, 69, 69 electrosurgery, 132–4 coagulation, 132 generators, 138 power density, 134 RF currents, 132, 133 tissue heating, 132–4, 133 voltage, 132 EMLA cream, 35, 108 EN450B15, 215–16 EN450T5, 215–16 end-tidal CO2 monitoring, 34 EndoCinch® sewing machine, 225, 225–7, 226 Enteryx® vs., 231–2 reflex related quality-of-life scoring, 227, 227 endoluminal gastroplasty, 231 endoluminal gastroplication, 225–7 endoscope(s) angle of view, 16, 16–17 close focus point, 17 control panel, 42, 43 disinfection, equipment assembly, 42 glue damage, 151, 154 handling, 42–4, 43 image resolution limit, 16 image reversal, 45 magnification, 16–17 manual cleaning, 26 mechanical cleaning, objective lens, 11 pre-procedure check-up, 42 reprocessing see endoscope reprocessing resolution, 16–17 resolving power, 16, 16 rotation, 42–3, 43 storage, 28 suction intensity checks, 42 torque technique, 43–4 see also video endoscopes endoscope reprocessing, 26–8 accessories, 28 automated reprocessors, 28 cleaning, 26, 27 personal protective equipment, 26 rinsing and disposal, 28 special channels, 27, 28 steam sterilization, 28 training, 26 endoscopic fundoplication, 230 endoscopic hemostasis, 88–90 categories, 88 constrictive mechanical devices, 90–92 non-thermal hemostasis, 88–90 Index sclerotherapy see sclerotherapy thermal coagulation, 92–4 endoscopic mucosal resection (EMR), 171 complications, 182–3 early stage cancer diagnosis, 183 extended, 182 lesion location/diagnosis, 180 mortality rates, 183 peripheral margin tattoos, 181 post resection management, 182 remnant tissue, 182 snare resection, 180, 181–2 stages, 180 submucosal lift, 181 technique, 180–182 Western practice, 180 endoscopic pancreatic cysto-gastrostomy, 203–5, 205 stents, 203, 204, 205 technique, 203–4, 204, 205 endoscopic retrograde cholangiopancreatography (ERCP), 188–202 accessories, 189, 189–90 biliary indications, 191, 191–4 with biliary sphincterotomy, 195 complications, 190–191 contrast media, 190 esophageal intubation, 190 fluoroscopy equipment, 190 hidden lumen, 190 indications, 188–9 long way technique, 190 orientation, 190 pancreatic indications, 194–9, 195 short way technique, 190 with stent placement, 194 technique, 190–191 endoscopic sphincterotomy (ES), 197, 197 endoscopic suturing devices, 225, 225–7, 226 endoscopic ultrasonography (EUS), 190, 199 endoscopic variceal ligation (EVL), 90–91, 91 endoscopy nurse, endoscopy setting, 4–6 endoscopy unit, endosonography (EUS), 203 enemas, 107 enteroscopy, 213–23 complications, 220 tattooing lesions, 213 Enteryx®, 231–2, 232 EndoCinch® vs., 231–2 eosinophilic esophagitis, 63–5 biopsy, 64 crêpe paper mucosa, 63 diagnosis, 63 endoscopy, 63–4 etiology, 63 histology, 63, 64–5 macroscopic abnormalities, 63, 64 239 pathogenesis, 63 prevalence, 63 symptoms, 63, 64 trachealization, 63, 64 eotaxin-3, 63 epiglottis, 45, 45 epinephrine injection, 90, 93 eschar, 66 esophageal biopsy, 54 esophageal burns, 66 esophageal cancer, 140–141 esophageal dilation, 165–6 complications, 165 devices, 165–6 guide wire technique, 166 indications, 165 purpose, 165 “rule of 3s,” 166 esophageal dysphasia, 140–141 esophageal intubation complications, 34 direct midline, 46, 46–7, 47 direct observation techniques, 44–7 endoscopic retrograde cholangiopancreatography, 190 infants, 47 initial phase, 44, 44 neonates, 47 patient positioning, 41 pharynx, approach to, 44, 44 preparation, 41–2 swallowing process, 47 techniques, 44–7, 45, 46, 47 esophageal orifice, 46, 47 esophageal stenosis, 61 esophageal stenting/stents, 156–64, 157–60 benign esophageal strictures, 156–64 caustic ingestion, 160 corrosive esophagitis, 160 esophageal perforation, 160 future developments, 162 indications, 156 pediatric experience, 160–162 stent migration, 159, 160 timing, 162 treatment duration, 162 types, 157 see also individual stents esophageal strictures, 60–61, 61 benign, 156–64 classification, 61 conventional treatments, 157 endoscopic balloon dilatation, 157 intractable, 165–9 mitomycin C, 165–9 pneumatic dilatation, 82–3, 83 refractory, 157–60 relapsing, 157–60 sclerotherapy-induced, 90 240 Index esophageal ulcers, 60 caustic ingestion, 66 sclerotherapy-induced, 90 esophagitis corrosive, 160 cytomegalovirus, 65 eosinophilic see eosinophilic esophagitis gastroesophageal reflux disease, 60, 60–61 GERD unrelated, 63–73 herpetic, 65, 65 infectious, 65 esophagogastroduodenoscopy (EGD), 3, 56, 56–7 esophagus cervical see cervical esophagus chromoendoscopy, 140–141 confocal laser endomicroscopy, 208 distal, 48 distention, 48 exploration, 47–50 narrow, 61 perforation, 160, 165 second physiological narrowing, 48, 48 thoracic portion, 48 trachealization, 63, 64 EsophyX® device, 227–9, 228 Ethanolamine, 89 etomidate, 36 excessive air pressure perforation, 119–121 extrahepatic bile duct strictures, 194 eye, light sensitivity, 17, 17 familial adenomatous polyposis (FAP), 126–7, 127 chromoendoscopy, 141, 147, 147 fentanyl, 36 fiberoptic bundle, 8, 13 fiberoptic endoscopes, fiberoptic illumination fibers, 10–11 fibrosing gastropathy, 66, 66 FICE (Fuji Intelligent Color Enhancement), 24 flumazenil, 36 fluorescein sodium (FS), 207–8 Foley catheter technique, 85 foreign bodies, upper GI tract, 84–8 foreign body retriever, 86, 86 foveolae (gastric pits), 208 Fuji Intelligent Color Enhancement (FICE), 24 Full Thickness Plicator®, 227, 227, 228 fundal varices band ligation complications, 152 endoultrasound, 152, 152 gamma loop, 118 Gardner’s syndrome, 69 gastric bezoar, 69–70 gastric biopsy, 54–5 gastric body, 49, 49, 53 diffuse nodularity, 67 gastric cardia, 53, 53, 54 gastric erosions, 55 gastric fundus, 53 gastric lavage, 57 gastric pits (foveolae), 208 gastric pull-through, 157 gastric tumors, 69–70 gastric ulcers, 55 gastric varices, 154 gastritis, 66–7 collagenous, 67, 67 cytomegalovirus, 67, 67 hemorrhagic, 58 herpetic, 67 gastrocutaneous fistula, 99 gastroduodenal tube placement, 101 gastroesophageal biopolymer injection, 231–2 gastroesophageal reflux disease (GERD) chromoendoscopy, 140 confocal laser endomicroscopy, 208 endoscopic treatment approaches, 224–34 esophagitis, 60, 60–61 methylene blue, 140 treatment aims, 224 gastrojejunal tube placement, 100–101 gastroscopes, 13 general anesthesia, 31 colonoscopy, 108 sclerotherapy, 89 GERD see gastroesophageal reflux disease (GERD) germicides, 28 glue extrusion, 154 glue injection complications, 154 gastric varices, 152–4 infants, 152 longer term efficacy, 152 needle withdrawal, 153, 153 technique, 152–4, 153 glutaraldehyde, gluten-sensitive enteropathy see celiac disease glycerin suppository, 106 goblet cells, 209 goose-skin sign, 126 graft-versus-host-disease (GVHD), 211, 211 heater probes (computer-controlled thermal probes), 92–3 Helicobacter pylori infection biopsy, 55 chromoendoscopy, 141, 145 gastritis, 66–7, 67 hemangiomas, colon, 128, 128 hematemesis, 57 hematochezia, 121 hemorrhage see bleeding hemorrhagic gastritis, 58 hemostasis, endoscopic see endoscopic hemostasis hemostatic clips, 91, 91–2 hepatic flexure, 112, 113, 118 Index herpes simplex virus (HSV) esophagitis, 65, 65 gastritis, 67 hiatal hernia, 62 high-grade dysplasia (HGD), 171–2 high magnification chromoscopic colonoscopy (HMCC), 173 clinical recommendations, 183–4 colitis associated cancer, 177–8 colorectal lesions, in vivo staging, 176–7, 177 diagnostic accuracy, 175 dyes, 174–5, 176 in vivo optical biopsy, 175–6 intraepithelial neoplasia detection, 177–8, 178 intraepithelial neoplasia vs ulcerative colitis, 178 lesion overstaging, 177 limitations, 178 mucosal signs, 173, 173 pit patterns, 174, 174, 175, 183–4 remnant tissue, 182 submucosal layer disease, 176 High Resolution Television (HDTV) monitors, 16 histoendoscopy, 178–9 hyoscine N-butylbromide (Buscopan), 144, 207 hyperplastic gastric polyp, 69, 69 hypertrophic gastropathy (Menetrier’s disease), 67–8 hypertrophic pyloric stenosis (HPS), 68, 69 hypnotics, 36 hypoxemia, 32, 34 i-Scan, 24 ileitis, back-washed, 122 ileo-colonic intussusception, 125, 125 ileocecal valve, 113, 113, 119, 119 ileum, terminal see terminal ileum immersion chromoendoscopy, 145–7, 147 impedance (tissue resistance), 132 incisura angularis, 49, 49 India ink, 143, 144 indigo carmine (IC), 143, 143 celiac disease, 141 colonic polyps, 141, 147 endoscopic mucosal resection, 180 high magnification chromoscopic colonoscopy, 174, 175, 176 ulcerative colitis, 181 infants colonoscopy preparation, 106 esophageal intubation, 47 small sigmoid colon, 110 upper GI bleeding, 58, 59 infectious endocarditis (IE), 56 infectious esophagitis, 65 inflammatory bowel disease (IBD) chromoendoscopy, 141–2, 148, 148 colonoscopy, 121–2 confocal laser endomicroscopy, 210, 210 evolution, 178 241 informed consent colonoscopy, 108 sedation, 33 insertion tube, 7–14, adjustable stiffness, 10 air system, 8, 11, 12, 13 angulation control wires, 8, 9, 12–13 angulation system, 11–13, 12 base stiffness, 10, 10 bending section, 11–13, 12 biopsy channel, 11 diameter, distal tip, 10–11, 11 elasticity, external layer, 9, 10 flexibility, 9–10, 10 helical bands, 9, ideal, 9, 10 instrument channel, internal components, suction system, 12, 13 tensioning wire, 8, 8, 9, 10 water system, 11, 11, 12, 13 interline transfer charge-coupled devices, 16 intestinal lymphangiectasia, 72–3, 73, 220, 220 primary (Waldmann’s disease), 72, 72–3, 73 secondary, 72 intestinal lymphoid hyperplasia, 124, 124–5 intra-operative enteroscopy technique, 214, 219–20, 220 intra-operative laparoscopy-assisted push enteroscopy, 214 intraepithelial neoplasia colonoscopic imaging, 170–187 endoluminal treatment, 170–187 high magnification chromoscopic colonoscopy, 177–8, 178 ulcerative colitis vs., 178 jejunum proximal, 75, 75 tube placement, 100–101, 101 juvenile polyposis, 126, 126 juvenile polyps, 124–5, 125, 126 juxtaposition of color sources, 20 Kerckring’s folds, 141 ketamine, 36–7 “kissing” duodenal ulcers, 66 laparoscopic-assisted enteroscopy, 219–20, 220 laparoscopic assisted PEG (lap PEG), 98 laparoscopic fundoplication, 224, 230 large volume lavage, 106 laryngeal mask airways (LMAs), 32 laryngospasm, sedation-induced, 32 larynx, 46, 46 laser scanning confocal microscopy (LCM), 178–9, 179 lavage solution, 106–7 leak testing, 24–5, 27 242 Index lens washing, 11 life support, 32 ligament of Treitz, 53, 53 light guide lens, 11, 13 light source, 42 line transfer charge-coupled device, 15 lineal furrow sign, 63, 64 local anesthetics, 35 longitudinal fold distal duodenum, 52 rectum, 109–10, 110 lower esophageal sphincter (LES), 83, 231 Lugol’s solution, 140, 142, 143, 145 Lye ingestion, 65 lymphangiectasia, intestinal, 72–3, 73, 220, 220 lymphoid follicles, rectal, 109 lymphoproliferative disorder, 70, 71 magnesium citrate, 106 magnesium oxide, 106 magnetic resonance cholangiopancreatography (MRCP), 188, 195, 195 Meckel’s diverticulum, 217, 217, 220 median raphae, 45 medical devices, semi-critical, 26 Menetrier’s disease (hypertrophic gastropathy), 67–8 mesenteric stretch, 34 methylene blue, 142, 143 Barrett’s esophagus, 140, 145 carcinogenesis risk, 142 celiac disease, 141, 145, 146 familial adenomatous polyposis, 141, 147, 147 GERD, 140 high magnification chromoscopic colonoscopy, 174, 176 inflammatory bowel disease, 148 ulcerative colitis, 142 methylprednosolone, 157 midazolam, 35 milk of magnesia, 106 “mini probe” ultrasound, 177 “mini” (small) snare, 134 minimal sedation (anxiolysis), 30, 35–6 minimum effective concentration (MEC), 28 mitomycin C, 166, 166–8, 167 adverse effects, 167–8 caustic strictures, 166, 166–7 esophageal strictures, 157, 165–9 mechanism of action, 166 therapeutic dose, 167 timing, 168 mobile unit, 4–5 moderate sedation and analgesia (conscious sedation), 30–31 multiple angiomata, 217, 217 multipolar thermal devices, 92 N loop, 117–18 naloxone, 36 narrow-band imaging (NBI), 22–4, 23 narrow esophagus, 61 nasoduodenal tube placement, 100–101 nasojejunal tube placement, 100–101, 101 neonatal intensive care unit, neonates esophageal intubation, 47 upper GI bleeding, 58, 59 nil per os (NPO) status, 33 nitinol, 157 non-Hodgkin’s lymphoma, 70, 70, 128–9, 128 non-lifting sign of Uno, 181 non-steroidal anti-inflammatory drugs (NSAIDs), 58 nursing staff, skills, octreotide, 88 “on-table” enteroscopy, 220 open Nissen’s fundoplication, 224, 230 operating room endoscopy, opioids, 36 over-the-wire method, 101 pain reflex withdrawal, 31 pancolitis, 127 pancreas, ectopic, 69, 69 pancreas divisum, 196, 196–7, 197 pancreatic endoscopic sphincterotomy, 196 pancreatic pseudocysts, 198–9, 203 endo-ultrasound, 203, 204 EUS guided drainage, 199 identification, 203, 204 post-traumatic, 199 pancreatic trauma, 198–9 pancreatitis acute see acute pancreatitis chronic, 198 endoscopic ultrasonography, 199 pancreas divisum, 196–7 post-endoscopic retrograde cholangiopancreatography, 190 recurrent, 195–6 papilla of Vater, 52, 52 paradoxical reactions, 35 Paris classification, 172 pectinate (dentate) line, 109, 110 Pediatric Endoscopy Database System Clinical Outcomes Research Initiative (PEDS-CORI), 32 pediatric endoscopy nurse, Pediatric Sedation Research Consortium, 32 PEG 3350, 106 Pentax EC3870CILK endoscope, 207, 207 peptic ulcers, 66, 66 percutaneous endoscopic gastrostomy (PEG), 94–9, 100 aborting procedure, 97–8, 100 atypical anatomy, 100 complications, 97, 98–9 contraindications, 94 Index decision to proceed, 94–5 feeding, 95, 97 indications, 94 laparoscopic assisted, 98 new uses, 99 patient preparation, 95 personnel, 95 post procedure management, 98 preprocedure evaluation, 94–5 safe tract technique, 96, 96 sedation, 95 surgical gastrostomy vs., 94 technique, 95, 95–8, 96, 97 tube replacement, 98 tube revisions, 99 percutaneous transhepatic cholangiography (PTC), 190 perforation argon plasma coagulation-induced, 93 caustic ingestion, 66 colonoscopy-induced, 120 double-balloon enteroscopy-induced, 218 endoscopic mucosal resection-induced, 183 esophagogastroduodenoscopy-induced, 56 pneumatic dilatation-induced, 83, 84 periform recess, 47, 47 Peutz-Jeghers syndrome (PJS) colonoscopy, 126 double-balloon enteroscopy, 215, 217 gastric polyps, 69–70, 70 multiple hamartomas, 69–70, 70 treatment, 126 pharyngoepiglottic fold, 47 pharynx, 44, 44 phenol red, 141, 143, 144, 145 photoelectric effect, 14 Pico-Salax, 106 picture elements (pixels), 14–15 piece-meal technique, 137 pig-tailed stents, 203, 204 pigmented spots, 58, 58 pixels (picture elements), 14–15 PJF 160, 189 plastic stents, 203 pneumatic dilatation (PD) achalasia, 83–4 balloon diameter, 82–3 complications, 84 endoscope-guided technique, 84 esophageal strictures, 82–3, 83 patient preparation, 84 sedation, 84 technique, 82–3 traditional/fluoroscopic-guide technique, 83, 84 Polidocanol, 89 poly-/-lactic acid monofilaments biodegradable esophageal stent, 159 polydioxanone, 159 polymeric glue, 151–5 polyp(s) 243 assessment, 136 juvenile, 124–5, 125, 126 removal, 137, 138 sessile, 136 small, 136–7 polyp retrieval nets, 138 polypectomy, 132–9 backwards snaring, 136 bowel preparation, 135 colonic intubation, 138 colonoscopy withdrawal phase, 138 complications, 121, 138 exophytic lesions, 171 generator testing, 135 large polyps, 137 modified technique, 137 pedunculated polyps, 137 Peutz-Jeghers syndrome, 70 piece-meal technique, 137 routine, 135 safety conditions, 135–8 safety routine, 135 snare loops see snare loops techniques, 135–8 polypectomy syndrome, 121 polyposis syndrome(s), 69 chromoendoscopy, 141, 147, 147, 148 colonoscopy, 124–8 portal hypertension, 89 post-cholecystectomy bile leak, 194, 194 post-traumatic biliary disease, 194 postsurgical biliary disease, 194 primary sclerosing cholangitis (PSC), 193–4, 194 primitive large intestine, 109 propofol, 36, 108 propofol infusion syndrome, 36 proton pump inhibitors, 58 pseudopolyps, 124–5 pull and twist technique, 50–54 punch-out lesions, 58 push dilators, 165 push enteroscopy/jejunoscopy, 74–6, 213–14 complications, 76, 220 technique, 74, 74–6, 75, 76 pylorus, 49–50, 50, 190 R/L knob, 44 radiofrequency energy delivery, 231 Rapunzel syndrome, 70 ratchet-wheel technique, 43, 43 reactive stains, 142 rectal mucosa, 109, 110 rectum bleeding, 121–4 embryology, 109 endoscopic anatomy, 110, 109–10, 110 recurrent abdominal pain (RAP), 59–60 red, green and blue (RGB), 18, 18 “red wale” marks (cherry red spots), 89, 89 244 Index reflection, total internal, 13 remifentanil, 36 reprocessing of endoscopes see endoscope reprocessing respiratory insufficiency, 34 retrograde ileoscopy, 73, 73 retroperitoneal perforation, 191 reverse Trendelenburg position, RGB sequential endoscopy system, 15, 24 advantages/disadvantages, 24 anti-color-slip circuit, 22 color-chip video endoscope vs., 21–2, 24 components, 18, 19 filter wheel, 18 green image, 19 illumination, 18–19 image misalignment, 22 imaging, 18–19, 20 production of motion, 22 red image, 19 second generation video processors, 22 RGB Sequential Imaging System, 18 rhabdomiosarcoma, biliary, 193, 193 Rigiflex 30mm diameter dilator, 84 Savary-Miller dilatators, 157 Schatski’s ring, 61, 61 sclerotherapy, 88–90 complications, 89–90 general anesthesia, 89 goals, 88 indications, 88–9 injection technique, 89, 89–90 polymeric glues, 90 procedure, 89 recurrent variceal bleeding, 89 repeat sessions, 89 screening colonoscopy, 104 screw and advance concept, 219 second physiological narrowing, 48 secretions, excessive, 32 sedation, 30–38 adverse effects, 32 baseline vital signs, 34 behavior control, 31 cardiorespiratory monitoring, 32–3 care after, 34–5 chromoendoscopy, 144 colonoscopy, 108 communication, 34 complications, 31–2 deep, 31, 95, 108 definitions/levels, 30–31 discharge criteria, 35 drug interactions, 33 fasting intervals, 33 goals, 31 heart exam, 33 informed consent, 33 instructions, 33 management during, 34 medical history, 33 medication administration timing, 34 minimal, 30, 35–6 oropharynx exam, 33 percutaneous endoscopic gastrostomy, 95 physical exam, 33 physical response interpretation, 31 precautions, 32 preparation for, 32–3 presedation assessment, 33 procedure analysis, 31 recovery area, 35 risk assessment, 33 risks, 31–2 staff numbers, 34 supplemental oxygen, 34 techniques, 35–7 transient desaturation, 32 sedation nurse, 34 sedatives, 35–6 self-expandable metal stents (SEMS), 157–8 complication rate, 157 covered, 157 endoscopic pancreatic cysto-gastrostomy, 203 fully covered, retrievable, 158, 158–9, 160, 162 limitations, 157–8 pediatric experience, 160 plastic prostheses vs., 157, 158 stent migration, 159, 160 self-expandable plastic stents (SEPS), 158, 158 complications, 158 pediatric experience, 160 self-expandable metal stents vs., 158 semi-critical medical devices, 26 sexual abuse, 109, 110 sharp objects, ingested, 87–8, 88 Sickle cell disease (SCD), 193 sigmoid colon, 110–11, 117–18 allergic colitis, 124, 124 bowel preparation-induced lesions, 124, 124 deviations, 109 hand pressure stabilization, 118 infants/toddlers, 109–10 loop creation, 117 loop prevention, 117 “shaped-up,” 111–112 transitional zone, 111, 111 sigmoid-descending junction, 116–17 single-balloon enteroscopy, 213, 218, 218–19 slim colonoscopes, 107, 107 small (“mini”) snare, 134 snare loops, 134–5 closing point marking, 134, 134–5 closure, 135, 136, 136 placement, 136, 136 safety routine, 135 squeezing pressure, 135, 135 sodium hydroxide ingestion, 65 Index sodium phosphate colonic lavage, 107–8 sodium picosulfate, 106 Sonde type enteroscope, 213 sphincter of Oddi, 191 sphincter of Oddi dysfunction (SOD), 197–8 spina bifida, 109, 110 spiral enteroscopy, 213, 219, 219 splenic flexure, 111–12, 112, 118–19 spray catheters, reusable, 142 squamo-columnar junction, 109, 110 staff, 4–6 percutaneous endoscopic gastrostomy, 95 sedation, 34 Standard Definition Television (SDTV) monitors, 16 stents biodegradable see biodegradable stents esophageal see esophageal stenting/stents tracheobronchial, 160, 162 stomach, 47–50 biopsy, 54–5 greater curvature, 49, 49 malignant tumors, 70 mucosal patters, 66 retrograde inspection, 53 see also entries beginning gastric Stretta® catheter, 231 Stretta® control module, 231 STRETTA® system, 231, 231 strictures biliary anastomosis, 216–18 esophageal see esophageal strictures extrahepatic bile duct, 194 stridor, 32 suction line, 13 suction valve, 13, 42, 43 sufentanil, 36 superior mesenteric artery, 52 supplemental oxygen, 34 teenagers, GI bleeding, 59 tenia coli, 110–111 terminal ileum double-balloon enteroscopy, 215, 215 exploration, 119, 120 intestinal lymphoid hyperplasia, 124, 124–5 non-Hodgkin’s lymphoma, 128–9, 128 thermal coagulation, 92–4 third physiological narrowing (diaphragmatic notch), 48 thrombin injections, 154 TIF2.procedure, 228–9 tip perforation, 120 tissue resistance (impedance), 132 toddlers small sigmoid colon, 110 upper GI bleeding, 58, 59 toluidine blue, 142, 143 tongue esophageal intubation, 45, 45 root of, 45, 45 245 torque screw technique, 105 total internal reflection, 13 tracheo-esophageal fistula, 87, 87 tracheobronchial remnants, 61 tracheobronchial stents, 160, 162 tranquilizers, 108 transient bacteremia, 56 Transoral Incisionless Fundoplication (TIF)® procedure, 227–8, 228, 229 transverse colon, 112, 112, 118–19 trauma, 109, 110 traumatic colonic perforations, 121 “triangular-cord” sign, 191 trichromatic vision, 17, 18, 18 U/D knob, 42–3, 43 U-turn maneuver, 53, 53, 54 UK National Poly Study, 171 ulcer(s) aphthous, 123, 123 endoscopic variceal ligation-induced, 91 esophageal see esophageal ulcers recurrent bleeding, 58 ulcerative colitis, 182 chromoendoscopy, 142, 145 colonic adenocarcinoma, 127 colonoscopy, 121–2, 122 confocal laser endomicroscopy, 209, 210 dysplasia, 178 intraepithelial neoplasia vs., 178 pseudopolyps, 122, 123 severe form, 122, 122 ultrasound scan (US), hypertrophic pyloric stenosis, 68 ultraviolet (UV) light, 180 unconscious see deep sedation upper gastrointestinal disorders, 206–7 upper gastrointestinal endoscopy age-related indications, 57 diagnostic indications, 59–62 elective, 59–62 therapeutic, 82–103 urgent, 57–9 V-shaped foreign bodies, 87–8, 88 valves of Houston, 109, 110 valvulae conniventes, 55, 71, 71 varices endoscopic hemostasis, 151–5 fundal see fundal varices gastric, 154 Veterans Affairs Study, 171 video endoscopes, 7–29 color reproduction, 17–21 components, digital imaging post-processing, 24 double-balloon enteroscopy, 214 electronic magnification system, 17 illumination system, 8, 13–14 image freezing, 24 246 Index video endoscopes (cont’d) iris, 13–14 objective lens, 15, 19 optical zoom, 17 reproduction of motion, 21–2 troubleshooting, 24–6, 25 water-jet nozzle, 11 video image capture, 14–15 video monitor, 19, 19 villous atrophy, 55 vital signs, 34 vital stains, 142 vocal cords, 46, 46 vomiting, 32 Waldmann’s disease (primary intestinal lymphangiectasia), 72, 72–3, 73 water-immersion technique, 55 water-jet nozzle, 11 water system, 11, 11, 12, 13 wireless capsule endoscopy (WCE), 214 complications, 214 double-balloon enteroscopy vs., 214 primary intestinal lymphangiectasia, 73 Z-line, 48, 48 cephalad displacement, 62 withdrawal, 53–4, 54 ... et al (20 08) Practical Gastrointestinal Endoscopy The Fundamentals (6th edn) pp 1 82 20 1, Blackwell Publishing, Oxford Gershman G, Ament ME (20 07) Practical Pediatric Gastrointestinal Endoscopy. .. varices Practical Pediatric Gastrointestinal Endoscopy, Second Edition George Gershman, Mike Thomson, Marvin Ament © 20 12 Blackwell Publishing Ltd Published 20 12 by Blackwell Publishing Ltd 1 52 Advanced... malabsorption Gastrointestinal Endoscopy, 46, 22 6 23 0 Weinstein W (20 05) Tissue sampling, specimen handling, and chromoendoscopy In: Ginsberg GG, Kochman ML, Norton ID, Gostout CJ (eds.) Clinical Gastrointestinal