Upper gastrointestinal endoscopy

Oesophago-gastro-duodenoscopy is performed identically in ventilated and non-ventilated patients. Additional sedation may be needed, especially if the patient is awake and/or agitated. A protected airway facilitates the procedure and also offers additional safety if the patient’s conscious level if obtunded, and there is a high risk of aspiration of gastric contents (blood or food/liquid if ileus or obstruction is present).

Indications

• Investigation of upper GI signs/symptoms. e.g. bleeding, pain, mass,

obstruction.

• Therapeutic, e.g. sclerotherapy and/or banding for varices, local

epinephrine (adrenaline) injection or heat probe (thermocoagulation)

for discrete bleeding points, e.g. in peptic ulcer base.

• Placement of nasojejunal tube (when gastric atony prevents enteral

feeding) or percutaneous gastrostomy (PEG).

• ERCP—relatively unusual in the ICU patient but may be needed for bile duct/pancreatic duct obstruction.

Complications

•  Local trauma causing haemorrhage or perforation.

•  Abdominal distension with gas, compromising respiratory function.

•  Aspiration of gastric contents.

Contraindications/cautions

• Severe coagulopathy should ideally be corrected.

• Caution with upper GI tract pathology as risk of perforation.

Procedure

Upper GI endoscopy should be performed by an experienced operator to minimise the duration and trauma of the procedure, and to minimize gaseous distension of the gut.

• The patient is usually placed in a lateral position.

• Increase FIO2 and ventilator pressure alarm settings. Consider increasing sedation and adjusting ventilator mode.

• Monitor ECG, SpO2, airway pressures, and haemodynamic variables throughout. If patient is on pressure support or pressure control ventilatory modes, also monitor tidal volumes. The operator should cease the procedure, at least temporarily, if the patient becomes compromised.

• At the end of the procedure, the operator should aspirate as much air as possible out of the GI tract to decompress the abdomen, and resite a nasogastric tube which often becomes displaced.