EGD (Esophagogastroduodenoscopy), also called upper GIT (Gastrointestinal tract) endoscopy, is a procedure used to visualize the proximal parts of the gastrointestinal tract, such as the oropharynx, esophagus, stomach, and proximal duodenum. The esophagus is a hollow muscular tube that is located behind the trachea. It begins after the cricoid cartilage and continues till the cardiac orifice of the stomach. The stomach is located below the diaphragm and begins at the cardiac portion. Then comes the fundus, body, pylorus, and finally, the stomach ends at the pyloric antrum, from which the duodenum continues. The duodenum is the first portion of the small intestine, which connects to the jejunum at the level of the ligament of Treitz.

The image illustrates the gastrointestinal tract. — Anatomy of the Digestive System

EGD is one of the most common diagnostic endoscopic procedures used by gastroenterologists.¹ It consists of a small flexible endoscope, a light source, and a camera that uses video chips or fiber optics for image transmission.²

Purpose of EGD

EGD is used to diagnose and treat esophageal, gastric, and small intestine disorders. During the procedure, the doctor or endoscopist can obtain diagnostic biopsies or perform therapies to achieve homeostasis and dilate strictures. EGD is generally safe and well-tolerated if a skilled technician performs it. Its availability and use in the pediatric population have also increased recently. Still, a critical review of this tool’s use is required to get the maximum desired results and minimize the risks.

What are the indications of an EGD?

You should consider getting an EGD if your doctor advises you because of the following indications:

Diagnostic:

Continuous abdominal pain or pain associated with alarming symptoms such as anorexia or weight loss
Chronic or severe symptoms of Gastrointestinal Reflux Disease (GERD) such as heartburn, chronic cough, etc.
Difficulty in swallowing, pain during swallowing, or feeding problems
Persistent vomiting of unknown cause or hematemesis
Irritable child with unexplained cause
Chronic diarrhea or malabsorption symptoms such as weight loss, difficulty to-flush stool, lethargy
Iron deficiency anemia with presumed chronic blood loss, when colonoscopy is normal or an upper GI source, is suspected clinically
Inspect for malignancy in patients with premalignant conditions of the upper gastrointestinal tract, such as previous caustic ingestion, Barrett esophagus, or polyposis syndromes
To assess for acute injury after caustic ingestion

Therapeutic:

Removal of foreign body
Stenting and dilatation of strictures
Ligation of esophageal varices
Controlling Upper GI bleed
Placing of feeding or draining tubes
Management of achalasia (balloon dilation or botulinum toxin)³

The image shows the indications of an EGD — Purpose of EGD

Contraindications of an EGD

Your doctor will advise you against EGD if its risks outweigh its benefits. Some of the absolute and relative contraindications are:

Absolute:

Suspected or known GIT perforation or peritonitis
Wound dehiscence
Severe sepsis, hypotension, or shock
Respiratory distress, hypoxemia, stridor

Relative:

Zenker’s diverticulum, an obstructing pharyngeal or laryngeal lesion, severe hypopharyngeal trauma
Severe coagulopathy (INR > 3.0, platelet count <30,000/cumm)⁴

What are the preparations made for an EGD?

The doctor will perform an EGD in an outpatient setting using parenteral or general anesthesia. He may also do it at the bedside in a hospital or an operative room.⁵

The doctor will inform you about the procedure’s indications, nature, risks, benefits, alternatives, and complications and will give you a consent form to ask for your consent.

Pre-Procedure Planning

After you’ve consented, the doctor will ask for your complete medical history and perform a physical exam to determine that you are fit for the procedure. He’ll document the significant findings in your medical record and give special attention to certain illnesses that might hinder the endoscopy, such as pulmonary and cardiovascular diseases. He’ll also ask you for a history of drug allergies and previous abdominal surgeries.
Afterward, you will undergo baseline tests such as Complete Blood Count (CBC), blood cross-matching, coagulation studies, urinalysis, electrolytes, pregnancy testing, Electrocardiography (ECG), and chest X-ray. These tests are based on the patient’s symptoms, and the doctor may suggest skipping them altogether if the patient is healthy and opting for an elective outpatient endoscopy. You’ll also be recommended antibiotic prophylaxis if you have an underlying high-risk health condition for infectious complications or are undergoing a high-risk endoscopic procedure. Specific recommendations for antibiotic prophylaxis based on the type of endoscopic procedure are available from the American Society for Gastrointestinal Endoscopy (ASGE).

Equipment

The medical staff or doctor will inform you about the type of endoscope they will use for your procedure. Several different types of endoscopes are available from various manufacturers. They may use a conventional endoscope or opt for a flexible ultrathin fiberoptic and video endoscope without sedation.

There are some newer endoscopes that have been introduced that provide higher resolution and magnifying endoscopy to evaluate certain GIT diseases. An advanced video endoscopy called narrow-band imaging (NBI) has recently been introduced, which uses optical filters and high relative intensity of blue light for imaging and characterization of mucosal morphology. An ultrasonic endoscopic has been developed to allow the simultaneous performance of EGD and EUS (Endoscopic ultrasound).⁶

Diet

The night before your EGD procedure, eat your largest meal before 6 pm. You can have a light snack till midnight but do not eat any solid food after midnight. You can have clear liquids until 4 hours before you arrive at your hospital.⁷

Medications

Consult your doctor about medications you can stop taking and which medicines you should continue. A week before the procedure, you’ll be advised to stop taking iron, aspirin, aspirin products, or Pepto Bismol. Five days before the procedure, you must stop taking non-steroidal anti-inflammatories (NSAIDs) such as Advil (ibuprofen), Celebrex, Motrin, etc. You’ll not be allowed to eat or drink (NPO) at least 8 hours before the procedure. Only medications can be taken 4 hours before examination with little sips of water.⁸

Patient Preparation

Anesthesia/Sedation & Monitoring

The anesthesiologist will give you a numbing medicine (anesthesia) to prevent discomfort and to provide amnesia for the procedure. The anesthesiologist will evaluate your medical and drug history to see if it’s safe for you to undergo anesthesia.⁹ Anesthesia is of two types: topical and general. Topical anesthesia, such as Cetacaine or Lidocaine, requires less time for the overall procedure, eliminates the risk of sedation, and decreases the cost of the procedure by reducing recovery time and nursing staff. It also has disadvantages like obstacles in performing the procedure on a patient who may not be still and discomfort.¹⁰
If you’re going through routine upper endoscopy, you’ll be sedated by giving IV propofol. For therapeutic endoscopic procedures and in young and uncooperative patients, general anesthesia will be given. Your vital signs and cardiopulmonary status will be continuously monitored throughout the endoscopic procedure.¹¹ ECG is also monitored in patients with cardiopulmonary disease, elderly patients, or during a prolonged procedure. Anesthetic agents used in EGD include Benzodiazepines, opioids, and reversal agents.

Positioning

You’ll be placed in a left lateral position.

What is the Procedure for an EGD?

The doctor administers topical and IV sedation to facilitate the procedure and minimize gagging. Additionally, they may administer an antispasmodic agent such as atropine, glucagon, or cimetropium bromide to suppress gastrointestinal peristalsis. A bite block is then placed to prevent damage to the endoscope and facilitate its passage through the mouth.
The doctor passes the endoscope through the pharynx, esophagus, stomach, and into the duodenum under direct vision, carefully inspecting both insertion and slow withdrawal. They insufflate air to distend the lumen for a better view and aspirate liquid and particulate matter through the suction channel. The findings are documented with pictures or a video system. The doctor may also obtain biopsy specimens by passing forceps and taking small mucosal samples for inspection on histology sites. During the endoscopy, the surgeon can perform various therapeutic procedures. The duration of the procedure may range from 5 to 30 minutes or longer, depending on the therapeutic or diagnostic maneuvers used.¹²

An image describing the images taken through an EGD — Images from emergency and follow-up EGD procedures. (A) Emergency EGD reveals a visible vessel spouting blood in the esophagus (arrow) (B). Bleeding ceases on its own, showing a white nipple sign (arrow). (C) A second EGD post arterial embolization displays an esophageal ulcer with a coil inside (arrow). (D) The third EGD, 7 days post-TAE, shows healing of the ulcer with a coil still inside (arrow). Image Courtesy: Yang, Kai-Chun & Lin, Men-Ying & Huang, Li-Ting & Chang, Wei-Lun. (2020). Massive upper gastrointestinal bleeding caused by an intercostal arterio-esophageal fistula: A rare case report. Radiology Case Reports. 15. 2026-2030. 10.1016/j.radcr.2020.07.083. available under license CC BY-NC-ND

What are the Potential Complications of an EGD?

EGD is a safe procedure; its complications are relatively uncommon, with only one complication per 1000 procedures.¹³ They most likely result from a prolonged or therapeutic EGD for procedures such as sclerotherapy, electrocautery, or dilations. Some of them are:

Pulmonary complications such as aspiration pneumonia, asthmatic attack, or respiratory depression
Cardiac complications such as hypotension, pulmonary edema, or myocardial infarction
Medication hypersensitivity such as rash, bronchospasm, or anaphylaxis
Perforation
Bleeding
Neurologic complications such as seizures and stroke
Laryngeal Injury
Infectious complications such as cellulitis, endocarditis, or septic phlebitis¹⁴

What is the post-op care of a patient who has just gone EGD?

After the procedure, you’ll be transferred to a recovery room, where an endoscopy nurse will monitor you. The nurse will observe your vitals and notify your attendant when you’re awake. Once alert and mobile, you can leave the recovery room with an attendant. You’ll be given some instructions regarding your diet and activity and advised to return immediately to the doctor in case of any alarming symptoms, such as:

Fever
Stomach cramps
Signs and symptoms of GI Bleeding

The medical staff will arrange a follow-up appointment with your primary care physician or endoscopist, and then they will discharge you.¹⁵ In some cases, such as treating bleeding from esophageal varices, the medical team will schedule a follow-up plan, including a short-interval repeat endoscopy procedure for the patient, and prescribe medications until the varices are removed.
Patients diagnosed with gastric ulcers must take Proton Pump Inhibitors (PPIs) or H2 antagonists and undergo testing for H. pylori infection. Patients who have undergone dilation of peptic or esophageal strictures will also receive PPI therapy.¹⁶

How long does it take to recover after an EGD?

The average recovery time after an upper endoscopic procedure is around 50 minutes, and you’ll be discharged on the same day after being observed for 6 hours (if anesthesia is given). Recovery time may differ depending on the patient’s condition, symptoms, and any complications. Patients who did not receive sedation tend to recover more quickly than those who did. Some patients may need extended hospital stays, such as patients who had:

Bleeding (Variceal or Non-Variceal)
Luminal Dilation and stenting
Foreign body removal
Percutaneous Endoscopic Gastrotomy (PEG)
Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection
Per Oral Endoscopic Myotomy (POEM)¹⁷

After an EGD, you may feel nausea, bloating, or a sore throat. You might also feel groggy for about 30 minutes after the procedure, and the feeling will fade within that hour. It’ll take some time for the effects of anesthesia to wear off, so you should avoid making any big decisions that day, and an attendant should take you home.¹⁸

Difference between an EGD & Endoscopy

Endoscopy is a procedure done to examine structures inside your body. It is done with an endoscope, which is an inspection instrument composed of an image sensor, an optical lens, a light source, and a mechanical device. There are many different types of endoscopy, and they’re named according to the part of the body that they inspect, such as bronchoscopy (to visualize the airways), hysteroscopy (to visualize the cervix and uterus), colonoscopy (to visualize the large intestine), sigmoidoscopy (to visualize the rectum and sigmoid colon), cystoscopy (to visualize the urinary bladder and urethra), etc. EGD is an endoscope that visualizes the upper GIT (oropharynx, esophagus, stomach, and proximal duodenum).

Difference between an EGD & Colonoscopy

The main difference between the two procedures lies in the areas they examine, with EGD focusing on the upper GIT, while colonoscopy focuses on the rectum and large intestine (colon). Colonoscopy’s main purpose is to screen and diagnose colon cancer in individuals aged 50 or older, while EGD is used for both diagnostic and therapeutic procedures of upper GIT symptoms.
The procedure lasts from 30 minutes to an hour in a colonoscopy. A patient is extensively prepared for a colonoscopy, with a special diet and restrictions on food intake. A day before the procedure, the patients must consume a low-fiber diet and only clear liquids. Doctors may also prescribe a stool softener or cleansing solution to clean the bowel thoroughly. The complications of both procedures are similar, such as bleeding, perforation, and infection, with a slightly higher risk of perforation during colonoscopy compared to EGD. The doctor may recommend further diagnostic tests or treatment depending on the endoscopy findings.¹⁹

Conclusion

To summarize, consider visiting a doctor and asking for an EGD if you’ve recurrent symptoms of upper GIT, such as abdominal pain, reflux symptoms, persistent vomiting, chronic diarrhea, or iron deficiency anemia. The EGD will visualize the proximal parts of the GIT and diagnose and treat the present disorders. It is a safe procedure with minimal risks and minimal recovery time. The medical team must rule out contraindications to this procedure and provide appropriate pre-op and post-op care to ensure a successful procedure. The biopsy results will further guide the management plan and ultimately result in the patient receiving complete treatment for the disease.

Refrences

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Esophagogastroduodenoscopy: Process & Benefits

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