Gastroenterology Procedures

Gastroesophageal reflux occurs when contents in the stomach flow back into the esophagus because the valve between the stomach and the esophagus, known as the lower esophageal sphincter, does not close properly. What is Gastroesophageal Reflux Disease (GERD)? Gastroesophageal reflux occurs when contents in the stomach flow back into the esophagus. This happens when the valve between the stomach and the esophagus, known as the lower esophageal sphincter, does not close properly. What are the symptoms of Gastroesophageal Reflux Disease? Common symptoms of gastroesophageal reflux disease are heartburn and/or acid regurgitation. Heartburn is a burning sensation felt behind the breast bone that occurs when stomach contents irritate the normal lining of the esophagus. Acid regurgitation is the sensation of stomach fluid coming up through the chest which may reach the mouth. Less common symptoms that may also be associated with gastroesophageal reflux include unexplained chest pain, wheezing, sore throat and cough, among others. What causes Gastroesophageal Reflux Disease? Gastroesophageal reflux disease (GERD) occurs when there is an imbalance between the normal defense mechanisms of the esophagus and offensive factors such as acid and other digestive juices and enzymes in the stomach. Often, the barrier between the stomach and the esophagus is impaired by weakening of the muscle (lower esophageal sphincter) or the presence of a hiatal hernia, where part of the stomach is displaced into the chest. Hiatal hernias, however, are common and not all people with a hiatal hernia have reflux. A major cause of reflux is obesity whereby increased pressure in the abdomen overcomes the barrier between the stomach and the esophagus. Obesity, pregnancy, smoking, excess alcohol use and consumption of a variety of foods such as coffee, citrus drinks, tomato-based products, chocolate, peppermint and fatty foods may also contribute to reflux symptoms. An endoscope is a medical device used by expert physicians to look inside the digestive tract. An upper endoscopy allows the physician to examine the lining of the upper part of the gastrointestinal (GI) tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine). The expert physician controls the movement of the flexible tube using the endoscope handle. How is Gastroesophageal Reflux Disease diagnosed? When a patient experiences common symptoms of gastroesophageal reflux disease, namely heartburn and/or acid regurgitation, additional tests prior to starting treatment are typically unnecessary. If symptoms do not respond to treatment, or if other symptoms such as weight loss, trouble swallowing or internal bleeding are present, additional testing may be necessary. Upper endoscopy is a test in which a small tube with a light at the end is used to examine the esophagus, stomach and duodenum (the first portion of the small intestine). Before this test, you will receive medications to help you relax and lessen any discomfort you may feel. An upper endoscopy allows your doctor to see the lining of the esophagus and detect any evidence of damage due to GERD. A biopsy of tissue may be done using an instrument similar to tweezers. Obtaining a biopsy does not cause pain or discomfort. Another test, known as pH testing, measures acid in the esophagus and can be done by either attaching a small sensor into the esophagus at the time of endoscopy or by placing a thin, flexible probe into the esophagus that will stay there for 24 hours while acid content is being measured. This information is transmitted to a small recorder that you wear on your belt. X-ray testing has no role in the initial evaluation of individuals with symptoms of reflux disease. How is Gastroesophageal Reflux Disease treated? Reflux symptoms sometimes disappear if dietary or lifestyle excesses that cause the symptoms are reduced or eliminated. Avoiding these items may reduce your discomfort: In an upper endoscopy, the physician passes a thin, flexible tube called an endoscope through your mouth and into the esophagus, stomach and duodenum. Propping up the head of the bed at night may be helpful. Should symptoms persist, over-the-counter antacids may decrease discomfort. Antacids, however, only work for a short time and for this reason, they have a limited role in treating reflux disease. Histamine H2 receptor antagonists (such as cimetidine, ranitidine, nizatidine, and famotidine) decrease acid production in the stomach. These medications work well for treating mild reflux symptoms and are quite safe, with few side effects. They are available over the counter at a reduced dose, or at a higher dose when given by prescription by your doctor. Proton pump inhibitors (such as omeprazole, lansoprazole, dexlansoprazole, pantoprazole, esomeprazole, and rabeprazole) are all highly effective in treating reflux symptoms. These medications act by blocking the final step of acid production in the stomach and are typically taken once or twice daily prior to meals. For reflux symptoms that occur frequently, proton pump inhibitors are the most effective medical treatment. These medications typically work well, are safe and have few side effects. There may possibly be an increased risk of certain side effects with high doses or with long-term use (over one year), however. You should discuss this with your doctor if you require long-term use or high doses. Symptoms of gastroesophageal reflux disease sometimes disappear if certain items are eliminated from the diet Prokinetics, or medications that stimulate muscle activity in the stomach and esophagus, are sometimes provided for the treatment of reflux disease. The only available drug in the market is metoclopramide, which has little benefit in the treatment of reflux disease and has some side effects, some of which can be serious. Surgery should be considered in patients with well-documented reflux disease who cannot tolerate medications or continue to have regurgitation as a primary symptom. If symptoms persist despite medical treatment, a comprehensive evaluation should be completed prior to considering surgery. The surgery for treating reflux disease is known as fundoplication. In this procedure, a hiatal hernia, if present, is eliminated and part of the stomach is wrapped around the lower end of the esophagus to strengthen the barrier between the esophagus and the stomach.

During endoscopy, a camera lens and a light source project images onto a video monitor, allowing the physician to see if there is a change in the lining of the esophagus. What is Barrett’s Esophagus? Barrett’s esophagus is a condition in which the lining of the esophagus changes, becoming more like the lining of the small intestine than the esophagus. This occurs in the area where the esophagus is joined to the stomach. It is believed that the main reason that Barrett’s esophagus develops is because of chronic inflammation resulting from Gastroesophageal Reflux Disease (GERD). Barrett’s esophagus is more common in people who have had GERD for a long period of time or who developed it at a young age. It is interesting that the frequency or the intensity of GERD symptoms, such as heartburn, does not affect the likelihood that someone will develop Barrett’s esophagus. Most patients with Barrett’s esophagus will not develop cancer. In some patients, however, a precancerous change in the tissue, called dysplasia, will develop. That precancerous change is more likely to develop into esophageal cancer. At the current time, a diagnosis of Barrett’s esophagus can only be made using endoscopy and detecting a change in the lining of the esophagus that can be confirmed by a biopsy of the tissue. The definitive diagnosis of Barrett’s esophagus requires biopsy confirmation of the change in the lining of the esophagus. Am I at risk for esophageal cancer? There are two main types of esophageal cancer: squamous cell cancer and adenocarcinoma of the esophagus. Squamous cell cancers occur most commonly in individuals who smoke cigarettes, use tobacco products and drink alcohol. In addition, African Americans are also at increased risk of developing this type of cancer. This cancer is also very common in many areas in Asia. The frequency of squamous cell cancer of the esophagus in the United States has remained the same. Another cancer, adenocarcinoma of the esophagus, occurs most commonly in people with GERD. It is also very common in Caucasian males with increased body weight. Adenocarcinoma of the esophagus is increasing in frequency in the United States. Barrett’s Esophagus occurs in the area where the esophagus is joined to the stomach. The most common symptom of GERD is heartburn, a condition that 20 percent of American adults experience at least twice a week. Although these individuals are at increased risk of developing esophageal cancer, the vast majority of them will never develop it. In a few patients with GERD (about 10 to 15 percent of patients), a change in the lining of the esophagus develops near the area where the esophagus and stomach join. When this happens, the condition is called Barrett’s esophagus. Doctors believe that most cases of adenocarcinoma of the esophagus begin in Barrett’s esophagus. How does my doctor test for Barrett’s Esophagus? Your doctor will first perform an imaging procedure of the esophagus using endoscopy to see if there are sufficient changes for Barrett’s esophagus. In an upper endoscopy, the physician passes a thin, flexible tube called an endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope has a camera lens and a light source and projects images onto a video monitor. This allows the physician to see if there is a change in the lining of the esophagus. If your doctor suspects Barrett’s esophagus, a sample of tissue (a biopsy) will be taken to make a definitive diagnosis. Capsule Endoscopy is another test that has been used to examine the esophagus. In capsule endoscopy, the patient swallows a pill-sized video capsule that passes naturally through your digestive tract while transmitting video images to a data recorder worn on your belt. With capsule endoscopy, the physician is not able to take a sample of the tissue (a biopsy). Both of these techniques allow the physician to view the end of the esophagus and determine whether or not the normal lining has changed. Only an upper endoscopy procedure can allow the doctor to take a sample of the tissue from the esophagus to confirm this diagnosis, as well as to look for changes of potential dysplasia that cannot be determined on endoscopic appearance alone. Barrett’s tissue has a different appearance than the normal lining of the esophagus and is visible during endoscopy. An endoscope is a medical device used by expert physicians to look inside the digestive tract. An upper endoscopy allows the physician to examine the lining of the upper part of the gastrointestinal (GI) tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine). The expert physician controls the movement of the flexible tube using the endoscope handle. Taking a sample of the tissue from the esophagus through an endoscope only slightly lengthens the procedure time, causes no discomfort and rarely causes complications. Your doctor can usually tell you the results of your endoscopy after the procedure, but you will have to wait a few days for the biopsy results. Who should be screened for Barrett’s Esophagus? Barrett’s esophagus is twice as common in men as women. It tends to occur in middle-aged Caucasian men who have had heartburn for many years. There is no agreement among experts on who should be screened. Even in patients with heartburn, Barrett’s esophagus is uncommon and esophageal cancer is rare. One recommendation is to screen patients older than 50 years of age who have had significant heartburn or who have required regular use of medications to control heartburn for several years. If that first screening is negative for Barrett’s tissue, there is no need to repeat it. There is a great deal of ongoing research in this area and so recommendations may change. You should check with your doctor on the latest recommendations. How is Barrett’s Esophagus treated? Medicines and/or surgery can effectively control the symptoms of GERD. However, neither medications nor surgery for GERD can reverse the presence of Barrett’s esophagus or eliminate the risk of cancer. There are some treatments available that

It is extremely important that your colon be thoroughly cleaned before your colonoscopy. This will let the doctor see any abnormalities, such as colon polyps, during the procedure. Polyps are small growths in the colon that could later turn into cancer. Cleansing the colon before a colonoscopy is called bowel preparation, or “prep.” It involves taking medication that causes diarrhea, emptying the colon. The medication is taken by mouth, and comes in liquid or tablet form. You will also need to change what you eat during the day or two before the colonoscopy. Most bowel preparations involve drinking some prep liquid at two different times. The best way to cleanse the colon is with a “split-dose” bowel preparation. This involves drinking the first portion of the liquid preparation the evening prior to the colonoscopy, and then drinking the second part of the liquid preparation on the day of the colonoscopy. If your colonoscopy is scheduled to start in the morning, you must wake up early in the morning on the day of the colonoscopy to drink the second part of the prep. This can be an inconvenience for some people, but it gives your doctor the best chance of finding polyps or cancers in your colon. Taking both portions of the bowel preparation the evening prior to the colonoscopy, instead of taking the second portion of the prep on the morning of your colonoscopy, is an alternative option for cleansing the bowel. However, studies have shown that taking at least half of the prep solution on the same day as the colonoscopy provides the best bowel cleansing, which improves your doctors ability to find polyps and cancers in your colon. You should not drink any liquids (not even prep solution) within 2-3 hours of your colonoscopy. It is important that you understand the prep instructions given to you by your doctor, which will provide instructions on when you should drink your bowel prep. What bowel preparations steps are involved before the colonoscopy? Your doctor will prescribe the type of bowel prep that is best for you. You will receive specific instructions. In general, here is what you can expect: Why is bowel prep important? Many patients feel that the bowel prep is the most difficult part of a colonoscopy. It is important that you try your best to fully complete the prep. After taking the entire bowel prep, you should be passing liquid that is watery or yellow and clear enough to see through. Your bowel must be clean so that your doctor can thoroughly examine your colon and not miss precancerous growths called polyps. If your colon is inadequately cleansed, your doctor may recommend repeating a colonoscopy sooner than if your colon had been properly cleansed. What are the types of bowel prep? Several types of bowel prep medications are available. Your physician will recommend which prep you should take. You will need to carefully follow your doctor’s instructions about the exact dose and timing of your prep. Some types of prep may be covered by your medical insurance. You’ll want to find out if you have any out-of-pocket costs. What determines the type of prep I get? Your medical condition is the most important factor in deciding which type of bowel prep is best for you. It is best to share your complete medical history with your doctor. Also, tell your doctor if you are pregnant or breast feeding, or if you have a history of bowel obstruction. Let the doctor know if you have diabetes, high blood pressure, heart, kidney or liver disease, or if you have had any of these diseases in the past. You need to mention any allergies you have to medications to the doctor. If you have had difficulty with a bowel prep in the past, be sure to mention this as well. Other factors in choosing the type of prep are the time of the colonoscopy appointment, individual preferences (taste and amount of medication), and out-of-pocket costs. What if I forget to take the medication when I should, or remember too late to finish the prep? Call your doctor and ask what to do if you are not able to complete the bowel prep as advised. The procedure might need to be canceled and rescheduled. What are the common side effects of bowel prep? You should expect to have multiple loose bowel movements with minimal discomfort while doing the prep. However, some people will have nausea, vomiting, bloating (swelling in the abdomen) or abdominal pain. Serious side effects are uncommon. Your doctor will explain the possible side effects of the prep selected for you.

Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique used to study the ducts of the gallbladder, pancreas and liver. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. The pancreatic duct is the drainage route from the pancreas. What is ERCP? Endoscopic retrograde cholangio-pancreatography, 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. An endoscope is a thin, flexible tube that lets your doctor see inside your digestive tract. During ERCP, your doctor will pass an endoscope through your mouth, esophagus and stomach into the first part of the small intestine. 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. ERCP is sometimes used to make a diagnosis of chronic pancreatitis. 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. ERCP is the most appropriate procedure to remove stones from the bile duct. On this X-ray, there are multiple stones lodged in the bile duct. 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 with you before you undergo the test. A large bile duct stone is impacted at the major duodenal papilla causing obstruction and severe infection of the bile duct. In this case, ERCP is urgently required to relieve the obstruction. 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.

The esophagus is a muscular tube that connects your throat to your stomach. At the lower end of the esophagus, a valve (a special sphincter muscle) remains closed except when food or liquid is swallowed or when you belch or vomit. Esophageal pain, heartburn, and/or difficulty swallowing are often caused by abnormalities in the contractions of the esophageal muscle or abnormalities in the sphincter at the lower end of the esophagus. What is esophageal testing, also called manometry, and why is it performed? Esophageal testing or manometry measures the pressures and the pattern of muscle contractions in your esophagus. Abnormalities in the contractions and strength of the muscle or in the sphincter at the lower end of the esophagus can result in pain, heartburn, and/or difficulty swallowing. Esophageal manometry is the test used to diagnose the conditions that can cause these symptoms. How should I prepare for esophageal testing? An empty stomach allows for the best and safest examination, so do not eat or drink anything for 6 hours before the test. Since many medications can affect esophageal pressure and the natural muscle contractions required for swallowing, be sure to discuss with your healthcare professional each medication you are taking. Your doctor may ask that you temporarily stop taking one or more of these medications before your test. What can I expect during the test? A healthcare professional will apply a cream to numb the inside of your nostrils. Then a thin, flexible, lubricated tube will be passed through your nose and advanced into your stomach while you swallow sips of water. Mild, brief gagging may occur while the tube is passed through the throat. When the tube is in position, you will be sitting upright or lying on your back while the tube is connected to a computer. Once the test begins it is important to breathe slowly and smoothly, remain as quiet as possible and avoid swallowing unless instructed to do so. As the tube is slowly pulled out of your esophagus, the computer measures and records the pressures in different parts of your esophagus. During the test, you may experience some discomfort in your nose and/or throat. The test will take approximately 30 minutes to complete and the results will be sent to your doctor’s office. What can I expect after the test? After the test, you may experience mild sore throat, stuffy nose, or a minor nosebleed; all typically improve within hours. Unless your physician has given you other instructions, you may resume normal meals, activities, and any interrupted medications. What are the possible risks associated with esophageal manometry? As with any medical procedure, there are certain risks. While serious side effects of this procedure are extremely rare, it is possible that you could experience irregular heartbeats, aspiration (when stomach contents flow back into the esophagus and are breathed into the lung), or perforation (a hole in the esophagus). During insertion, the tube may be misdirected into the windpipe before being repositioned. Precautions are taken to prevent such risks, and your physician believes the risks are outweighed by the benefits of this test. What if the tube cannot be passed? In some situations, correct placement of the tube may require passing it through the mouth or passing the tube using endoscopy (a procedure that uses a thin, flexible lighted tube). Your physician will determine the best approach.

Endoscopy of both the upper and lower gastrointestinal tracts is a mainstay of digestive disease treatment plans and health maintenance strategies. Endoscopic procedures already have a remarkable safety record and manufacturers are continually improving the design of endoscopic devices to further ensure patient safety. The Benefits of Endoscopy Endoscopy involves the use of flexible tubes, known as endoscopes, to provide a close-up, color television view of the inside of the digestive tract. Upper endoscopes are passed through the mouth to visualize the esophagus (food pipe), stomach, and duodenum (first portion of the small intestine), while lower endoscopes (colonoscopes) are passed through the rectum to view the colon or large intestine. Other special endoscopes allow physicians to view portions of the pancreas, liver and gallbladder as well. Endoscopy has been a major advance in the treatment of gastrointestinal diseases. For example, the use of endoscopes allows the detection of ulcers, cancers, polyps andsites of internal bleeding. Through endoscopy, tissue samples (biopsies) may be obtained, areas of blockage can be opened, and active bleeding can be stopped. Polyps in the colon can be removed, which has been shown to prevent colon cancer. Endoscopy is easily carried out on an outpatient basis and is very well tolerated by patients. The technique of endoscopy is extremely safe, with very low rates of complications, when performed by a properly trained endoscopist, such as members of the American Society for Gastrointestinal Endoscopy (ASGE). The Characteristics of an Endoscope An endoscope consists of a flexible tube, which is passed into the digestive tract to provide a video image, and a control section, which allows the endoscopist to maneuver the tip of the flexible tube in a precise manner. Within the tube are the electronics necessary to obtain the video image, cables that allow control of the flexible tip, and channels that permit the passage of devices to sample tissue, stop bleeding, or remove polyps. The endoscope is a complex but durable instrument and is safe for use in thousands of procedures. Effectiveness of the Reprocessing Guidelines The dissemination and implementation of the guidelines for endoscope reprocessing (cleaning and disinfecting) outlined here have resulted in a remarkable safety record for endoscopy. Based on medical literature, the Technology Committee of the ASGE estimates that the chance that a serious infection could be transmitted by endoscopy is only about 1 in 1.8 million. Given the multiple benefits of endoscopy, it is no wonder that the number of procedures performed grows each year and that endoscopy is a mainstay of digestive disease treatment plans and health maintenance strategies. Endoscope manufacturers are continually improving the design of endoscopes to ensure patient safety. Quality Assurance and Training Any facility in which gastrointestinal endoscopy is performed must have an effective quality assurance program in place to ensure that endoscopes are reprocessed properly. Quality assurance programs for endoscopy must include the supervision, training, and annual competency review of all staff involved in the process, systems that assure availability of appropriate equipment and supplies at all times, and strict procedures for reporting possible problems. Availability of Reprocessing Guidelines The ASGE guidelines for infection control during gastrointestinal endoscopy provide the latest techniques and step-by-step directions on the proper procedure for cleaning and disinfecting endoscopes. These are distributed to all members of ASGE and are regularly reviewed and updated. They are also easily accessed on the ASGE Web site (www.asge.org) or by calling or writing ASGE. An endoscope is a medical device containing a flexible tube, a light, and a camera. It is used by expert physicians to look inside the digestive tract. Endoscopy allows the physician to examine the lining of the gastrointestinal (GI) tract, which includes the esophagus, stomach, duodenum, colon, and rectum. The physician controls the movement of the flexible tube using the endoscope handle. How the Preparation of an Endoscope for Each Procedure Ensures Patient Safety In all areas of medicine and surgery, complex medical devices are generally not discarded after use in one patient but rather are reused in subsequent patients. This practice is very safe, provided that the devices are properly prepared, or reprocessed, prior to each procedure, so as to eliminate any risk that an infection could be transmitted from one patient to another. Prior to the performance of a procedure, an endoscope must be carefully cleaned and disinfected according to guidelines published by the American Society for Gastrointestinal Endoscopy, which have been endorsed by every major medical association dealing with endoscopy and infection control. The steps involved in cleaning and disinfecting an endoscope are as follows: Mechanical cleaning: The operating channels and external portions of the endoscope are washed thoroughly, wiped with special liquids that contain enzymes, and brushed with special cleaning instruments. Studies have shown that these steps alone can eliminate potentially harmful viruses and other microbes from an endoscope. However, much more is done before the endoscope is considered ready for use. Leakage testing: The endoscope is tested to be sure that there are no leaks in its internal operating channels. This not only ensures peak performance of the endoscope, but also allows immediate detection of internal defects that could be a potential focus of infection within the device. Despite its complex electronics, an entire endoscope can be submersed completely in liquid so that leakage testing can be carried out. Use of chemical disinfectants: Next, the endoscope is soaked continuously for an appropriate time period with one of several approved liquid chemicals that destroy microorganisms that can cause infections in humans, including the AIDS virus, hepatitis viruses, and potentially harmful bacteria. There are a variety of chemical disinfectants used to achieve high-level disinfection. This process eliminates virtually all microbial life except for some inactivate dormant organisms known as spores. However, spores are uncommonly found in endoscopes and, even if present, are not harmful to humans. Although most high-level disinfectants are also sterilants (which kill all spores), this requires a much longer exposure time, and has not been shown to be necessary. The human mouth, small intestine, colon

In the PEG procedure, the doctor places and secures a feeding tube into the stomach. PEG tubes can last for months or years, but if replacement is required, it is a simple procedure for the doctor to remove or replace the tube. What is a PEG? PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. This brochure will give you a basic understanding of the procedure-how it is performed, how it can help, and what side effects you might experience. How is the PEG performed? Your doctor will use a lighted flexible tube called an endoscope to guide the creation of a small opening through the skin of the upper abdomen and directly into the stomach. This procedure allows the doctor to place and secure a feeding tube into the stomach. Patients generally receive an intravenous sedative and local anesthesia, and an antibiotic is given by vein prior to the procedure. Patients can usually go home the day of the procedure or the next day. Who can benefit from a PEG? Patients who have difficulty swallowing, problems with their appetite or an inability to take adequate nutrition through the mouth can benefit from this procedure. In preparation for PEG, an endoscope-a lighted flexible tube manipulated by a handle-guides the creation of a small opening through the skin of the upper abdomen and directly into the stomach. How should I care for the PEG tube? A dressing will be placed on the PEG site following the procedure. This dressing is usually removed after one or two days. After that you should clean the site once a day with diluted soap and water and keep the site dry between cleansings. No special dressing or covering is needed. How are feedings given? Can I still eat and drink? Specialized liquid nutrition, as well as fluids, can be given through the PEG tube. If the PEG tube is placed because of swallowing difficulty (e.g., after a stroke), there will still be restrictions on oral intake. Although a few PEG patients may continue to eat or drink after the procedure, this is a very important issue to discuss with your physician. Are there complications from PEG placement? Complications can occur with the PEG placement. Possible complications include pain at the PEG site, leakage of stomach contents around the tube site and dislodgment or malfunction of the tube. Possible complications include infection of the PEG site, aspiration (inhalation of stomach contents into the lungs), bleeding and perforation (an unwanted hole in the bowel wall). Your doctor can describe symptoms to watch for that could indicate a possible complication. How long do these tubes last? How are they removed? PEG tubes can last for months or years. However, because they can break down or become clogged over extended periods of time, they might need to be replaced. Your doctor can easily remove or replace a tube without sedatives or anesthesia, although your doctor might opt to use sedation and endoscopy in some cases. Your doctor will remove the tube using firm traction and will either insert a new tube or let the opening close if no replacement is needed. PEG sites close quickly once the tube is removed, so accidental dislodgment requires immediate attention.

Capsule endoscopy takes approximately eight hours. Normal daily activities are largely unaffected by capsule endoscopy, unlike many endoscopic procedures that require sedation. When you return to the doctor’s office, the data recorder, worn on your belt during the procedure, is removed so that images of your small bowel can be put on a computer screen for physician review. What is capsule endoscopy? Capsule Endoscopy lets your doctor examine the lining of the middle part of your gastrointestinal tract, which includes the three portions of the small intestine (duodenum, jejunum and ileum). Your doctor will give you a pill-sized video camera for you to swallow. This camera has its own light source and takes pictures of your small intestine as it passes through. These pictures are sent to a small recording device you wear on your body. Your doctor will be able to view these pictures at a later time and might be able to provide you with useful information regarding your small intestine. Why is capsule endoscopy done? Capsule endoscopy helps your doctor evaluate the small intestine. This part of the bowel cannot be reached by traditional upper endoscopy or by colonoscopy. The most common reason for doing capsule endoscopy is to search for a cause of bleeding from the small intestine. It may also be useful for detecting polyps, inflammatory bowel disease (Crohn’s disease), ulcers and tumors of the small intestine. As is the case with most new diagnostic procedures, not all insurance companies are currently reimbursing for this procedure. You may need to check with your own insurance company to ensure that this is a covered benefit. How should I prepare for the procedure? An empty stomach allows for the best and safest examination, so you should have nothing to eat or drink, including water, for approximately twelve hours before the examination. Your doctor will tell you when to start fasting. Tell your doctor in advance about any medications you take including iron, aspirin, bismuth subsalicylate products and other over-the-counter medications. You might need to adjust your usual dose prior to the examination. Discuss any allergies to medications as well as medical conditions, such as swallowing disorders and heart or lung disease. Tell your doctor of the presence of a pacemaker or defibrillator, previous abdominal surgery, or previous history of bowel obstructions, inflammatory bowel disease or adhesions. Your doctor may ask you to do a bowel prep/cleansing prior to the examination. The small intestine can be the site of several gastrointestinal disorders, including bleeding, polyps, inflammatory bowel disease, ulcers, and tumors. Capsule endoscopy allows for examination of the small intestine, which cannot be easily reached by traditional methods of endoscopy. What can I expect during capsule endoscopy? Your doctor will prepare you for the examination by applying a sensor device to your abdomen with adhesive sleeves (similar to tape). The pill-sized capsule endoscope is swallowed and passes naturally through your digestive tract while transmitting video images to a data recorder worn on your belt for approximately eight hours. At the end of the procedure you will return to the office and the data recorder is removed so that images of your small bowel can be put on a computer screen for physician review. Most patients consider the test comfortable. The capsule endoscope is about the size of a large pill. After ingesting the capsule and until it is excreted, you should not be near an MRI device or schedule an MRI examination. What happens after capsule endoscopy? You will be able to drink clear liquids after two hours and eat a light meal after four hours following the capsule ingestion, unless your doctor instructs you otherwise. You will have to avoid vigorous physical activity such as running or jumping during the study. Your doctor generally can tell you the test results within the week following the procedure; however, the results of some tests might take longer. What are the possible complications of capsule endoscopy? Although complications can occur, they are generally rare when doctors who are specially trained and experienced in this procedure perform the test. There is a potential for the capsule to be stuck at a narrowed spot in the digestive tract resulting in bowel obstruction. This usually relates to a stricture (narrowing) of the digestive tract from inflammation, prior surgery or tumor. It is important to recognize obstruction early. Signs of obstruction include unusual bloating, abdominal pain, nausea or vomiting. You should call your doctor immediately for any such concerns. Also, if you develop a fever after the test, have trouble swallowing or experience chest pain, tell your doctor immediately. Be careful not to prematurely disconnect the system as this may result in loss of pictures being sent to your recording device.

The doctor may spray a local anesthetic into the throat and give you sedatives to help you relax before passing the endoscope through your mouth and into the esophagus. Then your doctor will determine whether to use a dilating balloon or plastic dilators to stretch your esophagus. What is Esophageal Dilation? Esophageal dilation is a procedure that allows your doctor to dilate, or stretch, a narrowed area of your esophagus [swallowing tube]. Doctors can use various techniques for this procedure. Your doctor might perform the procedure as part of a sedated endoscopy. Alternatively, your doctor might apply a local anesthetic spray to the back of your throat and then pass a weighted dilator through your mouth and into your esophagus. Why is esophageal dilation done? The most common cause of narrowing of the esophagus, or stricture, is scarring of the esophagus from reflux of stomach acid occurring in patients with heartburn. Patients with a narrowed portion of the esophagus often have trouble swallowing; food feels like it is “stuck” in the chest region, causing discomfort or pain. Less common causes of esophageal narrowing are webs or rings (which are thin layers of excess tissue), cancer of the esophagus, scarring after radiation treatment or a disorder of the way the esophagus moves [motility disorder]. An endoscope is a medical device used by expert physicians to look inside the digestive tract. How should I prepare for the procedure? An empty stomach allows for the best and safest examination, so you should have nothing to drink, including water, for at least six hours before the examination. Your doctor will tell you when to start fasting. Tell your doctor in advance about any medications you take, particularly aspirin products or anticoagulants (blood thinners such as warfarin or heparin), or clopidogrel. Most medications can be continued as usual, but you might need to adjust your usual dose before the examination. Your doctor will give you specific guidance. Tell your doctor if you have any allergies to medications as well as medical conditions such as heart or lung disease. Also, tell your doctor if you require antibiotics prior to dental procedures, because you might need antibiotics prior to esophageal dilation as well. What can I expect during esophageal dilation? Your doctor might perform esophageal dilation with sedation along with an upper endoscopy. Your doctor may spray your throat with a local anesthetic spray, and then give you sedatives to help you relax. Your doctor then will pass the endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope does not interfere with your breathing. At this point your doctor will determine whether to use a dilating balloon or plastic dilators over a guiding wire to stretch your esophagus. You might experience mild pressure in the back of your throat or in your chest during the procedure. Alternatively, your doctor might start by spraying your throat with a local anesthetic. Your doctor will then pass a tapered dilating instrument through your mouth and guide it into the esophagus. Your doctor may also use x-rays during the esophageal dilation procedure. These endoscopic images show views of the esophagus with findings of severe gastroesophageal reflux disease, a common cause of esophageal narrowing that may be treated with dilation. What can I expect after esophageal dilation? After the dilation is done, you will probably be observed for a short period of time and then allowed to return to your normal activities. You may resume drinking when the anesthetic no longer causes numbness to your throat, unless your doctor instructs you otherwise. Most patients experience no symptoms after this procedure and can resume eating the next day, but you might experience a mild sore throat for the remainder of the day. Your doctor will advise you on eating and drinking. If you received sedatives, you probably will be monitored in a recovery area until you are ready to leave. You will not be allowed to drive after the procedure even though you might not feel tired. You should arrange for someone to accompany you home, because the sedatives might affect your judgment and reflexes for the rest of the day. What are the potential complications of esophageal dilation? Although complications can occur even when the procedure is performed correctly, they are rare when performed by doctors who are specially trained. A perforation, or a hole of the esophagus lining, occurs in a small percentage of cases and may require surgery. A tear of the esophagus lining may occur and bleeding may result. There are also possible risks of side effects from sedatives. It is important to recognize early signs of possible complications. If you have chest pain, fever, trouble breathing, difficulty swallowing, bleeding or black bowel movements after the test, tell your doctor immediately. Will repeat dilations be necessary? Depending on the degree and cause of narrowing of your esophagus, it is common to require repeat dilations. This allows the dilation to be performed gradually and decreases the risk of complications. Once the stricture, or narrowed esophagus, is completely dilated, repeat dilations may not be required. If the stricture was due to acid reflux, acid-suppressing medicines can decrease the risk of stricture recurrence. Your doctor will advise you on this.

Flexible sigmoidoscopy enables the doctor to carefully examine the rectum and sigmoid colon, and to take tissue from the lining of the colon for a biopsy. 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 is important to follow your doctor’s instructions carefully. If polyps are found during the procedure, the doctor may take a tissue sample for biopsy. Some polyps are totally harmless. Others, though benign, may have a small risk of becoming cancerous. 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, anti-coagulants (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 lower part of the colon. As your doctor withdraws the instrument, your doctor will carefully examine the lining of the intestine. Flexible sigmoidoscopy is almost always done on an outpatient basis. The procedure typically takes less than 15 minutes. What if the flexible sigmoidoscopy finds something abnormal? If your doctor sees an area that needs further evaluation, he or she might take a biopsy (tissue sample) to be analyzed. Obtaining a biopsy does not cause 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 other 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. Flexible sigmoidoscopy enables the doctor to carefully examine the rectum and sigmoid colon, and to take tissue from the lining of the colon for a biopsy. 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.