[273] CHAPTER XXXV—GASTROSCOPY
The stomach of any individual having a normal esophagus and normal spine can be explored with an open-tube gastroscope. The adult size esophagoscope being 53 cm. long will reach the stomach of the average individual. Longer gastroscopes are used, when necessary, to explore a ptosed stomach. Various lens-system gastroscopes have been devised, which afford an excellent view of the walls of the air-inflated stomach. The optical system, however, interferes with the insertion of instruments, so that the open-tube gastroscope is required for the removal of gastric foreign bodies, the palpation of, or sponging secretions from, gastric lesions. The open-tube gastroscope may be closed with a window plug (Fig. 6) having a rubber diaphragm with a central perforation for forceps, when it is desired to inflate the stomach.
Technic.—Relaxation by general anesthesia permits lateral displacement of the dome of the diaphragm along with the esophagus, and thus makes possible a wider range of motion of the distal end of the gastroscope. All of the recent gastroscopies in the Bronchoscopic Clinic, however, have been performed without anesthesia. The method of introduction of the gastroscope through the esophagus is precisely the same as the introduction of the esophagoscope (q.v.). It should be emphasized that with the lens-system gastroscopes, the tube should be introduced into the stomach under direct ocular guidance, without a mandrin, and the optical apparatus should be inserted through the tube only after the stomach has been entered. Blind insertion of a rigid metallic tube into the esophagus is an extremely dangerous procedure.
The descriptions and illustrations of the stomach in anatomical works must be disregarded as cadaveric. In the living body, the empty stomach is usually found, on endoscopic inspection, to be a collapsed tube of such shape as to fit whatever space is available at the particular moment, with folds and rugae running in all directions, the impression given as to form being strikingly like searching among a mass of earth worms or boiled spaghetti. The color is pink, under proper illumination, if no food is present. Poor illumination may make the color appear deep crimson. If food is present, or has just been regurgitated, the color is bright red. To appreciate the appearance of gastritis, the eye must have been educated to the endoscopic appearances under a degree of illumination always the same. The left two-thirds of the stomach is most easily examined. The stomach wall can be pushed by the tube into almost any position, and with the aid of gentle external abdominal manipulation to draw over the pylorus it is possible to examine directly almost all of the gastric walls except the pyloric antrum, which is reachable in relatively few cases. A lateral motion of from 10 to 17 cm. can be imparted to the gastroscope, provided the diaphragmatic musculature is relaxed by deep anesthesia. The stomach is explored by progressive traverse. That is, after exploring down to the greater curvature, the tube-mouth is moved laterally about 2 centimeters, and the withdrawing travel explores a new field. Then a lateral movement affords a fresh field during the next insertion. This is repeated until the entire explorable area has been covered. Ballooning the stomach with air or oxygen is sometimes helpful, but the distension fixes the stomach, lessens the mobility of the arch of the diaphragm, and thus lessens the lateral range of gastroscopic vision. Furthermore, ballooning pushes the gastric walls far away from the reach of the tube-mouth. A window plug (Fig. 6) is inserted into the ocular end of the gastroscope for the ballooning procedure.
[275] Like many other valuable diagnostic means, gastroscopy is very valuable in its positive findings. Negative results are entitled to little weight except as to the explorable area.
The gastroscopist working in conjunction with the abdominal surgeon should be able to render him invaluable assistance in his work on the stomach. The surgeon with his gloved hand in the abdomen, by manipulating suspected areas of the stomach in front of the tube-mouth can receive immediately a report of its interior appearance, whether cancerous, ulcerated, hemorrhagic, etc.
Lens-system ballooning gastroscopy may possibly afford additional information after all possible data from open-tube gastroscopy has been obtained. Care must be exercised not to exert an injurious degree of air-pressure. The distended portion of the stomach assumes a funnel-like form ending at the apex in a depression with radiating folds, that leads the observer to think he is looking at the pylorus. The foreshortening produced by the lens system also contributes to this illusion. The best lens-system gastroscope is that of Henry Janeway, which combines the open-tube and the lens system.
Gastroscopy for Foreign Bodies.—The great majority of foreign bodies that reach the stomach unassisted are passed per rectum, provided the natural protective means are not impaired by the administration of cathartics, changes in diet, etcetera. This, however, does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods, or by esophagoscopy, because a swallowed object lodged in the esophagus can always be returned through the mouth. Foreign bodies in the stomach and intestines should be fluoroscopically watched each second day. If an object is seen to lodge five days in one location in the intestines, it should be removed by laparotomy, since it will almost certainly perforate. Certain objects reaching the stomach may be judged too large to pass the pylorus and intestinal angles. These should be removed by gastroscopy when such decision is made. It is to be remembered that gastric foreign bodies may be regurgitated and may lodge in the esophagus, whence they are easily removed by esophagoscopy. The double-planed fluoroscope of Manges is helpful in the removal of gastric foreign bodies, but there is great danger of injury to the stomach walls, and even the peritoneum, unless forceps are used with the utmost caution.