What is the technique for achieving a retroflex view during upper GI (Gastrointestinal) endoscopy to examine the esophago-gastric junction and fundus?

Technique for Retroflex View During Upper GI Endoscopy

To properly achieve a retroflex view during upper GI endoscopy for examining the esophago-gastric junction and fundus, the endoscopist should advance the endoscope to the gastric body, perform a J-maneuver by maximally deflecting the tip upward while rotating the scope, and then withdraw slightly to visualize the cardia and fundus. 1

Proper Retroflex Technique

• The fundus should be inspected by a J-maneuver in all patients during upper GI endoscopy, as this is essential for a complete examination 1
• When a hiatus hernia is present, the diaphragmatic pinch should be specifically inspected while in retroflexion 1
• Retroflexion in the stomach is considered a standard part of high-quality upper endoscopy to improve detection and characterization of abnormalities 1

Step-by-Step Approach

1. Initial Positioning:

   • Advance the endoscope through the esophagus into the stomach 1
   • Continue to the gastric body with moderate insufflation to create adequate space 1

2. Performing the J-Maneuver:

   • Once in the mid-gastric body, maximally deflect the tip upward 1
   • Apply clockwise rotation while maintaining upward deflection 1
   • The endoscope will fold back upon itself, creating a "J" shape 1

3. Visualization:

   • Withdraw the scope slightly to bring the gastroesophageal junction and fundus into view 1
   • Rotate the endoscope to examine the entire circumference of the cardia and fundus 1
   • Ensure adequate insufflation for proper mucosal visualization 1

Documentation Requirements

• Photo-documentation of the gastroesophageal junction/fundus in retroflexed view is considered a minimum requirement for a high-quality EGD 1
• The British Society of Gastroenterology recommends documenting the quality of mucosal visualization achieved during the examination 1
• Images should be captured of any abnormalities noted during retroflexion 1

Common Pitfalls and Solutions

• Insufficient insufflation: Adequate air insufflation is necessary to create enough space for the J-maneuver 1
• Poor mucosal views: Use mucosal cleansing techniques (water flush, simethicone) to improve visualization 1
• Difficulty achieving retroflexion: In patients with altered anatomy or prior surgery, gentle manipulation and patient repositioning may be required 1
• Scope damage risk: Avoid excessive force during the maneuver to prevent equipment damage 1

Clinical Importance

• Retroflexion is essential for examining areas not visible in the forward view, particularly the gastric cardia and proximal fundus 1
• This technique improves detection of lesions in the proximal stomach and at the gastroesophageal junction 1
• High-quality examination of the esophago-gastric junction is critical as this area may contain pathology that could be missed without proper retroflexion 1, 2

By following this standardized approach to retroflexion during upper GI endoscopy, endoscopists can ensure complete examination of the esophago-gastric junction and fundus, which is essential for high-quality diagnostic procedures and improved detection of significant pathology.