OPEN ACCESS ENDOSCOPE MALAYSIA

2012
HOSPITAL TUANKU JA’AFAR
SEREMBAN
NEGERI SEMBILAN
OPEN ACCESS ENDOSCOPE MALAYSIA
Reducing waiting time for endoscopy
Detecting Upper GI cancers early
CONTRIBUTORS:
Dr. Mahadevan Deva Tata
Surgeon
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
Prof. Dato' Dr. P. Kandasami
Professor of Surgery
IMU [Clinical School Seremban]
Honorary Consultant for Hospital Tuanku Ja’afar
Dr. Ramesh Gurunathan
President
Malaysian Society of Gastroentrology and Hepatology
Academy of Medicine Malaysia
Dr. Jasiah Zakaria
Head of Surgery Department
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
Dr. Dharmendran Ratnasingam
Surgeon
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
Dr. Azrina Abu Bakar
Surgeon
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
Dr. Chik Ian
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
Dr Shirley Tang
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
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Mr. Chu Teck Hoe
Hospital Tuanku Ja’afar
Seremban Negeri Sembilan
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1. RATIONALE
Gastric cancer is the second most common cause of cancer-related death in the world. Detecting
this cancer early has been an uphill task for decades. Most of the patients with gastric cancer
present with advance diseases. Most often treatment modalities are narrowed towards palliative
procedures rather than curative. Detecting cancers early is vital to ensure better survival and
outcome of the surgery.
It is crucial that all endoscopist have a good knowledge on endoscopic appearance of early upper
gastrointestinal cancers especially stomach and esophageal cancers. This guideline is aimed to
standardize the endoscope techniques in OPEN ACCESS endoscope service. This guideline will
ensure to serve as a guide for the endoscopist who are involve in OPEN ACCESS endoscope
service does the procedure using a systematic guide.
2. EARLY GASTRIC CANCER [EGC]
Early gastric cancer [EGC] is defined as a carcinoma confined to mucosa or sub mucosa,
regardless of nodal status. Detection of EGC is higher in regions where mass screening is done
routinely such as Japan. Macroscopically early stomach cancers [EGC] has been described as:
Protruding (type I)
Superficial (type II)
o
Elevated (IIa)
o
Flat (IIb)
o
Depressed (IIc)
o
Excavated (type III)
.
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Description of a lesion in the stomach
1.
Site
2.
size
3.
shape
4.
margin
5.
floor
Classification of macroscopic subtype of early gastric cancers
[Adapted from Japanese Classification of Gastric Carcinoma - 2nd
English Edition
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3. OPEN ACCESS ENDOSCOPE TECHNIQUES AND QUALITY CONTROL
RECOMMENDATION
During an upper endoscope procedure it is crucial that the endoscopist examine the whole
esophagus, stomach and duodenum thoroughly. In some countries multiple images are taken as
a proof of completeness of procedure. Video images are also recorded to enable the endoscopist
to re-look the lesions after the procedure. Eight regions have been described by European
Society of Gastrointestinal Endoscopy [ESGE] recommendation for quality control in
gastrointestinal endoscopy. [Figure below]
*Taken from ESGE recommendation for quality
control in gastrointestinal endoscopy
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Open Access endoscope guideline recommends nine regions or stations that have been identified
for standardizing the endoscope procedure. This is to ensure accurate and effective detection of
mucosal lesion. Endoscopist need to examine the following region or stations where necessary
take images.
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Station 1:
Upper esophagus - about 20cm from the incisor teeth to get a forward view of the esophagus.
This region also is needed to be observed to look for upper esophageal lesion. Some of the upper
esophageal lesions can be missed either at the start of the endoscope procedure (when going
pass the cricopharyngeal constrictions) or at the end of the procedure when withdrawing the
scope too fast without looking at the upper esophagus. Using NBI endoscope may be useful look
for dysplastic area (pink color sign) or Intra-papillary capillary loop (IPCL) type III or more.
Station 2:
This region is at 2cm above the squamocolumnar junction [Z line]. This region is important to
identify. It is also important to note any abnormalities at this region; particularly in the case of
esophagitis or Barrett’s esophagus. In case of suspicious lesions or irregular Z line;
chomoendoscopy or NBI may be useful to assist accurate biopsy. Hiatus hernia is better identified
and described at this station.
Station 3:
Distension of stomach and viewing of greater curvature and upper part of the lesser curvature.
This is one of the region where lesions are frequently missed especially atrophic gastritis border.
This region should be viewed after inflation of the stomach. This is to ensure good visibility.
Lesser curvature needs to examine as well.
Station 4:
Angulus incisura in partial inversion. Positioning the endoscope in front of the angulus incisura
provides conformation that a complete examination of the antrum, angulus and fundus seen in
inversion has been performed.
Station 5:
Antrum. The whole of the antrum is visualized at this region, assuming that the angulus has just
been examined as described above. Use of NBI will be added benefit to visualize mucosal pattern
for intestinal metaplasia and atrophic gastritis.
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Region 6:
Duodenal bulb. This area can be examined by positioning the endoscope on the bulbar side of the
pylorus in order to see the entire bulb.
Station 7:
Second part of the duodenum. This confirms that a complete examination has been performed
with the end of the endoscope positioned near the papillary area.
Station 8:
Fundus in inversion. After viewing the angulus, fundus can be visualized in a distance before
pulling the scope nearer to the cardia (upper part). This view of the fundus in inversion allows
good visualization of the fundus as a whole. Posterior wall of the stomach can be best examined
during this procedure.
Station 9:
Cardia in inversion. An examination of the cardia in inversion at a close range allows good
visualization of the cardia and the lesions at the cardia and cardioesophageal junction.
4. BIOPSY TECHNIQUES AND DATA COLLECTION
Biopsies will be done if there are any suspicious lesions found in the stomach. To standardize the
number of biopsy taken, at least 4 biopsies for stomach lesions and esophageal lesions need to
be taken using standard biopsy forcep.
If there are no suspicious lesions seen during the OGDS; no biopsies will be taken. Rapid test for
helicobacter pylori (CLO test) or similar test must be performed for all high risk patients to
diagnose Helicobacter pylori.
The biopsies will be sent to the department of pathology of the respective hospitals to be
analyzed. Results of the biopsies will be kept at the respective hospital to be included into the
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Open Access database. A copy of histopathology report needs to be kept with the patient’s
endoscope finding sheet.
5. FOLLOW UP
After the OGDS, only patients with positive (cancers and other disease which cannot be managed
at Health centre to be decided by the endoscope centre/hospital) finding will be followed up at the
centre. Other patients will be given discharge note (the endoscope report with recommended
treatment) to the referral centre on recommendation to follow up. All result of the biopsy report
must be kept in the Open Access endoscope file.
Patients with other diagnosis such as non-ulcer dyspepsia, Helicobacter pylori related dyspepsia,
Cholelithiasis, GERD and etc should be managed according to the NICE guideline or any local
guidelines.
6. IMPORTANT CONSIDERATIONS
Open Access endoscopic service is a statement of revolution in fast track medical services with
great potential to improve patient health. However, several potential problems could arise if this
service is not used appropriately.
The issue that may arise includes inappropriate referral and poorly informed patients. The
indications and pre- endoscopic information about the patient should be adequately provided,
including underlying medical problems and drug history that may complicate an endoscopic
procedure. Detailed information should also be provided to the patient, informing them in detail
regarding the procedure, pre- procedure preparation, potential complications as well as
justifications and benefits expected from an endoscopic procedure. A proper informed consent is
compulsory to improve patient satisfaction towards the procedure and avoid unnecessary delay or
cancellation.
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PHYSICIAN INFORMATION LEAFLET
OPEN ACCESS Endoscope Service in Malaysia
- A move towards specialized health care closer to people -
OPEN ACCESS endoscope service in Malaysia
To identify high risk patients for Upper GI cancer
To eliminate barriers in the current referral system for endoscope
To reduce the waiting time for endoscope for high risk patients
To improve the outcome of Upper Gastrointestinal cancers
OPEN ACCESS endoscope service was first started in Negeri Sembilan. It was initiated by
Department of Surgery of Hospital Tuanku Ja’afar Seremban in 2006. This project was aimed to
detect Upper Gastrointestinal cancers early. This project won 2011 National Quality Assurance
award.
WHY OPEN ACCESS endoscope?
 Dyspepsia is one of the most common presenting symptoms in public health centre.
 This symptom is also according to published data commonly found in 60-90% of the Upper
Gastrointestinal cancer patients.
 Making this discernible to identify high risk patients from general population.
 For the last 3 years our center which is a referral center for upper GI cancers and
disorders seen more than 50 cancers involving stomach and esophagus. More than 80%
of these patients present to us in advanced stages.
 More than 85% of these patients have been treated at private clinics and health centers for
symptoms called ‘gastritis’.
 The time delay from the first appearance of symptoms to the time of endoscope was
estimated to about 8 months
 Using this system we are hoping to filter and shorten the referral process of endoscopy
and detect gastric cancers early.

Subsequently to improve survival outcome of these patients.
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What is Open Access endoscope service?
Defined as the provision of a diagnostic endoscopic procedure by direct request of a medical
officer without prior hospital consultation, but including the provision of screening the
appropriateness of any referral. These have been widely practice in UK. OPEN ACCESS
endoscope is the first of its kind in Malaysia. We are using simple criteria called MARK’s
Quadrant.
This means any medical officers in health centre can request for endoscope procedure for high
risk patients without prior hospital consultation. This will establish a barrier free referral system for
at risk patients for early endoscopy service.
MARK’s Quadrant – symptoms based targeted screening tool. This tool was first developed in
Seremban in 2006. It was validated and tested in a prospective sample. MARK’s quadrant
recently won young investigator’s award in the 2011 International Gastric Cancer Congress in
Seoul, Korea.
QUADRANT A: AGE
Score
< 40 yrs
2
40 – 49 yrs
≥ 50 yrs
3
5
QUADRANT B: RECENT UGIB
(including melena)
Score
Occurred more than 1 year
ago
Occurred less than 1 year
Sector Total
Sector Total
QUADRANT C: MODIFIED
ALARM SYMPTOMS
Score
Anaemia
3
Epigastric Mass /
3
Fullness
Persistent vomiting
3
QUADRANT D: DYSPEPSIA
Significant LOW
Dysphagia
Early satiety / eating
less over a period of
time
Sector Total
Intermittent, more than 1 year
Intermittent, less than 1 year
Persistent for MORE than 2
weeks
1
5
Score
1
3
5
3
5
3
Sector Total
Figure above showing MARK’s Quadrant – targeted screening tool for Upper GI cancers
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How it works?
Once a patient scores 10 from any combination of the quadrant; he/she will be deemed high risk
and warrant an early endoscope appointment.
Call the respective endoscope centre near you (see OAE referral flow chart). We will give an
endoscope appt within 2 weeks. If the scope findings are positive for cancer we will continue the
management here. If it is negative send back the patient to your center with suggestion to follow
up. (Refer OAE follow-up guide)
Intervention impact
The screening of symptomatic patients through Open Access endoscope has been reported to
achieve a higher incidence of Early Gastric Carcinoma [EGC].
In Birmingham, a policy of screening dyspeptic patients over the age of 40 years in the 1990s had
seen an improvement of detecting EGC from 1 to 26%. Curative resections had also increased in
parallel from 20 to 63% 11. Similar results have been confirmed in Leeds, with a 4% incidence of
EGC in 1970 increasing to 26% in 198010.
In Negeri Sembilan, Open Access Endoscope service was introduced in Oct 2006. From the 210
patient data; there were 18 (8.6%) stomach cancers were diagnosed during this period through
Open Access endoscope service. These include 2 early cancers (Stage 1 & II).
The rest of the patients scoped had either precancerous lesion of the stomach (n=144, 68.6%),
Benign lesion of the stomach (n=38, 18.1%) or normal scope (n=10, 4.8%). All patients has their
scopes done within 2 weeks. Compared to mean 15 weeks in the routine referral system.
References
1.
2.
3.
4.
Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001; 2:533–543.
BC Cancer Agency, Oncology Nutrition November, 2004 Revised September 2005
National cancer registry 2003-2006.
Kandasami P et al. Gastric cancer in Malaysia: the need for early diagnosis. Med J
Malaysia. 2003
5. Yih K. Tan and John W.L. Fielding. Early diagnosis of early gastric cancer. European
Journal of Gastroenterology & Hepatology 2006, 18:821–829.
6. Goh KL. Clinical and epidemiological perspectives of dyspepsia in a multiracial Malaysian
population. J Gastroenterol Hepatol. 2011 Apr;26 Suppl 3:35-8.
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Summary
 60%-90% of patients with early stomach cancers have dyspepsia.
 Cancer can ‘heal’ by acid suppression*
 Makes the endoscopic identification impossible if the patient already been treated
with PPI
 Healing of malignant ulcer in 4 weeks after PPI. (Wayman J N Engl J Med 1998;
338:1924–1925)
 Bramble MG et al. – delay in diagnosis of 26 weeks after PPI (Gut 2000; 46:464–
467.)
 Refrain from prescribing antacids or PPI esp. for patients over 50 years old with
dyspepsia before OGDS
 Use MARK’s Quadrant to identify high risk patients
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PATIENT INFORMATION LEAFLET
What is an OESOPHAGODUODENOSCOPY (OGDS)?
Upper endoscopy lets your doctor examine the lining of the upper part of your gastrointestinal
tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine).
Your doctor will use a thin, flexible tube called an endoscope, which has its own lens and light
source, and will view the images on a video monitor.
Why is it done?
Upper endoscopy helps your doctor evaluate your complaints that may be related to illness of the
upper intestinal tract. It's the best procedure that would help doctors find out the cause of bleeding
from the upper gastrointestinal tract. It's more accurate than X-ray or CT scans for detecting
inflammation, ulcers and tumors of the esophagus, stomach and duodenum.
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Your doctor might use upper endoscopy to obtain a biopsy (small tissue samples). A biopsy helps
your doctor distinguish between benign and malignant (cancerous) tissues or to test for
Helicobacter pylori, a treatable cause for gastric ulcers.
Upper endoscopy is used not only use to visualize the gastrointestinal tract, but this procedure
can also be used to provide treatment. Your doctor can pass instruments through the endoscope
to directly treat many abnormalities which may cause little or no discomfort. For example, your
doctor might stretch a narrowed area, remove polyps or treat bleeding.
What preparations are required?
An empty stomach allows for the best and safest examination, so you should have nothing to eat
or drink, including water, for approximately six hours before the examination. Your doctor will tell
you when to start fasting as the timing can vary.
Tell your doctor in advance about any medications you take; you might need to adjust your usual
dose for the examination. Discuss any allergies to medications as well as medical conditions,
such as heart or lung disease. It is advisable to refrain from smoking six hours prior to the
procedure.
What to Bring
CT, MRI and X-Rays if you have any.
Medications that you are taking.
Phone number of contact person who will pick you up.
Can I take my current medications?
Most medications can be continued as usual, but some medications can interfere with the
preparation or the examination. Inform your doctor about medications you’re taking, particularly
aspirin products or antiplatelet agents, arthritis medications, anticoagulants (blood thinners such
as warfarin), clopidogrel, insulin or iron products. Also, be sure to mention any allergies you have
to medications.
What happens during upper endoscopy?
Your doctor might start by spraying your throat with a local anesthetic or by giving you a sedative
to help you relax. You'll then lie on your side, and your doctor will pass the endoscope through
your mouth and into the esophagus, stomach and duodenum. The endoscope doesn't interfere
with your breathing, Most patients consider the test only slightly uncomfortable, and many patients
fall asleep during the procedure.
What happens after upper endoscopy?
You will be monitored until most of the effects of the medication have worn off. Your throat might
be a little sore, and you might feel bloated because of the air introduced into your stomach during
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the test. You will be able to eat after you leave unless your doctor instructs you otherwise. Your
physician will explain the results of the examination to you, although you'll probably have to wait
for the results of any biopsies performed.
If you have been given sedatives during the procedure, someone must drive you home and stay
with you. Even if you feel alert after the procedure, your judgement and reflexes could be impaired
for the rest of the day.
The estimated time you will be here is 2 - 3 hours.
What are the possible complications of upper endoscopy?
Although complications can occur, they are rare when doctors who are specially trained and
experienced in this procedure perform the test. Bleeding can occur at a biopsy site or where a
polyp was removed, but it's usually minimal and rarely requires follow-up. Perforation (a hole or
tear in the gastrointestinal tract lining) may require surgery but this is a very uncommon
complication. Some patients might have a reaction to the sedatives or complications from heart or
lung disease.
Although complications after upper endoscopy are very uncommon, it's important to recognize
early signs of possible complications. Contact your doctor immediately if you have a fever after
the test or if you notice trouble swallowing or increasing throat, chest or abdominal pain, or
bleeding, including black stools. Note that bleeding can occur several days after the procedure.
If you have any concerns about a possible complication, it is always best to contact your doctor
right away.
IMPORTANT REMINDER:
This information is intended only to provide general guidance. It does not provide definitive
medical advice. It is very important that you consult your doctor about your specific condition.
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MAKLUMAT UNTUK PESAKIT
Apakah OESOPHAGODUODENOSCOPY (OGDS)?
Dengan mengunakan endoskopi (teropong), doktor anda boleh membuat pemeriksaan dalaman
saluran pencernaan anda, yang termasuk esofagus, perut dan duodenum (bahagian pertama
usus kecil). Doktor anda akan menggunakan saluran fleksibel (teropong) berkamera dan sumber
cahaya yang dipanggil endoskop, dan akan melihat imej saluran pencernaan anda akan
dipaparkan pada monitor video.
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Mengapa ia dilakukan?
Endoskopi membantu doktor mengenal pasti punca simptom anda yang mungkin berkaitan
dengan penyakit saluran pemakanan atas. Prosedur endoskopi adalah prosedur yang terbaik
dalam membantu doktor mencari punca pendarahan dari saluran pemakanan atas. Ia adalah
lebih tepat daripada sinar-X atau imbasan CT untuk mengesan radang, ulser dan tumor esofagus,
perut dan duodenum.Doktor anda mungkin menggunakan endoskopi atas untuk mendapatkan
biopsi (contoh tisu kecil). Biopsi membantu doktor anda membezakan antara tisu (kanser) yang
berjenis barah atau biasa atau untuk menguji jangkitan kuman Helicobacter pylori, punca dirawat
untuk ulser gastrik.Endoskopi bukan sahaja digunakan untuk memberi gambaran saluran usus,
tetapi prosedur ini juga boleh digunakan untuk memberi rawatan. Masalah pencernaan yang rumit
boleh dirawat dengan ketidak selesaan yang hanya sedikit atau tiada langsung. Sebagai contoh,
doktor anda mungkin melebarkan kawasan yang sempit, mengeluarkan polip atau merawat
pendarahan.
Persediaan apa yang diperlukan?
Perut yang kosong membenarkan peperiksaan yang terbaik dan paling selamat, jadi anda harus
berpuasa (termasuk air), selama lebih kurang enam jam sebelum peperiksaan. Doktor anda akan
memberikan
keterangan
lanjut
tentang
berpuasa
sebelum
endoskopi.
Beritahu doktor anda terlebih dahulu tentang apa-apa ubat yang anda ambil, anda mungkin perlu
mengubah dos biasa anda untuk peperiksaan. Bincangkan sebarang alahan kepada ubat-ubatan
serta keadaan perubatan, seperti jantung atau penyakit paru-paru. Ia adalah dinasihatkan supaya
mengelakkan diri daripada merokok enam jam sebelum prosedur.
Apa yang perlu dibawa
CT, MRI dan X-Rays jika anda mempunyai sebarang. Ubat-ubatan yang anda ambil. Nombor
telefon orang kenalan yang akan menjemput anda. Bayaran adalah lebih kurang RM 30.
Bolehkah saya mengambil ubat-ubatan semasa saya?
Kebanyakan ubat-ubatan boleh diteruskan seperti biasa, tetapi sesetengah ubat boleh
mengganggu penyediaan atau peperiksaan. Maklumkan kepada doktor anda mengenai ubatubatan yang anda ambil, terutamanya produk aspirin atau agen antiplatelet, ubat-ubatan artritis,
anticoagulants (pencair darah seperti warfarin), clopidogrel, insulin atau produk besi. Juga,
pastikan untuk menyatakan apa-apa alahan anda perlu kepada ubat-ubatan.
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Apakah yang berlaku semasa endoskopi atas?
Doktor anda mungkin bermula dengan menyembur tekak anda dengan ubat bius tempatan atau
dengan memberi anda ubat pelali untuk membantu anda berehat. Anda akan dipusing
menyebelah dalam keadaan baring, dan doktor anda akan memasukan teropong melalui mulut
anda dan ke dalam esofagus, perut dan duodenum. Endoskop itu tidak mengganggu pernafasan
anda, Kebanyakan pesakit menganggap ujian hanya sedikit tidak selesa, dan ramai pesakit
tertidur semasa prosedur.
Apa yang berlaku selepas endoskopi atas?
Anda akan dipantau sehingga kebanyakan kesan ubat-ubatan telah dipakai. Tekak anda mungkin
menjadi sakit sedikit, dan anda mungkin berasa yang mengembung kerana udara yang
diperkenalkan ke dalam perut anda semasa ujian. Anda akan dapat makan selepas anda
meninggalkan melainkan jika doktor mengarahkan sebaliknya. Doktor anda akan menerangkan
keputusan peperiksaan kepada anda, walaupun anda mungkin akan perlu menunggu keputusan
mana-mana biopsi yang dilakukan. Jika anda telah diberi sedatif semasa prosedur, seseorang
perlu memandu anda rumah dan tinggal bersama anda.
Anggaran masa anda akan berada di sini adalah 2 - 3 jam.
Apakah komplikasi yang mungkin endoskopi atas?
Walaupun komplikasi boleh berlaku, mereka jarang berlaku apabila doktor yang telah dilatih khas
dan berpengalaman dalam prosedur ini menjalankan ujian. Pendarahan boleh berlaku di tapak
biopsi atau polip telah dikeluarkan, tetapi ia biasanya kecil dan jarang memerlukan susulan. Luka
atau penembusan pada dinding saluran pemakan mungkin memerlukan pembedahan tetapi ini
adalah satu komplikasi yang sangat jarang berlaku. Sesetengah pesakit mungkin mempunyai
reaksi kepada sedatif atau komplikasi jantung atau jangkitan paru-paru.Walaupun komplikasi
selepas atas endoskopi adalah sangat jarang berlaku, ia adalah penting untuk mengenal pasti
tanda-tanda awal komplikasi yang mungkin. Hubungi doktor anda dengan segera jika anda
demam panas selepas ujian atau jika anda mendapati masalah menelan atau meningkatkan
kerongkong, dada atau sakit perut, atau pendarahan, termasuk najis hitam. Sila ambil perhatian
bahawa pendarahan boleh berlaku beberapa hari selepas prosedur.Jika anda mempunyai
sebarang kemusykilan tentang komplikasi endoskopi, seeloknya hubungi doktor anda dengan
segera.
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PERINGATAN PENTING:
Maklumat ini adalah hanya untuk panduan am. Anda perlu berbincang dengan doktor anda
tentang keadaan khusus anda untuk maklumat lebih lanjut.
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病人资料小册子
什么是 上消化道内窥镜检查 （胃镜）?
胃镜检查是借助一条纤细的丶可弯曲的丶末端装有一个光源并带微型电子摄影机的纤
维软管伸入胃中，医生从连接的主机电视屏幕上直接观察食道丶胃和十二指肠
为什么需要做此项检查?
胃镜检查可以直接观察食道丶胃和十二指肠有无炎症丶糜烂丶溃疡丶出血丶食管静脉
曲张丶血管瘤丶肿瘤（良性或恶性）丶胃肠憩室，壁弹性丶胃上口贲门丶胃下口幽门
口闭开是否正常，有无十二指肠液从胃下口幽门返流到胃等，并可以对可疑病变部位
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进行活检（BIOPSY） 明确是否癌变或幽门螺杆菌(HELICOBACTER
PYLORI)感染，切除息肉，注射治疗食管静脉曲张，收紧下食管括约肌，组织烧灼或给
药止血等的一种检查和治疗的方法
检查前准备
前一天晚上要先空腹（胃）-至少6
小时前不能吃东西或喝水。空腹是为了能更清楚地看到胃部，也防止检查过程中呕吐
或液体吸入肺内。
告诉医生你正在服用哪些药物，有没有对药物敏感，以及本身的健康问题（如心脏问
题，肺部问题等。）
检查前6小时最好能够避免抽烟。
需要携带什么？
CT, MRI 或 X-光（若有）
本身的药物
将会接你回家的家人或朋友的电话号码
我能够服用本身的药吗？
大致上的药物都能够继续服用。告诉医生你目前服用的药物（特别是降血糖药，降压
药，薄血药（BLOOD
THINNER）或其它心脏病的药物，医生会指导你如何服药）和药物过敏史。
胃镜的过程是怎样？
23 | P a g e
麻醉采用局部麻醉---咽喉的局部喷药（LIDOCANE
SPRAY）麻木，或给予静脉镇静药（INTRAVENOUS
SEDATION）。取下眼镜及假牙，取左侧卧位，牙齿间放置口垫，保护病人牙齿和胃
镜导管，胃镜经过口垫进入口腔丶食道丶胃和十二指肠。 胃镜不会影响你的呼吸。在检
查过程中，多数病人只会感觉到稍微的不适。
胃镜检查后会怎样？
你的喉咙可能会有些疼痛，你可能会觉得胃肠胀气，这是因为检查过程中空气的引入
。通常24小时内症状就会消失。你会被观察直道药物的效果消失为止。离开后你可以
如常吃东西（ 除非医生 指示不能吃东西）
医生将会为你解释胃镜的结果，但活检（BIOPSY）报告要等几天后才会出来。
你暂时不能开车，需要家人或朋友来接你回家。
整个过程（胃镜检查以及之后的观察）大约2-3小时
胃镜有哪些风险？
受过特别训练和经验丰富的医生会使这项检查的风险降到最低。活检的部位可能会有
少许的流血。一个可能的最大风险就是穿孔（可能需要动手术）。若有胃部持续性疼
痛或其它不适，请通知医生，不要耽搁，以免发生意外。
重要提示：
这份小册子只是大致上的讲解。请询问你的医生关于更详细的资料。
24 | P a g e
Detect
STOMACH CANCERS early….
25 | P a g e
MARK’s Quadrant
QUADRANT A: DYSPEPSIA
QUADRANT B:UGIB(including melena)
Score
Score
Intermittent, more than 1
year
1
Occurred more than 1 year ago
1
Intermittent, less than 1 year
3
Occurred less than 1 year
5
Persistent for 2 weeks
5
QUADRANT C: Modified ALARM
Symptoms
QUADRANT D: AGE
Score
Score
Anaemia
3
Less than 40 yrs
2
Epigastric Mass / Fullness
3
40 – 49 yrs
3
Persistent vomiting [>2wks]
3
≥ 50 yrs
5
Significant LOW
3
Total score:
Dysphagia
5
Early satiety
3
[a score of 10 and above will warrant an
urgent ODGS]
Definitions
1. Dyspepsia - is defined as pain or discomfort centered in the upper abdomen (i.e. in or around
the midline) – The Rome III definition.
Also defined as upper abdominal pain or discomfort that is episodic or persistent and often
associated with belching, bloating, heartburn, nausea or vomiting.
26 | P a g e
2. Melena – The term "melena" describes black, tarry, and foul -smelling stools or
"hematochezia" to describe red - or maroon-colored stools. Melena is a sign of
gastrointestinal bleeding.
3. Dysphagia- The difficult passage of food from the mouth to the stomach during one or more of
the three phases of normal swallowing, i.e. oral, pharyngeal, esophageal.
4. Persistent vomiting- continuous vomiting more 1 weeks without any underlying disease
diagnosed during the period and cannot be related to any particular disease process.
5. Anaemia- The lower limit of the normal range of hemoglobin should be used to
define anemia.
6. Unintentional
significant*
loss
of
weight -
is
a
decrease
in
body
+
weight/significant weight lost that is not voluntary.
*significant weight loss: loss of 5% body weight in 30 days, 7.5% in 60 days, or 10% in 180 days
7. Epigastric mass- A mass at the epigastric region during routine examination
8. Non-variceal Upper GI bleed- Upper-gastrointestinal (GI) bleeding refers to GI blood loss
whose origin is proximal to the ligament of Treitz. Acute upper-GI bleeding (UGIB) can
manifest as hematemesis, "coffee ground" emesis, the return of red blood via a nasogastric
tube, and/or melena with or without hemodynamic compromise. Non variceal bleeding
corresponds to OGDS findings/ evidence of esophageal varices.
9. Early satiety- A feeling of abdominal fullness which limits the patient’s ability to eat more than a
very small amount of food or liquid at any one time. Patient/ individual claims eating less over a
period of time less more than 3 months.
27 | P a g e
OPEN ACCESS
Endoscope service
Hospital _______________
OPEN ACCESS Endoscope service referral form
To request for endoscope service [OGDS or colonoscopy]
please complete this form and for endoscope date
 Call directly …………………
 Send it with the patient to Department….,
………hospital to get their appointments for endoscope
procedure or
 Fax to
– attention to ‘Open access
endoscope service, Department ………,
……hospital
Oesophagogastroduodenoscope [OGDS]
MARK’s quadrant [circle the score where necessary]
Intermittent, more than 1
year
Intermittent, less than 1
year
Persistent for 2 weeks
Score
1
3
QUADRANT B: RECENT
UGIB (including melena)
Occurred more
than 1 year ago
Occurred less
than 1 year
*Patients with score of 10 and above will be scoped
within __ weeks
Referring doctor:
………………………………….
Name:__________________________ Phone:
Fax:
NRIC:
Tel:
Race:
Important notice
Open Access endoscopic service is fast track endoscope
referral service under Ministry of Health Malaysia. This
service is aimed to reduce waiting time for endoscope for
high risk gastric cancer patient.
However, several potential problems could arise if this
service is not used appropriately; which include
inappropriate referral and poorly informed patients.
5
The MARK’s quadrant score and pre- endoscopic
information about the patient should be accurately provided
by the referring doctors; including underlying medical
problems and drug history to ensure this service benefit
those who really need it.
QUADRANT D: AGE
Score
< 40 yrs
2
40 – 49 yrs
3
≥ 50 yrs
5
Total score:
Age:
Score
1
5
QUADRANT C: Modified ALARM
Symptoms
Score
Anaemia
3
Epigastric Mass / Fullness
3
Persistent vomiting
3
[>2wks]
Significant LOW
3
Dysphagia
5
Early satiety / eating less
3
over a period of time
Name:
Appointment date:
*For referring doctors only
Please circle the appropriate scores below and refer to us
QUADRANT A: DYSPEPSIA
AFFIX NAME LABEL HERE
(if none, enter patient name, address, insurer)
Exclusion criteria for Open Access endoscope:1. Those who have already diagnosed with Upper
Gastrointestinal cancers.
2. Individuals who had previous endoscope done less
than one year and/or under follow up.
3. Acute upper gastrointestinal bleeding.
4. Emergency cases (yellow & red cases) in the
Accident and Emergency department.
5. In-patients from the hospitals.
6. Patients who are admitted for complication of
upper gastrointestinal malignancies.
7. Patient with severe medical illness which may be
hazardous for the procedure.
On the reverse side, most frequently asked questions have
been answered to assist the referring doctors while
explaining regarding this service to the patients and for
patients and family memebers to read after they are given
this form.
Medical history
Medical illness:……………………………………………………..
Drug allergies: � NO �YES
Is the patient on clopidogel � NO �YES Is the patient on warfarin? � NO �YES Is the patient on heparin? � NO �YES
Has patient been instructed to stop warfarin 3-5 days prior to the procedure: � NO �YES �NA
Current medications: ……………………………….
* If the patient has any medical illness or condition that may complicate the endoscope procedure; kindly inform the
endoscope centre.
MAKLUMAT UNTUK PESAKIT (PATIENT INFORMATION LEAFLET)
Apakah OESOPHAGODUODENOSCOPY (OGDS)?
Doktor anda akan menggunakan saluran fleksibel (teropong) berkamera dan sumber cahaya
yang dipanggil endoskop, dan akan melihat imejdan memeriksa saluran pencernaan (esofagus,
perut dan duodenum (bahagian pertama usus kecil) anda.
Mengapa ia dilakukan? Endoskopi membantu doktor mengenal pasti punca simptom anda
yang mungkin berkaitan dengan penyakit saluran pemakanan atas. Doktor anda mungkin
menggunakan endoskopi atas untuk mendapatkan biopsi (contoh tisu kecil). Biopsi membantu
doktor anda membezakan antara tisu (kanser) yang berjenis barah atau biasa atau untuk
menguji jangkitan kuman Helicobacter pylori, punca dirawat untuk ulser gastrik.
Persediaan apa yang diperlukan? Perut yang kosong membenarkan peperiksaan yang
terbaik dan paling selamat, jadi anda harus berpuasa (termasuk air), selama lebih kurang enam
jam sebelum peperiksaan. Doktor anda akan memberikan keterangan lanjut tentang berpuasa
sebelum
endoskopi.
Beritahu doktor anda terlebih dahulu tentang apa-apa ubat yang anda ambil, anda mungkin
perlu mengubah dos biasa anda untuk peperiksaan. Bincangkan sebarang alahan kepada ubatubatan serta keadaan perubatan, seperti jantung atau penyakit paru-paru. Ia adalah
dinasihatkan supaya mengelakkan diri daripada merokok enam jam sebelum prosedur.
Apa yang perlu dibawa? CT, MRI dan X-Rays jika anda mempunyai sebarang.
Ubat-ubatan yang anda ambil. Nombor telefon orang kenalan yang akan menjemput anda.
Bayaran adalah lebih kurang RM…..
Bolehkah saya mengambil ubat-ubatan semasa saya? Kebanyakan ubat-ubatan boleh
diteruskan seperti biasa, tetapi sesetengah ubat boleh mengganggu penyediaan atau
peperiksaan. Maklumkan kepada doktor anda mengenai ubat-ubatan yang anda ambil,
terutamanya produk aspirin atau agen antiplatelet, ubat-ubatan artritis, anticoagulants
(pencair darah seperti warfarin), clopidogrel, insulin atau produk besi. Juga, pastikan untuk
menyatakan apa-apa alahan anda perlu kepada ubat-ubatan.
Apakah yang berlaku semasa endoskopi atas? Doktor anda mungkin bermula dengan
menyembur tekak anda dengan ubat bius tempatan atau dengan memberi anda ubat pelali
untuk membantu anda berehat. Anda akan dipusing menyebelah dalam keadaan baring, dan
doktor anda akan memasukan teropong melalui mulut anda dan ke dalam esofagus, perut dan
duodenum. Endoskop itu tidak mengganggu pernafasan anda, Kebanyakan pesakit
menganggap ujian hanya sedikit tidak selesa, dan ramai pesakit tertidur semasa prosedur.
Apa yang berlaku selepas endoskopi atas? Anda akan dipantau sehingga kebanyakan kesan
ubat-ubatan telah dipakai. Tekak anda mungkin menjadi sakit sedikit, dan anda mungkin
berasa yang mengembung kerana udara yang diperkenalkan ke dalam perut anda semasa
ujian. Anda akan dapat makan selepas anda meninggalkan melainkan jika doktor mengarahkan
sebaliknya. Doktor anda akan menerangkan keputusan peperiksaan kepada anda, walaupun
anda mungkin akan perlu menunggu keputusan mana-mana biopsi yang dilakukan.
Jika anda telah diberi sedatif semasa prosedur, seseorang perlu memandu anda rumah dan
tinggal bersama anda.
Apakah komplikasi yang mungkin endoskopi atas? Walaupun komplikasi boleh berlaku,
mereka jarang berlaku apabila doktor yang telah dilatih khas dan berpengalaman dalam
prosedur ini menjalankan ujian. Pendarahan boleh berlaku di tapak biopsi atau polip telah
dikeluarkan, tetapi ia biasanya kecil dan jarang memerlukan susulan. Luka atau penembusan
pada dinding saluran pemakan mungkin memerlukan pembedahan tetapi ini adalah satu
komplikasi yang sangat jarang berlaku. Sesetengah pesakit mungkin mempunyai reaksi kepada
ubat sedatif atau komplikasi jantung atau jangkitan paru-paru. Walaupun komplikasi selepas
atas endoskopi adalah sangat jarang berlaku, ia adalah penting untuk mengenal pasti tandatanda awal komplikasi yang mungkin. Hubungi doktor anda dengan segera jika anda demam
panas selepas ujian atau jika anda mendapati masalah menelan atau meningkatkan
kerongkong, dada atau sakit perut, atau pendarahan, termasuk najis hitam. Jika anda
mempunyai sebarang kemusykilan tentang komplikasi endoskopi, seeloknya hubungi doktor
anda dengan segera.
and duodenum. The endoscope doesn't interfere with your breathing. Most patients consider
the test only slightly uncomfortable, and many patients fall asleep during the procedure.
What happens after upper endoscopy? You will be monitored until most of the effects of the
medication have worn off. Your throat might be a little sore, and you might feel bloated because
of the air introduced into your stomach during the test. You will be able to eat after you leave
unless your doctor instructs you otherwise. Your physician will explain the results of the
examination to you, although you'll probably have to wait for the results of any biopsies
performed.
If you have been given sedatives during the procedure, someone must drive you home and stay
with you. Even if you feel alert after the procedure, your judgement and reflexes could be
impaired for the rest of the day.
What are the possible complications of upper endoscopy? Although complications can
occur, they are rare when doctors who are specially trained and experienced in this procedure.
Bleeding can occur at a biopsy site or where a polyp was removed, but it's usually minimal and
rarely requires follow-up. Perforation (a hole or tear in the gastrointestinal tract lining) may
require surgery but this is a very uncommon complication. Some patients might have a reaction
to the sedatives or complications from heart or lung disease.
Although complications after upper endoscopy are very uncommon, it's important to recognize
early signs of possible complications. Contact your doctor immediately if you have a fever after
the test or if you notice trouble swallowing or increasing throat, chest or abdominal pain, or
bleeding, including black stools. Note that bleeding can occur several days after the procedure.
If you have any concerns about a possible complication, it is always best to contact your doctor
right away.
IMPORTANT REMINDER: This information is intended only to provide general guidance. It
does not provide definitive medical advice. It is very important that you consult your doctor
about your specific condition.
Chinese
什么是上消化道内窥镜检查（胃镜）? 胃镜检查是借助一条纤细的丶可弯曲的丶末端装有一
个光源并带微型电子摄影机的纤维软管伸入胃中，医生从连接的主机电视屏幕上直接观察食
道丶胃和十二指肠
为什么需要做此项检查?
胃镜检查可以直接观察食道丶胃和十二指肠有无炎症丶糜烂丶溃疡丶出血丶食管静脉曲张丶
血管瘤丶肿瘤（良性或恶性）丶胃肠憩室，壁弹性丶胃上口贲门丶胃下口幽门口闭开是否正
常，有无十二指肠液从胃下口幽门返流到胃等，并可以对可疑病变部位进行活检（biopsy）
明确是否癌变或幽门螺杆菌(Helicobacter pylori)感染，切除息肉，注射治疗食管静脉曲张，
收紧下食管括约肌，组织烧灼或给药止血等的一种检查和治疗的方法
检查前准备
前一天晚上要先空腹（胃）-至少6 小时前不能吃东西或喝水。空腹是为了能更清楚地看到胃
部，也防止检查过程中呕吐或液体吸入肺内。
告诉医生你正在服用哪些药物，有没有对药物敏感，以及本身的健康问题（如心脏问题，肺
部问题等。）
检查前6小时最好能够避免抽烟。
PERINGATAN PENTING: Maklumat ini adalah hanya untuk panduan am. Anda perlu berbincang
dengan doktor anda tentang keadaan khusus anda untuk maklumat lebih lanjut.
需要携带什么？CT,
MRI
将会接你回家的家人或朋友的电话号码
English
What is an OESOPHAGODUODENOSCOPY (OGDS)? Upper endoscopy lets your doctor
examine the lining of the upper part of your gastrointestinal tract, which includes the
esophagus, stomach and duodenum (first portion of the small intestine). Your doctor will use a
thin, flexible tube called an endoscope, which has its own lens and light source, and will view
the images on a video monitor.
我能够服用本身的药吗？
大致上的药物都能够继续服用。告诉医生你目前服用的药物（特别是降血糖药，降压药，薄
血药（blood thinner）或其它心脏病的药物，医生会指导你如何服药）和药物过敏史。
Why is it done? Upper endoscopy helps your doctor evaluate your complaints that may be
related to illness of the upper intestinal tract. It's the best procedure that would help doctors
find out the cause of bleeding from the upper gastrointestinal tract. Your doctor might use
upper endoscopy to obtain a biopsy (small tissue samples). A biopsy helps your doctor
distinguish between benign and malignant (cancerous) tissues or to test for Helicobacter
pylori, a treatable cause for gastric ulcers.
What preparations are required? An empty stomach allows for the best and safest
examination, so you should have nothing to eat or drink, including water, for approximately six
hours before the examination. Your doctor will tell you when to start fasting as the timing can
vary. Tell your doctor in advance about any medications you take; you might need to adjust
your usual dose for the examination. Discuss any allergies to medications as well as medical
conditions, such as heart or lung disease. It is advisable to refrain from smoking six hours prior
to the procedure.
What to Bring ? CT, MRI and X-Rays if you have any. Medications that you are taking. Phone
number of contact person who will pick you up.
Can I take my current medications? Most medications can be continued as usual, but some
medications can interfere with the preparation or the examination. Inform your doctor about
medications you’re taking, particularly aspirin products or antiplatelet agents, arthritis
medications, anticoagulants (blood thinners such as warfarin), clopidogrel, insulin or iron
products. Also, be sure to mention any allergies you have to medications.
What happens during upper endoscopy? Your doctor might start by spraying your throat
with a local anesthetic or by giving you a sedative to help you relax. You'll then lie on your side,
and your doctor will pass the endoscope through your mouth and into the esophagus, stomach
或
X-光（若有）,
本身的药物
胃镜的过程是怎样？
麻醉采用局部麻醉---咽喉的局部喷药（lidocane spray）麻木，或给予静脉镇静药（
Intravenous sedation）。取下眼镜及假牙，取左侧卧位，牙齿间放置口垫，保护病人牙齿和
胃镜导管，胃镜经过口垫进入口腔丶食道丶胃和十二指肠。胃镜不会影响你的呼吸。在检查
过程中，多数病人只会感觉到稍微的不适。
胃镜检查后会怎样？
你的喉咙可能会有些疼痛，你可能会觉得胃肠胀气，这是因为检查过程中空气的引入。通常
24小时内症状就会消失。你会被观察直道药物的效果消失为止。离开后你可以如常吃东西
（除非医生指示不能吃东西）
医生将会为你解释胃镜的结果，但活检（biopsy）报告要等几天后才会出来。
你暂时不能开车，需要家人或朋友来接你回家。
胃镜有哪些风险？
受过特别训练和经验丰富的医生会使这项检查的风险降到最低。活检的部位可能会有少许的
流血。一个可能的最大风险就是穿孔（可能需要动手术）。若有胃部持续性疼痛或其它不
适，请通知医生，不要耽搁，以免发生意外。