Expanding the Scope of Gastrointestinal Endoscopy
Monday February 5, 2001
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Colonoscopy, considered the most effective screening for colon cancer, is one of the most commonly performed types of gastrointestinal endoscopic procedures. Usually done in a specially equipped endoscopy suite on an outpatient basis, these procedures, which provide for evaluation and treatment of a number of medical conditions, allow the physician to directly visualize internal body structures and hollow cavities through the use of the endoscope, a tubular instrument with a light source and a system of lenses.1
The majority of GI endoscopic procedures are done with local anesthetics under intravenous conscious sedation, using agents such as meperidine (Demerol); fentanyl; Versed (midazolam); or Valium. "Versed, a potent but short-acting agent that can be quickly reversed using flumazenil, is an excellent choice for many endoscopic procedures," says Donna Buono, RN, BSN, CGRN, a staff nurse in the endoscopy unit at St. Mary Hospital, Hoboken (part of Bon Secours New Jersey Health System). Conscious sedation produces a depressed level of consciousness in which the patient can maintain an airway and respond to verbal commands or physical stimulation.
According to Buono, "IV conscious sedation decreases fear and anxiety during the procedure, elevates the pain threshold and provides an amnesia effect." If the patient is deemed not appropriate for IV conscious sedation - due to high risk factors such as extreme obesity or the probable need for intubation - the procedure will be done under general anesthesia. "If the physician is administering IV conscious sedation the RN's function is to closely monitor the patient. We can never take IV sedation lightly since the patient can desaturate [drop of oxygen levels] quickly," adds Buono.
Scoping Out the Problem
Upper endoscopic procedures can be used to visualize the esophagus, the duodenum, or the mucosal lining of the stomach. Common indications for upper endoscopy include: duodenal ulcers, tumors, inflammation, bleeding, Mallory-Weiss tears, viral hepatitis, and esophageal strictures or varices.1 They can also be done to retrieve foreign bodies which have been swallowed. Indications for lower endoscopy procedures such as colonoscopy/sigmoidoscopy include routine screening, rectal bleeding, inflammatory bowel disease, polyps, or neoplasms.1
Other specialized endoscopic procedures include -
· Percutaneous Endoscopic Gastrostomy (PEG) procedure: a fiberoptic gastroscope is used to place a gastrostomy tube through the esophagus into the stomach and is then pulled through a stab wound in the abdominal cavity wall. According to Buono, "Because patients with PEG procedure are NPO for 24 hours postprocedure, most of these procedures are done inhouse on patients who have dysphagia from neurological impairments such as Alzheimer's disease or brain injury. At our hospital, about 80% of feeding tubes are inserted by using a PEG procedure, and the tubes can also be removed endoscopically if they are no longer medically necessary."
· Endoscopic Retrograde Cholangiopancreatography (ERCP): This approach to biliary tract conditions is a safe alternative to more invasive surgical procedures and can be used to remove a stone from the distal common bile duct, to dilate strictures, and to obtain biopsy specimens. After an endoscope is inserted through the mouth into the duodenum and into the common bile and pancreatic ducts, a small cannula is threaded through the scope, which allows a liquid contrast material to be injected through the ducts. Indications for ERCP include jaundice, abdominal pain, abnormal x-ray findings, pancreatitis, strictures, bile duct stones and suspected malignancies.
According to Diana Torre, RN, director of nursing, Surgical Services, at White Plains Hospital Center, White Plains, NY, "Probably the greatest advancement in endoscopic technique and instrumentation is in the field of ERCP. Using very sophisticated equipment, the biliary ducts can be cannulated, and stones can be coagulated, crushed, vaporized, or removed, saving the patient a surgical procedure."
Nursing Care
Endoscopy is a high-tech, high-touch field. The endoscopy nurse must know how to operate, care for, and maintain equipment such as a flexible fiberoptic endoscope, light sources, electrosurgical generators, lasers, monitors, pulse oximeters, and probes and must also be clinically competent in physiological monitoring, providing psychological support, airway assessment and maintenance, and a variety of other nursing functions.
"A thorough nursing assessment is performed before any endoscopic procedure," says Buono, pointing out that "physical assessment including baseline vital signs is done and a history is taken, focusing on family history, and current and past medical conditions. The histories include such information as presence of artificial heart valves, medications, allergies, pretest preparation, and suitability for IV conscious sedation. Torre explains that the RN educates the patient about what to expect during the procedure. The nurse provides information such as positioning on the table, IV placement in arm for administration of conscious sedation, local anesthetic throat spray before insertion of the tube for an upper GI endoscopy, and the possibility of nasal oxygen administration, and gives postprocedure instructions before the procedure since the patient may be groggy afterwards due to sedation.
Standard monitoring measures during endoscopy include ECG, blood pressure, and pulse oximetry. Because local anesthetic agents, analgesics, and sedatives can cause hypersensitivity reactions, cardiovascular, respiratory, and central nervous system depression or toxicity, the patient must be monitored carefully during the procedure. If the conscious sedation is heavy, the nurse may need to maintain an airway or provide oxygen.
After the procedure is done, says Torre, the patient is generally transferred to a postprocedure recovery area, where he or she is monitored for an hour or more depending on the extent and type of the procedure that was performed. ERCP, which is often done under general anesthesia, is a more complicated procedure and may involve an overnight hospitalization. At St. Mary Hospital, says Buono, any patient receiving conscious sedation goes to the postanesthesia care unit (PACU) for observation. Patients are observed for complications such as abnormal bleeding, nausea and vomiting, or a serious change in their vital signs. Patients must return to their preprocedure Aldrete score, which measures vital signs, oxygen saturation, level of consciousness, and movement, before they are discharged.
The patient is generally not allowed any fluids for two hours after an upper endoscopy to ensure that the effects of the local anesthetic used to numb the throat have worn off. After a colonoscopy, the patient must recover for a sufficient time to expel the air that was instilled into the colon during the procedure. This is facilitated by having the patient change his position on the stretcher. Fluids are given once the air has been expelled. Patients are discharged in the care of a family member once they are stable and can generally return to full activity on the day after the procedure.
Possible complications related to endoscopy procedures include excessive bleeding, perforation of an organ, inflammation, infection or sepsis, and changes in vital signs resulting from IV conscious sedation or anesthesia. The American Gastroenterological Association reports that ERCP, which has a five to 10% risk of complications, can result in mild to severe inflammation of the pancreas, bleeding, infection, and perforation of the bowel wall or bile duct.3
Now and Then
"Advances in endoscopic procedures, such as banding of bleeding varices, injecting epinephrine to cauterize bleeding vessels by sclerotherapy, thermal therapy, the use of argon lasers, and papillotomies (endoscopic removal of stones in the common bile duct), have greatly reduced the need for surgical intervention," says Buono, adding that endoscopic procedures can now be used to treat volvulus, complications of ischemic colitis and a variety of other conditions.
Torre points out that, "The definition of endoscopy has been greatly refined as new, technologically sophisticated equipment has enhanced our capacity to use the endoscope for an increasingly wide variety of diagnostic and treatment procedures." In the future, virtual colonoscopy may offer an alternative to the traditional colonoscopy now done for colon cancer screening. Now in its infancy, virtual colonoscopy uses digital data generated by multiple computer scans to create a high resolution image of the intestine, which can then be displayed on a computer screen and visually probed for polyps and other abnormalities. In the meantime baby-boomers turn fifty in record numbers - the age at which a baseline colonoscopy is now recommended. Nurses everywhere should encourage their patients, friends, and relatives to go for a possibly lifesaving colon cancer screening. Remind them, in Katie Couric's words, that "It really doesn't hurt."
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