What is the preparation protocol for a patient undergoing Esophagogastroduodenoscopy (EGD)?

From the Guidelines

To prepare a patient for an esophagogastroduodenoscopy (EGD), instruct them to fast for at least 4-6 hours before the procedure, as recommended by the guidelines on the use of oesophageal dilatation in clinical practice 1.

Preparation Instructions

• Patients should provide a complete medication list and inform the healthcare provider about allergies, medical conditions, and pregnancy status.
• Certain medications may need adjustment: blood thinners like warfarin, clopidogrel, or direct oral anticoagulants might require temporary discontinuation 3-7 days before the procedure (following physician guidance), while essential medications like those for blood pressure can usually be taken with a small sip of water.
• Diabetic patients should receive specific instructions about insulin or oral hypoglycemic adjustments.
• Patients should arrange for someone to drive them home after the procedure if sedation will be used, as they cannot drive for 24 hours post-sedation.
• They should wear comfortable clothing, remove jewelry, dentures, and eyeglasses before the procedure.
• Fasting is necessary to ensure the stomach is empty for clear visualization and to prevent aspiration of stomach contents during sedation, which could cause serious respiratory complications.

Additional Considerations

• The American Society of Anesthesiologists (ASA) updated practice guidelines for preoperative fasting recommend that patients may consume clear liquids, including up to 400 mL of clear liquids containing simple or complex carbohydrates, up to 2 hours before the use of anesthesia or procedural sedation 1.
• Patients with achalasia are particularly prone to oesophageal stasis and may require a more prolonged fast or oesophageal lavage 1.
• The quality of mucosal visualization should be reported, and adequate mucosal visualization should be achieved by a combination of adequate air insufflation, aspiration, and the use of mucosal cleansing techniques 1.

From the Research

Preparation for EGD

To prepare a patient for an Esophagogastroduodenoscopy (EGD), several steps can be taken:

• Assess the patient's medical history, including any co-morbidities and medications that may promote bleeding 2
• Evaluate the patient's hemodynamic parameters and perform a physical examination, including a digital rectal examination 2
• Withhold certain medications, such as vitamin K antagonists and direct oral anticoagulants, as recommended by guidelines 2, 3, 4, 5
• Ensure the patient has fasted for the appropriate amount of time, with one study suggesting a 6-hour fast for solids and a 1-hour fast for water prior to endoscopy 6

Management of Anticoagulation

For patients on anticoagulants, management of bleeding is crucial:

• Reversal of anticoagulation may be necessary, with specific antidotes available for certain anticoagulants, such as idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors 3, 4
• Replacement of blood components, including red blood cells, platelets, and clotting factors, may be necessary 3, 4
• Administration of vitamin K and four-factor prothrombin complex concentrate may be recommended for patients on vitamin K antagonists 2, 3, 4

Patient Discomfort and Safety

To minimize patient discomfort and ensure safety:

• Use a visual analog scale to assess patient discomfort due to fasting 6
• Monitor for any complications attributable to endoscopy 6
• Ensure good endoscopic vision by aspirating fluid from the gastric fundus, if present 6