ENDOSCOPIC PROCEDURES

Summary

Endoscopes and enteroscopes allow your doctor to get a good view of the internal organs without opening you up. These procedures are done for diagnosis and treatment of various problems and conditions affecting the gastrointestinal tract and digestive system. Using only a thin tube-like instrument fitted with a light and camera, known as an endoscope, the inside of the digestive tract can be examined by your physician through the mouth or anus. Endoscopes and enteroscopes also have channels that allow special surgical tools to be passed down them. This equipment can be used to treat whatever is bleeding, to take biopsies, or to mark the location of a problem with a tattoo to aid a surgeon in locating it later.

The most common endoscopic procedures are gastroscopies and colonoscopies. A gastroscopy is done by inserting an endoscope through the mouth down the oesophagus, stomach and small intestine. A colonoscopy, on the other hand, is done by inserting an endoscopy in the anus through to the rectum and large intestine. In rarer cases, a capsule endoscopy, double-balloon enteroscopy, x-ray studies such as enteroclysis and CT enterography or intraoperative enteroscopy may be needed.

Reasons for endoscopic procedures

  • Diagnosis and screening of the gastrointestinal tract
  • Placement of a stent in the gastrointestinal tract
  • Dilatation of strictures in the gastrointestinal tract
  • Placement of feeding tubes (PEG)
  • Biopsy of benign and malignant lesions
  • Endoscopy for staging and palliation of Upper Gastrointestinal malignancy
  • To diagnose and treat small bowel bleeding

Types of endoscopic procedures

1Gastroscopy
An endoscope is inserted through the mouth down the oesophagus, stomach and small intestine. A gastroscopy is done with the patient lying on his or her side. A numbing spray is given to numb your throat before starting. The endoscopic tube-like instrument will be inserted into your mouth, and you will be asked to swallow to allow it to pass down your throat.

Once the tool has been passed down to your stomach, your doctor may want to use some air to aid him in the examination. This is done to get a better look at your insides. The gas may make you feel full and bloated. As the instrument passes down your throat and through your stomach, you may feel some mild cramping or a tugging sensation.

The entire procedure should only last 20 minutes but if any abnormalities like ulcers, blockages, growths and tumours, are found they may need to be removed or biopsied at this time. Once the gastroscopy is finished, you will be asked to wait in the room next door until the sedative has worn off and you have passed most of the air that was introduced during the examination.

Instructions for patients undergoing gastroscopy

When undergoing a gastroscopy, your physician will be looking to investigate the upper gastrointestinal tract, including the oesophagus, stomach and small intestine, using a long flexible tube known as an endoscope.

Before this procedure, you will need to prepare by ensuring your stomach is clean and empty for your doctor to make an accurate diagnosis. You will need to stop eating 6 hours before your procedure. Since only the upper part of the digestive system is being examined, there is no need for a laxative to empty your bowels.

Because many patients are apprehensive, Dormicum® and Pethidine® may be given to calm you for the gastroscopy. While this won’t put you to sleep, it will sedate you. (See “Conscious Sedation: What you need to know”). Be sure to tell your physician if you have had any previous problems or reactions to any of these drugs before they are given.
2Colonoscopy
An endoscopy inserted through the anus through to the rectum and large intestine. This is known as a colonoscopy. The examination is carried out with the patient lying on his left side on the examining table. A lubricant is applied around the anus, and the colonoscope is passed into the rectum. It is necessary for the doctor to use some air to aid him in the examination. This may cause you to feel distended and full. If you have the urge to pass this air by rectum, it is permissible to do so unless the doctor requests otherwise. The large intestine may be twisted and tortuous. As the instrument passes around some of these turns, it may cause a cramping or tugging sensation. This is usually relieved as the instrument is passed around a bend and straightened.

The examination may take anything from 15 – 60 minutes. If polyps are to be removed, it may take longer. A nurse is present to help the doctor and to assist in monitoring the patient’s condition. After the examination is completed, you will be asked to rest for an hour or two in an adjoining room until the effects of the medications have subsided and until you have passed much of the air, which was introduced during the examination. You may need to stay in hospital after the exam based on the findings or if any problems occurred.

Polyps are removed by first locating them with the colonoscope and then placing a wire loop around the base of the polyp. An electric current is used to cut the polyp off at its stalk or base. You will not feel this current.

The specimen is usually retrieved by applying suction to the instrument and catching the polyp on the tip of the instrument. Polyp and instrument are then both withdrawn. If there is more than one polyp, it is necessary to re-insert the instrument to remove the additional polyp.

Instructions for patients undergoing colonoscopy

Your physician has asked that the inside of your colon (large intestine) be inspected by using a long flexible tube (colonoscope) so that he can know what disease, if any, is present.

Proper preparation is extremely important for this examination. The large intestine must be clean and empty for the doctor to make an adequate examination. The preparation requires the use of a clear liquid diet for one day before the examination.

This is achieved by using a laxative known as picoprep; other preparations may be used by your doctor.

Because many patients are apprehensive, Dormicum® and Pethidine® are often given intravenously at the time of the examination to relax the patient. Ask him/her about this. These drugs will not put you to sleep but may cause some lightheadedness. (See "Conscious Sedation: What you need to know") If you have had an unfavourable reaction to any of these drugs, you should tell the examiner before the injection is given.
3X-ray studies
X-ray studies are sometimes used in people with bleeding because 20-25% of small bowel bleeding is caused by abnormalities in the intestinal wall. Since this is often the case, specialized x-ray studies are used to look for abnormalities such as tumours. There are three x-ray tests commonly used in the evaluation of the small bowel – small bowel follow-through, enteroclysis, and CT enterography.

The small bowel follow-through test is a series of abdominal x-rays that are taken at different times after a patient drinks a white, chalky fluid called barium. This white liquid shows up on x-rays and helps your doctor examine the lining of the intestine for any problems. This test is safe and easy to tolerate, and is good for large abnormalities, but can miss many smaller ones.

A second x-ray test, called the enteroclysis study, is similar to the small bowel follow-through in that it uses barium (the chalky white liquid) to visualize the inner wall of the small bowel. The enteroclysis study is more invasive though because it requires a small tube called a catheter to be slowly moved from the nose down the oesophagus, through the stomach, and into the small bowel. Through this catheter, the barium and air can be inserted into the small bowel. The advantage of this study is that pictures from enteroclysis have better resolution, so abnormalities missed by the small bowel follow-through test may be detected easier. A disadvantage of the enteroclysis study is that it can be an uncomfortable examination due to the presence of the catheter and the use of air to distend the small bowel while taking pictures. In some cases, a CT scan is used instead of regular x-rays. This allows for even more detail to be seen.

The third test is known as a CT enterography. A CT enterography is done the same way a normal CT scan is done. The patient drinks an oral contrast solution (often diluted barium), while also receiving intravenous (IV) contrast. Then numerous, very detailed images are taken to spot abnormalities and problems. A CT enterography differs from a standard CT scan in that the type of contrast that the patient drinks are designed to allow for a more detailed inspection of the lining of the small bowel.

While none of these tests is perfect at finding abnormalities, the advantage of these tests is that they can sometimes find bleeding sources that are out of reach of a standard enteroscope. The major limitations of these studies are that they cannot detect abnormal arteries and veins (AVMs), and if an abnormality is seen, there is no way to apply immediate treatment to stop the bleeding, to take biopsies to confirm a diagnosis, or to mark the location of the lesion with a tattoo. In addition, some patients are allergic to the IV contrast that is used as part of the CT scan.
4Capsule endoscopy
Capsule endoscopy uses a device about 26 mm x 11 mm in size, about the size of a large pill. It is made up of a battery with an 8-hour lifespan, a strong light source, a camera, and a small transmitter. This capsule once swallowed, begins taking images of the inside of the gastrointestinal tract from the oesophagus to the rectum. The capsule takes two pictures per second, for a total of about 55,000 images as it travels down the digestive tract. The capsule endoscope transmits images to a receiver worn by the patient. After 8 hours, the patient returns to the doctor. By this time the capsule would have been passed in the stool. In the toilet, the capsule can be discarded and flushed. You will return the receiver to your doctor so that he can download the images taken and review them in detail.

In about 15% of exams, the capsule does not view the entire small bowel prior to the battery running out and may need to be repeated. This is sometimes the case for those who aren’t regular.

Like x-rays, the capsule cannot be used to take biopsies, apply therapy, or mark abnormalities for surgery. Moreover, the capsule cannot be controlled once it has been swallowed, so once it has passed a suspicious area, it cannot be slowed to better look at the area. Despite these limitations, capsule endoscopy is frequently the test of choice for finding a source of small bowel bleeding if standard endoscopy has failed to do so because it is able to look at the whole small bowel and is an easy test for most people to do.

Overall, for those with occult bleeding (blood that is microscopically present in the stool, but the stool looks normal), capsule endoscopy finds a cause of bleeding in up to 67% of patients. In cases of overt bleeding (blood is seen in the stool, or the stool is black and tarry), the results are highly variable. If the bleed happened in the past, the yield may be as low as 6%. If, however, the doctor believes that there is active bleeding occurring at the time of the test, the yield is > 90%.

The capsule is generally safe and easy to take; however, rarely the capsule can get stuck in the small intestine. This may happen if there has been prior abdominal surgery causing scarring or other conditions that cause narrowing of the small intestine. If this happens and the capsule becomes stuck, endoscopic or surgical removal will need to be done. In most cases, there is a good chance that the capsule is stuck at the place where the bleeding is coming from, and thus removing the capsule may also mean your doctor can treat the problem, at the same time.
5Deep small bowel enteroscopy
In cases where a lesion or abnormality has been found deep in the small bowel, beyond the reach of a standard endoscopy, evaluation of the deep small bowel may be needed. One option to further evaluate or to treat problems in the deep small bowel is known as double-balloon enteroscopy. Using two balloons attached to the enteroscopy, the scope can be moved along the small bowel easier. Double balloon enteroscopy is able to reach very far into the small bowel (in some cases as far as the ileum, which is the final segment of the small bowel). This scope can also be inserted through the anus, which allows for examination of the deepest parts of the small bowel (the scope must first pass through the colon).

In some cases, by doing the test through both the mouth and through the anus, it is possible to examine the entire length of the small bowel, though this is not always possible.

A double-balloon enteroscopy test often takes a couple of hours to perform, as opposed to 20 minutes for standard endoscopy. Because an examination using a double-balloon enteroscopy is much more involved than standard endoscopy, it is usually only used if a bleeding site is found on either an x-ray or capsule endoscopy and is out of reach of a standard enteroscope. In one study, double-balloon enteroscopy was able to locate a bleeding source in 74% of patients.

Because the test is done with an endoscope if a source of bleeding is found, it may be possible to treat it, take biopsies, or mark the area with a tattoo. If a source is found, it can be treated in about 60 to 70 per cent of people.

In addition to double-balloon enteroscopy, there are two other options for deep small bowel enteroscopy. One is single balloon enteroscopy, which is a test similar to double-balloon enteroscopy, though in this case there is only one balloon attached to the scope. A second option is deep small bowel enteroscopy using a special spiral tube that fits over the scope and allows the endoscope to be advanced into the deep small bowel.
6Intraoperative enteroscopy
In some cases, surgery may be needed. Intraoperative enteroscopy is carried out in the operating room under general anaesthesia. The surgeon, often working with a gastroenterologist (a doctor who specializes in the gastrointestinal tract), inserts the endoscope through the patient’s mouth or through a small incision in the small bowel (an enterotomy). The surgeon then moves the endoscope through the intestine to examine the entire small bowel. The advantage of intraoperative enteroscopy is that it allows the doctor to treat the cause of bleeding if it is found (for AVMs), or to remove masses or polyps.

Because it is an invasive, surgical procedure, however, intraoperative enteroscopy is usually only used when other methods have failed to find or treat the source of bleeding. Overall, it is effective in treating the source of bleeding in approximately 70% of the patients who require the procedure.

Risks of endoscopic procedures

There are certain risks to this procedure:

  • There is a very small risk of perforation of the colon. If, however, this should happen, surgery may be required for repair.
  • Following the removal of a polyp, there is a small chance/risk of bleeding from the site. This may settle spontaneously, require re-examination or, rarely, surgical intervention. A blood transfusion may be required.
  • X-ray screening may be used during the procedure, so it is important to inform the doctor if you suspect you might be pregnant.
    It is important to note that, if you are concerned regarding any symptoms which develop following this procedure, you should contact your doctor. He/she will most likely request that you present for assessment without delay.

Hospital

Operating from the new state-of-the-art, multi-disciplinary facility equipped with only the most advanced medical technology,

Equipment

As one of only two such robots in the Western Cape, Dr Kavin operates from a hospital boasting Robotic Surgery capabilities,

Technique

As a surgeon with adept skill in minimally invasive techniques, Dr Kavin opts for laparoscopic keyhole surgery whenever possible.

Expertise

Dr Bruce Kavin is a General Surgeon with particular expertise in Endocrine, Colorectal and Gastrointestinal Surgery and Surgical Oncology.

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