A colonoscopy is an endoscopic procedure that visually examines the entire colon with a videoscope. The inside of the colon is then examined for any abnormalities that may exist. During this procedure, polyps may be safely removed.

What’s a polyp?
A polyp is extra tissue that grows inside your body. Colon polyps grow in the large intestine. The large intestine, also called the colon, is part of your digestive system. It's a long, hollow tube at the end of your digestive tract where your body makes and stores stool.

Most polyps are not dangerous. Most are benign, which means they are not cancer. But over time, some types of polyps can turn into colon cancer. Usually, polyps that are smaller than a pea aren't harmful. But larger polyps could someday become cancer or may already be cancer. To be safe, doctors remove all polyps and test them.

Why do I need a colonoscopy?
This procedure is commonly performed for evaluation of abnormal radiographic studies, removal of polyps, assessment of bleeding and screening for colon cancer.

Colonoscopy is indicated for patients with inflammatory bowel disease, GI hemorrhage, polyp removal, screening for colon cancer and evaluation of abnormal x-rays of the GI tract.

An alternative exam to assess the colon is the barium enema. CT scans of the abdomen and pelvis are useful but do not always provide sufficient information about the colon itself. CT scans are not a good test for looking at tubular structures. They are, however, excellent tests for looking at structures surrounding the colon and intestines.

Preparation
An oral laxative solution is given the day before the procedure. This will cleanse the waste from the colon. It is important that the preparation be followed completely. This procedure examines the inside of the colon. Thus, if feces are retained, or the preparation is inadequate, areas of the colon that may be of importance to your health may be missed or misinterpreted. Usually the preparations given for these are excellent. If you have specific difficulties with laxatives or the preparations, please inform your physician beforehand so that alternatives can be addressed.

Please make sure that your physician knows well beforehand if you are taking any blood thinners. Specific instructions regarding the preparation are available in the section regarding preparations for procedures.

Procedure
In general, this procedure takes approximately 30 to 45 minutes to perform when done by a trained gastroenterologist. The procedure may take longer depending upon the intervention that may be required for any individual patient.

During the procedure, a video endoscope will be inserted into the anus. The scope will then be advance through the inside of the colon to the cecum (last part of the colon). Inspection, removal of polyps, etc. usually occur during withdrawal of the endoscope.

Patients undergoing this procedure usually receive a combination of intravenous anesthetics. These are usually Demerol (meperidine), Versed (midazolam) or Fentanyl. The exact combination, dose and frequency of each of these are individualized for each patient. In most cases, patients do not remember their procedure or are adequately sedated such that the discomfort is well tolerated.

During the procedure, the nurse assisting your physician with the procedure will continuously monitor your heart rate, oxygen saturation and blood pressure. Thus, should any difficulties occur, your physician and his team will be aware of the change quickly.

Recovery
After the procedure, the physician will discuss the results with the family and/or the patient. In many cases, the patient will not recall having talked with their physician. This is a natural, and understandable, event since some medications used during the procedure will induce a temporary amnesia.

After the procedure, patients are returned to a recovery area where they are monitored during their stay for 30 – 60 minutes. When the patient is stable, he or she will be discharged.

Patients must have someone to drive him or her home after conscious sedation (analgesics) has been administered.

Most patients will be lethargic and forgetful during the afternoon after the procedure. During this period of time, someone should be available to check in with the patient to insure their safety. No driving, complicated or important decisions or alcoholic beverages are allowed on the day of the procedure. By the next morning, most patients are able to continue with their daily activities.

To assist our patients, a written explanation of the procedure and its findings, in lay terms, will be given to the patient. Recommendations will be made regarding any further testing, treatments or office visits.

A copy of the endoscopic record is sent to all our referring physicians. Thus, your primary care physician will be aware of your procedure, the results and your gastroenterologist's recommendations.

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ERCP is a diagnostic test to examine the duodenum (the first portion of the small intestine), the papilla of Vater (a small nipple-like structure with openings leading to the bile ducts and the pancreatic duct), the bile ducts, the gallbladder and the pancreatic duct. The procedure is performed by using a long, flexible, viewing instrument (a duodenoscope) about the diameter of a pen. The duodenoscope is flexible and can be directed and moved around the many bends of the stomach and intestine. Two types of duodenoscopes are currently available. A fiber-optic duodenoscope uses a thin fiber-optic bundle to transmit images to the lens at the viewing end of the instrument. A videoscope uses a thin wire with a chip at the tip of the instrument to transmit images to a TV screen. The duodenoscope is inserted through the mouth, to the back of the throat, down the food pipe, through the stomach and into the first portion of the small intestine (duodenum). Once the papilla of Vater is identified, a small plastic catheter (cannula) is passed through an open channel of the duodenoscope into the papilla of Vater, and into the bile ducts and/or the pancreatic duct. Contrast material (dye) is then injected and x-rays are taken of the bile ducts and the pancreatic duct. The open channel also allows other instruments to be passed through it in order to perform biopsies, to insert plastic or metal tubing to relieve obstruction of bile ducts caused by cancer or scarring, and to perform incision by using electrocautery (electric heat). For further information on the anatomy and physiology of bile production (by the liver) and circulation, please visit the Gallstones article.

The liver is a large solid organ located beneath the right diaphragm. The liver produces bile, which is stored in the gallbladder (a small sac located beneath the liver). After meals, the gallbladder contracts and empties the bile through the cystic duct, into the bile ducts, through the papilla of Vater, and into the intestine to help with digestion. The pancreas is located behind the stomach. It also produces digestive juice which drains through the pancreatic duct into the papilla of Vater, and into the intestine.

What kind of preparation is required?
For the best possible examination, the stomach must be empty. The patient should not eat anything after midnight on the evening preceding the exam. In case the procedure is performed early in the morning, no liquid should be taken. In case the examination is performed at noon time, a cup of tea, juice, milk, or coffee can be taken 4 hours earlier. Heart and blood pressure medications should always be taken with a small amount of water in the early morning. Since the procedure will require intravenous sedation, the patient needs to have a companion drive him/her home after the procedure.

What can be expected during and after the procedure?
The patient will be given medication through a vein to cause relaxation and sleepiness. The patient will be given some local anesthetic to decrease the gag reflex. Some physicians do not use local anesthetic and prefer to give the patients more intravenous medication for sedation. This also applies to those patients who have a history of allergy to Xylocaine, cannot tolerate the bitter taste of the local anesthetic, or the numbness sensation in the throat. While the patient is lying on the left side on the x-ray table, the intravenous medication is given and then the instrument inserted gently through the mouth into the duodenum. The instrument advances through the food pipe and not the air pipe. It does not interfere with the breathing and gagging is usually prevented or decreased by the medication.

When the patient is in semi-conscious state, he/she can still follow instructions to change the position on the x-rays table. Once the instrument has been advanced into the stomach, there is minimal discomfort except for the foreign body sensation in the throat. The procedure can last any where from fifteen minutes to one hour, depending on the skill of the physician and the anatomy or abnormalities in that area.

After the procedure, the patients should be observed in the recovery area until most of the effects from the medication have worn off. This usually takes one to two hours. The patient may feel bloated or slightly nauseated from the medication or the procedure. Very rarely a patient experiences vomiting and may belch or pass some gas through the rectum. Upon discharge, the patient should be driven home by his/her companion and is advised to stay home for the rest of the day. The patient can resume usual activity the next day. Even though the physician may explain to the patient or companion regarding the findings after the procedure, it is still necessary to call the physician the next day to ensure that the patient understands the results of the examination.

What are the reasons for the examination?
The liver, bile ducts, gallbladder, pancreas and the papilla of Vater can be involved in numerous diseases, causing myriad of symptoms. ERCP is used in diagnosing and treating the following conditions:

• Gallstones in the bile duct
• Blockage of the bile duct by stones, cancer, stricture or compression from adjacent organs
• Jaundice (yellow coloring of the skin) due to obstruction of the bile duct, also causing darkening of the urine and light colored stool
• Persistent or recurrent upper abdominal pain which cannot be diagnosed by other tests
• Unexplained loss of appetite and weight loss
• Confirming the diagnosis of cancer of the pancreas or the bile duct, so that surgery or other treatment can be tailored

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At Atlantic Gastroenterology, we use the patented and proprietary CRH-O’Regan Disposable Hemorrhoid Banding System. This system is considered to be the “gold standard” and Midwest Gastroenterology is the only treatment center in Kansas City trained in this procedure. This highly effective (99%), minimally invasive procedure is performed in our offices in less than a minute, and most patients return to work that same day. We make recommendations to reduce the chance of recurrence later (currently 5% in 2 years). If there are multiple hemorrhoids, we treat them one at a time in separate visits.

During the brief and painless procedure, our physician specialist places a small rubber band around the tissue just above the internal hemorrhoid where there are few pain-sensitive nerve endings. Unlike traditional banding techniques that use a metal-toothed clamp to grasp the tissue, we use a gentle suction device, reducing the risk of pain and bleeding. Advanced cases where the diagnosis is both internal and external hemorrhoids may require additional therapy, as rubber banding alone may not be suitable.

Our banding procedure works by cutting off the blood supply to the hemorrhoid. This causes the hemorrhoid to shrink and fall off, typically within a day or so. You probably won’t even notice when this happens or be able to spot the rubber band in the toilet. Once the hemorrhoid is gone, the wound usually heals in a week or two.

During the first 24 hours, some patients may experience a feeling of fullness or a dull ache in the rectum. This can typically be relieved with an over-the-counter pain medication. However, a remarkable 99.8% of patients treated with out method have no post-procedure pain.

In fact, thanks to design improvements, our procedure has a ten-fold reduction in complications compared to traditional banding. Our instruments are smaller, affording greater comfort for patients and better visibility for physicians. Unlike other devices, they are single use and 100% disposable.

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A hydrogen breath test (or HBT) is used as a clinical medical diagnosis for people with irritable bowel syndrome, and common food intolerances. The test is simple, non-invasive, and is performed after a short period of fasting (typically 8-12 hours). Even though the test is normally known as a "Hydrogen Breath Test" some physicians may also test for methane in addition to hydrogen. Many studies have shown that some patients (approximately 35% or more) do not produce hydrogen but actually produce methane. Some patients produce a combination of the two gases. Other patients don't produce any gas, which are known as "Non-Responders", some physicians believe that these individuals actually produce another gas which has not been determined yet. In addition to Hydrogen and Methane, some facilities also utilize Carbon Dioxide (CO2) in the patients breath to determine if the breath samples that are being analyzed are not contaminated (either with room air or bronchial dead space air).

Tests vary from country to country, so the following information is provided as a rough guide to typical uses of the hydrogen breath test:

Fructose malabsorption - the patient takes a base reading of hydrogen levels in his/her breath. The patient is then given a small amount of fructose, and then required to take readings every 15, 30 or 60 minutes for two to three hours. If the level of hydrogen rises above 20 ppm (parts per million) over the lowest preceding value within the test period, the patient is typically diagnosed as a fructose malabsorber. If the patient produces methane then the parts per million for the methane typically rises 12 ppm over the lowest preceding value to be considered positive. If the patient produces both hydrogen and methane then the values are typically added together and the mean of the numbers is used to determine positive results, usually 15 ppm over the lowest preceding value.

Lactose intolerance - the patient takes a base reading of hydrogen levels in his/her breath. The patient is then given a small amount of pure lactose (typically 20 to 25 g), and then required to take readings every 15, 30 or 60 minutes for two to three hours. If the level of hydrogen rises above 20 ppm (parts per million) over the lowest preceding value within the test period, the patient is typically diagnosed as a lactose malabsorber. If the patient produces methane then the parts per million for the methane typically rises 12 ppm over the lowest preceding value to be considered positive. If the patient produces both hydrogen and methane then the values are typically added together and the mean of the numbers is used to determine positive results, usually 15 ppm over the lowest preceding value.

Small Bowel Bacterial Overgrowth Syndrome (SBBOS) or Small Intestinal Bacterial Overgrowth (SIBO) - the patient is either given a challenge dose of glucose, also known as dextrose (75-100 grams) or lactulose (10 grams). Breath samples are then collected at 15 minute or 20 minute intervals after the baseline is collected for 3-5 hours. Positive diagnosis for a lactulose SIBO breath test - typically positive if the patient produces approximately 20 ppm of Hydrogen and/or Methane within the first two hours (indicates bacterial in the small intestine), followed by a much larger peak (colonic response). This is also known as a biphasic pattern. Lactulose is not absorbed by the digestive system and can help determine distal end bacterial overgrowth, which means the bacteria is lower in the small intestine. Positive diagnosis for a glucose SIBO breath test - Glucose is absorbed by the digestive system so studies have shown it to be harder to diagnose distal end bacterial overgrowth since the glucose typically doesn't reach the colon before being absorbed. An increase of approximately 12 ppm or more in hydrogen and/or methane during the breath test could conclude bacterial overgrowth.

The excess hydrogen or methane is typically caused by an overgrowth of otherwise normal intestinal bacteria.

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In a liver biopsy, the physician examines a small piece of tissue from your liver for signs of damage or disease. A special needle is used to remove the tissue from the liver. The physician decides to do a liver biopsy after tests suggest that the liver does not work properly. For example, a blood test might show that your blood contains higher than normal levels of liver enzymes or too much iron or copper. An x ray could suggest that the liver is swollen. Looking at liver tissue itself is the best way to determine whether the liver is healthy or what is causing it to be damaged.

Preparation
Before scheduling your biopsy, the physician will take blood samples to make sure your blood clots properly. Be sure to mention any medications you take, especially those that affect blood clotting, like blood thinners. One week before the procedure, you will have to stop taking aspirin, ibuprofen, and anticoagulants.

You must not eat or drink anything for 8 hours before the biopsy, and you should plan to arrive at the hospital about an hour before the scheduled time of the procedure. Your physician will tell you whether to take your regular medications during the fasting period and may give you other special instructions.

Procedure
Liver biopsy is considered minor surgery, so it is done at the hospital. For the biopsy, you will lie on a hospital bed on your back with your right hand above your head. After marking the outline of your liver and injecting a local anesthetic to numb the area, the physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue. In some cases, the physician may use an ultrasound image of the liver to help guide the needle to a specific spot.

You will need to hold very still so that the physician does not nick the lung or gallbladder, which are close to the liver. The physician will ask you to hold your breath for 5 to 10 seconds while he or she puts the needle in your liver. You may feel pressure and a dull pain. The entire procedure takes about 20 minutes.

Two other methods of liver biopsy are also available. For a laparoscopic biopsy, the physician inserts a special tube called a laparoscope through an incision in the abdomen. The laparoscope sends images of the liver to a monitor. The physician watches the monitor and uses instruments in the laparoscope to remove tissue samples from one or more parts of the liver. Physicians use this type of biopsy when they need tissue samples from specific parts of the liver.

Transvenous biopsy involves inserting a tube called a catheter into a vein in the neck and guiding it to the liver. The physician puts a biopsy needle into the catheter and then into the liver. Physicians use this procedure when patients have blood-clotting problems or fluid in the abdomen.

Recovery
After the biopsy, the physician will put a bandage over the incision and have you lie on your right side, pressed against a towel, for 1 to 2 hours. The nurse will monitor your vital signs and level of pain.

You will need to arrange for someone to take you home from the hospital since you will not be allowed to drive after having the sedative. You must go directly home and remain in bed (except to use the bathroom) for 8 to 12 hours, depending on your physician's instructions. Also, avoid exertion for the next week so that the incision and liver can heal. You can expect a little soreness at the incision site and possibly some pain in your right shoulder. This pain is caused by irritation of the diaphragm muscle (the pain usually radiates to the shoulder) and should disappear within a few hours or days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after surgery. These medicines decrease blood clotting, which is crucial for healing.

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Capsule endoscopy is a procedure designed to help your physician see what is happening inside parts of your gastrointestinal (GI) tract. The GI tract is the tube which extends from the mouth to the anus in which the movement of muscles digests food. During the procedure, a patient swallows a vitamin-sized pill with a camera inside. Transported smoothly and painlessly through the GI tract by the body’s own natural peristalsis, the PillCam video capsule transmits images of different parts of your body such as the small intestine and the esophagus. Since the first PillCam video capsule was approved by the FDA in 2001, more than 700,000 patients have safely swallowed one of the PillCam video capsules.

Capsule endoscopy is the least invasive and most direct way for doctor’s to see the entire small intestine and esophagus. Hundreds of clinical studies conducted by the world’s leading gastroenterologists have shown the value of the PillCam video capsules in helping doctors diagnose or rule out disorders of the GI tract.

The PillCam SB video capsule measures 11 mm x 26 mm and weighs less than 4 grams. It contains an imaging device and light-source on one-side and transmits images at a rate of 2 images per second generating more than 50,000 pictures over an 8-hour period.

PillCam SB was initially cleared by the U.S. Food and Drug Administration in 2001 and today is used by physicians to detect and diagnose disorders of the small intestine. This includes Crohn’s disease, small bowel tumors, malabsorption disorders (such as celiac disease), GI injuries induced by extended NSAID use and suspected GI bleeding of the small bowel.

The Company’s next generation small bowel video capsule, PillCam SB 2, was cleared for marketing by U.S. Food and Drug Administration in May 2007. It is the same size as the PillCam SB video capsule and offers advanced optics and a wider field of view to image the small intestine. PillCam SB 2 also captures nearly twice the mucosal area per image.

How the Procedure Works
A patient fasts starting at midnight the day before the procedure. The following morning they arrive at the physician’s office where they are prepped for the procedure. This includes attaching the sensor array to the patient’s abdomen and the data recorder to a belt around the patient’s waist. Once these tasks have been completed the patient will be given a glass of water to help swallow the vitamin-sized pill. The patient can resume daily activities once he or she has successfully swallowed the PillCam video capsule. After 8-hours the patient returns to the physician’s office to return the device and the pill passes naturally with a bowel movement usually within 24 hours.

Images are downloaded by the physician to the Given workstation for review and diagnosis. The proprietary RAPID software installed on the workstation contains an image atlas to help facilitate the analysis.

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Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, infection, tumors, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy.

For the procedure you will swallow a thin, flexible, lighted tube called an endoscope (EN-doh-skope). Right before the procedure, the physician will spray your throat with a numbing agent that may help prevent gagging. You may also receive pain medicine and a sedative to help you relax during the exam. The endoscope transmits an image of the inside of the esophagus, stomach and duodenum, so the physician can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for the physician to examine the stomach. The physician can see abnormalities, like inflammation or bleeding, through the endoscope that don't show up well on x-rays. The physician can also insert instruments into the scope to remove samples of tissue (biopsy) for further tests or treat bleeding abnormalities.

Possible complications of upper endoscopy include bleeding, perforation, or mild sore throat. However, such complications are rare. The procedure takes 20 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 30 to 60 minutes, or until the medication wears off.

Preparation
Your stomach and duodenum must be empty for the procedure to be thorough and safe, so you will not be able to eat or drink anything for at least 6 hours beforehand. Also, you must arrange for someone to take you home--you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions.

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