John had been popping antacids as long as he could remember. After he ate Mexican food, pizza, or other spicy food, he always had to belch a lot. He had an acid feeling in the back of his throat. It was really worse after dinner as he was lying in his easy chair to watch television. Sometimes in the middle of the night he would wake up with the same feeling. He had to clear his throat a lot and woke up with bad breath. John told his physician about this issue at his last physical and his provider prescribed a proton-pump inhibitor to turn off the “acid pump.” Three months later, it wasn’t getting any better and he called his doctor again. John’s physician scheduled him for an upper endoscopy-esophagogastroduodenoscopy (EGD) in the free-standing ambulatory center. A nurse from the center called him the next day to explain what would be going on. John would need someone to drive him home as he would receive conscious sedation for the procedure. His procedure was scheduled for a week from Thursday at 10 AM. John should only drink clear liquids after midnight and take any morning pills with a sip of water before 8 AM and then nothing else to eat or drink.

GI disorders have been a source of human misery since ancient times. Hippocrates (460 BC-370 BC) described clinical symptoms of dysentery, intestinal obstruction, and liver disease, and one of the earliest physiologists, Galan, studied digestion during the second century AD. Americans have long been involved in the study of GI diseases: Frontier physician William Beaumont (1785-1853), has been credited as the father of both American physiology and gastroenterology.¹ However, these early investigators had only symptoms or surgery to rely on for diagnostic aids.

In 1795, Bozzini documented the use of a rigid sigmoidoscope. More than a hundred years later, Kussmaul visualized the stomach with a rigid gastroscope. Rudolph Schindler designed the first semiflexible instrument in 1932. In 1958, a new gastroscope — the fiberscope — revolutionized gastroenterology by producing high-quality images and introducing simplicity and ease of use to these techniques.²

During the last 40 years, tremendous advances in fiberoptic technology allowed the development of more versatile instruments that made it possible for healthcare providers to make accurate diagnoses of stomach and colon disease without surgery.³ Videoscopes are now in widespread use, which allows the nurse to more easily assist the physician during a procedure. However, both diagnosticians and their patients depend on nurses to prepare patients properly and to guide them safely through these procedures.

The scope of the procedure

Endoscopes allow healthcare providers to visualize parts of the GI anatomy; the visualized images can be simultaneously transmitted to a video display for teaching or recording. An upper endoscopy is sometimes referred to as an esophagogastroduodenoscopy (EGD) and a lower endoscopy is called a colonoscopy.

Endoscopes are either rigid or flexible. A rigid endoscope is a straight, narrow viewing tube, which is about 25 cm in length; its light source is usually fiberoptic. A typical flexible fiberoptic sigmoidoscope is 60 cm long and used for examining the rectum and sigmoid and descending colon. Common parts of all endoscopes include an optic system for light transmission and an image, an umbilical cord, control head, and flexible insertion tube. The control head is for maneuvering up, down, left, and right and contains valves that regulate air, water, and suction. The insertion tube has channels for air, water flow, and suction/biopsy. The suction/biopsy channel allows the passage of accessories, such as biopsy forceps or cytology brushes.³

It is now more than 20 years since “chip in the tip” video endoscopy was first introduced for GI procedures, but the technological advances made since that time, especially in the miniaturization of electronics and increase in processing power, have resulted in system performance and functionality that could only be dreamed of in 1983.

Esophagogastroduodenoscopy — from the top down

An EGD or “gastroscope” provides direct visualization of the esophagus, stomach, and proximal duodenum. This procedure allows for the diagnosis, treatment, and documentation of abnormalities through the use of biopsy, brush cytology, polypectomy, electrocautery, laser therapy, thermal coagulation, and photography. The provider can also treat esophageal varices through banding or sclerosis, remove foreign bodies, and insert esophageal prostheses, either metal or plastic stents that support and open the esophagus.⁴

Preparation: The patient is usually advised to take nothing by mouth two to four hours prior to an EGD. Before the procedure, complete an initial assessment, including vital signs, allergies, current medications, current medical problems, and the reason for the procedure. Notify the physician of any abnormalities in the patient assessment or laboratory test results. Explain the procedure to the patient. Ensure that informed consent has been obtained and that there is a responsible adult to drive the patient home after the procedure, if sedation is to be used. Review the discharge instructions with the patient and family/significant other before the procedure. The document should be signed and dated and timed by the nurse, patient, and family member or significant other. Explain that additional instructions based on the findings of the procedure may be added. Start an IV per physician’s order. Remove dentures and partial plates before the procedure. Some physicians will order a topical anesthetic to be sprayed in the back of the throat to suppress the gag reflex and lessen the discomfort of the scope passage.

Procedure: Have the patient lie on his left side and insert a plastic mouthpiece to relax the jaw and protect the endoscope. Assure her or him that the mouthpiece and scope won’t interfere with normal breathing through the nose and mouth. The nursing priority during the procedure is to monitor the patient including vital signs, skin color, and level of consciousness. The nurse or assistant should also maintain the patient’s airway by positioning the head and suctioning any oral secretions. Lubricate the distal end of the instrument before insertion. As the physician advances the endoscope, air is introduced to improve visibility to the GI tract. Most of the air will be removed via the endoscope during the procedure.⁵

Postprocedural care: Monitor and document vital signs as required by institutional policy. Observe the patient for abdominal distention, vomiting, or signs of GI bleeding. Also, note any chest pain, palpitations, severe heartburn, or difficulty breathing. Do not allow the patient to have anything by mouth until the gag reflex returns and then note any difficulty in swallowing. Palpate the abdomen and evaluate bowel sounds. Complications can include pulmonary aspiration and gastric or esophageal perforation and/or hemorrhage. Remove the intravenous line prior to discharge and provide the patient/family with written discharge instructions for follow-up care.⁶

Colonoscopy

A colonoscopy is an endoscopic examination of the colon from the rectum to the ileocecal valve, where the colon attaches to the terminal ileum, the end of the small bowel. The bowel wall is observed for abnormalities such as bleeding sites, AVMs (arteriovenous malformations), diverticulum, polyps, inflammation, or tumors during the insertion and withdrawal of the colonoscope. Direct visualization allows for biopsies, cytology, excision of polyps, dilatation, fulguration of bleeding sites, and photographs.⁶ The possibility of performing a biopsy or removing an abnormality gives colonoscopy an important advantage over radiological examinations of the colon.

Even in the absence of suggestive symptoms, lower endoscopies have become important in detecting early disease. In 1997, The National Polyp Study reported reductions in colorectal cancer mortality could be achieved through detection and treatment of early-stage cancers and the identification and removal of adenomatous polyps, the precursor to cancer.⁷ The American Cancer Society recommends that beginning at the age of 50, average risk individuals should have a colorectal cancer screening by one of three methods:⁸ a standard colonoscopy every 10 years for normal results, fecal occult blood test every year and flexible sigmoidoscopy every five years for normal results, or double-contrast barium enema every five to ten years for normal results. Colonoscopy is the gold standard and examines the entire colon. Sigmoidoscopy involves examination of the lower 10 inches to 12 inches of the large intestines and rectum. Virtual colonoscopy is a new diagnostic method that is gaining popularity for colorectal cancer screening. This is an abdominal CT scan with air contrast.⁹

Preparation: Depending on patient needs, different preparations are used to cleanse the bowel. Many physicians have their own protocols and the patient should follow them exactly. Strict compliance is important since cancellation of the procedure is frequently due to inadequate bowel preparation.

One prep requires the patient to drink four to six liters of an electrolyte and salt lavage solution, such as Colyte or Golytely, beginning the day before the procedure. If nausea, vomiting, or hypothermia occurs during and after this type of preparation, the patient should be instructed to notify his physician immediately.¹⁰ Another approach uses a sodium biphosphate oral laxative (Fleet’s Phospho-Soda) the evening before and again on the morning of the procedure. This is also available in an oral pill form, OsmoPre and Visaco.¹¹ Magnesium citrate solution by mouth, followed by a bisacodyl (Dulcolax) suppository, may be used as a preparation for selected patients. Providers prescribe preps based on the patient’s history, chief complaint, present and previous illness, and family history. Generally, all of these protocols allow for a clear liquid diet the day before.

Instruct the patient to take nothing by mouth, including clear liquids, two to four hours before the procedure. Because prep solutions have a salty taste, they’re more palatable chilled. But don’t dilute them beyond what’s ordered. If the large volume electrolyte and salt lavage solution is ordered, advise the patient to drink the solution rapidly — eight ounces (240 ml) every 15 minutes — until a gallon has been consumed. It is better to rest from drinking between glasses, rather than continuously swallowing small amounts. Drinking the solution slowly won’t clean out the colon as efficiently.

Watery diarrhea usually begins 30 to 60 minutes after the first glass, and the GI tract empties within four hours. Enemas, such as Fleet’s, are still used, although many physicians only prescribe powerful oral preparations. After the GI tract has been cleared, the nurse can help ease the patient’s anxiety by telling him the most difficult part is over.

Lab studies may be indicated before the procedure, especially for patients expected to undergo biopsy, polypectomy, or electrocautery resection of lesions where bleeding may be a problem. Tests may include hemoglobin, hematocrit, INR, prothrombin time, partial thromboplastin time, and platelet count.¹¹

Colonoscopy can be safely performed on an outpatient basis without general or local anesthesia. However, conscious sedation is usually necessary because of the length and discomfort of the procedure. A patient’s biggest fear is often that the procedure will be painful, but you can provide assurance that an intravenous (IV) sedative will minimize any discomfort and produce a measure of amnesia.

Common agents include narcotic analgesics such as meperidine hydrochloride (Demerol and Fentanyl) with the addition of a benzodiazepine such as midazolam hydrochloride (Versed), or diazepam (Valium), administered through an IV access line. The object of sedation is to relax patients, not knock them out, because cooperation may be needed to turn from one side to the other or on the back to facilitate the movement of the colonoscope. It is also safer to sedate patients at a moderate sedation level where they maintain their protective reflexes.

Position the patient on the left side with knees flexed and head resting on a small pillow. Place a pad under the buttocks. The physician will perform a digital exam. This serves to check for distal masses, dilates the opening, and assesses the distal colon preparation. The distal end of the instrument will then be lubricated and the physician will insert the scope into the rectum and advance it slowly. Once the instrument has been advanced to the desired level, it is removed slowly as the physician meticulously examines the colon on the way out.¹²

Sometimes, the physician will ask for assistance to apply pressure on the abdomen to prevent the flexible scope from forming loops as it passes through the sigmoid colon; this maneuver is also effective in guiding the instrument through the proximal transverse colon. Initially and throughout the procedure, large amounts of lubricating jelly are applied to the anus to reduce friction and prevent trauma at the anal canal, and facilitate advancement of the endoscope. The nurse must monitor the patient throughout the procedure, noting vital signs, skin color and warmth, distention, pain tolerance, and level of consciousness. Other tasks may include repositioning the patient during the procedure and the application of abdominal pressure. Reassurance and emotional support throughout the procedure will also help ensure the patient’s cooperation.¹³

A nurse may also be responsible for the administration of IV fluids and medications depending on the customary practice of the diagnosing physician and the protocols of the facility. Oxygen therapy should be available and is recommended if the patient’s oxygen saturation drops below 90%.

Post-Procedural Care: Monitoring of the patient post-colonoscopy is similar to care provided after gastroscopy. Encourage the patient to pass flatus to relieve abdominal pressure from the insufflation of air during the procedure. Additionally, observe for bloody or tarry stools; vomiting or prolonged heaving; progressive, severe or colicky pain that persists without improvement; and side effects of any medications that have been administered. Also, note any chest pain, palpitations, severe heartburn, or difficulty breathing; fluid shifts, dehydration, or congestive heart failure can occur in association with the prep or the procedure. Complications can include perforation and/or hemorrhage of the colon.

John’s EGD only lasts 10 minutes. He had evidence of long-term gastric reflux in the esophagus. Esophageal tissue is composed of squamous tissue and exposure to acid leads to the growth of columnar tissue (as in the stomach) in the esophagus. This is called Barrett’s Esophagus. John will need to have surveillance with EGD and biopsy on a frequent basis to ensure there is no growth of dysplasia from the change in tissue from squamous to columnar epithelium. He will need to continue to take a proton-pump inhibitor and make some lifestyle changes. Losing any extra weight, not eating or drinking two to four hours before lying down, avoiding foods that increase acid reflux, and elevating the head of his bed will minimize the reflux.

Because John had received sedation, his wife drove him home. The nurse gave them both written and oral instructions that listed normal aftereffects from the procedures as well as signs, such as abnormal pain, visible bleeding, prolonged nausea or vomiting, severe abdominal bloating or tenderness, or high fever that he should report to his physician. Also included were instructions not to drive, drink any alcohol, operate heavy machinery, or make important legal decisions until the next day when the sedation has worn off.