What is involved in an Esophagogastroduodenoscopy (EGD) procedure?

Essential EGD (Esophagogastroduodenoscopy) Knowledge

A high-quality EGD requires systematic examination from the upper esophageal sphincter to the distal duodenum with an average inspection time of at least 7 minutes, photo-documentation of 8 anatomical landmarks, and appropriate biopsies based on specific clinical indications. 1

Pre-Procedure Requirements

Patient Preparation:

• Allocate minimum 20-minute time slots for standard diagnostic procedures, with longer slots for surveillance or high-risk conditions 2
• Administer mucolytic/defoaming agents (simethicone, N-acetylcysteine, or pronase) 10-30 minutes before the procedure to optimize mucosal visualization 1
• Complete safety checklist and obtain informed consent before starting 2

Endoscopist Qualifications:

• Only endoscopists with appropriate training and relevant competencies should perform independent EGD 1, 2
• Maintain proficiency by performing minimum 100 EGDs annually 1, 2

During the Procedure

Technical Standards:

• Use high-definition video endoscopy systems with image capture and biopsy capabilities 2
• Achieve adequate mucosal visualization through air insufflation, aspiration, and mucosal cleansing techniques 1
• Document quality of mucosal visualization using a validated scale 1

Systematic Examination:

• Begin after intubating the upper esophageal sphincter, advance to distal duodenum, then perform careful withdrawal and inspection 1
• Critical finding: Endoscopists spending >7 minutes on average have a 3-fold increase in diagnosing gastric cancer and dysplasia compared to those taking <7 minutes 1
• Photo-document 8 anatomical landmarks as recommended by ESGE guidelines 1

Biopsy Protocols by Anatomical Location

Esophagus:

• Do NOT obtain routine biopsies of normal-appearing esophagus or GE junction in patients with dyspepsia alone, regardless of immune status 1
• For Barrett's esophagus: Use Prague classification and Seattle protocol (quadrantic biopsies at 2 cm intervals) 2
• For suspected eosinophilic esophagitis: Take biopsies from two different esophageal regions in patients with dysphagia/food bolus obstruction 1, 2
• For grade D or atypical esophagitis/ulcers: Biopsy and re-evaluate after 4-6 weeks of PPI therapy 1, 2
• For strictures: Biopsy before dilatation to exclude malignancy and eosinophilic esophagitis 2

Stomach:

• Obtain routine biopsies from normal-appearing gastric body and antrum for H. pylori detection if infection status is unknown (both immunocompetent and immunocompromised patients) 1
• Use 5-biopsy Sydney System with all specimens in the same jar 1
• Do NOT obtain automatic special staining unless clinically indicated 1
• For gastric ulcers: Biopsy and re-evaluate after 6-8 weeks of treatment including H. pylori eradication 1, 2
• For gastric atrophy/intestinal metaplasia: Take separate biopsies from antrum and body 1, 2
• For gastric polyps: Record number, size, location, morphology and take representative biopsies 1, 2
• For suspected malignancy: Take minimum 6 biopsies with photo-documentation 2

Duodenum:

• Do NOT obtain routine biopsies of normal-appearing duodenum for celiac disease in patients with dyspepsia alone without signs/symptoms of increased celiac risk 1
• For suspected celiac disease: Take minimum 4 biopsies from second part of duodenum including duodenal bulb 1, 2
• For immunocompromised patients: Consider biopsies for GVHD (post-transplant) and opportunistic infections 1
• For iron deficiency anemia: Take duodenal specimens if celiac serology is positive or unmeasured 1, 2

Lesion Documentation

When lesions are identified:

• Describe morphology using Paris classification 1
• Document anatomical location precisely 1
• Obtain photo-documentation 1
• Take targeted biopsies as appropriate 1

Sedation Considerations

• Adhere to safe sedation guidelines with age and comorbidities in mind 1
• Intravenous sedation and topical anesthetic throat spray can be used together if needed, but exercise caution in aspiration-risk patients 1
• Document any requirement for naloxone, flumazenil, or ventilation due to oversedation 1

Post-Procedure Checklist

Before patient leaves room:

• Confirm number and correct labeling of histological samples 1
• Document sedation/analgesia doses 1
• Provide specific postprocedure advice 1
• Arrange follow-up as needed 1
• Ensure method for processing histological results is in place 2

Safety Profile

• Overall perforation risk is 0.033% (33 per 100,000 procedures) 3
• Perforation incidence is similar whether interventional procedures are performed or not (0.040% vs 0.029%) 3
• Mortality after perforation is 17% with 40% morbidity 3
• Most common perforation sites: esophagus (51%), duodenum (32%), jejunum (6%) 3

Common Pitfalls to Avoid

• Rushing the examination: Taking <7 minutes significantly reduces cancer detection rates 1
• Inadequate mucosal visualization: Failure to use mucolytics and proper cleansing techniques leads to missed lesions 1
• Not following standardized biopsy protocols: Missing Seattle protocol for Barrett's or Sydney System for H. pylori detection 2
• Failing to re-evaluate gastric ulcers: Can result in missed malignancy 1, 2
• Obtaining unnecessary biopsies: Routine esophageal biopsies in normal-appearing mucosa with dyspepsia alone are not indicated 1