Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine >Diagnostics in
Gastroenterology
Laura A. Huppert, Timothy G. Dyster, (Lead Contributing Editor)+
TABLE 4.2Diagnostic Tests in Gastroenterology
Study Indication
•Diagnosis: Upper GI bleed (UGIB), iron-deficiency anemia,
diarrhea with features of small bowel disease (e.g., celiac),
refractory GERD, dysphagia, odynophagia, upper abdominal
symptoms with alarm features (e.g., unintentional weight loss,
early satiety)
•Treatment:
Upper endoscopy (EGD)
•- UGIB: Injections, thermals/cautery, mechanical clipping
•- Varices: Variceal banding
•- Achalasia, stenosis, strictures
•- Pneumatic dilation, stent placement
•- Malignancy: Stent placement, resection
•Screening: Barrett’s esophagus, upper GI malignancies in high-
risk patients
•Diagnosis: Lower GI bleed (LGIB), iron-deficiency anemia, lower
GI symptoms (e.g., chronic diarrhea), evaluation for IBD
•Treatment:
Colonoscopy •- LGIB: Injections, thermals/cautery, mechanical clipping
•- Polyp removal
•- Decompression of sigmoid volvulus/colonic pseudo-obstruction
•- Balloon dilation of strictures
•Screening: Colorectal cancer (CRC)
•Diagnosis: LGIB, iron-deficiency anemia, lower GI symptoms
(e.g., chronic diarrhea), surveillance for IBD.
Flexible sigmoidoscopy
•Treatment: Polyp removal
•Screening: CRC (alternative to colonoscopy, q5yr)
•Diagnosis only: Iron-deficiency anemia with normal
Capsule endoscopy
EGD/colonoscopy, small bowel tumor, Crohn’s disease.
•Diagnosis/Treatment: Typically performed when both a
diagnostic/therapeutic indication are present, such as to evaluate
and possibly treat the following conditions:
•- Suspected biliary obstruction
•- Suspected pancreatic/biliary malignancy
Endoscopic retrograde cholangiopan-creatography (ERCP)
•- Acute pancreatitis with cholangitis or biliary obstruction
•- Choledocholithiasis
•- Biliary dyskinesia
•- Biliary strictures
•- Pancreatic pseudocyst drainage
•Limitation: Difficult to perform in Roux-en-Y anatomy
Procedure Details
•Prep: NPO for >8 hr
•Sedation: Options include moderate sedation, monitored
anesthesia care, general anesthesia
•Procedure: Endoscope inserted through the mouth and advanced
through the esophagus, stomach, and as far as to the second
portion of duodenum. Biopsies and therapeutics can be performed
as indicated.
•Push enteroscopy: Variation of an EGD that utilizes a longer
endoscope, which makes it possible to advance beyond the
ligament of Treitz and into the jejunum.
•Prep: Clear liquids × 1 day prior with bowel prep, NPO at least 2
hr
•Sedation: Options include no sedation, moderate sedation,
monitored anesthesia care, general anesthesia
•Procedure: Colonoscope inserted through the anus and advanced
through the rectum, large bowel, and small bowel up to the
cecum/terminal ileum. Biopsies and therapeutics can be
performed as indicated.
•Prep: Less involved than colonoscopy: Enemas × 2
•Sedation: None (benefit over colonoscopy)
•Procedure: Colonoscope inserted through the anus and advanced
through the rectum and up to the distal 60 cm of the colon (up to
the splenic flexure). Misses proximal/right-sided lesions. Thus,
colonoscopy is preferred for CRC screening.
•Prep: NPO for 12 hr
•Procedure: The patient swallows a video capsule. An external
wireless recorder captures images of the entire GI tract while the
capsule is in transit, and then the footage is analyzed. Capsules
are disposable and excreted with a bowel movement.
•Prep: Pregnancy testing, coagulation studies, NPO for 8 hr
•Sedation: Monitored anesthesia care or general anesthesia
•Procedure: Combined endoscopic/fluoroscopic procedure.
Duodenoscope is advanced through the mouth and to the
duodenum. A catheter is then inserted into the papilla of Vater
and contrast is injected. X-rays are taken of the biliary tree and
pancreatic duct. May perform sphincterotomy, stent placement,
CBD stone extraction, and/or dilation of strictures.
•Complications: >5% risk: Acute pancreatitis, bleeding,
cholangitis/sepsis, perforation

•Diagnosis: Pancreatic cancer with FNA, choledocholithiasis,
submucosal masses of stomach, duodenum, rectum.
Endoscopic ultrasound (EUS)
•Treatment: Pancreatic fluid collection drainage, celiac plexus
neurolysis (improves pain control in pancreatic cancer)
•Diagnosis only: Choledocholithiasis, biliary strictures, chronic
Magnetic resonance cholangiopan-creatography (MRCP) pancreatitis, suspected congenital anomaly of pancreaticobiliary
tract, preop/postop evaluation of biliary abnormalities
•Diagnosis only: Dysphagia, esophageal perforation, hiatal hernia,
Barium swallow malignancy, diverticula, esophageal motility disorders (e.g.,
achalasia, diffuse esophageal spasm)
•Diagnosis only: Esophageal motility disorders (e.g., achalasia,
Esophageal manometry
hypercontractile esophagus, distal esophageal spasm)
Ambulatory pH monitoring •Diagnosis only: GERD
Date of download: 09/13/21 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved.
•Prep: NPO for 8 hr
•Sedation: Monitored anesthesia care, general anesthesia
•Procedure: Endoscope with an ultrasound transducer is advanced
through the mouth and down to the duodenum. Enables clearer
view of the pancreas. Can be done in conjunction with FNA.
•Prep: NPO for 4 hr
•Procedure: Same as MRI scan. Allows for better visualization of
pancreaticobiliary tract
•Procedure: The patient is put in a prone or supine position with tilt
and then instructed to rapidly swallow barium contrast (100-200
cc). X-ray or fluoroscopy is used to evaluate the patient’s swallow,
enabling the localization of lesions and the initial identification of
some esophageal pathologies.
•Classic findings: “Bird beak” appearance of achalasia, “corkscrew
sign” in diffuse esophageal spasm
•Procedure: Can be conventional or high resolution (more pressure
sensors). A long tube is positioned in the esophagus terminating
in the stomach. The patient is instructed to swallow, and then the
system detects pressure changes generated by the esophagus or
the upper/lower esophageal sphincter.
•Procedure: Options include a transnasally placed catheter or a
wireless capsule that is fixed to the distal mucosa. pH sensor
results are analyzed after 24 hr to 4 days.