Practical Gastrointestinal Endoscopy

DIAGNOSTIC UPPER ENDOSCOPY TECHNIQUES 45
Fig. 4.14 The scope passes from
the antrum …
Fig. 4.15 … to the pylorus and
duodenal cap…
Fig. 4.16 … and tends to impact
in the duodenum.
hand for tip angulation torque to maintain the instrument tip in
the correct axis.
• advance with the pyloric ring in the center of the view. Passage is
both felt and seen. Entry into the duodenal bulb is recognized
by its granular and pale surface (Figs 4.15 & 4.16).
Patience may be needed to pass the pylorus, especially if there
is spasm or deformity; downwardangulation of the tip or deflation
may help its passage. As the instrument tip passes the resistance
of the pylorus, the loop which has inevitably developed in the
stomach straightens out and accelerates the tip to the distal bulb
(Fig. 4.16). So, to obtain optimal views of the duodenal bulb
• withdraw a few cm to disimpact the tip (and insufflate some air) to
obtain a view (Fig. 4.17).
• examine the bulb by circumferential manipulation of the tip during
advance and withdrawal. The area immediately beyond the pyloric
ring, especially the inferior part of the bulb, may be missed
by the inexperienced, who fail to withdraw sufficiently for fear
of falling back into the stomach.
• give an antispasmodic (Buscopan® or glucagon) intravenously if
visualization is impairedby duodenal motility.
• avoid excessive air insufflation, which will leave the patient uncomfortably
distended.
Passage into the descending duodenum
The superior duodenal angle is the key landmark (Fig. 4.17) connecting
the bulb and the descending duodenum. To pass into the
descending duodenum, GENTLY
• advance so that the tip lies at the angle
• rotate the shaft about 90° to the right
• angle to the right
• angle up.
Fig. 4.17 Withdraw the scope
to disimpact the tip and see the
superior duodenal angle—an
important landmark.