L-5

Endoscopic procedures

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ENDOSCOPY

The use of fiber-optic scopes for the purpose of examination, diagnosis, and treatment.

Began as a diagnostic tool. Now most scopes are equipped w/

various gizmos for: biopsy, cauterization, and a wide variety of instruments for advanced surgical procedures.

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COMPLICATIONS / RISKS

Risk depends on the nature of the procedure and the anesthesia involved.

There are possible 7 risks of any endoscopy.

1) Perforation. 2) Aspiration. 3) Adverse drug reaction. 4) Cardiovascular problems, arrhythmias. 5) Bleeding. 6) Infection. 7) Reaction to contrast material.

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BRONCHOSCOPY

Examination of the trachea and main stem bronchi.

Primary purpose is to diagnose malignancy. Also used to remove foreign bodies. Can do biopsies, washings, and brush

biopsies. Can culture for pathogens: Pneumocystis

carinii, Legionella. Done under conscious sedation w/ topical

anesthetic, or general anesthesia.

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LARYNX

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BRONCHOSCOPY

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GASTROINTESTINAL ENDODOSCOPY

ESOPHAGOSCOPY- esophagus only. GASTROSCOPY- esophagus and stomach. ESOPHAGOGASTRODUODENOSCOPY-

esophagus, stomach, & duodenum. PROCTOSCOPY- anus & rectum. SIGMOIDOSCOPY- rectum and sigmoid

colon. COLONOSCOPY- rectum and entire colon. Usually done under conscious sedation,

occasionally general

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GASTROINTESTINAL ENDODOSCOPY

USES DIAGNOSIS / DETECTION OF: malignancy,

ulcers, bleeding, inflammation, etc. Removal of foreign bodies. Biopsy of polyps, lesions suspicious for

malignancy, etc. Control of bleeding via cautery, ligation.

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ESOPHAGUS

IMAGES COMPLIMENTS OF :http://www.gicare.com/pated/ei00001.htm

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Barretts Esophagus

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Esophageal Varicies

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Gasric hypylori inflammation

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Duodenal Ascariasis

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Foreign body Duodenum

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EUS LIV. Metastasis

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Colonic Diverticuli

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LOWER ESOPHAGEAL SPHINCTER

CLOSED OPEN

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REFLUX – (GERD)

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ESOPHAGEAL VARICES

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ESOPHAGEAL POLYP

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CANCER OF THE ESOPHAGUS

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ESOPHAGEAL MONILIASIS

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NORMAL STOMACH

FUNDUS ANTRUM PYLORIS

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HEMORRHAGIC GASTRITIS

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GASTRIC ULCER

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FOREIGN BODY - STOMACH

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FOREIGN BODY - STOMACH

PEARL EAR-RING

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STOMACH CANCER

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POLYPS - STOMACH

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NORMAL DUODENUM

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AMPULLA OF VATER

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DUODENAL ULCERS

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DUODENAL STRICTURE

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E.R.C.P. Endoscopic Retrograde

Cholangiopancreatography. Endoscope passed to the duodenum, w/

cannulation of the Ampulla of Vater. Dye is injected and films taken. Used to evaluate the patency and

integrity of the common bile duct, R/O obstruction, such as w/ stones.

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E.R.C.P. Helpful in the post-cholecystectomy

patient who has a post-op complication: stone obstructing the CBD, stricture, etc.

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E.R.C.P.

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E.R.C.P.

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NORMAL JEJUNUM

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CELIAC SPRUE

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COLONOSCOPY

USES Evaluation of rectal bleeding, abdominal pain,

etc.- cancer, polyps, inflammatory bowel disease.

Biopsy of suspicious lesions, polyps, inflammation.

Control of bleeding, banding of hemorrhoids. Also used as a screening tool for early diagnosis

of colon cancer, along w/ rectal exam and test for fecal occult blood.

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NORMAL COLON

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INTERNAL HEMORRHOIDS

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DIVRTICULOSIS

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DIVERTICULITIS

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ADENOMATOUS POLYP

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CROHN’S DISEASE - COLON

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CROHN’S DISEASE - ILEUM

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ULCERATIVE COLITIS

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CANCEROUS COLON POLYP

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CANCER - RECTOSIGMOID

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LAPAROSCOPY

Endoscopy of the abdomen (and pelvis). Wide variety of uses, too numerous to

mention, but examples would be: diagnosis and treatment of gynecologic pathology – endometriosis, ectopic pregnancy, infertility, and much more;

Cholecystectomy; appendicitis, etc. Has greatly reduced the hospital stay, cost,

pain, and recovery period as compared to “open” procedures (laparotomy).

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LAPAROSCOPY The abdomen is insufflated w/ CO2 in order to

“lift” (distend) the abdominal wall up off the abdominal contents, to allow for visualization, room to work in, etc.

Post-op, these patients experience right shoulder pain as the CO2 lodges under the right hemi-diaphragm, which is innervated by C-3-4-5.

Because of the CO2, general anesthesia is generally used, as patients are unable to ventilate w/ large volume of CO2 on board.

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LAPAROSCOPY – ECTOPIC PREGNANCY

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LAPAROSCOPY – ECTOPIC PREGNANCY

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LAPAROSCOPY – GALL BLADDER

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LAPAROSCOPIC CHOLECYSTECTOMY

1 2

3

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HYSTEROSCOPY - FIBROID

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HYSTEROSCOPIC MYOMECTOMY

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ARTHROSCOPY

Evaluation of joint pathology. Most commonly used in the knee –

torn menisci, ACL’s, etc. Used both as a diagnostic tool and

for surgical repair. Depending on the joint, can be done

under general anesthesia, or w/ regional block and sedation.

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NORMAL KNEE ANATOMY

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ARTHROSCOPY – TORN MENISCUS (MF)

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ARTHROSCOPY – NORMAL ACL

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CYSTOSCOPY Evaluation of the bladder, and urethra. For diagnosis and treatment of urethral and

bladder pathology, as well as for TURP’s. Can also evaluate the ureteral orifices, and

can cannulate the orifice and inject dye into the ureter, a “retro-grade” pyelogram.

Topical anesthesia can be used, but if extensive diagnostic or therapeutic procedures are done, sedation or regional block can be used.

DIAGNOSTIC PROCEDURES RELATED TO THE CHILDBEARING YEARS

CHAPTER 28

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TESTS OF TUBAL PATENCY 1) THE HSG – HYSTEROSALPINGOGRAM – X-Ray study w/ dye injected thru the cervix –

detects tubal occlusion, also looks at the anatomy/contour etc. of the uterine cavity (ies).

2) LAPAROSCOPY W/ TUBAL DYE STUDY – If needed to look for intra-abdominal pathology

as the problem, such as endometriosis, etc

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IF EVERYTHING IS NORMAL… Would typically proceed w/ laparoscopy. Looking for: tubal patency (dye study),

presence of adhesions (old PID), and endometriosis, which is a common finding in patients w/ otherwise unexplained infertility to this point.

Some physicians would also do a hysteroscopy- looking inside the uterine cavity to look for anatomic malformations, intracavitary / sub-mucous firoids, adhesions (Asherman’s Syndrome), etc.

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TESTS DURING PREGNANCY

TO DETECT CHROMOSOMAL, GENETIC, AND/OR STRUCTURAL

ABNORMALITIES DONE IN PATIENTS W/: 1) Advanced Maternal Age Risk - > age

35. Risk of chromosomal abnormalities increases with increasing maternal age.

2) Family or personal history of genetic or chromosomal abnormalities.

Ultrasonography

Obstetrics

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CRL: Crown Rump Length

Earliest detection at 4-5 weeks

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11-12 week fetus shows division of hemispheres and choroid plexus

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Fetal Spine

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Liver/Lung Interface

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Study of intracranial features including the cerebellum and corpus callosum.

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Umbilical Cord

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3D imaging of placenta

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3D Imaging of eyeball sockets at 12 weeks

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Diagnosis of fetal malformation. Hydrocephalus Anencephaly Myelomeningocoele Achondroplasia, Spina bifida, Cleft lips/ palate and Congenital cardiac abnormalities

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placenta previa diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth

retardation

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ULTRASOUND 3 “levels” of ultrasound. Level I – the basics – how many babies, how much

fluid, where’s the placenta, gestational age, is the heart beating, etc.

Level II – all the above plus a cursory evaluation for structural abnormalities – how many kidneys, does the heart have 4 chambers, etc.

Level III – targets specific areas, looking for the “usual’ signs of Downs, specific cardiac defects, neurologic defects, etc – usually done in response to something not being normal, elevated AFP, etc.

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AMNIOCENTESIS Removal of amniotic fluid for evaluation for: 1) Karyotype – the chromosome analysis; looks

for Downs, other trisomies, etc. 2) Biochemical defects – numerous metabolic

disorders such as the glycogen storage diseases (galactosemia, Tay Sach’s, etc), and can also test for genetic “markers” for things such as Huntington’s Chorea, muscular dystrophy, etc.

Typically done under ultrasound guidance at 16-18 weeks, sometimes combined w/ a Level III scan.

Karyotype can take up to 2 weeks for results.

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CHORIONIC VILLUS SAMPLING

The CVS. Trans-cervical sampling of the chorionic

villi, part of the placenta of fetal origin. Since there is no fluid, is limited to

chromosomal and genetic analysis. Done at 10-12 weeks. Risk of amnio = 1/200. Risk of CVS = 1/100, but get earlier

results.

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AMNIOCENTESIS FOR Rh DISEASE Rh Disease = Isoimmune Erythroblastosis

Fetalis = Hemolytic Disease of the Newborn. The gist of it is that the mother’s anti-Rh

antibodies results in hemolysis of fetal RBC’s.

This results in excess bilirubin, which can be detected in the amniotic fluid.

In a nutshell, when hemolysis is severe enough, can decide to do an intrauterine transfusion or delivery, depending on gestational age.

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ASSESSMENT OF FETAL MATURITY

When deciding to deliver a baby, especially if it is pre-term, it is useful to know if the baby’s lungs are mature.

Ventilation depends on the ability of the alveoli to remain open, which is dependent on surface tension, which is dependent on surfactant.

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ASSESSMENT OF FETAL MATURITY There are 3 chemicals values which, when

present in the amniotic fluid, predict the presence of adequate surfactant and pulmonary maturity, so that delivery can proceed without having to worry about delivering a baby unable to breath / oxygenate.

These 3 chemical values are: 1) The L/S ratio- lecithin and sphingomyelin. 2) S/A ratio- surfactant and albumin. 3) PG- phosphatidylglycerol.

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TESTS OF FETAL WELL-BEING

Fetal well-being, in a nutshell, means the degree to which a fetus is receiving oxygen from the placenta.

3 tests are commonly done to assess this: 1) THE NST- the non-stress test. 2) THE CST-contraction stress test (your

text calls it the contraction stress test). 3) THE BIOPHYSICAL PROFILE.

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THE NST

The stress that is missing in the non-stress test is the stress of uterine contractions.

The healthy fetus (and placenta) will ordinarily show variation in the fetal heart rate (FHR).

The NST looks for this variation, which is often associated w/ fetal movement.

The results are read as reactive, non-reactive, and equivocal.

Reactive is reassuring, non-reactive is not.

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NON-STRESS TEST

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THE CST During a contraction, blood flow to the placenta

(utero-pacental blood flow) is greatly decreased. Normally, there is enough “placental and fetal reserve” to compensate for this lack of perfusion.

Pregnancies in which placental function is diminished do not have this reserve.

When diminished reserve is present, the fetal heart rate will slow during a contraction, which indicates a fetus that is now or is soon to be compromised, and one that will not likely withstand the stress of labor.

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THE CST If the CST is positive (non-reassuring), delivery

is generally considered, often by C-section.

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THE BIOPHYSICAL PROFILE

An ultrasonic evaluation of: 1) Fetal movement. 2) Amniotic fluid volume. 3) Fetal muscle tone. 4) Fetal breathing activity, and 5) The NST. Each parameter is given a score of 0, 1, or

2. 10 is good, below 6 or so is bad.