Anand Kesari MD                                                  (352) 237-1253

Colonoscopy is the visual examination of the large intestine (colon) using a lighted, flexible fiberoptic or video endoscope. The colon begins in the right-lower abdomen and looks like a big question mark as it moves up and around the abdomen, ending in the rectum. It is 5 to 6 feet long. The colon has a number of functions including withdrawing water from the liquid stool that enters it so that a formed stool is produced.

Equipment: The flexible colonoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the colon. These colonoscopes now come in two types. The original purely fiberoptic instrument has a flexible bundle of glass fibers that collects the lighted image at one end and transfers the image to the eye piece. The newer video endoscopes use a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to a computer which displays the image on a large video screen. An open channel in these scopes allows other instruments to be passed through in order to perform biopsies, remove polyps or inject solutions.

Reasons For The ExamThere are many types of problems that can occur in the colon. The medical history, physical exam, laboratory tests and x-rays can provide information useful in making a diagnosis. Directly viewing the inside of the colon by colonoscopy is usually the best exam.

Colonoscopy is used for:

• Colon cancer -- a serious but highly curable malignancy
  
• Polyps -- fleshy tumors which usually are the forerunners of colon cancer
  
• Colitis (ulcerative or Crohn's) -- chronic, recurrent inflammation of the colon
  
• Diverticulosis and diverticulitis -- pockets along the intestinal wall that develop over time and can become infected
  
• Bleeding lesions -- bleeding may occur from different points in the colon
  
• Abdominal symptoms, such as pain or discomfort, particularly if associated with weight loss or anemia
  
• Abnormal barium x-ray exam
  
• Chronic diarrhea, constipation, or a change in bowel habits
  
• Anemia
  

Preparation To obtain the full benefits of the exam, the colon must be clean and free of stool. The patient receives instructions on how to do this. It involves drinking a solution which flushes the colon clean or taking laxatives and enemas. Usually the patient drinks only clear liquids and eats no food for the day before the exam. The physician advises the patient regarding the use of regular medications during that time.

The ProcedureColonoscopy is usually performed on an outpatient basis. The patient is mildly sedated, the endoscope is inserted through the anus and moved gently around the bends of the colon. If a polyp is encountered, a thin wire snare is used to lasso it. Electrocautery (electrical heat) is applied to painlessly remove it. Other tests can be performed during colonoscopy, including biopsy to obtain a small tissue specimen for microscopic analysis.
The procedure takes 15 to 30 minutes and is seldom remembered by the sedated patient. A recovery area is available to monitor vital signs until the patient is fully awake. It is normal to experience mild cramping or abdominal pressure following the exam. This usually subsides in an hour or so.

Results After the exam, the physician explains the findings to the patient and family. If the effects of the sedatives are prolonged, the physician may suggest an appointment at a later date. If a biopsy has been performed or a polyp removed, the results of these are not available for three to seven days.

BenefitsA colonoscopy is performed to identify and/or correct a problem in the colon. The test enables a diagnosis to be made and specific treatment can be given. If a polyp is found during the exam, it can be removed at that time, eliminating the need for a major operation later. If a bleeding site is identified, treatment can be administered to stop the bleeding. Other treatments can be given through the endoscope when necessary.

Alternative TestingAlternative tests to colonoscopy include a barium enema or other types of x-ray exams that outline the colon and allow a diagnosis to be made. Study of the stools and blood can provide indirect information about a colon condition. These exams, however, do not allow direct viewing of the colon, removal of polyps, or the completion of biopsies.

Side Effects and RisksBloating and distension typically occur for about an hour after the exam until the air is expelled. Serious risks with colonoscopy, however, are very uncommon. One such risk is excessive bleeding, especially with the removal of a large polyp. In rare instances, a tear in the lining of the colon can occur. These complications may require hospitalization and, rarely, surgery. Quite uncommonly a diagnostic error or oversight may occur.

Due to the mild sedation, the patient should not drive or operate machinery following the exam. For this reason, someone should be available to drive the patient home.

SummaryColonoscopy is an outpatient exam that is performed with the patient lightly sedated. The procedure provides significant information used to determine which specific treatment will be given. In certain cases, therapy can be administered directly through the endoscope. Serious complications rarely occur from colonoscopy.

Sigmoidoscopy

Sigmoidoscopy is the visual examination of the inside of the rectum and sigmoid colon, using a lighted, flexible tube connected to an eyepiece or video screen for viewing. This device is called an endoscope. The colon (large intestine) is 5 to 6 feet long. During a sigmoidoscopy, only the last 1 to 2 feet of the colon is examined. This last part of the colon, just above the rectum, is called the sigmoid colon.

Equipment The flexible endoscope is a remarkable piece of equipment that can be directed and moved around the bends in the lower colon and rectum. The image in the bowel is transmitted through the endoscope either to the eyepiece or a video screen. An open channel in the scope allows other instruments to be passed through it to take tissue samples (biopsies) or to remove polyps.

Preparation for the TestTo obtain the full benefit of the exam and allow a thorough inspection, the rectum and sigmoid colon must be clean. Preparation usually involves drinking clear liquids the day before along with taking enemas and/or laxatives. Specific instructions for preparation are provided beforehand.

The Procedure Flexible sigmoidoscopy is usually performed on an outpatient basis. It is performed with the patient lying on the left side with the legs drawn up. A sheet is placed over the lower body. A finger or digital exam of the anus and rectum is performed. Then the endoscope is gently inserted into the rectum. Air is inflated into the bowel to expand it and allow for careful examination. The patient usually feels a slight discomfort similar to strong gas cramps. The endoscope is then advanced under direct vision and moved around the various bends in the lower bowel.

It is advanced as far as possible without causing undue discomfort. When possible, the exam is continued to 25 inches (60 cm). Certain conditions, such as diverticulosis, irritable bowel syndrome, or prior pelvic surgery may produce discomfort when the sigmoid colon is entered by the endoscope. The exam is stopped if this occurs. The exam usually takes 5 to 15 minutes. Sedation is not normally required.

BenefitsThe benefits of sigmoidoscopy can include the following:

• It is often possible to determine the specific cause of symptoms.
• Conditions such as colitis and diverticulosis can be monitored to determine effectiveness of treatment.
• Polyps and tumors can be discovered at an early stage.
  

Alternative TestingAlternative testing includes barium enema x-ray exams. Additionally, the stools can be examined in a variety of ways to uncover or study certain bowel conditions. However, a direct look at the lower rectum and lower bowel by sigmoidoscopy is by far the best method of examining this area.

Side Effects and RisksBloating and bowel distension are common due to the air inflated into the bowel. This usually lasts only 30 to 60 minutes. If biopsies are done or if a polyp is removed, there may be some spotting of blood. However, this is rarely serious. Other uncommon risks include a diagnostic error or oversight, or a tear (perforation) of the wall of the colon which might require surgery.

SummarySigmoidoscopy is a simple outpatient exam which can uncover a serious medical problem. Specific diagnoses can be made. Treatment programs can be evaluated, or reassurance can be provided when the exam is normal. It is one of the most useful and simple exams in medicine.

Capsule endoscopy is a procedure that uses a tiny wireless camera to take pictures of your digestive tract. A capsule endoscopy camera sits inside a vitamin-sized capsule that you swallow. As the capsule travels through your digestive tract, the camera takes thousands of pictures that are transmitted to a recorder you wear on a belt around your waist.

Capsule endoscopy helps doctors see inside your small intestine — an area that isn't easily reached with more-traditional endoscopy procedures.

Situations in which your doctor might recommend a capsule endoscopy procedure include:

• Gastrointestinal bleeding. Capsule endoscopy may help your doctor find the cause of gastrointestinal bleeding if other tests and procedures haven't been conclusive.
• Crohn's disease. Capsule endoscopy may reveal areas of inflammation in the small intestine that can help your doctor diagnose inflammatory bowel diseases, such as Crohn's disease.
• Cancer. Capsule endoscopy may show tumors in the small intestine or other parts of the digestive tract.
• Celiac disease. Capsule endoscopy is sometimes used in diagnosing and monitoring celiac disease.
• Polyps. People who have inherited syndromes that can cause polyps in the small intestine may occasionally undergo capsule endoscopy to screen for polyps.
• Follow-up testing after X-rays or other imaging tests. If results of an X-ray or other imaging test were unusual or unclear, your doctor may recommend a capsule endoscopy as a follow-up test.

Risks
A capsule that becomes lodged in the digestive tract
In most cases, the capsule that contains the tiny camera will leave your body when you have a bowel movement later in the day or within several days. In rare cases, the capsule can become lodged in your digestive tract.

The risk is thought to be small — 1 to 5 percent of people undergoing capsule endoscopy may experience capsule retention. Put another way, this means that for every 100 people who undergo capsule endoscopy, as many as five may still have the capsule in their bodies after two weeks. The risk may be slightly higher in people known to have Crohn's disease.

Patient Information for Undergoing Capsule Endoscopy

This procedure involves ingesting a capsule (about the size of a large vitamin pill). Capsule will pass naturally though your digestive system while taking pictures of the intestine. 

• The images are transmitted to the Sensor Array, a serious of wires and electrodes similar to those used when taking an EKG.  The Sensor Array is attached to a walkman-like given Data Recorder which saves all the images.  It is placed in the Recorder Belt, which is worn around your waist.
• After 8 hours you will return to endoscopy unit to have the Recorder Belt removed. Capsule is disposable and will be excreted naturally in your bowel movement.

• Plan to take it easy for the day. In most cases, you'll be allowed to go about your day after you swallow the capsule that contains the camera. But you won't be allowed to do any strenuous exercise or heavy lifting. If you have an active job, ask your doctor whether you can go back to work the day of your capsule endoscopy.

 
The day before the Capsule Endoscopy

• If you are diabetic and taking insulin, take only 1/2 of your regular dose the day before your capsule endoscopy.
• Drink "regular" sugar containing liquids rather than Sugar-Free liquids on the day before the test.
• If you are taking iron or iron containing supplements, stop taking them 1 week prior to your scheduled capsule endoscopy.

1. The entire day before the procedure,  you will be on a clear liquid diet.  This includes only: iced and hot black tea, black coffee, clear broth, apple or white grape juice, soda, Jell-O (do not have red Jell-O)
2. Do not eat or drink anything after midnight.
3. Do not take medications the morning of your exam.  You may bring them with you and you will be able to take them 2 hours after swallowing the capsule.

The day of the Capsule Endoscopy

• If you are diabetic and taking insulin, take only 1/2 of your regular dose the day of the capsule endoscopy.
• Have nothing to eat or drink.
• Do not take your regular medications, but you may bring them with you.  You will be able to take them 2 hours after you swallow the video capsule.

After ingesting the M2A Capsule

After swallowing the video capsule you will be given a sheet to record what you eat, drink, your activity, and unusual sensations - if any.

• Do not eat or drink anything for 2 hours after swallowing the capsule.
• After 2 hours you will be able to drink clear liquids.
• Four hours after swallowing the capsule you may have a light lunch and continue drinking clear liquids throughout the procedure.
• After ingesting the video capsule and until it is excreted, you should not be near any source of powerful electromagnetic fields such as some created near an MRI device or amateur (ham) radio.  Occasionally, some images may be lost due to radio occasions this may result in the need to repeat the capsule endoscopy examination.
• Capsule endoscopy lasts approximately 8 hours.  You do not have to remain in the hospital during this time.  Do not disconnect the equipment or remove the belt at any time during this period.
• The Data Recorder is actually a small computer, and should be treated with utmost care and protection.  Avoid sudden movement and banging of the Data Recorder. 
• You will need to return to Endoscopy Unit 8 hours after ingestion of the capsule to have the equipment removed.  Removing the equipment is a fairly quick process and should only take a few minutes.
• After the examination is completed you may return to your normal diet.
• Contact your physician immediately if you suffer from any abdominal pain, nausea, or vomiting during of after the Capsule Endoscopy.

Upper GI endoscopy, sometimes called EGD (esophagogastroduodenoscopy), is a visual examination of the upper intestinal tract using a lighted, flexible fiberoptic or video endoscope. The upper gastrointestinal tract begins with the mouth and continues with the esophagus (food tube) which carries food to the stomach. The

J-shaped stomach secretes a potent acid and churns food into small particles. The food then enters the duodenum, or small bowel, where bile from the liver and digestive juices from the pancreas mix with it to help the digestive process.

EquipmentThe flexible endoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the gastrointestinal tract. Endoscopes now come in two types. The original pure fiberoptic instrument has a flexible bundle of glass fibers that collect the lighted image at one end and transfer the image to the eye piece. The newer video endoscopes have a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to the computer which then displays the image on a large video screen. An open channel in these scopes allows other instruments to be passed through in order to take tissue samples, remove polyps and perform other exams.

Reasons for the ExamDue to factors related to diet, environment and heredity, the upper GI tract is the site of numerous disorders. These can develop into a variety of diseases and/or symptoms. Upper GI endoscopy helps in diagnosing and often in treating these conditions:

ulcers --which can develop in the esophagus, stomach, or duodenum; occasionally ulcers can be malignant tumors of the stomach or esophagus difficulty in swallowing upper abdominal pain or indigestion

intestinal bleeding -- hidden or massive bleeding can occur for various reasons

esophagitis and heartburn -- chronic inflammation of the esophagus due to reflux of stomach acid and digestive juices

gastritis -- inflammation of the lining of the stomach

PreparationIt is important not to eat or drink anything for at least eight hours before the exam. The physician instructs the patient about the use of regular medications, including blood thinners, before the exam.

The Procedure Upper GI endoscopy is usually performed on an outpatient basis. The throat is often anesthetized by a spray or liquid. Intravenous sedation is usually given to relax the patient, deaden the gag reflex and cause short-term amnesia. For some individuals who can relax on their own and whose gagging can be controlled, the exam is done without intravenous medications. The endoscope is then gently inserted into the upper esophagus. The patient can breath easily throughout the exam. Other instruments can be passed through the endoscope to perform additional procedures if necessary. For example, a biopsy can be done in which a small tissue specimen is obtained for microscopic analysis. A polyp or tumor can be removed using a thin wire snare and electrocautery (electrical heat). The exam takes from 15 to 30 minutes, after which the patient is taken to the recovery area. There is no pain with the procedure and patients seldom remember much about it.

ResultsAfter the exam, the physician will explain the results to the patient and family. If the effects of the sedatives are prolonged, the physician may suggest an interview at a later date when the results can be fully understood. If a biopsy has been performed or a polyp removed, the results are not available for three to seven days.

Benefits An upper GI endoscopy is performed primarily to identify and/or correct a problem in the upper gastrointestinal tract. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a bleeding site is identified, treatment can stop the bleeding, or if a polyp is found, it can be removed without a major operation. Other treatments can be given through the endoscope when necessary.

Alternative TestingAlternative tests to upper GI endoscopy include a barium x-ray and ultrasound (sonogram) to study the organs in the upper abdomen. Study of the stools, blood and stomach juice can provide indirect information about a gastrointestinal condition. These exams, however, do not allow for a direct viewing of the esophagus, stomach and duodenum, removing of polyps or taking of biopsies.

Side Effects and RisksA temporary, mild throat irritation sometimes occurs after the exam. Serious risks with upper GI endoscopy, however, are very uncommon. One such risk is excessive bleeding, especially with removal of a large polyp. In extremely rare instances, a perforation, or tear, in the esophagus or stomach wall can occur. These complications may require hospitalization and, rarely, surgery. Quite uncommonly, a diagnostic error or oversight may occur. Due to the mild sedation, the patient should not drive or operate machinery following the exam. For this reason, someone else should be available to drive the patient home.

SummaryUpper GI endoscopy is a simple outpatient exam that is often performed with the patient lightly sedated. The procedure provides significant information upon which specific treatment can be given. In certain cases, therapy can be administered directly through the endoscope. Serious complications rarely occur from upper GI endoscopy.

Esophageal Dilatation

Esophagus can become blocked or injured in a variety of ways. Esophageal dilatation is the technique used to stretch or open the blocked portion of the esophagus.

Causes of Esophageal Blockage: There are several causes of blockage or stricture of the esophagus. They all can make swallowing food and/or fluids difficult. The physician's first job is to find the reason for the stricture or narrowing. The answer can usually be provided by the medical history, physical exam, x-rays, and endoscopy which is a visual exam of the esophagus using a flexible fiberoptic tube.

Acid Peptic Stricture - This condition is very common. The stomach produces acid which, in turn, can reflux into the esophagus. This event is usually made worse by the presence of a hiatus hernia. Over time, the acid and peptic stomach juices injure the esophagus, causing inflammation and then scarring. The fibrous scar then contracts and narrows the esophageal opening.

Schatzki's Ring - This condition is really exactly that, a narrow ring of benign fibrous tissue constricting the lower esophagus. Physicians still do not know how it develops.

Achalasia - This condition is uncommon and quite fascinating to physicians. The problem is a persistent and marked spasm of the lower esophageal muscle. This spasm just does not open up to allow food and fluid through. The result is a persistent blockage with subsequent slow trickling of the esophageal contents into the stomach.

Ingestion of Caustic Agents - Children are particularly prone to swallowing liquid lye and other agents which can severely burn the esophagus, leaving it narrowed.

Tumors - Various forms of tumors, benign and malignant, can block the esophagus. This condition is obviously very important to diagnose and treat promptly.

Heredity - The esophagus may be partially or completely blocked at birth.

Methods of Esophageal DilatationIn most instances, the problem is a mechanical one with an obstruction acting like a dam across a stream. Therefore, the treatment must be mechanical. The dam must be broken. After a diagnosis is made, the physician determines the best method of treatment. The physician has a variety of techniques available. Each has benefits and is appropriate in specific cases.

Simple dilators (Bougies) - These are a series of flexible dilators of increasing thickness. One or more of these are passed down through the esophagus at a time. The bougie is the simplest and quickest method of opening the esophagus.

Guided Wire Bougie - >In some instances, the physican performs endoscopy and places a flexible wire across the stricture. The endoscope is removed and the wire left in place. A dilator with a hole through it from end to end is guided down the esophagus and across the stricture. One or more of these dilators are passed over the wire. At the end of the exam, the wire is removed. This type of treatment may be performed in the x-ray department under fluoroscopy.

Balloon dilators -Flexible endoscopy allows the physician to directly view the stricture. Deflated balloons are placed through the endoscope and across the stricture. When inflated, they become sausage shaped, stretch, and break the stricture.

Achalasia Dilators - Achalasia is a special situation which requires a larger, balloon-type dilator. The procedure is frequently done under x-ray control. In this situation, the spastic muscle fibers in the lower esophagus are stretched and broken, which in turn allows easier passage of food and liquid into the stomach.

The ProcedureAs mentioned, there are a number of dilating techniques available to the physician. Simple bougie dilatation may be done in the office, in a sitting position, and with only an anesthetic spray of the throat. If endoscopy is performed at the same time, then it will be done in the endoscopy suite, usually under sedation. If x-ray fluoroscopy equipment is needed, the procedure is performed in the x-ray unit. Simple bougie dilatation may take only a few minutes. The other techniques require 20 to 30 minutes. Recovery is usually quick and the patient can soon begin eating and drinking to test the effectiveness of the treatment.

ComplicationsEsophageal dilatation is usually performed effectively and without problems. However, some complications can occur. A small amount of bleeding almost always happens at the treatment site. At times, it can be excessive, requiring evaluation and treatment. An uncommon but known complication is perforation of the esophagus. The wall of the esophagus is thin and, despite the best efforts of the physician, can tear. An operation may be required to correct this problem.

Alternative TreatmentsThe alternative treatment options are to do nothing or to undergo major chest surgery. The latter is recommended only if dilatation is ineffective.

SummaryNarrowing or stricture of the esophagus is a very common problem. The physician can almost always uncover the specific cause of the stricture. And there are a variety of treatment options available for the physician. Complications are rare and, in most instances, a satisfactory outcome occurs with complete clearing of or improvement in the swallowing problem.

ERCP stands for endoscopic retrograde cholangiopancreatography. As hard as this is to say, the actual exam is fairly simple. A dye is injected into the bile and pancreatic ducts using a flexible, video endoscope. Then x-rays are taken to outline the bile ducts and pancreas. The liver produces bile, which flows through the ducts, passes or fills the gallbladder and then enters the intestine (duodenum) just beyond the stomach. The pancreas, which is six to eight inches long, sits behind the stomach. This organ secretes digestive enzymes that flow into the intestine through the same opening as the bile. Both bile and enzymes are needed to digest food.

Equipment

The flexible endoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the upper gastrointestinal tract. The newer video endoscopes have a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to the computer which then displays the image on a large video screen. An open channel in the scope allows other instruments to be passed through it to perform biopsies, inject solutions, or place stents.

Reasons for the Exam

Due to factors related to diet, environment and heredity, the bile ducts, gallbladder and pancreas are the seat of numerous disorders. These can develop into a variety of diseases and/or symptoms. ERCP helps in diagnosing and often in treating the condition.

ERCP is used for:
Gallstones, which are trapped in the main bile duct

• lockage of the bile duct
• Yellow jaundice, which turns the skin yellow and the urine dark
• Undiagnosed upper-abdominal pain
• Cancer of the bile ducts or pancreas
• Pancreatitis (inflammation of the pancreas)

Preparation
The only preparation needed before an ERCP is to not eat or drink for eight hours prior to the procedure. You may be asked to stop certain medications such as aspirin before the procedure. Check with the physician.
The Procedure
An ERCP uses x-ray films and is performed in an x-ray room. The throat is anesthetized with a spray or solution, and the patient is usually mildly sedated. The endoscope is then gently inserted into the upper esophagus. The patient breathes easily throughout the exam, with gagging rarely occurring. A thin tube is inserted through the endoscope to the main bile duct entering the duodenum. Dye is then injected into this bile duct and/or the pancreatic duct and x-ray films are taken. The patient lies on his or her left side and then turns onto the stomach to allow complete visualization of the ducts. If a gallstone is found, steps may be taken to remove it. If the duct has become narrowed, an incision can be made using electrocautery (electrical heat) to relieve the blockage. Additionally, it is possible to widen narrowed ducts and to place small tubing, called stents, in these areas to keep them open. The exam takes from 20 to 40 minutes, after which the patient is taken to the recovery area.
Results
After the exam, the physician explains the results. If the effects of the sedatives are prolonged, the physician may suggest an appointment for a later date when the patient can fully understand the results.
Benefits
An ERCP is performed primarily to identify and/or correct a problem in the bile ducts or pancreas. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a gallstone is found during the exam, it can often be removed, eliminating the need for major surgery. If a blockage in the bile duct causes yellow jaundice or pain, it can be relieved.
Alternative Testing
Alternative tests to ERCP include certain types of x-rays (MRI, CAT scan, CT) and sonography (ultrasound) to visualize the pancreas and bile ducts. In addition, dye can be injected into the bile ducts by placing a needle through the skin and into the liver. Small tubing can then be threaded into the bile ducts. Study of the blood also can provide some indirect information about the ducts and pancreas.

Side Effects and Risks
A temporary, mild sore throat sometimes occurs after the exam. Serious risks with ERCP however, are uncommon. One such risk is excessive bleeding, especially when electrocautery is used to open a blocked duct. In rare instances, a perforation or tear in the intestinal wall can occur. Inflammation of the pancreas also can develop. These complications may require hospitalization and, rarely, surgery.
Due to the mild sedation, the patient should not drive or operate machinery for 24 hours following the exam. For this reason, a driver MUST accompany the patient to the exam.