Gastroenterology Procedure Profiles

Colonoscopy

A High Quality Colonoscopy

Colonoscopy

Colonoscopy lets your doctor examine the lining of your large intestine (colon) for abnormalities by inserting a thin flexible tube, as thick as your finger, into your anus and slowly advancing it into the rectum and colon. This instrument, called a colonoscope, has its own lens and light source and it allows your doctor to view images on a video monitor.

Why is colonoscopy recommended?

Colonoscopy may be recommended as a screening test for colorectal cancer. Colorectal cancer is the third leading cause of cancer deaths in the United States. Annually, approximately 150,000 new cases of colorectal cancer are diagnosed in the United States and 50,000 people die from the disease. It has been estimated that increased awareness and screening would save at least 30,000 lives each year. Colonoscopy may also be recommended by your doctor to evaluate for symptoms such as bleeding and chronic diarrhea.

What preparations are required?

Your doctor will tell you what dietary restrictions to follow and what cleansing routine to use. In general, the preparation consists of limiting your diet to clear liquids the day before and consuming either a large volume of a special cleansing solution or special oral laxatives. The colon must be completely clean for the procedure to be accurate and comprehensive, 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 such as warfarin or heparin), clopidogrel, insulin or iron products. Also, be sure to mention allergies you have to medications.

What happens during colonoscopy?

Colonoscopy is well-tolerated and rarely causes much pain. You might feel pressure, bloating or cramping during the procedure. Typically, your doctor will give you a sedative or painkiller to help you relax and better tolerate any discomfort. You will lie on your side or back while your doctor slowly advances a colonoscope along 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 less than 45 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. Your doctor will advise you whether any additional testing is necessary.

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 small sample of the colon lining) to be analyzed. Biopsies are used to identify many conditions, and your doctor will often take a biopsy 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 cauterization (sealing off bleeding vessels with heat treatment) or by use of small clips. Your doctor might also find polyps duringcolonoscopy, 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 will usually remove polyps for analysis. Because cancer begins in polyps, removing them is an important means of preventing colorectal cancer.

How are polyps removed?

Your doctor may destroy tiny polyps by fulguration (burning) or by removing them with wire loops called snares or with biopsy instruments. Your doctor will use a technique called “snare polypectomy” to remove larger polyps. Your doctor will pass a wire loop through the colonoscope and remove the polyp from the intestinal wall using an electrical current. You should feel no pain during them polypectomy.

What happens after a colonoscopy?

You will be monitored until most of the effects of the sedatives have worn off. 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. 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 should be able to eat after the examination, but your doctor might restrict your diet and activities, especially after polypectomy. Your doctor will advise you on this.

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. Note that bleeding can occur several days after the procedure.

Upper Endoscopy (EGD)

What is upper endoscopy?

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 toupper endoscopy as upper GI endoscopy, esophagogastroduodenoscopy (EGD) or panendoscopy.

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.

Hemorrhoid Banding


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Hemorrhoid Banding 

Hemorrhoids are swollen veins located in the lower rectum or anus. There are two types of hemorrhoids: internal and external. Depending on the location, symptoms may include pain, inflammation, itching, and a feeling of fullness following a bowel movement. Additionally, there may be bright red blood covering the stool, on the toilet tissue or in the toilet bowl.

What causes hemorrhoids?
Hemorrhoids result from an increase in pressure in the veins of the rectum This may be caused by constipation, pregnancy, childbirth, obesity, heavy lifting, long periods of sitting, or diarrhea. In Western countries, constipation is associated with diets low in fiber and high in fat.

What technique is used and how does banding work?

Our physicians treat hemorrhoids by using the CRH O’Regan System™ First, your physician will examine you and confirm your diagnosis. If he or she determines a CRH System hemorrhoid banding procedure is right for you, you may begin treatment right away, or on a subsequent visit.

During the brief and painless banding procedure, your physician will use a gentle suction device – unlike the harsh metal clamps used in other banding treatments – to place a small rubber band around the base of the internal hemorrhoid where there are no pain-sensitive nerve endings. The whole thing typically takes less than 60 seconds. This cuts off blood supply to the hemorrhoid, causing it to shrink and fall off typically within one to five days. You probably won’t even notice when this happens or be able to spot the rubber band in the toilet

Does banding hurt?
No. Thanks to our improved instruments and technique, band placement is painless. You may experience a feeling of fullness or dull ache in the rectum for the first 24 hours, but this can generally be relieved by over-the-counter pain medication. A recent study of our banding technique shows that 99.1% of patients experience no significant post-procedural pain.

How is the recovery?

Once your doctor’s visit is complete, that’s it – no restrictive hemorrhoid recovery regimens to follow. You can resume your normal activities as tolerated. Simply avoid heavy lifting, rigorous exercise and similarly strenuous activity on the day of your treatment. You can resume all normal activity the next day.

You can have normal bowel movements during hemorrhoid recovery, though you may want to soak in a sitz bath (a warm tub with a tablespoon of table salt added) or use a bidet for a gentler cleansing of the anal opening.

How do I prevent future hemorrhoids from coming back?

To prevent hemorrhoids, you’ll need to

Avoid straining during bowel movements.

Drink a lot of fluids.  Unless your medical condition prohibits it, you should consume seven or eight glasses of water each day.

Add 15 grams of fiber to your diet (two tablespoons of natural oat or wheat bran, Metamucil, Benefiber, flax or other soluble fiber).

Do not sit longer than two minutes on the toilet. If you can’t have a bowel movement in that time, come back later. This “two-minute” rule can help keep you from straining during bowel movements without realizing it.

During air travel, be sure to stay hydrated, avoid alcohol, eat fiber and walk around when you can.

This information from CRHsystem.com

Flexible Sigmoidoscopy

What is flexible sigmoidoscopy?

Flexible sigmoidoscopy lets your doctor examine the lining of the rectum and a portion of the colon (large intestine) by inserting a flexible tube about the thickness of your finger into the anus and slowly advancing it into the rectum and lower part of the colon.

What preparation is required?

Your doctor will tell you what cleansing routine to use. In general, preparation consists of one or two enemas prior to the procedure but could include laxatives or dietary modifications as well. However, in some circumstances your doctor might advise you to forgo any special preparation. Because the rectum and lower colon must be completely empty for the procedure to be accurate, it’s important to follow your doctor’s instructions carefully.

Should I continue my current medications?

Most medications can be continued as usual. Inform your doctor about medications that you’re taking – particularly aspirin products or anticoagulants (blood thinners such as warfarin or heparin), or clopidogrel, as well as any allergies you have to medications.

What can I expect during flexible sigmoidoscopy?

Flexible sigmoidoscopy is usually well-tolerated. You might experience a feeling of pressure, bloating or cramping during the procedure. You will lie on your side while your doctor advances the sigmoidoscope through the rectum and colon. As your doctor withdraws the instrument, your doctor will carefully examine the lining of the intestine.

What if the flexible sigmoidoscopy finds something abnormal?

If your doctor sees an area that needs further evaluation, your doctor might take a biopsy (tissue sample) to be analyzed. Obtaining a biopsy does not cause any pain or discomfort. Biopsies are used to identify many conditions, and your doctor might order one even if he or she doesn’t suspect cancer.

If your doctor finds polyps, he or she might take a biopsy of them as well. Polyps, which are growths from the lining of the colon, vary in size and types. Polyps known as “hyperplastic” might not require removal, but benign polyps known as “adenomas” have a small risk of becoming cancerous. Your doctor will likely ask you to have a colonoscopy (a complete examination of the colon) to remove any large polyps or any small adenomas.

What happens after a flexible sigmoidoscopy?

Your doctor will explain the results to you when the procedure is done. You might feel bloating or some mild cramping because of the air that was passed into the colon during the examination. This will disappear quickly when you pass gas. You should be able to eat and resume your normal activities after leaving your doctor’s office or the hospital, assuming you did not receive any sedative medication.

What are possible complications of flexible sigmoidoscopy?

Flexible sigmoidoscopy and biopsy are safe when performed by doctors who are specially trained and experienced in these endoscopic procedures. Complications are rare, but it’s important for you to recognize early signs of possible complications. Contact your doctor if you notice severe abdominal pain, fevers and chills, or rectal bleeding. Note that rectal bleeding can occur several days after the exam.

Small Bowel Capsule Endoscopy (Pill Cam)

PROCEDURE:
A bowel prep to clean the intestine, similar to that used for colonoscopy, may be recommended by the  doctor to take the night before undergoing a capsule endoscopy. The exam is usually done in an office setting. Sensors are placed on the patient’s abdomen and the data recorder is attached to a large belt worn by the patient. The capsule is then activated and swallowed with a sip of water. The patient may leave the doctor’s office and continue with routine daily activities, including eating a light meal after several hours. Later, the patient returns for removal of the equipment, and then returns home. There is no sedation needed for the procedure and it is completely painless. The capsule is disposable and usually passes out of the GI tract unnoticed. The results are discussed in a follow up appointment with the patient’s doctor. Capsule endoscopy can also be performed in hospitalized patients and in children as young as 2 years old in special circumstances.

INDICATIONS:
The most frequent indication for performing a capsule endoscopy is the evaluation of obscure GI bleeding. Patients who have unexplained iron deficiency anemia or are losing blood from an unknown source in the GI tract are first evaluated with a colonoscopy and upper endoscopy (EGD). However, if these exams show no identifiable source of blood loss, then a capsule endoscopy study is the next step in trying to find the cause of the bleeding. About five percent of all obscure GI bleeding emanates from the small bowel, most often from small vascular lesions called angioectasias. These are small blood vessels with thin walls that may be found throughout the GI tract, and may bleed profusely or very subtlely over an extended time. Other causes of bleeding from the small bowel include ulcerations, erosions, inflammation, tumors, masses, or rare hereditary conditions.

Another common indication for capsule endoscopy is evaluation for Crohn’s Disease. Crohn’s is an inflammatory bowel disease which can affect the small intestine causing pain, inflammation, ulceration, and bleeding.

Small bowel capsule endoscopy is also a useful tool in evaluation of the small bowel for tumors such as lymphoma, carcinomas or carcinoids. This technology can be beneficial as an adjunctive diagnostic study in patients with celiac disease and for surveillance in patients with hereditary polyposis syndromes. Other potential indications for capsule endoscopy are under consideration and may include the evaluation of certain types of abdominal pain, refractory diarrhea or malabsorption.

CONTRAINDICATIONS:
Known small bowel obstruction is a contraindication for capsule endoscopy. Patients who are at risk for obstruction have swallowing disorders, have pacemakers or other implanted cardiac devices, or are pregnant should have careful evaluation by a specialist before undergoing a capsule endoscopy.

LIMITATIONS:
The capsule endoscopy system is purely diagnostic and is not used to biopsy or treat any conditions.

RISKS:
The primary risk with capsule endoscopy is possible retention of the device in the small bowel. In patients who undergo the test to evaluate for bleeding, the risk is very low, approximately one to two percent. For patients with Crohn’s Disease, the risk may increase to four to five percent. Most cases of retention resolve spontaneously after a short delay in the passage of the capsule, and most patients have no symptoms whatsoever. Occasionally, medications are given to help facilitate passage. In rare instances, there is an abnormality in the small bowel which blocks the passage. In such a case, the capsule can be retrieved during an endoscopic procedure called a double balloon enteroscopy, or in unusual instances, by surgical resection.

If the doctor is concerned about a possible blockage in the small bowel, a patency (or ‘dummy’) capsule can be ingested as a test beforehand to insure that no blockages exist.

ERCP

What is ERCP?

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.

H Pylori Breath Test

What is the H. pylori breath test?

The H. pylori breath test is a simple and safe test used to detect an active H. pylori infection.

What is H. pylori?

Helicobacter pylori (abbreviated as H. pylori) is a bacteria that can infect the stomach or duodenum (first part of the small intestine). If left untreated, H. pylori bacteria can cause gastritis (an inflammation or irritation of the stomach lining) and duodenal or gastric ulcers. In addition, infection with H. pylori increases the risk of other diseases and is also a risk factor for gastric cancer.

Accurate detection of H. pylori is the first step toward curing stomach and intestinal ulcers, and preventing the development of more serious gastrointestinal problems

What happens during the test?

During the test, you will be asked to exhale into a balloon-like bag. The air you breathe into this bag is tested to provide a basis for comparison (called a baseline sample). You will then be asked to drink a small amount of a pleasant lemon-flavored solution. Fifteen minutes after drinking the solution, a second breath sample will be taken. The air you breathe into this bag is tested for an increase in carbon dioxide.

Guidelines before the procedure

Special conditions

Be sure to tell your doctor if you are allergic to any medicines or if you are phenylketonuric.

Medications

Four weeks before the test do not take any antibiotics or Pepto Bismol® (oral bismuth subsalicylate).

Two weeks before the test do not take any prescription or over-the-counter proton pump inhibitors (Prilosec® [omeprazole], Prevacid [lansoprazole], Protonix® [pantoprazole], Aciphex® [rabeprazole] or Nexium® [esomeprazole], Dexilant® [dexlansoprazole]).

Please note: Do not stop taking any other medicine without first talking with your doctor.

Eating and drinking

One hour before the test, do not eat or drink anything (including water).

On the day of the procedure

A health care provider will explain the procedure in detail and answer any questions you might have. The procedure lasts about 20 to 30 minutes.

After the procedure

Your breath samples are sent to the laboratory where they are tested.

You may resume your normal activities.

You may resume your normal diet and medicines unless you have other tests that require dietary restrictions.

Test results

Your doctor will notify you as soon as your laboratory test results are available. If the test indicates that you do have a H. pylori infection, it can be treated with antibiotics. One month after antibiotic treatment your doctor might order a repeat breath test to make sure the infection has been cured.