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What is EGD (upper endoscopy) with biopsy?

Esophagogastroduodenoscopy (EGD) with biopsy, also known as upper endoscopy, is a procedure usually performed by a gastroenterologist (GI or intestinal doctor). This test involves passing an endoscope, a long, flexible black tube with a light and video camera on one end, through the mouth to examine the esophagus, stomach and the first part of the small intestine called the duodenum. The advantages of this test over the barium esophagram (x-ray test) are that the lining of the upper digestive tract can be directly viewed by the doctor and very small abnormalities seen. Endoscopic therapies (treatments) can be performed at the time of the procedure. Examples of such therapies include dilation of an esophageal stricture (stretching an esophageal narrowing with a tube) or treating a bleeding ulcer to stop the bleeding. Biopsies (taking small pieces of tissue) of any abnormality may also be done directly through the endoscope including biopsy of suspected Barrett's esophagus or duodenal and stomach ulcers.

EGD (upper endoscopy) may be performed in patients as part of a heartburn or GERD evaluation. It is indicated in patients who have bleeding from the upper GI tract or dysphagia (food sticking in the esophagus, sometimes caused by a stricture or tumor). If reflux esophagitis (inflammation of the esophagus from acid and bile), peptic stricture (a type of esophageal narrowing caused by GERD), or Barrett's esophagus is found, these are diagnostic of GERD and no further testing for the diagnosis per se is needed. However, less than 50% of patients who are referred for endoscopy for symptoms of GERD have esophagitis and even fewer have a stricture or Barrett's esophagus. Patients who have mild to moderate GERD can have symptoms of heartburn but no evidence of esophagitis or esophageal injury that can be seen by the doctor at upper endoscopy. If the patient's symptoms are typical for GERD, these patients may be treated with medications to decrease acid reflux. If they get better on these medications, then no further testing may be necessary. However, some patients may need to undergo intraesophageal pH testing to demonstrate that their symptoms are due to GERD and in some cases undergo esophageal manometry if anti-reflux surgery is anticipated.

Upper Endoscope

What to expect during a typical EGD

An EGD is performed in a hospital or a special treatment center called a GI endoscopy unit. You will be asked not to eat or drink anything for six to eight hours prior to the test, just like before a surgery. In the endoscopy unit, an intravenous (IV) line will be started in your arm. Because you will receive medication through the IV to make you sleepy, you will be placed on a monitor that checks your heart rate, blood pressure and oxygen level. The medication that you will get is called conscious sedation because it is not general anesthesia. The main goal of this sedation is to make you comfortable, less anxious, and diminish gagging. As a result of the sedation you may be asleep and not remember the procedure or you may be partially awake but comfortable.

After sedation, the doctor will pass the endoscope through your mouth into the back of your throat and ask you to swallow. Most people spontaneously swallow and the scope is easily passed into the esophagus. Using the endoscope, the doctor can see a magnified picture of the lining of the upper intestinal tract on a video monitor. Air, water and suction can be used through the scope so that the doctor can look very carefully at the upper GI tract lining.

Upper endoscope video monitor
Endoscopy video display of a
Barrett's esophagus
Photo courtesy of the Seattle Barrett's Esophagus Research Program

If the exam is normal, your esophagus will look white and your stomach will look red. If you have Barrett's esophagus, the doctor will see a red lining in the esophagus, always beginning at the bottom of the esophagus and extending a varying distance up the esophagus toward your mouth. Some patients have only a small portion or very bottom of their esophagus lined with Barrett's and some have a large portion. In some cases, almost the entire esophagus is lined with Barrett's. Most patients with Barrett's esophagus have a hiatal hernia.

Normally, stomach tissue can grow in the bottom of the esophagus and looks red through the endoscope just like Barrett's esophagus. To confirm that the red lining in the esophagus is Barrett's esophagus and not stomach tissue, the doctor will take biopsies through the endoscope. The biopsy device is called a forceps. It is a long wire with a biopsy device at one end of the wire. Many commonly used biopsy devices have a small metal spike in the middle and two cups on either side of the spike to spike, grab and pull off tissue. The doctor places the forceps through the biopsy channel in the endoscope, opens the forceps, spikes a piece of tissue, closes the forceps grasping the tissue and pulls the forceps, containing the biopsy, out of the endoscope. There is not much bleeding and most patients do not feel the biopsy. The biopsy is small, about the size of a grain of cooked rice. It is placed in a tissue preservative, called a fixative, and sent to the pathology lab for histologic analysis to identify  Barrett's tissue if present.

Normal Squamous Esophagus
Normal squamous esophagus
Upper endoscopic view of the normal squamous esophagus. In the illustration, the tip of the endoscope is
just above the bottom of the esophagus where it joins the stomach.

Upper endoscopic view of a short segment Barrett's esophagus
Short segment Barrett's esophagus
The short segment of Barrett's esophagus is seen here as a strip or "tongue" of red lining surrounded by
normal pinkish-white squamous lining. There is a small island of Barrett's esophagus, surrounded by normal
squamous lining, next to the tongue of Barrett's esophagus.

Upper endoscopic view of a short segment Barrett's esophagus
Long segment Barrett's esophagus
The squamocolumnar junction, where the Barrett's esophagus joins the normal squamous esophagus, is a great distance from the bottom of the esophagus due to the long segment of Barrett's esophagus.

Endoscope with Biopsy Forceps

Upper endoscope with biopsy forceps in the biopsy channel

During the endoscopy, the doctor passes the biopsy forceps through a channel in the endoscope. After the biopsy is taken, the forceps and the biopsy are pulled back and out of the biopsy channel.

Upper endoscope with biopsy forceps open and ready to take biopsy

Upper endoscope with biopsy forceps open
and ready to take a biopsy

Endoscopic photo of a closed biopsy forceps 'grasping' the esophageal lining

Endoscopic photo of a closed biopsy forceps "grasping" the esophageal lining

After the forceps is closed, the forceps is pulled out of the biopsy channel, opened and the biopsy is removed.
Photo courtesy of the Seattle Barrett's Esophagus Research Program

Endoscopic biopsy

An endoscopic biopsy

The biopsy is small, seen here to measure about one-half centimeter or one-quarter inch.

The typical  EGD procedure lasts about 15 to 20 minutes, depending upon whether there are any abnormalities, biopsies taken or therapy given. If you do have Barrett's esophagus, endoscopic biopsy surveillance (cancer surveillance) will be performed in you periodically. It is identical to the EGD procedure but involves taking more biopsies of the esophagus and thus, usually lasts longer, up to one hour in patients whose Barrett's esophagus is very long.

After the EGD procedure is over, you will stay in the endoscopy unit until you are fully awake. You will be told about your exam but will have to wait on biopsy results until the histologic analysis is completed . Because of the sedation, you will need someone to drive you home after the procedure. 

EGD safety

EGD is very safe and one of the most frequently performed endoscopic procedures. One possible severe complication that is rare, less than a 1 in 1000 chance of occurring, is accidentally making a hole or tear in the esophagus, stomach or small bowel that would likely require surgery to repair it. Other, possible but usually less severe complications include significant bleeding from the biopsies; pneumonia from getting stomach fluid or saliva into the lungs, and a bad reaction to the sedation medications . 

Endoscopic biopsies are very superficial, taking only the very top layer of the esophagus. Therefore, significant bleeding from the biopsies is rare and the biopsies do not scar the esophagus. A serious medication reaction is unusual and now reversal drugs are widely used to reverse or stop the sedation if complications occur. The usual complications of sedation are a low blood pressure and abnormally slowed breathing.

In summary,  the EGD is one of the most commonly performed GI procedures and  is very safe.  It is the most sensitive test for detection of abnormalities of the upper GI tract lining and the ONLY test that confirms the diagnosis of Barrett's esophagus.

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