If your doctor has determined that you should have an upper endoscopy, you may have some questions and concerns about the procedure. This handout will give you information about upper endoscopy and answers to questions that patients often ask.

An upper endoscopy is a very safe procedure that gives your doctor information that other tests may not be able to provide. The test involves swallowing a small flexible instrument that can allow your doctor to examine the upper part of the gastrointestinal system, which includes the esophagus (swallowing tube), the stomach, and the duodenum (the first section of the small intestine). An endoscopist, a doctor who has special training in the use of endoscopes, will examine the inside lining of these structures, looking for inflammation (redness, irritation), bleeding, ulcers, or tumors.

INDICATIONS FOR UPPER ENDOSCOPY — The most common reasons an upper endoscopy is performed are to evaluate the following:

• Persistent nausea and vomiting
• Upper abdominal pain, heartburn, or acid reflux symptoms (an acid or burning sensation in the throat or chest)
• Gastrointestinal (GI) bleeding (vomiting blood or blood found in the stool)
• Difficulty swallowing; food/liquids getting stuck in the esophagus
• Abnormal or unclear findings on an upper GI x-ray
• Removal of a foreign body
• To follow-up on previously found polyps (growths), tumors, or ulcers.

At the time of the procedure, the endoscopist may take tissue samples (biopsies) or stretch the esophagus with a small tube, depending upon what is found during the exam.

PREPARATION — Your doctor will provide specific instructions on how to prepare for the examination. The instructions are designed to maximize your safety during and after the examination and to minimize possible complications. It is important that you read the instructions ahead of time and follow them carefully. Do not hesitate to call your doctor or the endoscopy unit if you have questions.

You will be asked not to eat or drink anything for six to eight hours before the test. It is important for your stomach to be empty at the time of the examination to allow the endoscopist to see all the important structures and to decrease the possibility of food or fluid being vomited into your lungs while you are sedated; this is called aspiration.

You may be asked to adjust doses of your medications or to eliminate specific medications prior to the examination. Some medications need to be discontinued for several days, so read your doctor's instructions when you receive them. Be sure to ask your doctor specifically what you should do about your particular medications since some medicines are more important than others, and your doctor may want you to take them despite the examination.

You will also be instructed to arrange for a responsible person to escort you safely home after the examination. Even though you will be awake by the time you are discharged, the medications used to sedate you cause changes in your reflexes and judgment that will leave you feeling well, but will interfere with your ability to drive or make decisions coherently, similar to the effects of alcohol.

WHAT TO EXPECT IN THE ENDOSCOPY UNIT — Prior to the endoscopy, a nurse will prepare you for the examination. This will include taking a medical history from you to determine what you already know about the procedure and whether you understand why the examination is being done. The nurse will ask questions to determine if you are properly prepared, such as "have you been fasting?" and "do you have an escort home?" Other questions that you should be prepared to answer include:

• What medications do you take?
• Do you have any medical problems, such as heart disease, lung disease, etc?
• Do you have allergies to the medicines, Latex, or dyes used in medical procedures?
• Have had any previous adverse reactions to sedation medications or narcotics?

The nurse will start an intravenous line (put a needle in a vein in your arm) to administer medications to help you relax and keep you comfortable during the examination. This is just a pin prick, no worse than having your blood drawn. Your vital signs (blood pressure, heart rate, and blood oxygen level) will be monitored during the examination and for a time after it has been completed. The nurse will check your blood pressure and pulse either manually or with a machine that continuously monitors your heart rate and rhythm, oxygen level, and blood pressure. The monitoring devices are not painful. You may also be given oxygen during the exam.

A doctor will review the examination with you, including possible complications, and will ask you to sign a consent form. You will then be given medication to gargle to numb your throat, or, a numbing spray might be used. For safety reasons, you will be asked to remove dentures.

THE PROCEDURE — The endoscopy will be performed with you lying on your left side. Medications will be administered through the intravenous line. Most endoscopy units use a combination of a sedative, to help you relax, and a narcotic, to diminish any unpleasant sensations. A plastic mouth guard will be placed between your teeth to prevent damage to your teeth and the scope. You will be asked to swallow the tube when it is introduced into your mouth, though you may not remember doing this once the medications have taken effect. Many patients are concerned that they will have difficulty swallowing the tube. However, the medications given make swallowing of the tube easy for almost all patients. Many people sleep during the test; others are very relaxed, comfortable, and generally not very aware of the examination. The best advice is to relax, breath through your nose and try to sleep.

The endoscope is a flexible tube with a lens and a light source that allows the endoscopist to either look into the scope or to look at a TV monitor. If the image is reflected on a TV monitor, it is magnified many times so the endoscopist can see minute changes in tissue.

The endoscope contains channels that allow the endoscopist to take biopsies (small pieces of tissue) and to introduce or withdraw fluid and air. Biopsies are not painful. Air is introduced through the scope to open up the esophagus, stomach, and intestine so the scope can be passed through these structures and to allow the endoscopist to see. You may experience a mild discomfort from the air as it distends the tissue. It is not harmful to you, and you may belch to relieve the sensation. It is important to remember that the endoscope does not interfere with your breathing, and that, in fact, concentrating on taking slow, deep breaths during the procedure may help you to relax further.

RECOVERY — After the endoscopy, you will be kept for a time for observation while some of the medicine wears off. The most common discomfort after the examination is a feeling of bloating from the air introduced during the examination, which resolves quickly. Some patients also have a mild sore throat. Unless you are given other instructions, you should be able to eat a few hours after the examination. The medicines leave many patients feeling tired afterwards or they may have difficulty concentrating, so it is usually advised that you do not to return to work that day.

The endoscopist can usually tell you the results of your examination before you leave the endoscopy unit. If biopsies have been taken or polyps removed, you will be instructed to call back for results. Tissue that has been removed is sent to a lab for analysis and it may take several days for a report to be completed.

COMPLICATIONS — Upper endoscopy is a safe procedure and complications are rare, but can occur:

• Aspiration of food or fluids into the lungs, the risk of which can be minimized by having you refrain from eating or drinking for several hours before the examination.
• The endoscope can cause a tear or hole in the tissue being examined. This is a serious complication but fortunately occurs only very rarely.
• Bleeding can occur from biopsies or the removal of polyps, but it is usually minimal and stops quickly on its own or can be easily controlled.
• Reactions to the medicines used to sedate you are possible, so the endoscopy team (doctors and nurses) will ask you about previous medication allergies or reactions and about health problems such as heart, lung, kidney, or liver disease. Providing this information to the team ensures a safer examination.
• The medications can also produce irritation in the vein at the site of the intravenous line. If redness, swelling, or warmth occurs, warm to hot wet towels applied to the site may relieve the discomfort. If discomfort persists, notify your doctor or the endoscopy unit.

The following symptoms should be reported immediately:

• Severe abdominal pain (not just gas cramps)
• A firm, distended abdomen
• Vomiting
• Fever
• Difficulty swallowing/severe sore throat
• A crunching feeling under the skin.

AFTER UPPER ENDOSCOPY — Though patients worry about the discomforts of the examination, most people tolerate it very well and feel fine afterwards. Some fatigue is common after the examination, and you should plan to take it easy and relax the rest of the day.

You should contact your doctor about the results of your test if you have any questions and especially if biopsies were taken. The endoscopy team can give you some guidelines as to when your doctor should have all the results and whether further treatment will be necessary.