BASIC SKILLS
An introduction to flexible
endoscopy
Katie Schwab
Sukhpal Singh
Abstract
The use of flexible endoscopes is common in both medical and surgical
specialties. Flexible endoscopes provide the unique ability to reach cavi-
ties and viscera not visible to the naked eye. They allow for minimally
invasive investigation of symptoms, diagnosis of pathology and applica-
tion of directed therapies. Although the ability to see inside the human
body has challenged pioneers of medical science for centuries, it is
only in the last 100 years that technology has evolved to produce the
advances in computers, fibreoptics and mechanics required for endos-
copy. The commonest flexible endoscopic examinations of the gastroin-
testinal (GI) tract are oesophagogastroduodenoscopy (OGD) and
colonoscopy. These are discussed in detail in this article, including their
indications, preparation for, risks and the procedure itself. Future applica-
tions of flexible endoscopy include advances in the imaging systems,
newer endoscopes with ‘self-drive’ capabilities and enhancement of tar-
geted therapeutics. Also falling under the future umbrella of flexible endo-
scopists is the application of NOTE (Natural Orifice Transluminal
Endoscopic) surgery.
Keywords Colonoscopy; complications; flexible endoscopy; history;
procedure; oesophagogastroduodenoscopy; sigmoidoscopy
What is endoscopy?
The word ‘endoscopy’ comes from the Greek Endon ¼ inside and
Skopeo ¼ to look at, therefore is the ability of a medical practi-
tioner to look inside cavities and viscera. Endoscopy can be
subdivided into rigid and flexible, related to the scopes used. This
article addresses the basics of gastrointestinal (GI) flexible
endoscopy. Rigid endoscopy is discussed elsewhere in this issue.
A brief history of endoscopy
Early civilizations, including the Egyptians, Greeks and Romans,
tried to visualize internal body cavities with a variety of tools
including early specula. The first endoscope came from Bozzini,
a German urologist in 1806. He used concave mirrors and candle
light to allow examination of the bladder through a hollow tube,
called the ‘Lichtleiter’ (light conductor). Nitze, also a German
urologist, improved on Bozzini’s work by the addition of an
electric light. Desormeaux introduced the word ‘L’endoscopie’ in
Katie Schwab MBBS (Hons) BSc MRCS is an ST4 in General Surgery at
Frimley Park Hospital, Surrey, UK. Conflicts of interest: none declared.
Sukhpal Singh FRCS is a Consultant Upper Gastrointestinal and General
Surgeon at Frimley Park Hospital, Surrey, UK. Conflicts of interest: none
declared.
SURGERY 29:2
the mid-1800s and Kussmaul performed the first direct oeso-
phagogastroscopy with the assistance of a sword swallower in
the 1860s. The 1930s saw the engineering of semi-flexible
endoscopes, called gastroscopes, but it was the technological
advances in the post-war period of the 1950s which saw the birth
of fibreoptics and Hopkins’s fibreoptic endoscope.
The flexible endoscope
Although there are many different applications for the flexible
endoscope, the basic equipment is similar between all types of
scopes. The main equipment includes the endoscope, stack and
instrumental tools.
 Endoscope
B Optic fibre system to conduct light from a source through
the scope to its tip
B Chip camera positioned at tip and connector system to
relay image back to screen
B Plumbing systems with independent channels to allow
irrigation of tip, suction and insufflation
B Working channel for passage of instruments
B Control body (Figure 1) which houses the outlets for the
plumbing systems, ports for access to the working channel
(s) and the control knobs which allow rotation of the distal
tip via a complex angulation system
 Stack (Figure 2)
B Light source
B Insufflator system
B Suction unit and water reservoir
B Electrosurgical unit argon plasma system
B Image recorder (video/digital recorder; photo-capture and
printer)
 Instruments/extras
B Biopsy forceps
B Snares
B Injecting and cutting needles
B Electrosurgical probes
B Dilating and stenting kits.
A variety of specialized flexible endoscopes are used in medical
practice (Table 1 and Figure 3).
Gastrointestinal flexible endoscopy
Joint Advisory Group on GI endoscopy (JAG)
‘JAG ensures the quality and safety of patient care by defining
and maintaining the standards by which endoscopy is practised
in the UK’ www.thejag.org.uk.
JAG provides nationwide training for doctors and nurses
through regional training and mentored assessment programmes,
as well as running centralised basic and advanced skills courses.
To practice independently as an endoscopist, JAG certification is
needed and course attendance compulsory, although for surgical
trainees this is not expected until after the fifth year of registrar
training. JAG also provides guidance on the set up and running of
endoscopy units, to ensure universal standards are met.
Endoscopy units
Gastrointestinal flexible endoscopies are usually performed in
dedicated endoscopy day units with specially trained staff. The
units consist of a reception and waiting area for patients, with
80 Ó 2010 Elsevier Ltd. All rights reserved.
 BASIC SKILLS
Picture of the control body of a flexible endoscope
Control knobs
for rotation
and angulation
of the tip
Figure 1
easily accessible toilet facilities, individual private treatment
rooms for the provision of the endoscopy, a step-down/recovery
area, cleaning and sterilizing facilities for the turnaround of the
scopes and administration offices. The most commonly per-
formed gastrointestinal endoscopies are oesophagogastroscopy
and colonoscopy.
Sedation and monitoring
Patient tolerance of endoscopic procedures may be improved
with sedation and analgesic agents. National guidelines exist
with evidence-based recommendations, summarized as follows:
 Safe secure intravenous (IV) access (non-butterfly) to be used
and remain until post-recovery.
 Continuous non-invasive blood pressure and pulse oximetry
monitoring.
 Continuous peri-procedural oxygenation of patient.
 Benzodiazepine and opioid IV to be used as sedative and
analgesic.
 Any escalation of sedation to be done in presence of
anaesthetist.
 Appropriate dose for age and physiological condition of
patient, given as small aliquots and titrated.
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Plumbing controls
allowing insufflation,
suction and irrigation
at tip
Port for access
to the working
channel
 Good communication with nursing staff regarding dosage and
vital signs.
 Awareness of cardiopulmonary complications of drugs and
their management (head down and IV fluids for low blood
pressure, over-sedation and respiratory depression requiring
reversal agents and appropriate resuscitation).
 Clear thorough documentation of entire procedure not just
endoscopic findings.
Consent
Before undergoing an endoscopy, patients should have under-
gone the process of giving informed consent e adequate proce-
dural information given, risks and complications explained, co-
morbidities and possible use of sedation addressed with ample
opportunity for questions to be answered. Consent is usually
supported with information leaflets.
Upper gastrointestinal tract endoscopy
Indications
1. Diagnostic
a To investigate causes of anaemia, upper GI haemorrhage,
persistent vomiting
81 Ó 2010 Elsevier Ltd. All rights reserved.
 BASIC SKILLS

Stack systems and extras for flexible endoscopy

Light source and

insufflation system

Electrosurgical unit

Monitor

Suction unit and

water reservoir

Image recording systems,

photo-capture and printer

Figure 2

b To investigate upper GI symptoms including dyspepsia, b Variceal treatment e including injecting, banding and
reflux, dysphagia (difficulty in swallowing) and odyno- glue
phagia (pain on swallowing) c Polyp snaring
2. Surveillance d Removal of foreign bodies
a Review of peptic ulcer healing e Dilatation of strictures or achalasia
b Barrett’s oesophagitis f Stenting
c Post-surgery 5. Specialist endoscopic procedures
3. Biopsying a EUS (endoscopic ultrasound assessment of organs)  EUS
a Clo test for Helicobacter pylori guided FNA (fine needle aspiration)
b Duodenal biopsy for coeliac disease b Endoscopic retrograde cholangiopancreatography (ERCP)
c Mucosal biopsy for pathology e utilizing a side-viewing scope and fluoroscopy to access
4. Therapeutic the bile and pancreatic ducts
a Intervention of upper GI bleeding e including adrenaline c Percutaneous endoscopic gastrostomy (PEG) insertion,
injection, clips, gold probe guidance of enteral feeding tubes under direct vision

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 BASIC SKILLS

Various specialised flexible endoscopes used in medical practice

Body system Name of endoscopy What is visualized/accessed

Gastrointestinal (GI) tract Oesophagogastroduodenoscopy (OGD) Oesophagus, stomach and duodenum

Enteroscopy Small intestine
Colonoscopy Large intestine (and terminal ileum)
Sigmoidoscopy Sigmoid colon, rectum
Endoscopic UltraSound (EUS) Upper GI tract and biliary tree
Biliary tree Endoscopic retrograde cholangiopancreatography Pancreas, common bile duct, hepatic ducts and
(ERCP) gallbladder
Choledocoscopy Intraoperative access to bile ducts
Duodenoscope-assisted cholangiopancreatoscopy
Respiratory tract Bronchoscopy/endobronchial ultrasound Trachea, large and small bronchi
Ear, nose and throat Rhinoscopy Nose
Laryngoscopy Throat
Urological Cystoscopy Bladder, urethra
Uretoscopy Ureters
Gynaecological Hysteroscopy Uterus
Falloscopy Fallopian tubes

Table 1

d Endoscopic or EUS-guided drainage (e.g. pancreatic
pseudocysts).
The procedure
Patients are kept nil by mouth for 4e6 hours before the procedure.
Local anaesthetic spray is administered to the oropharynx to
reduce the gag reflex and intravenous sedation may be adminis-
tered. The patient lies on their left side with monitoring attached
and a mouth guard is placed between their teeth to prevent scope
damage. The endoscopist, after checking that the scope has been
connected to the stack correctly (light, suction, insufflation and
irrigation) gently passes the scope over the tongue and manoeu-
vres alongside the epiglottis to intubate the oesophagus. The scope
is passed through the oesophagus and stomach through to
duodenum under direct vision, noting pathology as seen. Retro-
flexion or J-manoeuvre allows for full vision of the fundus of the
stomach and the gastro-oesophageal junction (GOJ). Any extra
instrumentation such as biopsy can be performed and photo-
graphs may be taken as evidence of findings. Any insufflated gas
can be removed on withdrawal of the scope.
Risks/complications of oesophagogastroduodenoscopy (OGD)
The risk of complications is quoted as approximately 1 in 1000,
increased in therapeutic procedures.
The main risks in order of most common are:
 cardiopulmonary problems (aspiration, respiratory depression,
hypotension, arrhythmias)
 perforation
 bleeding
 injury to teeth.
Lower gastrointestinal endoscopy
Indications
1. Diagnostic
a Investigation of change of bowel habit, especially diar-
rhoea and increased frequency of stool
b Investigate anaemia (usually in conjunction with OGD)
c Investigate symptoms including abdominal pain, bloating,
weight loss and unexplained rectal bleeding
2. Surveillance
a Inflammatory bowel disease
b Polyposis
c Post-cancer surgery
3. Biopsying
a Terminal ileum biopsies for Crohn’s disease
b Biopsying pathology visualized on radiological imaging
c Tattooing lesions for laparoscopic resection
4. Therapeutic
a Snaring polyps
b APC or laser therapy to vascular anomalies
c Haemorrhage control
d Stenting
5. Screening for cancer
a Positive faecal occult blood results (FOBs) in the national
screening programme
b Strong family history
c Familial polyposis syndrome.
The procedure
Bowel preparation is required before lower GI endoscopy to
ensure clear vision of all colonic mucosa. This consists of 2e3
days of a low-fibre diet prior to colonoscopy and prescribed oral
laxatives to clear the colon the day before (for colonoscopy) or
enemas on the day (for flexible sigmoidoscopy). Care needs to be
taken with preparation in patients with significant renal or
cardiovascular co-morbidities due to the osmotic laxative effects.
If there are concerns, a patient can be admitted for administration
of the preparation and supplemental fluid. Intravenous analgesia
and sedation are given before the procedure to help the patient

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 BASIC SKILLS
Figure 3 Examples of different flexible endoscopes. (From left to right,
Colonoscope, OGD, Cystoscope).
tolerate the colonoscopy. This is not usually required for flexible
sigmoidoscopy.
A digital rectal examination is performed first to check sphincter
tone, assess bowel preparation, lubricate the anus and ensure no
anal lesions have been missed. The colonoscope is then inserted
into the anus and guided through the rectum and colon (sigmoid,
descending, transverse and ascending) to caecum and possibly
terminal ileum. Sigmoidoscopy will visualize the left colon.
Insufflation is required to visualise the lumen. ‘Looping’ of the
colonoscope in the non-fixed colon may result in discomfort for the
patient and lack of forward progress. Methods to resolve formation
of the loop and prevent recurrence can include torque application
to the scope, fixation of scope tip and withdrawal to straighten the
scope, stiffening of the scope, repositioning of the patient and
SURGERY 29:2
pressure applied by an assistant to the patients abdomen. To try to
ensure that no pathology is missed, slow withdrawal of scope is
advised. Polyps can be snared, biopsies and photographs taken
and interventions performed throughout the procedure.
Risks/complications of lower GI endoscopy
 Cardiopulmonary problems (as listed for OGD)
 Dehydration from bowel preparation
 Perforation (risk increases with biopsy & polypectomy) 0.2%
 Bleeding 1.5%
Future developments in flexible endoscopy
Imaging
 High-definition systems e enhancing the quality of image
 3D ability e improving assessment of structures and pathology
 Narrow band imaging-filter enhances the quality of fine
structures and capillary network of the mucosal surfaces
 Computed virtual chromoendoscopy and endomicroscopy e
enhancing abnormal cellular areas in mucosa
Endoscopes/endoscopic assistance
 Improved angle of vision from 140 to 170 /210 /even 360
 Self-propelling endoscopes e scopes with gas propulsion
systems to ‘pull’ themselves around the colon
 Self-guiding systems e allowing for computer mapping and
driving of scope by computer not hand
 Guiding systems e providing computer-generated scope posi-
tioning to allow endoscopist improved awareness of anatomical
position of scope and information of direction of loop formation
Therapeutic tools
 Advances in stents e shapes, materials, deployment systems,
possible drug impregnation for targeted delivery
Future techniques not yet fully in practice
 Full thickness mucosal resection of tumours
 NOTES e Natural Orifice Transluminal Endoscopic Surgery e
the ability to reach intra-abdominal organs endoscopically
through the mucosal wall of the GI tract (such as stomach) and
vaginal vault, with operating tools manipulated through the work
channels of an endoscope. There has been reported success with
appendicectomy and cholecystectomy. The aim is to improve
patient recovery, reduce anaesthesia requirements and possibly
allow day surgery with minimal perioperative requirements. A
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Hart R, Classen M. Complications of diagnostic gastrointestinal endos-
copy. Endoscopy 1990 Sep; 22: 229e33.
Majumdar SK. A short history of gastrointestinal endoscopy. Bull Inst Hist
Med Hyderabad 1993; 23: 67e86.
Sivak MV. Gastrointestinal endoscopy: past and future. Gut 2006; 55: 1061e4.
Standards of Practice Committee of the American Society for Gastrointestinal,
Lichtenstein DR, Jagannath S, Baron TH, et al. Sedation and anesthesia in
GI endoscopy. Gastrointest Endosc 2008 Nov; 68: 815e26.
84 Ó 2010 Elsevier Ltd. All rights reserved.