Upper GI Endoscopy (OGD / Gastroscopy)
- Oesophago-Gastro-Duodenoscopy — examines oesophagus, stomach, first and second parts of duodenum
- Standard adult gastroscope: 9–10 mm diameter, ~100 cm working length
- Paediatric gastroscope: 5.9–7.9 mm diameter for neonates and children
- Direct vision to D2; biopsies, haemostasis, stent placement possible
OGD
Gastroscopy
Oesophagoscopy
Lower GI Endoscopy
- Colonoscopy: entire colon from rectum to caecum (terminal ileum if indicated). ~160 cm scope
- Flexible Sigmoidoscopy: rectum and sigmoid colon only (~60 cm scope), minimal bowel prep required
- Proctoscopy: rigid instrument for anorectal examination
- CO2 insufflation preferred over air — less post-procedure bloating, safer in therapeutic cases
ERCP
Endoscopic Retrograde Cholangiopancreatography
- Side-viewing duodenoscope accesses ampulla of Vater (D2)
- Cannulates common bile duct (CBD) and/or pancreatic duct
- Fluoroscopy used intra-procedure for contrast injection and stone/stent visualisation
- Therapeutic: sphincterotomy, stone extraction (basket/balloon), biliary stenting, PTBD drainage
- Special risk: Post-ERCP pancreatitis (most common serious complication, ~3–5%)
EUS & Capsule Endoscopy
- EUS (Endoscopic Ultrasound): echoendoscope combines endoscopy with ultrasound for staging oesophageal/pancreatic/rectal tumours; EUS-FNA for tissue sampling
- Capsule Endoscopy: swallowed wireless camera capsule (11×26 mm); images small bowel mucosa not accessible by standard scope; patient wears sensor belt; 8–12h recording
- Absolute contraindication for capsule: known stricture or swallowing disorder unless patency capsule cleared
| Procedure | Common Indications | Notes |
|---|
| OGD |
Dysphagia, dyspepsia refractory to treatment, haematemesis / melaena, iron-deficiency anaemia, Barrett's oesophagus surveillance, H. pylori testing & eradication confirmation, weight loss, vomiting |
NICE guideline: urgent 2-week-wait OGD for age >55 with weight loss + any of: dysphagia, upper abdominal pain, reflux, nausea, vomiting |
| Colonoscopy |
Colorectal cancer (CRC) screening/surveillance, polyp surveillance, IBD diagnosis & surveillance, rectal bleeding, change in bowel habit >6 weeks, iron-deficiency anaemia, positive faecal immunochemical test (FIT) |
UAE & Saudi National CRC screening programmes: FIT-based with colonoscopy for positives |
| ERCP |
CBD stones (choledocholithiasis), biliary obstruction (jaundice), cholangitis, pancreatic duct strictures, hilar/distal CBD strictures (cancer) |
Diagnostic ERCP largely replaced by MRCP; ERCP now predominantly therapeutic |
| EUS |
Staging of oesophageal, gastric, pancreatic, rectal cancers; submucosal lesion characterisation; FNA of mediastinal/pancreatic lesions |
T-stage and N-stage accuracy superior to CT for oesophageal cancer |
Absolute Contraindications
Do not proceed — endoscopy contraindicated
- Suspected or confirmed bowel / oesophageal perforation (free air on imaging)
- Haemodynamic instability not yet resuscitated (relative in life-threatening haemorrhage)
- Patient refusal / no valid consent
- Inadequate monitoring/resuscitation facilities available
Relative Contraindications — Risk vs Benefit Assessment
- Recent myocardial infarction (<4 weeks) — cardiology review required
- Uncorrected coagulopathy (INR >1.5 for therapeutic procedures)
- Severe thrombocytopaenia (<50 × 10⁹/L for biopsy)
- Large abdominal aortic aneurysm (risk of compression during colonoscopy)
- Oesophageal varices with active bleeding — high risk but often indication for emergency OGD
- Uncooperative patient without adequate sedation plan
- Pregnancy (first trimester — elective endoscopy deferred where possible)
Flexible Endoscope — Key Components
- Control Head: contains angulation controls (up/down, left/right dials), suction button, air/water button, biopsy port cap
- Insertion Tube: flexible shaft inserted into patient; contains all channels
- Universal Cord: connects scope to light source and processor
- Distal Tip: contains CCD/CMOS image sensor, lens, air/water nozzle, instrument channel opening
- Bending Section: 4-way angulation (up 210°, down 90° typical for gastroscope)
Internal Channels / Lumens
- Working Channel (Instrument Channel): 2.8 mm (standard) / 3.7 mm (therapeutic) — accepts biopsy forceps, snares, needles
- Air/Water Channel: air for insufflation; water for lens washing
- Suction Channel: removes fluid and debris; shares distal opening with working channel
Scope Sizing
- Paediatric gastroscope: 5.9–7.9 mm outer diameter
- Standard adult gastroscope: 9.2–9.9 mm
- Therapeutic gastroscope: 9.9–11.3 mm (large working channel)
- Standard colonoscope: 12.8–13.2 mm
Light Source & Processor: Xenon light source (300W) or LED; video processor converts CCD/CMOS signals to high-definition video output on the display monitor. Narrow Band Imaging (NBI) / i-Scan / BLI enhance mucosal vascular patterns without dye.
Critical Safety Point: Inadequate endoscope decontamination is a patient safety never-event. Flexible endoscopes are semi-critical devices but cannot withstand autoclaving — they require high-level disinfection (HLD) after every patient use.
Pathogens of Concern in Endoscopy Cross-Infection
Blood-borne Viruses
- HIV
- Hepatitis B virus (HBV)
- Hepatitis C virus (HCV)
Bacterial Pathogens
- Helicobacter pylori
- Pseudomonas aeruginosa (wet scopes)
- Non-tuberculous Mycobacteria (NTM)
- CRE / carbapenem-resistant organisms (ERCP)
Prion Risk
- vCJD — variant Creutzfeldt-Jakob Disease
- Single-use forceps required for at-risk patients
- Prions not inactivated by standard HLD
Step-by-Step Manual Cleaning Process
- Immediate Pre-clean (bedside — within 60 seconds of scope withdrawal): wipe external surface with enzymatic detergent wipe; suction 250 mL enzymatic detergent through working channel; flush air/water channels. This prevents biofilm formation in the decontamination room.
- Transport: in a sealed, labelled transport container. Never transport in an open tray. Universal precautions (PPE: gloves, apron, mask, eye protection).
- Leak Testing: before immersion in water — connects to pressure tester. Inflate scope body; submerge in water; observe for bubbles (indicates channel breach). Do not proceed with AER if leak detected — remove from service.
- Full Manual Clean: immerse in enzymatic detergent (per manufacturer dilution). Brush all accessible channels with correct channel brush (working channel, air/water, suction). Brush insertion tube externally. Flush all channels with detergent using a 30–50 mL syringe.
- Rinse: thorough rinsing with filtered/purified water to remove detergent residue before AER.
Aldehyde-Based Systems (Glutaraldehyde)
- 2% glutaraldehyde — effective against bacteria, viruses, spores
- Exposure time: 20–45 minutes at room temperature for high-level disinfection
- Occupational hazard: vapour causes respiratory/skin sensitisation — must be used in ventilated wash rooms
- Largely being replaced by peracetic acid systems in modern units
Peracetic Acid (PAA) Systems
- 0.2–0.35% peracetic acid — rapid action, no toxic residue, breaks down to acetic acid and water
- Cycle time: ~30 minutes
- Preferred in most modern endoscopy units (e.g., Medivator, Olympus OER, Soluscope)
- Requires scope compatibility check — PAA can degrade certain scope materials
- All channels must be connected to the AER manifold and patent
Drying — The Most Overlooked Step
Most common source of contamination failure is inadequate drying. Pseudomonas aeruginosa and NTM thrive in residual water within channels.
- Flush all channels with 70–80% isopropyl alcohol (IPA) after final rinse — accelerates evaporative drying
- Purge channels with filtered/medical air until dry (minimum 10 air purges per channel)
- External surfaces wiped dry with a clean lint-free cloth
- Minimum drying / air-drying time before storage: 1–3 hours
- Some units use forced air drying cabinets (DACS — drying and storage cabinets)
Scope Storage Requirements
- Store hanging vertically in a dry, ventilated, clean endoscope storage cabinet
- Caps removed (biopsy port caps, distal caps) to allow airflow through channels
- No coiling — risk of internal damage and water pooling
- Maximum storage time before re-processing: 72 hours (BSG guidance, though local policy may vary)
- Document storage date and re-process if storage limit exceeded
Tracking System Requirements
- Each scope has a unique identifier (scope ID / serial number)
- Track: which patient → which scope → which AER cycle → which staff member → storage location
- Electronic tracking systems (e.g., Olympus ENDOALPHA, Medivator Advantage Pass) provide audit trails
- Essential for patient recall in event of decontamination failure
- Reprocessing cycle record must be retained per local policy (usually 10–30 years)
Elevated Risk — Elevator Mechanism
Duodenoscopes (ERCP scopes) have a fixed elevator channel that is extremely difficult to clean by standard AER methods alone. Multiple CRE outbreak investigations worldwide linked to inadequate duodenoscope decontamination.
- Enhanced reprocessing options: ethylene oxide (EtO) sterilisation; double AER cycle; liquid chemical sterilant (ortho-phthalaldehyde 0.55%)
- Single-use disposable duodenoscope caps/accessories where available
- Fully disposable duodenoscopes now available (Exalt — Boston Scientific)
- Elevator must be manually cleaned in fully raised and lowered positions
- Microbiological surveillance sampling recommended per manufacturer cycle
FRED — Focused Risk Evaluation for Decontamination
- All patients should be risk-assessed for CJD/prion risk before endoscopy (part of pre-assessment)
- At-risk indicators: family history of prion disease, known CJD diagnosis, received human pituitary-derived hormones, received dura mater graft before 1992
- For OGD in at-risk patients taking gastric biopsy: single-use (disposable) biopsy forceps mandatory — prions are not destroyed by standard HLD
- Endoscopes used on high-risk CJD patients may require quarantine pending patient CJD test results
- BSG / HPS / PHE guidance should be followed locally; GCC units typically follow BSG/PHE framework
Minimum Requirements
- Initial competency assessment before independent decontamination practice
- Annual competency reassessment and update training
- Training on each make and model of scope in use
- PPE use and spillage protocols
- Documentation and tracking system training
Key Guidelines
- BSG (British Society of Gastroenterology) Decontamination Guidelines (current edition)
- SGNA (Society of Gastroenterology Nurses and Associates) — Reprocessing Standards
- ESGE/ESGENA Endoscope Reprocessing Guidelines
- ISO 15883 (Washer-disinfector standards)
Booking Verification Checklist
- Correct procedure confirmed (OGD vs colonoscopy vs flex sig)
- Correct laterality/side where applicable
- Indication documented and clinically appropriate
- Consent obtained by the performing endoscopist (not delegated to nursing staff unless trained/competent in endoscopy consent)
- WHO Surgical Safety Checklist adapted for endoscopy — sign-in, time-out, sign-out
- Interpreter arranged if required
- Transport home arranged for sedated patients
Allergy Assessment — Critical Points
- Latex allergy: latex-free gloves, latex-free equipment, first case of the day scheduling to minimise aerosolised latex from prior cases
- Drug allergies: midazolam, fentanyl, propofol, buscopan (hyoscine butylbromide), contrast (ERCP), latex
- Food allergies: propofol contains egg lecithin and soybean oil — caution in soy/egg allergy (though evidence for cross-reactivity is weak, document and assess)
- Allergy wristband applied before procedure
Pre-endoscopy Medication Management — British Society of Gastroenterology / ASGE Guidelines
| Drug | Low-risk Procedure (biopsy / diagnostic) | High-risk Procedure (polypectomy, ERCP sphincterotomy, EMR) |
|---|
| Aspirin |
Continue |
Continue (low-dose aspirin for CV protection) |
| Clopidogrel / P2Y12 inhibitors |
Continue |
Stop 5–7 days before (discuss with cardiology if drug-eluting stent within 12 months) |
| Warfarin |
Continue if INR in therapeutic range (<3) |
Stop 5 days before; check INR on day; bridging LMWH for high thrombotic risk patients (AF with prior stroke, mechanical valve) |
| DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) |
Last dose 24h before procedure (48h if eGFR <50 for dabigatran) |
Stop 48h before (72h for dabigatran / renal impairment); no routine bridging unless very high thrombotic risk |
| NSAIDS |
Continue |
Stop 5 days before therapeutic colonoscopy |
Key principle: The risk of stopping anticoagulation (thromboembolism) must be weighed against the risk of haemorrhage if continued. Multidisciplinary decision involving gastroenterologist and prescribing physician/cardiologist.
Bowel Preparation Regimens
Standard Polyethylene Glycol (PEG) Prep
- Klean-Prep / MoviPrep / Moviprep: PEG 3350 + electrolytes. High volume (2–4 litres); osmotically balanced; safe in renal/cardiac disease
- Split-dose regimen: half evening before procedure + half morning of procedure (3–5h before) — superior mucosal cleansing vs single-dose day-before
- Clear fluids encouraged throughout prep period
- Low-residue diet for 3 days prior reduces residue burden
Alternatives
- Sodium picosulfate / magnesium citrate (Picolax / CitraFleet): low volume; popular in GCC; avoid in renal impairment
- Sodium phosphate: largely withdrawn due to acute phosphate nephropathy risk — avoid
- Picoprep / Eziclen: newer low-volume options; check local formulary
Special Populations
- Diabetes: insulin adjustment protocol on NPO day (see below)
- Renal impairment: avoid sodium phosphate; use PEG-based prep with caution
- Elderly/debilitated: consider reduced-volume prep with dietician input
Standard NPO Fasting Times
- 6 hours: solid food, milk, milky drinks before sedated upper GI endoscopy
- 2 hours: clear fluids (water, clear juice, black coffee/tea) before sedated procedure
- Note: Unsedated/no-sedation OGD (topical only) — standard fasting still applies to ensure adequate mucosal views
- For colonoscopy: bowel prep regimen itself constitutes part of the preparation — follow unit protocol for final clear fluid timing
Diabetes Management on NPO Day
- Type 1 / insulin-treated Type 2: reduce long-acting insulin by 20–30% the night before; omit short-acting insulin while NBM; monitor capillary glucose 2-hourly; target 6–12 mmol/L
- Metformin: hold on the day of procedure if IV contrast used (ERCP); otherwise continue
- Sulphonylureas: hold on morning of procedure (hypoglycaemia risk while fasting)
- SGLT2 inhibitors: hold 72h before procedure if ketoacidosis risk (local protocol)
- Ensure IV access and dextrose available for hypoglycaemia management
Pre-procedure Nursing Assessment
- Confirm patient identity (2 identifiers: name + DOB)
- Confirm procedure and consent form signed/present
- Allergy status reviewed and wristband in place
- Baseline vital signs: BP, HR, SpO2, RR, temperature
- IV access established (18G or 20G cannula — antecubital fossa preferred)
- IV access patent (flush with normal saline)
- Bowel preparation adequacy self-reported (colonoscopy) — document type, completion
- Anticoagulant / antiplatelet medication status confirmed per plan
- Responsible adult escort confirmed (for sedated patients)
- Dentures, jewellery, hearing aids removed / documented
- Completion of FRED — CJD risk screening questions
- Patient questions answered; anxiety addressed
No Sedation — Topical Throat Spray (OGD Only)
- 10% lidocaine throat spray (1–2 actuations to posterior pharynx)
- Spray takes effect in 2–3 minutes; duration ~30 minutes
- Advantages: no recovery time, no escort requirement, lower cost, lower risk
- Disadvantages: more patient discomfort; not suitable for anxious patients or therapeutic procedures
- Patient must not eat or drink for 1 hour post-procedure (loss of gag reflex)
- No driving restriction if no IV sedation given
Conscious Sedation — Most Common (IV Midazolam + Opioid)
- Midazolam: 1–5 mg IV titrated (benzodiazepine — anxiolytic, amnesic, sedative). Onset 2–5 min; duration 30–60 min. Reduce dose in elderly (>70 years: max 2.5 mg starting dose), renal/hepatic impairment
- Fentanyl: 50–100 mcg IV (opioid analgesic). Synergistic with midazolam — reduces midazolam dose needed. Short acting (peak 3–5 min)
- Reversal agents: Flumazenil (Anexate) 200 mcg IV then 100 mcg increments (max 1 mg) reverses midazolam; Naloxone 400 mcg IV (in increments) reverses opioid
- Verbal contact maintained throughout — patient rousable
Propofol Sedation / Deep Sedation
- Propofol (2,6-diisopropylphenol): rapid onset (<1 min), rapid recovery, excellent amnesia
- Administered by: anaesthetist (gold standard), or by trained nurse-administered propofol sedation (NAPS) in specific jurisdictions where permitted
- In GCC: most units require anaesthetist for propofol; NAPS protocols limited to specific approved centres
- Risk: loss of airway protective reflexes — must have airway management capability (airway trolley, bag-valve-mask, skilled person available)
- Propofol contains egg lecithin/soya — note allergy history
Buscopan (Hyoscine Butylbromide) — Antispasmodic
- 20 mg IV reduces colonic spasm during colonoscopy — improves mucosal views
- Contraindicated: glaucoma, prostatic hypertrophy, myasthenia gravis, tachycardia, cardiac disease
- Causes transient tachycardia and urinary retention — warn patient
- Glucagon (0.5–1 mg IV) used as alternative in USA/some GCC units
Monitoring Standards During Conscious Sedation
- SpO2 (Pulse Oximetry): continuous, mandatory for all sedated patients
- Supplemental Oxygen: nasal cannula 2–4 L/min for sedated patients (prevents desaturation from respiratory depression)
- Blood Pressure: at minimum — start of procedure, end of procedure, any time clinically indicated; more frequently in ASA III–IV patients
- Heart Rate: via pulse oximetry continuously
- ECG: cardiac monitoring for patients with known cardiac disease, arrhythmias, or complex ERCP/EUS
- Verbal Contact: maintained throughout conscious sedation — patient responds to voice; any loss of responsiveness → concern → stop/assess
- Capnography (end-tidal CO2): increasingly used for deeper sedation/ERCP/EUS — detects respiratory depression before SpO2 drops
- Documentation: drugs/doses/times, vital signs at key intervals, any adverse events, scope ID, procedure findings
- Emergency trolley: immediately accessible; suction available and functioning; reversal agents drawn up
| Procedure | Position | Rationale |
|---|
| OGD (Upper GI) |
Left lateral decubitus (left side down) |
Reduces aspiration risk; pools gastric secretions away from cardia; anatomically easier scope passage |
| Colonoscopy |
Left lateral to start; may reposition supine/right lateral for hepatic flexure/caecal intubation |
Gravity assists scope advancement; repositioning overcomes loops |
| ERCP |
Semi-prone (prone with head turned right) or prone |
Side-viewing scope approach to ampulla; fluoroscopy easier; reduces aspiration risk from left-lateral position |
| EUS |
Left lateral (upper GI EUS); left lateral / supine (rectal EUS) |
As per standard upper/lower endoscopy |
Endoscopy Nurse 1 — Patient Care Nurse
- Monitoring vital signs and sedation level
- IV drug administration (midazolam, fentanyl, buscopan)
- Patient communication and reassurance
- Airway management / positioning adjustments
- Documentation of procedure, drugs, events
- Suction and airway support as needed
Endoscopy Nurse 2 — Endoscopist Assistant
- Scope passing during colonoscopy (loop reduction)
- Patient position changes on endoscopist instruction
- Passing instruments through working channel (biopsy forceps, snares, clip applicators, needles)
- Specimen handling and labelling
- Retrieval of polyps (net, suction trap)
- Diathermy unit / argon plasma coagulation (APC) operation
| Specimen Type | Container / Medium | Purpose | Notes |
|---|
| Tissue biopsy (standard) |
10% neutral buffered formalin |
Histopathology |
Label immediately with patient ID, site, date; separate pots per anatomical site |
| CLO test biopsy (antrum/corpus) |
CLO test (urease) kit |
H. pylori rapid urease test — colour change from yellow to magenta/pink = positive (within 1–3h at room temp) |
Document site (antrum and/or corpus); not valid if patient on PPI (false negative) |
| Tissue for microbiology |
Dry container / saline — NOT formalin |
Culture and sensitivity |
e.g. duodenal biopsy for Giardia; gastric for culture |
| Polypectomy specimen |
Formalin (per biopsy); cold snare polyps retrieved via suction trap |
Histopathology — adenoma vs hyperplastic vs serrated |
Document size, morphology (Paris classification), site; hot snare — artefact may affect histology |
Polypectomy Techniques
- Cold snare: mechanical transection, no diathermy; preferred for polyps <10 mm; lower bleeding risk
- Hot snare: diathermy coagulation; polyps 10–20 mm; nurse activates diathermy pedal on endoscopist instruction
- EMR (Endoscopic Mucosal Resection): saline/adrenaline submucosal injection + snare; large flat polyps; dedicated EMR nurse circulator needed
- ESD (Endoscopic Submucosal Dissection): en-bloc resection of large lesions; high complication risk; anaesthetist usually present
Haemostasis Methods
- Adrenaline injection: 1:10,000 or 1:20,000 in saline; reduces bleeding by vasoconstriction and tamponade effect; never use alone (rebound haemorrhage)
- Haemoclips: mechanical closure of bleeding vessel / post-polypectomy defect; nurse loads clip applicator into working channel
- Argon Plasma Coagulation (APC): non-contact electrical coagulation via argon gas; used for AVMs, GAVE, superficial bleeding
- Thermal probes (heater probe / bipolar): contact coagulation for peptic ulcer haemostasis (Forrest Ia-IIb lesions)
Post-procedure Recovery Monitoring
- Continuous SpO2 and HR monitoring until patient fully alert and baseline SpO2 maintained on room air
- BP check on arrival to recovery, 15 minutes later, then as per unit protocol
- Airway assessment: airway position (recovery position / semi-recumbent), gag reflex return
- Observe for early complications: abdominal pain, distension, haematemesis, rectal bleeding, respiratory distress
- Supplemental oxygen until SpO2 consistently ≥94–96% on room air
- Monitor and document any delayed sedation effect or emergence
Modified Aldrete Scoring — Discharge Readiness Assessment
| Parameter | Score 2 | Score 1 | Score 0 |
|---|
| Activity | Moves all 4 limbs on command | Moves 2 limbs | Unable to move |
| Respiration | Breathes deeply, coughs freely | Dyspnoea or limited breathing | Apnoeic / requires support |
| Circulation | BP within 20% pre-op | BP 20–49% from pre-op | BP >50% from pre-op |
| Consciousness | Fully awake, oriented | Arousable on calling | Not responding |
| SpO2 | ≥92% on room air | O2 required to maintain ≥92% | <90% with O2 supplementation |
Score ≥9/10 required for discharge from recovery. Patient must also meet all discharge criteria below.
Discharge Criteria (Sedated Patients)
- Vital signs at or near baseline — stable for minimum 30–60 minutes
- Fully oriented to person, place, time
- Able to ambulate independently (or baseline level)
- No significant nausea or vomiting
- Pain adequately controlled
- Aldrete score ≥9
- Responsible adult escort present and able to take patient home (not by public transport alone)
- No driving or operating machinery for 24 hours post-sedation
- No alcohol for 24 hours post-sedation
- No signing of legal documents for 24 hours post-sedation
- Written aftercare instructions provided and understood
- Contact number for complications provided
Immediate action required: Any patient with chest or abdominal pain post-procedure should be assessed for perforation until proven otherwise.
Perforation — Surgical Emergency
- Signs: severe abdominal pain (disproportionate to procedure), abdominal rigidity/guarding, subcutaneous emphysema, clinical deterioration
- Diagnosis: erect CXR or AXR (free air under diaphragm); CT abdomen (gold standard — shows pneumoperitoneum, extravasation)
- Management: immediate surgical review; IV access + fluids; IV antibiotics; nil by mouth; analgesia; NBM
- Risk factors: therapeutic procedures (EMR/ESD), older patients, colonic diverticulum, inexperienced endoscopist
- Colonic perforation rate: diagnostic colonoscopy ~0.03–0.1%; therapeutic ~0.5%
Haemorrhage — GI Bleeding Post-procedure
- Immediate post-polypectomy bleeding (<24h): visible spurting / haemostasis failure at endoscopy; endoscopist applies clips / APC / adrenaline injection during procedure
- Delayed post-polypectomy bleeding (up to 14 days): most common delayed complication of colonoscopic polypectomy; presents with rectal bleeding ± haemodynamic compromise
- Management: IV access, group & cross-match, resuscitate, repeat colonoscopy (haemoclips/adrenaline injection); interventional radiology if endoscopy fails; surgery last resort
- Avoid NSAIDs post-polypectomy for 2 weeks; avoid anticoagulants per plan
Post-ERCP Pancreatitis (PEP) — Most Common ERCP Complication
- Incidence: 3–5% overall; up to 15–30% in high-risk patients (sphincter of Oddi dysfunction, female, young patient, prior PEP, difficult cannulation)
- Definition: new or worsening abdominal pain + serum amylase >3× upper normal at 24h post-ERCP requiring hospitalisation
- Prophylaxis — RECTAL DICLOFENAC: 100 mg rectally immediately before or after ERCP — reduces PEP incidence by ~50% (NSAID inhibits phospholipase A2 cascade). Now standard of care. Contraindicated: renal failure, NSAID allergy, active GI bleeding
- Management: IV fluids (aggressive hydration — Ringer's lactate superior to saline), analgesia, NBM, monitor. Severe: ICU, ERCP surgeon input
Aspiration Pneumonia
- Risk factors: impaired gag reflex, active vomiting, delayed gastric emptying (gastroparesis, GOO), achalasia, emergency endoscopy, deep sedation/propofol
- Prevention: adequate fasting, left lateral position (pools secretions inferiorly), suction readily available at start of procedure, rapid suction of regurgitated material
- Signs: desaturation during/after procedure, new wheeze/crackles, fever, productive cough post-procedure
- Management: high-flow O2, chest physiotherapy, IV antibiotics (co-amoxiclav / metronidazole for anaerobic cover), chest X-ray, escalate to respiratory team
Post-polypectomy Syndrome (Electrocoagulation Syndrome)
Distinct from perforation: peritoneal irritation by transmural burn without frank perforation. Conservative management.
- Incidence: ~0.3–0.7% post-hot snare polypectomy
- Presentation: abdominal pain, fever, leukocytosis 1–5 days post-polypectomy; no free air on imaging (differentiates from perforation)
- Management: NBM, IV fluids, IV antibiotics (broad-spectrum), analgesia, observation. Usually resolves in 24–48h without surgery
- If free air found → perforation → surgical emergency, not conservative management
Prague Classification & Seattle Biopsy Protocol
Prague C&M Classification
- C value: circumferential extent of Barrett's mucosa above gastro-oesophageal junction (GOJ) in cm
- M value: maximal extent of Barrett's above GOJ in cm (including tongues/islands)
- Example: C3M5 = 3 cm circumferential, 5 cm maximal extent
- Reliable inter-observer agreement when using Prague criteria
Seattle Biopsy Protocol
- 4-quadrant biopsies every 2 cm throughout Barrett's segment + any visible lesions (targeted biopsy first)
- Each biopsy level in separate labelled formalin pot
- Purpose: detect dysplasia (low-grade, high-grade) or adenocarcinoma
- Surveillance intervals (BSG): non-dysplastic Barrett's <3 cm = 5-yearly; ≥3 cm = 3-yearly; low-grade dysplasia = 6-monthly
H. pylori & Upper GI Disease in GCC
- H. pylori seroprevalence in GCC countries: 50–80% (significantly higher than Western Europe)
- High rates among expatriate workers (particularly South Asian and East African populations)
- Saudi Arabia: estimated 70% prevalence; gastric cancer remains the most common GI malignancy diagnosed by OGD in the region
- UAE: rising dyspepsia presentations; DHA guidelines promote early OGD for red-flag symptoms; FIT-based screening programmes developing
- CLO test (rapid urease) used widely intra-procedurally; C13 urea breath test and faecal antigen test for eradication confirmation
- First-line eradication: PPI + amoxicillin + clarithromycin × 7–14 days (local resistance patterns to clarithromycin rising)
Colorectal Cancer Screening in GCC
- Colorectal cancer is the most common cancer in males in Saudi Arabia (Saudi Cancer Registry)
- UAE: CRC second most common cancer in males; DHA/DOH have initiated national CRC screening pilots
- FIT (faecal immunochemical test) recommended as first-line screening test; colonoscopy for FIT positives
- Average-risk screening begins at age 45–50 years across GCC programmes
- High demand for colonoscopy-trained nurses due to growing screening volume
- Qatar National Cancer Strategy includes endoscopy expansion in scope of practice
DHA / DOH / SCFHS Endoscopy Nursing — Regulatory Context
- DHA (Dubai Health Authority): Nurses working in endoscopy must be registered RNs with minimum 1 year post-registration clinical experience; endoscopy-specific competency assessment required for independent practice
- DOH Abu Dhabi: Endoscopy nursing scope of practice guided by facility policy; sedation administration requires demonstrated competency sign-off
- SCFHS (Saudi Commission for Health Specialties): Saudi Gastrointestinal Nursing sub-specialty recognition; written and practical examination; emphasis on decontamination standards, sedation monitoring, and complication recognition
- GCC nurses seeking endoscopy nursing roles typically need: endoscopy-specific portfolio, BLS/ALS certification, sedation monitoring certificate
- BSG Joint Advisory Group (JAG) accreditation model increasingly referenced by GCC units for quality benchmarking
Decontamination: Pre-clean must happen at bedside within 60 seconds of scope withdrawal — prevents biofilm. Leak test before AER. Drying with IPA then air is essential to prevent Pseudomonas contamination.
Post-ERCP Pancreatitis: Most common serious complication of ERCP (3–5%). Rectal diclofenac 100 mg is the evidence-based prophylaxis of choice. Defined as pain + amylase >3× ULN at 24h requiring hospitalisation.
Conscious sedation monitoring: SpO2 (with supplemental O2 via nasal cannula), verbal contact maintained, BP at minimum start/end. Flumazenil reverses midazolam; naloxone reverses opioid.
Bowel prep — split dose: Half evening before + half morning of colonoscopy gives superior prep quality vs. single evening dose (Boston Bowel Prep Scale target ≥6, no segment score <2).
Perforation vs Post-polypectomy Syndrome: Both cause post-colonoscopy abdominal pain/fever. Free air on imaging = perforation (surgical emergency). No free air + conservative management = post-polypectomy syndrome.
DOAC management: Stop 48h before high-risk procedures (72h for dabigatran if eGFR <50). No routine bridging unlike warfarin. Resume 48h post-procedure when haemostasis secured.
Duodenoscope CRE outbreak risk: Elevator channel in ERCP scopes requires enhanced reprocessing — double AER cycle, EtO sterilisation, or single-use disposable duodenoscopes. Standard AER alone insufficient.
Barrett's surveillance: Prague C&M classification documents extent. Seattle protocol: 4-quadrant biopsies every 2 cm in separate pots. Non-dysplastic <3 cm = 5-yearly surveillance.
CLO test: Antral biopsy in CLO (urease) kit — yellow to pink/magenta = H. pylori positive. False negatives if patient on PPI (must stop PPI 2–4 weeks before test).
Latex allergy in endoscopy: Schedule as first case of day; latex-free gloves and equipment; alert endoscopist and anaesthetist. OGD bite guards, suction equipment, IV tubing all must be latex-free.
Select an answer, then click "Check Answer" to see the explanation. Aligned with DHA/DOH/SCFHS endoscopy nursing examination style.