PROCEDURES

To the patient:
Because education is an important part of comprehensive medical care, you have been provided with this information to prepare you for this procedure. If you have questions about your need for colonoscopy, alternative tests, the cost of the procedure, methods of billing, or insurance coverage, do not hesitate to speak to our office staff. Our physicians are highly trained specialists and welcome your questions regarding their credentials and training. It you have questions that have not been answered, please discuss them with the nurse or your physician before the examination begins.

What is a colonoscopy?
Colonoscopy is a procedure that enables your physician to examine the lining of the colon (large bowel) for abnormalities by inserting a flexible colonoscope that is about the thickness of your finger into the anus and advancing it slowly into the rectum and colon.

What preparation is required?
The colon must be completely clean for the procedure to be accurate and complete. Your physician will give you detailed instructions regarding the dietary restrictions to be followed and the cleansing routine to be used. In general, preparation involves either consumption of a large volume of a special cleaning solution or a day of clear liquids, laxatives, and an enema prior to the examination. Follow your doctor’s instructions carefully. If you do not, the procedure may have to be cancelled and repeated later.

What about my current medications?
Most medications may be continued as usual, but some medications can interfere with the preparation or the examination. It is therefore best to inform your physician of your current medications as well as any allergies to medications several days prior to the examination. Aspirin products, arthritis medications, anticoagulants (blood thinners), insulin and iron products are examples of medications whose use should be discussed with your physician prior to the examination. You should alert your doctor if you require antibiotics prior to undergoing dental procedures, since you may need antibiotics prior to colonoscopy as well.

What can be expected during colonoscopy?
Colonoscopy is usually well-tolerated and rarely causes much pain. There is often a feeling of pressure, bloating, or cramping at time during the procedure. Your doctor may give you medication through a vein to help you relax and better tolerate any discomfort from the procedure. You will be lying on your side or on your back while the colonoscope is advanced slowly through the large intestine. As the colonoscope is slowly withdrawn the lining is again carefully examined. The procedure usually takes 15 to 60 minutes. In some cases, passage of the colonoscope through the entire colon to its junction with the small intestine cannot be achieved. The physician will decide if the limited examination is sufficient or if other examinations are necessary.

What if the colonoscopy shows something abnormal?
If your doctor thinks an area of the bowel needs to be evaluated in greater detail, a forceps instrument is passed through the colonoscope to obtain a biopsy (a sample of the colon lining). This specimen is submitted to the pathology laboratory for analysis. If colonoscopy is being performed to identify sites of bleeding, the areas of bleeding may be controlled through the colonoscope by injecting certain medications or by coagulation (sealing off bleeding vessels with heat treatment). None of these additional procedures typically produce pain. Remember, biopsies are taken for many reasons and do not necessarily mean that cancer is suspected.

What are polyps and why are they removed?
Polyps are abnormal growths from the lining of the colon which vary in size from a tiny dot to several inches. The majority of polyps are benign (noncancerous) but the doctor cannot always tell a benign from a malignant (cancerous) polyp by its outer appearance alone. For this reason, removed polyps are sent for tissue analysis. Removal of colon polyps is an important means of preventing colorectal cancer.

How are polyps removed?
Tiny polyps may be totally destroyed by fulguration (burning), but larger polyps are removed by a technique called snare polypectomy. The doctor passes a wire loop (snare) through the colonoscope and severs the attachment of the polyp from the intestinal wall by means of an electrical current. You should feel no pain during the polypectomy. There is a small risk that removing a polyp will cause bleeding or result in a burn to the wall of the colon, which could require emergency surgery.

What happens after a colonoscopy?
After colonoscopy, your physician will explain the results to you. If you have been given medications during the procedure someone must accompany you home from the procedure because of the sedation used during the examination. Even if you feel alert after the procedure, your judgment and reflexes may be impaired by the sedation for the rest of the day, making it unsafe for you to drive or operate any machinery.

You may have some cramping or bloating because of the air introduced into the colon during the examination. This should disappear quickly with passage of flatus (gas). Generally, you should be able to eat after the procedure, but your doctor may restrict your diet and activities especially after polypectomy.

What are the possible complications of colonoscopy?
Colonoscopy and polypectomy are generally safe when performed by physicians who have been specially trained and are experienced in these endoscopic procedures.

One possible complication is a perforation or tear through the bowel wall that could require surgery. Bleeding may occur from the site of biopsy or polypectomy. It is usually minor and stops on its own or can be controlled through the colonoscopy. Rarely, blood transfusions or surgery may be required. Other potential risks include a reaction to the sedatives used and complications from heart or lung disease. Localized irritation of the vein where medications were injected may rarely cause a tender lump lasting for several weeks, but this will go away eventually. Applying hot packs or hot moist towels may help relieve discomfort.

Although complications after colonoscopy are uncommon, it is important for you to recognize early signs of any possible complication. Contact the physician who performed you colonoscopy if you notice any pain, fever and chills, or rectal bleeding of more than one-half cup. Bleeding can occur several days after polypectomy.

Cancer of the colon and rectum, called colorectal cancer, is the second leading cause of cancer deaths among men and women in the United States. However, if detected early, colorectal cancer can be cured. With simple preventative steps, you can greatly reduce your risk of developing the disease. It is important for you to understand your risks for colorectal cancer, the symptoms, and screening tests that can detect cancerous growths. Colorectal cancer develops from non-cancer polyps called adenomatous polyps. A polyp is a grape-like growth on the inside wall of the colon or rectum. Polyps grow slowly, over three to ten years. Most people do not develop polyps until after the age of 50. Some polyps become cancerous, others do not. In order to prevent colorectal cancer, it is important to get screened to find out if you have polyps, and to have them removed if you do. Removal of polyps has been shown to prevent colorectal cancer.

How do I know if I’m at risk for Colorectal Cancer (CRC)?

You have an increased risk for CRC if you:

  • Have a personal history of an inflammatory bowel disease; such as ulcerative colitis or Crohn’s disease.
  • Have a family history – one or more parents, brothers and/or sisters, or children – of CRC or adenomatous polyps
  • Have a family history of multiple cancers; involving the breast, ovary, uterus, and/or other organs.
  • Have a personal history of an inflammatory bowel disease; such as ulcerative colitis or Crohn’s disease.

You are at average risk if you:

  • Are age 50 or older and have no other risk factors.

What types of screenings are available?

There are several types of screening tests. Talk with your doctor about which one is best for you. People at average risk should start screenings at age 50. People at increased risk should start at age 40.

Digital rectal examination: In this test, the doctor manually inserts a gloved finger into the rectum to feel for abnormalities.

Fecal occult blood test (FOBT): In this procedure, the stool is tested for the presence of blood that is invisible to the eye. This test is available in a kit and can be taken home to collect stool samples. The stool cards can be mailed to your doctor. This test is recommended annually for persons beginning at age 50 for people at average risk.

Sigmoidoscopy: Your doctor will use a long, flexible, lighted tube to check the rectum and the lower part of the colon for polyps and cancer. If a polyp is found, it can be sampled through the scope and sent to a lab to be tested. This can be performed in a doctor’s office, and does not require any anesthesia or sedation, but does require a prep. This test is recommended every 5 years beginning at age 50 for people at average risk.

Colonoscopy: Your doctor will use a long, flexible lighted tube — called the colonoscope — to view the entire rectum for polyps or cancer. A bowel cleansing prep is required before the colonoscopy. The colonoscope has a camera at the end, which can project images on a TV screen. If a polyp is found, it can be removed by a wire loop that is passed through the colonoscope and is hooked around the base of the polyp. The polyp is then sent to the laboratory for testing to determine if it is cancerous. This procedure requires patients to be sedated, and usually takes about 20 minutes.

What is ERCP?
Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique used to study the bile ducts, liver, pancreatic duct and gallbladder. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. The pancreatic duct is the drainage channel from the pancreas.

How is ERCP performed?
During ERCP, your doctor will pass an endoscope through your mouth, esophagus and stomach into the duodenum (first part of the small intestine). An endoscope is a thin, flexible tube that lets your doctor see inside your bowels. After your doctor sees the common opening to the ducts from the liver and pancreas, called the major duodenal papilla, your doctor will pass a narrow plastic tube called a catheter through the endoscope and into the ducts. Your doctor will inject a contrast material (dye) into the pancreatic or biliary ducts and will take X-rays.

What preparation is required?
You should fast for at least six hours (and preferably overnight) before the procedure to make sure you have an empty stomach, which is necessary for the best examination. Your doctor will give you precise instructions about how to prepare. You should talk to your doctor about medications you take regularly and any allergies you have to medications or to intravenous contrast material (dye). Although an allergy doesn’t prevent you from having ERCP, it’s important to discuss it with your doctor prior to the procedure, as you may require specific allergy medications for the ERCP. Inform your doctor about medications you’re taking, particularly aspirin products, arthritis medications, anticoagulants (blood thinners, such as warfarin or heparin), clopidogrel or insulin. Also, be sure to tell your doctor if you have heart or lung conditions or other major diseases which might prevent or impact the decision to conduct endoscopy.

What can I expect during ERCP?
Your doctor might apply a local anesthetic to your throat and/or give you a sedative to make you more comfortable. Your doctor might even ask an anesthesiologist to administer sedation if your procedure is complex or lengthy. Some patients also receive antibiotics before the procedure. You will lie on your abdomen on an X-ray table. The instrument does not interfere with breathing, but you might feel a bloating sensation because of the air introduced through the instrument.

What are possible complications of ERCP?
ERCP is a well-tolerated procedure when performed by doctors who are specially trained and experienced in the technique. Although complications requiring hospitalization can occur, they are uncommon. Complications can include pancreatitis (inflammation of the pancreas), infections, bowel perforation and bleeding. Some patients can have an adverse reaction to the sedative used. Sometimes the procedure cannot be completed for technical reasons.

Risks vary, depending on why the test is performed, what is found during the procedure, what therapeutic intervention is undertaken, and whether a patient has major medical problems. Patients undergoing therapeutic ERCP, such as for stone removal, face a higher risk of complications than patients undergoing diagnostic ERCP. Your doctor will discuss your likelihood of complications before you undergo the test.

What can I expect after ERCP?
If you have ERCP as an outpatient, you will be observed for complications until most of the effects of the medications have worn off before being sent home. You might experience bloating or pass gas because of the air introduced during the examination. You can resume your usual diet unless you are instructed otherwise.

Someone must accompany you home from the procedure because of the sedatives used during the examination. Even if you feel alert after the procedure, the sedative can affect your judgment and reflexes for the rest of the day.

Because individual circumstances may vary, this brochure may not answer all of your questions, please ask your doctor about anything you don’t understand.

IMPORTANT REMINDER:
This information is intended only to provide general guidance. It does not provide definitive medical advice. It is very important that you consult your doctor about your specific condition.

You’ve been referred to have an endoscopic ultrasonography, or EUS, which will help your doctor, evaluate or treat your condition.

What is EUS?
Endoscopic ultrasonography (EUS) allows your doctor to examine your esophageal and stomach linings as well as the walls of your upper and lower gastrointestinal tract. The upper tract consists of the esophagus, stomach and duodenum; the lower tract includes your colon and rectum. EUS is also used to study other organs that are near the gastrointestinal tract, including the lungs, liver, gall bladder and pancreas.

Endoscopists are highly trained specialists who welcome your questions regarding their credentials, training and experience. Your endoscopist will use a thin, flexible tube called an endoscope that has a built-in miniature ultrasound probe. Your doctor will pass the endoscope through your mouth or anus to the area to be examined. Your doctor then will use the ultrasound to use sound waves to create visual images of the digestive tract.

Why is EUS done?
EUS provides your doctor with more information than other imaging tests by providing detailed images of your digestive tract. Your doctor can use EUS to diagnose certain conditions that may cause abdominal pain or abnormal weight loss.

EUS is also used to evaluate known abnormalities, including lumps or lesions, which were detected at a prior endoscopy or were seen on x-ray tests, such as a computed tomography (CT) scan. EUS provides a detailed image of the lump or lesion, which can help your doctor determine its origin and help treatment decisions. EUS can be used to diagnose diseases of the pancreas, bile duct and gallbladder when other tests are inconclusive or conflicting.

Why is EUS used for patients with cancer?
EUS helps your doctor determine the extent of spread of certain cancers of the digestive and respiratory systems. EUS allows your doctor to accurately assess the cancer’s depth and whether it has spread to adjacent lymph glands or nearby vital structures, such as major blood vessels. In some patients, EUS can be used to obtain a needle biopsy of a lump or lesion to help your doctor determine the proper treatment.

How should I prepare for EUS?
For EUS of the upper gastrointestinal tract, you should have nothing to eat or drink, overnight before the examination. Your doctor will tell you then to start this fasting and whether it is advisable to take your regular prescription medications.

For EUS of the rectum or colon, your doctor will instruct you to either consume a colonic cleansing solution or to follow a clear liquid diet combines with laxatives or enemas prior to the examination. The procedure might have to be rescheduled if you don’t follow your doctor’s instructions carefully.

What about my current medications or allergies?
You can take most medications as usual until the day of the EUS examination. Tell your doctor about all medications that you’re taking and about any allergies you have. Anticoagulant medications (blood thinners such as warfarin or heparin) and clopidogrel may need to be adjusted before the procedure. Insulin also needs to be adjusted on the day of EUS. In general, you can safely take aspirin and non-steroidal anti-inflammatory medications (ibuprofen, naproxen, etc.) before an EUS examination. Check with your doctor in advance regarding these recommendations.

Check with your doctor about which medications you should take the morning of the EUS examination, and take only essential medications with a small sip of water.

If you have an allergy to latex, you should inform your doctor prior to your test. Patients with latex allergies often require special equipment and may not be able to have a complete EUS examination.

Do I need to take antibiotics?
Antibiotics are not generally required before or after EUS examinations. However, your doctor might prescribe antibiotics if you are having specialized EUS procedures, such as to drain a fluid collection or a cyst using EUS guidance.

Should I arrange for help after the examination?
If you received sedatives, you will not be allowed to drive after the procedure, even if you do not feel tired. You should arrange a ride home in advance. You should also plan to have someone stay with you at home after the examination, because the sedatives could affect your judgment and reflexes for the rest of the day.

What can I expect during EUS?
Practices vary among doctors, but for an EUS examination of the upper gastrointestinal tract, some endoscopists spray your throat with a local anesthetic before the test begins. Most often you will receive sedatives intravenously to help you relax. You will most likely begin by lying on your left side. After you receive sedatives, your endoscopist will pass the ultrasound endoscope through your mouth, esophagus and stomach into the duodenum. The instrument does not interfere with your ability to breathe. The actual examination generally takes less than 60 minutes. Many do not recall the procedure. Most patients consider it only slightly uncomfortable, and many fall asleep during it.

An EUS examination of the lower gastrointestinal tract can often be performed safely and comfortable without medications, but you’ll receive a sedative if the examination will be prolonged or if the doctor will examine a significant distance into the colon. You will start by lying on your left side with your back toward the doctor. Most EUS examinations of the rectum generally take less than 45 minutes. You should know that is a needle biopsy of a lesion or drainage of a cyst is performed during the EUS, then the procedure will be longer and may take up to two hours.

What happens after EUS?
If you received sedatives, you will be monitored in the recovery area until most of the sedative medication’s effects have worn off. If you had an upper EUS, your throat might be a little sore. You might feel bloated because of the air and water that were introduced during the examination.

You’ll be able to eat after you leave the procedure area, unless you’re instructed otherwise. Your doctor generally can inform you of the preliminary results of the procedure that day, but the results of some test, including biopsies, may take several days.

What are the possible complications of EUS?
Although complications can occur, they are rare when doctors with specialized training and experience perform the EUS examination. Bleeding might occur at a biopsy site, but it’s usually minimal and rarely requires follow-up. You might have a slight sore throat for a day or so. Nonprescription anesthetictype throat lozenges help soothe a sore throat.

Other potential but uncommon risks of EUS include a reaction to the sedatives used, aspiration of stomach contents into your lungs, infection, and complications from heart or lung diseases. One major but very uncommon complication of EUS is perforation. This is a tear through the lining of the intestine that might require surgery to repair.

The possibility of complications increases slightly if a needle biopsy is performed during the EUS examination, including an increased risk of pancreatitis or infection. These risks must be balanced against the potential benefits of the procedure and the risk of alternative approaches to the condition.

Additional Questions?
If you have any questions about your need for EUS, alternative approaches to your problem, the cost of the procedure, methods of billing or insurance coverage, do not hesitate to speak to your doctor or doctor’s office staff about it.

IMPORTANT REMINDER:
This information is intended only to provide general guidance. It does not provide definitive medical advice. It is very important that you consult your doctor about your specific condition.

To the patient:
Because education is an important part of comprehensive medical care, you have been provided with this information to prepare you for this procedure. If you have questions about your need for flexible sigmoidoscopy, alternative tests, the cost of the procedure, methods of billing, or insurance coverage, do not hesitate to speak to our office staff. Our physicians are highly trained specialists and welcome your questions regarding their credentials and training. If you have questions that have not been answered, please discuss them with the nurse or your physician before the examination begins.

What is flexible sigmoidoscopy?
Flexible sigmoidoscopy is a procedure that enables your physician to examine the lining of the rectum and a portion of the colon (large bowel) by inserting a flexible tube that is about the thickness of your finger into the anus and advancing it slowly into the rectum and lower part of the colon.

What preparation is required?
The rectum and lower colon must be completely empty of waste material for the procedure to be accurate and complete. Your physician will give you detailed instructions regarding the cleansing routine to be used.  In general, preparation consists of one or two enemas prior to the procedure but may include laxatives or dietary modifications. In some circumstances, for example, if you have acute diarrhea or colitis, your physician may advise you to forgo any special preparation before the examination.

What about my current medications?
Most medications can be continued as usual. You should inform your physician of all current medications as well as any allergies to medications several days prior to the examination. However, drugs such as aspirin or anticoagulants (blood thinners) are examples of medications whose use should be discussed with your physician.

You should alert your doctor if you require antibiotics prior to undergoing dental procedures, since you may need antibiotics prior to sigmoidoscopy as well.

What can be expected during flexible sigmoidoscopy?
Flexible sigmoidoscopy is usually well tolerated and rarely causes much pain. There is often a feeling of pressure, bloating, or cramping at various times during the procedure. You will be lying on your side while the sigmoidoscope is advanced through the rectum and colon. As the instrument is withdrawn, the lining of the intestine is carefully examined. The procedure usually takes anywhere from 5 to 15 minutes.

What if the flexible sigmoidoscopy shows something abnormal?
If the doctor sees an area that needs evaluation in greater detail, a biopsy (sample of the colon lining) may be obtained and submitted to a laboratory for greater analysis. If polyps (growths from the lining of the colon which vary in size) are found, they can be biopsied, but usually are not removed at the time of the sigmoidoscopy.

Polyps are of varying types; certain benign polyps, knows as “adenomas,” are potentially precancerous. Certain other polyps (“hyperplastic” by biopsy analysis) may not require removal. Your doctor will likely request that you have a colonoscopy (a complete examination of the colon) to remove any large polyp that is found, or any small polyp that is adenomatous after biopsy analysis.

What happens after flexible sigmoidoscopy?
After sigmoidoscopy, the physician will explain the results to you. You may have some mild cramping or bloating sensation because of the air that has been passed into the colon during the examination. This will disappear quickly with the passage of flatus (gas). You should be able to eat and resume your normal activities after leaving your doctor’s office or the hospital.

What are the possible complications of flexible sigmoidoscopy?
Flexible sigmoidoscopy and biopsy are generally safe. Complications can occur but are rare when the test is performed by physicians with specialized training and experience in this procedure. Possible complications include a perforation (tear through the bowel wall) and bleeding form the site of the biopsy. Although the complications after flexible sigmoidoscopy are rare, it is important for you to recognize early signs of any possible complication. Contact your physician if you notice any of the following symptoms: severe abdominal pain, fevers and chills, or rectal bleeding of more than one-half cup. It is important to note that rectal bleeding can occur even several days after a biopsy.

To the patient:
Because education is an important part of comprehensive medical care, you have been provided with this information to prepare you for this procedure. If you have questions about your need for upper endoscopy, alternative tests, the cost of the procedure, methods of billing, or insurance coverage, do not hesitate to speak to our office staff. Our physicians are highly trained specialists and welcome your questions regarding their credentials and training. It you have questions that have not been answered, please discuss them with the nurse or your physician before the examination begins.

What is an Upper Endoscopy?
Upper Endoscopy (also known as an upper GI Endoscopy, Esophagogastroduodenoscopy [EGD], or panendoscopy) is a procedure that enables your physician to examine the lining of the upper part of your gastrointestinal tract, ie, the esophagus (swallowing tube), stomach, and duodenum (first portion of the small intestine) using a thin flexible tube with its own lens and light source.

Why is upper Endoscopy done?
Upper Endoscopy is usually performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, or difficulty swallowing. It is also the best test for finding the cause of bleeding from the upper gastrointestinal tract. Upper Endoscopy is more accurate than x-ray films for detecting inflammation, ulcers, or tumors of the esophagus, stomach, and duodenum. Upper endoscopy can detect early cancer and can distinguish between benign and malignant (cancerous) conditions when biopsies (small tissue samples) of suspicious areas are obtained. Biopsies are taken for many reason and do not necessarily mean that cancer is suspected. A cytology test (introduction of a small brush to collect cells) may also be performed.

Upper Endoscopy is also used to treat conditions present in the upper gastrointestinal tract. A variety of instruments can be passed through the endoscope that allow many abnormalities to be treated directly with little or no discomfort, for example, stretching narrowed areas, removing polyps (usually benign growths) or swallowed objects, or treating upper gastrointestinal bleeding. Safe and effective endoscopic control of bleeding has reduced the need for transfusions and surgery in many patients.

What preparation is required?
For the best (and safest) examination, the stomach must be completely empty. You should have nothing to eat or drink, including water, for approximately 6 hours before the examination. Your doctor will be more specific about the time to begin fasting; depending on the time of day that you test is scheduled.

What about my current medications?
Before the test, be sure to discuss with the doctor whether you should adjust any of your usual medications before the procedure, any drug allergies you may have, and whether you have any other major diseases such as a heart or lung condition that might require special attention during the procedure.

What can be expected during the Upper Endoscopy?
Your doctor will review with you why upper Endoscopy is being performed, whether any alternative tests are available and possible complications from the procedure. Practices may vary among doctors, but you may have throat sprayed with a local anesthetic before the test begins and may be given medication through a vein to help you relax during the test. While you are in a comfortable position on your side, the endoscope is passed through the mouth and then in turn through the esophagus, stomach, and duodenum. The endoscope does not interfere with your breathing during the test. Most patients consider the test to be only slightly uncomfortable and many patients fall asleep during the procedure.

High resolution esophageal manometry, commonly referred to as simply manometry, is a diagnostic test used in the workup of conditions that lead to difficulty swallowing, chest pain, heartburn or regurgitation of food. It is an ambulatory test that involves placing a very thin catheter into the first part of the stomach, having the patient swallow several times, and then measuring many different aspects of the swallowing process. This includes how the lower throat opens, how the esophagus (the muscular tube that takes food from the mouth to the stomach) behaves and if there is any impediment to swallowed material reaching the stomach. The test itself typically takes less than 10-15 minutes, and the doctor can then look at the recorded information to determine if there are any abnormalities. It is a very safe procedure with no serious complications.