Colonoscopy

A colonoscopy is an exam that views the inside of the colon (large intestine) and rectum, using a tool called a colonoscope. The colonoscope has a small camera attached to a flexible tube that can reach the length of the colon.

How the Test is Performed ?

You will usually be given medicine into a vein to help you relax. You should not feel any discomfort. You will be awake during the test and may even be able to speak, but you probably will not remember anything.

You will lie on your left side with your knees drawn up toward your chest. The colonoscope is inserted through the anus. It is gently moved into the beginning of the large bowel and slowly advanced as far as the lowest part of the small intestine.

Air will be inserted through the scope to provide a better view. Suction may be used to remove fluid or stool.

The health care provider gets a better view as the colonoscope is moved back out. Therefore, a more careful exam is done while the scope is being pulled back. The doctor may take tissue samples with tiny biopsy forceps inserted through the scope. Polyps may be removed with snares, and images may be taken. Specialized procedures, such as laser therapy, may also be done.

How to Prepare for the Test ?

You will need to completely cleanse your intestines. A problem in your large intestine that needs to be treated may be missed if your intestines are not cleaned out.

Your health care provider give you the steps for cleansing your intestines. This may include using enemas, not eating solid foods for 2 or 3 days before the test, and taking laxatives.

Upper Endoscopy

What is upper endoscopy?

Upper endoscopy lets your doctor examine the lining of the upper part of your gastrointestinal tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine). Your doctor will use a thin, flexible tube called an endoscope and will view the images on a video monitor.

Why is upper endoscopy done?

Upper endoscopy helps your doctor evaluate symptoms of persistent upper abdominal pain, nausea, vomiting or difficulty swallowing. It's the best test for finding the cause of bleeding from the upper gastrointestinal tract. It's also more accurate than X-rays for detecting inflammation, ulcers and tumors of the esophagus, stomach and duodenum. Your doctor might use upper endoscopy to obtain a biopsy (small tissue samples). A biopsy helps your doctor distinguish between benign and malignant (cancerous) tissues. Remember, biopsies are taken for many reasons, and your doctor might order one even if he or she does not suspect cancer. For example, your doctor might use a biopsy to test for the bacterium that causes ulcers.

Your doctor might also use upper endoscopy to perform a cytology test, where he or she will introduce a small brush to collect cells for analysis. Upper endoscopy is also used to treat conditions of the upper gastrointestinal tract. Your doctor can pass instruments through the endoscope to directly treat many abnormalities – this will cause you little or no discomfort. For example, your doctor might stretch (dilate) a narrowed area, remove polyps (usually benign growths) or treat bleeding.

What preparations are required?

An empty stomach allows for the best and safest examination, so you should have nothing to eat or drink, including water, for approximately six hours before the examination. Your doctor will tell you when to start fasting as the timing can vary.

Can I take my current medications?

Most medications can be continued as usual, but some medications can interfere with the preparation or the examination. Inform your doctor about medications you’re taking, particularly aspirin products or antiplatelet agents, arthritis medications, anticoagulants (blood thinners such as warfarin or heparin), clopidogrel, insulin or iron products. Also, be sure to mention any allergies you have to medications.

What happens during upper endoscopy?

Your doctor might start by spraying your throat with a local anesthetic or by giving you a sedative to help you relax. You'll then lie on your side and your doctor will pass the endoscope through your mouth and into the esophagus, stomach and duodenum. The endoscope doesn't interfere with your breathing.  Most patients consider the test only slightly uncomfortable, and many patients fall asleep during the procedure.

Tell your doctor in advance about any medications you take; you might need to adjust your usual dose for the examination. Discuss any allergies to medications as well as medical conditions, such as heart or lung disease.

What happens after upper endoscopy?

You will be monitored until most of the effects of the medication have worn off. Your throat might be a little sore, and you might feel bloated because of the air introduced into your stomach during the test. You will be able to eat after you leave unless your doctor instructs you otherwise. Your physician will explain the results of the examination to you, although you'll probably have to wait for the results of any biopsies performed.

If you have been given sedatives during the procedure, someone must drive you home and stay with you. Even if you feel alert after the procedure, your judgement and reflexes could be impaired for the rest of the day.

What are the possible complications of upper endoscopy?

Although complications can occur, they are rare when doctors who are specially trained and experienced in this procedure perform the test. Bleeding can occur at a biopsy site or where a polyp was removed, but it's usually minimal and rarely requires follow-up. Perforation (a hole or tear in the gastrointestinal tract lining) may require surgery but this is a very uncommon complication. Some patients might have a reaction to the sedatives or complications from heart or lung disease.

While very uncommon, it's important to recognize early signs of possible complications. Contact your doctor immediately if you have a fever after the test or if you notice trouble swallowing or increasing throat, chest or abdominal pain, or bleeding, including black stools. Note that bleeding can occur several days after the procedure.  If you have any concerns about a possible complication, it is always best to contact your doctor right away.

ERCP

What is a therapeutic ERCP?

ERCP, is a study of the ducts that drain the liver and pancreas. Ducts are drainage routes into the bowel. The ones that drain the liver and gallbladder are called bile ducts.

Diagnostic ERCP is when X-ray contrast dye is injected into the bile duct, the pancreatic duct, or both.  X-rays are taken during ERCP to get pictures of these ducts. Most ERCPs are done for treatment and not just picture taking. When an ERCP is done to allow treatment, it is called therapeutic ERCP.

What treatments can be during ERCP?

Stone Removal -The most common treatment through an ERCP scope is removal of bile duct stones. These stones may have formed in the gallbladder and traveled into the bile duct or may form in the duct itself years after your gallbladder has been removed.

Stent Placement – Stents are placed into the bile or pancreatic ducts to bypass strictures, or narrowed parts of the duct. These narrowed areas are due to scar tissue or tumors that cause blockage of normal duct drainage. There are two types of stents that are commonly used. The first is made of plastic and looks like a small straw. A plastic stent can be pushed through the ERCP scope into a blocked duct to allow normal drainage. The second type of stent is made of metal wires that looks like the cross wires of a fence. The metal stent is flexible and springs open to a larger diameter than plastic stents. Your doctor will choose the best type of stent for your problem.

Balloon Dilation – These are ERCP catheters fitted with dilating balloons that can be placed across a narrowed area or stricture. The balloon is then inflated to stretch out the narrowing. Dilation with balloons is often performed when the cause of the narrowing is benign (not a cancer). After balloon dilation, a temporary stent may be placed for a few months to help maintain the dilation.

Tissue Sampling – One procedure that is commonly performed through the ERCP scope is to take samples of tissue. Tissue samples can help decide if a  narrowing, is due to a cancer. If the sample is positive for cancer it is very accurate.

What can you expect before, during, and after a therapeutic ERCP?

You should not eat for at least 6 hours before the procedure. You should tell your doctor about medications that you take regularly and whether you have any allergies to medications or contrast material.

You will have an IV placed in your arm so you can receive medicine during the procedure. You will be given sedatives that will make you comfortable during the ERCP. Some patients require antibiotics before the procedure. The procedure is performed on a X-ray table. After the ERCP is complete you will go to a recovery area until the sedation effects reside. Some patients are admitted to the hospital for a day but many go home from the recovery unit. You should not drive a car for the rest of the day although most patients can return to full activity the next day.

What are possible complications of therapeutic ERCP?

The overall ERCP complication rate requiring hospitalization is 6-10%. Depending on your age, your other medical problems, what therapy is performed, and the indication for your procedure, your complication rate may be higher or lower than the average. Your doctor will discuss your likelihood of complications before you undergo the test. The most common complication is pancreatitis, or inflammation of the pancreas. Other complications include bleeding, infection, an adverse reaction to the sedative medication, or bowel perforation. Most complications are managed without surgery but may require you to stay in the hospital for treatment.

Halo Barretts Ablation

HALO Barrett's "ablation" is a technique where tissue is heated until it is no longer viable or alive. Physicians have used various forms of ablation for nearly a century to treat a number of cancerous and precancerous conditions, as well as to control bleeding. The HALO ablation technology is a very specific type of ablation, in which heat energy is delivered in a precise and highly-controlled manner.

Barrett's esophagus tissue is very thin and is therefore a good candidate for removal with ablative energy and for complete removal of the diseased tissue without damage to the normal underlying structures. Clinical studies have demonstrated the Barrett's tissue can be completely eliminated with the HALO ablation technology in 98.4% of patients.

What happens during treatment with the HALO ablation technology?

Ablation therapy is performed in conjunction with upper endoscopy. The treatment is performed in an outpatient setting and no incisions are involved.

What to expect after treatment?

Patients may experience some chest discomfort and difficulty swallowing for several days after the procedure, both of which are managed with medications provided by the physician. In clinical trials, these symptoms typically resolved within 3-4 days. Patients are provided with antacid medications to promote healing of the treated esophagus and replacement of the diseased Barrett's tissue with a normal, healthy esophagus lining. A follow-up appointment is scheduled within 2-3 months to assess the response to treatment.

How is GERD managed after a successful ablation?

Successful elimination of the Barrett's esophagus tissue does not cure pre-existing GERD or the associated symptoms. The physician will guide the patient regarding long-term GERD therapy.

Bravo Reflux Test

What is BRAVO pH Monitoring?

Bravo pH monitoring is a patient friendly test for identifying the cause of heartburn. This test allows your doctor to evaluate your heartburn symptoms to determine the frequency and duration of acid coming up into your esophagus and to confirm if your condition may be Reflux Disease. The test involves a miniature pH capsule, approximately the size of a gelcap, that is attached to your esophagus. Throughout the test period, the Bravo pH capsule measure the pH in the esophagus and transmits this information to a small receiver worn on your belt or waistband just like a pager or mobile phone.

What Can I Expect During the Procedure?

The capsule takes only moments to place in the esophagus during an EGD/Upper Endoscopy procedure. The testing period last 48 hours or more, depending on the doctor's request. The capsule is small and you can eat normally and go about your daily routine. Some patients say they feel the capsule when they eat or when food passes the capsule. Should you experience this, chewing food carefully and drinking fluids may minimize this sensation.

You will be given a diary to write down the times when you have reflux symptoms (for example: coughing, heartburn, regurgitation) when eating or when lying down. After the test is completed, you return the diary and the receiver to the Hospital or facility where you had the procedure performed. The test data will upload into the computer system and be analyzed by your doctor to diagnose your condition. You will be scheduled for a follow up office visit to discuss your results.

What are the Benefits of the Bravo pH Monitoring Procedure?

The Bravo pH monitor procedure is catheter-free so you are free to move about as long as you stay within three feet or approximately one meter of the receiver. You can bathe and get a restful night's sleep because you can place the receiver outside the shower or on our nightstand, and the test will not be interrupted.

Will the Test Restrict My Diet and Activities?

No, one of the added benefits of the capsule is that it is so small that you may eat normally and go about your daily routine.

What Happens to the Capsule after the Test?

Several days after the test, the capsule naturally falls off the wall of the esophagus and passes through your digestive tract.

Is the Bravo pH Monitoring Procedure a Good Solution for Everyone?

Bravo pH monitoring is not for everyone. Risks include: premature detachment, discomfort, failure to detach, bleeding and perforation.  Medical, endoscopic or surgical intervention may be necessary to address any of these complications, should they occur. Please consult your physician for detailed information.

Capsule Endoscopy

What is a Capsule Endoscopy?

A procedure that lets your doctor examine the lining of the middle part of your gastrointestinal tract, which includes the three protions of the small intestine (duodenum, jejunum, ileum). Your doctor will use a pill sized video capsule (which has its own lens and light source) that will view the images on a video monitor. You might hear your doctor or other medical staff refer to capsule endoscopy as small bowel endoscopy, capsule entereoscopy, or wireless endoscopy. These images are transmitted to a Data Recorder wich saves them. The Data Recorder is worn around your waist (size of a walkman). Approximately 8 hours after, you will return to our office and get the recorder removed. The capsule is disposable and will naturally excrete within your bowel movement.

Breath Tests

We utilize breath testing with the Quintron SC- Breathalyzer to test for:

• Lactose Intolerance
• Fructose Intolerance and
• Small Intestinal Bacterial Overgrowth Syndrome (SIBO)

What is Hydrogen Breath Testing?

Hydrogen breath testing is used to diagnose three primary conditions. First, hydrogen breath testing detects sugars like lactose that are not properly digested and metabolized. Secondly, hydrogen breath testing detects sugars like fructose that are not absorbed in sufficient levels. Thirdly, hydrogen breath testing is used to diagnose bacterial overgrowth of the small bowel.

What is the principle of the Small Intestinal Bacterial Overgrowth (SIBO) Breath Test?

Hydrogen breath testing is the most common method to diagnose small intestinal bacterial overgrowth (SIBO) in clinical practice due to its low risk, lower costs than intestinal cultures of small bowel aspirates, and ease of use. SIBO hydrogen breath testing uses the orally ingested carbohydrate lactulose as a substrate.

Hydrogen and methane gas are only produced in the body from intestinal bacteria. Bacteria ferment sugars such as lactulose to hydrogen and/or methane gas. Hydrogen and methane are absorbed by the intestinal mucosa, enter the vasculature, and get transported to the lungs. A change in the level of hydrogen and/or methane gas above 20 parts per million within 60 minutes is diagnostic for SIBO. The majority, but not all malabsorbers produce hydrogen gas. Approximately 15% of patients are methane producers rather than hydrogen producers. These patients will only be properly diagnosed by measuring methane levels. As a result, each breath specimen is measured by Metabolic Solutions for hydrogen and methane.

What causes Bacterial Overgrowth?

Normally the proximal small intestine contains no or low levels of colonic-type bacteria. Small intestinal bacterial overgrowth is the presence of anaerobic organisms in an atypical location of the small bowel. SIBO is defined as the presence of >105 colony forming units per milliliter (cfu/ml) in the proximal small intestine. It has been suggested that even 103 cfu/ml can induce symptoms of bacterial overgrowth if the bacterial species are colonic in orgin.

Two major factors are responsible for controlling the number of bacteria in the small bowel. Normal small bowel motility is the first defense against attachment of bacterial organisms to intestinal walls. Gastric acid is the second defense by destroying invading ingested organisms. Both of these mechanisms are compromised during the natural aging process and with the presence of anatomical changes, functional pH or dysmotility syndromes, or miscellaneous diseases that introduce motility derangements.

Liver Biopsy

What is a liver biopsy?

A liver biopsy is a procedure to remove a small piece of the liver so it can be examined with a microscope for signs of damage or disease.

What is the liver?

The liver is a vital organ with many important functions.

• removes harmful chemicals from the blood
• fights infection
• helps digest food
• stores nutrients and vitamins
• stores energy

When is a liver biopsy performed?

A liver biopsy is performed when a liver problem is difficult to diagnose with blood tests or imaging techniques, such as ultrasound and x ray. More often, a liver biopsy is performed to estimate the degree of liver damage—a process called staging. Staging helps guide treatment.

How does a person prepare for a liver biopsy?

At least 1 week before a scheduled liver biopsy, patients should inform their doctor of all medications they are taking. Patients may be asked to temporarily stop taking medications that affect blood clotting or interact with sedatives, which are sometimes given during a liver biopsy.

Medications that may be restricted before and after a liver biopsy include

• nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, and naproxen
• blood thinners
• high blood pressure medication
• diabetes medications
• antidepressants
• antibiotics
• asthma medications
• dietary supplements

Prior to a liver biopsy, blood will be drawn to determine its ability to clot. People with severe liver disease often have blood clotting problems that can increase the risk of bleeding after the procedure. A medicine given just before a liver biopsy reduces the risk of bleeding in patients with blood clotting abnormalities.

Patients who will be sedated should not eat or drink for 8 hours before the liver biopsy and should arrange a ride home, as driving is prohibited for 12 hours after the procedure. Mild sedation is sometimes used during liver biopsy to help patients stay relaxed. Unlike general anesthesia where patients are unconscious, patients can communicate while sedated but then often have no memory of the procedure. Sedatives are often given through an intravenous (IV) tube placed in a vein. The IV can also be used to give pain medication, if necessary, after the procedure.

How is a liver biopsy performed?

There are three main types of liver biopsy; all of which remove liver tissue with a needle. A liver biopsy may be performed at a hospital or outpatient center.

How soon do results come back from a liver biopsy?

Results from a liver biopsy take a few days to come back. The liver sample goes to a laboratory where the tissue is stained. Staining highlights important details within the liver tissue and helps the pathologist identify signs of liver disease. The pathologist looks at the tissue with a microscope and sends a report to the patient's doctor.

How long does it take to recover from a liver biopsy?

Most patients fully recover from a liver biopsy in 1 to 2 days. Patients should avoid intense activity, exercise, or heavy lifting during this time. Soreness around the incision site may persist for about a week. Acetaminophen (Tylenol) or other pain medications that do not interfere with blood clotting may help. Patients should check with their doctor before taking any pain medications.

What are the risks of a liver biopsy?

Pain at the biopsy site is the most frequent risk of percutaneous liver biopsy, occurring in about 20 percent of patients. The risk of excessive bleeding is about 1 in 500 to 1 in 1,000. Risk of death is about 1 in 10,000 to 1 in 12,000. If bleeding occurs, a procedure called embolization can be used to stop the bleeding. In some cases, a blood transfusion is necessary. Surgery can also be used to stop a hemorrhage. Other risks include puncture of other internal organs, infection, and spread of cancer cells, called cancer seeding.