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Upper GI Endoscopy:

Upper GI endoscopy is a procedure that uses a flexible endoscope to visualize the upper GI tract. The upper GI tract includes the oesophagus, stomach, and duodenum - the first part of the small intestine.

Applications

  • Treating diffused mucosal bleed with Argon plasma coagulation (APC)
  • Dilation of narrowed food pipe (Balloon dilation of stricture and achalasia cardia)
  • Metallic stenting of narrowed segments of food pipe or stomach
  • Removal of polyps (polypectomy)
  • Creating alternative pathway for feeding directly to stomach (PEG) or small intestine (PEG-J)
  • Draining fluid collections though stomach (Cystogastrostomy) in patients with pancreatitis

How is upper GI endoscopy performed?

During the procedure, patients lie on their back or side on an examination table. An endoscope is carefully fed down the oesophagus and into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a video monitor, allowing close examination of the intestinal lining. Air is pumped through the endoscope to inflate the stomach and duodenum, making them easier to see. Special tools that slide through the endoscope allow the doctor to perform biopsies, stop bleeding, and remove abnormal growths.

What problems can upper GI endoscopy detect?

    Upper GI endoscopy can be used to determine the cause of
  • Abdominal pain
  • Nausea
  • Nomiting
  • Swallowing difficulties
  • Gastric reflux
  • Unexplained weight loss
  • Anaemia
  • Bleeding in the upper GI tract
    It is used for both diagnostic and therapeutic procedures.
    Diagnostic upper GI endoscopy is done to detect
  • Ulcers
  • Abnormal growths
  • Obstruction
  • Inflammation
  • Hiatal hernia
    • source of bleeding
    • tissue samples (biopsy) are also taken during endoscopy and sent for pathological examination to confirm the diagnosis
    The following therapeutic (treatment) procedures are also performed through upper GI endoscopy:
  • Foreign body removal
  • Treat bleeding ulcers by
    • injection of medication (injection therapy)
    • application of heat (coagulation) or
    • application of clips (hemoclips) to the bleeding vessel
  • Treat bleeding varices (engorged veins in liver disease) by applying plastic rings (EVL)
  • Glue injection for gastric varix

Capsule Endoscopy

Capsule endoscopy can help in visualizing and evaluating the lining of the middle part of the gastrointestinal tract, which includes the three portions of the small intestine (duodenum, jejunum and ileum).

What problems can capsule endoscopy be used to diagnose?

Capsule endoscopy evaluates 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 identify cause of bleeding from the small intestine
  • for detecting polyps,
  • diagnosing inflammatory bowel disease (Crohn's disease),
  • diagnosing small bowel ulcers
  • detecting tumors of the small intestine

How is capsule endoscopy done?

A sensor device is applied and fastened to your abdomen with adhesive sleeves (similar to tape). The capsule endoscope is swallowed and as it passes naturally through your digestive tract, it transmits 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 the physician's review.

Enteroscopy

Enteroscopy is a procedure used to examine the small intestine (small bowel).

Why is this test performed?

This test is most often performed to help diagnose diseases of the small intestines. It may be done if you have:

  • Unexplained diarrhoea
  • Unexplained gastrointestinal bleeding
  • Abnormal barium meal follow through (BMFT) or CT enteroclysis reports
  • Tumours in the small intestines

How is the test performed?

A thin, flexible tube (endoscope) is inserted through the mouth or nose and into the upper gastrointestinal tract. During a single-balloon enteroscopy, balloon attached to the endoscope can be inflated to allow the doctor to view the entire small bowel. Tissue samples removed during enteroscopy are sent to the laboratory for examination.

Colonoscopy

Colonoscopy is a procedure used to see inside the colon and rectum.

What problems can colonoscopy detect?

Colonoscopy can help doctors diagnose the reasons for

  • Unexplained changes in bowel habits
  • Abdominal pain
  • Bleeding from the anus
  • Unexplained weight loss

Colonoscopy can also detect inflamed tissue, ulcers, and abnormal growths.

The procedure is used to look for early signs of colorectal cancer. The doctor can also take samples from abnormal-looking tissues during colonoscopy. The procedure, called a biopsy, allows the doctor to later look at the tissue with a microscope for signs of disease.

The doctor removes polyps and takes biopsy tissue using tiny tools passed through the scope. If bleeding occurs, the doctor can usually stop it with an electrical probe or special medications passed through the scope. Tissue removal and the treatments to stop bleeding are usually painless.

Colonoscopy can be used to:

  • Remove polyps (polypectomy)
  • Dilate narrowed segments (stricture dilation) of large intestine and place metallic stents across them (colonic stenting)
  • Banding for haemorrhoids (piles banding)

How is colonoscopy performed?

During colonoscopy, patients lie on their left side on an examination table. The doctor inserts a long, flexible, lighted tube called a colonoscope, into the anus and slowly guides it through the rectum and into the colon. The scope inflates the large intestine with carbon dioxide gas to give the doctor a better view. A small camera mounted on the scope transmits a video image from inside the large intestine to a computer screen, allowing the doctor to carefully examine the intestinal lining. The doctor may ask the patient to move periodically so the scope can be adjusted for better viewing.

Once the scope has reached the opening to the small intestine, it is slowly withdrawn and the lining of the large intestine is carefully examined again. Bleeding and puncture of the large intestine are possible but they are uncommon complications during colonoscopy.

E R C P

ERCP enables the physician to diagnose problems in the gallbladder, bile ducts, and pancreas. The liver is a large organ that makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and also secretes hormones such as insulin.

Applications

ERCP is primarily used as a therapeutic procedure for treatment of diseases of

  • Bile duct
    • extraction of bile duct stones by balloon/basket (balloon/basket extraction)
    • by crushing large bile stones and retrieving them (mechanical lithotripsy)
    • relieving jaundice due to bile duct narrowing by dilating passage with balloon (balloon dilation)
    • treatment of bile duct infection (cholangitis) by draining pus by cutting open bile duct opening (biliary sphincterotomy) and placing stents /catheter in bile duct for free drainage of bile into duodenum ( plastic stent/ENBD placement)
    • stopping leakage of bile in bile duct injuries as a result of trauma and surgery
    • metallic stent placement for relief of itcing and jaundice in bile duct, pancreatic, gallbladder cancers (metallic stent placement)
  • Pancreas
    • relief of pain in chronic pancreatitis
    • by removal of pancreatic duct stones
    • dilating the narrowed pancreatic duct
    • placing of stents to facilitate drainage of infected fluid collection in pancreatitis (Pseudocyst drainage)
How is ERCP performed?

ERCP combines the use of X-rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on X-rays.

For the procedure, you will lie on your left side on an examining table in an X-ray room. You will be given medication to help numb the back of your throat and a sedative to help you relax during the examination. You will swallow the endoscope, and the physician will then guide the scope through your oesophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. At this time, you will be turned to lie flat on your stomach, and the physician will pass a small plastic tube through the scope. Through the tube, the physician will inject a dye into the ducts to make them show up clearly on X-rays. X-rays are taken as soon as the dye is injected.

Manometry

Oesophageal Manometry

When you swallow, muscles in your oesophagus contract to help push food towards your stomach. Valves, or sphincters, inside the oesophagus open to let food and liquid through, and then close to prevent food, fluids, and gastric acid from moving backward. The sphincter at the bottom of the oesophagus is called the lower oesophageal sphincter or LES.

The purpose of oesophageal manometry is to see if the oesophagus is contracting and relaxing properly.

The test helps diagnose

  • Cause for swallowing problems
  • Achalasia cardia
  • Non cardiac chest pain
  • Diffuse oesophageal spasm
  • Nutcracker oesophagus
  • Gastroesophageal reflux disease (GERD)

How is oesophageal manometry done?

During oesophageal manometry, a thin, pressure-sensitive tube is passed through your mouth or nose and into your stomach. Once in place, the tube is pulled slowly back into your oesophagus. When the tube is in your oesophagus, you will be asked to swallow. The pressure of the muscle contractions will be measured along several sections of the tube.

Oesophageal pH monitoring

Oesophageal pH monitoring is a test that measures how often and for how long the stomach acid enters the food pipe (oesophagus).

It is a test for diagnosing gastroesophageal reflux disease (GERD) in patients in whom upper GI endoscopy is normal, or in those who have atypical symptoms of GERD (dry cough, throat pain, asthma, hoarseness of voice).

How is the test performed?

A thin tube is passed through your nose or mouth to your stomach. Then it is pulled back into your oesophagus. The tube is attached to a monitor that measures the level of acidity in your oesophagus. You will wear this monitor on a strap and will be asked to keep a diary of your symptoms and activity over the next 24 hours. The next day you will return and the tube will be removed. The information from the monitor will be compared with the diary notes you provide.

Anorectal manometry

It is a test performed to evaluate patients with constipation or fecal incontinence. This test measures the pressures of the anal sphincter muscles, the sensation in the rectum, and the neural reflexes that are needed for normal bowel movements.

How is anorectal manometry done?

The patient lies on his or her left side. A small, flexible tube, about the size of a thermometer, with a balloon at the end is inserted into the rectum. The catheter is connected to a machine that measures the pressure. During the test, the small balloon attached to the catheter may be inflated in the rectum to assess the normal reflex pathways. The nurse or technician may also ask the person to squeeze, relax, and push at various times. The anal sphincter muscle pressures are measured during each of these maneuvers. To squeeze, the patient tightens the sphincter muscles as if trying to prevent anything from coming out. To push or bear down, the patient strains down as if trying to have a bowel movement.

Anal manometry

It measures how strong the sphincter muscles are and whether they relax as they are supposed to while passing a stool. It provides helpful information to the doctor in treating patients with fecal incontinence or severe constipation.

Applications

Fecal incontinence

Weak anal sphincter muscles or poor sensation in the rectum can contribute to fecal incontinence. If these abnormalities are present, they can be treated. Bio-feedback techniques using anal manometry and special exercises of the pelvic floor muscles can strengthen the muscles and improve sensation. This can help treat fecal incontinence.

Constipation

In some patients with constipation, the anal sphincter muscles do not relax appropriately when bearing down or pushing to have a bowel movement. This abnormal muscle function may cause a functional type of obstruction. Muscles that do not relax with bearing down can be retrained with biofeedback techniques using anal manometry.

Endoscopic Ultrasonography

Endoscopic Ultrasonography [EUS] is an imaging technique that combines endoscopy with ultrasonography. EUS is performed using an endoscope with a small ultrasound mechine attached to the tip of the endoscope. The endoultrasound probe is passed through the mouth or anus to the area to be examined under endoscopic view. The ultrasound component is then utilized to examine the walls and the surrounding structures of the upper and lower gastrointestinal tract. The esophagus, stomach, duodenum and the rectum are the organs which are studied by this equipment. EUS is also used to study internal organs that lie next to the gastrointestinal tract, such as the mediastinum, gallbladder, biliary tract and the pancreas.

There are two types of EUS probes each one of them having specific applications.

Radial Probe

The radial probe is a diagnostic scope with a view similar to the view obtained in CT scan. It is equipped with a high frequency probe which gives high clarity images of objects closer to the probe. There is no radiation because this technology uses only sound waves. Objects as small as 2mm can be seen separately.

Linear Probe

The linear probe gives images of smaller area and hence should be rotated to get to the required position. This scope is provided with an additional facility enabling the specialist to pass needles and other accessories into the sorrounding tissues under full ultrasound guided visualization. There is a doppler scanning mechanism that helps avoid blood vessels during the puncture. The needle is used for aspiration of tissues and fluid for cytology (FNAC) examination. This scope is also called a therapeutic scope because it is used for various treatment purposes.

Applications of EUS

  • EUS provides detailed images of the anatomy of the digestive tract.
  • EUS can be performed to further evaluate the pancreas when abnormalities are noted on CT or conventional abdominal ultrasonography.
  • EUS can also be performed to evaluate abnormal areas in the esophagus, stomach and duodenum noted on either endoscopy or an X-ray examination.
  • EUS is the only investigation which shows the gastrointestinal wall as a layered structure as seen in microscopic examination of tissues. This feature is helpful understand the exact nature of the pathology.

Applications of EUS in patients with cancer

  • EUS can help determine the extent of certain malignancies of the gastrointestinal tract. These include cancer of the esophagus, pancreas, stomach, and rectum. EUS provides information as to the depth of involvement of the cancer.
  • EUS shows if malignant cells have invaded the walls of the GI tract or whether malignancy has spread to adjacent lymph nodes or nearby vital structures such as major blood vessels.
  • EUS is the only investigation which can identify lymph nodes smaller than 1cm. Together with a fine needle aspiration, EUS can be a valuable tool in the diagnosis and accurate staging of cancer spread and to guide in the proper treatment of cancers. EUS can help determine the need for or avoidance of surgical procedures.
  • Together with fine needle aspiration, EUS can be a valuable tool in the diagnosis and accurate staging of lung cancer. EUS helps to differentiate a malignant lymph node from a tuberculous lymphnode particularly in the mediastinum.

Applications of EUS in evaluation of the Common bile duct

  • EUS is a very useful tool to evaluate the CBD. Abnormalities like tumours, stones and dilataton of CBD can be detected.
  • Microlithiasis in CBD and gallbladder can be detected and EUS is the only test which detects microlithiasis. Microlithiasis of the gallbladder is an important cause of biliary pancreatitis.

EUS for management of pseudocyst of pancreas

EUS is the most appropriate treatment of choice for the drainage of pseudocyst of pancreas. EUS can clearly show the type of cyst, its contents and also whether there is any blood vessel on the needle track during the puncture. It is possible to deploy stent inside the cyst from the stomach.

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