Share this page:
.

Endoscopy Service

This section deals with gastroscopy guidelines for inpatients; urgent gastroscopy out of hours or weekend; pre-gastroscopy requirements; indications for diagnostic gastroscopy; relative contra-indications to gastroscopy; therapeutic gastroscopy & how to organise; inpatient flexible sigmoidoscopy guidelines; contraindications for flexible sigmoidoscopy; colonoscopy guidelines; indications for colonoscopy; contraindications for colonoscopy; ERCP guidelines; indications for ERCP; antibiotic prophylaxis for endoscopic procedures and patients on anticoagulants requiring endoscopy.


 Gastroscopy guidelines for inpatients

  • Use Inpatient Gastroscopy Request Form
    • ensure reason for request & clinical condition clearly documented
    • hand the request to one of the nursing staff in the unit, who will check that you have given sufficient information on the form
    • out of hours the form can be posted in / slid under the endoscopy unit door
    • you must ensure that the patient understands what the procedure involves and why they need it. If the patient is unable to give informed consent for the procedure, you must ensure that a consent form 4 has been completed by your consultant
    • give the patient the inpatient gastroscopy explanation leaflet and a consent form for them to read and fill in if they wish and are able (formal consent will be taken or confirmed in the endoscopy unit)
  • All request forms are vetted by one of the consultants in endoscopy and if there is insufficient information for them to decide that the procedure is appropriate and safe you will be contacted to provide more information before the procedure is organised
  • Once the endoscopy consultant has confirmed the procedure is to be done, the endoscopy nurses will organise this with the wards
  • Two gastroscopy slots are reserved at 8am (work days) for in-patient requests, other procedures will be fitted in wherever possible
  • If a procedure is very urgent, you should come down to the endoscopy unit to discuss this with one of the consultants there. Endoscopy will only be performed once the patient has been adequately resuscitated 

Urgent gastroscopy out of hours or weekend

  • Firstly discuss this with the consultant in charge of the patient
  • Contact the duty Endoscopist
    • the rota is posted on the door of the endoscopy unit, in the main theatre and on AAU

There is only nursing cover for out of hours gastroscopy from 6am-6pm at the weekend.

  • Inform the surgical SpR on call  

Pre-gastroscopy requirements

Patients should not have any food for 6 hours before a procedure, but can drink clear fluids until 2 hours before a procedure.

  • All patients coming down for a procedure MUST have intravenous access
  • Patients should be haemodynamically stable  

Indications for diagnostic gastroscopy

  • Upper GI bleeding
  • Dysphagia
  • Progressive unintentional weight loss
  • Persistent vomiting
  • Iron deficiency anaemia
  • Epigastric mass
  • Abnormal imaging
  • Follow up of gastric ulcers (6 weeks after the initial gastroscopy) and Barrett's oesophagus (2 yearly unless dysplasia detected) 

Relative contra-indications to gastroscopy

  • INR >3.0 (biopsies will not be taken, increased risk of bleeding)
  • Recent MI or CVA - endoscopy should not be performed within 4 weeks of an MI
    • unless there is a strong indication or the results are likely to significantly alter management
  • Severe COPD with hypoxaemia
  • Pregnancy - endoscopy should be avoided in the first trimester if at all possible 

Therapeutic gastroscopy and how to organise

  • Upper GI bleeding
  • Variceal banding
  • Relief of bolus obstruction
  • Foreign body removal
  • Placement of feeding tubes, such as NJ tube or PEG insertion**
  • Oesophageal or pyloric dilatation**
  • Insertion of oesophageal, pyloric or duodenal stent**

** Requests for therapeutic endoscopy, other than for GI bleeds and relief of bolus obstruction and foreign body removal, should be sent by a standard yellow board to the appropriate consultant and the relevant nurse specialist informed.

  • All requests for oesophageal dilatation or oesophageal stent insertion should be sent to Dr Simmonds secretary
  • All requests for PEG insertion should be sent to Dr Mylvaganam (DME patients) or Dr Simmonds and the nutrition nurses must be informed ASAP 

Inpatient flexible sigmoidoscopy guidelines

  • Inpatient Flexible Sigmoidoscopy Request form should be completed
    • ensure reason for request & clinical condition clearly documented
    • hand the request to one of the nursing staff in the unit, who will check that you have given sufficient information on the form
    • out of hours the form can be posted in / slid under the endoscopy unit door
    • you must ensure that the patient understands what the procedure involves and why they need it. If the patient is unable to give informed consent for the procedure, you must ensure that a consent form 4 has been completed by your consultant
    • give the patient the in patient Flexible Sigmoidoscopy explanation leaflet and a consent form for them to read and fill in if they wish and are able (formal consent will be taken or confirmed in the endoscopy unit)
  • All request forms are vetted by one of the consultants in endoscopy and if there is insufficient information for them to decide that the procedure is appropriate and safe you will be contacted to provide more information before the procedure is organised
  • Once the endoscopy consultant has confirmed the procedure is to be done, the endoscopy nurses will organise this with the wards
  • The procedure is done either without sedation, with entonox or with conscious sedation using low doses of midazolam 

Pre-flexible sigmoidoscopy requirements

  • All patients coming down for a procedure would have intravenous access
  • Phosphate enema (written up on the drug chart) to be given on the ward about 30 minutes before the scheduled procedure time 

Indications for flexible sigmoidoscopy

  • Evaluation of fresh rectal bleeding in the absence of an obvious anal cause
  • Evaluation for an anastomotic recurrence in rectosigmoid carcinoma
  • Evaluation of the sigmoid colon where there is uncertainty following a radiological investigation
  • Decompression of sigmoid volvulus

Please note: rigid (NOT flexible) sigmoidoscopy is required to exclude an obstructing rectal tumour prior to barium enema or CT colongraphy. 


Contraindications for flexible sigmoidoscopy

  • Acute severe colitis
  • Acute severe diverticulitis
  • Where a colonoscopy would be more appropriate 

Colonoscopy guidelines

  • Colonoscopy is rarely necessary to perform as an inpatient as it requires full bowel preparation before the procedure and is a longer procedure taking about 45 minutes, which is difficult to fit in at short notice
  • Colonoscopy is usually done under conscious sedation
    • using a combination of  pethidine, midazolam and / or entonox

If a colonoscopy is required as an inpatient, you should bring a form to the Endoscopy unit and discuss this with one of the Endoscopy consultants. 


Indications for colonoscopy

  • Unexplained iron-deficiency anaemia
  • Evaluation of unexplained GI bleeding (melaena after an upper GI source has been excluded, presence of faecal occult blood)
  • Evaluation of a clinically significant lesion on either a barium enema or CT scan
  • Inflammatory bowel disease (evaluation of disease extent / activity, surveillance for colorectal cancer)
  • Clinically significant diarrhoea of unexplained origin
  • Change in bowel habit to looser more frequent stools lasting more than 6 weeks (age >60 OR >40 if associated with rectal bleeding)
  • Surveillance for colonic neoplasia (BSG 2002)
    • colonic adenomas
    • IBD
    • uretero-sigmoidostomy
    • acromegaly
    • familial adenomatous polyposis, juvenile polyposis, Peutz-Jeghers syndrome, HNPCC, family history of colorectal cancer (1 first degree relative <45years or 2/more first degree relatives any age)
    • positive FOBs in the national bowel cancer screening programme 

Contraindications for colonoscopy

  • See contraindications for gastroscopy
  • Patients unable to cope with or unfit for full bowel preparation
  • Acute severe colitis
  • Acute severe diverticulitis
  • Under general anaesthesia 

ERCP guidelines

  • ERCP is performed by Miss Cheslyn-Curtis and Mr Whitelaw
  • Patients should be referred using a yellow board.
  • If patients are scheduled to have an ERCP as an inpatient
    • they should be given an ERCP information sheet and endoscopy consent form
    • adequate time and information to make an "informed decision" about giving their consent to the procedure 

Indications for ERCP

  • Obstructive jaundice thought to be due to biliary obstruction
  • Clinical and biochemical or imaging data suggest pancreatic or biliary tract disease
  • Stent placement across benign or malignant strictures, fistulae, postoperative bile leak, or large common bile duct stones
  • Tissue sampling from pancreatic or bile ducts 

Antibiotic prophylaxis for endoscopic procedures

  • NICE guidelines (2008) no longer recommend antibiotics for the prophylaxis of endocarditis - full guidelines available from the British Society of Gastroenterology.
  • Routine prophylaxis for ERCP (where complete biliary drainage unlikely to be achieved)
    • oral ciprofloxacin 750mg 2 hours before the procedure or iv gentamicin if unable to take oral medications only in the following circumstances
      • biliary disorders - primary sclerosing cholangitis or hilar cholangiocarcinoma
      • liver transplantation
      • pancreatic pseudocyst
  • PEG insertion
    • co-amoxiclav 1.2 g stat 30 minutes before the procedure OR teicoplanin 400mg iv stat if allergic to pencillin (patients who are already on antibiotics do not need additional prophylaxis)
  • Variceal bleeding
    • patients should already be on antibiotics for the prevention of bacterial peritonitis (piperacillin / tazobactam)
  • Profound immunocompromise (severe neutropenia (<0.5x109/l) and/or advanced haematological malignancy)
    • only indicated in procedures with a high risk of bacteraemia (eg sclertherapy, dilatation, ERCP with obstructed system) 

Patients on anticoagulants requiring endoscopy

Detailed guidance is available from Hospital Guidelines on Anticoagulation for Invasive Procedures in Patients on Warfarin and the British Society of Gastroenterology. If in doubt seek advice from endoscopy.