Basic operation of gastroscopy

Gastroscopy is a necessary skill for gastroenterologists and plays an important role in the diagnosis and treatment of digestive diseases. This article is a collection of some operation materials when learning gastroscopy. It is summarized as follows. I hope everyone will criticize and correct.
1. Preparation
Patient: Gastroscopy has some discomfort, and patients often have fear (except painless gastroscopy). Before the examination, it is necessary to eliminate the patient's nervousness and make the patient actively cooperate. The patient generally takes the left side lying position, bends the knees, tilts the head back (makes the throat and esophagus in a straight line), gently bites the dental pad, and asks the patient to let the saliva flow naturally without swallowing.

Doctor: Before entering the scope, first make sure that you are in a suitable position between the patient and the monitor, so that it is convenient for operation and observation. Then move the size knob to check whether the fixed valve, air/water supply device, and suction device are normal, and finally adjust the white balance.

2. Enter the scope

Hold the scope body at 20 cm with the right hand, hold the operating handle with the left hand and place it on the left chest, and move the size knob to see the movement direction of the front end of the gastroscope. When inserting the scope, place the front end of the scope body close to the patient's tongue surface. After seeing the midline of the tongue, adjust the tongue surface image to the top of the monitor and insert the scope. The glottis can be seen when it is about 15 cm away from the incisors.

First observe the piriform recess on both sides, and generally choose the left piriform recess as the direction of insertion. At this time, turn the operating handle to the right with your left hand (clockwise) and push the big button up, and gently push the scope body with your right hand. If you encounter resistance during the forward push, you can push forward while rotating the scope body or ask the patient to swallow. There will be a sense of emptiness when entering the esophagus. If you see straight blood vessels and light red mucosa (orange-red gastric mucosa) in the field of view, you can confirm that you have entered the esophagus.

If you see irregular reticular capillaries in the field of view, then the scope body is likely to be in the piriform recess or esophageal diverticulum, and you need to withdraw the scope and re-enter it; if you see a pale or grayish-white ring structure in the field of view, then the scope body must have entered the trachea, and you must withdraw the scope immediately.

After entering the esophagus, the endoscope can be "inserted through the cavity", and appropriate air can be injected to observe whether there are lesions such as stenosis and inflammation in the esophagus, and collect pictures. When the endoscope reaches the dentate line, air is injected, and the patient is asked to "take a deep breath". When the dentate line is clear, images are collected and the range of the dentate line is observed.

Continue to advance the endoscope into the stomach. When entering the stomach, the lens will be orange-red because it is close to the gastric mucosa. A small amount of air needs to be injected to slightly open the gastric body. At this time, gastric mucosal folds and mucus lakes can be seen (if there is a lot of mucus lake, it can be sucked). Then push the big button up and press the small button down to "insert the endoscope through the cavity" along the lesser curvature of the upper gastric body, or rotate the operating handle to the left and push the big button up while raising the right hand.

If a black endoscope body is seen when passing through the gastric body, it means that the gastroscope has reversed at the fundus of the stomach. At this time, the endoscope can be withdrawn to the bottom of the cardia to adjust the direction before entering. Take pictures in time when you see gastric lesions.

When the endoscope is advanced through the cavity of the gastric body, you will see an arched structure, which is the gastric angle, which is the dividing line between the gastric body and the gastric antrum.

When the front end of the endoscope is at the junction of the gastric body and the gastric antrum, press the big button with your left hand and slowly push forward with your right hand. At this time, the endoscope will turn over, and you can see the gastric angle and the black endoscope body. Observe the gastric angle and take pictures.

Withdraw the endoscope backwards, inject air while withdrawing the endoscope, expand the gastric mucosa, pull the front end of the gastroscope along the lesser curvature of the gastric body to the gastric fundus, rotate the operating handle with your left hand to observe the gastric fundus, mucus lake and cardia, and suck when there is a lot of mucus. If the field of vision is unclear, you can inject water to flush.

After taking pictures of the gastric fundus, slowly release the big button and continue to advance the endoscope. Through the gastric angle, you can see the flat gastric antral mucosa and pylorus. There are peristaltic waves in the gastric antrum, which will affect the observation and photography of the gastric antrum. After the peristaltic waves pass, you can inject air to expand the gastric antrum for observation and photography.

Due to individual differences, different stomach shapes will affect the entry from the gastric antrum into the duodenum. At this time, you need to constantly adjust the knob and the endoscope body to aim at the pyloric opening to advance the endoscope. There will also be a more obvious sense of failure when passing through the pylorus. If you see the villous mucosa, it means that the front end of the gastroscope has entered the duodenal bulb. Observe whether there are any lesions in the duodenal bulb and take photos. Continue to move the endoscope forward. Before entering the descending part of the duodenum, you will see a crescent-shaped structure - the superior angle of the duodenum, which is the dividing line between the bulb and the descending part.

It is difficult to enter the descending part from the bulb. When the right side of the superior angle of the duodenum is about to disappear, fully rotate the endoscope to the right (hold the operating handle with your left hand and rotate it to the right, be sure to fully), slowly press the big button to the bottom and hold it, and move the endoscope. If you see the intestinal mucosa with circular folds, it means that you have entered the descending part of the duodenum.

After observing and taking photos, you can withdraw the endoscope.

Beginners who learn gastroscopy always have a certain sense of winning and losing, thinking that they must do a good job and complete a gastroscopy. Once they fail, they will attribute the reason to their poor skills and become depressed. In fact, even skilled gastroscopy doctors can do poorly sometimes. Patients vary greatly from person to person, and no one can guarantee that every gastroscopy will be completed smoothly. I once heard that a gastroscopy teacher limited the operation time of gastroscopy to 30 minutes. If the operation is not completed after the time limit, the endoscope will be withdrawn. Learning to give up at the right time is a wiser choice.