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. You might hear your doctor or other medical staff refer to upper endoscopy as upper GI endoscopy,esophagogastroduodenoscopy (EGD) or pan-endoscopy.
Why is upper endoscopy done?
Upper endoscopy helps your doctor evaluate symptoms of persistent upper abdominal pain, nausea, vomiting or difficulty swallowing. It's the best test for finding the cause of bleeding from the upper gastrointestinal tract. It's also more accurate than X-ray films for detecting inflammation, ulcers and tumors of the esophagus, stomach and duodenum.
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. Remember, biopsies are taken for many reasons, and your doctor might order one even if he or she does not suspect cancer. For example, your doctor might use a biopsy to test for Helicobacter pylori, the bacterium that causes ulcers.
Your doctor might also use upper endoscopy to perform a cytology test, where he or she will introduce a small brush to collect cells for analysis.
Upper endoscopy is also used to treat conditions of the upper gastrointestinal tract. Your doctor can pass instruments through the endoscope to directly treat many abnormalities - this will cause you little or no discomfort. For example, your doctor might stretch (dilate) a narrowed area, remove polyps (usually benign growths) 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.
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 or heparin), 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 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 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.
What is Narrow Band Imaging (NBI)
Narrow band imaging (NBI) represents an advanced endoscopic technique consistings in the assessment of surface patterns and microvascular architecture by utilization of a narrowed spectrum light. Blue and green wavelengths are selected by optical filters, with the elimination of red light. These lights with narrowed bandwidths penetrate the superficial mucosal structures and are better absorbed by hemoglobin, providing an enhancement of mucosal features and blood vessels (capillaries from superficial mucosal layer, deeper mucosal and submucosal vessels).
Clinical studies have shown the ability of NBI method to evaluate lesions and to estimate their histology in real time. The combination between NBI and magnification endoscopy (NBI-ME) enables an accurate assessment of lesions in the gastrointestinal (GI) tract, the differentiation between premalignant and malignant lesions, and the detection of early neoplasia by emphasizing neovascularization. The visualization of vascular details by magnification allows the early detection of changes associated with malignant transformation. Different classification systems including mucosal and vascular patterns were proposed to differentiate preneoplastic and neoplastic lesions and also to predict the depth of invasion in superficial cancer.
Colonoscopy enables your doctor to examine the lining of your colon (large intestine) for abnormalities by inserting a flexible tube as thick as your finger into your anus and slowly advancing it into the rectum and colon. If your doctor has recommended a colonoscopy, this brochure will give you a basic understanding of the procedure - how it's performed, how it can help, and what side effects you might experience. It can't answer all of your questions since much depends on the individual patient and the doctor. Please ask your doctor about anything you don't understand.
What preparation is required?
Your doctor will tell you what dietary restrictions to follow and what cleansing routine to use. In general, the preparation consists of either consuming a large volume of a special cleansing solution or clear liquids and special oral laxatives. The colon must be completely clean for the procedure to be accurate and complete, so be sure to follow your doctor's instructions carefully.
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, arthritis medications, anticoagulants (blood thinners), insulin or iron products. Also, be sure to mention allergies you have to medications. Alert your doctor if you require antibiotics prior to dental procedures, because you might need antibiotics before a colonoscopy as well.
What happens during colonoscopy?
Colonoscopy is well-tolerated and rarely causes much pain. You might feel pressure, bloating or cramping during the procedure. Your doctor might give you a sedative to help you relax and better tolerate any discomfort.
You will lie on your side or back while your doctor slowly advances a colonoscope through your large intestine to examine the lining. Your doctor will examine the lining again as he or she slowly withdraws the colonoscope. The procedure itself usually takes 15 to 60 minutes, although you should plan on two to three hours for waiting, preparation and recovery.
In some cases, the doctor cannot pass the colonoscope through the entire colon to where it meets the small intestine. Although another examination might be needed, your doctor might decide that the limited examination is sufficient.
What if the colonoscopy shows something abnormal?
If your doctor thinks an area needs further evaluation, he or she might pass an instrument through the colonoscope to obtain a biopsy (a sample of the colon lining) to be analyzed. Biopsies are used to identify many conditions, and your doctor might order one even if he or she doesn't suspect cancer. If colonoscopy is being performed to identify sites of bleeding, your doctor might control the bleeding through the colonoscope by injecting medications or by coagulation (sealing off bleeding vessels with heat treatment). Your doctor might also find polyps during colonoscopy, and he or she will most likely remove them during the examination. These procedures don't usually cause any pain.
What are polyps and why are they removed?
Polyps are abnormal growths in the colon lining that are usually benign (noncancerous). They vary in size from a tiny dot to several inches. Your doctor can't always tell a benign polyp from a malignant (cancerous) polyp by its outer appearance, so he or she might send removed polyps for analysis. Because cancer begins in polyps, removing them is an important means of preventing colorectal cancer.
How are polyps removed?
Your doctor might destroy tiny polyps by fulguration (burning) or by removing them with wire loops called snares or with biopsy instruments. Your doctor might use a technique called "snare polypectomy" to remove larger polyps. That technique involves passing a wire loop through the colonoscope and removing the polyp from the intestinal wall using an electrical current. You should feel no pain during the polypectomy.
What happens after a colonoscopy?
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 judgment and reflexes could be impaired for the rest of the day. You might have some cramping or bloating because of the air introduced into the colon during the examination. This should disappear quickly when you pass gas.
You should be able to eat after the examination, but your doctor might restrict your diet and activities, especially after polypectomy.
What are the possible complications of colonoscopy?
Colonoscopy and polypectomy are generally safe when performed by doctors who have been specially trained and are experienced in these procedures.
One possible complication is a perforation, or tear, through the bowel wall that could require surgery. Bleeding might occur at the site of biopsy or polypectomy, but it's usually minor. Bleeding can stop on its own or be controlled through the colonoscope; it rarely requires follow-up treatment. Some patients might have a reaction to the sedatives or complications from heart or lung disease.
Although complications after colonoscopy are uncommon, it's important to recognize early signs of possible complications. Contact your doctor if you notice severe abdominal pain, fever and chills, or rectal bleeding of more than one-half cup. Note that bleeding can occur several days after the procedure.
How are polyps removed?
Your doctor might destroy tiny polyps by fulguration (burning) or by removing them with wire loops called snares or with biopsy instruments. Your doctor might use a technique called "snare polypectomy" to remove larger polyps. That technique involves passing a wire loop through the colonoscope and removing the polyp from the intestinal wall using an electrical current. You should feel no pain during the polypectomy.
What happens after a colonoscopy?
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 judgment and reflexes could be impaired for the rest of the day. You might have some cramping or bloating because of the air introduced into the colon during the examination. This should disappear quickly when you pass gas.
You should be able to eat after the examination, but your doctor might restrict your diet and activities, especially after polypectomy.
What are the possible complications of colonoscopy?
Colonoscopy and polypectomy are generally safe when performed by doctors who have been specially trained and are experienced in these procedures.
One possible complication is a perforation, or tear, through the bowel wall that could require surgery. Bleeding might occur at the site of biopsy or polypectomy, but it's usually minor. Bleeding can stop on its own or be controlled through the colonoscope; it rarely requires follow-up treatment. Some patients might have a reaction to the sedatives or complications from heart or lung disease.
Although complications after colonoscopy are uncommon, it's important to recognize early signs of possible complications. Contact your doctor if you notice severe abdominal pain, fever and chills, or rectal bleeding of more than one-half cup. Note that bleeding can occur several days after the procedure.
Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique used to study the bile ducts, pancreatic duct and gallbladder. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. The pancreatic duct is the drainage channel from the pancreas.
How is ERCP performed?
During ERCP, your doctor will pass an endoscope through your mouth, esophagus and stomach into the duodenum (first part of the small intestine). An endoscope is a thin, flexible tube that lets your doctor see inside your bowels. After your doctor sees the common opening to the ducts from the liver and pancreas, called the major duodenal papilla, your doctor will pass a narrow plastic tube called a catheter through the endoscope and into the ducts. Your doctor will inject a contrast material (dye) into the pancreatic or biliary ducts and will take X-rays.
What preparation is required ?
You should fast for at least six hours (and preferably overnight) before the procedure to make sure you have an empty stomach, which is necessary for the best examination. Your doctor will give you precise instructions about how to prepare. You should talk to your doctor about medications you take regularly and any allergies you have to medications or to intravenous contrast material (dye). Although an allergy doesn’t prevent you from having ERCP, it’s important to discuss it with your doctor prior to the procedure, as you may require specific allergy medications before the ERCP. Inform your doctor about medications you’re taking, particularly aspirin products, arthritis medications, anticoagulants (blood thinners, such as warfarin or heparin), clopidogrel or insulin. Also, be sure to tell your doctor if you have heart or lung conditions or other major diseases which might prevent or impact the decision to conduct endoscopy.
What can I expect during ERCP?
Your doctor might apply a local anesthetic to your throat and/or give you a sedative to make you more comfortable. Your doctor might even ask an anesthesiologist to administer sedation if your procedure is complex or lengthy. Some patients also receive antibiotics before the procedure. You will lie on your abdomen on an X-ray table. The instrument does not interfere with breathing, but you might feel a bloating sensation because of the air introduced through the instrument.
What are possible complications of ERCP?
ERCP is a well-tolerated procedure when performed by doctors who are specially trained and experienced in the technique. Although complications requiring hospitalization can occur, they are uncommon. Complications can include pancreatitis (inflammation of the pancreas), infections, bowel perforation and bleeding. Some patients can have an adverse reaction to the sedative used. Sometimes the procedure cannot be completed for technical reasons.
Risks vary, depending on why the test is performed, what is found during the procedure, what therapeutic intervention is undertaken, and whether a patient has major medical problems. Patients undergoing therapeutic ERCP, such as for stone removal, face a higher risk of complications than patients undergoing diagnostic ERCP. Your doctor will discuss your likelihood of complications before you undergo the test.
What can I expect after ERCP?
If you have ERCP as an outpatient, you will be observed for complications until most of the effects of the medications have worn off before being sent home. You might experience bloating or pass gas because of the air introduced during the examination. You can resume your usual diet unless you are instructed otherwise.
Someone must accompany you home from the procedure because of the sedatives used during the examination. Even if you feel alert after the procedure, the sedatives can affect your judgment and reflexes for the rest of the day.
Because individual circumstances may vary, this brochure may not answer all of your questions. Please ask your doctor about anything you don’t understand.
What is a therapeutic ERCP?
Endoscopic retrograde cholangiopancreatography, or ERCP, is a study of the ducts that drain the liver and pancreas. Ducts are drainage routes into the bowel. The ones that drain the liver and gallbladder are called bile or biliary ducts. The one that drains the pancreas is called the pancreatic duct. The bile and pancreatic ducts join together just before they drain into the upper bowel, about 3 inches from the stomach. The drainage opening is called the papilla. The papilla is surrounded by a circular muscle, called the sphincter of Oddi.
Diagnostic ERCP is when X-ray contrast dye is injected into the bile duct, the pancreatic duct, or both. This contrast dye is squirted through a small tube called a catheter that fits through the ERCP endoscope. X-rays are taken during ERCP to get pictures of these ducts. That is called diagnostic ERCP. However, most ERCPs are actually done for treatment and not just picture taking. When an ERCP is done to allow treatment, it is called therapeutic ERCP.
What treatments can be done through an ERCP scope?
Sphincterotomy
Sphincterotomy is cutting the muscle that surrounds the opening of the ducts, or the papilla. This cut is made to enlarge the opening. The cut is made while your doctor looks through the ERCP scope at the papilla, or duct opening. A small wire on a specialized catheter uses electric current to cut the tissue. A sphincterotomy does not cause discomfort, you do not have nerve endings there. The actual cut is quite small, usually less than a 1/2 inch. This small cut, or sphincterotomy, allows various treatments in the ducts. Most commonly the cut is directed towards the bile duct, called a biliary sphincterotomy. Occasionally, the cutting is directed towards the pancreatic duct, depending on the type of treatment you need.
Stone Removal
The most common treatment through an ERCP scope is removal of bile duct stones. These stones may have formed in the gallbladder and traveled into the bile duct or may form in the duct itself years after your gallbladder has been removed. After a sphincterotomy is performed to enlarge the opening of the bile duct, stones can be pulled from the duct into the bowel. A variety of balloons and baskets attached to specialized catheters can be passed through the ERCP scope into the ducts allowing stone removal. Very large stones may require crushing in the duct with a specialized basket so the fragments can be pulled out through the sphincterotomy.
Stent Placement
Stents are placed into the bile or pancreatic ducts to bypass strictures, or narrowed parts of the duct. These narrowed areas of the bile or pancreatic duct are due to scar tissue or tumors that cause blockage of normal duct drainage. There are two types of stents that are commonly used. The first is made of plastic and looks like a small straw. A plastic stent can be pushed through the ERCP scope into a blocked duct to allow normal drainage. The second type of stent is made of metal wires that looks like the cross wires of a fence. The metal stent is flexible and springs open to a larger diameter than plastic stents. Both plastic and metal stents tend to clog up after several months and you may require another ERCP to place a new stent. Metal stents are permanent while plastic stents are easily removed at a repeat procedure. Your doctor will choose the best type of stent for your problem.
Balloon Dilation
There are ERCP catheters fitted with dilating balloons that can be placed across a narrowed area or stricture. The balloon is then inflated to stretch out the narrowing. Dilation with balloons is often performed when the cause of the narrowing is benign (not a cancer). After balloon dilation, a temporary stent may be placed for a few months to help maintain the dilation.
Tissue Sampling
One procedure that is commonly performed through the ERCP scope is to take samples of tissue from the papilla or from the bile or pancreatic ducts. There are several different sampling techniques although the most common is to brush the area with subsequent examination of the cells obtained. Tissue samples can help decide if a stricture, or narrowing, is due to a cancer. If the sample is positive for cancer it is very accurate. Unfortunately, a tissue sampling that does not show cancer may not be accurate.
What can you expect before, during, and after a therapeutic ERCP?
You should not eat for at least 6 hours before the procedure. You should tell your doctor about medications that you take regularly and whether you have any allergies to medications or contrast material.
You will have an intravenous needle placed in your arm so you can receive medicine during the procedure. You will be given sedatives that will make you comfortable during the ERCP. Some patients require antibiotics before the procedure. The procedure is performed on a X-ray table. After the ERCP is complete you will go to a recovery area until the sedation effects reside. Some patients are admitted to the hospital for a day but many go home from the recovery unit. You should not drive a car for the rest of the day although most patients can return to full activity the next day.
What are possible complications of therapeutic ERCP?
The overall ERCP complication rate requiring hospitalization is 6-10%. Depending on your age, your other medical problems, what therapy is performed, and the indication for your procedure, your complication rate may be higher or lower than the average. Your doctor will discuss your likelihood of complications before you undergo the test. The most common complication is pancreatitis, or inflammation of the pancreas. Other complications include bleeding, infection, an adverse reaction to the sedative medication, or bowel perforation. Most complications are managed without surgery but may require you to stay in the hospital for treatment.
You've been referred to have an endoscopic ultrasonography, or EUS, which will help your doctor, evaluate or treat your condition.
What is EUS?
Endoscopic ultrasonography (EUS) allows your doctor to examine your esophageal and stomach linings as well as the walls of your upper and lower gastrointestinal tract. The upper tract consists of the esophagus, stomach and duodenum; the lower tract includes your colon and rectum. EUS is also used to study other organs that are near the gastrointestinal tract, including the lungs, liver, gall bladder and pancreas.
Endoscopists are highly trained specialists who welcome your questions regarding their credentials, training and experience. Your endoscopist will use a thin, flexible tube called an endoscope that has a built-in miniature ultrasound probe. Your doctor will pass the endoscope through your mouth or anus to the area to be examined. Your doctor then will use the ultrasound to use sound waves to create visual images of the digestive tract.
Why is EUS done?
EUS provides your doctor with more information than other imaging tests by providing detailed images of your digestive tract. Your doctor can use EUS to diagnose certain conditions that may cause abdominal pain or abnormal weight loss.
EUS is also used to evaluate known abnormalities, including lumps or lesions, which were detected at a prior endoscopy or were seen on x-ray tests, such as a computed tomography (CT) scan. EUS provides a detailed image of the lump or lesion, which can help your doctor determine its origin and help treatment decisions. EUS can be used to diagnose diseases of the pancreas, bile duct and gallbladder when other tests are inconclusive or conflicting.
Why is EUS used for patients with cancer?
EUS helps your doctor determine the extent of spread of certain cancers of the digestive and respiratory systems. EUS allows your doctor to accurately assess the cancer’s depth and whether it has spread to adjacent lymph glands or nearby vital structures, such as major blood vessels. In some patients, EUS can be used to obtain a needle biopsy of a lump or lesion to help your doctor determine the proper treatment.
How should I prepare for EUS?
For EUS of the upper gastrointestinal tract, you should have nothing to eat or drink, usually for six hours before the examination. Your doctor will tell you when to start this fasting and whether it is advisable to take your regular prescription medications.
For EUS of the rectum or colon, your doctor will instruct you to either consume a colonic cleansing solution or to follow a clear liquid diet combined with laxatives or enemas prior to the examination. The procedure might have to be rescheduled if you don’t follow your doctor’s instructions carefully.
What about my current medications or allergies?
You can take most medications as usual until the day of the EUS examination. Tell your doctor about all medications that you’re taking and about any allergies you have. Anticoagulant medications (blood thinners such as warfarin or heparin) and clopidogrel may need to be adjusted before the procedure. Insulin also needs to be adjusted on the day of EUS. In general, you can safely take aspirin and non-steroidal anti-inflammatory medications (ibuprofen, naproxen, etc.) before an EUS examination. Check with your doctor in advance regarding these recommendations.
Check with your doctor about which medications you should take the morning of the EUS examination, and take only essential medications with a small sip of water.
If you have an allergy to latex, you should inform your doctor prior to your test. Patients with latex allergies often require special equipment and may not be able to have a complete EUS examination.
Do I need to take antibiotics?
Antibiotics are not generally required before or after EUS examinations. However, your doctor might prescribe antibiotics if you are having specialized EUS procedures, such as to drain a fluid collection or a cyst using EUS guidance.
Should I arrange for help after the examination?
If you received sedatives, you will not be allowed to drive after the procedure, even if you do not feel tired. You should arrange a ride home in advance. You should also plan to have someone stay with you at home after the examination, because the sedatives could affect your judgment and reflexes for the rest of the day.
What can I expect during EUS?
Practices vary among doctors, but for an EUS examination of the upper gastrointestinal tract, some endoscopists spray your throat with a local anesthetic before the test begins. Most often you will receive sedatives intravenously to help you relax. You will most likely begin by lying on your left side. After you receive sedatives, your endoscopist will pass the ultrasound endoscope through your mouth, esophagus and stomach into the duodenum. The instrument does not interfere with your ability to breathe. The actual examination generally takes less than 60 minutes. Many do not recall the procedure. Most patients consider it only slightly uncomfortable, and many fall asleep during it.
An EUS examination of the lower gastrointestinal tract can often be performed safely and comfortably without medications, but you’ll receive a sedative if the examination will be prolonged or if the doctor will examine a significant distance into the colon. You will start by lying on your left side with your back toward the doctor. Most EUS examinations of the rectum generally take less than 45 minutes. You should know that if a needle biopsy of a lesion or drainage of a cyst is performed during the EUS, then the procedure will be longer and may take up to two hours.
What happens after EUS?
If you received sedatives, you will be monitored in the recovery area until most of the sedative medication’s effects have worn off. If you had an upper EUS, your throat might be a little sore. You might feel bloated because of the air and water that were introduced during the examination.
You’ll be able to eat after you leave the procedure area, unless you’re instructed otherwise.
Your doctor generally can inform you of the preliminary results of the procedure that day, but the results of some tests, including biopsies, may take several days.
What are the possible complications of EUS?
Although complications can occur, they are rare when doctors with specialized training and experience perform the EUS examination. Bleeding might occur at a biopsy site, but it’s usually minimal and rarely requires follow-up. You might have a slight sore throat for a day or so. Nonprescription anesthetic type throat lozenges help soothe a sore throat.
Other potential but uncommon risks of EUS include a reaction to the sedatives used, aspiration of stomach contents into your lungs, infection, and complications from heart or lung diseases. One major but very uncommon complication of EUS is perforation. This is a tear through the lining of the intestine that might require surgery to repair.
The possibility of complications increases slightly if a needle biopsy is performed during the EUS examination, including an increased risk of pancreatitis or infection. These risks must be balanced against the potential benefits of the procedure and the risks of alternative approaches to the condition.
Additional Questions?
If you have any questions about your need for EUS, alternative approaches to your problem, the cost of the procedure, methods of billing or insurance coverage, do not hesitate to speak to your doctor or doctor’s office staff about it.
Key Points
BACKGROUND:
The small bowel is approximately 20 feet in length and, historically was an inaccessible part of the gastrointestinal tract. In 2001 the FDA approved the use of the first wireless video capsule endoscopy system which allowed unprecedented visualization of lesions and abnormalities in the small bowel. This technology created the need for therapeutic intervention in the small bowel, and the deep enteroscopy systems were developed to allow non-surgical treatment and biopsy of small bowel pathology. Through this new technique, many treatments of the small bowel are now possible including stricture dilation, polyp removal, tissue sampling, and various hemostatic procedures to stop active blood loss or destroy bleeding lesions. In some instances, therapy with a balloon assisted enteroscope may allow patients to avoid surgical intervention on the small bowel.
SYSTEM COMPONENTS:
The balloon system consists of a 200 cm endoscope and an overtube. There are one or two inflatable balloons attached to the scope and/or overtube. The technique allows the scope to advance through the length of the small bowel via the process of inflating and deflating the balloon(s), which grip the walls of the small intestine. With a series of 'reductions,' the process pleats the small bowel over the overtube, like a curtain over a rod, and advances the scope. The spiral overtube technique works by pleating the small bowel over the tube, allowing passage of a small caliber enteroscope deep into the small bowel. Accessories such as biopsy forceps, dilating devices, and cautery probes can be passed through channels in the scope in order to treat abnormal findings in the small intestine.
PROCEDURE:
Balloon assisted or deep enteroscopy can be performed in an outpatient or inpatient setting and may require several hours, depending on the therapy required. It is often performed with general anesthesia, although some patients may require only moderate sedation. Fluoroscopy, or the use of X-ray, may be employed during the procedure. Most procedures are performed through the mouth (antegrade), although the retrograde approach, through the rectum, may allow better access to lesions in the lower part of the small bowel.
RISKS:
The risks of the procedure are similar to those for colonoscopy and upper endoscopy (EGD) and include bleeding, perforation, and complications of sedation. Unique to balloon enteroscopy are the risks of ileus (transient slowing of the bowel) and pancreatitis, which occur in less than one percent of procedures.
INDICATIONS:
The indications for balloon assisted enteroscopy include the need for treatment of small intestinal lesions found on other gastrointestinal exams, such as capsule endoscopy or CT scan. The procedure is not used as a first line therapy and is performed only after careful evaluation by a specially trained gastroenterologist. Most procedures are done for bleeding lesions seen on capsule endoscopy, worrisome lesions or masses seen by other modalities, polyps in patients with hereditary syndromes, retained foreign objects, and small bowel strictures.
THERAPIES:
As noted above, therapies include treatment of bleeding lesions such as angioectasias, dilation of strictures using a hydrostatic balloon dilator, removal by snare or biopsy of polyps or small bowel masses, retrieval and removal of foreign objects or retained capsules, and biopsy of abnormal tissue. Balloon assisted enteroscopy has also been used in gaining access to parts of the gastrointestinal tract in patients with surgically altered anatomy.
CONTRAINDICATIONS:
Patients who are not medically stable should not undergo balloon assisted enteroscopy. Those who have had extensive abdominal surgeries may be poor candidates because of adhesions or altered anatomy which may prevent the scope from advancing.
Capsule Endoscopy lets your doctor examine the lining of the middle part of your gastrointestinal tract, which includes the three portions of the small intestine (duodenum, jejunum, ileum). Your doctor will give you a pill sized video camera for you to swallow. This camera has its own light source and takes pictures of your small intestine as it passes through. These pictures are sent to a small recording device you have to wear on your body.
Your doctor will be able to view these pictures at a later time and might be able to provide you with useful information regarding your small intestine.
Why is Capsule Endoscopy Done?
Capsule endoscopy helps your doctor evaluate the small intestine. This part of the bowel cannot be reached by traditional upper endoscopy or by colonoscopy. The most common reason for doing capsule endoscopy is to search for a cause of bleeding from the small intestine. It may also be useful for detecting polyps, inflammatory bowel disease (Crohn’s disease), ulcers, and tumors of the small intestine.
As is the case with most new diagnostic procedures, not all insurance companies are currently reimbursing for this procedure. You may need to check with your own insurance company to ensure that this is a covered benefit.
How Should I Prepare for the Procedure?
An empty stomach allows for the best and safest examination, so you should have nothing to eat or drink, including water, for approximately twelve hours before the examination. Your doctor will tell you when to start fasting.
Tell your doctor in advance about any medications you take including iron, aspirin, bismuth subsalicylate products and other over-the-counter medications. You might need to adjust your usual dose prior to the examination.
Discuss any allergies to medications as well as medical conditions, such as swallowing disorders and heart or lung disease.
Tell your doctor of the presence of a pacemaker or defibrillator, previous abdominal surgery, or previous history of bowel obstructions in the bowel, inflammatory bowel disease, or adhesions.
Your doctor may ask you to do a bowel prep/cleansing prior to the examination.
What Can I Expect During Capsule Endoscopy?
Your doctor will prepare you for the examination by applying a sensor device to your abdomen with adhesive sleeves (similar to tape). The pill-sized capsule endoscope is swallowed and passes naturally through your digestive tract while transmitting video images to a data recorder worn on your belt for approximately eight hours. At the end of the procedure you will return to the office and the data recorder is removed so that images of your small bowel can be put on a computer screen for physician review.
Most patients consider the test comfortable. The capsule endoscope is about the size of a large pill. After ingesting the capsule and until it is excreted you should not be near an MRI device or schedule an MRI examination.
What Happens After Capsule Endoscopy?
You will be able to drink clear liquids after two hours and eat a light meal after four hours following the capsule ingestion, unless your doctor instructs you otherwise. You will have to avoid vigorous physical activity such as running or jumping during the study. Your doctor generally can tell you the test results within the week following the procedure; however, the results of some tests might take longer.
What are the Possible Complications of Capsule Endoscopy?
Although complications can occur, they are rare when doctors who are specially trained and experienced in this procedure perform the test. There is potential for the capsule to be stuck at a narrowed spot in the digestive tract resulting in bowel obstruction. This usually relates to a stricture (narrowing) of the digestive tract from inflammation, prior surgery, or tumor. It’s important to recognize obstruction early. Signs of obstruction include unusual bloating, abdominal pain, nausea or vomiting. You should call your doctor immediately for any such concerns. Also, if you develop a fever after the test, have trouble swallowing or experience chest pain, tell your doctor immediately. Be careful not to prematurely disconnect the system as this may result in loss of pictures being sent to your recording device.Capsule endoscopy may also be called:
Capsule endoscopy allows for examination of the small intestine, which cannot be easily reached by traditional methods of endoscopy.
The Esophagus
The esophagus is a muscular tube that connects your throat to your stomach. With each swallow, the esophagus muscle contracts and pushes food into the stomach. At the lower end of the esophagus, a valve (a special sphincter muscle) remains closed except when food or liquid is swallowed or when you belch or vomit.
What is esophageal testing, also called manometry, and why is it performed?
Esophageal testing or manometry measures the pressures and the pattern of muscle contractions in your esophagus. Abnormalities in the contractions and strength of the muscle or in the sphincter at the lower end of the esophagus can result in pain, heartburn, and/or difficulty swallowing. Esophageal manometry is used to diagnose the conditions that can cause these symptoms.
How should I prepare for esophageal testing?
An empty stomach allows for the best and safest examination, so do not eat or drink anything for 6 hours before the test. Since many medications can affect esophageal pressure and the natural muscle contractions required for swallowing, be sure to discuss with your healthcare professional each medication you are taking. Your doctor may ask that you temporarily stop taking one or more medications before your test.
What can I expect during the test?
A healthcare professional will apply a cream to numb the inside of your nostrils. Then a thin, flexible, lubricated tube will be passed through your nose and advanced into your stomach while you swallow sips of water. Mild, brief gagging may occur while the tube is passed through the throat. When the tube is in position, you will be sitting upright or lying on your back while the tube is connected to a computer. Once the test begins it is important to breathe slowly and smoothly, remain as quiet as possible and avoid swallowing unless instructed to do so. As the tube is slowly pulled out of your esophagus, the computer measures and records the pressures in different parts of your esophagus.
During the test, you may experience some discomfort in your nose and/or throat. The test will take approximately 30 minutes to complete and the results will be sent to your doctor’s office.
What can I expect after the test?
After the test, you may experience mild sore throat, stuffy nose, or a minor nosebleed; all typically improve within hours. Unless your physician has given you other instructions, you may resume normal meals, activities, and any interrupted medications.
What are the possible risks associated with esophageal manometry?
As with any medical procedure, there are certain risks. While serious side effects of this procedure are extremely rare, it is possible that you could experience irregular heartbeats, aspiration (when stomach contents flow back into the esophagus and are breathed into the lung), or perforation (a hole in the esophagus). During insertion, the tube may be misdirected into the windpipe before being repositioned. Precautions are taken to prevent such risks, and your physician believes the risks are outweighed by the benefits of this test.
What if the tube cannot be passed?
In some situations, correct placement of the tube may require passage through the mouth or passing the tube using endoscopy (a procedure that uses a thin, flexible lighted tube). Your physician will determine the best approach.
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.
Understanding Esophageal Dilation
What is Esophageal Dilation?
Esophageal dilation is a procedure that allows your doctor to dilate, or stretch, a narrowed area of your esophagus [swallowing tube]. Doctors can use various techniques for this procedure. Your doctor might perform the procedure as part of a sedated endoscopy. Alternatively, your doctor might apply a local anesthetic spray to the back of your throat and then pass a weighted dilator through your mouth and into your esophagus.
Why is Esophageal Dilation Done?
The most common cause of narrowing of the esophagus, or stricture, is scarring of the esophagus from reflux of stomach acid occurring in patients with heartburn. Patients with a narrowed portion of the esophagus often have trouble swallowing; food feels like it is “stuck” in the chest region, causing discomfort or pain. Less common causes of esophageal narrowing are webs or rings (which are thin layers of excess tissue), cancer of the esophagus, scarring after radiation treatment or a disorder of the way the esophagus moves [motility disorder].
How Should I Prepare for the Procedure?
An empty stomach allows for the best and safest examination, so you should have nothing to drink, including water, for at least six hours before the examination. Your doctor will tell you when to start fasting.
Tell your doctor in advance about any medications you take, particularly aspirin products or anticoagulants (blood thinners such as warfarin or heparin), or clopidogrel. Most medications can be continued as usual, but you might need to adjust your usual dose before the examination. Your doctor will give you specific guidance. Tell your doctor if you have any allergies to medications as well as medical conditions such as heart or lung disease. Also, tell your doctor if you require antibiotics prior to dental procedures, because you might need antibiotics prior to esophageal dilation as well.
What Can I Expect during Esophageal Dilation?
Your doctor might perform esophageal dilation with sedation along with an upper endoscopy. Your doctor may spray your throat with a local anesthetic spray, and then give you sedatives to help you relax. Your doctor then will pass the endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope does not interfere with your breathing. At this point your doctor will determine whether to use a dilating balloon or plastic dilators over a guiding wire to stretch your esophagus. You might experience mild pressure in the back of your throat or in your chest during the procedure. Alternatively, your doctor might start by spraying your throat with a local anesthetic. Your doctor will then pass a tapered dilating instrument through your mouth and guide it into the esophagus. Your doctor may also use x-rays during the esophageal dilation procedure.
What Can I Expect after Esophageal Dilation?
After the dilation is done, you will probably be observed for a short period of time and then allowed to return to your normal activities. You may resume drinking when the anesthetic no longer causes numbness to your throat, unless your doctor instructs you otherwise. Most patients experience no symptoms after this procedure and can resume eating the next day, but you might experience a mild sore throat for the remainder of the day.
If you received sedatives, you probably will be monitored in a recovery area until you are ready to leave. You will not be allowed to drive after the procedure even though you might not feel tired. You should arrange for someone to accompany you home, because the sedatives might affect your judgment and reflexes for the rest of the day.
What are the Potential Complications of Esophageal Dilation?
Although complications can occur even when the procedure is performed correctly, they are rare when performed by doctors who are specially trained. A perforation, or hole, of the esophagus lining occurs in a small percentage of cases and may require surgery. A tear of the esophagus lining may occur and bleeding may result. There are also possible risks of side effects from sedatives.
It is important to recognize early signs of possible complications. If you have chest pain, fever, trouble breathing, difficulty swallowing, bleeding or black bowel movements after the test, tell your doctor immediately.
Will Repeat Dilations be Necessary?
Depending on the degree and cause of narrowing of your esophagus, it is common to require repeat dilations. This allows the dilation to be performed gradually and decreases the risk of complications. Once the stricture, or narrowed esophagus, is completely dilated, repeat dilations may not be required. If the stricture was due to acid reflux, acid-suppressing medicines can decrease the risk of stricture recurrence. Your doctor will advise you on this.
What Is a Colon Polyp?
Polyps are benign growths (noncancerous tumors or neoplasms) involving the lining of the bowel. They can occur in several locations in the gastrointestinal tract but are most common in the colon. They vary in size from less than a quarter of an inch to several inches in diameter. They look like small bumps growing from the lining of the bowel and protruding into the lumen (bowel cavity). They sometimes grow on a “stalk” and look like mushrooms. Some polyps can also be flat. Many patients have several polyps scattered in different parts of the colon. Some polyps can contain small areas of cancer, although the vast majority of polyps do not.
How Common Are Colon Polyps? What Causes Them?
Polyps are very common in adults, who have an increased chance of acquiring them, especially as we get older. While quite rare in 20-year-olds, it’s estimated that the average 60-year-old without special risk factors for polyps has a 25 percent chance of having a polyp. We don’t know what causes polyps. Some experts believe a high-fat, low-fiber diet can be a predisposition to polyp formation. There may be a genetic risk to develop polyps as well.
What Are Known Risks for Developing Polyps?
The biggest risk factor for developing polyps is being older than 50. A family history of colon polyps or colon cancer increases the risk of polyps. Also, patients with a personal history of polyps or colon cancer are at risk of developing new polyps. In addition, there are some rare polyp or cancer syndromes that run in families and increase the risk of polyps occurring at younger ages.
There are two common types: hyperplastic polyp and adenoma. The hyperplastic polyp is not at risk for cancer. The adenoma, however, is thought to be the precursor (origin) for almost all colon cancers, although most adenomas never become cancers.
Histology examination of tissue under a microscope) is the best way to differentiate between hyperplastic and adenomatous polyps.
Although it’s impossible to tell which adenomatous polyps will become cancers, larger polyps are more likely to become cancers and some of the largest ones (those larger than 1 inch) can already contain small areas of cancer. Because your doctor cannot be certain of the tissue type by the polyp’s appearance, doctors generally recommend removing all polyps found during a colonoscopy.
How Are Polyps Found?
Most polyps cause no symptoms. Larger ones can cause blood in the stools, but even they are usually asymptomatic. Therefore, the best way to detect polyps is by screening individuals with no symptoms. Several other screening techniques are available: testing stool specimens for traces of blood, performing sigmoidoscopy to look into the lower third of the colon, or using a radiology test such as a barium enema or CT colonography. If one of these tests finds or suspects polyps, your doctor will generally recommend colonoscopy to remove them. Because colonoscopy is the most accurate way to detect polyps, many experts now recommend colonoscopy as a screening method so that any polyps found or suspected can be removed during the same procedure.
How Are Polyps Removed?
Most polyps found during colonoscopy can be completely removed during the procedure. Various removal techniques are available; most involve removing them with a wire loop biopsy forceps and/or burning the polyp base with an electric current. This is called polyp resection. Because the bowel’s lining isn’t sensitive to cutting or burning, polyp resection doesn’t cause discomfort. Resected polyps are then examined under a microscope by a pathologist to determine the tissue type and to detect any cancer. If a large or unusual looking polyp is removed or left for possible surgical management, the endoscopist may mark the site by injecting small amounts of sterile India ink or carbon black into the bowel wall, this is called endoscopic tattooing.
What Are the Risks of Polyp Removal?
Polyp removal (or polypectomy) during colonoscopy is a routine outpatient procedure. Possible complications, which are uncommon, include bleeding from the polypectomy site and perforation (a hole or tear) of the colon. Bleeding from the polypectomy site can be immediate or delayed for several days; persistent bleeding can almost always be stopped by treatment during colonoscopy. Perforations rarely occur and may require surgery to repair.
How Often Do I Need Colonoscopy if I Have Polyps Removed?
Your doctor will decide when your next colonoscopy is necessary. The timing depends on several factors, including the number and size of polyps removed, the polyp’s tissue type and the quality of the colon cleansing for your previous procedure. The quality of cleansing affects your doctor’s ability to see the surface of the colon.
If the polyps were small and the entire colon was well seen during your colonoscopy, doctors generally recommend a repeat colonoscopy in three to five years. If your repeat colonoscopy doesn’t show any indication of polyps, you might not need another procedure for an additional five years.
However, if the polyps were large and flat, your doctor might recommend an interval of only months before a repeat colonoscopy to assure complete polyp removal. Your doctor will discuss those options with you.
IMPORTANT REMINDER: The preceding information is intended only to provide general information and not as a definitive basis for diagnosis or treatment in any particular case. It is very important that you consult your doctor about your specific condition.
The urea breath test (UBT) is a test for diagnosing the presence of a bacterium, Helicobacter pylori (H. pylori) infection in the stomach. H. pylori causes inflammation, ulcers, and atrophy of the stomach. The test also may be used to demonstrate that H. pylori has been eliminated by treatment with antibiotics.
What is the preparation for the urea breath test? How is it performed?
You're doctor or other healthcare professional will provide you with instructions to prepare for the urea breath test.
During the test you will swallow a capsule containing urea, which is made from an isotope of carbon. (Isotopes of carbon occur in minuscule amounts in nature, and can be measured with special testing machines.) If H. pylori is present in the stomach, the urea is broken up and turned into carbon dioxide. The carbon dioxide is absorbed across the lining of the stomach and into the blood. It then travels in the blood to the lungs where it is excreted in the breath. Samples of exhaled breath are collected, and the isotopic carbon in the exhaled carbon dioxide is measured.
How does the urea breath test diagnose H. pylori infection?
The urea breath test is based on the ability of H. pylori to break down urea, a chemical made up of nitrogen and carbon into carbon dioxide which then is absorbed from the stomach and eliminated in the breath. (Urea normally is produced by the body from excess or "waste" nitrogen-containing chemicals and then eliminated in the urine.)
How are the results of the urea breath test interpreted?
If the urea breath test is positive and the isotope is detected in the breath, it means that H. pylori is present in the stomach. If the isotope is not found in the breath, the test results are negative for the infection.
When the H. pylori is effectively treated (eradicated) by antibiotics, the test changes from positive (isotope present) to negative (isotope absent).
Are there any side effects, risks, or complications of the urea breath test?
There are no side effects, risks, or complications of the urea breath test. You need to stop taking medications especially proton pump inhibitors (PPIs) for 5 days, prior to having the procedure performed by a doctor.
Endoscopic submucosal dissection (ESD) is an outpatient procedure to remove deep tumors from the gastrointestinal (GI) tract. Gastroenterologists (doctors specially trained to treat the GI tract) use flexible, tube-like imaging tools called endoscopes to perform ESD. Most people go home the same day.
Only a few centers in the India perform ESD because the procedure requires a high degree of expertise with the procedure. Our center has helped many patients recover faster, often with less pain, than with open or laparoscopic surgical procedures.
Endoscopic Submucosal Dissection: Why It’s Performed
In some cases, ESD is a more effective option than endoscopic mucosal resection for removing growths or tumors. ESD’s outcomes are comparable to those of surgical interventions.
ESD may treat:
Endoscopic Submucosal Dissection: How to Prepare
Before your procedure:
Endoscopic Submucosal Dissection: What to Expect
On the day of your procedure, plan to arrive at the endoscopy unit three or more hours before the procedure. You will register and provide your medical history, including any medications you have taken. Be sure a driver is available to take you home.
During the procedure, your gastroenterologist will:
After the procedure, we will monitor your recovery while the sedative wears off. This procedure can be done as an outpatient procedure, or it may require an overnight hospital stay. Your doctor will discuss your results with you before you leave.
POEM is a therapeutic endoscopic procedure performed in the endoscopy unit at our hospital. We high-definition upper endoscopes to perform the procedure. POEM takes approximately two to three hours, and you are expected to stay in the hospital for an average of two days for monitoring and to receive intravenous antibiotics.
POEM: Why It’s Performed
Our doctors perform POEM to treat the following disease:
POEM: What to Expect
Before your procedure, you will need to follow specific preparation instructions. Your doctor will discuss them with you in detail. Preparation instructions are as follows:
On the day of the procedure, arrive three hours before your POEM is scheduled to start. When you arrive, you will register and give your medical history.
During POEM:
POEM: How It's Performed
Figures
Fig. 1. Entry to the submucosal space. After submucosal injection of saline and 0.3% indigo carmine mixture, a 2-cm longitudinal mucosal incision is made at the mid esophagus.
Fig. 2. Submucosal tunneling. A long submucosal tunnel is created 2?3 cm distal to the esophagogastric junction. The circular muscle fibers are perpendicular to the longitudinal direction of the tunnel.
Fig. 3. Endoscopic myotomy of circular muscle bundle begins from 2?3 cm distal to the mucosal entry and extends to 2?3 cm distal to the esophagogastric junction. By using a triangle tfe, endoscopic myotomy of inner circular muscle bundles is done, leaving the outer longitudinal muscle layer intact.
Fig. 4. Closure of the mucosal entry. The mucosal incision of entry point is completely closed with hemostatic clips.
Foreign body retrieval is the removal of objects or substances that have been introduced into the body. Objects may be inhaled into the airway, swallowed or lodged in the throat or stomach, or embedded in the soft tissues.