Endoscopy & Imaging the gut

In an upper GI endoscopy (sometimes also called gastroscopy), the oesophagus (gullet), stomach and the first part of the small intestine (duodenum) are visually examined using a flexible instrument endoscope (a flexible fibreoptic tube less than a third of the diameter of the food pipe). The endoscope does not interfere with the patient’s breathing.
After a local anaesthetic is sprayed onto the back of the throat, the endoscope is passed through the mouth into the oesophagus to see the lining clearly. Some air is blown into the stomach to open it up to allow the doctor to inspect the stomach

Please do not come to the hospital wearing jewellery or carrying valuables. In case you need sedation, they may remain unattended. You may be asked to change your clothing and given a cap to tuck all your hair into. You may leave your belongings, your dentures, hearing aids, glasses, and contact lens in a secure locker provided by us, the key of which will remain with you or your
relations till you leave.
At first, our nursing staff will review all your previous medical records. They will ask you about the last time you had anything to eat or drink and if you have any allergies. They will ask about special needs or concerns. You will lie on a stretcher in the procedure room. Monitoring equipment may be applied to your chest and a finger. This allows the endoscopy team to continuously observe your heart rate, blood pressure and oxygen level in your blood. Safety devices will be used to keep you safe, comfortable, and secure throughout your procedure. More commonly, the entire procedure can be comfortably done following just a local anaesthetic sprayed on the back of the throat. There may be some gagging as the endoscope passes the mouth, but if you remember to breathe quietly through the nose or the mouth
during the procedure, it’s not so unpleasant.
Patients who smoke may gag violently even with adequate local spray. We offer doing these outpatients Conscious Sedation (you are in a sleep-like state, feel no pain, and are able to breathe on your own without assistance). You may, however, need to wait for 2 to 3 hours following the procedure till the drug effects
wane. After the procedure, you will have the privacy to change and tidy up. Your Endoscopy report will
be made available to you as soon as possible, and you can discuss the findings with your doctor. In case additional procedures (like a biopsy, etc) were done during Endoscopy, please confirm with the Staff when these reports would be available, so you could schedule your Follow up appointments. before finally passing the endoscope into the duodenum. The air is sucked out and the instrument is removed.
Photographs & video recordings can be made during the procedure.

Examination of the upper digestive tract is also possible by a barium test. However, even I the best of hands, some information cannot be got by a barium test. During Endoscopy, the doctor can
directly look at specific areas to better evaluate and detect problems.

Following endoscopy, you may feel a little bloated for a short while, or feel you have a sore throat. The commoner side effects of the sedatives used include drowsiness, lightheartedness and nausea. But the risk of a complication happening during a diagnostic endoscopy is negligible(less than 0.01%). You do realize that you yourself can minimize the risks when you read the following. Food in the stomach may get inhaled into the lungs. Thus, we prefer to call patients fasting in the morning. Patients with procedures scheduled afternoon may be allowed a cup of tea; but only if the doctor doing the procedure gives prior permission. If sedation is used, it may cause some slowing or lightening of breathing, increasing this risk further.
If you are taking any medication daily on a regular basis (like for diabetes, blood pressure, heart ailments, etc.) please discuss the timing of the doses with the Endoscopist or your regular doctor for the day of endoscopy.
If you are using aspirin or medicine that ‘thins’ blood (anticoagulants), the Endoscopist will need to take precautions so that you will not have significant bleeding in case a biopsy is performed during the Endoscopy. He may even need to withhold these drugs or even reschedule your Endoscopy.

Please remove your dentures (even partial dentures) before the procedure. If dislodged during the procedure, they may accidentally come into your airway and obstruct your breathing. There are a very small risk dental crowns or bridgework may be damaged. Some of the above risks are more likely if you smoke, are overweight, have heart disease, have high blood pressure or have diabetes. All major Hospitals have stringent protocols for sterilization, and we assure that all aseptic precautions are in place to prevent transmission
of infections during Endoscopy Mentioned above are the common FAQs about risks. There may be other unusual risks that have not been listed here. Please ask your doctor if you have any general or specific concerns.

Usually in children, and in adults where some treatment is being planned during endoscopy; sedation is routinely offered, to reduce the sense of discomfort duing a prolonged procedure. Let me reassure you that the procedure can routinely be done safely with “local” anaesthesia to the throat alone.

When no sedation is used, you could leave after the procedure immediately; and go to work as well, after eating breakfast. When sedation is used, you will need to be monitored for about 1-2 hours and may need to take the rest of the day off from work. We will still respect your choice if you wish to be unaware of the procedure. It would help if you could inform us of this choice well in advance, so we could arrange to have the necessary staff ready for you at the time of the procedure.

If you are coming as an outpatient, please arrive at least 15 minutes prior to your procedure. The Receptionist will greet you & guide you after that. If you desire, our professional staff will again explain what you and your family members should expect. In case you need more clarifications, please feel free to voice your concerns to the doctor before you give your consent. Concerns about your family members are welcome and may wait for you in the designated waiting area. They may bring along
something to read. Often (and only with your consent) a member may view the procedure on the screen.
Family members may be necessary as designated drivers if sedation is considered for your procedure. The procedure may not be performed if you do not have someone to drive home. If the person accompanying you cannot drive but is an adult, a cab ride is permissible.

Your doctor has recommended that you have a colonoscopy. A colonoscopy is a test that allows your doctor to examine the lining of your colon for any abnormalities. The colonoscope, which is a thin, flexible, fiber optic instrument, is passed from your rectum to your cecum (the point where the small intestine joins with the large intestine).

Colonoscopy is considered the “gold standard” to evaluate intestinal inflammation, ulceration, bleeding, diverticulosis and tumours. It is possible to remove most colon polyps during a colonoscopy, there is no pain or any sensation as the polyp is removed.

A colonoscopy is a safe and highly effective procedure. The procedure is quick (usually between 10 – 40 minutes) and generally quite painless. You may be given sedation if required to make you relaxed and sleepy. Usually, patients remember very little and are pleasantly surprised by how easy the procedure was.

Depending on your symptoms and circumstances, it may be possible to diagnose your bowel condition using a different test. Alternatives available are a Barium enema, CT scan, or, recently, virtual colonoscopy or a CT colonography. None of these tests sees the textural details of the mucosal lining under magnification as does a colonoscopy. In your specific instance, you may talk to your doctor about the relevance of these tests over a colonoscopy.

Following colonoscopy, you may feel a little bloated for a short while. The commoner side effects of the sedatives used include drowsiness, light-headedness and nausea. But the risk of a complication happening during a diagnostic test is negligible(less than 0.01%). You do realize that you yourself can minimize the risks when you read the following.

Being on blood-thinning medications (Warfarin, clopidogrel, Xarelto, Eliquis, Aspirin, Naproxen) may increase the risk of bleeding even from a simple biopsy during the colonoscopy. You may discuss this with the endoscopist or your treating doctor. It is fine to take Acetaminophen or paracetamol.

You need to inform the endoscopy team in case you are already receiving the following medication, as adequate precautions can be taken during the procedure:

• Diabetes medications such as Insulin or oral diabetes medications
• Heart problems or related surgeries, Heart valve replacement & Joint replacement; Chemotherapy treatments or immunosuppressive drugs (steroids, azathioprine, etc) (you may then need to have a prophylactic antibiotic during colonoscopy)
• Kidney problems (to prevent drug side effects)
• Some medications such as seizure disorders should not be stopped.

Most major Hospitals have stringent protocols for sterilization, and we assure that all aseptic precautions are in place to prevent transmission of infections during Endoscopy.

For your doctor to see the bowel wall clearly, the bowel needs to be completely empty. To help clear it out you will be asked to follow one of two protocols if you want a faultless procedure

The first involves drinking two litres of a solution of polyethene glycol (Peglec or Colopeg) that causes temporary diarrhoea. It comes in 2 flavours, which, unfortunately, only partially mask a somewhat unpleasant taste. Refrigerating the solution may make it more palatable. Drinking such a large volume of the cold solution may cause a patient to feel chilled, but the sensation is temporary. Do not add flavouring (additional sugar or salt) to the solution. Many patients say that drinking the purgative solution is the most unpleasant part of the examination!

I usually prefer to ask patients to make the solution the night before; so they will not lose time making it when they wake up. You could drink it in two hours about 4 to 6 hours before the scheduled time for the test; at the rate of glass (200 ml) every 10 minutes.

In case you feel nauseous, slow down, so you do not throw up and need to start with a fresh two-litre solution all over. You will pass about 5 to 8 watery stools, the last of which are expected to be the colour of the solution you drank.

The second method involves drinking a solution called Exelyte (2 bottles of 45 ml each in a box) mixed in 300 ml lime juice or Limca over half an hour, followed by several glasses of fluids. This preparation is easier to consume (just 2 glasses of juice, each over 15 minutes) than the Polyethylene glycol. However, Exeter is cathartic; it makes you lose body water to make loose stools and you should be careful not to get dehydrated.

I prefer to check that you do not already have borderline renal damage (do a Blood urea & creatinine test); else giving this solution and not hydrating later may aggravate the kidney damage. It also contains a large amount of phosphorus, which may be a problem for people with heart or kidney conditions.

It is very important that you drink frequently throughout the day to avoid dehydration. Drink water, soft drinks, fresh as well as canned juices, chicken or vegetable soups, coffee or tea (no milk; sugar is fine). Avoid foods with seeds the previous day (brinjal, guava) as well as supari & saunf; it remains undigested and then clogs our scopes!

Please wear loose, comfortable clothing. Please leave your valuables at home. Wear comfortable, stable shoes since you may be a little unsteady when you leave. You will be changing into a patient gown before the procedure.

With you resting on your left side, your doctor will gently examine your back passage with a gloved finger & lubricating jelly before carefully inserting the colonoscope. Air is then usually passed through the tube into the colon to make it expand and the bowel wall easier to see. This may briefly cause pains similar to having wind and you may get an urge to go to the toilet, but as the colon is empty, this won’t be possible.

Most people pass some wind. There is no need to feel embarrassed about this as your doctor will expect this to happen. During the procedure, you may be asked to change your position – for example turning from your side onto your back. This helps your doctor to examine different areas of the colon more easily. If necessary, your doctor will take a biopsy and/or remove polyps. This is done using special instruments passed inside the colonoscope and is quick and painless.

Our Anaesthesia team will make sure you are comfortable throughout the procedure. It would be preferable for them to review your records in advance, so they can plan appropriately for the day of the procedure. The sedative will be injected through the cannula placed in the back of your hand, and you should start to feel relaxed and drowsy almost immediately. Sedatives can sometimes affect your breathing, so the amount of oxygen in your blood will be monitored constantly through a clasp on your finger and you may be given extra oxygen through a mask.

After your procedure is complete you will be taken to the recovery area. The nurses there will continue to monitor your blood pressure, pulse and oxygen saturation. Your “significant other” or friend may come sit with you in recovery at this time. You may need to stay in the recovery area for even up to three hours. Plan so you do not need to drive, operate machinery, sign any important documents or make important decisions until the next day. You should not exercise strenuously until the next day.

You must make arrangements for a responsible adult to drive you home after your procedure. Taxis and buses are not permitted unless you are accompanied by a responsible adult.

ERCP is a well-tolerated procedure when performed by doctors trained & experienced in the technique. Complications requiring hospitalization are uncommon. These may include pancreatitis (inflammation of the pancreas), infections, bowel perforations & bleeding; which are, however, rare. Some patients may get an adverse reaction to an antibiotic, sedative or radiologic dye. Sometimes the procedure may not be completed due to technical difficulties. The risks vary, depending upon whether the patient already has major medical problems, and the degree of difficulty in the therapeutic intervention planned. Your doctor will be able to tell you what the risks are in your specific case.

Obstructions to the bile ducts due to stones slipped from the gall bladder, or due to cancerous growths of the gall bladder, bile duct & pancreas block the flow of bile resulting in jaundice. If infection sets in the stagnant bile it can progress rapidly with life-threatening consequences.

Blocks in the pancreatic duct can also happen due to pancreatitis or tumours, resulting in severe constant pain. ERCP can identify the cause & precise level of the block, as well as give access to relieve the obstruction too. Suspicion of these diseases is made during an ultrasound or CT scan examinations.

Visualization of the bile & pancreatic ducts is now possible by MRI techniques called MRCP. Thus, MRCP is an alternative if being done for diagnosis alone. ERCP has reasonable accuracy for obtaining tissue to confirm the presence of cancer, which MRCP cannot give. If a patient has confirmed cancer that is operable for a cure, your doctor may suggest you see a surgeon right away and not have the ERCP at all. Removals of bile duct stones by ERCP are now standard-of-care procedures; meaning the alternative of removal by surgery is accepted to be more morbid. Every problem ERCP addresses have previously been offered a surgical option. For your specific abdominal disease & co-morbid conditions, your doctor will be able to tell you what the relative risks & benefits are, between ERCP and surgery.

ERCP is usually done after admitting the patient indoors. Your stomach should be empty so you have advised an overnight (or at least 6 hours) fast, else you may aspirate the gastric contents into your lungs leading to pneumonia. . You are likely to receive an antibiotic before the procedure, so inform your doctor if you have allergies to any drugs previously.

If the procedure is likely to be lengthy, your doctor may plan conscious sedation; so you are unaware of the procedure, but your basic reflexes are intact. Rarely is full anaesthesia required? You should tell your doctor in case you are using medication for major chronic ailments (like diabetes, blood pressure, heart or lung disease, arthritis, etc.) as he can take appropriate precautions.

A duodenoscope is passed from the mouth into the duodenum till the doctor sees the common opening of the ducts of the liver & the pancreas. The instrument does not interfere with your breathing, but there may be a bloating sensation if your doctor needs to pass air to have a clear field of vision till the Common Duodenal Papilla is seen. A narrow plastic tube (catheter) is passed through the duodenoscope into the ducts & contrast material (dye) is injected so the ducts show up on X-ray screens. Please inform your doctor if you have had previous radiologic procedures involving injection of dye, and had an untoward reaction to it. Once the problem is identified, the mouth of the papilla is widened with a cut, so larger treatment devices can gain access into the duct. If you are using aspirin, or blood thinners (clopidogrel, warfarin, etc) tell your doctor well in advance, so he will take appropriate precautions to prevent a risk of bleeding.

At the end of the procedure, a thin plastic (Teflon or Polyurethane) tube is left where the ducts were entered. This is because the handling of tissues causes swelling and may block the ducts. This tube (stent) allows the free flow of digestive juices till healing is completed by the body around it.

The stent is an artificial device; it can get blocked within 2-3 months. Your doctor will thus need to reassess you by duodenoscopy within this period for removal.

In some patients, permanent relief from obstruction to bile ducts due to tumours can be done by placing SEMS (Self Expanding Metallic Stent). This is usually offered to those patients where the obstruction is confirmed to be due to cancer; & surgery for the tumour is unlikely. These stents will not need to be removed as they are not associated with a risk of infection & blockage.

Following the procedure, you may need to remain indoors for between 6 hours to 4-5 days, depending upon the severity of the problem you are being treated for.

ERCP has been advised to you because you are suspected to have

And you also have co-morbid conditions

ERCP will give the following additional information about your condition

During ERCP, the following treatment options are being considered to relieve your

symptoms (Sphincterotomy / Basket for removal of stones / Mechanical Lithotripsy / Teflon

CBD stenting / Expandable Metallic stenting)

A capsule has a size of 11 x 30 mm; thus is larger than the largest pill. The capsule is easy to swallow, but it will not be possible in known swallowing disorders. The Capsule contains one or two video chips (cameras), a light bulb, a battery, and a UHF band telemetry transmitter. As the capsule travels down, it takes photographs rapidly. The photographs are transmitted by the radio transmitter to a small receiver that is worn on the waist of the patient who is undergoing the capsule endoscopy. At the end of the procedure, approximately 8 hours later, the photographs are downloaded from the receiver into a computer, and the images are reviewed by a physician. The capsule is a single use device and need not be brought back.

The capsule is easy to swallow; the procedure is painless and sedation free & the patient can relax in comfort and walk about; and there is no exposure to potentially harmful radiation. Endoscopes have been made to enter and evaluate the small intestine (Double Balloon Enteroscopes) but this procedure will need deep sedation, may need between 1-2 hours, and have much more risks than Capsule Endoscopy.

Rapid transit of the capsule may give blurred photographs. Stool or food debris may hide a finding; hence the importance of a good bowel preparation prior to the capsule endoscopy. It should take 6-8 hours on an average for the capsule to reach the colon. If the transit is so slow that the capsule examines only part of the small intestine before the battery fails, the study will remain incomplete. Often, the life of the battery may last till 12 hours; so the test can go beyond 8 hours if it is found that the entire small intestine has not been crossed.

The small bowel is 12 feet long. If a finding is seen that require surgical resection or further investigation, the capsule cannot mark or ‘flag’ that point so that it will get seen in surgery.

Going through the tens of thousands of photographs is very time consuming, and needs a conscientious reviewer. Reporting could take 2-3 days as it is huge data. You will get printed report and CD of the procedure.

The capsule can get stuck in the narrow area (this is called Capsule Retention) and though it may not cause obstruction of the intestine, it may require surgical removal. Capsule retention happens only 0.75% times as we have ways to prevent it. In patients who are suspected of having a stricture, a self-dissolving, dummy ‘Patency capsule’ is swallowed first. If the dummy capsule sticks, it can be seen on an x-ray of the abdomen and the location of the stricture determined. Because it dissolves with time, however, the obstruction from the capsule will resolve without surgery, and the real capsule will not be used. It is important that you follow the instructions below for your physician to be able to get accurate information.

The Clinical Consent: The Gastroenterologist will see you; and confirm that the Capsule Endoscopy is appropriate test to be done, is safe as well as will serve the purpose of giving your diagnosis. You will need to show your other illness records (diabetes, hypertension & cardiac disease, thyroid illness, etc); the medications you concurrently use on a daily basis, as these will have to be rescheduled on the day of the test. There may be some medications that could be safely stopped during the time of this test (iron & supplements). You will be explained the appropriate Bowel Preparation to cleanse your intestine; as well as what time to take this. To save costs, this is easily done at home prior arrival. If the patient is visually challenged; has a difficulty with use of a commode; or is too weak, you may prefer to admit for the bowel preparation itself.

The Financial Consent: the Office will appraise you about the costs of the test, expenses incurred during the stay; and any other expenses if applicable. In case you have paperwork regarding your Medical Insurance, you could get it cleared at this instance. Make sure you have understood all of this as you would not wish a delay in starting the test for administrative reasons.

Your doctor will go through the following check list:

• Time of the last meal in the evening before.
• Timing of all the medications you usually take in the evening as well as the night.
• If you are regularly using a night time sedative, whether you could take it on this night too.
• Timing of starting the Bowel prep in the night / morning, as well as what prep to take.
• Timing of any medication that you normally take in the morning empty stomach
• Timing of morning doses of diabetic medication / insulin that you would normally take till 10 am.
• Timing of reporting to the hospital in the morning.

The morning of the Capsule Endoscopy:

Report to the Casualty; the medical details will be attended by the Casualty doctor

• medication taken;
• any monitoring of co morbid conditions;
• how well prepared the bowel is and should be;
• completing the Consent process);

And the Admission formalities will be done by the Reception

• Assigning the bed,
• Completing the Medical File Record,
• Finishing with the Admission Deposit.

Your arrival will be intimated to

• the Consultant overseeing the procedure
• your physician for co morbid illnesses
• The Biomedical Department for preparing the Capsule equipment.
• The Dietitian who will provide you diet requirements at the designated times.

You should be in your designated bed / room within an hour of reporting to the hospital.

How the test will start:

The staff nurse & ward doctors will be attending to you is you have any medical issue – difficulty in swallowing the capsule, any pain, queries regarding concurrent medication, any monitoring of vitals, blood sugar, etc.

The Sensor Belt will be applied to your abdomen and the Data Recorder will be attached to it; you will then be instructed to ingest the Pill Cam in the presence of the Medical Staff. He will confirm that the assembly is operational and recording properly. He will also instruct you how to check the recording is going on; who to call in case there is any doubt about equipment function; how to track the location of the capsule and progress.

Throughout the procedure (every fifteen minutes) you will be asked to check that the blue light on the top of the data recorder continues to blink twice a second. This signals that the capsule images are being transmitted correctly. Please contact the biomedical personnel immediately if the light goes off.

Meals: After swallowing the capsule you are not to eat or drink for a further 2 hours. What you could take and when has already been designated by your doctor, and the dietitian will see you will be provided meals appropriately. You may drink only drink liquids till 4 hours, when you may eat a light snack. It is preferable you do not have a heavy meal until after the procedure has finished. Contact the medical attendants immediately if you experience any abdominal pain or vomiting during the procedure.

Medications during the time the Capsule Endoscopy is being conducted: the timing of all your medication will have been explained to you by your doctor. Usually, no medication may be taken upto 2 hours after the capsule has been ingested. The ward doctor and nurses will look after this.

What not to do during Capsule Endoscopy: you are free to leave your room, but stay away from any powerful radio fields such as MRI & X- ray department.  Stay away when you know portable x-rays are being taken close to you. Capsule Endoscopy takes approximately 8 hours. Do not disconnect the equipment or remove the belt at any time during this period. The equipment must be treated with utmost care and protection due to its sensitivity and value. For the duration of the procedure, avoid strenuous exercise or physical activities that involve stooping/bending or cause sweating. This may move the sensors or make the transmission and recording faulty.