Performing forward-viewing endoscopy at time of pancreaticobiliary EUS and ERCP may detect additional upper gastrointestinal lesions

Background and study aims: It is unknown whether significant incidental upper gastrointestinal lesions are missed when using non-forward-viewing endoscopes without completing a forward-viewing exam in linear endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) exams. We evaluated whether significant upper GI lesions are missed during EUS and ERCP when upper endoscopy is not performed routinely with a gastroscope.

Patients and methods: A retrospective analysis was performed in which an EGD with a forward-viewing gastroscope was performed after using a non-forward-viewing endoscope (linear echoendoscope, duodenoscope, or both) during a single procedure. Upper gastrointestinal tract findings were recorded separately for each procedure. Significant lesions found with a forward-viewing gastroscope were defined as findings that led to a change in the patient’s medication regimen, additional endoscopic surveillance/interventions, or the need for other imaging studies.

Results: A total of 168 patients were evaluated. In 83 patients, a linear echoendoscope was used, in 52 patients a duodenoscope was used, and in 33 patients both devices were used. Clinically significant additional lesions diagnosed with a gastroscope but missed by a non-forward-viewing endoscope were found in 30 /168 patients (18 %). EGD after linear EUS resulted in additional lesion findings in 17 /83 patients (20.5 %, χ² = 13.385, P = 0.00025). EGD after use of a duodenoscope resulted in additional lesions findings in 10 /52 patients (19.2 %, χ² = 9.987, P = 0.00157). EGD after the use of both a linear echoendoscope and a duodenoscope resulted in additional lesions findings in 3/33 patients (9 %, χ² = 3.219, P = 0.07).

Conclusion: Non forward-viewing endoscopes miss a significant amount of incidental upper gastrointestinal lesions during pancreaticobiliary endoscopy. Performing an EGD with a gastroscope at the time of linear EUS or ERCP can lead to increased yield of upper gastrointestinal lesions.

^* These authors contributed equally to the study.

• References

• 1 Andriulli A, Loperfido S, Napolitano G et al. Incidence rates of post ERCP complications. Am J Gastroenterol 2007; 102: 781-1788
• 2 Mekky MA, Abbas WA. Endoscopic ultrasound in Gastroenterology: From diagnosis to therapeutic implications. World J Gastroenterol 2014; 20: 7801-7807
• 3 Sahakian AB, Aslanian AS, Mehra M et al. The utility of esophagogastroduodenoscopy before endoscopic ultrasonography in patients undergoing endoscopic ultrasonography for pancreatio-biliary and mediastinal indications. J Clin Gastroenterol 2013; 47: 857-860
• 4 Chang KJ, Erickson RA, Chak A et al. EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain. Gastrointest Endosc 2010; 72: 967-974
• 5 Lee YT, Lai AC, Hui Y et al. EUS in the management of uninvestigated dyspepsia. Gastrointet Endosc 2002; 56: 842-848
• 6 Knopp H, Halm U, Lamberts R et al. Incidental and ablation-induced findings during upper gastrointestinal endoscopy in patients after ablation of atrial fibrillation: A retrospective study of 425 patients. Heart Rhythm 2014; 11: 574-578
• 7 Sharaf RN, Weinshel EH, Bini EJ et al. Endoscopy plays an important preoperative role in bariatric surgery. Obesity Surgery 2004; 14: 1367-1372
• 8 El-Dika S, Baltz J, White GE et al. Leading the blind: standard upper endoscopy provides an important road map prior to endoscopic ultrasound in patients without known luminal pathology. Gastrointest Endosc 2009; 69: AB336
• 9 ASGE Standards of Practice Committee. Early DS, Acosta RD et al. Adverse events associated with EUS and EUS with FNA. Gastrointest Endosc 2013; 77: 839-843