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An endoscope is a flexible tube that has a small digital camera at one end, and control knobs at the other end. Endoscopes allow excellent examination of the lining of the gastrointestinal tract.

 
 
   
 

Getting ready for any of these examinations depends on what specific examination is to be done. In general, you need to fast for a minimum of eight hours. In addition, special bowel prep is needed if you are scheduled for a colonoscopy.

 
     
 

Please let your doctor know if you are taking any anticoagulant medications, such as Coumadin, Plavix, or Aspirin. Most likely you will be asked to stop using those medications for approximately 4 days prior to your procedure. Your doctor should also be made aware of any heart condition that you may have which requires the use of prophylactic antibiotics (Have you been advised to use prophylactic antibiotics before having dental work?).

 
     
 

Intravenous sedative medications are usually administered during most endoscopic procedures. This means that you should arrange for a ride home as you will not be able to drive.

 
       
 

Endoscopic procedures are very safe. There is a small potential for complications, however. Possible complications are: bleeding, perforation and infection. Certain procedures, like ERCP or EUS, may cause pancreatitis. Other possible complications are: unexpected reactions to the sedative medications and inflammation of the veins at the site of the intravenous catheter.

 
       
       
     
       
     
 
Colonoscopy, or Lower Gastrointestinal Endoscopy, is the examination of the large bowel with a flexible video endoscope. This procedure may be performed for gastrointestinal emergencies on hospitalized patients, but more commonly it is used as a screening or diagnostic procedure in the outpatient setting. However, the indications for which a Colonoscopy is performed are numerous and include:
  
     
  • Evaluation of anemia
• Evaluation of rectal or gastrointestinal bleeding
• Evaluation of stool positive for occult blood  
• Evaluation of diarrhea or constipation
• Evaluation of abdominal pain.
• Evaluation of change in bowel habits
• Evaluation of weight loss		  
     
 
Most commonly today the procedure is done on asymptomatic patients as a screening test for polyps and colon cancer. Currently the standard of care is for everyone, men and women alike, to undergo a colonoscopy beginning at age fifty and to have this procedure performed every ten years. (The recommended age to begin screening may be earlier than fifty if there is a first degree family relative with colon polyps or cancer.) Should precancerous or adenomatous polyps be found on the colonoscopy, your doctor will discuss with you when a repeat colonoscopy is recommended.
  
     
 
You will be given detailed instructions on how to prepare for the Colonoscopy by your doctor's office. You will need to be on a clear liquid diet the day before the procedure and take a powerful oral laxative on the evening before the colonoscopy. Additionally you will have nothing to eat or drink after midnight prior to the day the colonoscopy is performed.
  
     
 
For outpatient colonoscopy your time at the Endoscopy Center is similar to that outlined below in the section on Upper Endoscopy. Please refer to that section for details. Colonoscopy typically lasts fifteen to twenty minutes unless some therapeutic intervention is needed. Once the procedure is completed, you will be then taken to the recovery room where you will spend approximately 30 minutes before discharge home. Overall, you will spend approximately one and a half to two hours in the Endoscopy Center.
  
       
 
The colonoscopy procedure may be both diagnostic and therapeutic. That is, should polyps or growths from the lining of the colon be seen, they will be removed. This is technically feasible in the vast majority of cases. Biopsies to aid in the diagnosis of various conditions may also be taken. Additionally, if a source of bleeding is identified, treatment with epinephrine injection and/or electro-cauterization may be performed to control the bleeding site.
  
       
       
 
Colonoscopy is overall quite safe. Potential risks and complications include bleeding (particularly secondary to polyp removal), missing a polyp or other lesion, and perforation which would require surgical intervention (either direct surgical repair of the perforation or creation of a temporary colostomy which would be reversed or taken down at a later date). Infection and an allergic or medication reaction are rare occurrences.
  
       
 
At the conclusion of the procedure you will be given a written report and representative photographs. Your doctor may also discuss the procedure findings with you in the recovery area. If indicated, you will be asked to schedule a follow up appointment with your doctor at his or her office to further discuss the results of the procedure and treatment plan.
  
       
 
Many people have fears and have heard horror stories about Colonoscopy. However, the vast majority of patients find the procedure to be quite underwhelming. All of us attempt to make the patient as comfortable as possible for colonoscopy. Thus, there should be no reason why fear should preclude one from undergoing this important and potentially life-saving procedure.
  
       
       
   
       
 
Upper GI endoscopy is examination of the esophagus, stomach and duodenum. It is also known as EGD (esophago-gastro-duodenoscopy). There are many reasons for which an EGD is performed. Here are some of the more common indications of an EGD:
  
       
 
• Evaluation of the cause of difficult swallowing
• Evaluation of the cause of painful swallowing
• Evaluation of the condition of the esophagus in someone with frequent heartburn to rule out the possibility of
  esophagitis “inflammation of the esophagus” or Barrett’s esophagus
• Evaluation of the cause of abdominal pain, especially in the upper abdomen
• Evaluation of the cause of black tarry stools, as this may be a sign of upper GI bleeding
• Evaluation of the cause of vomiting blood
• Evaluation of the cause of anemia
• Evaluation of the cause of weight loss
 
       
 
The procedure may be also used to treat some of the above mentioned conditions. For example, an esophageal stricture may be dilated thus alleviating the swallowing difficulty. Also, if the source of bleeding is an ulcer with an exposed blood vessel, the blood vessel may be cauterized and bleeding may be controlled.
  
       
 
In preparation for the EGD, you need to fast for at least 8 (eight) hours before the examination is performed. Also, please read the section titled “An Overview of Endoscopy” above.
  
     
 
 EGD is usually performed on outpatient basis. When you check into the endoscopy unit, a nurse will place an intravenous line. You will be given intravenous fluids. In the procedure room, the doctor or the assisting nurse will give you intravenous sedative medications. We usually use Versed and Fentanyl as a combination. Some doctors may spray the back of the mouth with a numbing medicine to help weaken the gag reflex. You will be asked to sleep on you left side. The doctor will introduce the scope through you mouth all the way down to the duodenum. Biopsies may be taken if needed.
 
     
 
The examination typically lasts for 5-10 minutes unless some therapeutic intervention is needed. You will be then taken to the recovery room where you will spend approximately 30 minutes before you are allowed to go home. Overall, you will spend approximately one and half to two hours in the endoscopy unit.
  
     
 
An EGD is a very safe procedure. There is a small risk of complications however. As listed above, the possible complications are bleeding, perforation, infection, allergy or unexpected reaction to the medications used during the procedure.
  
     
 
You will be given a printed report at the conclusion of the procedure. If you are reasonably awake, your doctor will discuss the procedure findings with you. You are encouraged to schedule a follow up appointment with your doctor at his or her office to further discuss the results of the procedure.
  
       
       
   
       
 
A gastrostomy is an “opening into the stomach”. A plastic tube may be placed into this opening to allow feeding. This procedure is indicated in certain situations in which a person is not able to swallow. Examples of such situations are: strokes, head trauma, or any neurological illness that may interfere with a person’s ability to swallow. Also, patients in the intensive care unit who are on mechanical ventilation may need a gastrostomy tube for feeding.
  
       
 
The patient should be fasting for approximately 8 hours before the procedure is performed. The doctor then performs an upper GI endoscopy (EGD) while the patient is asleep on his or her back. The stomach is inflated with air so that it comes in contact with the anterior abdominal wall. A small incision is made into the skin of the abdomen and the gastrostomy tube (GT) is placed. This is an easy procedure which takes approximately 10-15 minutes. Intravenous antibiotics may be given to help prevent infection. Like any other endoscopic procedure, it is safe with only a small risk of complications, namely bleeding, perforation or infection.
  
       
 
Feeding is usually given via the tube within 6 hours of its placement. Different feeding formulas may be used. If the patient suffers from a brain injury or stroke, his or her hands may be tied to prevent the patient from pulling on the tube which may lead to its migration out of the stomach.
  
       
       
   
       
 
Endoscopic Retrograde Cholangiopancreatography(ERCP) is an endoscopic procedure used to view the bile ducts and the internal ductal system of the pancreas, and to perform a variety of therapies within these structures.
ERCP
 
  
     
  How is the procedure done?
  
       
 
ERCP is performed in the radiology (x-ray) department at Huntington Hospital. Radiology equipment is required because most of what is done is done under x-ray guidance. Many of the procedures are done on an outpatient basis. Intravenous anesthesia is administered by an anesthesiologist and the patient is completely asleep throughout the procedure. An endoscope is advanced through the mouth to a point in the upper intestine just beyond the stomach where bile and pancreatic fluid enter the intestine through a very small opening. A tiny catheter (tube) is then passed through the endoscope and introduced into the bile ducts or pancreatic ducts. Depending on exactly what is to be done, the small opening is often enlarged by cutting with a wire through which electrical current is passed. ERCP generally takes 20-60 minutes. There is a recovery period of about an hour. Patients undergoing ERCP as an outpatient will usually be at the hospital for 3 to 4 hours.
 
       
  What are the reasons for doing an ERCP?    
       
 
There are a number of diseases and conditions of the bile ducts and pancreas in which ERCP can be helpful. The two most common uses are to remove stones from the bile ducts and to relieve blockage of the bile ducts caused by tumors growing in the pancreas, bile ducts, or intestine. Stones occur in the bile ducts either when they become lodged there after passing out of the gallbladder or they may form in the main bile duct after the gallbladder has been removed. Blockage of the bile ducts by tumors is relieved by placing plastic or metal mesh stents (tubes) from the intestine into the bile ducts. Some of the other uses of ERCP include treating complications of pancreatitis and aiding the healing of bile leaks, which occur as a rare complication of gallbladder removal. In a number of instances ERCP and Endoscopic Ultrasound (described elsewhere on this website) are used in combination when investigating and treating bile duct and pancreatic diseases.
 
       
  What are the risks of ERCP and how can they be minimized?    
       
 
ERCP is an invasive procedure and is not without risk. The most common complication of the procedure is pancreatitis or worsening of existing pancreatitis. Pancreatitis simply means inflammation of the pancreas. The chance of this occurring after an ERCP is about 1 in 30, though the risk is influenced by the patient’s underlying disease and exactly what is done during the procedure. The pancreatitis is usually mild and resolves within a few days. But, on rare occasions, it can be a severe illness. Less common complications include bleeding, infection, and very rarely, perforation of the intestine. The most important factors in reducing complications from ERCP are knowing exactly which patients will benefit from it (so unnecessary procedures are not done) and expertise in performing the procedure. It should be noted that the alternatives to therapeutic ERCP are surgery or other invasive procedures, which carry a significantly higher risk.
 
       
  Alliance Digestive Disease Consultants and ERCP
    
       
 
ERCP is a highly technical procedure, which is not done by all gastroenterologists. Furthermore, it has been shown in a number of studies that gastroenterologists who are most successful at ERCP, and have the lowest complication rates, are those that perform them regularly. Five of the six gastroenterologists in the group perform ERCP. These five doctors have extensive experience with the procedure and the diseases in which it is used. Patients are frequently referred to the group because of these physicians known expertise in the procedure.
  
       
       
   
       
 
Endoscopic ultrasonography, or EUS, allows your doctor to examine the different layers of the wall of the gastrointestinal tract using a small ultrasound transducer at the tip of the endoscope. It is a combination of both endoscopy and ultrasonography. It also allows accurate evaluation of the internal organs that are located close to the stomach or the colon, such as the pancreas. If a lesion is seen in one of these organs, tissue specimens can be obtained via fine needle aspiration (FNA), under ultrasound guidance.
  
       
  The following are examples of conditions in which EUS is usually indicated:    
       
 
• Evaluation of lumps found during routine endoscopy
• Evaluation of a possible abnormality of the pancreas identified during a CT scan
  of the abdomen
• Staging of esophageal cancer
• Staging of lung cancer
• Staging of cancer of the pancreas
• Staging of rectal cancer
 
     
 
In getting ready for the EUS examination, please refer to the instructions under “Upper Endoscopy” if you are undergoing examination of the upper GI tract, or “colonoscopy” if you are undergoing an examination of the rectum.
  
       
 
Dr. Beblawi is our EUS expert. He performs these procedures at Huntington Hospital in Pasadena. An intravenous line will be placed. You will be asked to lie on your left side. If you are scheduled to have an EUS of the upper GI tract, an anesthesiologist will give you intravenous medicines which produce deep sedation. For EUS of the rectum, mild sedation is usually used. These medicines are given by the nurse assisting Dr. Beblawi. The procedure time varies from patient to patient depending on the indication. Most procedures however are completed in less than one hour. You will be kept comfortable during the procedure. You will then spend sometime in the recovery room until you are ready to be discharged home. Expect to spend approximately 4 hours in the endoscopy unit, from the time you arrive to the time you are ready to go home.
  
       
 
Both EUS and EUS-FNA are very safe procedures. There is a small potential for complications however. Possible complications are: bleeding, perforation (which means puncturing the wall of the esophagus, stomach, small intestines or colon), or infection. In addition, there is a small risk of pancreatitis if an FNA of the pancreas is performed. Other possible complications are usually related to sedation or anesthesia, including unexpected reactions to the medications, or inflammation of the veins at the site of the venous catheter.
  
   
 
You will be advised to schedule a follow up office visit with Dr. Beblawi or with your referring physician to discuss the results of the procedure or the results of the pathology examination if an FNA was performed.
  
       
       
   
       
 
Alliance Digestive Disease Consultants is pleased to offer the latest state-of-the-art diagnostic procedure in gastroenterology: Capsule Endoscopy of the Small Bowel. This noninvasive test can be performed right in our office, and gives an unprecedented look into the workings of the small intestine.
  
     
  What is capsule endoscopy?  
     
 
Capsule endoscopy is endoscopy with a difference! Unlike other forms of endoscopy, the video images of the intestine are in this case captured through an ingestible capsule, rather than with a long tube-like scope inserted into the patient. The capsule “endoscope” is literally a pill, roughly the size of a large vitamin, which contains a camera, light source, and transmitter. It looks like this:
  
       
   What part of the gastrointestinal tract does the capsule endoscope examine?  
       
 
The small bowel capsule is specifically designed to obtain detailed images of the SMALL INTESTINE, which consists of 3 parts: the duodenum, the jejunum, and the ileum. Despite its name, the “small” intestine is the longest segment in the gastrointestinal tract: approximately 20 feet long!
 
       
 
As a result of this length, it has been impossible to visualize the entire length of the small intestine using conventional tube-like endoscopes. Capsule endoscopy is the only diagnostic technique that yields detailed images of the lining of the entire small intestine.
 
       
  What parts of the gastrointestinal tract does the capsule endoscope NOT examine?  
       
 
Bear in mind that capsule endoscopy is not a substitute for conventional upper GI endoscopy and colonoscopy. The small bowel capsule is not designed to give accurate images of the esophagus, stomach, or colon, which are often the sites of very significant disorders and diseases.
  
       
  What is the process of getting a capsule endoscopy like?    
       
 
The patient must follow certain very important preparatory steps, such as diet and medication changes, prior to the capsule examination (see Preparation Instructions for Capsule Endoscopy below). On the morning of the examination, the patient comes to the office, usually by 8:30 am. Several wires are attached to the abdominal skin using self-adhesive patches. These are connected to a monitor that is worn on a special belt. The patient swallows the capsule and then goes on his or her way, free to do virtually anything he or she wishes. At the end of the day, usually by approximately 4:30 pm, the patient comes back to the office, where the monitor and wires are removed, and the images are uploaded to a special computer. One of the Alliance Digestive Disease Consultants physicians will review the 8 hours of recorded images in the week or two following the examination. The capsule is disposable and will pass naturally with your bowel movement in the next several days. You probably won’t even notice it! The images of your small intestine will look like this:
  
       
  Are there any risks to capsule endoscopy?    
       
 
Like any medical procedure, capsule endoscopy carries with it a few, very rare potential complications. Because of the size of the capsule, there is a very small chance of its getting “stuck” in the esophagus, stomach, or small intestine. On very rare occasions, blockage of the small intestine from a retained capsule could require surgery to remove the capsule. Those at increased risk of blockage from a capsule include patients with:
  
       
  • Difficulty swallowing pills
• Schatzki rings or strictures of the esophagus
• History of small bowel obstruction
• History of abdominal surgery		    
       
 
Be sure to let your physician know if you have any of the above conditions. He or she will discuss the risks and benefits of the procedure with you. Prior to capsule endoscopy, all patients will be asked to sign a form acknowledging that they understand the risks of the procedure (see Consent Form for Capsule Endoscopy below).
  
       
  What kind of problems might warrant doing a capsule endoscopy?    
       
  Your physician may recommend capsule endoscopy for many reasons, but the most common reasons would be:  
       
 
• Unexplained gastrointestinal bleeding (usually after stomach and colon sources have been ruled out by conventional
  endoscopy)
• Chronic diarrhea
• Follow up of Crohn’s disease
• Unexplained iron deficiency anemia
 
       
  What conditions might be diagnosed by capsule endoscopy?    
       
 
There are many different diseases that may affect the small intestine. Some of the most common include: vascular malformations, Crohn’s disease, celiac disease, and ulceration from medications. Less common findings include tumors, diverticula, parasitic infections, and radiation injury. Your doctor will discuss with you in more detail which possible diagnoses are most relevant to your case.
  
       
       
   
       
  What is 24 Hour pH study of the esophagus?    
       
 
The esophagus is a tube like structure that transfers the food from the mouth to the stomach. The stomach contains a large volume of acid, which is used to digest food. Sometimes the acid inside the stomach refluxes backwards into the esophagus. This is called acid reflux, which is related to a condition called gastroesophageal reflux disease (GERD). The pH study of the esophagus involves the use of a very thin acid-sensing probe that is left in the esophagus for 24 hours to measure the extent of acid exposure in the esophagus.
  
       
   Preparation for the procedure:    
       
 
Typically no food or liquids should be consumed for at least 8 hours prior to the pH study. Depending on your gastroenterologist’s decision, certain medications that are used for decreasing stomach acid such as Nexium, Prevacid, Aciphex, Prilosec and Protonix are sometimes discontinued 1 week prior to the pH study of the esophagus. Other milder acid reducers such as Zantac, Tagamet, and Pepcid are discontinued 2 days prior to the pH study. Medications such as Reglan, Erythromycin, Nitroglycerin, Levsin, Donnatol, Librax and calcium channel blockers are usually discontinued 1 day prior to your pH procedure. Please provide your doctor with your medication list and consult our office regarding discontinuation of your medications. You do not need to have a driver. Most patients resume eating and other daily activities right after the procedure.
 
 
       
  How is 24 Hour pH study esophageal done?    
       
 
First the nose is anesthetized with a numbing gel that contains xylocaine. The nurse specialist applies the numbing gel into the nose using a Q-tip. Then a very thin long tube called the pH catheter is gently advanced through the anesthetized nose and slowly swallowed by patient into the esophagus. This very thin pH catheter is then left in the esophagus for 24 hours, with the external portion of the catheter secured to the nose with small pieces of adhesive tape. The pH probe placement takes less than 10 minutes. However, patients are asked to arrive an hour prior to the procedure in order to be registered and checked in to the GI lab at Huntington Hospital. Our office staff will provide you with the time of arrival and approximate procedure start time. A full typed report will be mailed to your referring physician within 4 days of the procedure.
 
       
       
   
       
  What is esophageal manometry?    
       
 
The esophagus is a tube like structure that transfers the food from the mouth to the stomach. The structure of the esophagus can be visualized and evaluated with procedures such as upper endoscopy (EGD). The function of the esophagus is evaluated with a procedure named esophageal manometry. The movement and contractions of the esophageal muscles are measured during the esophageal manometry. Typically the test involves measurement of the rhythmic and coordinated contractions (peristalsis) of the esophagus. Esophageal manometry also measures the function and competency of the doorway between the esophagus and stomach. This doorway or valve is called the lower esophageal sphincter (LES).
  
   Preparation for the procedure:    
       
 
Typically no food or liquids should be consumed for at least 8 hours prior to the esophageal manometry. Certain medications such as Reglan, Erythromycin, Nitroglycerin, Levsin, Donnatol, Librax and calcium channel blockers are usually discontinued 24 hours prior to your manometry procedure. Please provide your doctor with your medication list and consult our office regarding discontinuation of your medications. You do not need to have a driver. Most patients resume eating and other daily activities right after the procedure.
  
       
  How is esophageal manometry done?    
       
 
First the nose is anesthetized with a numbing gel that contains xylocaine. The nurse specialist applies the numbing gel into the nose using a Q-tip. Then a thin long tube called the manometry catheter is gently advanced through the anesthetized nose and slowly swallowed by patient into the esophagus. The manometry catheter is then gently removed while the patient is swallowing small amounts of water. The entire study takes less than 45 minutes. However, patients are usually asked to arrive an hour prior to procedure in order to be registered and checked into the manometry lab at Huntington Hospital. Our office staff will provide you with the time of arrival and approximate procedure start time. A full typed report will be mailed to your referring physician within 4 days of the procedure.
 
       
       
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