Gastroscopy


Categories: ACUTE STENOSIS OF THE LARYNX
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The stomach of any individual having a normal esophagus and normal

spine can be explored with an open-tube gastroscope. The adult size

esophagoscope being 53 cm. long will reach the stomach of the average

individual. Longer gastroscopes are used, when necessary, to explore a

ptosed stomach. Various lens-system gastroscopes have been devised,

which afford an excellent view of the walls of the air-inflated

stomach. The optical system, however, interferes with the insertion of

instruments, so that the open-tube gastroscope is required for the

removal of gastric foreign bodies, the palpation of, or sponging

secretions from, gastric lesions. The open-tube gastroscope may be

closed with a window plug (Fig. 6) having a rubber diaphragm with a

central perforation for forceps, when it is desired to inflate the

stomach.



Technic.--Relaxation by general anesthesia permits lateral

displacement of the dome of the diaphragm along with the esophagus,

and thus makes possible a wider range of motion of the distal end of

the gastroscope. All of the recent gastroscopies in the Bronchoscopic

Clinic, however, have been performed without anesthesia. The method of

introduction of the gastroscope through the esophagus is precisely the

same as the introduction of the esophagoscope (q.v.). It should be

emphasized that with the lens-system gastroscopes, the tube should be

introduced into the stomach under direct ocular guidance, without a

mandrin, and the optical apparatus should be inserted through the tube

only after the stomach has been entered. Blind insertion of a rigid

metallic tube into the esophagus is an extremely dangerous procedure.



The descriptions and illustrations of the stomach in anatomical works

must be disregarded as cadaveric. In the living body, the empty

stomach is usually found, on endoscopic inspection, to be a collapsed

tube of such shape as to fit whatever space is available at the

particular moment, with folds and rugae running in all directions, the

impression given as to form being strikingly like searching among a

mass of earth worms or boiled spaghetti. The color is pink, under

proper illumination, if no food is present. Poor illumination may make

the color appear deep crimson. If food is present, or has just been

regurgitated, the color is bright red. To appreciate the appearance of

gastritis, the eye must have been educated to the endoscopic

appearances under a degree of illumination always the same. The left

two-thirds of the stomach is most easily examined. The stomach wall

can be pushed by the tube into almost any position, and with the aid

of gentle external abdominal manipulation to draw over the pylorus it

is possible to examine directly almost all of the gastric walls except

the pyloric antrum, which is reachable in relatively few cases. A

lateral motion of from 10 to 17 cm. can be imparted to the

gastroscope, provided the diaphragmatic musculature is relaxed by deep

anesthesia. The stomach is explored by progressive traverse. That is,

after exploring down to the greater curvature, the tube-mouth is moved

laterally about 2 centimeters, and the withdrawing travel explores a

new field. Then a lateral movement affords a fresh field during the

next insertion. This is repeated until the entire explorable area has

been covered. Ballooning the stomach with air or oxygen is sometimes

helpful, but the distension fixes the stomach, lessens the mobility of

the arch of the diaphragm, and thus lessens the lateral range of

gastroscopic vision. Furthermore, ballooning pushes the gastric walls

far away from the reach of the tube-mouth. A window plug (Fig. 6) is

inserted into the ocular end of the gastroscope for the ballooning

procedure.



[275] Like many other valuable diagnostic means, gastroscopy is very

valuable in its positive findings. Negative results are entitled to

little weight except as to the explorable area.



The gastroscopist working in conjunction with the abdominal surgeon

should be able to render him invaluable assistance in his work on the

stomach. The surgeon with his gloved hand in the abdomen, by

manipulating suspected areas of the stomach in front of the tube-mouth

can receive immediately a report of its interior appearance, whether

cancerous, ulcerated, hemorrhagic, etc.



Lens-system ballooning gastroscopy may possibly afford additional

information after all possible data from open-tube gastroscopy has

been obtained. Care must be exercised not to exert an injurious degree

of air-pressure. The distended portion of the stomach assumes a

funnel-like form ending at the apex in a depression with radiating

folds, that leads the observer to think he is looking at the pylorus.

The foreshortening produced by the lens system also contributes to

this illusion. The best lens-system gastroscope is that of Henry

Janeway, which combines the open-tube and the lens system.



Gastroscopy for Foreign Bodies.--The great majority of foreign

bodies that reach the stomach unassisted are passed per rectum,

provided the natural protective means are not impaired by the

administration of cathartics, changes in diet, etcetera. This,

however, does not mean that esophageal foreign bodies should be pushed

into the stomach by blind methods, or by esophagoscopy, because a

swallowed object lodged in the esophagus can always be returned

through the mouth. Foreign bodies in the stomach and intestines should

be fluoroscopically watched each second day. If an object is seen to

lodge five days in one location in the intestines, it should be

removed by laparotomy, since it will almost certainly perforate.

Certain objects reaching the stomach may be judged too large to pass

the pylorus and intestinal angles. These should be removed by

gastroscopy when such decision is made. It is to be remembered that

gastric foreign bodies may be regurgitated and may lodge in the

esophagus, whence they are easily removed by esophagoscopy. The

double-planed fluoroscope of Manges is helpful in the removal of

gastric foreign bodies, but there is great danger of injury to the

stomach walls, and even the peritoneum, unless forceps are used with

the utmost caution.





More

;