Lower GI Endoscopy Basic Skills Training Resource Folder

Lower GI Endoscopy Basic Skills Training Resource Folder 

Background 2 

E-portfolio/JAG certification for the lower GI basic skills course 3 

What is the JETS e-portfolio 3 

How do I register with the e-portfolio? 3 

Why use the e-portfolio? 3 

JAG certification 3 

Eligibility criteria for colonoscopy 4 

Provisional Certification 4 

Full Certification 4 

Polypectomy 5 

Numbers 5 

Complications 5 

Informed Consent in Endoscopy. 6 

Indications for Colonoscopy 8 

Diagnostic 8 

Screening 8 

Surveillance 8 

Contraindications to Lower GI Endoscopy 9 

Absolute contraindications 9 

Relative contraindications 9 

General patient comorbidity factors 9 

Drug therapy 9 

Specific contraindications to lower GI endoscopy 9 

Summary 10 

Complications of Lower GI endoscopy 11 

Procedure Related complications 11 

Complications related to Endoscopy: General Considerations 13 

Risk vs benefit 13 

Sedation (see below) 13 

The risks of infection 13 

Risks of bleeding 13 

Anticoagulation Issues 13 

Post procedure advice/ contact details 13 

Clinical Governance 14 

Key Messages 14 

Diathermy 15 

LGI Resource Folder JTA 2012 Page 1

How diathermy works 15 

Monopolar diathermy 16 

Bipolar diathermy 16 

Precautions when using diathermy 18 

Further Reading 19 

Endoscope Design and Function 20 

Overview 20 

Head of instrument 20 

Channels 21 

Decontamination of GI endoscopes 22 

Potential advantages and complications of oral bowel cleansing agents 23 

Suggested Background reading for Basic lower GI endoscopy course 24 

Suggested Website Resources 25 

Background 

This folder was created in a collective project by the regional endoscopy training centre in the UK. It 

constitutes some basic background knowledge relevant to modern endoscopic practice. It is not intended 

to be exhaustive or comprehensive, but merely to act as a reference resource to support endoscopy 

training both on the JAG endoscopy courses and at base hospitals. 

Contributions from: 

John Anderson 

Paul Dunckley 

Mark Feeney 

Rachael Hodson 

Roger Leicester 

Brian McKaig 

Paul O’Toole 

Richard Robinson 

John Silcock 

John Todd 

Maggie Vance 

John Anderson 


E-portfolio/JAG certification for the lower GI basic skills course 

Paul Dunckley, Gloucestershire Training Centre 

What is the JETS e-portfolio 

The JETS e-portfolio is JAG’s logbook for trainees in endoscopy. It is available for all trainees. It has been 

designed to make it as easy as possible for trainees to submit their key endoscopic data and provides 

trainees with all the performance outputs that they need to chart their competence progression and 

then apply for JAG certification. The e-portfolio can be accessed via the JETS website (www.jets.nhs.uk). 

More detailed information about the e-portfolio can be found on the JAG website 

(www.thejag.org.uk/TrainingforEndoscopists/eportfolio.aspx). 

How do I register with the e-portfolio? 

In order to start using the JETS e-portfolio, the trust e-portfolio administrator or training lead will need 

to add a trainee to their system. The trainee will need to provide them with their GMC number and 

personal e-mail address. Once added to the trust system they will be able to log all of their endoscopic 

procedures. 

Why use the e-portfolio? 

The e-portfolio provides the user with the following benefits: 

o A simple way of logging endoscopic experience 

o It provides all key summary performance data in output tables 

o Online DOPS assessments 

o Generates a personal development plan through DOPS assessments 

o Provides output graphs of progression in DOPS scores 

o Submitting data to the e-portfolio is a pre-requisite for JAG certification application 

JAG certification 

In order to practice endoscopy independently within a JAG accredited endoscopy unit, trainees will need 

to be certified by JAG in each procedure. Once trainees have achieved the necessary eligibility criteria 

(table 1), they will need to have a summative assessment (see 

http://www.thejag.org.uk/TrainingforEndoscopists/EndoscopyTrainees/TraineeCertification/Summative 

Assessments.aspx). This is co-ordinated through the JETS e-portfolio as is the submission of your 

application to the JAG office. 

For colonoscopy, evidence of competence in polypectomy will also be required before certification is 

granted. There is a two stage certification process. Initially trainees will be provisionally certified which 

means that they have demonstrated competence in diagnostic colonoscopy and removing smaller 

(1cm) polyps. 


Eligibility criteria for colonoscopy 

Eligibility criteria are shown in the tables below. The previous 3 months of data on the e-portfolio will be 

used to calculate the eligibility criteria. 

Provisional Certification 

Eligibility criteria Requirement Notes 

Caecal intubation rate >90% 

Formative DOPS scores >90% “3”s and “4”s A minimum of 10 DOPS required 

Formative DOPyS scores* >90% “3”s and “4”s Last 4 DOPyS scores, or last 3 months, whichever is greater 

Unassisted physically >90% I.e. the trainer does not take the scope for >90% of procedures 

Basic skills lower GI course Attended 

* polypectomy level 1 

Full Certification 

Eligibility criteria Requirement Notes 

Caecal intubation rate >90% 

Polyp detection and removal >10% 

Serious complications 90% “3”s and “4”s Last 4 DOPyS scores, or last 3 months, whichever is 

greater 

** Serious complications defined as death, perforation, significant bleeding requiring > 2 unit 

transfusion, post-procedure hospital stay of > 24 hours (related to procedure) or admission to 

hospital due to a complication of the procedure following discharge from endoscopy unit. This figure is 

calculated over the preceding year. 

*** - Under 70yrs < 5mgs midazolam 

Polypectomy 

Trainees will be expected to have been assessed at their polypectomy skills. When a polyp is identified, 

the trainer should join the trainee, observe/train on polypectomy followed by the completion of a 

DOPyS. A DOPyS is a DOPS form created specifically to assess polypectomy. It can be found in the DOPS 

sections of the JETS e-portfolio. DOPyS can be completed during either flexible sigmoidoscopies or 

colonoscopies. Polypectomy level 1 denotes all polyps less than 1cm in size, level 2 denotes all polyps 

greater than 1cm in size. 

Numbers 

The recommended numbers of procedures by JAG for each trainee applying for provisional certification 

is 200. For full colonoscopy certification, it is 300. Number of procedures is no longer a mandatory 

requirement for application. However, only under exceptional circumstances will trainees be granted 

provisional or full certification if they have performed significantly fewer than the recommended 

number of procedures since all common pathology and unusual anatomy may not be encountered with 

lower procedural experience. .JAG reviewers may seek additional evidence of competence and evidence 

of support from their trainer in this situation. 

Complications 

Trainees with just 2 serious complications may find that they have complication rates of >0.5%. If a 

serious complication occurs, the JETS e-portfolio will automatically ask the trainee to provide details of 

the event, what the trainee did and what the trainee learnt from that event. These boxes will have to be 

signed off by one of their trainers. These boxes will be assessed by the JAG reviewer on application to 

ensure that sufficient learning was gained from each episode. It will be at the discretion of the JAG 

reviewer whether or not to allow certification based on the information provided. 


Informed Consent in Endoscopy. 

Maggie Vance, St Mark’s Hospital 

Definition 

Consent is the process of confirming a patient’s agreement to permit a health care professional to 

provide care. 1 

The Department of Health (DH) has published a reference guide for clinicians on informed consent. 2 A 

key part of consent is assessing the patient’s capacity to give consent for a procedure. Please refer to the 

above DH publication for guidance on mental capacity. 

The BSG has written a specific guideline concerning valid informed consent in Endoscopy, accessed on 

the following website. This is required reading for all endoscopy department staff involved in the 

process of informed consent. The guidance provides information on who can consent, who can provide 

consent and the information that should be provided during the consent process. 

In summary the BSG recommends that all flexible endoscopic procedures require written consent. As 

part of informed consent, health care professionals must provide patients with accurate information 

about the reasons for the procedure, the potential risks, benefits and alternatives of the procedure to 

enable the patient to make an informed decision as to whether they should undergo endoscopy. A 

crucial part of the consent process is to check the patient’s understanding of the information given. The 

following information should be provided concerning the procedure to enable the patient to make an 

informed decision - 

• Explanation - of the procedure 

• Motivation - why this procedure 

• Benefits - expected outcomes 

• Risks & complications - rare and serious and how these would be managed 

• Alternatives available 

• Consequences - of doing nothing 

• Side Effects - frequent and temporary 

• Sedation 

• Taking and retention of specimens 

• Taking of photographic or video record 

• The skilled supervision of and presence of any trainees 

• The use of any experimental technique 


References 

1. Guidance for Obtaining a Valid Consent for Elective Endoscopic Procedures (2008). www.bsg.org.uk. 

Accessed April 2012 

2. Reference guide to consent for examination or treatment, second edition 2009. DoH. 

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D 

H_103643. Accessed April 2012. 

Further reading on the subject can be found on the following publications. 

General Medical Council (2007) Consent: patients and doctors making 

Decisions together. A draft for consultation. May-August 2007 

Mental Capacity Act (2005) 

Human Rights Act (1998) 

Department of Health (2009) Reference guide to consent for examination 

or treatment 


Indications for Colonoscopy 

Richard Robinson, Leicester Training Centre 

NB: Colonoscopy is NOT the only test for the indications listed below: it may not always be the most 

appropriate or timely test (see below) 

Diagnostic 

1. Rectal bleeding 

2. Iron deficiency anaemia (confirm with MCV 60y, (or > 40y if associated with rectal bleeding) 

Screening 

1. National Bowel Cancer Screening Programme 

2. Family History (including familial polyp syndromes) 

Surveillance 

Surveillance for neoplasia in patients at risk (see family cancer syndromes) 

o previous polyp / cancer 

o IBD 

o uretero-sigmoidoscopy 

o acromegaly 


Contraindications to Lower GI Endoscopy 

Brian McKaig, Wolverhampton Training Centre 

These can be considered in 2 categories 

Absolute contraindications 

Relative contraindications 

Absolute contraindications 

1. Withdrawal of consent by competent patient. 

2. Endoscopist not accredited / incompetent to perform procedure. 

This is critically important. As an endoscopist it is essential that you (independently) undertake 

only those procedures in which you have been deemed competent. This includes competency in 

any therapy (eg polypectomy, dye spray) which is likely to be encountered during the procedure. 

3. Uncooperative patient, unable to be safely sedated. 

Relative contraindications 

1. Relative contraindications are those situations in which risk is substantially increased. 

2. There are many factors which influence the risks vs benefits of lower GI endoscopy. 

3. Every procedure in every patient must be assessed with regard to risks & benefits as this will 

vary between patients and will be influenced by the urgency of the intended endoscopic 

intervention. 

4. It is vitally important to optimise the patient’s condition prior to undertaking any form of 

endoscopy. Patients with ASA 3 or higher are at particular risk 

5. If there is any doubt as to whether LGI endoscopy is contraindicated then senior advice should 

be sought at the earliest opportunity. 

General patient comorbidity factors 

Respiratory: COPD / hypoxia / infection 

Cardiac: unstable IHD / acute MI 

Neurological: CVA, any condition resulting in reduced GCS 

Cardiovascular instability: hypotension and uncontrolled hypertension 

Electrolyte abnormalities / hypo & hyperglycaemia 

Frailty 

Drug therapy 

Anticoagulation/antiplatelet therapy: BSG guideline anticoagulant-antiplatelet-therapy 

Specific contraindications to lower GI endoscopy 

Acute severe colitis / toxic megacolon 

Acute diverticulitis 

Acute abdomen 

Perforated viscus 


Summary 

Most contraindications to lower GI endoscopy are relative and need to be considered with 

current clinical situation 

Remember that colonoscopy involves bowel prep, sedation as well as the procedure/therapy 

If in doubt, seek senior advice 


Complications of Lower GI endoscopy 

Mark Feeney, Torbay Training Centre 

Procedure Related complications 

Perforation 

Perforation during diagnostic colonoscopy in a healthy bowel is an unusual occurrence. Most 

perforations occur as a result of therapy such as polypectomy or due to a weakness in the bowel wall 

e.g. diverticular change or severe colitis. Factors associated with a poor outcome after perforation 

include (a) increasing age; (b) significant co-morbidity; (c) delayed recognition of perforation; (d) 

delayed treatment; (e) poor bowel preparation. 

Bleeding 

There is approximately 1% risk of post-polypectomy bleeding. It may be immediately apparent and 

allows the endoscopist to take immediate action to achieve haemostasis, or admit the patient to 

consider other treatment +/- surgery. Delayed bleeds are a well recognised complication of polypectomy 

and can occur up to 10 days post procedure. It is important that the patient is aware of this possibility 

and has a plan to seek reassessment urgently if a late bleed occurs. Some polyps are particularly high 

risk for bleeding e.g. large stalk in a position with poor access. The endoscopist should only attempt 

procedures within their personal range of expertise. A full range of equipment should be available to 

stop bleeding e.g. clips and loops, the assisting staff must be familiar with their use. (See anticoagulation 

issues below). 

Missed pathology 

The possibility of missed pathology can be classified as a complication of colonoscopy. Some studies 

suggest a miss rate of significant pathology in up to 5 % of cases. This should be discussed at during the 

consent process. The patient should be told that even after a normal colonoscopy they should not 

ignore rectal bleeding or subsequent change in bowel habit; they should be reassessed. 

Bowel Preparation 

Bowel preparation can cause electrolyte imbalances and cause renal injury especially when phosphate 

based products are used (Picolax). Recognised effects include hypovolaemia, hyponatraemnia , 

hypokalaemia, hypocalcaemia and hyperphosphataemia. Frail patients may develop postural 

hypotension related to bowel prep and this, may increase their risk of falling. To minimise these side 

effects bowel preparation should be prescribed by a clinician who can assess each patient individually. 

The large volume non-absorbed iso-osmotic agents such as Klean prep are less likely to cause electrolyte 

imbalance and fluid shifts but are less well tolerated by some patients 

Guidelines for the prevention and management of complications of gastrointestinal endoscopy. October 

2006 Jonathon Green for the BSG http://www.bsg.org.uk 


Example of algorithm to guide management of a complication – Perforation 

Communication with 

patient/family 

NB note keeping 

Soon 

Emergency 

surgery 

Is Immediate 

endoscopic 

treatment possible? 

Define extent of 

perforation: CT 

Urgent 

Surgical 

Review 

Clinical Symptoms 

of a perforation 

Conservative 

management 

Stabilize the patient 

i.v fluids, Pain relief 

i.v antibiotics, NBM 

Antibiotics 

Immediate 

Admit to high 

dependency area 


Complications related to Endoscopy: General Considerations 

Risk vs benefit 

The risk of a complication depends on the pathology encountered and the procedure undertaken. The 

outcome of any complication is greatly influenced by the underlying condition of the patient and their 

co-morbidities. Before any invasive endoscopic test is undertaken consideration should be given to the 

use of less invasive tests; could another test/ procedure provide similar information with less risk? The 

examination of risk benefit is particularly important when considering therapeutic intervention. 

Therapeutic procedures, especially involving abnormal tissue, have the greatest risk of significant 

complications. The clinician must be sure that the potential benefit of the intervention is greater than 

the risk; this will depend on an assessment for each individual patient. To achieve good decision making 

and allow an appropriate consent the clinician must have a thorough knowledge of complications and 

good clinical judgement to assess each case individually. 

Sedation (see below) 

Both opiates and benzodiazepines can lead to respiratory depression and their effects are synergistic. 

(1)Pre-oxygenation will reduce risks, (2)Titrate doses of drugs, (3) Give opioid first, (4) continuous 

Oxygen saturation monitoring during the procedure and in recovery. 

The risks of infection 

These risks are relatively low. Units should follow the decontamination guidelines.The indications for 

prophylactic antibiotics are quite selective and are available at BSG guidelines. 

Risks of bleeding 

Diagnostic biopsies unlikley to cause significant bleeding unless clotting deranged. Biopsies can usually 

be safely undertaken with platelet counts > 20,000 and an INR < 2.5 . 

Anticoagulation Issues 

If more invasive procedures are planned then the management of anticoagulation should be reviewed 

several weeks before any elective procedure. Decisions will depend on the risk of the procedure and the 

risks related to interrupting anticoagulation. Warfarin may need to be stopped and heparin considered if 

the indication for ongoing anti-coagulatuion is essential. Clopidogrel can cause a significant increased 

risk of bleeding. Discussion with other clinicians e.g. haematologist and cardiologist may be essential to 

make the most appropriate and safe plan. See BSG Guidelines Veitch et al. 

Post procedure advice/ contact details 

After the procedure before discharge from the unit the patient should be told what to do if they have 

any problems e.g. bleeding or pain. They should be given a sheet explain how to seek advice by 

telephone or if necessary reassessment (attend with a copy of their endoscopy report). It is essential to 

have a system to identify late complications to ensure appropriate assessment and treatment. 


Clinical Governance 

All complications should be recorded and presented at regular Endoscopy Users Group meetings. This 

will allow review to identify any trends to be identified so that safety can be improved. 

Endoscopic procedure Major complication Risk 

Diagnostic upper GI Perforation 1 in 5000 

Haemorrhage < 1 in 5000 

Oesophageal dilatation (benign lesion) Perforation 1 in 200 

Oesophageal dilatation (malignant lesion) Perforation 1 in 25 

Achalasia balloon dilatation Perforation Up to 1 in 20 

Diagnostic lower GI (colonoscopy) Perforation 1 in 1500 

Haemorrhage 1 in 500 

Therapeutic lower GI polypectomy Perforation 1 in 500 

Haemorrhage 1 in 100 

Reducing the risk of endoscopic complications 

Assess Risk v Benefit (esp. Therapeutic procedures) 

Ensure appropriate preparation (assess co-morbidities, anticoagulation etc ) 

Appropriate monitoring and use of sedation 

Supervision of trainees 

Team Culture that prioritises safety first 

Key Messages 

Diagnostic colonoscopy is generally a safe procedure. Complications may occur related to: 

Bowel preparation 

Therapeutic procedures, particularly polypectomy 

Abnormal diseased tissue e.g. severe colitis or acute diverticulitis 

Outcome of complications will be worse in the elderly with significant co-morbidity, or if the recognition 

of the complication is delayed 

On discharge patients should be given written information to explain what they should do if they have a 

problem after their procedure 

All complications should be reviewed by the endoscopy users group 


Diathermy 

Roger Leicester, St George’s Endoscopy Training Centre 

Edited by Dr Paul O’Toole and Dr John Anderson 

How diathermy works 

When an electrical current passes through a conductor some of its energy appears as heat. For any given 

conductor, the heat generated depends upon its resistance and the density of current flow. Heat 

generated in tissue during the passage of a diathermy current can be used for cutting, coagulation or 

tissue destruction. 

Thermal devitalisation: Irreversible death of biological tissue. Occurs above temp 41.5⁰C. The high the 

temperature the faster the devitalisation. Often not a visible phenomenon and can occur outside the 

borders of coagulation zone (intentionally or not). 

Thermal Coagulation: conversion of collloidal systems from sol to gel state (e.g. boiling an egg). Temp 

above 60⁰C cause tissue coagulation. Associated with change of colour to tissues, formation of 

derivatives of collagen, contraction of collagen containing tissue. Can result in glue effect sealing tissues 

to each other and accessories. Colour change to tissue can be used as an indicator of area of controlled 

tissue devitalisation, but this is not precise. 

Thermal desiccation: Heat induced dehydration of tissue. Temperature is equal to boiling point of the 

water in tissue. (100⁰C). Desiccation causes contraction of tissue, adhesive effect and dry layer which 

acts to insulate tissue electrically. This can result in no cutting effect from snare mid-polypectomy with 

snare around tissue and unable to be disengaged. 

Thermal carbonisation: Partial oxidation of tissue hydrocarbon compounds if the temperature exceeds 

200⁰C. Can cause smoke to form and leaves tissue black. 

Thermal Vaporisation: Combustion of desiccated and/or carbonated tissue. Occurs above 500⁰C. Can be 

used for thermal ablation of tissues as well as indirectly for cutting (e.g. Nd:YAG laser). 

Thermal damage 

levels that can be 

induced by diathermy 

Mains electricity is 50 Hz and produces intense muscle and nerve activation (Faradism). Diathermy uses 

high frequency (Radio Frequency) current in the range of 300kHz to 3MHz which has no effect on 

muscles or nerves or cardiac tissue. 


There are two types of diathermy, monopolar and bipolar. 

Monopolar diathermy 

In monopolar diathermy, current passes between the endoscope accessory and the patient plate. As the 

surface area of the accessory is significantly less than that of the plate, localised heating is produced at 

the accessory. The large return electrode (patient plate), which completes the circuit, spreads the 

current over a wide area and produces little heat. The polypectomy snare and hot biopsy forceps are 

examples of monopolar accessories. 

Bipolar diathermy 

In bipolar diathermy, two electrodes are combined in the accessory (e.g. gold probe). Current passes 

through the tissue between the electrodes and not through the rest of the patient’s body. A return 

plate is not required. 

Settings 

The document has purposefully omitted indicating any particular settings for diathermy. Setting need to 

take into account the diathermy unit being used, type, size and location of tissue it is being applied on 

and finally the effect desired. The manufacturers recommendations and guides to settings are useful, 

but may also need to be modified in line with departmental guidance and individual experience. A 

general principle should be that the lowest settings are used to safely obtain the desired effect required. 

Cutting occurs when heating of cellular water occurs so rapidly that cells burst. 

CUT mode achieves this by delivering current in a high amplitude continuous wave, producing sparks 

whose heat explodes intracellular water to steam. CUT mode is activated by depressing the YELLOW 

pedal. 

Coagulation is a less violent heating effect leading to cell death by dehydration and protein 

denaturation. The dead tissue is shrunken and dried with distortion of blood vessel walls, coagulation of 

plasma proteins and stimulation of the clotting mechanism. Coagulated tissue typically appears white. 

COAG effect can be achieved by using a continuous waveform of low peak voltage (‘soft coagulation’) or 

by using current that has an interrupted (modulated) waveform with the energy delivered in short 

bursts (‘forced coagulation’). Combined with pressure (e.g. from a closing snare), forced coagulation 

current will cut through tissue. COAG is activated by depressing the BLUE pedal. 


Peak voltage and mean power output can be 

varied by adjusting the duration of current bursts 

and their intensity to give a combination of cutting 

and coagulation. This is known as ‘blended’ 

current. 

More modern diathermy units incorporate 

‘Endocut’ (or ‘PulseCut’) which deliver pulses of 

cutting followed by coagulation current at 

predetermined powers and intervals. 

Many operators select this mode of operation for 

polypectomy. Others prefer to use bursts of forced 

coagulation while applying increasing tension on 

the snare to control the rate at which the tissue is 

transected. The diathermy mode should be 

selected by the operator after taking into account 

the type of lesion (flat vs pedunculated), site of lesion (stomach, duodenum, right colon, left colon) and 

possible risks (e.g. bleeding, perforation). 

Blend ‘clever cut’ 

Cut current 

Coagulation current 

Endocut or PulseCut, (clever-cut) modes consisting or alternating bursts of cutting and coagulation 

currents. The time intervals between the different modes of cutting and coagulation can be varied to 

have more cut or more coagulation in the cycles. 

If using Endocut (or PulseCut), the following recommendations for safe use should be followed: 

Press yellow pedal continuously 

Gently close snare around polyp to resistance - often does not need tightening 

Do not ‘tap & shake’ 

Use sub-mucosal lifting solution + adrenalin +/- dye 


Power Settings 

Diathermy generators from different manufacturers vary widely and there is often little relationship 

between the output settings of one machine and another. Further variation is introduced by using 

snares of different wire thickness. 

As tissue is desiccated, its electrical resistance increases and more energy is required to cut it. Many 

modern units can monitor tissue impedance and adjust the current automatically - known as adaptive 

diathermy or ‘clever cut’. 

The power setting and mode of operation selected will depend on the type of procedure, tissue 

structure, patient’s body mass index and accessory used. As mentioned above, the aim is to use the 

lowest power setting possible that will accomplish the desired tissue effect. 

In addition to the desired cutting or coagulation, diathermy will produce a zone of thermal devitalisation 

beyond the visibly coagulated tissue. Subsequent necrosis of devitalised tissue can result in late 

perforation or bleeding. For this reason, reduced power settings are used in areas of the GI tract where 

the bowel wall is thin (e.g. right colon). Coagulation current usually results in a deeper heat penetration 

of the tissue that cut current (dependent on settings). 

For pedunculated polyps the main risk is of bleeding and the focus is on safe coagulation of the 

supplying vessel (coagulation). For sessile lesions, the risk and focus is ensuring no transmural injury 

occurs, therefore endoscopists favour the use of a lifting solution and cut or ‘clever-cut’. 

Precautions when using diathermy 

Endoscopic accessories 

The electrode wire should not be deformed, frayed, or broken. The insulation should not be 

cracked or have exposed metal surfaces. 

Do not allow metal parts of the accessory to touch the scope during operation. 

Patient plate 

A check that the patient plate has not been forgotten or become separated should be routine. 

The full surface of the patient plate should be in firm contact with part of the patient’s body. 

Areas with heavy body hair or scars should be avoided. 

Always use a single-use plate, preferably one which has an equipotential ring which will alarm 

and inhibit operation if it becomes partially detached 

Diathermy unit 

Check that the various functions of the power supply are working normally in accordance with 

the instruction manual before use. 

Check that you are able to select between cutting, coagulation and blend or ‘Endocut’ (or 

‘PulseCut’) modes. 

Check that the desired output level can be set. 

Check that the output can be controlled by the foot switch. 


Combustible gases 

Do not perform electrosurgery in the presence of combustible gases (such as anaesthetic gases). 

In locations where combustible gases may be present, such as the colon, the procedure should 

be preceded by replacement of the intraluminal gas with air or a carbon dioxide. 

Body surface protection 

Check that the patient’s body is not in contact with metal fittings on the bed. 

The operator and assistant should wear gloves. 

Interference with electrical equipment 

Diathermy has the potential to interfere with implanted cardiac pacemakers and defibrillators. 

Special precautions must be taken in line with local and national guidelines. 

Further Reading 

Rey, J. F.; Beilenhoff, U.; Neumann, C. S.; Dumonceau, J. M.: European Society of Gastrointestinal 

Endoscopy (ESGE) guideline: the use of electrosurgical units. Appendix 

MHRA Guidelines for the perioperative management of patients with implantable pacemakers or 

implantable cardioverter defibrillators, where the use of surgical diathermy/electrocautery is 

anticipated. (2006) http://www.mhra.gov.uk/ 

G Farin and KE Grund. Principles of Electrosurgery, Laser, and Argon Beam Coagulation with Paricular 

Regard to Colonoscopy . Colonoscopy Principle and Practice 2 nd Edition, Ed Wiley-Blackwell. Section 7, 

pages 326-345. 


Endoscope Design and Function 

Welsh Institute for Minimal Access Therapy (WIMAT) and John Anderson 

Overview 

Head of instrument 


Channels 


Decontamination of GI endoscopes 

Rachael, Hodson, East Yorkshire Training Centre, Hull 

Flexible GI endoscopes are part of a range of reusable equipment in endoscopy, and require 

decontaminating between patients. This is in order to prevent infection, protect the quality of diagnostic 

samples, to prolong the life of the equipment and to protect staff. The reported frequency of endoscope 

transmitted infection is 1 in 1.8 million procedures. However, cases of infection or contamination are 

not reported and onset of infections may occur following discharge. Many infections such as VCJD have 

long intubation periods and people do not know they are high risk. The key National Endoscopy Team 

document Decontamination Standards for Flexible Endoscopes 2009 draws together all UK guidance and 

standards to be followed for systems and processes, workforce and training, environment and 

equipment and policies and processes. 

GI endoscopes in most units undergo high level decontamination, as they are heat sensitive and not 

amenable to usual methods of cost effective, easy sterilisation. This is a highly technical process and 

most units will be happy to take an endoscopist through the endoscope pathway to familiarise them 

with the whole process and associated elements. The endoscopist is responsible for the primary wiping 

down and flushing of a used endoscope before it is handed to the assistant. In a suitably designed area, 

with separate dirty, clean and storage areas, the assistant will manually clean the endoscope in a 

detergent solution, and brush through the channels to remove visible debris, before rinsing it in clean 

water. The endoscope undergoes further decontamination in an Automated Endoscope Reprocessor 

(AER) Channels connected to the valves and ports pump further detergent, disinfectant and water 

through the scope, completing a cleaning cycle. 

The endoscope is dried, and must be used within three hours to prevent growth of channel vegetation, 

or stored immediately within a locked endoscopy drying/ storage cabinet. These allow a cleaned 

endoscope to be stored for up to 31 days without requiring cleaning again. Endoscopes should be 

moved in special containers approved for the purpose e.g. lidded endoscope trays. Throughout this 

process, all parts, machinery and staff handling the endoscope must be tracked. This allows a look back 

exercise if an infection was suspected. Prions which transmit CJD and vCJD cannot be removed by any 

decontamination. Therefore valves must be kept as a unique set with the endoscope, and biopsy valves 

are replaced after a biopsy has been taken. It takes about an 45 minutes to one hour for an endoscope 

to go through this process fully. 

Wherever possible, single use accessories should be used, and any equipment suitable for sterilisation 

should be decontaminated in this way. 

An endoscopist who undertakes an out of hours service must know how to undertake primary 

decontamination of an endoscope, which can then be safely left for up to 24 hours before full 

decontamination is undertaken. 

Key message 

SWEEP: effective and safe endoscope decontamination is a combination of systems and processes, 

workforce, equipment and environment and policies and procedures. 


Potential advantages and complications of oral bowel cleansing agents 

Paul O’Toole, Mersey Training Centre, Liverpool 

Oral Bowel 

Cleansing Agent 

(OBCA) 

Picolax ® or 

Citrafleet ® 

(Sodium 

picosulphate & 

magnesium 

citrate) 

Citramag ® 

(magnesium 

carbonate and 

citric acid) 

Klean Prep ® 

(polyethylene 

glycol) 

Moviprep ® 

(polyethylene 

glycol) 

Fleet 

Phosphosoda ® 

(sodium 

phosphate) 

Potential 

advantages of 

this OBCA 

Produces the 

lowest watery 

residue: 

potentially 

advantageous 

for radiological 

investigation. 

Produces a low 

watery residue 

(although not 

as low as 

Picolax ® ). 

Less likely to 

cause 

hypovolaemia. 

1. Less likely to 

cause 

hypovolaemia 

2. Bowel 

preparation can 

be completed 

within 12 hrs. 

Tolerability and 

ease of use 

Powder is 

reconstituted 

with a low 

volume of 

water. It then 

arms on mixing. 

Powder is 

reconstituted 

with a low 

volume of hot 

water. 

Powder is 

reconstituted 

with a high 

volume of water 

(up to 4 litres). 

Powder is 

reconstituted 

with a moderate 

volume of water 

(approx 2 litres). 

Well tolerated. A low volume of 

liquid (45 mls) is 

mixed with a 

low volume of 

water (120 mls). 

Is a low 

residue diet 

advised prior 

to dosing? 

Are there complications 

specific to this OBCA? * 

Yes 1. Higher risk of 

hyponatraemia (if excessive 

water ingestion) than with 

other OBCA’s. 

2. Risk of 

hypermagnesaemia in 

patients with advanced 

Chronic Kidney Disease. 

Yes. 1. Higher risk of 

hyponatraemia (if excessive 

water ingestion) than with 

other OBCA’s. 

2. Risk of 

hypermagnesaemia in 

patients with advanced 

Chronic Kidney Disease. 

Yes. Lowest risk of provoking 

hypovolaemia and/or 

hyponatraemia. 

Yes. Lowest risk of provoking 

hypovolaemia and/or 

hyponatraemia. 

No. It is 

sufficient to 

simply avoid 

solid food 

during the 

dosing 

period. 

1. Acute Phosphate 

Nephropathy. 

2. Hypocalcaemia resulting 

from hyper-phosphataemia. 

3. Highest risk of 

hypovolaemia. 

Are there any 

contraindications specific to 

this OBCA? + 

It is particularly important 

that patients with conditions 

predisposing to 

hypovolaemia are evaluated 

prior to receiving this OBCA. 

It is particularly important 

that patients with conditions 

predisposing to 

hypovolaemia are evaluated 

prior to receiving this OBCA. 

G6PD deficiency. 

Should not be prescribed to 

patients with; 

1. hypovolaemia 

2. eGFR < 60 

ml/min/1.73m 2 

3. hepatic cirrhosis 

4. cardiac failure 

5. hypertension 

6. renin-angiotensin blockade 

…unless all other OBCA’s are 

contraindicated. 

* 

It should be remembered that the administration of ALL types of OBCA may be complicated by hypovolaemia and/or electrolyte disturbances (including hypokalaemia, 

hyponatraemia and hypernatraemia). 

+ 

The following are absolute contraindications to ALL types of OBCA: gastrointestinal obstruction, perforation or ileus; acute intestinal ulceration; severe inflammatory bowel dise 

reduced consciousness; hypersensitivity to any of the ingredients; ileostomy. 


Suggested Background reading for Basic lower GI endoscopy course 

John Todd, Cushieri Skills Centre, Dundee 

Antibiotic prophylaxis 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/prophylaxis_09.pdf 

Anticoagulation 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/anticoagulant_08.pdf 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/anticoagulant_flow_08.p 

df 

Consent 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/consent08.pdf 

Decontamination 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/decontamination_2008. 

pdf 

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasse 

t/dh_123588.pdf 

Complications of GI endoscopy 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf 

Sedation 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/sedation.doc 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/sedation_elderly.pdf 

Colorectal cancer/ polyp surveillance 

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/ccs_10.pdf 

Colonoscopy: Principles and Practice, 2nd Edition 

JD Waye, DK Rex, PB Cotton 

Publisher: John Wiley & Sons 

ISBN: 978-1-4051-7599-9 

Practical Gastrointestinal Endoscopy. The fundamentals. 6 th Ed. 

PB Cotton, CB Williams, RH Hawes, BP Saunders 

Publisher: John Wiley & Sons 

ISBN: 9781405159029 


Suggested Website Resources 

Paul O’Toole, Mersey Training Centre, Liverpool 

https://www.jets.nhs.uk/ 

https://www.bcsp.nhs.uk/ 

http://www.bsg.org.uk/ 

http://www.thejag.org.uk/ 

http://www.gmc-uk.org/ 

http://www.cancerscreening.nhs.uk/bowel/index.html 

http://www.ncbi.nlm.nih.gov/pubmed/ 

http://www.grs.nhs.uk/ 

http://www.library.nhs.uk/gastroliver/ 

http://www.cqc.org.uk/ 

http://www.screenersupport.nhs.uk/ 

http://www.esge.com/ 

http://www.thieme-connect.com/ejournals/toc/endoscopy 

http://www.mdconsult.com/ 

http://daveproject.org/ 

http://www.gastrolab.net/ 

http://www.asge.org/ 

http://www.endoatlas.com/ 

http://www.gastrohep.com 

http://www.gastrointestinalatlas.com/ 

http://gut.bmjjournals.com/ 

http://www.murrasaca.com/ 

http://www.sign.ac.uk/ 

http://www.nice.org.uk/ 

http://www.nccn.org/professionals/physicians_gls/f_guidelines.asp 

http://www.npsa.nhs.uk 

http://www.ncepod.org.uk/ 

http://gastrojournal.org/ 

http://acpgbi.org.uk/ 

http://augis.org/ 

http://www.nhs.uk 

http://daveproject.org

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