What is the preparation and treatment approach for a patient undergoing an Esophagogastroduodenoscopy (EGD)?

Preparation and Treatment Approach for EGD

Patients undergoing diagnostic EGD should fast for at least 6 hours from solid food and may consume clear liquids up to 2 hours before the procedure, with informed consent obtained and appropriate sedation provided. 1

Pre-Procedure Assessment and Consent

Patient Evaluation

• Assess fitness for the procedure including review of pre-existing conditions, medications, and coagulation status (INR <1.5, platelets >50,000/mm³, PTT <50 seconds) 1
• Obtain legally valid written informed consent before performing EGD, as this is both a legal requirement and clinical standard 1
• Provide combined written and oral information about the procedure and associated risks before the procedure date, allowing patients opportunity to ask questions 1

Medication Management

• Review antiplatelet and anticoagulant therapy and adjust according to guidelines, documenting and communicating any changes to the patient 1
• No need to discontinue H2 receptor antagonists or proton pump inhibitors prior to EGD 1
• Low-dose aspirin can generally be continued without increased complication risk 1

Fasting Requirements

Standard Fasting Protocol

• Fast for at least 6-8 hours from solid food prior to the procedure 1
• Clear liquids may be consumed up to 2 hours before sedation 2, 3
• Longer fasting periods may be needed if gastric motility impairment is suspected 1

Evidence-Based Rationale

Research demonstrates that a 6-hour fast for solids and 1-hour fast for water provides good endoscopic vision with minimal patient discomfort 4. Studies show that gastric residual volume 2-3 hours after last fluid intake is not significantly different from overnight fasting (21 ± 24 mL vs 24 ± 22 mL) 5. Patient education about these specific fasting times significantly improves adherence and reduces discomfort from thirst, hunger, headache, and anxiety 6.

Procedure Setup

Time Allocation and Scheduling

• Allocate a minimum 20-minute time slot for standard diagnostic EGD, with longer times for surveillance or high-risk conditions 1
• The actual inspection time should average approximately 7 minutes, as endoscopists taking >7 minutes have three-fold increased detection of gastric cancer and dysplasia 1

Equipment and Access

• Insert an indwelling venous catheter for sedation administration 1
• Use high-definition video endoscopy systems with image capture capability 1
• Complete a safety checklist before starting the procedure 1

Sedation Approach

Standard Sedation Protocol

• Administer short-acting benzodiazepine (midazolam 3-5 mg IV) for conscious sedation 1
• Intravenous sedation and local anesthetic throat spray can be used in conjunction if required 1
• Exercise caution in patients at risk of aspiration 1
• Children typically require general anesthesia 1

Safety Considerations

Endoscopy units must adhere to safe sedation practices with appropriate monitoring 1. The risk of aspiration is identical whether patients fast overnight or consume clear liquids 2 hours before the procedure 5.

During the Procedure

Complete Examination Standards

• Assess all relevant anatomical landmarks and high-risk stations during a systematic examination 1
• Photo-document a minimum of 8 anatomical landmarks according to standardized protocols 1
• Achieve adequate mucosal visualization through air insufflation, aspiration, and mucosal cleansing techniques 1

Mucosal Preparation

• Use mucolytic and defoaming agents (simethicone, N-acetylcysteine, or pronase) to disperse bubbles and mucus 1
• Premedication with swallowed mucolytic 10-30 minutes before the procedure reduces washing time and improves mucosal views 1
• Document the quality of mucosal visualization in the procedure report 1

Lesion Documentation

• Describe any identified lesions using the Paris classification with anatomical location specified 1
• Obtain photo-documentation and targeted biopsies as appropriate 1

Post-Procedure Care

Recovery and Monitoring

• Allow adequate recovery time from sedation, typically 2-4 hours 3
• Complete a post-procedure checklist before the patient leaves the endoscopy room 1

Complications

The overall perforation rate with diagnostic EGD is extremely low (0.033%), with similar rates whether interventional procedures are performed or not 7. Mortality after perforation is 17% with 40% morbidity, emphasizing the importance of proper technique 7.

Special Populations

Patients Requiring Same-Day Dialysis

• Perform EGD first, followed by regularly scheduled dialysis 3
• No additional or more frequent dialysis sessions are needed after EGD 3

Patients with Specific Conditions

• Severe erosive gastritis or ulcers should be healed before elective procedures like PEG placement 1
• Previous gastrointestinal surgery (Billroth I/II, total gastrectomy) is not a contraindication for endoscopic procedures 1

Quality Metrics

Only endoscopists with appropriate training and relevant competencies should independently perform EGD, with a suggested minimum of 100 procedures annually to maintain high-quality examination standards 1.