Lesson 1

Lesson 1

1 The development of endoscopic methods of examination. 2 Modern methods of endoscopic diagnosis. 3 Organization of endoscopic services in Ukraine.

 

The development of endoscopy, beginning from the end of XVIII century, passed several successive stages, each of which is characterized by improving equipment and the advent of new techniques, although the first attempts were made to examine the man inside in ancient times. Thus, there were conducted research rectum, vagina, throat using tools like modern anoscope and colposcope by Hippocrates in about 400 BC. The source of light in these devices was sunlight. The proof of these were the archeological excavations of Pompeii (destroyed in 70 years BC), during which there was revealed vaginal mirror.

Whom and when was performed first endoscopy  is impossible to say , although it is believed that it was made by the Arab Abdul Qasim healer (936-1013), who, using a glass mirror reflector examined cervix.

Generally, there are 4 stages in the history of development of endoscopy:

1.     Rigid (1795 – 1932).

2.     Half flexible (1932 – 1958).

3.     Fiber Optic (1958 – 1984).

4.     Electronic (1984-present)

Fundamentals of modern endoscopy were laid in the nineteenth century by German doctor (1773-1809), from Frankfurt am Main Philipp Bozzini, who introduced lichtleiter (Fig. 1), or “light guide”, which was first announced in the pages of Frankfurt newspaper in 1804 and later was published in a separate book. The following year there was carefully described the device and was reported the first test. His unit gave rise to the first period of Endoscopy – Rigid.

The device consisted of two components: 1 – the light source and the optical system, 2 – a system of mirrors and observation tubes. The light source in the device lichtleiter were candle and mirror, that were located in a housing that had the shape of the vase. Light of them held through one pipe segment overview, while the doctor could see the image in another segment of the same pipe.

A major drawback of the device was insufficient lighting of candle. From the very beginninf Philipp Bozzini planned to use lichtleiter as a tool for inspection of the vagina, as he demonstrated later. However, in a few years, he found that he could use and examine mouth, nose, ears, urethra, bladder and rectum by the mean od device.

Image 1

In order to conduct clinical trials of the device in Vienna, Philipp Bozzini made the relevant request to the Austrian Erzherzog Carl Ludwig Johann Joseph Laurentius von Österreich, Herzog von Teschen, the service of which was the chief surgeon. However, due to professional, often unfair competition, clinical trials have led to the collapse of such as progressive idea at the time. Joseph von Gabrielly, director of Josephs Academy, founded in 1785 as a progressive center for training military physicians responded favorably to the new device, noting that the device is “useful for the study of acute vision and, ultimately, with a brilliant mind, so the idea is worth of attention, and inventor of gratitude. “Opposite content review received the device from the head of the Medical Faculty, University of Vienna Andreas Josef von Stifft, who claimed “reasonable physician judgment and finger experienced researcher will still remain, as in the past, the only means by which patients who appointed lichtleiter, will receive appropriate treatment.

In April 1808 Philipp Bozzini of Frankfurt city was appointed as a local doctor responsible for the prevention of epidemic diseases. In this capacity, he contracted typhus during the examination of the patient. Philipp Bozzini died from the disease in April 4, 1809 at the age of 35 years. Despite the competition, he set a precedent with the device lichtleiter, and all next projects within a half century were initiated by his instrument.

Nowadays, the original unit is in the American College of Surgeons (American College of Surgeons).

In 1826r.  a French doctor HL Segales reported the use of advanced apparatus, constructed by Bozzini, called Speculum urethra cisticum (Figure 2).A French surgeon Antoine Jean Desormeaux, who is considered to be the “father of endoscopy,” in 1853 used for lighting alcohol lamp during endoscopy, which gave a white, bright light, making it possible to review in more detail. The tool was designed for use in gynecology and urology and combined a system of mirrors and lenses.

                              Image 2 Speculum urethra cisticum

The disadvantage of the device was the occurrence of burns due to more or less long review. However, in this invention, it was renamed by Paris medical Academy, and the device has received application in clinical practice. Desormeaux first used the term “endoscope”.

The disadvantage of the device was the occurrence of burns due to more or less long review. However, due to this invention, he was awarded by Medical Academy Award-winning Paris, and the device has received application in clinical practice. It was the first time, when  Desormeaux  used the term “endoscope”.

Later, in 1868, a prominent German physician A. Kussmaul was involved in practice of gastroscopy method using a metal tube with a flexible obturator. First he pour some water into the stomach flexible conductor (obturator), and on it an empty metal tube. For this purpose it was necessary to align the axis of the teeth and esophagus in the same plane. Later A. Kussmaul’s principle was the basis of all methods using rigid and semi-rigid gastroscope. Priority of A. Kussmaul was established and explained by G. Killian.

In the same 1868, Bevan, and in 1870 Waldenburg independently developed tubular esophagoscopy. Bevan used the endoscope to 4 inches (10 cm) long and 3.4 inches (about 2 cm) in diameter, Walden-burg – 8 cm in length and 15 mm in diameter. Both of them hung up the long metal handle, which also was a spatula to press the tongue. Lighting and a review was carried out by using laryngoscope. During one of these reviews Waldenburg firstly diagnosed tsenkerivskyy diverticulum of the esophagus. In the same 1870 P. Stoerk, realizing the necessity of passing upholstery pharyngeal-esophageal curvature designed a new type of endoscope – the tube that bend. The length of device was 11 cm, consisted of 9 separate parts which are movably connected side hinges. The device is easily included into the esophagus and has worked well in practice. Mackenzie and Lowe used for examination of the esophagus esophagoscopy, consisting of two metal plates adjustably interconnected by means of multiple lumbar spaced metal rings. Plates are converging and almost touching each other. In this position, the device was introduced into the esophagus. The plate is then expanding to the width of the rings, thus expanding the esophagus.

An important step in the development of gastroscopy was the work of          J. Mikulicz (1881), who was the first when he had described a detailed picture of the esophagus iormal and pathological conditions. Based on careful anatomical studies developed by the machine, curved in the distal third of the angle of 30 °. His idea was while technically difficult to implement, however, this principle was used in the later development of devices for examination of the stomach.

An Austrian doctor v. Hacker working in the hospital of T.Billroth, in Vienna using esophagoscopy started successfully get foreign bodies from the esophagus.

T. Rosenheim, G.Kelling and other well known surgeon at that time developed the original apparatus by means of which they investigated the gastrointestinal tract, urethra, vagina, nasal cavity and pharynx. In addition, they have worked how to examine patient without pain for him or her. Thus, the same T. Rosenheim first used local anesthesia by cocaine. Soon this method was improved by F. Lange and D. Meltzing (1898) who used for photography gastrocamera stomach. In 1898 Dr.Kelling, created a gastroscopy that bent according to the anatomical features of the organ that was examined.

An important step in the development of endoscopy was the invention of incandescent T.Edison 1879, which for the first time of practice working with endoscopes used JTTurtle (1902) in rectoscopy, T.Rosenheim (1906) during gastroscopy, W.Brunnings (1908) in bronhoezofahoskopiyi, and its machine from the electric light, called an electroscope, used in practice to 70-ies of XX century. Works T.Rosenheim related to the use of endoscopic diagnosis of esophageal cancer, stenosis, extensions, diverticula, spasm and atony. In addition, in 70% of cases it was possible to examine the cardia of the stomach.

Proposed in 1903, Jackson’s had esophagoscopy model had tubes of different diameters. The body tube had two channels – for the aspiration of contents and the introduction of metal wire with a bulb at the end, allowing the lead through the entire review lumen tube.

In 1908 Lening and Stida tried creating a flexible gastroscope. It consisted of fixed proximal flexible and directly introduced into the esophagus. Inside the unit there was located straight tube with an optical system and a light bulb.

The endoscope Philipp Bozzini.

Developments Antoine Jean Desormeaux

Methods of gastroscopy A. Kussmaul

Tubular esophagoscopy Bevan and Waldenburg

The endoscope P. Stoerk

Works J. Mikulicz

Apparatus T. Rosenheim, G.Kelling

Works T.Rosenheim

Esophagoscopy Jackson

The invention R. Schindler – beginning of half flexible period

Gastroscopy N. Taylor

Operating gastroscopy with biopsy channel Benedict

Practical application fibrogastroscopy Hirschowitz B. I.

Work Boyle and Smith

Development Welch Allyn – beginning of period electronic endoscopy.

In 1918 K.Takagi first performed arthroscopy of the knee joint, and after 10 years it was also designed astroskop diameter of only 3.5 mm. In 1920, the American physician Ondoorff developed Trocar with automatic valve for the introduction of laparoscopic instruments and preventing the release of gases.

 

Despite the improvement of equipment, gastroscopy rigid endoscopes had not found widespread use because the complexity of the techniques, a significant risk of complications and lack of descriptiveness. Scientists and doctors are not left trying to create a flexible endoscope. The turning point in the creation of such a device was the invention R. Schindler in 1932, which gave rise to a new period in the development of endoscopy – half flexible. The length of designed gastroscopy was the tube 78 cm with a flexible part length of 24 cm and a diameter of 1.2 cm, which had a large number of Short-lenses. At the proximal end of the device located upstream from the eyepiece of his lighting and bulb Richardson. Gastroscopy in this design with minor structural changes produced in the 60s of the twentieth century. The device is allowed to examine in detail the mucosa of almost all of the stomach. And, although the review was accompanied by severe discomfort for the patient, the invention allows R. Schindler rightly consider him to be the “father of gastroscopy.”

 

During next years there have been produced many modifications of half flexible gastroscope. Models of N. Henning (1939, 1948) distinguished thinner flexible portion (7.5 mm), allowing to review patients with less discomfort.

 

N. Taylor (1941) constructed a gastroscopy with a flexible part that allows the stomach to inspect areas previously inaccessible. Later model “Edel-Palmer” curved distal in one plane. In 1948. Benedict made ​​operational gastroscopy, who had biopsy channel that allowed manipulation inside the stomach. In 1956 the system was developed, which had a small electronic flash that allowed to make photos directly during gastroscopy and thus, document examination.

 

However, the lack of flexibility of endoscopes, the inability to see the initial parts of the small intestine, poor tolerance examining the patients prompted doctors and engineers to develop new, more advanced technologies. And in 1958, Hirschowitz B. I, along with co-authors published an article devoted to the practical application of flexible fibrogastroscopy where light was transmitted through glass fibers, making it possible to speak of a new era in the development of endoscopy – fiber optic. The idea of transmission of light through fiber optics belongs Baird and dates from 1928 year, and its practical application was due to research Van Heel (1954), who discovered the material with low refractive index coating fiberglass. Principle of transmission of light in fiber-lightguide diameter of several tens of microns is its total internal reflection: the light that falls on the end of a long thin fibers consistently reflected on its internal walls and completely goes to the opposite end. Transfering of light occurs any bending device. Hastroduodenoskop, designed by A.K.M.I., had a length of 90 cm, diameter 11 mm, angle of examine 34 °. It consisted of 150 000 fibers with a diameter of 11 microns each. It should be noted that in 1960, was first established independent source of cold light, which significantly improved the lighting and color reproduction. During the years 1963-1966 Japanese firms Machida Seisakusho, Olympus and Fuji Photo Optical fibrogastroscopy developed and fibrokolonoskop, and in 1966 had established their production. In 1968, Ikeda and colleagues created the first fibrobronhoskop. The disadvantage of fiber optics was the fragility of the fibers as a result of mechanical factors, as manifested appearance of blackheads and thus deteriorating the image.

 

Over time, viewing angle endoscopes greatly expanded, reaching values ​​of 210 °, took two sets of instrumental channels. Simultaneously developing ancillary techniques that have transformed the front endoscopy surgery industry and started a new period – electronic.

 

The beginning of a new phase began the works of Bell Laboratories (AT & T), when Boyle and Smith in 1969 created a charge-coupled device (CCD), which transformed optical signals into electrical impulses. After 10 years, engineers from American companies Welch Allyn created the first electronic endoscope through which endoscopy entered the world of digital technology. In clinical practice Videoendoscopes also appeared in 1984 in the United States under the name EVF-F, EVD-XL, EVC-M. The real breakthrough was the opportunity to participate in a survey to several specialists. Through the use of highly efficient and accurate lens of digital signal processing using CCD retrieve high-quality image with the maximum increase in current devices up to 1400 times.

 

Further development of science and technology contributes to the continuous development of new high technology, which greatly facilitates diagnosis and perform endoscopic treatments.

 

Modern methods of endoscopic diagnosis

 

Number of technical innovations that have emerged in flexible endoscopy in the past five years, ten times the number introduced in the 20th century. If at the beginning of endoscopy equipment improvement represented a unique for 60s fiber optics, followed by solving technical problems by optimizing the diameter of the machine definition image of controllability on total body and its inspection, object, obtaining biopsy for morphological studies, it is in the 80th year endoscopy was video electronic arm technique. Unlike fiber endoscopes directly transmit light signals, electronic video endoscopes convert light signals into images through electronic signals using semiconductor elements and allow you to implement various forms of electronic imaging and its analysis. At present, it is impossible to imagine of endoscopy without video electronic modern technology. It caot only visualize endoscopic picture of the body that looks, but also detail its structural characteristics.

The emergence of new technologies makes endoscopy experience revolutionary changes. Requirements of our time such that little to get the highest quality images, a more revealing diagnostic value of imaging is impossible with standard optical image. Before doctor endoscopist include new diagnostic tasks that possible with the understanding that new methods have proven higher specificity and sensitivity to effectively use it in practice.

To be a competent specialist in endoscopic innovation, it is necessary to monitor the exponentially increasing information flow. So the number of publications relating to issues of diagnostic endoscopy, according to Pub Med, increased tenfold in the past three years.

 

Esophagogastroduodenoscopy – a modern method for visualization and further examination of the walls of the mucosa of the upper gastrointestinal tract, namely the esophagus, stomach and duodenum.

Preparing patients for ezofahohastroskopii

Esophagogastroduodenoscopy performed on an empty stomach after 4 hours or more after the last meal. If you suspect stenosis interval between the last meal and even water before the study is extended to 8 hours or more. Endoscopy is performed not earlier than 24 hours after X-ray as a barium can completely block the channel of the endoscope.

Preparing the patient for ezofahohastroskopii includes psychological (clarification of tasks and the basic rules of conduct during the investigation) and drug (withdrawal of emotional stress, anesthesia, prevention of pathological reflux).

Acquisition of modern endoscopic system:

endoscope;

endoscopic video center;

endoscopic monitor

light source (halogen, xenon, LED);

 endoscopic aspiration pump;

device for recording DVD-ROM drive;

 printer;

electrocoagulator (monopolar, bipolar).

 

Optional equipment:

   flushing pump;

  video and;

  mobile endoscopy cart;

  block thermal probe;

  ultrasonic cleaner;

  washing endoscopes;

  tester for leak testing

 

 

 

 

 

 

Methods of endoscopic diagnosis

Esophagogastroduodenoscopy

Colonoscopy

Bronchoscopy

Endoscopic retrograde cholangiopancreatography (ERCP)

Double balloon intestinoscopy

Capsule endoscopy

Autofluorescence endoscopy

Endoscopic ultrasonography

Virtual chromatography (Narrow Band Imaging (NBI)

Chromoendoscopy

Confocal laser endomicroscopy

 

Esophagogastroduodenoscopy

When using flexible endoscopes esophagogastroduodenoscopy, can change the configuration of the working parts to the form of the studied organs. The optical system of flexible fiber endoscopes provides transmission of light and images on optical fibers, allows to make a lighting system outside the endoscope and achieve sufficient illumination of the object without heating the tissue. After working esophagogastroscopy of the endoscope and its channels to be washed, cleaned and dried. Ambulances for esophagogastroscopy sterilized in special chambers in pairs substances with bactericidal action, ultrasound machines, or process in antiseptic solution. Esophagogastroscopy complications are extremely rare and can be avoided if strict compliance with the rules provided by the preparation and conduct of the study.

The most common devices with a socket optics, allowing successively examine the esophagus, stomach, duodenum Methods of examination of the upper gastrointestinal tract is described in the special instructions.

Features endoscopic investigation of the upper gastrointestinal tract is not limited to visual inspection of cavities, walls and taking biopsies. There are a number of additional methods that are used along with an endoscopy (chromogastroscopy, transendoscopy pH meter, etc.). The more additional methods used in the endoscopic examination, the closer its description and conclusion to the true diagnosis.

Important in describing the use of conventional terminology, noting the severity and location of edema, erythema, hyperplasia and atrophy of folds, intramural hemorrhage, erosions (flat, raised), ulcers, varices and other mucosal changes and investigational authority to use the categories relevant to certain diagnostic

         Esophagogastroscopy is performed on the left side under local (10% lidocaine) or general anesthesia.

 

Endoscopy in general shown:

A. Complaints from the upper abdomen held, despite appropriate therapy.

B. Complaints from the upper abdomen, accompanied by other symptoms that suggest a serious illness (anorexia, weight loss, etc.) in patients older than 45 years.

C. Dysphagia or odynophagia.

D. Reflux symptoms that persist or recur despite appropriate therapy.

E. Persistent vomiting of unknown origin.

F. Other diseases in which the presence of pathology upper TC may influence the choice of treatment (eg, gastrointestinal ulcer or a history of organ transplantation in planning, long-term anticoagulant therapy, long-term NSAID therapy, as well as cancer of the head and neck).

G. Family (family) polypous adenomatous syndromes.

H. To confirm and histological verification of the diagnosis of diseases detected radiologically:

   1 neoplastic lesion.

   2 ulcers of the stomach or esophagus.

I. Gastrointestinal bleeding:

   1 In patients with active or recent bleeding.

   2 If you suspect chronic blood loss or anemia with iron, when the clinical situation suggests a source in the upper gastrointestinal tract (GIT) or negative colonoscopy result.

J. As shown taking a sample of tissue or fluid.

K. In patients with portal hypertension to identify esophageal varicose veins.

L. To assess acute injury after receiving per os caustic substances.

M. Treatment of lesions, bleeding, such as ulcers, tumors, vascular lesions, etc. (electrocoagulation, argon-plasma coagulation (APC) probe, laser photocoagulation, radiofrequency coagulation (RCHK), injection therapy, etc.).

N. Ligation, clipping or sclerotherapy varicose veins.

O. Removal of foreign bodies.

P. Removal of benign tumors or cancers early.

Q. Installing probes for feeding or drainage (oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy.

R. Dilatation stenotic lesions (eg transendoscopy balloon dilatation or dilatation using guide).

S. Treatment of achalasia (balloon dilatation, botulinum toxin administration).

T. Palliative treatment of stenosing tumors (laser, multipolar electrocoagulation, APK, installing stents, etc.).

U. Supervision of healed ulcers.

 

Endoscopy is generally not indicated:

A. Complaints are considered functional in origin (except when endoscopy is performed once to exclude organic disease, especially if there is no response to therapy).

B. Metastatic adenocarcinoma of unknown primary site (when the result is not affected by treatment).

C. Radiographic findings:

     1 asymptomatic or uncomplicated sliding esophageal hernia (except

       examination before surgery).

     2 uncomplicated duodenal ulcer provided responses to therapy.

     3 deformed bulb duodenal ulcer (DU) in the absence

       symptoms or adequate response to the antiulcer therapy.

 

Endoscopy consistently or occasionally may be indicated:

A. Surveillance of patients with precancerous lesions (eg, paved

columnar epithelium esophagus with specialized intestinal metaplasia)

 

Endoscopy consistently or intermittently generally not shown:

A. Surveillance of patients with atrophic gastritis, pernicious anemia and after

   operations on the stomach over benign diseases.

B. Surveillance of healed benign disease (esophagitis, duodenal ulcers).

C. Supervision repeated dilation of benign strictures, if the patient conditioo change.

 

Quality indicators for endoscopic intervention period:

1 Endoscopy should be performed for indications recommended.

2 Before the endoscopy to obtain informed consent, including discuss the risks associated with the intervention.

3 Antibiotics prophylactically administered to patients with liver cirrhosis and acute gastrointestinal upper gastrointestinal tract undergoing endoscopy.

4 Antibiotics prophylactically administered before performing percutaneous endoscopic gastrostomy – PEG, percutaneous endoscopic jejunostomy.

 

Indicators of the quality of the implementation period of endoscopic intervention:

1 If necessary to complete examination of the esophagus, stomach and duodenum, including examination of the stomach in the inversion.

2 If you find gastric ulcers biopsy should be performed.

3 If you find columnar epithelium lined esophagus (CLE) it is measured by the Prague classification “C & M”. Biopsy performed in all cases CLE to determine the availability of specialized intestinal epithelium. It is recommended to perform after one-month treatment with standard doses of PPIs.

4 Upon detection of gastric ulcer or duodenal need to test for the presence of Helicobacter pylori.

5 Damage type, which is the source of gastrointestinal bleeding, described and documented with the definition of localization and endoscopic signs of bleeding – stigmata.

6 In the absence of contraindications performed endoscopic stop active bleeding and prevention of rebleeding held at vessels clots and fixed clusters.

7 In cases of attempts at endoscopic hemostasis of gastrointestinal bleeding should be clearly stated whether it achieved.

8 If using injection of epinephrine to stop gastrointestinal bleeding, you should additionally use a second method of endoscopic hemostasis – such as coagulation or clipping.

9 Endoscopic treatment of esophageal varicose veins in most cases preferred ligation.

 

Indicators of quality period after endoscopic intervention:

1 Instructing the patient beyond, including the possibility of specific complaints and symptoms associated with endoscopy.

2 Patients who performed dilatation of peptic esophageal strictures, appointed PPI therapy.

3 After the mini-invasive surgery in order to endosurgical stop or prevention of rebleeding need to record and analyze the incidence of rebleeding as adverse events and record in the logbook endoscopic studies.

 

 

 

                 

 

                      

                    

The upper, middle, lower third of the stomach and angle

   The bottom of the stomach in retroinvertion

 

Superior part of duodenum	The descending part of duodenum
Small duodenal papilla	Large duodenal papilla
Ascending part of the duodenum

 

 

                           

 

 

Colonoscopy

Colonoscopy – is a kind of endoscopic view of diagnosis, which allows you to fully explore the large intestine. Survey preferably carried out under anesthesia because the procedure is quite uncomfortable for the patient. During endoscopic colonoscopy moving from direct to the small intestine. Thus examined in detail all the colon. If necessary, it is also possible the colonoscope into the small intestine. Research performed flexible endoscopes. The light source is lighter, running on halogen, xenon or LED bulbs eliminates burn mucosa. In a study conducted air supply in the intestine for smoothing the wall, it allows you to create so-called “Airbag”, which minimizes the risk of trauma. During the procedure, endoscopist examines the condition of the mucous membrane of the colon and can see almost all of its possible changes. Knowing the endoscopic anatomy allows him to navigate the lumen of the intestine and to determine the location of the device for typical endoscopic features. Among the currently available methods for detecting colon cancer colonoscopy is the most reliable. Overview, beam diagnostic methods (ultrasound, X-ray, CT) and laboratory tests can also help in diagnosis. However, they are complementary and only colonoscopy allows the doctor without surgery to look inside the intestines and immediately see the status of the intestinal wall.

Indications for colonoscopy:

– With rectal polyps detected at proctosigmoidoscope;

– In diffuse polyposis;

– Ulcerative colitis and Crohn’s disease;

– When unidentified sources intestinal bleeding;

– With clinical or radiological evidence of benign or malignant neoplasms of the  

   colon;

– For any process in the colon when the diagnosis necessary morphological

   verification;

– Benign tumors for the dynamic observation;

– Therapeutic colonoscopy (removal of polyps, stop bleeding, enlarged biopsy,

   removal of foreign and so on.)

– For the purpose of screening for colorectal cancer in all patients older than 45 years.

Promotion scheme osprey colonies in the large intestine

Absolute contraindications to colonoscopy:

– Acute cerebrovascular accident;

– Acute myocardial infarction

– Severe degree of cardiopulmonary failure;

– Severe cardiac arrhythmias;

– Aortic aneurysm and heart;

– Acute inflammatory infiltrates and abdominal abscess

 

Relative contraindications to colonoscopy:

– Acute inflammatory diseases of the anorectal area

– The early postoperative period after abdominal surgery cavity and pelvis

– Pregnancy

– Hepatosplenomegaly

– Tense ascites

– Hydrothorax, hydropericardium

– Hemorrhagic vasculitis, the beginning of the menstrual cycle in women

 

Prepare for colonoscopy:

 Diet:

 – 2-3 days prior to the examination to exclude from the diet: fresh fruits

(raspberries, currants, grapes, kiwi in any form), herbs, berries, mushrooms, beans, peas, black bread, sunflower seeds, nuts, soft drinks, milk, meat, fish in sauce, sausage. Do not use charcoal and preparations containing iron. You can: soup, boiled meat, fish, poultry fillet, cheese, white bread (or crackers yesterday) without fiber cookies, tea, coffee, carbonated drinks, fruit juices without pulp;

 – When receiving debilitating drugs may be a slight increase in their dose;

 – The day before the test is allowed only liquid food (filtered broth, jelly, lit juice

   without pulp juices except red and purple), non-carbonated drinks.

 

  Drug preparation:

– 1 day before the test starting at 16 o’clock – a solution with Fortrans rate of 1  

   packet dissolved in 1 liter of water for 15 kg drunk small portions;

– 4 hours before the test solution of Endofalk 200-300 ml every 10 minutes until the washings become clear, or until drunk 3 -4 liters of solution;

– 1 bottle of Fleet phospho-soda the day before the test, 2nd vial through 12 hours

   after the 1st, but at least 4 hours before the test;

– 4 packages of Moviprep dissolved in 2 liters of water from 16 th to 19 pm the day before the test.

 

                                               

Methods of colonoscopy.

The colonoscope is introduced into the anus in the position of the subject’s left side with bent legs to the abdomen. During the manipulations performed moderate air supply to the intestine folds dealt, just moderate, but not excessive, since it, in the absence of narcotic anesthesia, leads to the appearance of strong pain. Usually when you reach splenic angle it is necessary to shift the patient on the back to facilitate further passage. When performing a colonoscopy is necessary to alternate advancement system forward with stretching and aspiration of air, which makes it possible to gut string colonoscope. Also during manipulation is necessary duty position of the subject’s left and right side, depending on the anatomical features of the intestine. If done correctly, a colonoscopy reach endpoint colon can at 90-110 cm osprey colonies.

Double balloon enteroscopy

The small intestine has a considerable length, a large number of bends, mobile and, therefore, the objectives of its divisions are extremely difficult to investigate. Before the introduction of the small intestine endoscopy videokapsulnoyi considered body relatively rare affected by various diseases. Surgeries in the deep parts of the small intestines and iliac rarely performed. Thanks to modern beam technique to study significantly improved diagnosis of diseases, but even three-dimensional image reconstruction (virtual enteroscopy) were able to detect a significant number of non-positive disease. Over the past 50 years and there were many attempts to examine the small intestine using optical devices, but most of them were unsuccessful due to the small penetration depth. In 2006, in clinical practice was introduced one balloonn enteroscope, and in 2008 published an article on spiral tube for bowel enteroscopy by stringing on the endoscope. Until recently, there were three methods of introducing the endoscope into the small intestine. It endoscopy carried out by push, probe and wiring endoscopy endoscopy. However, each of which had serious shortcomings. Devices, which provided an overview of successful deep small intestine was dvobalonnyy Videoendoscopes created by Japanese doctor Yamomoto in 2001. Together Dzhichi School of Medicine (Japan) by Fujinon has developed a fundamentally new dvobalonni enteroskopy, which made it possible to examine in detail and topically to treat small intestine with minimal risk to the patient.

Double balloon enteroscopy is a new method of examination, which allows you to fully examine the small intestine – the most difficult of the Department for endoscopist. The technique was developed in 2001, the year in Japan and is now used by many gastroenterologists and endoscopists worldwide. Compared with capsule endoscopy, which also makes it possible to examine the small intestine, it is much cheaper and more informative, since it allows more detail to conduct a study, in addition to carry out medical procedures and take a biopsy.

The system of double balloon enteroscopy consists: intestinoscope with a balloon that is inflated and the outer silicone tube, which also has a balloon. Cylinders connected to the compressor and control panel. The method is based on advancing the endoscope through the small intestine with alternate fixation of the endoscope and the outer tube of silicone in the lumen of the small intestine by two cylinders that can provide successful and safe conduct intestinoscope almost throughout the small intestine. It caot be performed during normal endoscopy as small bowel twists not allow the machine without it hyperextension. When Double balloon enteroscopy inserted into the small intestine, small intestine strung and straightened her curves. Originally performed antegrade examination of the small intestine. After the maximum possible view of the small intestine antegrade, retrograde stage is carried out – through the colon. Promotion of intestine endoscope is performed under X-ray control, and the presence of instrumental channel allows medical diagnostic manipulation and biopsy for histological examination in any section of the small intestine.

Impressions:

– Bleeding from the gastrointestinal tract, accompanied iron deficiency anemia;

– Crohn’s disease;

– Abnormalities of the small intestine revealed by X-ray;

– Chronic diarrhea (suspected malabsorption syndrome) and chronic abdominal

  pain;

– Suspicion of tumors of the small intestine;

– Multiple polyps;

– Stop intestinal bleeding (using argon plasma coagulation or clipping)

– Removal of tumors of the small intestine;

– Balloon dilatation of strictures of the small intestine;

– Removal of a foreign body of the small intestine;

– Perform endoscopic retrograde interventions in patients with altered anatomy

  upper gastrointestinal tract due to deferred surgical interventions;

– Monitoring the syndrome that occurring with multiple polyposis small intestine  

  (Peyttsa-Jeghers syndrome, familial adenomatous polyposis);

– Assessment of the dynamics of the small intestine in patients with previously

  diagnosed diseases of the small intenstine, particularly to monitor treatment

  efficacy

 -Crohn’s disease, enteropathy

 

 

 

 

 

 

 

 

 

           Scheme of implementation of antegrade double balloon endoscopy

 

Contraindications:

The same as during gastroscopy and colonoscopy

 

Features double baloon endoscopy:

– Review of remote areas of the small intestine;

– Diagnosis of small-size defects;

– A combination of endoscopy with X-ray examination, CT or MRI;

– Evaluation of the local effects of drugs in diseases such as UC or disease Crown;

– Stop bleeding from small angiectasia;

– Removal of a foreign body;

– Removal of polyps;

– Dilatation of strictures or walls intestine;

– Direct jejunostomy;

– Fence material for cytological and histological study.

 

The advantages of double baloon endoscopy should include:

– Outpatient procedure performed;

– Takes from 45 minutes to 2 hours (depending on impressions);

– Examination passes while taking sedatives or short-acting general anesthetic;

– Small intestine passes through the mouth or anus (depending on which department to look).

 

During this process, air is used instead of carbon dioxide, which minimizes bloating and, consequently, reduces discomfort to the subject.

 

Common side effects after double baloon endoscopy include:

– Sore throat

– Bloating

– Nausea

– Slight bleeding

Components of double baloon endoscopy system:

– Video processor;

– Intestinoscope;

– Monitor;

– External silicone tube;

– Water tank;

– Cylinders;

– Controller cylinders;

– Air pump;

– Controller cylinders;

– Suction;

– Tightness tester

                  View of distal end of double balloon intestinoscope

Bronchoscopy

 

Bronchoscopy – endoscopic evaluation of the mucosa and lumen of the trachea and bronchus.

A survey carried out by means of flexible endoscopes which are introduced into the lumen of the trachea and bronchus. Before performing bronchoscopy should be carried out X-ray examination of the chest.

Endoscopic methods occupy an important place in the diagnosis of bronchopulmonary pathology. This is because these manipulations allow biopsy with morphological verification of pathological lesions.

In conducting bronchoscopy is important to know the anatomy of the trachea and bronchus. The trachea begins at the level of body VI-VII cervical vertebra and ends at the bifurcation level IV-V thoracic vertebrae, or II-III sternocleidomastoid rib joint. The length of the trachea – 10-12cm, men to 1-2 cm longer than women. In the trachea is 15-20 cartilaginous rings. Cartilage rings up 3.2 disk and open back (tunica fibrosa). Paries membranaceus consists of: muscular fibers in longitudinal and oblique directions; of elastic and collagen fibers in the longitudinal direction. The trachea divides into right and left main bronchus. Right main bronchus from the trachea forms an angle of 155 degrees, and the left – 120 degrees. Right bronchus is shorter on the left (respectively 15-20 mm and 45-50 mm.).

Bronchoscopy is currently the only method that allows you to see the inner surface of the bronchus. The main historical stages in the development of this diagnostic method are as follows:

– 1897 р. Killian performed the world’s first bronchoscopy under local anesthesia with cocaine;

– 1956 р. Friedel created the modern model of rigid bronchoscope;

– 1968 р. Ikeda, Vanai, Ishikawa told about the appearance fibrobronchoscope.

         Today you caot talk about work pulmonologist or thoracic surgeon without bronchoscopy. There are two methods of bronchoscopy:

rigid bronchoscopy, which is made using a hard gear and fibrobronchoscopy, through which you can see all the bronchi IV procedure, 86% of the bronchi – V order and 56% of the bronchi – VI order. Visually controlled biopsy is possible from all segmental bronchi in 74% of bronchial IV procedure and in 38% of bronchial V order.

Rigid bronchoscopy is used most often to remove foreign bodies and for mild surgeries in the tracheobronchial tree. System used Bronchoscopes Jackson and Friedel. Feature of rigid bronchoscopy is that it is performed under general anesthesia and in the apparatus is a device for mechanical ventilation.

Typically FBS performed under local anesthesia, it is possible to conduct through the nose or through the mouth. Premedication before FBS held 0.1% solution of atropine or metacin (to reduce secretion and decreased muscle tone of the bronchi). As an anesthetic used mostly lidocaine. Pharynx while covered 10% solution for anesthesia directly tracheobronchial tree using 2% concentration of anesthetic. At bronchoscopy the patient lies on his back, under the shoulder he puts a small pillow tight. Head and neck lift 10-12 cm roller or a special holder, thereby straightening the neck.

If bronchoscopy is performed in sitting position of the patient, the patient is placed in front of the doctor, slightly tilting the body forward. Patient’s hand dropped between her legs, head slightly thrown back. Children spend only bronchoscopy under general anesthesia on an empty stomach, relieving bladder and rectum. After researching child should lie in bed in a horizontal position. In case of vomiting should be prepared dishes to collect vomit, apparatus for artificial respiration. Drinking and meat to no earlier than 3 hours after bronchoscopy.

         The following rules bronchoscopy. Perform bronchoscopy on an empty stomach or 2-3 hours after breakfast in the dressing room or endoscopic. A nurse washes hands as before the operation, supports the patient in a certain position and watching his condition. The duties of a nurse checking function also includes bronchoscope sterilization and inspection of tubes and other system components.

To begin with it is necessary to review the bronchi of healthy lungs. If you lose the benchmark bronchoscope tighten to the emergence of the field of view of any of the known patterns. Spillage of phlegm, mucus, blood in the distal lens should ask the patient cough, bronchial wash channel NaCI solution or distal bronchoscope rubbed against the wall of the trachea. In conducting PBS should evaluate several factors:

– View mucosa;

– The type and quality of secretions;

– Elasticity of the walls of the trachea and bronchus;

– Bleeding in the mucous instrumental palpation;

– Appearance and mobility spurs and mouths segmental and subsegmental bronchus;

– View mucosal vascular pattern;

– The form and nature of folding mucosa;

– Dystonia trachea and bronchus

Particular attention is paid to the presence or absence of “Plus” – tissue defect, or “minus” – tissue.

 

         Therapeutic bronchoscopy

One fairly common causes of adverse patient outcomes in the postoperative period is the development of pneumonia or bronchial obstruction. Most prone to complications such older patients after laparotomnoy and prolonged laparoscopic surgery on the abdominal cavity. Despite the fact that new models of apparatus for artificial respiration, how active management of patients and measures of prevention of pulmonary complications, unfortunately, to achieve real success in preventing pneumonia and bronchitis caot always. With increasing proportion of patients in older age groups the problem of prevention and treatment of postoperative complications is becoming increasingly important.

Severe head injury remains relevant medical and social problem. High mortality of extracranial complications, primarily from pneumonia, forcing seek effective ways to prevent and treat pulmonary complications in these patients. Emphasis is given to changes in the lung parenchyma. Using a combination of conventional methods of prevention and treatment of pulmonary complications (turning patients in bed, massages, inhalation, special modes of ventilation, antibiotic therapy, electrophoresis, UV blood, etc.) with TBI and in patients with neurological profile does not bring the desired effect. The use of therapeutic bronchoscopy in respiratory failure is still controversial, although known for the high efficiency of the method in the treatment of postoperative atelectasis, pneumonia and epistasis thermal lesions of the respiratory system.

 

Indications for bronchoscopy, based on clinic symptoms:

– In all cases when the doctor says lingering chronic inflammatory process in the lungs;

– Unwarranted cough (cough lasting as the only symptom of the disease);

– Inadequate symptomatic cough (severe prolonged cough that does not explained

  nature of diagnosed pathological process);

– Shortness of breath, inadequate volume of impressions;

– Hemoptysis and pulmonary hemorrhage;

– Sudden changes in the number of sputum in a short period of time (possible

  obstacle in the bronchus);

– Presence or absence of mycobacterium tuberculosis and in the absence of clearly expressed tuberculosis impression of the lungs (bronchi possible tuberculosis, broncho nodular fistula);

– The need for bacteriological, cytological research pathological material from the bronchi.

 

Indications for bronchoscopy, based on radiological symptoms:

-Presence of signs of bronchial obstruction: reduction or lung its parts in volume,

  presence of hypoventilation, atelectasis, lung or abdominal parts there of;

-Protracted and chronic pneumonia (prolonged or chronic inflammation often

  occurs on the background of a disease);

-The presence of the shadow of unknown etiology in basal, middle sections and  

  also at the root of the lung and mediastinum;

– Quick resizing intrapulmonary cavity (with cavernous tuberculosis or abscess);

– Disseminated lung disease;

– Pulmonary tuberculosis;

– Effusion of unknown etiology.

Bronchoscopy is required in all cases before surgery on the organs of the chest.

 

Indications for therapeutic bronchoscopy:

-The need to eliminate obstruction of bronchial mucus, pus, blood, a foreign  

  bodies;

-Stop bleeding tamponade equity lung bronchus;

-Treatment of purulent bronchitis;

-Manure from intrapulmonary cavities;

-Treatment bronchopleural and broncho nodular fistula;

-Treatment after inflammatory stenosis of the trachea and bronchus.

 

Indications for emergency bronchoscopy:

– Massive after inflammatory pulmonary hemorrhage;

– A large foreign body of trachea or bronchus;

– Postoperative atelectasis and hypoventilation of the lungs;

– Aspiration of stomach contents;

– Status of asthmatic bronchial obturation viscous mucus;

– Chest trauma with damage to the trachea and bronchus;

– Thermochemical airway injury;

 

The purpose of emergency bronchoscopy – urgent diagnosis and removal main causes of bronchial obstruction, improve pulmonary gas exchange

 

Contraindications to perform bronchoscopy:

absolute:

– Intolerance of drugs used for local anesthesia;

– Myocardial infarction, moved less than 6 months ago;

– Acute stroke;

– Cardiac arrhythmia (above III degree);

– Hypertension with increased diastolic blood pressure 100 mm more Hg. c .;

– Pulmonary heart and cardiovascular failure III level;

– Bronchial asthma in acute phase, when interval between attacks less than 3

   weeks;

– Stenosis of the larynx and (or) the trachea II-III degree;

– Neuropsychiatric disorders (epilepsy, conditions after traumatic brain injury

   schizophrenia);

– Pain in the abdomen;

– The dire condition of the patient when further diagnosis caot influence the therapeutic approach.

 

relative:

– Acute respiratory disease of the upper respiratory tract;

– Ischemic heart disease;

– Severe diabetes;

– Pregnancy (second half);

– Chronic alcoholism;

– Increase in thyroid III level;

– The period of the menstrual cycle

        

         The middle third of the trachea        Bifurcation of trachea

 

Complications of bronchoscopy:

Related to anesthesia:

  -reaction local anesthetics – dizziness, tachycardia, nausea, hypotension,  

   larinhospazm, bronchospasm.

Related bronchoscopy:

  -nasal bleeding;

  -acute laryngitis;

  – hypoxia;

  -bleeding after biopsy (according to Herf, Suratt bleeding than stated in 50 ml

   1.3%);

  – pneumothorax

 

Endoscopic retrograde cholangiopancreatography (ERCP) and papillosphincterotomy (EPST)

 

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically difficult and dangerous surgery performed endoscopist. There fore, the most successful and secure its implementation requires intensive specialized training and some experience. Now from a purely diagnostic ERCP became predominantly in miniinvasive endosurgical intervention (ERI). Relations with ERCP is an effective treatment of various diseases of the biliary-pancreatic area. Often used to remove calculus from bile duct and elimination of jaundice caused by malignant neoplasms.

Endoscopic retrograde cholangiopancreatography is a combination of endoscopy (to identify ampoules major duodenal papilla) and X-ray examination after administration of contrast medium into the bile and pancreatic ducts. In image acquisition biliary tract and pancreas, endoscopic retrograde cholangiopancreatography (ERCP) allows to examine the upper gastrointestinal tract and periampular area and biopsy or surgical cause (eg sphincterotomy, removal of gallstones or stent placement in the bile duct).

To successfully perform endoscopic retrograde cholangiopancreatography and obtaining quality radiographs, except endoscopes and catheters required set x-ray tele visionary installation and opaque products. In most cases, ERCP performed using endoscopes with a side optics. In patients who underwent resection of stomach by Billroth-II, to perform endoscopic retrograde cholangiopancreatography endoscopes must be used with an end or beveled optics.

Requirements for X-ray equipment is high. It should provide a visual inspection of the implementation of the study, obtaining quality images of cholangiopancreatography at various stages, the permissible level of exposure of the patient during the study. Endoscopic retrograde cholangiopancreatography use different opaque water-soluble drugs: verographin, urographin, angiographin, triombrast.

 

Methods of endoscopic retrograde cholangiopancreatography:

Endoscopic retrograde cholangiopancreatography includes the following steps:

Revision of the duodenum and papilla major.

Cannulation of major duodenal papilla and the introduction of radiopaque drug test.

Contrast of one or both ductal systems.

Radiography.

Monitoring the evacuation of contrast material.

Measures for the prevention of complications.

 

Evaluation of large duodenal papilla (shape, size, morphological changes, the type and number of holes) is important for diagnosis of duodenal ulcer disease (tumor, papillitis, papillary stenosis) and to assess the anatomical and topographical relationships intestine, large papillary and ductal systems. For the detection of biliary tract pathology is of great importance to the character of discharge papilla: pus, blood, cement, sand, parasites.

When endoscopic examination of the duodenum papilla showing on the inner wall of the descending colon when viewed from above. Detailed audit papilla hampered in severe peristalsis and contraction of the department caused by pancreatic head cancer, primary cancer of the duodenum, pancreas increased in chronic pancreatitis. Of great practical importance is the identification of two duodenal papillae – large and small. Differentiate can be on location, size and nature of the discharge. Great papilla located distally, height and its diameter ranging from 5 to 10 mm through hole on top of bile secreted. Small papilla located approximately 2 cm proximal and closer to front, its dimensions do not exceed 5 mm.

At baseline audits duodenum and large duodenal papilla in the patient’s left side. However, in this position papilla often seen in lateral projectioot only cannulation, but also a detailed review of it is difficult, especially in patients who underwent surgery for biliary ducts. Convenient for cannulation and radiography great position papillary often only manage to achieve in the patient’s belly. In some cases (if the diverticulum in patients after surgery for extrahepatic bile ducts) papillary large output in a convenient position for cannulation possible only in the position on the right side.

Cannulation of great papillary and test injection of contrast material. Success of cannulation ampoules papilla major and contrast depends on many factors: good relaxation duodenum, experience of the doctor, the nature of the morphological changes of the papilla and others. An important factor is the position of the great papillary. Cannulation can be performed only if it is located in the frontal plane and the end of the endoscope wound below the nipple so that it looks upward and clearly visible opening ampoules. In this position the direction of the common bile duct is upward at an angle of 90 °, and pancreatic – upward and forward at an angle of 45 °. Actions endoscopist and the effectiveness of selective cannulation determined by the nature of ductal fusion and depth introduction cannula. Pre-filled catheter contrast medium in order to avoid diagnostic errors. It should enter slowly, precisely defining the opening ampoules his distinctive mind and end bile. Rushing cannulation can fail due to spasm of the papilla and its sphincter.

In separate location holes biliary and pancreatic ductal systems papilla contrast to the first of these catheter is introduced into the top corner crack hole and to fill the second – in the bottom corner, giving the catheter above direction. When ampullar version VDS to reach the mouth of the bile duct is necessary by bending the distal end of the endoscope and catheter movement to enter the lift upwards. It will slide along the inner surface of the “roof papilla major” and gently lift it that noticeable, especially at the confluence of the bile duct and duodenum at an acute angle and the presence of long intramural department of the common bile duct. To reach the mouth of the pancreatic duct catheter introduced into the opening ampoules, pushing forward to entering this contrast agent. Using the techniques listed, you can either selectively or simultaneously contrasted bile and pancreatic ducts.

In patients who underwent surgery (including choledochoduodenostomy) often have selective contrast ducts not only through the mouth of a large duodenal papilla, but also through the hole anastomosis. Only such a complex investigation reveals the cause of disease states.

X-ray control of the position of the catheter are possible with the introduction of 0.5-1 ml of contrast medium. With the lack of depth cannulation (less than 5 mm) and low (close to the ampoule) block biliary tract stone or tumor cholangiography may be unsuccessful. When placing the cannula in a large vial papillary can contrast the two ducts system, and with a deep (10-20 mm) putting it – one.

If only pancreatic duct expressed, you should try to get a picture of the bile ducts, introducing contrast material during extraction catheter and performing re cannulation shallow (3-5 mm) ampoules large duodenal papilla, guiding catheter up and left. If cannula introduced 10-20 mm, and contrast material in the ducts is not visible, it means that it rests on the wall duct.

Number of contrast medium required to perform cholangiography, varies depending on the size of the bile ducts, character pathology, deferred transactions and so on. Usually just enter 20-40 ml of contrast medium. It is excreted slowly and this allows X-ray projections in the most comfortable that the doctor chooses visually. The concentration of the first portions should not exceed 25-30%. This avoids errors in the diagnosis of choledocholithiasis as a result “clogging” concretions highly contrasting agents.

Upon receipt of informed consent to perform ERCP should pay attention to the 5 most common complications: 1) pancreatitis, 2) bleeding after sphincterotomy, 3) infectious complications usually cholangitis, cholecystitis but also savings and infected pancreatic fluid, 4) cardio-pulmonary complications are usually associated with sedation, and 5) perforation. The patient should be informed about the need for hospitalization (if intervention performed in the office) in case of complications and the possibility of operation in the event of perforation or bleeding.

 

Indications for ERCP:

1 Obstructive jaundice (Hyperbilirubinemia).

2 Increased activity of enzymes of cholestasis: alkaline phosphatase and  

   GGT.

3 Increased transaminase activity and, above all, ALT in combination with at

 least one of the indications listed in p.p.1, 2, 4, 5, 6, 7.

4 Expansion of the total bile duct more than 8 mm by ultrasound.

5 Stones biliary ducts.

6 Cholangitis.

7 Suspected Iatrogenic damage, scarring or tumors biliary ducts, to

   determine the area and length of the lesion, and the state of upper biliary  

   tract.

 

Indications for EPST:

1 Extra hepatic stones of bile duct

2 Major duodenal papilla stenosis.

3 Chronic pancreatitis with biliary ductal hypertension, against papillitis,  

   stenosis of the major duodenal papilla or herniation in his vial concrement.

4 “Blind sac syndrome” after holedohoduodeno- or holedohoyeyunostomiyi.

5 Tumors duodenopankreatobiliarnoyi area of ductal obstruction.

 

Therapeutic manipulation in the area major duodenal papilla include the following possible interventions:

• Endoscopic papillosphincterotomy;

• Endoscopic balloon papilodylyatatsiya (sfinkteroklaziya);

• Endoscopic virsunhotomiya;

• litoekstraktsiya calculus biliary and pancreatic ducts;

• mechanical lithotripsy;

• nazobiliarne drainage;

• transpapilyarne bilioduodenalne arthroplasty;

• transpapillyarne pancreatoduodenal arthroplasty;

• balloon dilatation malignant and benign biliary strictures

    duct and pancreatic duct;

• endoscopic removal of adenomas major duodenal papilla

 

Canulation of large duodenal papilla

Contrast of biliary tract

Capsule endoscopy

Capsule endoscopy is a modern, highly informative diagnostic method that makes it possible to obtain an image of the mucosa of the small intestine and identify pathological changes that occur in it. Promoting it is due to the peristaltic contraction, while images are made throughout with a frequency of 2-3 per second (depending on model).

In 1981 a talented mechanic Dr. Havriel Iddan, senior engineer of electro-optical structures research group of the Ministry of Defense of Israel during their vacation took a problem that has long interested him – creating images of internal organs for medical purposes. The idea arose during the development of defense projects, including the creation of electro-optical imaging for missiles. He came up with the concept of tiny “missiles”, which, being swallowed by the patient, is in his gastrointestinal tract (GIT) and simultaneously transmits images to a receiver located outside. Of particular interest seemed that this method will enable the first direct visualization of the small intestine, which also was terra incognita, inaccessible to optical imaging. In late 1998 a group of developers that included Dr. Havrielya Iddana, Dr. Paul and Dr. Pile Arcadia Gluhovskaya, came to embody this exciting ideas. Successfully overcoming numerous difficulties associated with measuring devices, power transmitter, battery power, image resolution, etc.. These scientists in January 1999 proposed working model of the capsule. In May 2000 during the American Weekly gastrointestinal diseases (DDW) Dr. pile supported by Given Imaging demonstrated the results of animal experiments conducted using it developed a working model.

In 2001 conducted the first clinical trials videocapsula endoscopy and received positive feedback from many patients and doctors. Analyzed sensors fixed to the anterior abdominal wall, Recorder battery – at the waist of the patient, and then he swallows the capsule. During the test duration 8:00 patient is free lifestyle. After the end of the study obtained information, which is a “movie” lasting 1-2 hours, is handling the workstation.

Impressions:

– Abdominal pain of unknown origin with normal gastroscopy and results

    colonoscopy;

-pryhovana gastrointestinal bleeding, manifested ground and

    positive results of examination of stool for blood;

– Crohn’s disease;

– Celiac disease (gluten enteropathy);

– amyloidosis

– Hereditary polyposis syndrome;

– Tumors of the small bowel (polyps syndrome, Peutz-Jeghers, hereditary

   adenomatous polyposis, lymphoma, carcinoma, lipoma, hemangioma, GIST-

    tumor)

– Iron deficiency anemia;

– Enteritis (bloating, reduced, increased stool)

– Tuberculosis.

– Impressions of the intestine due to use of nonsteroidal anti-inflammatory

 

Contraindications:

– Suspected obstruction;

– Dysphagia;

– Pregnancy;

– Epilepsy;

– Pacemaker or defibrillator in a patient;

– Diverticulosis of the patient;

– Poor digestion or slow evacuation of the stomach.

 

Complications arising from the capsule endoscope:

The most serious danger during capsule endoscopy is possibility of intestinal obstruction due to obstruction of the lumen

small intestine videocapsule narrowing in place. According to researchers, J. Barkin and O’Loughlin, had to resort to surgery in 7 (0.75%) of 934 held endoscope. In all these cases, the patients in the small intestine was found pathological process that explains the hidden gastrointestinal bleeding, about which the survey was conducted.

In other, more rare complications that arose during the capsule endosopy described in the literature were capsule aspiration, capsule retention in pear sinus and Meckel’s diverticulum.

Capsule, sensors, transmitter, endoscopic picture

 

 

 

 

 

 

optical shell (1), lens (2), svitodiody (3) Camera (4) batery (5) Transmitter (6) Antenna (7)

Disadvantages of capsule endoscopy:

With all the benefits of capsule endoscopy, as well as any other diagnostic method has its drawbacks:  Capsule endoscopy caot specify the nature of the detected tumors (benign or malignant it), because there is no possibility of taking a biopsy, that is a piece of tissue for further analysis. Maybe in the future should expect to see in medical practice, something like “radio controlled videokapsul” can take the analysis of interest to medical fabrics;

– Unlike spiral CT capsule endoscopy can detect superficial pathological processes of the small intestine. In turn, using spiral CT successfully diagnosed inner walls bulky lesions and pathological processes that are about the small intestine (in the mesentery, omentum and retroperitoneal space);

  – Not always possible to interpret unambiguously detected at capsule endoscopy inflammatory changes in the small intestine as a sign of Crohn’s disease. Sometimes the signs outside characteristic of the initial stages of Crohn’s disease, caot differentiate (distinguish) from ulcers, which are caused by use of nonsteroidal anti-inflammatory drugs (NSAIDs). At the same time, a comparative analysis of the diagnostic value of capsule endoscopy and radiological methods of investigation of the small intestine in patients with suspected Crohn’s disease, many researchers noted a significant advantage endoscopy using videokapsule.

Preparation for capsule endoscopy

– Stopping the use of iron supplements 1 month before the survey;

– 2-3 days before the test the patient should follow

    Without cereals diet;

    day of the test:

– Dinner: the patient can eat normally, then should strictly

    follow liquid diet;

– Refrain from eating at least 12 hours before the test;

– Since after dinner drink only water;

– To clean the bowel the night before the patient drinks 2 liters

    polyethylene glycol (endofalk, Fortrans), and the test in the morning is 1

    liter;

– Cease receiving any medication 2 hours before the test.

– 30 minutes before swallowing the capsule Drink 50 ml antifoam

   (Espumizan, simethicone)

– During the examination are allowed to use water 2 hours after swallowing the capsule, and after 2 hours – use a light meal.

 

 

Good preparation                                               Poor preparation

Normal folds of the small intestine. Unlike conventional endoscopy folds not re stretched air, they can be seen in the different phases of contraction.

Normal mucosal vascular pattern

Normal mucosal villi

Videocapsule image esophagus

Confocal Endomicroscopy

When using confocal endomikroskopu an opportunity to examine closely and evaluate the microstructure of the tissue to the size of the cell nucleus. Laser technology Pentax system provides a high quality and clear images through the 1000-fold increase in resolving power 0,7mkm, viewing surface and subsurface microstructures to 250mkm deep and sight 500h500mkm. Confocal endomikroskopy helps accelerate diagnosis and treatment prescription in conditions such as cancer / precancerous bowel, ulcerative colitis, Barrett’s esophagus, H. Pylori, abdominal disease, GERD and NERD.

Technology: to create a confocal image of blue light laser distal end of the endoscope is focused on the surface of the fabric.

Methods: Pre-application (locally or intravenously) fluorescent substances in the mucous excited laser light and special confocal optical unit takes only fluorescent light in exactly a given horizontal plane.

Result: The obtained microscopic images of high-definition allows to consider and evaluate the microstructure of the tissue to the size of the cell nucleus.

With the advent in 2012 – 2013 years endoscopy tech High increase – confocal laser endomikroskopy precision studies of gastric mucosa reached a new level. Using this methodology was to assess the gastric mucosa to microstructural level – cellular and tissue.

Features confocal endomicroscopy

Microscopy in vivo during routine endoscopy

Diagnosis tissue in real time

Very high accuracy and correlation with histology

Simple classification for diagnosis

The ability to detect neoplasia and H.pilory

Penetration into deeper layers (0-250 m) (35 image layers)

The ability to discern the cell nucleus staining at the local

Ability to assess vascular morphology in vivo

It does not require the use of additional materials

 

The advantages of confocal endomicroscopy:

– Early, more effective detection of tumors at a curable stage;

– Reducing the number of routine biopsy, thanks to “intelligent biopsy”;

– Optimization of the process of endoscopy;

– The use of advances in immunology and genetics for

 endoscopy (molecular markers);

– Effective use of new specific therapeutic interventions (microscopic / molecular monitoring of performance).

 

Features confocal endomicroscopy:

• Microscopy in vivo during routine endoscopy

• Diagnosis tissue in real time

• Very high accuracy and correlation with histology

• Simple classification for diagnosis

• The ability to detect neoplasia and H.pilory

• Penetration into deeper layers (0-250 m) (35 image layers)

• Ability to discern the cell nucleus staining at the local

• Ability to assess vascular morphology in vivo

• Does not require the use of additional materials

Scheme to obtain images with confocal laser endomikroskopy (left to right).

Location tissue and plane scanning (used image Professor A. Polglase, Cabrini Hospital, Australia):

– Light microscopy, transverse cross-section;

– Light microscopy, horizontal slice;

– Endomikroskopy, horizontal slice.

A -representations in white light. B chromoendoscopy. C, D -confocal e endomicroscopy. E -gistology image.

Endoscopic ultrasonography (endosonohrafiya, EUS, endoscopic ultrasound

 

Modern method to evaluate the nature and depth of the lesion wall of the upper gastrointestinal tract, endoscopic ultrasonography is. The method is based on the use of ultrasound scanning at the location of the sensor in direct contact with the wall of the hollow body. The sensor is located at the distal end of the endoscope, or used ultrasonic sensors, probes, which are inserted through the biopsy channel of the endoscope usual. To create the optimal environment for the ultrasonic wave sensor ehoendoskopa variables covered latex balloon, which is filled with water to the test. The same purpose can perform research, fill with water very hollow organ or by combining these methods during manipulation. Unlike traditional ultrasound examination sensor location in the lumen investigated the esophagus, stomach or duodenum excludes screening ultrasound waves air. High resolution endoscopic ultrasound to clearly differentiate the layers of the wall of the gastrointestinal tract and produce differential diagnosis of lesions of the mucosa, submucosal lesions and tumors.

High frequency ultrasound allows you to accurately determine the prevalence of neoplastic lesions as during and in depth. Malignant lesions are typically visualized in the form of various tissue echogenicity that gives regular Sharov wall structure and body with fuzzy contours. Endoscopic ultrasound to determine the length vrvzhennya, which is especially relevant in the infiltrative forms of cancer that tend to increase in submucosal layer without visible changes of the mucosa. Informative research on the staging of cancer significantly increases the ability to visualize the affected regional lymph nodes. When submucosal lesions endosonohrafiya to adjust the size formation, character growth and its precise localization in a particular layer of the wall of the hollow body. This method is crucial for the choice of the removal of submucosal tumors as well as tumors and cysts arising from its own muscle plate mucosa or submucosa and can be removed endoscopically. At the same time, large tumors localized in the muscular wall or adventive layers of the gastrointestinal tract require surgery. When varicose veins of the esophagus and gastric endoscopic ultrasonography reveals the expansion of blood vessels, trace the dynamics of changes in disease progression or stages of treatment. Use ehoendoskopiv of the sector scan provided the ability to perform biopsy pathological lesion or sclerotherapy vein under ultrasound guidance. Endoscopic ultrasonography in the dynamics to monitor the effectiveness of intervention

Cancer of the stomach: left – videoendosopy; from the right – endosonografy (arrows indicated tumor infiltrate all layers of the stomach wall).

Submucosal lesion – esophageal cyst. Left – videoendoskopy; from the right – endosonohrafiya (visible cyst, which is located in the submucosal layer of the esophageal wall, possible endoscopic removal).

The main indications for endoscopic ultrasonography:

– Diagnosis of lesions of the pancreas volume, VDS,

    intraductal tumors, the extent of their distribution;

– Identification of regional and distant metastases in limfouzlah;

– Determine the stage of malignancy and depth impression at low

    scale formation;

– Identify stones zhovchevyh ducts without the use of ERCP;

– Diagnosis of the severity of changes parenchyma and pancreatic duct in chronic pancreatitis and its

   complications;

– Submucosal tumors of the upper gastrointestinal tract or suspicion of their presence on the results

   endoscopic examination.

 

Additional indications for endoscopic ultrasonography:

– Diagnosis of metastatic mediastinal impression with cancer of the lungs and

tumors of the mediastinum;

– In determining the risk of recurrence of gastrointestinal bleeding

experiences ulcerative gastrointestinal tract;

– Monitoring of endoscopic hemostatic measures in bleeding

varicose veins of the esophagus and cardia of the stomach;

– To assess the major duodenal papilla intraampulyarnyh tumor (adenoma-carcinoma);

– Acute destructive pancreatitis to determine the etiology pancreatitis and indications for surgical interventions.

    The procedure is done on an empty stomach or with anesthesia support a total vein anesthesia

 

Benefits endosonografy

– Informative;

– No risk of radiological exposure to personnel and patient;

– Mobility equipment that allows to examine in the intensive care department ion-transportable patients, or operatsioniy  elsewhere;

– Opportunity to avoid obstacles created by gas in the intestines and fat

cloth.

– Low rate of complications (less than 1 in 2000).

 

Absolute contraindications to perform:

– Extremely severe general condition of the patient, which makes it impossible to carry out endoscopic examination of the upper gastrointestinal tract without the threat of inhibition of the respiratory and cardiovascular activity;

– Diseases of the esophagus, stomach and duodenum, complicated obstruction, which leads to the impossibility of performing endoscopic examination.

 

Relative contraindications to perform:

– Stenosing diseases of the esophagus and proximal stomach, which empede of the endoscope into the lumen of the stomach and duodenum intestine;

– Compression of the esophagus from the outside (large goiter, cervical deformity of the thoracic spine);

– Rough scar-ulcer or postoperative deformity bulbs duodenum, which prevents adequate position ultrasonic sensor endoscope;

– Status after gastrectomy (inaccessibility area large duodenal papilla).

 

Features endoscopic ultrasonography:

1.  Accurately diagnose choledocholithiasis in patients with negative data conventional ultrasound (bile duct is not dilated, no stones in the lumen) also reasonably reject the assumption of stones in the biliary ducts (diagnostic accuracy of 92.2 – 97.4%, sensitivity of 84.2 – 96.9% specificity of 98.1 – 100%). This avoids unnecessary, expensive ERCP in 56.7%, or a reasonably perform minimally invasive endoscopic interventions on the bile ducts in endosono graphically diagnosed diseases.

2. Accurately detect tumor impression of the esophagus, stomach, colon, bile ducts and pancreas (when tumors pancreatic biliary zone diagnostic accuracy of tumor impression is of 86.5%; sensitivity – 87.9%, specificity – 84.2% accuracy of limforehionalnoho metastasis – 84.8% sensitivity – 84.6%, specificity – 85.7%. This enables the first avoid unreasonable eksploratyvnyh laparotomiy in tumor impressions 4th stage or in unresectable tumors and accurately determine indications to perform radical or palliative deliberately surgery.

3.  Precision diagnose submucosal tumors of the walls of the digestive tract in  its various parts (diagnostic accuracy of the method – 96%, sensitivity – 100 %, Specificity – 83.3%, positive predicted value – 95% negative predicted value – 100%), to determine the precise localization of layers of the wall of the gastrointestinal tract, to predict the histological structure of some tumor lesions (lipoma, leiomyoma, brush), and produce a differential diagnosis between benign and malignant submucosal tumors.

4. Accurately diagnose these lesions in the pancreas chronic pancreatitis as cysts (less than 3 cm) pancreatic stones duct, pancreatic duct dilatation without using x-ray survey methods (CT and ERCP) and, accordingly, reasonably formulate indications to perform endoscopic or surgery on the pancreas or to determine the need exclusion of conservative treatment.

5. Intra ampullar noninvasive diagnosis of benign and malignant tumors major duodenal papilla of the duodenum with standard endosonohrafichnomu pankreatobiliarnoi survey area and in the early stages of the disease to determine the indications for radical surgical treatment.

6. In acute pancreatitis (especially destructive) correctly determine the cause of pancreatitis (biliary or standalone), severity necrotic changes in the gland and verify their topographical location (data comparable with the data computed tomography).

7. In patients with gastrointestinal bleeding verify the invisible large vessels in the days of bleeding ulcers, to determine the risk of recurrence bleeding and to assess endoscopic hemostatic measures conducted.

 

Chromoendoscopy

Chromoendoscopy – method of endoscopic examination of the gastrointestinal tract with different coloring dyes safe for human putative pathological changes of the surface of the mucous membrane of the studied organs that can detect and differentiate minimal pathological changes in the epithelium of the mucous membrane by a complex visual study through endofibroskop and histological examination of biopsy material sighting.

Chromoendoscopy used for differential diagnosis of diseases that are difficult to vary in endoscopic signs. Most concerned benign and malignant diseases, especially early forms and limits tumor definition of truth and experience degenerative and inflammatory changes in the mucosa. As the dyes used methylene blue, congo red, indigokarmina, Lugol’s solution, acetic acid

Efficiency vital dyes based on contrast, biological, chemical and fluorescent effects on tissue. Thanks contrast enhanced relief of mucous membrane when applied to him dye (methylene blue, indigokarmina, Evans blue). Biological effects of mean dye penetration through the cell membrane into the cytoplasm and staining in vitro (methylene blue). Dye (Congo red, neutral red, Lugol’s solution) may enter into a chemical reaction with the environment of the epithelial cells and the secret that has the appropriate pH, from which we can conclude the functional state of organs.

 

Direct chromoendoscopy

The dye is applied to the surface of immediately before endoscopy through a catheter or endoscope channel tool. Spray dye can be precisely or totally, with the possible diagnostic errors due to the fact that not only stained fabric body, but also a number of other structures (fibrin, mucus). Avoid these mistakes helps meticulous preparation before applying the dye (mechanical cleaning, dissolving and removing mucus neutralization environment, etc.).

 

Indirect chromoendoscopy

Indirect methods are based on hromoskopiyi dye into the lumen of the organ studied before endoscopy: the patient can drink solution or dye is injected through a tube. As with direct hromoskopiyi required preconditioning mucosa.

 

 

 

 

 

 

 

The rear wall of the cardiac esophagus. It can be seen tongues cylindrical epithelium on the background plane up to 2 cm

chromoendoscopy methylene blue: clearly relief areas metaplasia

The right wall of the gastric cardia (without chromoendoscopy)

The right wall of the gastric cardia (chromoendoscopy methylene blue)

 

Auto fluorescence endoscopy

Fluorescent substances submucosa auto fluorescence rays emitted in contact with them the exciting blue light. Iormal, healthy parts of auto fluorescence stronger compared to plots affected by the tumor. This is because the thickening of the mucous layer and the increased number of blood vessels caused by pathological changes hinder the passage auto fluorescence’s rays. This phenomenon is observed not only in the case of malignant impressions, but with early cancer and precancerous conditions. Auto fluorescence system makes capture and viewing auto fluorescence image using a color CCD, which is in Video endoscopes. Blue exciting laser light passes through fiber Video endoscopes. A special filter that is located before color CCD, cuts exciting light, allowing capture only auto fluorescence. This makes it possible to obtain an image which has the difference in level betweeormal auto fluorescence, healthy and areas of pathology.

To ensure the full screen image is used video endoskopich a color CCD that allows you to browse through video endoscopes auto fluorescence image without losing high resolution. By means of the buttons on the endoscope can choose from 3 modes of image:

– Ordinary endoscopic image;

auto fluorescence image;

roadblock and endoscopic images in auto fluorescence

   two modes:

TWIN – 2 pictures on one screen, MIX – the combination of conventional and

  fluorescence. The system can also provide fluorescence pseudo color pictures that match the intensity of fluorescence, allowing the doctor to visual information, greatly facilitating the examination.

 

Normal image (tracheal bifurcation)

 

Auto fluorescence image

 

Virtual chromohrafy (Narrow Band Imaging (NBI)

 

Narrow Band Imaging (NBI) – This technology allows for exercise” the blood vessels and other tissue structures without causing dyes. The principle of virtual hromohrafiyi based on preferred pohlnanni light of a certain wavelength hemoglobin. Thus, in light of the mucous membrane of the gastrointestinal tract narrow spectral beam (mainly blue-green range) light actively absorbed by blood vessels and to a much lesser extent – areas devoid of them. As a result, the possibility of contrasting selection appears capillaries and other structures. At the inspection mode narrowband illumination capillaries of the lamina propria with brown color and veins submucosal layer – blue. Application mode NBI in the study of the upper gastrointestinal tract helps to identify foci of intestinal metaplasia and picture identification, characteristic of esophageal-gastric junction, which is a valuable diagnostic method for CLE metaplasia. Assessment of microvascular pattern makes it possible to identify areas with a high degree of dysplasia and malignant impression detect at an early stage, including carcinoma in situ.

    Endoscopy with increasing                             Endoscopy NBI