How is a digestive disorder diagnosed?
In order to reach a diagnosis for digestive disorders, a thorough and accurate medical history will be taken by your healthcare provider, noting the symptoms you have experienced and any other pertinent information. A physical exam is also done to help assess the problem more completely.
Rapid strides have been made in gastro-intestinal endoscopy (gastroscopy, colonoscopy, ERCP, and related techniques) in the last thirty years. Gastro-intestinal endoscopy, once largely diagnostic, has evolved such that therapeutic procedures are often performed at the same time. This may prevent the need for major surgery. Safe and effective sedation has been a major factor in the development of therapeutic endoscopy. However, not all patients require sedation for endoscopic procedures. Some patients are quite comfortable with no sedation, or only minimal sedation, depending on the type and duration of the procedure. Some patients need to undergo a more extensive diagnostic evaluation. This may include lab tests, imaging tests, and/or endoscopic procedures.
Patients usually have three major concerns prior to endoscopy – the outcome of the procedure (could it be cancer?), complications of the procedure, and most importantly the question “Doctor, how much will I feel the procedure?” or “Will it hurt?” With modern sedation and careful monitoring the great majority of patients will feel comfortable during the procedure.
What is the Purpose of Colonoscopy?
To examine the lower gastrointestinal tract (colon or large bowel), to remove polyps (small benign growths), inject bleeding blood vessels, and to take samples of tissue (biopsies) for examination by a pathologist. Colonoscopy is the most reliable method of bowel examination but small abnormalities including cancers can very occasionally be missed.
How are you Prepared?
Prior to the procedure you will be given a bowel preparation kit with instructions. The bowel preparation cleans the colon. Without this it is not possible to perform a full examination of the colon. Although the bowel preparation is unpleasant, it is very rare for it to be harmful. If you have had difficulties with the preparation in the past, or if you have severe heart, lung, or kidney disease you should discuss this with the doctor.
How is Colonoscopy Done?
A long, thin flexible tube is passed around the bowel from the anus. This takes about 15 minutes and is done under intravenous sedation (Midazolam, Fentanyl, and sometimes Propofol). Reactions to these medications are rare. After the procedure you must not drive or use machinery until the next day, or longer if you feel unsteady or tired the next day. If you object to the use of sedation please discuss.
Colonoscopies are done usually on a day case basis. You would be required to attend for about 3 hours if you have sedation for your colonoscopy. You will need to arrange transport to and from the hospital.
Are there Alternatives to Colonoscopy?
A barium enema x-ray of the bowel will give similar information but it is not as accurate for certain problems, it does not allow biopsies or removal of polyps. It does not require sedation or hospital admission.
Colonoscopy and polypectomy are very safe. Serious complications are rare. These include:
- Reaction or sensitivity to medication used for sedation (this may affect your breathing briefly)
- Perforation (puncture) of the lining of the bowel (about 1 patient in 2000-5000)
- Bleeding – if blood vessels are injected or a polyp is removed (about 1 patient in 300-500)
- Infection of the bowel, blood, and other organs
- Heart attacks, cardiac arrest, blood clots, and breathing problems (very rare)
- There are other very rare complications – please advise if you wish to be given more details
Everything will be done to minimise the risk of these complications. There are ways of detecting these complications early and specific treatments are available if they do arise. Very rarely there may be a need for hospitalisation, major surgery, intravenous feeding, or blood transfusion. Although death can result from complications of colonoscopy this is very rare.
Special Precautions will need to be taken:
- if you suspect or know you are pregnant or if you are breastfeeding
- have severe heart, lung, or kidney disease
- have lymphoma, leukaemia, or you are receiving chemotherapy
- if you have had heart valve disease, a pacemaker, aortic graft or other blood vessel graft
- if you bleed very easily or if you take blood thinning tablets (warfarin), aspirin, or arthritis tablets
- if you are allergic or sensitive to any medication
- Colonoscopy is a procedure that allows the healthcare provider to view the entire length of the large intestine (colon). It can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the healthcare provider to see the lining of the colon, remove tissue for further exam, and possibly treat some problems that are discovered.
- Endoscopic retrograde cholangiopancreatography (ERCP). ERCP is a procedure that allows the healthcare provider to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines X-ray and the use of an endoscope. This is a long, flexible, lighted tube. The scope is guided through the patient’s mouth and throat, then through the esophagus, stomach, and duodenum (the first part of the small intestine). The healthcare provider can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected that will allow the internal organs to appear on an X-ray.
- Esophagogastroduodenoscopy (also called EGD or upper endoscopy). An EGD (upper endoscopy) is a procedure that allows the healthcare provider to examine the inside of the esophagus, stomach, and duodenum with an endoscope. This is guided into the mouth and throat, then into the esophagus, stomach, and duodenum. The endoscope allows the healthcare provider to view the inside of this area of the body, as well as to insert instruments through the scope for the removal of a sample of tissue for biopsy (if necessary).
- A sigmoidoscopy is a diagnostic procedure that allows the healthcare provider to examine the inside of a portion of the large intestine, and is helpful in identifying the causes of diarrhea, abdominal pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through the rectum. The scope blows air into the intestine to inflate it and make viewing the inside easier.
Before the Endoscopy
It is most likely that you will have your endoscopy in a day surgery unit in a public or private hospital. During the procedure an anaesthetist or sedationist (doctor or nurse trained in sedation and resuscitation) will be present throughout the procedure to provide monitoring of your level of consciousness, your cardiorespiratory state and provide the right amount of anaesthetic sedation to keep you comfortable throughout.
Prior to the procedure, you will meet the doctor giving the sedation. You will be asked (by the doctor or nursing staff) to provide your medical history, including the reason you are having the test, whether you have heart or lung disease (including asthma, angina or heart failure), liver or kidney disease, gastro-intestinal bleeding or other bleeding problems, or anaemia. The anaesthetist will wish to ensure you have fasted (i.e. not had food or drink) for the required number of hours before the procedure. A brief physical examination may be performed. If you are dehydrated, intravenous fluids may be administered. The doctor will wish to know your allergies and a list of your medications.
This is the time to ask any questions you may have regarding the sedation. An intravenous cannula or needle will be placed in the back of the hand or forearm. This is for the administration of intravenous sedative drugs.
During the Endoscopy
When you are wheeled into the procedure room, you will be connected to monitoring equipment which is essential when sedative agents are to be used. Monitoring detects early signs of impaired lung or heart function resulting from the sedatives, permitting early correction, thus maximising patient safety. Years ago, the anaesthetist would monitor the patient by checking skin colour, pulse rate, and rate of breathing. Modern equipment, in combination with careful clinical observation, can do much better than this.
You will also be given a mask or some type of oxygen delivery system to increase the level of oxygen in the air that you are breathing – this is now standard for endoscopic procedures. Oxygen will continue throughout the procedure. When you are asleep you may be aware of suction in the mouth or throat, which is used to remove any unwanted secretions.
After the endoscopy
Usually you will be regaining conscious awareness just as you are being wheeled to the recovery area. You may be attached to the same monitors as were used in the procedure area. You will be closely monitored at this time by experienced nursing staff, who will check your blood pressure and vital signs frequently. This is a time to relax and gradually awaken. A long awaited cup of tea and a light meal may be provided about an hour after your procedure. Often it is wise to eat only lightly for the rest of the day following an endoscopic procedure.
You will be fit for discharge when you are wide awake, have had some food, and are able to get up, get dressed, and walk around without any unsteadiness. Another person should accompany you home. You must not drive or use machinery for the remainder of the day.
For the remainder of that day (and sometimes the next, if you still feel tired and unsteady),
do not –
- drive a motor vehicle
- use machinery that requires judgement or skill
- drink alcohol
- cook (because of the risk of burns)
- take sedative medication unless prescribed by your doctor
- sign legal documents
- make major financial decisions
- be the only person in charge of children or other dependent individuals.
What is a bronchoscopy?
Bronchoscopy is a procedure that allows the physician to see the larynx (voice box), trachea (windpipe), and the large and small air passages in the lungs (bronchi and bronchioles). This procedure is performed by a respirologist (lung doctor) usually at the request of your hematologist. This exam may be done to:
- Collect a tissue or cell sample (biopsy)
- Collect a fluid or sputum sample
- Locate areas that may be bleeding
- Remove foreign bodies
- Help diagnose infections, or pulmonary edema (too much fluid in the lung tissue)
- Diagnose lung problems of undetermined cause.
The bronchoscope is a flexible, small tube. It contains fibres that carry light down the tube and project a picture up the tube. Another open channel is used to take biopsies. A small brush may be used to brush the tissue walls to collect cells or secretions. An instrument called biopsy forceps may be used to pinch off a tiny bit of tissue. This channel can also be used for suctioning, oxygen, and anaesthetic.
You must not eat or drink anything for at least eight hours before the exam. Dentures must be removed before starting the procedure. Before the procedure, you may be given something to help you relax and to decrease secretions in the lungs. This will make your mouth feel dry.
The Procedure – What to Expect
The exam can be done with you lying on your back or sitting upright. A local anaesthetic and an intravenous sedative are usually used. Your mouth, throat, and tongue will be sprayed with the local anaesthetic. This will stop you from gagging. The spray works in 2-3 minutes. It may taste bitter and make the tongue and throat feel swollen. An anaesthetic jelly is used to help the bronchoscope insert more easily, and to prevent coughing or gagging.
After the Procedure
You may feel groggy from the sedative. Your throat may be sore and your voice may be hoarse. These symptoms will go away.
You will not be allowed to eat or drink anything until the gag reflex returns. This may take several hours. The patient care officers will check carefully to make sure you can swallow without any problems. Back in the rest room, you should lie on your side with the head of the bed raised. The patient care officer will check to make sure you don’t have any breathing or other problems.
The procedure often takes 1 to 1 ½ hours. If your white blood cell count is low, you will be asked to wear a mask while out of your room.