What is the procedure and management for a Push (Esophagogastroduodenoscopy) EGD?

Push Esophagogastroduodenoscopy (EGD): Procedure and Management

Push EGD is a safe and effective endoscopic procedure for examining the upper gastrointestinal tract, with specific techniques required for successful completion and minimal complications.

Procedure Overview

Pre-Procedure Preparation

• Obtain informed consent
• Administer appropriate analgesia/sedation (e.g., midazolam IV) 1
• For high-risk patients (e.g., morbidly obese), consider transnasal small-caliber EGD which requires minimal to no sedation 2
• Antibiotic prophylaxis is recommended before interventional EGD procedures 1

Equipment and Technique

• The Push technique (also known as Seldinger technique) involves:
  • Insertion of the endoscope through the mouth or nose
  • Advancement through the esophagus, stomach, and into the duodenum
  • Use of air insufflation to maintain visualization
  • Gentle pushing of the endoscope under direct visualization

Indications for Push EGD

1. Diagnostic purposes:

   • Evaluation of upper GI symptoms
   • Screening for esophageal varices in cirrhosis 1
   • Evaluation of dysphagia
   • Investigation of suspected upper GI bleeding

2. Therapeutic purposes:

   • Foreign body removal (emergent within 2-6 hours for sharp objects, batteries, magnets) 1
   • Food bolus impaction management 1
   • Placement of feeding tubes (PEG) 1
   • Treatment of GI bleeding
   • Dilation of strictures

Special Considerations for Food Bolus Impaction

• Emergent endoscopy is recommended for food bolus impaction 1
• Gently pushing the bolus into the stomach is recommended as first-line treatment 1
• If pushing is unsuccessful, retrieval should be considered using baskets, snares, or grasping forceps 1
• Biopsies should be taken at index endoscopy to diagnose potential underlying conditions like eosinophilic esophagitis 1

Post-Procedure Management

Immediate Post-Procedure Care

• Monitor vital signs
• Observe for complications
• For uncomplicated procedures, patients can resume oral intake after recovery from sedation
• For PEG placement, nutrients can be delivered via the tube 1 hour after uncomplicated placement 1

Potential Complications and Management

• Perforation:

  • Incidence is approximately 0.033% 3
  • Most common sites: esophagus (51%), duodenum (32%) 3
  • Management depends on severity - conservative management may be appropriate if no evidence of contrast extravasation or free fluid on imaging 3

• Bleeding:

  • Rare complication
  • Management includes endoscopic hemostasis techniques

• Sedation-related complications:

  • Hypoxia
  • Aspiration
  • Cardiovascular events

• Procedure-specific complications:

  • For transnasal EGD: epistaxis (0.9%), sinusitis (0.4%) 4

Follow-up Recommendations

• For diagnostic EGD: follow-up based on findings
• For screening EGD in cirrhosis 1:
  • If no varices found: repeat EGD in 2-3 years for compensated cirrhosis
  • If small varices found: repeat EGD in 1-2 years
  • If decompensated cirrhosis: repeat EGD yearly

Special Considerations During COVID-19 Pandemic

• Reserve EGD for urgent/emergent indications 1
• Appropriate PPE for all personnel
• Consider alternative approaches (e.g., interventional radiology) for certain procedures in COVID-positive patients 1

Training Requirements

• For EGD with advanced interventions (e.g., pseudocyst drainage), ERCP skills are beneficial 1
• Proficiency typically requires supervised training and performance of multiple procedures 1

Conclusion

Push EGD is a fundamental endoscopic procedure with both diagnostic and therapeutic applications. When performed by trained endoscopists following proper protocols, it has a high success rate and low complication rate. The technique should be tailored based on the specific indication, with special attention to sedation requirements, patient positioning, and post-procedure monitoring.