Procedures

UPPER GI ENDOSCOPY (UGIE) or ESOPHAGOGASTRODUODENOSCOPY (EGD)

An upper GI endoscopy looks at the upper part of the gastrointestinal tract including the esophagus, the stomach and the first part of the small intestine, called the duodenum. The esophagus is a hollow tube that carries the food to the stomach and small intestine for digestion.

The gastroenterologist uses an endoscope, a long, thin, flexible tube with a light and camera at the end to help guide the scope throughout the duration of the procedure. The camera on the end helps the physician both guide the endoscope throughout the length of the upper GI tract, and take pictures.

Gastroenterologists commonly perform this procedure as a way to evaluate and diagnose various problems, such as chronic heartburn (acid reflux), difficulty swallowing, stomach or abdominal pain, bleeding, ulcers and tumors.

The patient remains comfortable during the procedure with the help of local and/or intravenous sedation. The drug enables the patient to remain awake and comfortable throughout the procedure.

Patient preparation for the procedure
The procedure normally takes 2-5 minutes. Once the medication dissipates, the patient may feel soreness in the back of the throat. (if i.v. sedation given) the patient waits in the recovery room while the anesthetic wears off. Due to the lingering effects from the sedation, the patient cannot drive or work for the remainder of the day, and therefore must have a ride home.

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ENDOSCOPIC VARICEAL LIGATION (EVL)

Endoscopic Variceal Ligation (EVL) is a procedure in which an enlarged vein or a varix (the plural is varices) in the esophagus is tied off or ligated by a rubber band delivered via an endoscope. It is also called rubber band ligation.
Esophageal varices develop as a complication of a sustained increase in blood pressure in the liver (portal hypertension), most commonly found in cirrhosis. The major problem with Esophageal Varices is the risk of bleeding.
EVL is used control or stop bleeding or to prevent re-bleeding. The success of the procedure is in the range of 90%. The procedure is performed as in regular EGD. An accompanying device is inserted into the endoscope channel which allows the delivery of ligating rubber bands to the engorged varix. Number of banding depends on the varices seen and may average 4-6.
Complications associated with EVL include additional bleeding due to tearing additional varices, ulceration of the lining over the varices, perforation or tear of the esophagus and aspiration of blood or gastric juice into the lungs.Patient preparation for the procedure
Preparation for EVL is fasting for 4-6 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.
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Video

ENDOSCOPIC SCLEROTHERAPY (EST)

Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. Sclerosant injected directly into the vein causes blood clots to form and stops the bleeding, while sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel.
Sclerotherapy for esophageal varices is performed with the patient awake but sedated. During the procedure, an endoscope is passed through the patient’s mouth to the esophagus to allow the surgeon to view the inside. The branches of the blood vessels at or just above where the stomach and esophagus come together, the usual site of variceal bleeding, are located.
After the bleeding vein is identified, a long, flexible sclerotherapy needle is passed through the endoscope. When the tip of the needle’s sheath is in place, the needle is advanced, and the sclerosant is injected into the vein or the surrounding area. The most commonly used sclerosants are ethanolamine and sodium tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as many times as necessary to eradicate all distended veins.
Minor complications, which cause discomfort but do not require active treatment or prolonged hospitalization, include transient chest pain, difficulty swallowing, and fever, which usually go away after a few days. Some patients may have allergic reactions to the sclerosant solution. Infection occurs in up to 50% of cases. In 2-10% of patients, the esophagus tightens, but this complication can usually be treated with dilatation. More serious complications may occur in 10-15% of patients. These include perforation or bleeding of the esophagus and lung problems, such as aspiration pneumonia. Long-term sclerotherapy can also damage the esophagus and increase the patient’s risk of developing cancer.
Sclerotherapy for esophageal varices has a 20-40% incidence of complications and a 1–2% mortality rate. The procedure controls acute bleeding in about 90% of patients, but it may have to be repeated within the first 48 hours to achieve this success rate.Patient preparation for the procedure
Preparation for EST is fasting for 4-6 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.

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PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen (laparotomy). It is used in patients who will be unable to take in food by mouth for a prolonged period of time. A gastrostomy, or surgical opening into the stomach, is made through the skin using an a flexible, lighted instrument (endoscope) passed orally into the stomach to assist with the placement of the tube and secure it in place. The purpose of a percutaneous endoscopic gastronomy is to feed those patients who cannot swallow food. Irrespective of the age of the patient or their medical condition, the purpose of percutaneous endoscopic gastronomy is to provide fluids and nutrition directly into the stomach.
PEG is performed in a hospital or outpatient surgical facility. It is not necessary to perform a percutaneous endoscopic gastronomy in an operating room. Local anesthesia (usually lidocaine or another spray) is used to anesthetize the throat. An endoscope (a flexible tube with a camera and a light on the end) is passed through the mouth, throat and esophagus into the stomach. The physician then makes a small incision (cut) in the skin of the abdomen over the stomach and pushes a needle through the skin and into the stomach. The tube for feeding then is pushed through the needle and into the stomach. The tube then is sutured (tied) in place to the skin.
Possible complications include infection of the puncture site (as in any kind of surgery,) dislodgement of the tube with leakage of the liquid diet that is fed through the tube into the abdomen, and clogging of the tube.
Percutaneous endoscopic gastronomy takes less time, carries less risk and costs less than a surgical gastrostomy which requires opening the abdomen. Percutaneous endoscopic gastronomy is a commonly-performed so there are many physicians with experience in performing the procedure. When feasible, percutaneous endoscopic gastronomy is preferable to a surgical gastrostomy.Patient preparation for the procedure
Preparation for EVL is fasting for 4-6 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.

ESOPHAGEAL DIALATATION

An upper gastrointestinal (GI) endoscopy is a procedure to look at the inside of the oesophagus (gullet), stomach and duodenum using a flexible telescope. This procedure is sometimes known as a gastroscopy. A dilatation involves stretching the narrowed area. This is done either using ballon dilator, plastic graduated dilators (Gillard Savory dialators) or Bougie dilators.
If appropriate, the endoscopist may offer you a sedative to help you relax. An upper GI endoscopy usually takes about a quarter of an hour. The procedure involves placing a flexible telescope (endoscope) into the back of your throat. From here the endoscope will pass on into your duodenum. The endoscopist will be able to look for problems in these organs. They will be able to perform biopsies and take photographs to help make the diagnosis. The endoscopist can perform a dilatation using a guidewire and dilators or a balloon dilator.
Complications that can happen include Allergic reaction, Breathing difficulties or heart irregularities, Making a hole in the oesophagus, stomach or duodenum at the narrowing, damage to teeth or bridgework, Bleeding, Incomplete procedure etc.
If you were given intravenous sedation, you will normally recover in about an hour. A member of the team will tell you what was found during the endoscopy and will discuss with you any treatment or follow-up you need. You should be able to go back to work one to two days after the endoscopy. An upper GI endoscopy and dilatation is usually a safe and effective way of finding out if you have a problem with the upper part of your digestive system and treating your symptoms.Patient preparation for the procedure
Preparation for EVL is fasting for 4-6 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.

ENDOSCOPIC SEMS (SELF EXPANDABLE METALLIC STENT) STENTING

A self-expandable metallic stent (or SEMS) is a metallic tube, or stent, used in order to hold open a structure in the gastrointestinal tract in order to allow the passage of food, chyme, stool, or other secretions required for digestion. SEMS are inserted by endoscopy, wherein a fibre optic camera is inserted either through the mouth or retrograde through the colon, in order to reach an area of narrowing. As such, it is termed an endoprosthesis. SEMS can also be inserted using fluoroscopy where an X-ray image is used to guide insertion, or used as an adjunct to endoscopy.
The vast majority of SEMS are used to alleviate symptoms caused by cancers of the gastrointestinal tract that obstruct the interior of the tube-like (or luminal) structures of the bowel — namely the esophagus, duodenum, common bile duct and colon. SEMS are designed to be permanent and, as a result, are often used when the cancer is at an advanced stage and cannot be removed by surgery.Patient preparation for the procedure
Preparation for EVL is fasting for 4-6 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.

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GLUE INJECTION IN GASTRIC VARICES

Gastric varices are enlarged veins found in the stomach. They also occur in portal hypertension. . While gastric varices bleed less frequently than esophageal varices, the severity of bleeding and associated mortality is greater. Cyanoacrylate glue is a liquid substance with the consistency of water that transforms into a solid state when added to a physiological medium such as blood. When instilled into a varix using the standard method of intravariceal injection, the glue undergoes an instantaneous polymerization reaction and hardens to a rock hard substance, thereby plugging the lumen of the varix. This enables rapid hemostasis of active bleeding and prevents rebleeding.
A therapeutic gastroscope with a large working channel is used for injection. Variceal injection is performed with a 23-gauge disposable sclerotherapy needle. The varix is punctured under direct visualization and approximately 1cc of the glue is injected intravariceally. After injection, the patency of the varix is assessed with blunt catheter palpation and additional glue injected until the varices are obliterated.
Numerous studies from around the world with over 1,000 treated patients have reported control of active variceal bleeding in 93-100% of patients with rates of recurrent bleeding around 10%.
Cyanoacrylate compounds are routinely used in different medical and surgical subspecialties for embolization of aneurysms, arteriovenous malformations and fistulae, and as a wound or tissue adhesive. The safety profile of cyanoacrylate glue for varix obliteration is excellent. A minority of patients develop transient fever and pain after injection. There have been rare case reports of complications related to embolization, which include cerebral stroke and pulmonary embolism. Visceral fistulas have also been reported, probably due to misguided injections.
Prophylactically treat patients with varices >1 cm with either red signs or advanced liver disease (Child B or C). The one-year risk of bleeding in a Child C cirrhotic with red marks on a large fundal varix is estimated at 65%.
Patient preparation for the procedurePreparation for Glue Injection is fasting for 6-8 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.

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HAEMOCLIP APPLICATION IN GI BLEED

  • Haemoclips are mechanical devices used to approximate two sides of a vessel to immediately, definitively, and securely occlude and arrest bleeding. On opening, the haemoclip is typically 11–12 mm wide from jaw to jaw.
  • Haemoclips are best deployed enface rather than tangentially. Haemoclip need to be placed at the correct angle and precise spot. Missing a target, even slightly, can render a haemoclip ineffective
  • At least two haemoclips are generally placed to clamp an actively bleeding artery in an ulcer. Haemoclips are relatively inefficacious for arteries that are larger than 2 mm wide. Haemoclips generally fall off 10–14 days after deployment—after the lesion has partly healed and when the lesion is unlikely to rebleed
  • The placement of these clips rarely produces complications other than failed efficacy. Haemoclips are less successful for the treatment of fibrotic lesions such as chronic ulcers
  • Hemoclips and thermocoagulation or electrocoagulations are equally efficacious in achieving long term haemostasis.

Patient preparation for the procedure
Preparation for haemocliping is fasting for 4-6 hours similar to performing a regular esophagogastroduodenoscopy (EGD). An intravenous line is placed to deliver sedation or other medications.

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FLEXIBLE SIGMOIDOSCOPY

“Sigmoidoscopy” is a procedure that allows the physician to examine the inside of the sigmoid colon. The colon, also known as the large bowel, is the last portion of your gastrointestinal tract. The sigmoid is the section of the colon closest to the rectum and anus. The colon, a hollow tube, measures four feet in length, 20 inches of which is the sigmoid colon. The function of the sigmoid colon, like the remainder of the colon is to store food byproducts until its elimination.
A colonoscope is used to perform this procedure. A colonoscope is a long, thin, flexible tube with a miniature video camera and light at its end. The gastroenterologist will infuse a little bit of air into the colon as he or she inserts the scope. The camera on the end helps the physician both guide the colonoscope throughout the length of the sigmoid colon and take pictures of the colon.
Flexible sigmoidoscopies are most commonly performed to evaluate problems such as blood loss, pain and changes in bowel habits. The patient will remain awake throughout the procedure. The patient may elect to watch the procedure on a television monitor above the bed. Air introduced to the colon during the procedure, may cause feelings of fullness and cramping, but acute pain is very rare. The procedure normally takes 10-15 minutes. Afterwards, the patient may drive home and resume normal activities. .

Patient preparation for the procedure
Preparation for Sigmoidoscopy requires an application of Proctoclyss enema around 1 hr prior to the procedure

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COLONOSCOPY

“The colon, also known as the large bowel, is the last portion of your gastrointestinal tract. It starts at the cecum, which is connected to your small intestine, and ends at your rectum. The colon is a hollow tube, measuring four feet in length on average, and its main function is to store food byproducts prior to their elimination. A colonoscope is a long, thin, flexible tube with a miniature video camera and light at its end. The gastroenterologist will put a little bit of air into the colon as he/she inserts the scope. The camera on the end helps the physician both guide the colonoscope throughout the length of the colon and take pictures of the colon.
This procedure also allows other instruments to be passed through the colonoscope. For example, forceps may be used to painlessly remove a suspicious looking growth for analysis. During the colonoscopy, the gastroenterologist can remove polyps with a procedure called “polypectomy”. In this way, a colonoscopy may help to avoid surgery or better determine what kind of surgery needs to be performed. Colonoscopies are most commonly performed in colorectal cancer screening and prevention. It is also increasingly used to evaluate problems such as blood loss, abdominal pain and changes in bowel habits. Patients remain comfortable throughout the procedure with the help of intravenous sedation. The drugs enable the patients to remain awake but comfortable throughout. The air introduced into the colon may cause cramping and feeling of fullness.
A colonoscopy typically takes about 30 minutes. Afterwards, the patient is moved to a recovery room while the anesthetic wears off. Patients should not drive or work for the remainder of the day, and, must, therefore have a ride home. All feelings of bloating and cramping should fade within 24 hours.

Patient preparation for the procedure
Preparation for Colonoscopy is a liquid diet for 24 hrs and followed by a Bowel preparation using Polyethylene Glycol(PEG) (Available as PEGLEC, COLOCLEAN, COLOWASH etc). Around 150 g of PEG is mixed into 2 Liters of Water to be taken in 2hrs. This is to be followed up by another 2 liters of fluid intake.
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POLYPECTOMY

The removal of a polyp is called a polypectomy and can be achieved by using a variety of instruments through channels of the endoscope.
If a polyp is found on the left side of your bowel, there is a higher chance of you having polyps on the right side of your bowel. As a flexible sigmoidoscopy does not reach the right side of your bowel, you may be asked to return on another day for a full colonoscopy, if a polyp is found. A colonoscopy allows the entire large bowel to be examined and any further polyps to be removed.

Patient preparation for the procedure

Preparation for Polypectomy is sae as in Colonoscopy is a liquid diet for 24 hrs and followed by a Bowel preparation using Polyethylene Glycol(PEG) (Available as PEGLEC, COLOCLEAN, COLOWASH etc). Around 150 g of PEG is mixed into 2 Liters of Water to be taken in 2hrs. This is to be followed up by another 2 liters of fluid intake.

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ERCP

During an endoscopic retrograde cholangiopancreatography, or ERCP, the gastroenterologist uses an endoscope, a long, thin, flexible tube with a light and camera at the end, through the esophagus, the stomach, and the first part of the small intestine, called the duodenum. Once the endoscope reaches the papilla, which is the opening of the common bile duct, the physician injects dye through these ducts, enabling x-rays to be taken.
Bile, a liquid that helps digest fat, is produced by the liver and carried to the gallbladder, where it is stored, through a series of tubes called ducts. The main duct from the pancreas joins the common bile duct and allows pancreatic juices to help with further digestion in the duodenum. After eating, both bile and pancreatic juices flow through the papilla and into the duodenum, where they mix with food and play a major role in digestion.
A physician may recommend an ERCP if the patient is experiencing abdominal pain or develops jaundice (yellowing of the eyes). This procedure is helpful in identifying gallstones, tumors or scar tissue obstructing the bile duct. After using x-ray imaging to discover the nature of the obstruction, the endoscopist is usually able to clear the ducts. This is done by cutting open the papilla and then either pushing or pulling the stone out, or by inserting a device, such as an inflatable balloon, to help stretch scar tissue.
The patient remains comfortable during the procedure with the help of IV sedation. The drugs will enable the patient to remain semi-conscious throughout the procedure, but usually prevent the patient from remembering the experience.

The procedure normally takes about 40 minutes. Afterwards, the patient waits in the recovery room while the anesthetic wears off. Soreness in the back of the throat is not uncommon once the anesthesia dissipates. Due to the lingering effects from the sedation, the patient cannot drive or work for the remainder of the day, and therefore must have a ride home.

EUS

Endoscopic ultrasonography, or EUS, is used to examine the upper or lower part of the gastrointestinal tract. The upper GI tract includes the esophagus, stomach and first part of the small intestine, called the duodenum; the lower GI tract includes the colon, anus and rectum. EUS can also be used to examine other internal organs, such as the pancreas and gallbladder.
EUS involves the use of an endoscope or colonoscope, long, thin, flexible tubes with a light and camera at the end, to help guide the scope throughout the duration of the procedure. However, these scopes are different than those used in colonscopy and ERCP: they emit sound waves that create visual images of the digestive tract that a normal endoscope cannot detect.
EUS is used to aid in the diagnosis and treatment of various GI disorders. It may also be used to assess the nature of a tumor that may have been detected during a prior endoscopic procedure or CT scan. In conjunction with examination of a tissue sample obtained using a procedure called a “fine needle aspiration,” EUS can help diagnose diseases of the pancreas, gallbladder and bile duct The patient will remain comfortable during the procedure with the help of intravenous sedation. The drug will enable the patient to remain semi-conscious but comfortable throughout the procedure.

The procedure normally lasts about 45 minutes. Afterwards, the patient will wait in the recovery room while the anesthetic wears off. Once the medication dissipates, the patient may feel soreness in the back of the throat or some abdominal cramping and fullness depending on which type of scope was used during the procedure. Due to the lingering effects from the sedation, the patient cannot drive or work for the remainder of the day, and therefore must have a ride home.

Liver Biopsy

A liver biopsy is used to determine the presence of inflammation, fibrosis and to help diagnose various liver diseases.

During this procedure, the patient is fully conscious. A physician numbs the area around the liver using a local anesthetic (similar to that used by a dentist), and then using a long, narrow needle obtains a tiny piece of liver tissue.

After the procedure, the patient is kept in recovery for four hours for monitoring. If the patient experiences any pain or discomfort, a nurse can administer pain medications. Since these medications have a lingering effect, the patient will not be able to drive or work for the remainder of the day, and therefore must have a ride home.

Capsule Endoscopy

Capsule endoscopy allows examination of the entire small intestine by ingesting a vitamin-pill sized video capsule with its own camera and light source. During the eight-hour exam, the patient is free to move about. While the video capsule travels through the body, it sends images to a data recorder on a waist belt worn by the patient. Afterwards the doctor will view the images on a video monitor.

Capsule endoscopy helps determine the cause for recurrent or persistent symptoms such as abdominal pain, diarrhea, bleeding or anemia undiagnosed by other techniques including endoscopy, colonoscopy and x-rays. In certain chronic gastrointestinal diseases, this method can also help to evaluate the extent to which the small intestine is involved or monitor the effect of therapy.

Double Balloon Enteroscopy

Double balloon enteroscopy is a new method of examining the small intestine that previous techniques could not reach. Double balloon enteroscopy employs a high- resolution video endoscope with latex balloons attached at the tips that can be inflated and deflated with air from a pressure-controlled pump system.

A sequence of inflation/deflation cycles allow the scope to be advanced further into the small intestine. This technique can be performed using either an oral or anal route.

Indications for double balloon enteroscopy include obscure gastrointestinal bleeding, Crohn’s disease, unexplained diarrhea, but also pancreaticobiliary disease in patients with altered anatomy such as Roux-en-Y, access to the excluded stomach after bariatric surgery and incomplete colonoscopy.

       

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