Endoscopy ranks as one of the most

important technical advances in

medicine of the last few decades. Not
only has it added a new precision to
gastrointestinal and pancreaticobiliary
diagnosis, particularly when used in
conjunction with cytology or biopsy, but
it has also been one of the earliest
tools, along with interventional
radiological techniques, in the
advances of minimally invasive therapy.
There are two types of endoscopy

Rigid Flexible
-Proctoscope
-Esofagogastroscopy
-Sigmoidoscope
-Duodenoscopy
-Thoracoscopy
-Colonoscopy
-Cystoscope
-Sigmoscopy
-Laparoscopy
-Bronchscopy
-Athroscopy
The modern flexible endoscope has
the following features:
Light source – in the handle with a fibreoptic bundle for
the transmission of light to the area under investigation.
Viewing system – Photons impacting on this are
converted into a digital video signal which can then be
viewed on a screen. The video image can easily be
stored for use in teaching and can be enhanced by
electronic processing.
Control and manipulative elements which are still
mechanical and allow the tip to be defected and
instruments such as snares, stents, biopsy forceps,
balloons and baskets to be passed along a working
channel.
Preparing patient for examination
The patient must have an empty stomach; nothing
by mouth for 6 h beforehand is usually sufficient.
Pharyngeal anesthesia to blunt the gag reflex is
achieved with benzocaine or lidocaine.
The patient is also given intravenous sedation and
is monitored during the procedure with blood
pressure determinations, pulse oximetry and
electrocardiography.
 Procedure:
Most endoscopists place the patient on his or her
left side.
Doctor hold the instrument in the left hand and
alternately manipulate the scope controls and
shaft with the right hand.
After placing a bite block between the patient’s
teeth, the endoscope is inserted into his or her
mouth.
The tongue is followed down to its base where the
upper larynx can be seen.
 Procedure:
The oesophagus is best entered under
vision.
The scope is guided posterior to the
arytenoid cartilages, where the view
becomes obscured by the contracted
cricopharyngeus muscle.
While maintaining gentle pressure against
the muscle with the scope, the patient is
asked to swallow.
 Procedure:
This maneuver allows ready passage of the
instrument into the upper esophagus.
If not, one should back up into the posterior
pharynx, suction out any saliva with the scope,
and try once more after the patient catches his
breath.
Keeping the gut lumen in the center of the field
of view the operator advances the scope distally
with deflection of the tip and twisting of the shaft
as necessary.
 INDICATIONS.
Diagnostic esophagogastroduodenoscopy
is especially valuable for evaluating upper
gastrointestinal tumors, strictures, ulcers,
varices, and mucosal changes such as
esophagitis and gastritis. It is less useful
for judging functional or motility disorders
or extraluminal lesions.
 The major indications for diagnostic
upper gastrointestinal endoscopy are:
(1) persistent upper abdominal pain or distress,
especially if it is associated with symptoms or signs
suggestive of serious disease (anorexia, weight loss,
anemia);
(2)persistent symptoms of gastro-esophageal reflux
despite treatment;
(3)swallowing difficulties;
(4)persistent vomiting of unknown cause;
(5)surveillance for upper gastrointestinal malignancy in
high-risk patients;
(6)evaluation of upper gastrointestinal bleeding of
unexplained iron deficiency anemia;
(7)evaluation of ulcers, strictures, and tumors found by a
barium meal examination
 Indications for therapeutic
esophagogastroduodenoscopy are:
(1)cauterization of injection of bleeding peptic
ulcers (and occasionally vascular
malformations);
(2)injection sclerosis of esophageal varices that
have bled;
(3)removal of foreign bodies or bezoars;
(4)removal of gastric polyps;
(5)dilatation of esophageal strictures;
(6)palliative treatment of malignant upper
gastrointestinal obstruction by dilatation, laser
fulguration, or intubation;
(7)placement of gastrostomy tubes.
 Contraindications to
esophagogastroduodenoscopy
Endoscope should be avoided if there is a
possibility of a perforated viscus. If the stomach
is not empty, little useful inspection is possible,
and the risk of vomiting and aspiration
pneumonia is great. A poor airway
contraindicates upper gastrointestinal
endoscopy. Respiratory arrest may result if there
is a marginal passage (for example, pharyngeal
tumor) combined with intravenous sedation, as
well as partial occlusion and edema induced by
the endoscope. Endoscope surgery should not
be carried out if the patient is anticoagulated or
has a coagulopathy.
 Complications
Complications due to diagnostic
esophagogastroduodenoscopy are uncommon.
Aspiration pneumonia may occur because of the
combination of pharyngeal anaesthesia and
instrumentation, especially in obtunded patients,
or if there is active upper gastrointestinal
bleeding. Although adverse cardiorespiratory
events are rare, they may occur if the patient is
frail or if sedation is excessive. Perforation and
bleeding are infrequent unless endoscopic
surgery is done. As is the case for colonoscopy,
drug reactions, vasovagal reflex, bacteraemia,
and superficial phlebitis are other less serious
potential problems.
Erosion of stomach
Ulcers of stomach
Ulcers of cardiac part of stomach
Bleeding
Tumor of stomach
Varices of esophagus.
 Laparoscopy
The peritoneal cavity of a dog was examined
in 1902 by Kelling, using air insufflation and
the insertion of a cystoscope through the
abdominal wall. The first clinical use was
described in 1912 by Jacobaeus, although it
was a further decade before a purpose-built
scope was in use by Kalk (1929) and the era
of modern-day laparoscopy (peritoneoscopy)
began.
 PROCEDURE (DIAGNOSTIC
LAPAROSCOPY)
The patient is positioned supine on the operating
table. A general anaesthetic with muscle relaxation
is usually preferred, but it is possible to use local
anaesthetic and sedation with intravenous
benzodiazepines. The Verres needle is introduced
via a stab incision. This is usually subumbilical in
position, but the presence of scars may influence the
precise location. The needle contains a spring-
loaded blunt probe, and compression of the spring
against the skin retracts the probe to expose the
needle. Damage to intra-abdominal viscera can be
minimized by holding up the anterior abdominal wall
with one hand while inserting the needle with the
other
 PROCEDURE (DIAGNOSTIC
LAPAROSCOPY)
When the needle has passed through the abdominal wall the
resistance falls and the spring pushes forwards the probe
covering the needle. Free flow of normal saline solution
through the needle confirms that the linea alba and
peritoneum have been punctured. The abdomen is then
insufflated with carbon dioxide, using approximately 2 to 3
litres for an adult. During insufflation, the intra-abdominal
pressure should not exceed 15 mmHg. The Verres needle is
then withdrawn and the incision is enlarged to accommodate
the laparoscope trocar, which is pushed down and back into
the pelvis. The end- or side-view telescope is then inserted
and laparoscopy commenced. Biopsy forceps and a
palpating probe can be used in other, suitably placed stab
incisions through the anterior abdominal wall. This allows the
peritoneal contents to be inspected. Throughout the
procedure, carbon dioxide is continually insufflated at low
pressure.
 CONTRAINDICATIONS
There are few absolute contraindications to the
procedure, but certain conditions should alert the
surgeon to potential problems. Multiple scars make
introduction of the scope hazardous, and adhesions
from repeated abdominal procedures may hinder
the view within the peritoneum. Abdominal wall
sepsis may introduce intraperitoneal infection. The
procedure is not tolerated well in patients with
severe pulmonary or cardiac problems, due to the
intra-abdominal distension. Bleeding diatheses may
result in body wall or intraperitoneal bleeding.
 COMPLICATIONS
To minimize complications, laparoscopy is a
procedure best performed by surgeons experienced in
the technique, in an operating theatre equipped with
the facilities to proceed to a laparotomy if necessary.
Minor complications include abdominal wall bruising,
subcutaneous emphysema, the development of a
wound infection/hernia, and postoperative shoulder
pain. Other complications are related to accidental
visceral damage and bleeding from vessel injury.
These problems should be noted at the time of
laparoscopy and dealt with by prompt laparotomy if
necessary. Mortality rates of 0.03 to 0.1 per cent are
reported.
 INDICATIONS
In patients with localized peritonism, diagnostic
laparoscopy is most commonly used in the
management of patients with acute right iliac fossa
pain. With the aid of a palpating probe inserted
through the anterior abdominal wall of the right iliac
fossa, the surrounding ileum and omentum may be
manipulated away in order to see the appendix. In the
case of a retrocaecal or retroileal appendix, it may be
impossible to visualize the target organ, but other
signs of acute inflammation may be noted.
Alternatively, other causes of right iliac fossa pain may
be apparent, and, if these require surgery, an
appropriate incision can be made.
 INDICATIONS
The role of diagnostic laparoscopy in the
management of the patient with abdominal trauma
is in conjunction with imaging techniques (CT and
ultrasound scanning) and peritoneal lavage. The
relative importance of each is not established
clearly, although aggressive use of laparoscopy in
this clinical situation may reduce the number of
unnecessary laparotomies performed for minimal or
moderate haemoperitoneum. The procedure can be
performed in the accident and emergency
department under local anaesthesia with
intravenous sedation.
Inflammation of appendix
Uterus with myomas node
Abdominal pregnancy
Inflammation of ovary (ovaritis)
Inflammation of gallbladder
Metastasis of stomach cancer