Upper Gastrointestinal Endoscopy

General Information About Gastrointestinal Carcinoid Tumors

Newly found organ may lead to 'dramatic medical advances'
Fact checked by Jasmin Collier. A test solid-food meal containing a technetium isotopic tracer is ingested, and scintography is used to quantitatively measure the rate of gastric emptying. A total of 17 patients with GERD were managed in a standardized manner consisting of pre-operative assessment with symptom scoring, endoscopy, hour pH studies, and manometry. G astrointestinal GI disorders are common among all people, including those affected by diabetes. Pitt et al noted that the EndoFLIP can be used to evaluate dimensions and distensibility of the upper and lower esophageal sphincter.

Digestive System Anatomy

What Is a Gastrointestinal Carcinoid Tumor?

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Nutritional Issues in HIV. Side Effects of Antiretroviral Drugs. Interactions of Antiretroviral Drugs. Antiretroviral Treatment Monitoring in Developing Countries. Substance Abuse and HIV. Community-Based Care in the Developing World. Group 1 -- findings that did not significantly change management e. A general estimating equation GEE model accounting for the correlated data within each study was used to calculate confidence intervals Cis around the estimate of how frequently surgery was delayed or altered.

Mean age was The revised estimate was The approximate incidence of BE and carcinoma were 0. The authors concluded that a selective approach to pre-operative EGD may be considered, based on the patients' symptoms, risk factors, and type of procedure planned.

According to Michigan Health Lab, endoluminal functional lumen imaging probe EndoFLIP; Crospon Ltd, Galway, Ireland is a new, minimally invasive device created to complement traditional diagnostic tests, such as high resolution esophageal manometry and barium esophagram.

EndoFLIP uses a balloon mounted on a thin catheter placed trans-orally at the time of a sedated endoscopy. In comparison to the traditional diagnostic tests, EndoFLIP offers the additional capability of measuring the cross-sectional area CSA and intra-luminal pressure of the esophagus while under distension as if a solid bolus was present.

The technology uses impedance planimetry to estimate CSA. Familiari et al noted that per-oral endoscopic myotomy POEM has been recently introduced in clinical practice for the treatment of achalasia. During follow-up, patients underwent esophagogastroduodenoscopy, esophageal pH monitoring and manometry. A total of 23 patients 12 men, mean age of Pre-operative mean basal lower esophageal sphincter pressure was No complications occurred during a mean follow-up of 5 months.

Median post-operative Eckardt score was 1; 3 patients Follow-up studies revealed GERD in The authors stated that additional studies with follow-up are needed to evaluate the true utility of this system during POEM. Malik et al stated that pyloric dysfunction has been associated with gastroparesis, especially diabetic gastroparesis. EndoFLIP uses 16 sensors inside a balloon that is inflated inside a sphincter to evaluate physiologic characteristics.

In addition, the relationship between pyloric pathophysiology with gastroparesis etiology, symptoms, and gastric emptying was assessed. EndoFLIP was performed in 54 patients 39 idiopathic gastroparesis, 15 diabetic gastroparesis. Pressure, diameter, CSA, and distensibility of the pylorus were measured at 20, 30, 40, and 50 cc balloon volume.

Pyloric sphincter contour was seen best at 40 cc balloon distension diameter There was a wide range seen in diameter 5. Symptoms of early satiety and post-prandial fullness were inversely correlated with pyloric sphincter diameter and CSA.

No significant difference was seen between diabetic and idiopathic gastroparetics. The authors concluded that EndoFLIP is a novel technique that can be used to assess pyloric physiologic characteristics.

Early satiety and post-prandial fullness were inversely correlated with diameter and CSA of the pyloric sphincter. No significant differences were seen comparing diabetic and idiopathic gastroparetics. They stated that this technology may be of benefit to help select patients with pyloric sphincter abnormalities. In a subgroup of 25 patients, EndoFLIP measurement was repeated both post-operative and at 6 months follow-up.

Treatment outcome was assessed according to esophageal acid exposure time AET; objective outcome and symptom scores clinical outcome 6 months after TIF. Multiple logistic regression analysis showed that pre-operative EGJ distensibility odds ratio [OR], 0. The best cut-off value for objective outcome was 2. The authors concluded that pre-operative EGJ distensibility and pre-operative AET were independent predictors for objective treatment outcome but not for clinical outcome after TIF.

They stated that according to these findings, the EndoFLIP technique has no added value either in the pre-operative diagnostic work-up or in the post-procedure evaluation of endoluminal anti-reflux therapy. Pitt et al noted that the EndoFLIP can be used to evaluate dimensions and distensibility of the upper and lower esophageal sphincter. The null hypotheses for this study were that EndoFLIP variables would be stable between anesthetic episodes and would not be affected by body position when evaluating the upper and lower esophageal sphincters in healthy dogs.

During each of 3 consecutive general anesthesia episodes administered to 8 healthy adult research colony dogs with a standardized protocol, the EndoFLIP catheter was positioned to measure CSA, intra-bag pressure, upper and lower esophageal sphincter length at 2 different balloon fill volumes 30 and 40 ml and 2 body positions lateral and dorsal recumbency.

From these measured variables, a DI was also calculated. Mixed effect analysis of variance was used to evaluate the fixed marginal and interaction effects of anesthesia episode, body position, and balloon volume on measured and calculated variables. For the upper esophageal sphincter significant interactions were present between anesthetic episode and body position for all variables except intra-bag pressure; adjusting for body position significant differences were present between anesthetic episodes for all variables except DI; adjusting for anesthetic episode CSA, intra-bag pressure, upper esophageal sphincter length and DI were all affected by body position.

For the lower esophageal sphincter DI was the only variable where a significant interaction between anesthesia episode and body position occurred; CSA, intra-bag pressure, and lower esophageal length were not significantly affected by anesthesia episode when adjusting for body position; DI was the only variable significantly affected by body position.

Measurements of the geometry of the lower esophageal sphincter as measured by the EndoFLIP device were consistent under conditions of general anesthesia. Similar measurements taken at the upper esophageal sphincter displayed greater variability between anesthetic episodes and were affected to a greater extent by body position.

The authors concluded that body position should be standardized in studies using the EndoFLIP to assess geometric and functional characteristics of the upper and lower esophageal sphincters.

Ata-Lawenko and Lee stated that gastro-intestinal sphincters play a vital role in gut function and motility by separating the gut into functional segments. Traditionally, function of sphincters including the EGJ is studied using endoscopy and manometry.

However, due to its dynamic biomechanical properties, data on distensibility and compliance may provide a more accurate representation of the sphincter function. The EndoFLIP system can provide data on tissue distensibility and geometric changes in the sphincter as measured through resistance to volumetric distention with real-time images. It may be utilized as a tool in predicting effectiveness of endoscopic and surgical treatments as well as patient outcomes.

Pharyngo-esophageal junction PEJ stricturing is an important contributor. PEJ stricture was defined as the presence of a mucosal tear post-dilation. They stated that EndoFLIP may complement conventional diagnostic tools in the detection of pharyngeal outflow obstruction.

Clinical Policy Bulletin Notes. Links to various non-Aetna sites are provided for your convenience only. Persons with symptomatic pernicious anemia e.

Evaluation of upper abdominal symptoms associated with other symptoms or signs suggesting serious organic disease e. Evaluation of esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy. Evaluation of persons with signs or symptoms of loco-regional recurrence after resection of esophageal cancer. Evaluation of other diseases in which the presence of upper gastro-intestinal GI pathological conditions might modify other planned management e.

Confirmation and specific histological diagnosis of radiologically demonstrated lesions: Surveillance of persons with BE and high-grade dysplasia every 3 months for at least 1 year. Surveillance of recurrence of adenomatous polyps in synchronous and metachronous sites at 3- to 5-year intervals.

Evaluation of symptoms that are considered functional in origin. There are exceptions in which an EGD may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy.

Evaluation of metastatic adenocarcinoma of unknown primary site when the results will not alter management. Routine evaluation of abdominal pain in children i. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy. Uncomplicated duodenal ulcer that has responded to therapy. Surveillance of healed benign disease e. Surveillance during repeated dilations of benign strictures unless there is a change in status. Surveillance of persons with previous aerodigestive squamous cell cancer.

Surveillance of persons following adequate sampling or removal of non-dysplastic gastric polyps. Upper endoscopy is useful in the management of occult and obscure GI bleeding. Upper abdominal symptoms associated with other symptoms or signs suggesting serious organic disease e. Other diseases in which the presence of upper GI pathological conditions might modify other planned management e. For confirmation and specific histological diagnosis of radiologically demonstrated lesions: For presumed chronic blood loss and for IDA when the clinical situation suggests an upper GI source or when colonoscopy results are negative.

Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities e. Placement of feeding or drainage tubes peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy.

Dilation of stenotic lesions e. Palliative treatment of stenosing neoplasms e. Symptoms that are considered functional in origin there are exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy. In patients with Barrett's esophagus without dysplasia, the cost effectiveness of surveillance endoscopy is controversial.

If surveillance is performed, an interval of 3 years is acceptable C. Although an increased cancer risk has not been established in patients with Barrett's esophagus and low-grade dysplasia, endoscopy at 6 months and yearly thereafter should be considered C.

Patients with Barrett's esophagus with confirmed high-grade dysplasia should be considered for surgery or aggressive endoscopic therapy B. Patients with high-grade dysplasia who elect endoscopic surveillance should be followed up closely i. If no further high-grade dysplasia is confirmed, then the interval between follow-ups may be lengthened B. Patients with a severe caustic esophageal injury should undergo surveillance every 1 to 3 years beginning 15 to 20 years after the injury C.

Patients with tylosis should undergo surveillance endoscopy every 1 to 3 years beginning at age 30 years C. There are insufficient data to support routine endoscopic surveillance for patients with previous aerodigestive squamous cell cancer C. Adenomatous gastric polyps should be resected because of the risk for malignant transformation B. Adenomatous polyps may recur in synchronous and metachronous sites, and surveillance endoscopies should be performed at 3- to 5-year intervals C.

Endoscopic surveillance for gastric intestinal metaplasia has not been extensively studied in the U. However, there may be a subgroup of high-risk patients who will benefit from endoscopic surveillance B. Patients with confirmed gastric high-grade dysplasia should be considered for gastrectomy or local resection because of the high incidence of prevalent carcinoma B.

Patients with pernicious anemia may be considered for a single screening endoscopy, particularly if symptomatic, but there are insufficient data to recommend ongoing surveillance C. There are insufficient data to support routine endoscopic surveillance in patients with previous partial gastrectomy for peptic ulcer disease C. Patients with familial adenomatous polyposis should undergo regular surveillance endoscopy using both end-viewing and side-viewing endoscopes, starting around the time of colectomy or after age 30 years B.

Patients with hereditary non-polyposis colorectal cancer have an increased risk of gastric and small-bowel cancer B. Surveillance should be strongly considered C. Ilczyszyn and Botha noted that increased esophago-gastric junction EGJ distensibility has been implicated in the development of gastro-esophageal reflux disease GERD.

Previous investigators have reported a reduction in distensibility following anti-reflux surgery, but the changes during the operation are unclear. These researchers determined the feasibility of measuring intra-operative distensibility changes and examined if this would have potential to modify the operation.

A total of 17 patients with GERD were managed in a standardized manner consisting of pre-operative assessment with symptom scoring, endoscopy, hour pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intra-operative distensibility measurement using an EndoFLIP EF functional luminal imaging probe. This device measures CSA and distensibility within a balloon-tipped catheter. This was inflated at the EGJ to fixed distension volumes.

Post-operatively, patients continued on protocol and were discharged after a 2-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial EGJ distensibility index DI than those without. Two individual cases in the series high-lighted the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0. Laparoscopic Nissen fundoplication resulted in a significant reduction in the distensibility of the EGJ.

The authors concluded that the EndoFLIP system was able to demonstrate significant changes during the operation and may help guide intra-operative modification. Moreover, they stated that larger multi-center studies with long-term follow up are needed to develop a target range of distensibility associated with good outcome. Gourcerol et al noted that anal manometry is the standard technique for evaluating anal sphincter function.

However, EndoFLIP can be used to measure sphincter distensibility during volume-controlled distensions. A ml anal DI was selected for further comparisons as it provided the best discrimination between the FI patients and the healthy subjects. The DI at rest and during voluntary contraction appeared to be more appropriate than anal pressures for discriminating between FI patients and healthy subjects. The authors concluded that the findings of this study confirmed that FI is associated with an abnormally high DI at rest and during voluntary contraction; and the ability of the DI to discriminate between FI patients and healthy subjects was significantly better than anal pressure.

American Gastroenterological Association medical position statement: Evaluation and management of occult and obscure gastrointestinal bleeding. American Society for Gastrointestinal Endoscopy. The role of endoscopy in the assessment and treatment of esophageal cancer.

Gastrointest Endosc ;57 7: Managing dyspepsia in adults in primary care. Evidence-based Clinical Practice Guideline. Newcastle upon Tyne, UK: Accessed August 10, The role of endoscopy in the management of variceal hemorrhage, updated July Gastrointest Endosc ;62 5: Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The role of endoscopy in the patient with lower-GI bleeding. The Merck Manual Online.

Merck Research Laboratories; updated November Accessed August 14, Quality indicators for esophagogastroduodenoscopy. Gastrointest Endosc ;63 4 Suppl: Endoscopy in the diagnosis and treatment of inflammatory bowel disease.

The role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Differentiating ulcerative colitis from Crohn disease in children and young adults: J Pediatr Gastroenterol Nutr. The diagnosis of gastroesophageal reflux disease. Review History Review History. Information in the [brackets] below has been added for clarification purposes.

CPT codes covered if selection criteria are met: Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen s by brushing or washing separate procedure. ICD codes covered if selection criteria are met: Malignant neoplasm of pyriform sinus and hypopharynx [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Malignant neoplasm of esophagus, stomach, and small intestine [to identify prevalent lesions]. Malignant neoplasm of larynx and trachea [to identify prevalent lesions].

Vitamin B12 deficiency anemia due to intrinsic factor deficiency [symptomatic e. Gastro-esophageal reflux disease without esophagitis [chronic 5 years or more]. Malignant neoplasm of esophagus, stomach, and small intestine [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Malignant neoplasm of larynx and trachea [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Secondary malignant neoplasm of mediastinum [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Secondary malignant neoplasm of other and unspecified respiratory organs trachea [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Secondary malignant neoplasm of small intestine [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Nodular lymphocyte predominant Hodgkin lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Nodular sclerosis classical Hodgkin lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Mixed cellularity classical Hodgkin lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Lymphocyte-depleted classical Hodgkin lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Lymphocyte-rich classical Hodgkin lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Other classical Hodgkin lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Hodgkin lymphoma, unspecified, involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Follicular lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Small cell B-cell lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Mantle cell lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Diffuse large B-cell lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Lymphoblastic diffuse lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Burkitt lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Other non-follicular lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Non-follicular diffuse lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

Mycosis fungoides involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions]. Sezary disease involving lymph nodes of head, face, neck, intrathoracic and intra-abdominal [confirmation and specific histological diagnosis of radiologically demonstrated lesions].

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