Our physicians offer a vast number of procedure-related services to assist in the diagnosis and management of digestive health problems. These range from standard to those more highly specialized procedures often only available at large academic-university centers. You can be reassured of the quality of services we provide, as our physicians perform routine colonoscopies at a level that exceeds national averages. Moreover, as each physician has specific areas of interest and expertise that translates to a concentrated experience in a particular procedure resulting in a high level of skill rarely encountered in a community based practice.
Direct visual examination of the colon, ileocecal valve, and portions of the terminal ileum by means of a fiberoptic endoscope. Colonoscopy is best performed by a board certified gastroenterology specialist in a specialized endoscopy suite (occasionally may be carried out at the bedside in an intensive care unit). With the patient awake but sedated, a flexible endoscope is inserted into the rectum and advanced through the various portions of the lower GI tract. Important anatomic landmarks are identified and mucosal surfaces are examined for ulcerations, polyps, friable areas, hemorrhagic sites, neoplasms, strictures, etc. Minor operative procedures may then be performed utilizing the standard colonoscope with appropriate accessories. These procedures include tissue biopsy for histopathology and/or microbiologic culture, polypectomy, electrocoagulation of bleeding sites, removal of foreign bodies, hot biopsy/fulguration of tumor, and others.
Reasons to Perform Colonoscopy
• colon cancer screening
Colonoscopy Bowel Preparation
In order to perform a colonoscopy it is imperative that the entire large intestine (colon) be clean. Therefore, the preparation must be thorough and requires strict adherence to dietary restrictions and the instructions for taking the laxative product(s). There are more than one preparation available. Please discuss which one is recommended for you with your physician.
What do I need to do to prepare for the colonoscopy?
The colon cleansing preparation is very important for you to get an optimal result. If the colon is poorly prepared then important findings such as cancer or precancerous tumors might be missed. The preparation involves dietary restriction to only clear liquids for most or all of the day prior to the exam in addition to taking a large volume bowel cleansing preparation that is usually divided into two doses. It is important to comply with all the instructions for this to be effective. You should also receive special guidance in regards to certain medications you may be taking; e.g if you are on blood thinning agents you may or may not be advised to hold this several days prior to the procedure.
Upper Endoscopy (also known as gastroscopy, EGD, or esophagogastroduodenoscopy) is a procedure that enables your surgeon to examine the lining of the esophagus (swallowing tube), stomach and duodenum (first portion of the small intestine). A bendable, lighted tube about the thickness of your little finger is placed through your mouth and into the stomach and duodenum.
Reasons to Perform Upper Endoscopy
- Acid Reflux
- Hiatal Hernias
Why is an upper endoscopy performed?
Upper endoscopy is performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, difficulty swallowing or heartburn. It is an excellent method for finding the cause of bleeding from the upper gastrointestinal tract. It can be used to evaluate the esophagus or stomach after major surgery. It is more accurate than X-rays for detecting inflammation, ulcers or tumors of the esophagus, stomach and duodenum. Upper endoscopy can detect early cancer and can distinguish between cancerous and non-cancerous conditions by performing biopsies of suspicious areas. Biopsies are taken by using a specialized instrument to sample tissue. These samples are then sent to the laboratory to be analyzed. A biopsy is taken for many reasons and does not mean that cancer is suspected.
A variety of instruments can be passed through the endoscope that allows the surgeon to treat many abnormalities with little or no discomfort. Your surgeon can stretch narrowed areas, remove polyps, remove swallowed objects, or treat upper gastrointestinal bleeding. Safe and effective control of bleeding has reduced the need for transfusions and surgery in many patients.
What preparation is required?
The stomach should be completely empty. You should have nothing to eat or drink for approximately 8 hours before the examination. Your surgeon will be more specific about the time to begin fasting depending on the time of day that your test is scheduled.
Medication may need to be adjusted or avoided. It is best to inform your surgeon of ALL your current medications as well as allergies to medications a few days prior to the examination. Most medications can be continued as usual. Medication use such as aspirin, non-steroidal anti-inflammatories, blood thinners and insulin should be discussed with your surgeon prior to the examination. It is essential that you alert your surgeon if you require antibiotics prior to undergoing dental procedures, since you may also require antibiotics prior to gastroscopy.
Also, if you have any major diseases, such as heart or lung disease that may require special attention during the procedure, discuss this with your surgeon.
You will most likely be sedated during the procedure and an arrangement to have someone drive you home afterward is imperative. Sedatives will affect your judgment and reflexes for the rest of the day. You should not drive or operate machinery until the next day.
What can be expected during the upper endoscopy?
You may have your throat sprayed with a local anesthetic before the test begins and given medication through a vein to help you relax during the examination. You will be laid on your side or back in a comfortable position as the endoscope is gently passed through your mouth and into your esophagus, stomach and duodenum. Air is introduced into your stomach during the procedure to allow a better view of the stomach lining. The procedure usually lasts 15-60 minutes. The endoscope does not interfere with your breathing. Most patients fall asleep during the procedure; a few find it only slightly uncomfortable.
What happens after upper endoscopy?
You will be monitored in the endoscopy area for 1-2 hours until the effects of the sedatives have worn off. Your throat may be a little sore for a day or two. You may feel bloated immediately after the procedure because of the air that is introduced into your stomach during the examination. You will be able to resume your diet and take your routine medication after you leave the endoscopy area, unless otherwise instructed. Your surgeon will usually inform you of your test results on the day of the procedure, unless biopsy samples were taken. These results take several days to return. If you do not remember what your surgeon told you about the examination or follow up instructions, call your surgeon’s office to find out what you were supposed to do.
What complications can occur?
Gastroscopy and biopsy are generally safe when performed by surgeons who have had special training and are experienced in these endoscopic procedures. Complications are rare, however, they can occur. They include bleeding from the site of a biopsy or polypectomy and a tear (perforation) through the lining of the intestinal wall. Blood transfusions are rarely required. A reaction to the sedatives can occur. Irritation to the vein that medications were given is uncommon, but may cause a tender lump lasting a few weeks. Warm, moist towels will help relieve this discomfort.
It is important for you to recognize the early signs of possible complications and to contact your surgeon if you notice symptoms of difficulty swallowing, worsening throat pain, chest pains, severe abdominal pain, fevers, chills or rectal bleeding of more than one-half cup.
A sigmoidoscopy is an examination of the lower portion (sigmoid) of the colon using a flexible instrument with a light and camera. The instrument is passed under direct guidance a distance of 1-2 feet corresponding to 20-40% of the colon being visualized. This usually incorporates detailed inspection of the lining of the colon as well as obtaining samples for analysis of tissue specimens under the microscope. This is performed commonly in the office or endoscopy center after the patient receives only enemas to empty the lower colon as no oral-based bowel preparation is required. Although mild discomfort can be experienced the exam is brief and the cramping is very transient.
Reasons to Perform Sigmoidoscopy
• abdominal pain
• constipation or diarrhea
• rectal bleeding
• change in bowel habits
• radiographic abnormality
• suspected colitis; infection or inflammation of a chronic nature
• colorectal cancer screening
Sigmoidoscopy Bowel Preparation
Since this examination only involves the inspection of the lowest most portion of the colon it does not usually require the entire large intestine to be clean. Most often, it is only necessary to take 1 or 2 phosphate-based (Fleet) or alternative type of enemas administered into rectum. They are usually administered immediately before the examination is performed.
Is sedation used for sigmoidoscopy?
In most instances sedation is not used as this procedure is a brief and generally well tolerated by patients. Currently, a small diameter very flexible instrument is used making this a more comfortable exam versus older generation sigmoidoscopes that were larger in size and sometimes rigid.
What are the risks of sigmoidoscopy?
Although extremely remote in possibility the risks include bleeding, infection or bowel perforation. The frequency of the latter circumstance is estimated as less then 1 in 10,000
What if precancerous polyps(tumors) or cancer is found at the time of sigmoidoscopy?
If this occurs then thorough inspection of the entire colon via colonoscopy is needed to identify and/or remove any additional polyps or cancers that could be discovered.
Capsule endoscopy can help to determine the cause for a variety of gastrointestinal symptoms. The capsule is swallowed, and the miniature video camera contained in the capsule captures images of the intestine as it travels through the body. The images are transmitted to a small data recorder device attached to a belt worn around the waste. These images are down loaded to a computer for a physician to review and make a diagnosis.
Reasons to Perform Capsule Endoscopy
• Gastrointestinal bleeding of unknown origin
• Anemia of suspected GI cause
• Abdominal pain
• Malabsorption (celiac disease)
• Suspected or known Crohn’s disease
How long is the procedure?
Approximately eight hours, however after the capsule is swallowed you may leave the office and continue with your normal activities. After eight hours, return to the office and the data recorder is removed.
How large is the capsule?
The capsule has a very smooth texture and is easy to swallow. It is approximately the size of a vitamin pill.
What is the main risk of capsule endoscopy?
Rarely the capsule can become lodged or impacted in the gastrointestinal tract and may require surgical removal. The incidence of capsule impaction is less than one percent.
A small bowel enteroscopy is a procedure in which an endoscope of extra length is used to visualize the lumen and lining of the proximal portion of the small intestine. It is used to diagnose and treat a variety of problems such as gastrointestinal bleeding and subsequent anemia. Gastrointestinal bleeding most commonly arises from minute cluster of blood vessels known as an arteriovenous malformation and can be either visible or microscopic (invisible). Additionally, any thickening or growths involving the wall of the small intestine identified by other means can be further evaluated with direct inspection and biopsy samples. Because this procedure often requires special equipment and sometimes x-ray equipment it is performed at the hospital. No special preparation is required with the exception of fasting overnight.
Reasons to Perform Enteroscopy
• unexplained anemia
• non-visible gastrointestinal bleeding
• small bowel tumors or polyps
• Crohn’s disease of the small bowel
What happens during the procedure?
The patient experience is essentially the same as that with standard endoscopy of the stomach. During the procedure you will be positioned on your left side. Following the administration of conscious sedation, the endoscope is placed into the mouth and guided with direct visualization through the stomach into the small intestine as far as technically possible. The examination typically lasts around 30 minutes.
Is the exam painful?
Generally, enteroscopy is not a painful procedure but mild discomfort can occasionally be experienced due to air put into the stomach and small intestine. These symptoms are minimized with the administration of sedative medications used to provide comfort during the examination.
How do I feel after the procedure?
The most common after effect from enteroscopy is a sensation of fullness in the abdomen. This is a result of air which is placed into the small intestine during the procedure to allow for maximum visualization of the lumen of the small bowel.. This usually subsides within two to three hours after the exam is completed. As with any type of endoscopic procedure, there will also be some degree of drowsiness. Although often improved in an hour or so it will still be necessary for someone to drive you home as it can take up to a full day for all the effects of the sedatives to wear off.
ERCP (endoscopic retrograde cholangio-pancreatography) is a procedure which uses a combination of an endoscope and Xray to examine the bile ducts and pancreatic duct. The endoscope is a flexible tube with a small video camera. With the patient under sedation the endoscope is inserted from the mouth to the upper part of the small intestine. Through the endoscope a catheter is advanced into the ducts and Xray pictures are taken. If abnormalities are found, then instruments can be used to take samples for diagnosis or to perform therapies such as stone removal or placement of stents.
Reasons to Perform ERCP
• Assess cause of jaundice
• Evaluate abnormal liver enzyme levels
• Investigate pain of suspected biliary origin
• Remove stones from the bile duct
• Diagnose tumors of the bile duct or pancreas
• Establish drainage of obstructed bile flow
• Treat sequelae of pancreatitis
• Management of complications from gallbladder surgery
How is ERCP performed?
An ERCP is performed at the hospital by one of our physicians working with a well-trained team of nurses, technicians, and sometimes other physicians. In many cases it can be done as an outpatient. While lying on an Xray table the patient is given strongly sedating medications by vein. The ERCP scope is inserted into the mouth and gently advanced through the esophagus and just past the stomach into the duodenum, the uppermost part of the small intestine. Tiny instruments are then advanced through the scope and into the ducts where contrast material is injected to enable the ducts to be seen on Xray. In many cases sphincterotomy (an incision of the muscle at the lower end of the duct) or other endoscopic therapies are performed. The procedure takes about an hour on average but can vary from thirty minutes to more than 2 hours.
What is a “SpyGlass” procedure?
In some cases it can be difficult to make a definite diagnosis with standard Xray and tissue sampling techniques. Spyglass is an advanced technology which uses a second tiny “daughter scope.” This tiny camera is passed through the standard ERCP scope and then directly into the bile duct. This enables the physician to get a direct view of the inside lining of the duct.
What can I expect after an ERCP?
After the procedure the patient is observed closely in the recovery room while the sedative begins to wear off. Since it takes several hours for full recovery the patient must have a driver to take them home. During the procedure air is inserted into the bowel so the patient may have some bloating, gas, or nausea. Severe pain or fever are not expected and if these occur should prompt notification of our physician. ERCP is an invasive procedure and has about a 10% risk of a complication, similar to many surgical procedures. In some cases the patient is admitted to the hospital after the procedure.
A liver biopsy is a procedure that involves obtaining a small piece of liver tissue, which is then analyzed in the laboratory. Liver biopsy may be recommended to diagnose a problem or determine the severity of liver disease. Looking at liver tissue itself is the best way to determine whether the liver is healthy or what is causing it to be damaged.
Reasons to Perform Liver Biopsy
• Unexplained elevated liver tests
• Large or swollen liver
• Fatty liver
• Hepatitis B or C
• Chronic liver diseases
• Monitoring after liver transplantation
What happens during a liver biopsy?
Liver biopsies are done in the hospital. During the liver biopsy you will lie on your back with your right hand behind your head. The doctor examines the lower right side of your chest and abdomen to find the best area for the biopsy. An ultrasound is often used in this process. The area is then cleaned and numbed with lidocaine. This stings briefly. A tiny cut is then made in your skin, but you should not feel it.
The doctor passes the biopsy needle quickly into and out of the liver through the small cut. You will be asked to hold your breath for five to 10 seconds during the biopsy. Because you will need to cooperate during the exam, you will not be given medications to induce sleep. You may feel pressure, a pulling sensation, a pinch, or a dull pain. Finally, a band-aid is placed over the cut. No stitches are needed. The entire procedure takes about 20 minutes.
What happens after a liver biopsy?
You will lie on your right side for up to two hours, and then be carefully monitored during the next four to six hours. You will stay in bed during this time and a nurse will check your pulse and blood pressure often. You can expect a little soreness at the incision site and possibly some pain in your right shoulder.
Like any procedure, liver biopsy does have some risks, such as puncture of the lung or gallbladder, infection, bleeding, and pain, but these complications are rare. If a problem occurs, you will have to stay in the hospital. If there are no problems, you can go home six hours after the test. You will not be allowed to leave alone. An adult must take you home. You may not drive yourself.
What happens after I go home?
For 72 hours after a liver biopsy you will be instructed to avoid strenuous exercise, sports, or lifting of any objects over 5 pounds. Otherwise, you can return to your normal activities the next day.
You should call your doctor with any concerns, including: severe pain at the biopsy site or shoulder, shortness of breath, chest pain, bleeding from the biopsy site, fever (temperature greater than 100.4º F or 38º C), abdominal pain, weakness, sweating, or heart palpitations.
You should avoid blood thinning medications for several days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after surgery. These medicines decrease blood clotting, which is crucial for healing.
The biopsy report is usually available within a few days to a week after the biopsy. Patients usually have a follow-up appointment to discuss the results of the biopsy and what treatment (if any) is needed.
Percutaneous endoscopic gastrostomy (PEG) feeding tubes were first described in 1980. Early studies typically demonstrated it to be an easy and safe technique when compared with the available alternatives such as open gastrostomy. PEG feeding tubes are increasingly used for long term enteral nutrition. It is used where patients cannot maintain adequate nutrition with oral intake.
Neurological conditions are most commonly associated with such disability and constitute the most common indication for PEG. Its simplicity has led some to concern about use when there is little or no clinical benefit.
Care needs to be taken when looking at studies on use of PEG as there are differences in patient selection which affect for example outcome measures and complications. There are sometimes ethical factors to consider (see below). Several court cases have considered use of PEG feeding in patients who have lost the capacity for self determination.
Reasons to Perform PEG
• swallowing dysfunction
PEG insertion method
- Can be done as an outpatient procedure
- Takes on average less than 20 minutes
- Requires sedation and upper GI endoscopy
- Can be with either ‘push’ or ‘pull’ insertion
- ‘Pull’ insertion more usual and best given with antibiotic prophylaxis
- PEG tubes are made of polyurethane or silicone with a retaining mechanism
- For feeding longer than 1 month a silicone button (flush with the skin) is used retained usually with intragastric balloon
- Can be done by suitably trained and supervised nurse practitioners
- Antibiotic prophylaxis now usually recommended
Benefits of PEG feeding
- Well tolerated (better than nasogastric tubes)
- Improved nutritional status
- Ease of usage over other methods (nasogastric or oral feeding) reported by carers
- Satisfactory use by home carers
- Low incidence of complications
- Reduction in aspiration pneumonia associated with swallowing disorders
- Cost effective relative to alternative methods particularly when reasonably long survival expected
Morbidity and mortality are generally considered to be low with studies reporting major complications between 3% and 8% of patients and minor in around 14%. Mortality from the procedure itself is very low and less than 1%. However other studies report higher and rising complication rates. These often relate to the underlying illnesses with for example higher rates of wound infections in malignant disease and may also reflect a lowered threshold for PEG insertion.
An esophageal pH test measures and records the pH in your esophagus to determine if you have gastroesophageal reflux disease (GERD). The test can also be done to determine the effectiveness of medications or surgical treatment for GERD. A small capsule, about the size of a gel cap, is temporarily attached to the wall of the esophagus during an upper endoscopy. The capsule measures pH levels in the esophagus and transmits readings by radio telecommunications to a receiver (about the size of a pager) worn on your belt or waistband. The capsule will automatically detact after 48 hours and pass through the GI system and out with your stool. The receiver has several buttons on it that you will press to record symptoms of GERD such as heartburn (the nurse will tell you what symptoms to record). You will be asked to maintain a diary to record certain events such as when you start and stop eating and drinking, when you lie down, and when you get back up.
Reasons to Perform ph Bravo Testing
• Frequent heartburn
• Reflux unrelieved by acid blockers
• Chest pain with negative cardiac evaluation
• Atypical reflux symptom: cough, hoarseness, sore throat
• Assessment of severity for consideration of anti-reflux surgery
What happens during esophageal reflux?
A specialized muscle, called the lower esophageal sphincter, is located where the esophagus meets the stomach (see figure). This sphincter opens to allow food and liquid to pass into the stomach, then closes. When the sphincter does not close tightly, food particles, stomach acid and other digestive juices can splash back up into the esophagus. When this happens, the condition is called gastroesophageal reflux. When reflux occurs on a regular basis, it can cause permanent damage to the esophagus. The esophageal pH test measures how often stomach contents reflux into the lower esophagus and how much acid the reflux contains.
How do I prepare for the Bravo esophageal pH test?
Let your physician know if you have a pacemaker or implantable heart defibrillator, a history of bleeding problems, dilated blood vessels, and any other previously known problems with your esophagus.
Seven days before the monitoring period, do not take proton pump inhibitors: omeprazole (Prilosec®), lansoprazole (Prevacid®), rabeprazole (Aciphex®), pantoprazole (Protonix®), esomeprazole (Nexium®)
Two days (48 hours) before the monitoring period, do not take the H2 blockers: ranitidine (Zantac®), cimetidine (Tagamet®), famotidine (Pepcid®), nizatidine (Axid®); or the promotility drug, metoclopramide (Reglan®)
Six hours before the monitoring period, do not take antacids (such as Alka-Seltzer®, Gaviscon®, Maalox®, Milk of Magnesia®, Mylanta®, Phillips®, Riopan®, Tums® or any other brands)
Four to 6 hours before your appointment do not eat or drink
Please note: Occasionally, your doctor may want you to continue taking a certain medication during the monitoring period to determine if it is effective.
Once the test has begun, what do I need to know and do?
Activity: Follow your usual daily routine. Do not reduce or change your activities during the monitoring period. Doing so can make the monitoring results less useful. Note: do not get the receiver wet; it is not waterproof!
Eating: Eat your regular meals at the usual times. If you do not eat during the monitoring period, your stomach will not produce acid as usual, and the test results will not be accurate. Eat at least 2 meals a day. Eat foods that tend to increase your symptoms (without making yourself miserable)! Avoid snacking. Do not suck on hard candy or lozenges and do not chew gum during the monitoring period.
Lying down: Remain upright throughout the day. Do not lie down until you go to bed (unless napping or lying down during the day is part of your daily routine).
Medications: Continue to follow your doctor’s advice regarding medications to avoid during the monitoring period.
Recording symptoms: Press the appropriate button on the receiver when symptoms occur (as discussed with the nurse). Record the time you start and stop eating and drinking (anything other than plain water). Record the time you lie down (even if just resting) and when you get back up. The nurse will explain this.
Unusual symptoms or side effects: If you think you may be experiencing any unusual symptoms or side effects, call your doctor.
IRC is a procedure to treat symptomatic small to medium sized internal hemorrhoids, which are dilated blood vessels in the anal area due to increased pressure from behaviors such as childbirth, prolonged sitting or straining with defecation.
IRC involves the placement of a small handheld probe in the rectum in order to apply pulses of light energy to hemorrhoid tissue. This collapses the veins above the hemorrhoid causing them to shrink and recede and prevents prolapse with the pinpoint scar that is formed. The procedure usually takes only 10-15 minutes.
Complications are extremely infrequent with IRC when compared to standard hemorrhoid surgery and/or other procedures used to treat hemorrhoids. Most people will return to work or usual daily activities on the day of their procedure.
Reasons to Perform IRC
• Hygiene problems
• Anemia (rarely)
Is the procedure painful?
In general, the answer is no. Most people will experience a brief (one second) sensation of warmth or a “pin prick” during treatment, but pain is extremely uncommon. A topical anesthetic is usually applied but oral or intravenous medications are not needed since the procedure is so well tolerated.
How do I prepare for IRC?
All that is required is a single enema to clean the rectum prior to the procedure. There is no special diet or laxative to drink.
Will my hemorrhoids come back?
Most literature supports a 92 % cure rate for hemorrhoids treated by IRC. Although other methods for treating hemorrhoids exist they either are associated with higher complications, less tolerated by patients or have a lower success rate in terms of curing hemorrhoids. Very large hemorrhoids may need surgery for ultimate relief; however, surgery is generally not as well tolerated by patients when compared with IRC.