ESOPHAGOGASTRODUODENOSCOPY (EGD)

CORE CURRICULUM – June 2004

Draft submitted by
ASGE Committee on Training

PREAMBLE

This document, prepared by the ASGE Committee on Training, was undertaken to describe
recommendations for upper endoscopy training and written primarily for those endoscopists
involved in teaching endoscopy to fellows/trainees. This core curriculum was developed as an
overview of techniques currently favored for the performance and training of upper endoscopy
and serve to as a guide to published references, videotapes and other resources available to the
trainer. By providing information to endoscopy trainers about the common practices utilized by
experts in performing the technical aspects of the procedure, the Committee on Training hopes
to improve the teaching and performance of upper endoscopy.

I. INTRODUCTION

Acquiring the skills to perform upper endoscopy safely, effectively, and comfortably requires an
understanding of the indications, risks, and limitations of the procedure. It also requires
competence in maximizing visualization of the esophagus, stomach, and duodenum, minimizing
patient discomfort, ensuring the appropriate identification normal and abnormal findings and
performs therapeutic techniques. A recently updated ASGE guideline entitled “Principles of
Training of Gastrointestinal Endoscopy” and the section of the Gastroenterology Core
Curriculum developed by the Task Force in Gastrointestinal Endoscopy review the overall
objectives of endoscopic training, the requirements for endoscopic trainers, and the training
process itself. The evolving issue of competency assessment in endoscopy training is also
reviewed. These core documents are pertinent and are recommended to endoscopic trainers and
trainees alike.

II. PERI-PROCEDURE MANAGEMENT

A. Pre-procedure Management

Training in the techniques of upper endoscopy must go hand-in-hand with the

development of expertise in the wide variety of upper gastrointestinal disease confronted
by the endoscopist. A thorough knowledge of indications, contraindications,
complications and issues of informed consent, patient education, antibiotic prophylaxis,
and anticoagulation management are essential and should be taught to all trainees.
Ideally, these issues should be addressed with the trainee during the initial patient
encounters before the procedures are scheduled. Full reviews of these topics are beyond
the scope of this document but are covered in ASGE guidelines referenced, and are also
available on the ASGE website (http://www.asge.org).

The critical importance of preparation for optimal visualization, safety and ease of upper
endoscopy examination must be taught to all trainees. In general, an upper endoscopy is

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 performed when the patient has been fasting for solids and nonclear liquids for 6 to 8
hours or since midnight and for 2 to 3 hours for clear liquids prior to the procedure
(Anesthesiology 1996; 84:459-71).

B. Patient Management and Physician Behavior during Upper Endoscopy

Maintenance of patient comfort, dignity and privacy are of paramount importance during
upper endoscopy; these are skills best taught by example, supplemented with feedback
and constructive criticism to the trainee. During the procedure itself, communication and
feedback between the endoscopist, assistant and patient are essential for patient comfort
and safety, but these skills may be underdeveloped by the early trainee focused on the
technical aspects of the procedure. In particular, good patient communication is
extremely important in relieving patient anxiety and limiting discomfort, and should be
an important part of upper endoscopy training. The art and science of conscious sedation
must also be mastered to trainees of endoscopy with ASGE documents and other
published guidelines very helpful in the teaching process.

Finally, a positive teaching environment must be maintained in the procedure room at all
times, and interruptions kept to a minimum. Individual teaching styles vary, but the
trainer must foster a positive, professional learning environment by offering constructive
comments.

C. Post-procedure Management

Following upper endoscopy, communication of findings, therapeutic results, and plan for
follow-up must be emphasized to the trainee as an extremely important phase of the
procedure. This involves both discussions with the patient and effective communication
to the referring health professional. The importance of complete procedure reporting
cannot be overemphasized, and the need to utilize accepted nomenclature to describe
findings must be imbued in the trainee. Trainers and trainees alike should utilize the
accepted minimum standard terminology (MST) in their computerized procedure
reporting system or dictated reports, to foster standardization of reporting and data
collection throughout the endoscopic community.

III. BASIC/DIAGNOSTIC TECHNIQUES

A. Esophageal Intubation

A most difficult challenge in upper endoscopy, especially for beginning trainees, is the
intubation of the esophagus. In general, trainees should be taught the principles of
intubating the esophagus under direct visualization. The principles of intubating the
esophagus under direct visualization go hand in hand with the most basic endoscopic
principle: the endoscope should never be advanced blindly or forcefully. All trainees
should not only be taught the landmarks that will guide them to the upper esophageal
orifice but that, despite good endoscopic techniques, the esophagus may be difficult to
intubate in some patients. These patients may have inadequate sedation, a prominent
cervical spine that interferes with the passage of the endoscope, a Zenker diverticulum, or

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 a tumor. Understanding the potential reasons for inability to intubate the esophagus and
using appropriate alternative diagnostic modalities is an important part of training. While
the majority of upper endoscopies are performed with patients lying in the left lateral
position, trainees should become familiar with intubating the esophagus with patients
lying in the supine position. Familiarity in intubating the esophagus of supine patients is
often essential in the performance of upper endoscopy in ICU patients. Several general
book chapters cited address this issue, and excellent demonstrations of these techniques
exist in the ASGE instructional videos.

B. Pyloric Intubation

Pyloric intubation is achieved in almost all patients with modern endoscopes in expert
hands. The beginning trainee may be anxious in his or her ability to intubate the pylorus.
Once it has been intubated, the trainee may be equally anxious that the endoscope will
return to the stomach unintentionally. The basic endoscopic principle that the endoscope
should not be advanced blindly is equally valid in pyloric intubation. The pylorus is
easiest to intubate when it is well visualized. The endoscopist in training should be taught
the technique of examining the duodenal bulb immediately beyond the pylorus carefully
and effectively, since pathology in this area can easily be missed. Furthermore,
therapeutic maneuvers in the duodenal bulb are often needed in the treatment of bleeding
duodenal ulcers.

C. Retroflexion in the Stomach

When the endoscope is pulled back into the stomach to the level of the angularis,
retroflexion is performed in order to view areas that otherwise would be seen only
tangentially upon initial entry into the stomach: the angulus, fundus, and cardia.
Trainees should be taught this routine to ensure that the entire upper gastrointestinal tract
is examined thoroughly, effectively and efficiently using ante and retroflexion
maneuvers.

D. Identification of normal and abnormal findings

Interpretation of endoscopic findings is one of the core aspects of endoscopic training. It

begins by understanding the anatomical relationship between the oropharyngeal
structures, esophagus, stomach, and duodenum, and the surrounding organs. An atlas of
endoscopic findings should be available and used on a regular basis. In addition,
understanding of pathologic and radiologic correlates is essential. It is suggested that
regular clinicopathologic-radiologic and endoscopic conferences should be available as
part of the training. Program directors should strongly encourage all their trainees to
actively participate in such conferences. Interpretation of normal and abnormal
endoscopic findings requires a broad-based and repetitious exposure to a range of
endoscopic findings and is best learned when they are complemented by clinical,
pathologic and, radiologic findings.

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E. Use of alternative endoscopes

The endoscopist in training must be taught the importance of proper endoscope

selection according to the clinical situation being addressed. Specific recommendations
for all clinical situations are beyond the scope of this document, but some important
examples of proper endoscope selection are noted below.

i. Limitation of forward-viewing endoscope in the evaluation of the second

portion of the duodenum

The wall of the second portion of the duodenum can be difficult to examine
effectively. Trainees must be taught that the ampulla and its surrounding
structures cannot be well studied using the forward-viewing endoscope alone. The
importance of using a side-viewing endoscope in selected cases must be
emphasized. The ASGE recommends that patients with familial adenomatous
polyposis undergo screening examination for ampullary adenomas or
adenocarcinomas using both end-viewing and side-viewing endoscopes.

ii. Use of Alternative endoscopes

a. Smaller diameter or double channel endoscope

Smaller diameter endoscopes present an alternative to the regular endoscope when

faced with a stricture. Recent advances in charged coupled device technology
have allowed the development of ultrathin endoscopes with outer diameters of
approximately 6 mm or even less. While transnasal upper endoscopy appears
promising, the technique is currently not available for widespread use.

Therapeutic endoscopes or double channel endoscopes are often used in patients

with active upper gastrointestinal bleeding and are typically available in most
endoscopy unit. Double channel endoscopes are also particularly useful in the
performance of endoscopic mucosal resection.

b. Pediatric colonoscope or push enteroscope

Push enteroscopy is a technique that is readily available to most endoscopists. The

pediatric colonoscope or enteroscope is often used to perform push enteroscopy in
the evaluation of patients with occult gastrointestinal bleeding who have a
negative upper endoscopy and colonoscopy. Chak and colleagues performed push
enteroscopy in asymptomatic patients with iron deficiency anemia.
Approximately 25% of the 31 patients they studied had source of blood loss in the
jejunum. In the appropriate setting, trainees should be taught the performance of
enteroscopy using a pediatric colonoscope or push enteroscope if available.

iii. Fluoroscopy

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 The endoscopist in training should be taught the importance and utility of using
fluoroscopy to facilitate guidewire placement in cases where a critical stricture is
encountered.

IV. THERAPEUTIC TECHNIQUES

A. TECHNIQUES FOR BIOPSY

The technique of forceps biopsy during upper endoscopy is straightforward and similar to
that in colonoscopy. There is little published information outlining this basic technique.
Specific biopsy recommendations for all disease states are beyond the scope of this
document, but some important points are noted below.

i. Columnar epithelium-line esophagus (Barrett’s esophagus)

The risk of developing adenocarcinoma in the esophagus of patients with

Barrett’s esophagus with specialized intestinal metaplasia is well recognized. The
cancer incidence is estimated to be approximately 1 in 200 patient-years. Barrett’s
cancer may be microinvasive and multifocal. Extensive random biopsy of the
entire Barrett’s segment should be performed. One method of tissue sampling
includes four-quadrant biopsies with large particle forceps taken at 2 cm intervals,
starting 1 cm below the esophagogastric junction and extending 1 cm above the
squamocolumnar junction. Surveillance should be performed while the patient’s
reflux is well controlled. The interval range of one to three years has been
recommended in patients with no history of dysplasia. When dysplasia is
discovered, some general guidelines have been recommended by the ASGE.

ii. Peptic ulcer disease

Biopsy adds to the accuracy of endoscopic examination of gastric ulcer and

multiple biopsies should be obtained except when the ulcer is actively bleeding.
Follow-up endoscopy or double contrast barium x-ray has been recommended in
the majority of cases to document healing. Biopsy of a gastric ulcer should
include four-quadrant biopsies from the margin of the ulcer. Biopsy of a duodenal
ulcer is not indicated and endoscopy has no role in the follow-up of
uncomplicated duodenal ulcer.

B. TECHNIQUES FOR NONVARICEAL HEMOSTASIS

i. Injection of epinephrine or sclerosing agent

Injection of epinephrine, saline or sclerosing agents may be used to achieve

hemostasis by inducing vasoconstriction, mechanical tamponade or tissue
destruction. The endoscopist-in-training must be knowledgeable of the different
injection agents currently available, as well as associated indications for use and

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 potential adverse effects. Various techniques for injection have been described in
various sited textbooks. Epinephrine injection therapy may work by causing
constriction of blood vessels and/or increasing tissue pressure, producing
tamponade. The location of the vessel coursing through the ulcer base is usually
not obvious. Injection therapy should involve injection around a visible vessel or
directly into the vessel. The technique is a safe and effective method to control
bleeding immediately and should be part of standard training. The trainee must be
technically adept to maintain good control of the endoscope at all times, while
performing targeted injections under direct visualization, in a safe and efficient
manner.

ii. Electrocautery

A thorough understanding of the principles of electrosurgical cautery is essential.

A number of excellent texts and other reference sources are available and listed.
Trainees should be introduced to the accessory used (gold-probe or heater-probe).
Trainers should also provide detailed hands-on instruction for the basic operation,
trouble-shooting and safety checking of their particular model of generator.

Techniques for cauterizing a visible vessel should be taught as part of standard

training. The techniques require application of the coaptive coagulation probe
directly on and immediately adjacent to the site of the visible vessel. The probe
needs to be applied with enough pressure and heat in order to stop active bleeding
and obliterate a visible vessel. Appropriate coaptive coagulation will result in
whitening of the area and a deeper ulcer.

Techniques for obliteration of angiodysplasia are relatively straightforward.

Use of well established electrothermal devices (Bicap and heater probes) are
effective in obliteration of angiodysplasia and should be taught to trainees.

Hot biopsy forceps have been recommended for obliteration of angiodysplasia by

some, but as a monopolar device, these have the potential for deep wall injury and
perforation. Thus, thermal probes such as heater probe or bicap probes may be
preferable for routine use.

iii. Endoscopic Hemoclip

A potential drawback of thermal methods in the treatment of nonvariceal causes

of bleeding is that these methods may cause excessive tissue injury, leading to
necrosis and perforation. The application of a metal hemoclip to a bleeding vessel
is increasingly being used. Its safety and efficacy have been reported in a number
of studies. However, in the United States, hemoclipping is available only in
selected centers. The trainee should be exposed to hemoclip technique if available
and become familiar with the techniques for loading, deployment and positioning
prior to use in the setting of active gastrointestinal bleeding.

iv. Endoscopic Ligation and Argon Plasma Coagulator

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 The technique of endoscopic variceal ligation has been used for treatment of
Dieulafoy’s lesion and appears to have improved efficacy compared with thermal
methods. Given the urgency and severity of Dieulafoy’s bleeding and the
significant concern of the attending endoscopist, the trainee may find himself with
limited scope time during these rare events early in his training. However, the
techniques employed are similar to that used in the treatment of variceal bleeding.
Given the potential severity of a bleeding Dieulafoy’s lesion, trainees should be
taught the potential benefits and use of non-traditional methods of its treatment,
such as endoscopic ligation, and the limitations of traditional thermal methods.

The argon plasma coagulator (APC) has also recently been utilized for
obliteration of arteriovenous malformation. It may be especially advantageous in
gastric antral vascular ectasia, although bicap and heater probe can also be used,
and is well accepted for treatment of this condition.

C. TECHNIQUES FOR VARICEAL HEMOSTASIS

i. Endoscopic Sclerotherapy

Similar to the injection techniques discussed for nonvariceal hemostasis, the

trainee must be aware of the available sclerosing agents, recommended
concentrations and volumes and associated risks and limitations of treatment. The
technique for variceal sclerotherapy is operator dependent, however, the trainee
should understand the basic pathophysiologic effect that is desired from the most
commonly accepted techniques. Intravariceal injection of sclerosant induces
thrombus formation, while paravariceal injection produces submucosal fibrosis
and obliteration of feeding perforating vessels. The trainee should also be
technically adept to perform targeted injections safely and efficiently, particularly
when performing tangential maneuvers within the esophagus. The importance of
maintaining the sclerotherapy needle in a retracted position when not in use
cannot be overemphasized, as unintentional mucosal trauma and hemorrhage are
potential complications when this technique is not routinely practiced. No
recommendations for follow-up therapy have been firmly established. In general,
the trainee should understand that frequent sclerotherapy treatments are associated
with more rapid obliteration of varices, however, the risk of associated
complications may be increased.

ii. Endoscopic Variceal Ligation

Efficient and safe use of the variceal ligation device requires good technical skill
and ability to perform maneuvers under limited visibility. Prior to initiating the
procedure, the trainee should obtain hands-on experience with appropriate and
secure attachment of the ligation device onto the upper endoscope. In addition,
the trainee should understand the rotational maneuver necessary to achievement
successful band deployment. Although attachment of the ligating device
produces unavoidable limitations to the visual field, the endoscopist-in-training

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 should be trained to always perform maneuvers under direct visualization. Upon
entry into the esophagus, the trainee should be able to recognize and interpret
variceal stigmata of recent bleeding and target these areas for treatment. In
general, the trainee should understand the technical advantage of applying bands
to the most distal varices first, followed by application of bands to more proximal
varices. The coordinated technique of variceal suction into the channel,
producing a “red out” appearance, followed by timely deployment of the ligating
device cannot be overemphasized. The trainee should obtain hand-on technical
skill with the endosopic variceal ligation device to avoid inappropriate misfiring
of the device in the setting of acute variceal hemorrhage.

D. TECHNIQUES FOR FOREIGN BODY REMOVAL

Ingestion of foreign bodies is a commonly encountered problem, accounted for

approximately 1500 deaths per year in the United States. Although foreign body
ingestion is most commonly observed in the pediatric population, unintentional foreign
body impaction may occur in adults with underlying anatomical abnormalities of the
oropharynx or gastrointestinal tract, psychiatric disturbances or poor dentition. The
trainee should also understand the limitations of medicinal agents aimed at promoting
passage of objects through the gastrointestinal tract, and be prepared to implement early
endoscopic intervention. Safe removal of foreign objects necessitates a thorough history,
radiographic evaluation when necessary and careful implementation of a pre-determined
plan of action. Endoscopic management of foreign bodies in the gastrointestinal tract
should be part of standard training. Trainee should be taught the importance of safe and
effective performance of emergency upper endoscopy in the management of impacted
foreign body. Foreign body impaction in the esophagus has been reported to cause
aspiration pneumonia, perforation, and mediastinitis. The importance of airway
protection must be emphasized. The hazard of pushing a food impaction in the esophagus
as well as the different techniques used to handle the different types of foreign body
should be illustrated. Teaching technique of using overtube in the management of small,
slippery, sharp or pointy objects should be part of the curriculum. Prevention of the step
formation between the endoscope and the overtube by preloading the overtube over an
appropriate sized bougie or a therapeutic endoscope should be highlighted. The trainee
should have hands-on exposure to the application of an overtube to the endoscope and
safe intubation of the esophagus.

E. TECHNIQUES FOR ESOPHAGEAL DILATION

Esophageal stricture dilation is amenable to balloon dilation, with many reports

documenting success using through-the-scope balloon systems. The techniques involved
may not be difficult for trainees to master. Training of esophageal dilation should also
include training using Maloney dilators, if available. Esophageal dilation for achalasia,
however, is unique as it involves forceful disruption of the lower esophageal sphincter
and is associated with a significant (1 to 4%) risk of perforation. Trainees should be
acquainted with the indication, technique, risks and benefits of esophageal dilation for
achalasia.

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 F. TECHNIQUES FOR PERCUTANEOUS GASTROSTOMY (PEG) OR
JEJUNOSTOMY PLACEMENT AND REMOVAL

Prior to performing any endoscopic procedure for enteral feeding, it is essential for the
trainee to understand the indications, contraindications, complications, and post
procedure management of these patients, as well as the emerging body of literature on
ethics and outcomes of PEG placement in the elderly and terminally ill. Techniques for
routine PEG placement are well established and include the “pull” method of Ponsky and
Gauderer, and the Sachs-Vine “push method”. Although most studies have shown no
difference in safety and success between these basic techniques, the trainee should ideally
be exposed to both, depending upon the preference of the endoscopy trainer and the
availability of PEG kits in the individual institutions. Regardless of the method
employed, the trainee should be taught the importance of proper technique in both roles
of the procedure, the importance of good teamwork and communication, and other
elements of the procedure that may prevent complications. These include prophylactic
antibiotics, verification of proper transillumination and finger pressure, the use of the
syringe aspiration method to identify overlying bowel, adequate skin incision length, and
proper bumper positioning. The basic technique of PEG placement are usually mastered
quickly by trainees with other significant experience in endoscopy, but broader
experience should be provided to expose the trainee to the variety of situations where
PEG placement is ill-advised to begin with, or should be aborted before completion.
Finally, the importance of post procedure follow-up, patient/caregiver teaching, and
evaluation of the problem PEG site must be emphasized to the trainee who may focus on
the endoscopic procedure alone.

Small bowel feedings via a jejunal extension tube placed through a PEG (PEG-JET,
PEG-J) or direct percutaneous endoscopic jejunostomy (D-PEG) are also possible options
for enteral feeding. Placement of these tubes may be indicated for those patients at high
risk for aspiration, those with gastric retention, or in diseases where enteral feeding is
favored, but proximal feeding may be harmful such as pancreatitis. Enthusiasm for PEG-J
placement varies widely among individual endoscopists and institutions, in part due to
the technical challenges inherent in their placement, and the oft-cited frequency of early
clogging or retrograde migration. Techniques employed include the “drag and pull”
methods where a string at the tip of the J tube is grasped and pulled into the jejunum
alongside the endoscope, and multiple wire-guided methods. Each basic technique has
multiple variations in the literature, bespeaking the fact that no single technique has
proven superior, and none have been universally accepted. The trainee should strive to
identify one or two of these methods and learn the subtleties of these techniques which
will allow successful placement in a variety of situations. An excellent recent review on
the techniques is available

V. ADVANCED THERAPEUTIC TECHNIQUES

A. TECHNIQUES TO LOCALIZE DYSPLASIA OR EARLY CANCER

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 Chromoendoscopy, or the use of topically applied contrast agents in conjunction with
endoscopy, has been utilized successfully to help visualizing subtle lesions and defining
their borders. In the esophagus, the use of Lugol’s solution has been particularly useful
for screening and in assessing tumor-extent of esophageal squamous cell carcinoma. The
use of indigo-carmine solution enhances the contours and topography of flat lesions at
any part of the gastrointestinal tract. The use of methylene blue has the potential to
identify high-grade dysplasia or adenocarcinoma in the setting of Barrett’s esophagus.
Widespread use of methylene blue in screening for dysplasia in Barrett’s esophagus,
however, is yet to be established. With the exception of the use of methylene blue, the
greatest use of chromoendoscopy has been predominantly in Japan, where the ability to
detect flat neoplasms is especially important. However, these techniques are relatively
easy to perform. The trainee should be aware of their development and exposed to the
techniques if available.

Endoscopically placed metal clips have been developed which are released through the
working channel of the endoscopes and clipped into mucosa. Endoscopically placed
hemoclips may be useful for marking the margins of lesions in selected cases.

B. TECHNIQUES TO REMOVE EARLY CANCER/ENDOSCOPIC MUCOSAL

RESECTION (EMR)

Recent advances in EMR of dysplasia or superficial early gastrointestinal tract cancers

are truly remarkable. Long-term studies in Japan have demonstrated that the outcomes
after EMR are similar to those of surgery, and have led to the acceptance of EMR as a
standard procedure. In the United States, EMR has been used primarily in the resection of
large sessile colon polyps. However, there is significant potential for application of EMR
in the upper gastrointestinal tract. EMR has been shown to be safe and effective in the
removal of a variety of subepithelial lesions. Its potential in the treatment of Barrett’s
dysplasia or early cancer is attractive, but will require further long-term study. Trainees
should understand the indications, techniques, and outcomes of EMR.

C. TECHNIQUES FOR ESOPHAGEAL AND ENTERAL STENT PLACEMENT

The majority of esophageal cancer is incurable. The use of self-expandable metallic

stents (SEMS) is an important treatment modality in the palliative management of
esophageal obstruction and esophagorespiratory fistula. SEMS designed for gastric or
small intestinal use are also available and can provide palliation of obstruction in selected
patients. Trainee should know the indication, technique, and outcomes of use of SEMS
with exposure to the techniques if possible. Placement of SEMS in esophageal, gastric or
duodenal malignant stricture may be appropriate for select trainees if expert trainers and
procedure volume is available.

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 ESOPHAGOGASTRODUODENOSCOPY (EGD)
CORE CURRICULUM
GENERAL REFERENCES

CD ROMS

Sivak MV, (ed) In: Gastroenterologic Endoscopy, 2nd ed. Philadelphia, WB Saunders, CD-Rom,
1999

BOOKS

Soehendra N, Binmoeller KF, Seifert H, Schreiber HW, Therapeutic Endoscopy. Stuttgart:

Thieme, 1998.

Cotton P, Williams CB (eds) Practical Gastrointestinal Endoscopy, 4th edition, Oxford:

Blackwell Science, 1996.

Baillie J: Gastrointestinal Endoscopy: Beyond the basics. Newton, MA: Butterworth-

Heinemann, 1997.

Barkin J, Ophelan CA (eds): Advanced Therapeutic Endoscopy, 2nd ed. Philadelphia: Lippincott-
Raven, 1996.

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 REFERENCES BY TOPIC

I. INTRODUCTION

ASGE: Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1999;

49:845-53.

The Gastroenterology Leadership Council: American Association for the Study of Liver
Diseases, American College of Gastroenterology, American Gastroenterological
Association, and American Society for Gastrointestinal Endoscopy: Training the
gastroenterologist of the future: The Gastroenterology Core Curriculum.
Gastroenterology 1996; 110:1266-1300.

II. PERI-PROCEDURE MANAGEMENT

A. Pre-procedure Management

The ASGE Standard of Practice Committee: Antibiotic prophylaxis for gastrointestinal

endoscopy. Gastrointest Endosc 1995;42:615-617.

The ASGE Standard of Practice Committee: Management of anticoagulation and

antiplatelet therapy for endoscopic procedures 1998.

ASGE Guideline: Informed consent for gastrointestinal endoscopy. Gastrointest Endosc

1988;34(3):26S-27S.

ASGE: Preparation of patients for gastrointestinal endscopy. Gastrointest Endosc

1998;48:691-694.

B. Patient Management and Physician Behavior during Upper Endoscopy

American Society of Anesthesiologists: Practice guidelines for sedation and analgesia by

non-anesthesiologists. Anesthesiology 1996;84:459-471.

ASGE Committee on Training: Guidelines for training in patient monitoring and

sedation. Gastrointest Endosc 1998;48:669-671.

Boyce H.W. Behavior in the endoscopy room. Gastrointest Endosc 2001;53:133-6.

C. Post-procedure Management

ASGE Guideline: Quality improvement of gastrointestinal endoscopy. 1998.

Joint Committee for Minimal Standard Terminology of European Society for

Gastrointestinal Endoscopy, American Society for Gastrointestinal Endoscopy and
Organisation Mondial d’Endoscopie Digestive: Digestive Endoscopy Minimal Standard
Terminology: International Edition, 1998.

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III. BASIC/DIAGNOSTIC TECHNIQUES

A. Esophageal Intubation
B. Pyloric Intubation
C. Retroflexion in the Stomach
D. Identification of normal and abnormal findings
E. Use of alternative endoscopes

i. Limitation of forward-viewing endoscope in the evaluation of the second

portion of the duodenum

ASGE Guideline. The Role of Endoscopy in the Surveillance of Premalignant

Conditions of the Upper Gastrointestinal Tract. Gastrointest Endosc 1998;48:663-
8

Kim MH. Duodenoscopic Differentiation of Various Ampullary Lesions. ASGE

Endoscopic Learning Library DVD

ii. Smaller diameter endoscope

Saeian K, Townsend WF, Rochling FA, Bardan E, Dua K, Phadnis S, Dunn BE,
Darnell K, Shaker R. Unsedated transnasal EGD: an alternative approach to
conventional esophagogastroduodenoscopy for documenting Helicobacter pylori
eradication. Gastrointest Endosc. 1999;49:297-301.

IV. THERAPEUTIC TECHNIQUES

A. TECHNIQUES FOR BIOPSY

B. TECHNIQUES FOR NONVARICEAL HEMOSTASIS

i. Injection of epinephrine or sclerosing agent

Christopher J. Gostout, MD. Endoscopic Management Principles for Acute GI

Bleeding. ASGE Endoscopic Learning Library DVD

Chung S, Leung J. Injection Therapy For Bleeding Peptic Ulcer. ASGE Endoscopic
Learning Library DVD

ii. Electrocautery

Tucker, RD: Principles of electrosurgery. In: Gastroenterologic Endoscopy, 2nd ed.

Philadelphia, WB Saunders, Sivak MV, (ed) CD-Rom, 1999.

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 Curtiss LE: High frequency circuits in endoscopy: A review of principles and
precautions. Gastrointest Endosc, 1973;20:9-12.

Barlow DE: Endoscopic applications of electrosurgery: A review of basic principles.

Gastrointest Endosc, 1982; 28:73-6.

Wu D, Silverstein FE: Principles of electrosurgery. In: Raskin JB, Nord HJ, eds.
Colonoscopy: Principles and Technique. Tokyo: Igaku-Shoin, 1995:83-93.

Laine L, Peterson Wl. Bleeding peptic ulcers. New Eng J Med, 1994;331:717-24.

Johnston JH. Endoscopic Heater Probe Treatment of Bleeding Peptic Ulcers. ASGE
Endoscopic Learning Library DVD

iii. Endoscopic Hemoclip

Soehendra N, Sriram PV, Ponchon T, Chung SC. Hemostatic clip in gastrointestinal

bleeding. Endoscopy. 2001 Feb;33:172-80.

Steven L. Kadish, M.D., Michael L. Kochman, M.D., William Long, M.D., Gregory
Ginsberg, M.D. Endoscopic Mucosal Clips: Applications and Innovations. ASGE
Endoscopic Learning Library DVD

iv. Endoscopic Ligation and Argon Plasma Coagulator

Waye J. Argon Plasma Coagulator. ASGE Endoscopic Learning Library DVD

C. TECHNIQUES FOR VARICEAL HEMOSTASIS

i. Injection of sclerosing agent

ASGE Guideline. The Role of Endoscopic Therapy in the Management of Variceal

Hemorrhage. Gastrointest Endosc1998;48:697-8

ii. Endoscopic Variceal Ligation

Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of

esophageal variceal bleeding. A meta-analysis. Ann Intern Med. 1995;123:280-7.

Carr-Locke DL. Multiband Ligators for Esophageal Varices . ASGE Endoscopic

Learning Library DVD

D. TECHNIQUES FOR FOREIGN BODY REMOVAL

Soehendra N, Binmoeller KF, Seifert H, Schreiber HW, Therapeutic Endoscopy.

Stuttgart: Thieme, 1998.

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 Ponsky JL. Therapeutic Endoscopy: Approach to Foreign Bodies, Gastrointestinal
Strictures and Endoscopic Feeding. ASGE Endoscopic Learning Library DVD

E. TECHNIQUES FOR ESOPHAGEAL DILATION

Graham DY, Fleischer DE. UGI Strictures: Benign and Malignant. ASGE Endoscopic
Learning Library DVD

F. TECHNIQUES FOR PERCUTANEOUS GASTROSTOMY (PEG) OR

JEJUNOSTOMY PLACEMENT AND REMOVAL

Jeffrey L. Ponsky, MD. Therapeutic Endoscopy: Approach to Foreign Bodies,

Gastrointestinal Strictures and Endoscopic Feeding. ASGE Endoscopic Learning
Library DVD

G. TECHNIQUES FOR PLACEMENT OF FEEDING TUBE

SAGES. Percutaneous Endoscopic Gastrostomy/Jejunostomy. ASGE Endoscopic

Learning Library DVD

V. ADVANCED THERAPEUTIC TECHNIQUES

A. TECHNIQUES TO LOCALIZE DYSPLASIA OR EARLY CANCER

Jung M, Kiesslich R. Chromoendoscopy and intravital staining techniques. Bailiere’s

Clinical Gastroenterology 1999:13;11-9.

Inoue H, Rey JF, Lightdale C. Lugol chromoendoscopy for esophageal squamous

cell cancer. Endoscopy. 2001 Jan;33:75-9.

Canto MI, Setrakian S, Willis J, Chak A, Petras R, Powe NR, Sivak MV Jr.
Methylene blue-directed biopsies improve detection of intestinal metaplasia and
dysplasia in Barrett's esophagus. Gastrointest Endosc. 2000;51:560-8.

B. TECHNIQUES TO REMOVE EARLY CANCER/ENDOSCOPIC MUCOSAL

RESECTION

Soetikno RM, Inoue H, Chang KJ. Endoscopic mucosal resection. Current concepts.
Gastrointest Endosc Clin N Am. 2000;10:595-617.

Shim, C –S. Endoscopic Mucosal Resection: An Overview of the Value of Different

Techniques. Endoscopy. 2001;33:271-5.

ASGE Technology Committee. Endoscopic Mucosal Resection. Gastrointestinal

Endosc 2000;52:860-3.

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 Inoue H. Endoscopic Mucosal Resection for GI Mucosal Lesions. ASGE Endoscopic
Learning Library DVD

Yamamoto H. Endoscopic Mucosal Resection (EMR) Using a Mucinous Substance

Sodium Hyaluronate. ASGE Endoscopic Learning Library DVD

C. TECHNIQUES FOR TUMOR ABLATION

D. TECHNIQUES FOR ESOPHAGEAL STENT PLACEMENT

Nelson D. The Wallstent I and II for Malignant Esophageal Obstruction. Gastrointest

Endosc Clin N Am 1999:9; 403-12.

Mokhashi MS, Hawes RH. The Ultraflex Stents for Malignant Esophageal
Obstruction. Gastrointest Endosc Clin N Am 1999:9;413-22.

Soetikno RM, Carr-Locke DL. Expandable metal stents for gastric-outlet, duodenal,
and small intestinal obstruction. Gastrointest Endosc Clin N Am. 1999:9;447-58.

Chung S, Leung J. Self-Expanding Metal Stents For Esophagal Carcinoma. ASGE

Endoscopic Learning Library DVD

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