Upper Gastrointestinal Endoscopy: Technique and Findings
Systematic inspection
Upper endoscopy is a structured examination, not a quick look. Confirm fasting (6-8 hours solids, 2 hours clear liquids), consent, and the antithrombotic plan. Topical lidocaine and sedation are optional; left lateral decubitus is standard. Insert under direct vision, insufflate judiciously, and examine the esophagus, Z-line, cardia, fundus (retroflexion), body, angulus, antrum, pylorus, duodenal bulb, and descending duodenum (D2). Photodocument landmarks.
Characterize lesions with validated schemes. Barrett esophagus is measured from the gastroesophageal junction and described by the Prague classification (circumferential and maximum length). Esophagitis uses the Los Angeles grade A-D. Gastric and duodenal ulcers use the Forrest classification: Ia spurting, Ib oozing, IIa visible vessel, IIb adherent clot, IIc flat pigmented spot, III clean base. Ia, Ib, and IIa clearly benefit from endoscopic therapy; IIb is individualized. Early neoplasia is described by Paris morphology and assessed with narrow-band imaging, Lugol iodine, or acetic acid as appropriate.
Biopsy protocols matter: Seattle protocol for Barrett esophagus (four-quadrant every 1-2 cm), mapping for suspected gastric cancer or lymphoma, and multiple duodenal biopsies for celiac disease. Test for H. pylori with biopsy, stool antigen, or urea breath test; avoid serology for active infection.
Traps: failing to retroflex in the stomach (missed fundus/cardia lesions), overinsufflation in a frail patient, calling a clean-based ulcer high-risk, and under-documenting Barrett length. Rule of thumb: retroflex in every stomach and photograph the retroflexion.