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Endoscopic procedures

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1 Endoscopic procedures
L-5 Endoscopic procedures

2 ENDOSCOPY The use of fiber-optic scopes for the purpose of examination, diagnosis, and treatment. Began as a diagnostic tool. Now most scopes are equipped w/ various gizmos for: biopsy, cauterization, and a wide variety of instruments for advanced surgical procedures.

3 COMPLICATIONS / RISKS Risk depends on the nature of the procedure and the anesthesia involved. There are possible 7 risks of any endoscopy. 1) Perforation. 2) Aspiration. 3) Adverse drug reaction. 4) Cardiovascular problems, arrhythmias. 5) Bleeding. 6) Infection. 7) Reaction to contrast material.

4 BRONCHOSCOPY Examination of the trachea and main stem bronchi.
Primary purpose is to diagnose malignancy. Also used to remove foreign bodies. Can do biopsies, washings, and brush biopsies. Can culture for pathogens: Pneumocystis carinii, Legionella. Done under conscious sedation w/ topical anesthetic, or general anesthesia.

5 LARYNX

6 BRONCHOSCOPY

7 GASTROINTESTINAL ENDODOSCOPY
ESOPHAGOSCOPY- esophagus only. GASTROSCOPY- esophagus and stomach. ESOPHAGOGASTRODUODENOSCOPY- esophagus, stomach, & duodenum. PROCTOSCOPY- anus & rectum. SIGMOIDOSCOPY- rectum and sigmoid colon. COLONOSCOPY- rectum and entire colon. Usually done under conscious sedation, occasionally general

8 GASTROINTESTINAL ENDODOSCOPY
USES DIAGNOSIS / DETECTION OF: malignancy, ulcers, bleeding, inflammation, etc. Removal of foreign bodies. Biopsy of polyps, lesions suspicious for malignancy, etc. Control of bleeding via cautery, ligation.

9 ESOPHAGUS IMAGES COMPLIMENTS OF :http://www.gicare.com/pated/ei00001.htm

10 Barretts Esophagus

11 Esophageal Varicies

12 Gasric hypylori inflammation

13 Duodenal Ascariasis

14 Foreign body Duodenum

15 EUS LIV. Metastasis

16 Colonic Diverticuli

17 LOWER ESOPHAGEAL SPHINCTER
CLOSED OPEN

18 REFLUX – (GERD)

19 ESOPHAGEAL VARICES

20 ESOPHAGEAL POLYP

21 CANCER OF THE ESOPHAGUS

22 ESOPHAGEAL MONILIASIS

23 NORMAL STOMACH PYLORIS FUNDUS ANTRUM

24 HEMORRHAGIC GASTRITIS

25 GASTRIC ULCER

26 FOREIGN BODY - STOMACH

27 FOREIGN BODY - STOMACH PEARL EAR-RING

28 STOMACH CANCER

29 POLYPS - STOMACH

30 NORMAL DUODENUM

31 AMPULLA OF VATER

32 DUODENAL ULCERS

33 DUODENAL STRICTURE

34 E.R.C.P. Endoscopic Retrograde Cholangiopancreatography.
Endoscope passed to the duodenum, w/ cannulation of the Ampulla of Vater. Dye is injected and films taken. Used to evaluate the patency and integrity of the common bile duct, R/O obstruction, such as w/ stones.

35 E.R.C.P. Helpful in the post-cholecystectomy patient who has a post-op complication: stone obstructing the CBD, stricture, etc.

36 E.R.C.P.

37 E.R.C.P.

38 NORMAL JEJUNUM

39 CELIAC SPRUE

40 COLONOSCOPY USES Evaluation of rectal bleeding, abdominal pain, etc.- cancer, polyps, inflammatory bowel disease. Biopsy of suspicious lesions, polyps, inflammation. Control of bleeding, banding of hemorrhoids. Also used as a screening tool for early diagnosis of colon cancer, along w/ rectal exam and test for fecal occult blood.

41 NORMAL COLON

42 INTERNAL HEMORRHOIDS

43 DIVRTICULOSIS

44 DIVERTICULITIS

45 ADENOMATOUS POLYP

46 CROHN’S DISEASE - COLON

47 CROHN’S DISEASE - ILEUM

48 ULCERATIVE COLITIS

49 CANCEROUS COLON POLYP

50 CANCER - RECTOSIGMOID

51 LAPAROSCOPY Endoscopy of the abdomen (and pelvis).
Wide variety of uses, too numerous to mention, but examples would be: diagnosis and treatment of gynecologic pathology – endometriosis, ectopic pregnancy, infertility, and much more; Cholecystectomy; appendicitis, etc. Has greatly reduced the hospital stay, cost, pain, and recovery period as compared to “open” procedures (laparotomy).

52 LAPAROSCOPY The abdomen is insufflated w/ CO2 in order to “lift” (distend) the abdominal wall up off the abdominal contents, to allow for visualization, room to work in, etc. Post-op, these patients experience right shoulder pain as the CO2 lodges under the right hemi-diaphragm, which is innervated by C Because of the CO2, general anesthesia is generally used, as patients are unable to ventilate w/ large volume of CO2 on board.

53 LAPAROSCOPY – ECTOPIC PREGNANCY

54 LAPAROSCOPY – ECTOPIC PREGNANCY

55 LAPAROSCOPY – GALL BLADDER

56 LAPAROSCOPIC CHOLECYSTECTOMY
1 2 3

57 HYSTEROSCOPY - FIBROID

58 HYSTEROSCOPIC MYOMECTOMY

59 ARTHROSCOPY Evaluation of joint pathology.
Most commonly used in the knee – torn menisci, ACL’s, etc. Used both as a diagnostic tool and for surgical repair. Depending on the joint, can be done under general anesthesia, or w/ regional block and sedation.

60 NORMAL KNEE ANATOMY

61 ARTHROSCOPY – TORN MENISCUS (MF)

62 ARTHROSCOPY – NORMAL ACL

63 CYSTOSCOPY Evaluation of the bladder, and urethra.
For diagnosis and treatment of urethral and bladder pathology, as well as for TURP’s. Can also evaluate the ureteral orifices, and can cannulate the orifice and inject dye into the ureter, a “retro-grade” pyelogram. Topical anesthesia can be used, but if extensive diagnostic or therapeutic procedures are done, sedation or regional block can be used.

64 DIAGNOSTIC PROCEDURES RELATED TO THE CHILDBEARING YEARS
CHAPTER 28

65 TESTS OF TUBAL PATENCY 1) THE HSG – HYSTEROSALPINGOGRAM –
X-Ray study w/ dye injected thru the cervix – detects tubal occlusion, also looks at the anatomy/contour etc. of the uterine cavity (ies). 2) LAPAROSCOPY W/ TUBAL DYE STUDY – If needed to look for intra-abdominal pathology as the problem, such as endometriosis, etc

66 IF EVERYTHING IS NORMAL…
Would typically proceed w/ laparoscopy. Looking for: tubal patency (dye study), presence of adhesions (old PID), and endometriosis, which is a common finding in patients w/ otherwise unexplained infertility to this point. Some physicians would also do a hysteroscopy- looking inside the uterine cavity to look for anatomic malformations, intracavitary / sub-mucous firoids, adhesions (Asherman’s Syndrome), etc.

67 TESTS DURING PREGNANCY
TO DETECT CHROMOSOMAL, GENETIC, AND/OR STRUCTURAL ABNORMALITIES DONE IN PATIENTS W/: 1) Advanced Maternal Age Risk - > age 35. Risk of chromosomal abnormalities increases with increasing maternal age. 2) Family or personal history of genetic or chromosomal abnormalities.

68 Ultrasonography Obstetrics

69 CRL: Crown Rump Length Earliest detection at 4-5 weeks

70 11-12 week fetus shows division of hemispheres and choroid plexus

71 Fetal Spine

72 Liver/Lung Interface

73 Study of intracranial features including the cerebellum and corpus callosum.

74 Umbilical Cord

75 3D imaging of placenta

76 3D Imaging of eyeball sockets at 12 weeks

77 Diagnosis of fetal malformation.
Hydrocephalus Anencephaly Myelomeningocoele Achondroplasia, Spina bifida, Cleft lips/ palate and Congenital cardiac abnormalities

78 placenta previa diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth retardation

79 ULTRASOUND 3 “levels” of ultrasound.
Level I – the basics – how many babies, how much fluid, where’s the placenta, gestational age, is the heart beating, etc. Level II – all the above plus a cursory evaluation for structural abnormalities – how many kidneys, does the heart have 4 chambers, etc. Level III – targets specific areas, looking for the “usual’ signs of Downs, specific cardiac defects, neurologic defects, etc – usually done in response to something not being normal, elevated AFP, etc.

80 AMNIOCENTESIS Removal of amniotic fluid for evaluation for:
1) Karyotype – the chromosome analysis; looks for Downs, other trisomies, etc. 2) Biochemical defects – numerous metabolic disorders such as the glycogen storage diseases (galactosemia, Tay Sach’s, etc), and can also test for genetic “markers” for things such as Huntington’s Chorea, muscular dystrophy, etc. Typically done under ultrasound guidance at weeks, sometimes combined w/ a Level III scan. Karyotype can take up to 2 weeks for results.

81 CHORIONIC VILLUS SAMPLING
The CVS. Trans-cervical sampling of the chorionic villi, part of the placenta of fetal origin. Since there is no fluid, is limited to chromosomal and genetic analysis. Done at weeks. Risk of amnio = 1/200. Risk of CVS = 1/100, but get earlier results.

82 AMNIOCENTESIS FOR Rh DISEASE
Rh Disease = Isoimmune Erythroblastosis Fetalis = Hemolytic Disease of the Newborn. The gist of it is that the mother’s anti-Rh antibodies results in hemolysis of fetal RBC’s. This results in excess bilirubin, which can be detected in the amniotic fluid. In a nutshell, when hemolysis is severe enough, can decide to do an intrauterine transfusion or delivery, depending on gestational age.

83 ASSESSMENT OF FETAL MATURITY
When deciding to deliver a baby, especially if it is pre-term, it is useful to know if the baby’s lungs are mature. Ventilation depends on the ability of the alveoli to remain open, which is dependent on surface tension, which is dependent on surfactant.

84 ASSESSMENT OF FETAL MATURITY
There are 3 chemicals values which, when present in the amniotic fluid, predict the presence of adequate surfactant and pulmonary maturity, so that delivery can proceed without having to worry about delivering a baby unable to breath / oxygenate. These 3 chemical values are: 1) The L/S ratio- lecithin and sphingomyelin. 2) S/A ratio- surfactant and albumin. 3) PG- phosphatidylglycerol.

85 TESTS OF FETAL WELL-BEING
Fetal well-being, in a nutshell, means the degree to which a fetus is receiving oxygen from the placenta. 3 tests are commonly done to assess this: 1) THE NST- the non-stress test. 2) THE CST-contraction stress test (your text calls it the contraction stress test). 3) THE BIOPHYSICAL PROFILE.

86 THE NST The stress that is missing in the non-stress test is the stress of uterine contractions. The healthy fetus (and placenta) will ordinarily show variation in the fetal heart rate (FHR). The NST looks for this variation, which is often associated w/ fetal movement. The results are read as reactive, non-reactive, and equivocal. Reactive is reassuring, non-reactive is not.

87 NON-STRESS TEST

88 THE CST During a contraction, blood flow to the placenta (utero-pacental blood flow) is greatly decreased. Normally, there is enough “placental and fetal reserve” to compensate for this lack of perfusion. Pregnancies in which placental function is diminished do not have this reserve. When diminished reserve is present, the fetal heart rate will slow during a contraction, which indicates a fetus that is now or is soon to be compromised, and one that will not likely withstand the stress of labor.

89 THE CST If the CST is positive (non-reassuring), delivery is generally considered, often by C-section.

90 THE BIOPHYSICAL PROFILE
An ultrasonic evaluation of: 1) Fetal movement. 2) Amniotic fluid volume. 3) Fetal muscle tone. 4) Fetal breathing activity, and 5) The NST. Each parameter is given a score of 0, 1, or 2. 10 is good, below 6 or so is bad.


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