Procedure Information

You may find more detailed information about your scheduled procedure from the list below. If you have any specific questions, feel free to contact your physician or one of our office nurses.

Upper Endoscopy


WHAT IS THE FUNCTION OF THE UPPER GASTROINTESTINAL TRACT?

The upper gastrointestinal tract is divided into three sections - the esophagus, stomach and duodenum (the first part of the small intestine). The esophagus is a tubular organ that delivers food from the mouth to the stomach. The stomach is an organ that is bathed in acid produced by certain cells in the upper portion of the organ. Food is mixed with acid in the stomach, churned, and slowly released into the duodenum where digestion and absorption begins.

WHAT IS UPPER ENDOSCOPY?

Upper endoscopy is the examination of the upper gastrointestinal tract through the use of a long, flexible scope. The procedure allows your physician to observe all parts of the upper gastrointestinal tract with little or no discomfort to the patient. The instrument used is an upper endoscope. It is a long, thin, flexible tube about twice the diameter of a pencil. There are approximately four channels within the "scope" through which the physician may illuminate, wash, suction, photograph and biopsy the upper gastrointestinal tract. These channels provide the means for biopsying abnormal tissue, removing polyps, cauterizing blood vessels to stop active bleeding, or to prevent re-bleeding. In addition, sclerosing agents can be injected into varices, (dilated vessels seen in the upper portion of the stomach or esophagus in patients with cirrhosis of the liver), or these varices can be banded with small rubber bands. Strictures (narrowed areas in the upper GI tract secondary to scarring from reflux or ulcer disease), can be dilated utilizing several different types of dilators.

WHY DO I NEED UPPER ENDOSCOPY?

Occasional upper gastrointestinal symptoms caused by anxiety, diet, mild disease or other related factors are relatively common in our society. However, should these symptoms persist medical investigation is warranted, especially if worrisome symptoms such as bleeding, weight loss, progressive difficulty with swallowing, etc., are present. In order to diagnose a problem or confirm a suspected abnormality, which may not have been revealed by earlier tests, an upper endoscopy is performed. Some indications for upper endoscopy are:

  1. To discover the source or bleeding from the upper gastrointestinal tract, which could be manifested by the symptom of passing black bowel movements or vomiting blood. If a significant bleeding site is identified, that site might be treated at the same time utilizing cautery or injection of sclerosing agents into the tissue.
  2. To assess healing of a gastric ulcer or monitor chronic problems such as Barretts esophagus.
  3. To biopsy (painless removal of a small piece of tissue for microscopic examination), suspicious tissue or a mass which may or may not have been revealed by x-ray examination.
  4. To investigate upper abdominal pain, vomiting, chronic heartburn, or difficultly swallowing. If strictures or rings are seen in the esophagus, dilation of these narrowed areas can be performed with a through-the scope balloon or by utilizing a tapered-tip dilator (Savary), which is passed over a wire after the scope has been removed. Strictures of the pylorus (the junction between the stomach and duodenum), or in the duodenum (the first part of the small intestine), can be dilated with a balloon.

WHERE AND HOW IS IT DONE?

Arrangements for your procedure will be made by this office. The only preparation is to refrain from eating or drinking on the day of the procedure so that your stomach will be empty for the exam. This is important to obtain a good quality exam, and to minimize the risk of aspirating stomach contents into the lungs. Upon admission you will be asked a series of medically related questions. You will change into a hospital gown and be shown to a bed. Any family member or a friend may accompany you and will be asked to stay in the waiting room. Due to the amnesia-like effects of the sedation used for upper endoscopy, it is likely you will not remember information given to you immediately following your procedure. Therefore, your doctor will have the discharge nurse/clinician speak with you and your family approximately 30 minutes after the completion of your procedure. At that time the procedure findings will be explained to you. You will be scheduled for any follow-up procedures that might be necessary, and any questions you and your family might have will be answered.

In our experiences, the majority of patients want to go home as soon as possible after their procedure. However, if you wish to speak to your physician, he/she will be happy to accommodate your request.

Due to the nature of the medications used during the procedure, it is absolutely mandatory that you have someone available after the procedure to drive you home. Once you have returned home, do not operate dangerous machinery, and be sure not to drive for at least 24 hours, since minor effects of the drugs may persist the rest of that day.

Pathology results from tissue removed/biopsied is routinely available within 14 days. If you have not received notification after this period of time please call our office.

WHAT ARE THE RISKS INVOLVED IN UPPER ENDOSCOPY?

It is your right to be thoroughly informed of the risks and possible complications before you decide whether or not to undergo the recommended upper endoscopy procedure.

  1. There is a 1 in 100 chance of some complications when upper endoscopy is used to diagnose your problem, but most of these are very minor, and serious problems are uncommon.
  2. There is a risk of bleeding in about 1 of 3000 procedures. Any persistent bleeding that is manifested by vomiting blood or passing black bowel movements should be reported to your physician.
  3. There is a risk of perforating the upper gastrointestinal tract with the scope in about 1 of 4000 procedures.
  4. There is a risk of temporary irregularity of the heart. For this reason, if you have a history of heart disease your heart may be monitored with an electrocardiogram to minimize risk to you.
  5. There is a risk of an allergic or other reaction to the drugs administered during the procedure. These are rare and the effects of the drugs can be reversed with other drugs.
  6. There is a risk of aspiration (vomiting stomach contents and going into the lungs). This is rare and the stomach should be empty at the time of the procedure.
  7. There is a slightly higher risk of complications if dilation or sclerotherapy is performed during your procedure.
  8. Death is extremely rare but remains a possibility.

Once the inspection is complete the upper endoscope will be removed. The entire examination requires between 10 and 30 minutes. You will then be taken to the postoperative area for recovery. It is very common, due to the nature of the medications used for sedation, for patients to remember little or nothing of the procedure. You may experience some abdominal discomfort due to the presence of gas which may last for 20-to-30 minutes, but generally this is minimal.

Although any medical test has some risk associated with it, in actuality, serious problems with upper endoscopy are very uncommon, and when they occur are very treatable. Because of its acceptability, low risk, accuracy, and the wide variety of tasks it can accomplish, upper endoscopy is well recognized as a very important test in appropriate situations, and is used frequently in patients with upper gastrointestinal symptoms or problems.

WHAT ARE THE SIDE EFFECTS OF THE PROCEDURE?

Abdominal gas or bloating caused by the introduction of air into the stomach may cause some discomfort for a short time after the procedure. Belching or passing gas will help to relieve this symptom. Refrain from eating large amounts of food until you have returned to your normal state of comfort.

Uncommonly, nausea my result from the abdominal gas and/or the medications used during the procedure. It is recommended that you remain on clear fluids until the nausea subsides. Should vomiting occur for an extended period of time (more than 6 hours), please notify your physician. Bedrest is recommended.

Occasionally a sore throat may be present following the procedure due to the passage of the scope through the oropharynx into the esophagus. If this occurs, it is generally mild and lasts only for 1-to-2 days. Topical therapy with throat lozenges or sprays usually help to relieve this symptom, and gargling with saltwater may help to decrease inflammation. If a severe sore throat is present or this symptom persists longer than 3 days, you should call your physician.

Localized irritation of the vein (phlebitis) is rare but may occur at the site of medication injection. A tender lump develops which may remain for several weeks to several months, but goes away eventually. Elevation of the arm and warm set compresses applied to the site several times per day should rectify the situation. If a red streak should form which appears to follow the route of a vein and extends up your arm, please notify your doctor at once. If any serious or persistent symptoms develop you should notify your doctor.

WHAT ARE THE ALTERNATIVES?

The most common alternative to upper endoscopy is an upper GI x-ray examination utilizing barium. This examination requires that you swallow barium (a chalky liquid), and x-rays are taken. Some abnormalities of the upper gastrointestinal tract can be detected by studying these films; however, the procedure is generally recognized as not being as accurate as an upper endoscopy, and does not allow for biopsy and removal of tissue.

Other procedures which may be done prior to upper endoscopy (but are not considered alternatives to the procedure), are CAT scan, ultrasound, and nuclear medicine scans. These studies are utilized to assess other structures, but may complement the findings of endoscopy.

Colonoscopy

Your doctor has determined that your medical condition warrants further examination and a colonoscopy is recommended.

The following discussion explains the procedure in detail in an effort to inform and reassure you. You are encouraged to read it. You will be required to sign the consent form prior to the procedure at OEC.

WHY DO I NEED A COLONOSCOPY?

Occasional lower bowel complaints caused by anxiety, diet, mild disease and other related factors are relatively common in our society. However, should these symptoms persist, medical investigation is warranted, especially if worrisome symptoms such as bleeding, persistent pain, change in bowel habits, etc. are present.

In order to diagnose a problem or confirm a suspected abnormality which may not have been revealed by earlier tests, a colonoscopy is performed. Some indications for colonoscopy are:

  • To discover the source of bleeding from the rectal area or colon.
  • To monitor the progress of chronic problems such as ulcerative colitis, Crohns disease, etc.
  • To biopsy (painless removal of a small piece of tissue for microscopic examination) suspicious tissue or a mass which may or may not have been revealed by x-ray examination.
  • To remove and biopsy (painlessly) polyps (growths on the inside wall of the colon).
  • To detect cancerous changes in the colon and monitor pre-cancerous changes in order to obtain effective management and treatment.
  • To evaluate pain in the lower abdomen or back.

WHAT IS THE FUNCTION OF THE COLON?

The primary function of the colon (also called the large intestine) is to reabsorb fluids from the liquid waste material that comes from the small intestine. When malfunctions occur, the colon can sometimes be the source of abdominal pain, diarrhea or constipation.

WHAT IS A COLONOSCOPY?

"Colon" refers to the large intestine or the last four-to-six feet of the digestive tract. "Oscopy" means "looking into." Colonoscopy allows your physician to observe the entire length of the colon effectively and generally with little or no discomfort to the patient.

The instrument used in colonoscopy is called a colonoscope. It is a long, thin, flexible tube about twice the diameter of a pencil. There are approximately four channels within the "scope" through which the physician may illuminate, wash, suction, photograph and biopsy the colon. These channels provide the means for removal of most polyps and the cauterization of blood vessels to prevent bleeding.

WHERE AND HOW IS IT DONE?

Arrangements for your procedure will be made by this office. OEC will validate your parking. Also, special written instructions for preparing your bowel (i.e., cleaning it out) involving a special diet and medication instructions will be given to you. These are very important to allow a good quality examination and should be followed carefully!

Upon admission you will be asked a series of medically related questions. You will change into a procedure gown and be shown to a bed.

Due to the amnesia-like effects of the sedation used for colonoscopy, it is likely you will not remember information given to you immediately following the procedure. Therefore, your doctors will have the office nurse/clinician speak with you and your family approximately 1 hour after the completion of the colonoscopy. At that time the procedure findings will be explained to you; you will be scheduled for any followup procedures that might be necessary, and any questions you and your family might have will be answered.

In our experience, the majority of patients want to go home as soon as possible after their procedure. However, if you wish to speak to your physician, he/she will be happy to accommodate your request.

Due to the nature of the medications used during the procedure, it is absolutely mandatory that you have someone meet you at OEC after the procedure to drive you home. Once you have returned home, do not operate any dangerous machinery and be sure not to drive for at least 24 hours, since minor effects of the drugs may persist the rest of that day.

Pathology results from tissue removed/biopsied is routinely available within 7 days. If you have not received notification after this period of time, please call our office.

WHAT ARE THE RISKS INVOLVED IN COLONOSCOPY?

It is your right to be thoroughly informed of the risks and possible complications before you decide whether or not to undergo the recommended colonoscopy procedure.

  1. There is a 1 in 100 chance of some complication occurring when colonoscopy is used to diagnose your problem, but serious problems are very uncommon.
  2. There is a 1 in 300 chance of a significant amount of bleeding from the colon or rectum. Minor bleeding is more common but seldom requires treatment. Any persistent bleeding should be reported to your physician.
  3. There is a 1 in 500 chance of a puncture of the colon.
  4. There is a risk of temporary irregularity of the heart rhythm. For this reason, if you have a history of heart disease, your heart may be monitored with an electrocardiogram to minimize risk to you.
  5. There is a risk of an allergic reaction to the drugs administered during the procedure, although these are rare.
  6. Death is extremely rare but remains a possibility.

Once you have completed the admission procedure, you will have an intravenous line started in your arm or hand. This provides the means by which your physician can administer sedation and pain medication before and during the procedure. If you have any history of drug reactions or allergies, heart or lung condition, artificial joints (e.g., artificial hip or knee), you should be sure to inform your nurse and doctor before the procedure begins. Please notify us if you are taking the medication NARDIL.

Colonoscopy is performed in a specially equipped room where you will be asked to turn on your left side with your knees drawn up. Every effort will be made to ensure that you are as comfortable and relaxed as possible. Your pulse, blood pressure and oxygel level will be monitored continuously throughout the procedure. After lubricating both the colonoscope and the rectal area, your doctor will gently insert the colonoscope. If there is any resistance, you may be asked to aid the insertion of the instrument by gently bearing down, as if you were having a bowel movement. Since the bowel should be totally empty, the chance of soiling oneself with fecal matter is almost non-existent.

During the procedure, it is necessary to inflate the bowel with air in order to smooth out the normally wrinkled walls of the colon. This will ease the insertion of the scope and improve the viewing of the lining of the colon, but at the same time, this may cause you to feel as if you have to have a bowel movement. This feeling of urgency will soon pass.

Your doctor will examine the entire large bowel up to and including the ileocecal valve which marks the junction of the small and large intestine. The colonoscope will be removed slowly as the doctor double-checks each section of the intestine upon withdrawal. If, during the inspection of the colon, any inflammation, irregularity or growth it discovered, your physician may painlessly remove or biopsy that tissue. Biopsy forceps can be inserted through the hollow channel of the scope, allowing your doctor to remove a tissue sample for testing. Removal or biopsy will only be performed when necessary and permission to do it is included in the consent you sign.

Once the inspection is complete, the colonoscope will be carefully removed. The entire examination requires between thirty minutes and one hour. You will then be wheeled out to the postoperative area for recovery. It is very common, due to the nature of the medications used for sedation, for patients to remember little or nothing of the procedure. You may experience some abdominal discomfort due to the presence of gas which may last up to several hours, but generally this is minimal.

Although any medical test has some risk associated with it, in actuality, serious problems with colonoscopy are very uncommon and when they occur, are very treatable. Because of its acceptability, low risk, accuracy and the wide variety of tasks it can accomplish, colonoscopy is well recognized as a very important test in appropriate situations and is used frequently in patients with lower bowel symptoms or problems.

WHAT ARE THE SIDE EFFECTS OF THE PROCEDURE?

Abdominal gas or bloating caused by the introduction of air into the colon to enhance and ensure good visualization. Walking assists the passing of gas. Refrain from eating large amounts of food until you have returned to your normal state of comfort.

Uncommonly, nausea may also be a result of the abdominal gas and/or the use of medications during the procedure. It is recommended that you remain on clear fluids until nausea subsides. Should vomiting occur over an extended period of time (more than 6 hours), please notify your physician. Bed rest is recommended.

Localized irritation of the vein (phlebitis) is rare but may occur at the site of medication injection. A tender lump develops which may remain for several weeks to several months, but goes away eventually. Elevation of the arm and hot, wet compresses applied to the site several times per day should rectify the situation. If a red streak should form which appears to follow the route of a vein or extends up your arm, please notify your doctor at once.

If any serious or persistent symptoms develop, you should notify your doctor.

WHAT ARE THE ALTERNATIVES?

The most common alternative to colonoscopy is barium enema. This examination requires barium (a chalky liquid) to be inserted into the rectum which fills the colon, after which x-rays are taken. Some abnormalities of the colon can be detected by studying these films. However, this procedure is generally recognized as not being as accurate as colonoscopy, nor does it allow for biopsy or removal of polyps.

Three procedures which may be done prior to colonoscopy (but are not considered alternatives to colonoscopy) are sigmoidoscopy, CAT scan and nuclear scan. Since findings from these three procedures may need to be confirmed by colonoscopy anyway, your physician may not perform them.

IN SUMMARY

Colonoscopy makes it possible to inspect the entire colon quickly and safely for over 95% who undergo this procedure. Colonoscopy detects the cause of rectal bleeding in a high percentage of patients whose problems cannot be diagnosed by other means. In addition, the colonoscopy procedure may enable your physician to determine the presence or absence of polyps, cancer or inflammatory diseases within the viewing range of the scope.

Colonoscopy is recognized as an acceptably safe and worthwhile procedure which is very well tolerated; it is invaluable in the diagnosis and management of disorders of the lower digestive tract. The decision to perform this procedure was based upon assessment of your particular problem. If you have any questions about your need for a colonoscopy or the procedure itself, do not hesitate to speak with your doctor. Both of you share a common goal - your good health - and this can best be achieved through mutual trust, respect and understanding.

Endoscopic Ultrasound (EUS)

WHAT IS ENDOSCOPIC ULTRASOUND?

Endoscopic ultrasound (EUS) is state of the art technology that allows for detailed pictures of the intestinal tract and organs adjacent to the intestinal tract. The test involves passing a thin, flexible tube called an endoscope into the upper or lower GI tract. With EUS, the doctor then turns on the ultrasound component attached to the endoscope to produce sound waves that create visual images of the digestive tract. The ultrasound creates an image of the underlying area. Thus, the physician can get a view of the tissues and organs beneath the intestinal surface. And when combined with fine-needle aspiration, EUS is a minimally invasive, alternative to exploratory surgery to remove tissue samples from abdominal and other organs.

WHY IS EUS PERFORMED?

EUS is a minimally invasive tool used to diagnose and stage gastrointestinal and lung cancers. EUS can accurately determine how deeply a tumor penetrates the gut wall and also helps determine whether cancer has spread to adjacent lymph nodes. Accurate staging is crucial in determining what type of therapy is appropriate. Early stage tumors can often be treated with endoscopic therapy or surgery. Advanced stage tumors usually require chemotherapy and radiation followed by surgery. On occasions, detecting advanced disease with EUS may prevent unhelpful and invasive therapy.

Specifically, EUS can be used to evaluate the following:

  • Esophageal cancer
  • Pancreatic cancer and precancerous cysts
  • Rectal cancer
  • Gastric/stomach tumors and nodules
  • Enlarged lymph nodes
  • Barrett's esophagus with high-grade dysplasia
  • Neuroendocrine tumors
  • Gastric cancer/MALT lymphoma
  • Lung cancer

Your doctor can also use EUS to diagnose the cause of conditions such as abdominal pain or abnormal weight loss, such as gallstones, bile duct stones, or chronic pancreatitis. Or, if your doctor has ruled out certain conditions, EUS can confirm your diagnosis and offer reassurance.

WHAT ARE THE RISKS?

In general, EUS is a very safe procedure. Complications during EUS are a rare occurrence when performed by an experienced physician. During the procedure, patients are routinely monitored to minimize risks of complications from medications. Complications are similar to those reported with standard endoscopy of the upper gastrointestinal tract, which include sore throat, bleeding, perforation, or heart or lung problems. There is a small risk of infection when a fine needle biopsy is performed on a cystic growth, or pancreatitis when the pancreas is biopsied. Antibiotics may be administered before and after the procedure to reduce the risk of infection.

Liver Biopsy

In a liver biopsy the physician examines a small piece of tissue from your liver for signs of damage or disease. A special needle is used to remove the tissue from the liver. The physician decides to do a liver biopsy after tests suggest that the liver does not work properly. For example, a blood test might show that your blood contains higher than normal levels of liver enzymes or too much iron or copper. Looking at liver tissue itself is the best way to determine whether the liver is healthy or what is causing it to be damaged.

Preparation

Before scheduling your biopsy, the physician will take blood samples to make sure your blood clots properly. Be sure to mention any medications you take, especially those that affect blood clotting, like blood thinners. One week before the procedure, you will have to stop taking aspirin, ibuprofen, and anticoagulants.

You must not eat or drink anything for 8 hours before the biopsy, and you should plan to arrive at the hospital about an hour before the scheduled time of the procedure. Your physician will tell you whether to take your regular medications during the fasting period and may give you other special instructions.

Procedure

Liver biopsy is considered minor surgery, so it is done at the hospital. For the biopsy, you will lie on a hospital bed on your back with your right hand above your head. After marking the outline of your liver and injecting a local anesthetic to numb the area, the physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue. In some cases, the physician may use an ultrasound image of the liver to help guide the needle to a specific spot. Most patients will receive a small amount of intravenous medication to help relax them or for treatment of any discomfort with the procedure. We do not, however, “knock you out” as we need to have you cooperate with holding your breath at the time of the biopsy (see below).

You will need to hold very still so that the physician does not nick the lung or gallbladder, which are close to the liver. The physician will ask you to hold your breath for 5 to 10 seconds while he or she puts the needle in your liver. You may feel pressure and a dull pain. The entire procedure takes about 20 minutes.

Recovery

After the biopsy, the physician will put a bandage over the incision and have you lie on your right side, pressed against a towel, for 1 to 2 hours. The nurse will monitor your vital signs and level of pain.

You will need to arrange for someone to take you home from the hospital since you will not be allowed to drive after having the sedative. You must go directly home and remain in bed (except to use the bathroom) for 8 to 12 hours, depending on your physician's instructions. Also, avoid exertion for the next week so that the incision and liver can heal. You can expect a little soreness at the incision site and possibly some pain in your right shoulder. This pain is caused by irritation of the diaphragm muscle (the pain usually radiates to the shoulder) and should disappear within a few hours or days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after the biopsy. These medicines decrease blood clotting and, therefore, can increase the risk of bleeding after the biopsy.

Risks

As with any surgery, liver biopsy does have some risks. These risks include such complications such as accidental puncture of the lung, bowel, or gallbladder; infection, bleeding; and pain. Although very rare, even death can occur due to complications of a liver biopsy. Usually signs and symptoms of these complications appear during the observation period after the biopsy. Treatment of a complication may require hospitalization, blood transfusion, or even surgery. A list of the possible complications and their range of frequencies are listed below:

  • Pain (0.056-22%)
  • Bleeding (0.03%-23%)
  • Bile peritonitis (0.03-0.22%)
  • Severe infection (0.088%)
  • Pneumothorax and/or pleural effusion (0.08-0.28%)
  • Hemothorax (0.18-0.49%)
  • Arteriovenous fistula (5.4%)
  • Subcutaneous emphysema (0.014%)
  • Anesthetic reaction (0.029%)
  • Needle break (0.02-0.059%)
  • Biopsy of other organs

    • Lung (0.001-0.014%)
    • Gallbladder (0.034-0.117%)
    • Kidney (0.096-0.029%)
    • Colon (0.0038-0.044%)
  • Mortality (0.0088-0.3%)

Alternatives

Although there are no alternatives to a liver biopsy, there are different methods of obtaining liver tissue. Sometimes a liver biopsy can be performed via the jugular vein in the neck. Access to the liver is via the jugular vein => inferior vena cava =>hepatic vein => liver. This method is usually employed if the patient has an increased risk of bleeding, excessive fluid in the abdomen (ascites) making it unsafe to perform by the abdominal approach, or difficult anatomy/body habitus again making it unsafe to perform by the usual approach. At other times the biopsy is obtained surgically, usually via the laparoscopic approach. This is the preferred approach if there are other reasons for the patient to have a laparoscopy (i.e. removal of the gallbladder, inspection of the peritoneal cavity, etc.)

Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP (endoscopic retrograde cholangiopancreatography) is used in the diagnosis and treatment of disorders of the pancreas, bile duct, liver and gallbladder. The doctor passes an endoscope (a thin, flexible fiberoptic scope), through your mouth past the esophagus and stomach into the beginning portion of the small intestine/duodenum. The doctor then injects contrast dye into an opening in the small bowel (major or minor ampulla) which leads into the bile ducts or pancreatic duct, in order to take detailed x-ray pictures or to perform therapeutic maneuvers.

Since x-rays are taken you should inform us if there is a possibility of pregnancy.

Preparation

To allow a clear view you should not eat or drink anything after midnight. If you must take prescription medications use only a small sip of water. Do not take antacids.

What will happen?

The doctor and/or nurse will explain the procedure and answer your questions. If you have any questions be sure to ask. Please tell us if you have had any other endoscopic examinations or any allergies or bad reactions to medications or contrast dye. You will be asked to sign a consent form giving your permission for the procedure. You will need to put on a hospital gown and remove eyeglasses, contact lens and dentures.

The examination is performed on an x-ray table. Local anesthetic may be sprayed in your mouth to make it numb, and you will be given medication by injection through a vein to make you sleepy and relaxed. You will also receive intravenous antibiotics to prevent potential infection from the procedure While in the prone position the doctor will pass the endoscope through your mouth and down your throat. A dental guard will be placed to protect your teeth. The endoscope will not interfere with your breathing and will not cause any pain. You may be asked to change positions during the examination, assisted by a nurse. The examination usually takes from 30 to 90 minutes.

After the procedure

Your throat may feel numb and slightly sore. Because of the local anesthetic and sedation you should not attempt to take anything by mouth for at least one hour. It is wise to take only clear liquids for the rest of the day. If you are an outpatient you will remain in the short stay unit for at least 2 to 3 hours following the procedure. A companion must be available to drive you home, as the sedation impairs your reflexes and judgment. For the remainder of the day you should not drive a car, operate machinery or make any important decisions. We suggest that you rest quietly.

Risks

Endoscopy can result in complications such as reactions to medications, perforation of the intestine and bleeding. Injection of contrast dye through the endoscope into the pancreatic duct or bile duct can cause an allergic reaction, inflammation of the pancreas (pancreatitis), and infection of the bile duct (cholangitis). These complications are infrequent but may require urgent treatment, even surgery. Be sure to inform us if you have any pain, fever or vomiting in the 24 hours after ERCP.

Questions or problems

We have a doctor on call 24-hours a day and he/she may be contacted by phoning 541 868-9500 (or toll free 877 484-4501). The emergency room is also an option for more serious problems.

ERCP Treatments

  • Sphincterotomy: If the x-ray shows a gallstone or other blockage, the doctor can enlarge the opening of the bile duct by making an incision using cautery. This is called a sphincterotomy and is done with an electrically heated wire (which you will not feel). Any stones will be collected into a tiny basket or left to pass into the intestine.
  • Stenting: A stent is a small plastic tube which is pushed through the endoscope and into the narrowed area of the bile duct. This relieves the jaundice by allowing the bile to drain freely into the intestines. Stents are also sometimes placed into the pancreatic duct when it is narrowed or blocked.
  • Nasobiliary tube: Sometimes a small plastic tube is left in the bile duct and brought out through the nose. This tube may be left in place for a few days. This helps the drainage of bile and allows for further x-rays to be taken to check when the duct is clear. The presence of the tube may be slightly uncomfortable at first, but does not interfere with eating or drinking.
  • Rendezvous procedure/transhepatic cholangiogram: For a variety of reasons it is sometimes necessary to request a radiologist (a specialist in x-rays), to perform a transhepatic cholangiogram in conjunction with an ERCP. This procedure involves passing a thin needle through the abdomen into the bile ducts, allowing the placement of drainage catheters, guide wires, etc. At times this can be very useful in difficult cases to make it easier to perform a sphincterotomy, place a stent, perform a dilatation or other procedure. Frequently the decision whether this procedure will be necessary cannot be made until the patient is sedated while the ERCP is being performed.

Risks

These treatments for stones and blockages have been developed and are recommended to you because they are simpler and safer than standard surgical operations. However, you should realize that they are not always successful and problems can arise. Potential complications include perforation of the intestine, bleeding, inflammation of the pancreas (pancreatitis), and infectionof the bile duct (cholangitis). These complications are infrequent but may be serious enough to require urgent treatment and even surgery.

It is very unusual for other biliary problems to develop in the months or years after sphincterotomy, but jaundice, fevers and even new stones can infrequently occur. Usually these can be dealt with by a repeat endoscopic procedure.

Percutaneous Endoscopic Gastrostomy (PEG) feeding tube Placement

What is a PEG?

A PEG is a feeding tube which passes through the abdominal wall directly into the stomach, so that nutrition can be provided without swallowing, or in some cases to supplement ordinary food. The PEG tube can be connected to a mechanical pump to provide feeds continuously or a syringe can be use to receive feeds at intervals.

Why is a PEG required?

PEGs are used in patients who are unable to swallow or who are unable to eat enough and need long term artificial feeding. Common causes include patients with stroke (CVA), head injuries, neurological diseases such as multiple sclerosis or motor neuronal disease, surgery to the head or neck, or patients undergoing chemotherapy. In some cases PEGs are used to give extra nutrition (or supplements) to people who can still eat, such as patients with cystic fibrosis.

How is the PEG inserted?

PEG placement involves an examination of the stomach with an endoscope. A PEG feeding tube is then passed into the stomach through a small opening on the wall of the abdomen. Attached to the tube there is a small plastic disc which lies close to the skin to prevent movement of the tube and a small clamp or plastic cap which keep the tube closed when feeding is not taking place. The procedure requires a minor operation and is usually performed in the outpatient setting with an intravenous sedative injection. Some patients, however, may require hospitalization and/or general anesthesia. For a few hours after the procedure you will probably feel drowsy and may have a sore throat where the endoscope has been passed. There may also be some discomfort at the incision site on your abdomen. You will be instructed on how to clean the incision site, when to start feeding after insertion of the tube, and how to administer feedings through the PEG feeding tube.

What are the Risks?

The risks of the PEG placement are similar to those with standard upper endoscopy. These include the risk of bleeding, bowel perforation and adverse reaction to the sedative medications. In addition, with the abdominal incision there is a risk of accidental puncture of nearby organs as well as infection of the skin (cellulitis). Prophylactic intravenous antibiotics will be administered with the procedure as a preventative measure for potential infection. The overall risk of a complication occurring is estimated as being 1/1000 patients. Although the risk of death is extremely rare, this too is a potential complication of the procedure.

What are the Alternatives?

Feeding tubes can also be placed percutaneously (across the abdominal wall) either by the radiologists (using X-ray guidance) or by the surgeons. On occasion, if the PEG feeding tube cannot be placed safely by the endoscopic approach, the patient will be referred for one of these other options.

A feeding tube can also be placed non-invasively via the nose and directed into the stomach or small intestine. Although this can be performed with minimal risk, the tube can accidentally be pulled out or fall out, and often can be uncomfortable if the tube is to remain for a prolonged period of time.

Esophageal Manometry

The esophagus is the tube that carries food and liquid from the throat to the stomach. The wall of the esophagus contains muscle that rhythmically contracts whenever a person swallows. This contraction occurs as a sweeping wave (peristalsis) carrying food down the esophagus. It literally strips the food or liquid from the throat to the stomach.

Another important part of the esophagus is the lower esophageal sphincter, or LES. This is a specialized muscle that remains closed most of the time, only opening when swallowed food or liquid is moved down the esophagus or when a person belches or vomits. This muscle protects the lower esophagus from caustic stomach acid and bile. These substances can cause the discomfort of heartburn and in time can lead to damage and scarring in the esophagus.

Manometry is the recording of pressures within the esophagus. It can evaluate the contraction amplitude and coordination of the stripping muscle waves in the main portion of the esophagus as well as in the lower esophageal sphincter (LES).

Reasons for the Exam

There are a number of symptoms that originate in the esophagus. These include difficulty swallowing food or liquid, heartburn, and chest pain. Additionally, an x-ray (barium swallow or upper GI series) or endoscopy may show abnormalities that need to be studied further by manometry. The exam is often done before surgical treatment for heartburn/ gastsroesophageal reflux disease.

Preparation

The preparation for esophageal manometry is very simple. The patient should take no food or liquid for about eight hours before the exam. Your usual medications may be taken with small sips of water on the day of the exam. As the examination will be performed without sedative medications, you may drive yourself to and from the examination. Certain medications (such as Reglan/metaclopramide) may be held prior to the procedure as they may affect the contractility of the esophagus.

The Procedure

The procedure takes about one hour from start to finish. While seated in a chair or lying on the side, thin soft tubing is gently passed through the nose, or occasionally the mouth. Upon swallowing, the tip of the tube enters the esophagus and the technician then quickly passes it down to the desired level. There is usually some slight gagging at this point, but it is easily controlled by following instructions. During the exam, the technician will ask you to swallow saliva (called a dry swallow) or water (called a wet swallow). Pressure recordings are made and the tubing is withdrawn. Patients can usually resume regular activity, eating, and medicines immediately after the exam.

Results

The manometry tracings are performed by the technician, but interpreted by your physician. You will be contacted regarding the results which help to determine the appropriate next step in diagnosis and treatment.

Benefits

The primary benefit of the exam is that the physician has clear documentation of the muscle function of the esophagus. With this information, a specific treatment program can be outlined or reassurance provided if the exam is normal.

Alternatives to Manometry

Nothing really takes the place of manometry. Other techniques that are used to study the esophagus include: upper GI x-ray series using swallowed liquid barium; upper endoscopy to visualize the inside lining of the esophagus; and a 24-hour probe left in the end of the esophagus to measure acidity as it refluxes from the stomach.

Side Effects and Complications

There minimal risks associated with manometry. Theoretically, esophageal tear/ perforation and/or bleeding could occur, but this complication is extremely rare. Slight gagging is normal during the exam, and a temporary sore throat may be present afterward.

Summary

“Esophageal manometry” is a very valuable method of recording and evaluating the muscular function of the esophagus. The test is simple and quick to perform. With this information, the physician can usually develop effective treatment for most patients with esophageal muscle disorders.

24-hour Ambulatory pH Study

24 Hour Esophageal pH Study is used to measure the number of the reflux episodes during the patient's day. The study also measures the amount of time (in minutes) that stomach acid is present in the patient's esophagus. The 24 hour test allows evaluation of the patient's symptoms with activity, at home or work, and especially during sleep.

The information obtained from this study will show if reflux of acid is the cause of non-cardiac chest pain, hoarseness, coughing, halitosis, or asthma. This study can show how much reflux a patient is having when endoscopy findings are normal. This information will assist your physician in planning treatment for your particular health problem. Your appointment will last about 30-40 minutes; this includes out-patient admission, instruction and placement of the pH catheter. If esophageal manometry is also being performed at the same time, the procedure will be longer, approximately 1-1 ½ hours.

Your procedure will take place in an examination room. No sedation is given. A nurse will spray your throat with a topical anesthetic and she will use an anesthetic lubricant on the small, flexible pH tube. The tube is 1/8 inch in diameter: about 1/3 the diameter of a pencil. This tube is gently placed into one nostril and guided into your esophagus. The end of the tube is positioned precisely 2 inches above the diaphragm, where acid sensing occurs. You will be lying on an examination table during the placement. You do not have to remove your clothing,

After the pH catheter is placed, the catheter is secured with small pieces of tape to the end of your nose and the side of your face. The catheter is attached to a "Walkman" type recorder that is worn on a belt, which is provided. You will not be able to bathe or shower with this catheter in place. Some patients find this catheter does not interfere with their normal activities; others find it to be annoying and would appreciate having someone to drive them home. It may make your eyes water, your nose run, and your throat sore. You will have to return 24 hours later for removal of the catheter. This return visit will take about 5 minutes.

24-hour pH esophageal monitoring is a very low risk procedure. Complications such as perforations (tearing) or bleeding of the gastrointestinal wall can occur, but they are extremely rare.

Flexible Sigmoidoscopy

FLEXIBLE SIGMOIDOSCOPY is an endoscopic technique for visually inspecting the lower 1/3rd portion of the colon and rectum with the use of a flexible tube with a light on the end.

The examination is usually performed when visualization of the whole colon is not required. As an example, flexible sigmoidoscopy can be used for the evaluation of rectal bleeding, status of an established patient with inflammatory bowel disease or an abnormality seen on barium enema/CAT scan. Although flexible sigmoidoscopy was previously used as a tool for colon cancer screening, a full examination of the colon with a colonoscopy is now the preferred and recommended procedure.

Because a two-foot-long mechanical instrument is being inserted into the bowel there is a risk of lacerating or perforating the bowel wall during this procedure. The estimated risk of this happening is one case in a thousand. Perforation of the bowel wall is a serious complication that requires emergent surgical attention.

Alternatives include a barium enema, which is an X-ray study of the colon. However, if the barium enema is abnormal, this usually leads to a follow-up examination with a flexible sigmoidoscopy or colonoscopy. Of note, biopsies and polyp removal cannot be performed during a barium enema.


Treatment of Barrett's Esophagus

WHAT IS BARRETT’S ESOPHAGUS?

Barrett’s esophagus is a change in the lining of the esophagus, typically in response to chronic acid damage. Barrett’s esophagus can only be diagnosed by performance of Upper Endoscopy with biopsy. Barrett’s esophagus carries the risk of deteriorating to cancer in a significant percentage of patients.

WHY TREAT BARRETT’S ESOPHAGUS?

Barrett’s esophagus is treated to decrease the risk of progression to cancer.

HOW IS BARRETT’S TREATED?

Many methods have been investigated to eliminate (or ablate) Barrett’s esophagus: freezing (cryotherapy), laser, electrical burning (cautery), and radio-frequency energy. The best treatment currently is called Radio Frequency Ablation (RFA), which is energy delivered to precisely destroy (or ablate) the Barrett’s tissue. The advantage of this method over others is the very precise depth of energy penetration which decreases the frequency of complications.

The physicians of Eugene Gastroenterology Consultants are fully trained in using Radio Frequency Ablation to treat Barrett’s esophagus in those patients in whom ablation (or destruction) of Barrett’s esophagus is felt to be appropriate. At this time, not every patient with Barrett’s esophagus needs to undergo Radio Frequency Ablation. If you are interested in this treatment, but are not sure if you are an appropriate candidate, please make an office appointment to discuss this in detail.

WHERE IS BARRETT’S ABLATION PERFORMED?

Treatment of Barrett’s esophagus with radio-frequency ablation is performed at either the Oregon Endoscopy Center or Sacred Heart Medical Center – RiverBend. The size of the Barrett’s esophagus and medical complexity are two factors which may influence where the procedure is performed.

For more detailed information on ablation of Barrett’s esophagus, please click here..

You may also visit http://www.Barrx.com/Patients_and_Families for information specifically about RFA using instruments manufactured by Barrx.

Small Bowel Capsule Endoscopy


WHAT IS CAPSULE ENDOSCOPY?

Small bowel capsule endoscopy is used to help direct the management of small bowel diseases such as small bowel bleeding, Crohn's disease and small bowel tumors. The study involves swallowing a capsule the size of a large vitamin which will pass naturally through the digestive system while taking 2 pictures per second. For up to 8 hours the capsule transmits intestinal images wirelessly to a video recorder that is worn on a belt by the patient. The images are downloaded into a computer and later a physician analyzes the images of the small bowel for any abnormalities.

WHAT ARE THE RISKS?

All medical procedures carry some risks. Rare complications of capsule endoscopy include capsule retention, intestinal obstruction and difficulty with swallowing the capsule device. Contraindications to capsule endoscopy include known or suspected gastrointestinal obstructions, strictures or fistulas; cardiac pacemakers or other inplantable electromedical devices; and swallowing disorders.

More information on small bowel capsule endoscopy can be found at: http://www.givenimaging.com/en-us/Patients/Pages/pageSmallBowel.aspx

Note: the information in this section is provided as a supplement to information discussed with your healthcare provider. It is not intended to serve as a complete description of a particular topic or substitute for a clinic visit.

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