Health News, Information and Advice from a British Doctor
Having an Endoscopy (Gastroscopy)
The thought of having an endoscopy can strike fear into the heart of even the most hardened and stoical of patients and I have witnessed burly farmers and rugby players reduced to tears at the thought of this examination, but this fear is frequently unfounded.
Humans love to tell ‘horror’ stories of their own experience, but when pinned down they will frequently admit that the procedure wasn’t too bad at all!
This article is designed to explain the processes and procedures of an endoscopy and hopefully allay some of the fears and bad press that this highly useful examination generates.
Who Should Have One?
By far the commonest indication is straight-forward indigestion (dyspepsia) and by far the commonest finding at endoscopy is acid reflux. This is where concentrated hydrochloric acid produced by the stomach (the same stuff that builders use to clean concrete), refluxes back up the gullet (oesophagus) either due to a weak valve at the bottom end of the gullet, or a hiatus hernia (where part of the stomach slides above the diaphragm into the chest).
This can cause nasty symptoms of burning, early satiety, the sensation of a ball stuck in the pit of the stomach, or occasionally the sensation of something stuck in the throat.
Gastritis (inflammation of the stomach), duodenitis (inflammation of the duodenum) are less common and even less common, is ulcer disease.
Sometimes an endoscopy is organised to obtain special samples (biopsies) to diagnose certain conditions such as Coeliac disease or Helicobacter infection or as surveillance for certain conditions such as Barrett’s oesophagus. Because the gastrointestinal tract has no pain sensors in the true sense of the word, these biopsies are completely painless but patients may experience a gentle tug at the time of the biopsy.
More worrying indications for endoscopy include:
- weight loss
- intractable pain
- internal bleeding
- difficulty swallowing
These are sometimes referred to as ‘alarm’ or ‘red flag’ symptoms and your doctor will be pushing to get an early endoscopy for you if these occur. Obviously the worry here is the big ‘C’ but in reality stomach cancer is in decline in western civilized countries although oesophageal cancer still remains a problem.
Sedation or Throat Spray?
Patients are usually offered sedation or throat spray or both. The throat spray is a local anaesthetic and produces the same kind of numbness in the back of the throat as a dentist injection. It usually wears off after an hour and patients are advised not to eat or drink during this time (as occasionally food or fluid can ‘go down the wrong way’). This is the commonest choice by patients.
The sedating injection is usually midazolam (a bit like Valium). It works by relaxing the patient but most importantly it causes amnesia so that patients frequently can’t remember what has happened to them. It does not put patients to sleep. Frequently it takes longer to find a vein for the injection than it actually does to do the test!
This is because patients are often a bit dehydrated from starving for 4 hours and also anxious, which makes the normally good peripheral veins mysteriously disappear! If patients have opted for sedation then they must certainly not drive or operate heavy machinery for 24h and most units usually insist that there is a responsible adult in the house overnight.
Firstly in most good units with experienced endoscopists (I would suggest that the vast majority of NHS units apply here) and for routine diagnostic gastroscopy, the procedure itself takes less than 5 minutes. However with all the patient details that have to be checked and double-checked by the nurses, you may well be in the unit for a couple of hours and even longer if you have had sedation
You will have been asked to starve for 4 hours prior to your appointment time, certainly for solids, although some of the more progressive units may allow you to have sips of water right up to time of the procedure.
Consent for the procedure should have been obtained as an outpatient or on arrival. It is generally considered bad practice to obtain this actually within the treatment room. You will be told about the ‘most frequently occurring complications’ which include perforation, haemorrhage and complications of sedation. In reality these are vanishingly rare for straightforward diagnostic gastroscopy
When you enter the room there will be at least 2 nurses to greet you plus one or more doctors, or in more progressive units, a nurse endoscopist and all will be introduced to you. The nurses will run through your details again and then either spray your throat and/or put a cannula in your arm. You will be asked to lie on your left hand side and a blood pressure cuff put on your arm, some nasal specs in your nostrils for delivering oxygen, a peg on your finger for measuring oxygen levels in the blood and a mouth guard in your mouth to protect your teeth but also to prevent you from crunching down on the £30 000 endoscope about to be entrusted to your mouth! If you have opted for sedation it will be given now and you probably will have only sketchy memories of the next few minutes, if at all.
The procedure should hardly be painful at all, although some slight discomfort in the back of the throat, or a fullness and bloating in the tummy may be experienced. What patients tend to dislike is the retching and gagging that may occur and the sensation of not being able to breathe. However these are quickly overcome, the more relaxed the patients are.
From start to finish may only be a few minutes during which time the endoscopist should have had the opportunity to have a good look at your oesophagus, stomach and duodenum and obtained whichever samples or biopsies may be required.
After the procedure has finished you will be wheeled (if you have had sedation) or walked (if you haven’t) around to the recovery area where the recovery nurses will check your vital obs again. Just prior to leaving the room or when you are in the recovery area, is usually when the endoscopist will explain the findings of the examination.
Any biopsies taken usually take about 5 working days to come back to the doctor.
Anticoagulation (Warfarin) and antiplatelet drugs (aspirin and clopidogrel)
Unless special therapies or multiple biopsies are intended, it is usually safe to continue these drugs. If you have any doubt or anxieties then phone the unit for advice
For tablet or diet controlled diabetics then simply abstain from taking the tablets on the morning of the procedure.
For insulin controlled diabetics (IDDM) then it is best to phone up the unit and seek advice. Usually these patients are done at the start of the morning lists and simply abstaining from the morning injection (to be given after the procedure) is all that is required but occasionally patients are admitted and put on a drip prior to the procedure.