Gastroenterology Department
A sub-specialty of Internal medicine, gastroenterology deals with the diagnosis, treatment and management of components of the gastrointestinal tract. A gastroenterologist covers all concerns starting from the oesophagus to the rectum and treat illnesses such as Achalasia, Gastroparesis and Appendicitis.
Hepatology deals with all diseases of the liver and associated concerns. According to WHO, there is an influx of approximately 150,000 cases of Hepatitis each year in Pakistan. This is due to the poor sanitation and sewage conditions of Pakistan, which cause the persistence of the virus. The study of hepatology works to administer medical care which can combat the liver damage sustained due to hepatitis and other diseases such as cirrhosis, Liver cancer and polycystic liver disease.
Both branches of medicine require significant aftercare to ensure a good quality of life. Medical Practitioners aim to do so through the introduction of minimally invasive technology that can aid in the diagnosis of the concerned areas.
An upper endoscopy/Gastroscopy/EGD
An upper endoscopy is a procedure used to visually examine your upper digestive system with a tiny camera on the end of a long, flexible tube. A specialist in diseases of the digestive system (gastroenterologist) uses an endoscopy to diagnose and, sometimes, treat conditions that affect the esophagus, stomach and beginning of the small intestine (duodenum).
The medical term for an upper endoscopy is esophagogastroduodenoscopy. You may have an upper endoscopy done in your doctor’s office, an outpatient surgery center or a hospital.
Why it’s done
An upper endoscopy is used to diagnose and, sometimes, treat conditions that affect the upper part of your digestive system, including the esophagus, stomach and beginning of the small intestine (duodenum).
Your doctor may recommend an endoscopy procedure to:
- Investigate symptoms. An endoscopy may help your doctor determine what’s causing digestive signs and symptoms, such as nausea, vomiting, abdominal pain, difficulty swallowing and gastrointestinal bleeding.
- Diagnose. Your doctor may use an endoscopy to collect tissue samples (biopsy) to test for diseases and conditions, such as anemia, bleeding, inflammation, diarrhea or cancers of the digestive system.
- Treat. Your doctor can pass special tools through the endoscope to treat problems in your digestive system, such as burning a bleeding vessel to stop bleeding, widening a narrow esophagus, clipping off a polyp or removing a foreign object.
An endoscopy is sometimes combined with other procedures, such as an ultrasound. An ultrasound probe may be attached to the endoscope to create specialized images of the wall of your esophagus or stomach. An endoscopic ultrasound may also help your doctor create images of hard-to-reach organs, such as your pancreas. Newer endoscopes use high-definition video to provide clearer images.
Many endoscopes allow your doctor to use technology called narrow band imaging, which uses special light to help better detect precancerous conditions, such as Barrett’s esophagus.
Risks
An endoscopy is a very 
safe procedure. Rare complications include:
- Bleeding. Your risk of bleeding complications after an endoscopy is increased if the procedure involves removing a piece of tissue for testing (biopsy) or treating a digestive system problem. In rare cases, such bleeding may require a blood transfusion.
- Infection. Most endoscopies consist of an examination and biopsy, and risk of infection is low. The risk of infection increases when additional procedures are performed as part of your endoscopy. Most infections are minor and can be treated with antibiotics. Your doctor may give you preventive antibiotics before your procedure if you are at higher risk of infection.
- Tearing of the gastrointestinal tract. A tear in your esophagus or another part of your upper digestive tract may require hospitalization, and sometimes surgery to repair it. The risk of this complication is very low — it occurs in an estimated 1 of every 2,500 to 11,000 diagnostic upper endoscopies. The risk increases if additional procedures, such as dilation to widen your esophagus, are performed.
You can reduce your risk of complications by carefully following your doctor’s instructions for preparing for an endoscopy, such as fasting and stopping certain medications.
Signs and symptoms that could indicate a complication
Signs and symptoms to watch for after your endoscopy include:
- Fever
- Chest Pain
- Shortness of breath
- Bloody, black or very dark colored stool
- Difficulty swallowing
- Severe or persistent abdominal pain
- Vomiting, especially if your vomit is bloody or looks like coffee grounds
Call your doctor immediately or go to an emergency room if you experience any of these signs or symptoms.
How you prepare
Your doctor will give you specific instructions to prepare for your endoscopy. In some cases your doctor may ask that you:
- Fast before the endoscopy. You will need to stop drinking and eating four to eight hours before your endoscopy to ensure your stomach is empty for the procedure.
- Stop taking certain medications. You will need to stop taking certain blood-thinning medications in the days before your endoscopy. Blood thinners may increase your risk of bleeding if certain procedures are performed during the endoscopy. If you have chronic conditions, such as diabetes, heart disease or high blood pressure, your doctor will give you specific instructions regarding your medications.
Tell your doctor about all the medications and supplements you’re taking before your endoscopy.
Plan ahead for your recovery
Most people undergoing an upper endoscopy will receive a sedative to relax them and make them more comfortable during the procedure. Plan ahead for your recovery while the sedative wears off. You may feel mentally alert, but your memory, reaction times and judgment may be impaired. Find someone to drive you home. You may also need to take the day off from work. Don’t make any important personal or financial decisions for 24 hours.
What you can expect
During an endoscopy
During an upper endoscopy procedure, you’ll be asked to lie down on a table on your back or on your side. As the procedure gets underway:
- Monitors often will be attached to your body. This will allow your health care team to monitor your breathing, blood pressure and heart rate.
- You may receive a sedative medication. This medication, given through a vein in your forearm, helps you relax during the endoscopy.
- Your doctor may spray an anesthetic in your mouth. This medication will numb your throat in preparation for insertion of the long, flexible tube (endoscope). You may be asked to wear a plastic mouth guard to hold your mouth open.
- Then the endoscope is inserted in your mouth. Your doctor may ask you to swallow as the scope passes down your throat. You may feel some pressure in your throat, but you shouldn’t feel pain.
You can’t talk after the endoscope passes down your throat, though you can make noises. The endoscope doesn’t interfere with your breathing.
As your doctor passes the endoscope down your esophagus:
- A tiny camera at the tip transmits images to a video monitor in the exam room. Your doctor watches this monitor to look for abnormalities in your upper digestive tract. If abnormalities are found in your digestive tract, your doctor may record images for later examination.
- Gentle air pressure may be fed into your esophagus to inflate your digestive tract. This allows the endoscope to move freely. And it allows your doctor to more easily examine the folds of your digestive tract. You may feel pressure or fullness from the added air.
- Your doctor will pass special surgical tools through the endoscope to collect a tissue sample or remove a polyp. Your doctor watches the video monitor to guide the tools.
When your doctor has finished the exam, the endoscope is slowly retracted through your mouth. An endoscopy typically takes 15 to 30 minutes, depending on your situation.
After the Endoscopy
You’ll be taken to a recovery area to sit or lie quietly after your endoscopy. You may stay for an hour or so. This allows your health care team to monitor you as the sedative begins to wear off.Once you’re at home, you may experience some mildly uncomfortable signs and symptoms after endoscopy, such as:
- Bloating and gas
- Cramping
- Sore Throat
These signs and symptoms will improve with time. If you’re concerned or quite uncomfortable, call your doctor.
Take it easy for the rest of the day after your endoscopy. After receiving a sedative, you may feel alert, but your reaction times are affected and judgment is delayed.
When you receive the results of your endoscopy will depend on your situation. If, for instance, your doctor performed the endoscopy to look for an ulcer, you may learn the findings right after your procedure. If he or she collected a tissue sample (biopsy), you may need to wait a few days to get results from the testing laboratory. Ask your doctor when you can expect the results of your endoscopy.
You may go back to your usual diet and activities after the procedure, unless your healthcare provider tells you otherwise.
Tell your healthcare provider if you have any of the following:
- Fever or chills
- Redness, swelling, or bleeding or other drainage from the IV site
- Abdominal pain, nausea, or vomiting
- Black, tarry, or bloody stools
- Trouble swallowing
- Throat or chest pain that worsens
Your healthcare provider may give you other instructions after the procedure, based on your situation.
Next steps
Before you agree to the test or the procedure make sure you know:
- The name of the test or procedure
- The reason you are having the test or procedure
- What results to expect and what they mean
- The risks and benefits of the test or procedure
- What the possible side effects or complications are
- When and where you are to have the test or procedure
- Who will do the test or procedure and what that person’s qualifications are
- What would happen if you did not have the test or procedure
- Any alternative tests or procedures to think about
- When and how will you get the results
- Who to call after the test or procedure if you have questions or problems
- How much will you have to pay for the test or procedure
A colonoscopy is an exam used to detect changes or abnormalities in the large intestine (colon) and rectum.
During a colonoscopy, a long, flexible tube (colonoscope) is inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the inside of the entire colon.
If necessary, polyps or other types of abnormal tissue can be removed through the scope during a colonoscopy. Tissue samples (biopsies) can be taken during a colonoscopy as well.
Your doctor may recommend a colonoscopy to:
- Investigate intestinal signs and symptoms. A colonoscopy can help your doctor explore possible causes of abdominal pain, rectal bleeding, chronic constipation, chronic diarrhea and other intestinal problems.
- Screen for colon cancer. If you’re age 50 or older and at average risk of colon cancer — you have no colon cancer risk factors other than age — your doctor may recommend a colonoscopy every 10 years or sometimes sooner to screen for colon cancer. Colonoscopy is one option for colon cancer screening. Talk with your doctor about your options.
- Look for more polyps. If you have had polyps before, your doctor may recommend a follow-up colonoscopy to look for and remove any additional polyps. This is done to reduce your risk of colon cancer.
Risks
A colonoscopy poses few risks. Rarely, complications of a colonoscopy may include:
- Adverse reaction to the sedative used during the exam
- Bleeding from the site where a tissue sample (biopsy) was taken or a polyp or other abnormal tissue was removed
- A tear in the colon or rectum wall (perforation)
After discussing the risks of colonoscopy with you, your doctor will ask you to sign a consent form authorizing the procedure.
How you prepare
Before a colonoscopy, you’ll need to clean out (empty) your colon. Any residue in your colon may obscure the view of your colon and rectum during the exam. To empty your colon, your doctor may ask you to:
- Follow a special diet the day before the exam. Typically, you won’t be able to eat solid food the day before the exam. Drinks may be limited to clear liquids — plain water, tea and coffee without milk or cream, broth, and carbonated beverages. Avoid red liquids, which can be confused with blood during the colonoscopy. You may not be able to eat or drink anything after midnight the night before the exam.
- Take a laxative. Your doctor will usually recommend taking a laxative, in either pill form or liquid form. You may be instructed to take the laxative the night before your colonoscopy, or you may be asked to use the laxative both the night before and the morning of the procedure.
- Use an enema kit. In some cases, you may need to use an over-the-counter enema kit — either the night before the exam or a few hours before the exam — to empty your colon. This is generally only effective in emptying the lower colon and is usually not recommended as a primary way of emptying your colon.
- Adjust your medications. Remind your doctor of your medications at least a week before the exam — especially if you have diabetes, high blood pressure or heart problems or if you take medications or supplements that contain iron.
Also tell your doctor if you take aspirin or other medications that thin the blood, such as warfarin (Coumadin, Jantoven); newer anticoagulants, such as dabigatran (Pradaxa) or rivaroxaban (Xarelto), used to reduce risk of blot clots or stroke; or heart medications that affect platelets, such as clopidogrel (Plavix). You may need to adjust your dosages or stop taking the medications temporarily.
What you can expect
During the procedure
During a colonoscopy, you’ll wear a gown, but likely nothing else. Sedation is usually recommended. Sometimes a mild sedative is given in pill form. In other cases, the sedative is combined with an intravenous pain medication to minimize any discomfort.
You’ll begin the exam lying on your side on the exam table, usually with your knees drawn toward your chest. The doctor will insert a colonoscope into your rectum.
The scope — which is long enough to reach the entire length of your colon — contains a light and a tube (channel) that allows the doctor to pump air or carbon dioxide into your colon. The air or carbon dioxide inflates the colon, which provides a better view of the lining of the colon.
When the scope is moved or air is introduced, you may feel abdominal cramping or the urge to have a bowel movement.
The colonoscope also contains a tiny video camera at its tip. The camera sends images to an external monitor so that the doctor can study the inside of your colon.
The doctor can also insert instruments through the channel to take tissue samples (biopsies) or remove polyps or other areas of abnormal tissue.
A colonoscopy typically takes about 30 to 60 minutes.
After the procedure
After the exam, it takes about an hour to begin to recover from the sedative. You’ll need someone to take you home because it can take up to a day for the full effects of the sedative to wear off. Don’t drive or make important decisions or go back to work for the rest of the day.
If your doctor removed a polyp during your colonoscopy, you may be advised to eat a special diet temporarily. You may feel bloated or pass gas for a few hours after the exam, as you clear the air from your colon. Walking may help relieve any discomfort.
You may also notice a small amount of blood with your first bowel movement after the exam. Usually this isn’t cause for alarm. Consult your doctor if you continue to pass blood or blood clots or if you have persistent abdominal pain or a fever. While unlikely, this may occur immediately or in the first few days after the procedure, but may be delayed for up to one to two weeks.
Results
Your doctor will review the results of the colonoscopy and then share the results with you.
Negative result
A colonoscopy is considered negative if the doctor doesn’t find any abnormalities in the colon.
Your doctor may recommend that you have another colonoscopy:
- In 10 years, if you’re at average risk of colon cancer — you have no colon cancer risk factors other than age
- In 5 years, if you have a history of polyps in previous colonoscopy procedures
- In one year, if there was residual stool in the colon that prevented complete examination of your colon
Positive result
A colonoscopy is considered positive if the doctor finds any polyps or abnormal tissue in the colon.
Most polyps aren’t cancerous, but some can be precancerous. Polyps removed during colonoscopy are sent to a laboratory for analysis to determine whether they are cancerous, precancerous or noncancerous.
Depending on the size and number of polyps, you may need to follow a more rigorous surveillance schedule in the future to look for more polyps. If your doctor finds one or two polyps less than 0.4 inch (1 centimeter) in diameter, he or she may recommend a repeat colonoscopy in five to 10 years, depending on your other risk factors for colon cancer.
Your doctor will recommend another colonoscopy sooner if you have:
- More than two polyps
- A large polyp — larger than 0.4 inch (1 centimeter)
- Polyps and also residual stool in the colon that prevents complete examination of the colon
- Polyps with certain cell characteristics that indicate a higher risk of future cancer
- Cancerous polyps
If you have a polyp or other abnormal tissue that couldn’t be removed during the colonoscopy, your doctor may recommend a repeat exam with a gastroenterologist who has special expertise in removing large polyps, or surgery.
Problems with your exam
If your doctor is concerned about the quality of the view through the scope, he or she may recommend a repeat colonoscopy or a shorter time until your next colonoscopy. If your doctor wasn’t able to advance the scope through your entire colon, a barium enema or virtual colonoscopy may be recommended to examine the rest of your colon.
You may go back to your usual diet and activities after the procedure, unless your healthcare provider tells you otherwise.
Tell your healthcare provider if you have any of the following:
- Fever or chills
- Redness, swelling, or bleeding or other drainage from the IV site
- Abdominal pain, nausea, or vomiting
- Black, tarry, or bloody stools
- Trouble swallowing
- Throat or chest pain that worsens
Your healthcare provider may give you other instructions after the procedure, based on your situation.
Next steps
Before you agree to the test or the procedure make sure you know:
- The name of the test or procedure
- The reason you are having the test or procedure
- What results to expect and what they mean
- The risks and benefits of the test or procedure
- What the possible side effects or complications are
- When and where you are to have the test or procedure
- Who will do the test or procedure and what that person’s qualifications are
- What would happen if you did not have the test or procedure
- Any alternative tests or procedures to think about
- When and how will you get the results
- Who to call after the test or procedure if you have questions or problems
- How much will you have to pay for the test or procedure
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope—a long, flexible, lighted tube. Your healthcare provider guides the scope through your mouth and throat, then down the esophagus, stomach, and the first part of the small intestine (duodenum). Your healthcare provider can view the inside of these organs and check for problems. Next, he or she will pass a tube through the scope and inject a dye. This highlights the organs on X-ray.
Why might I need ERCP?
You may need ERCP to find the cause of unexplained abdominal pain or yellowing of the skin and eyes (jaundice). It may be used to get more information if you have pancreatitis or cancer of the liver, pancreas, or bile ducts.
Other things that may be found with ERCP include:
- Blockages or stones in the bile ducts
- Fluid leakage from the bile or pancreatic ducts
- Blockages or narrowing of the pancreatic ducts
- Tumors
- Infection in the bile ducts
Your healthcare provider may have other reasons to recommend an ERCP.
What are the risks of ERCP?
You may want to ask your healthcare provider about the amount of radiation used during the test. Also ask about the risks as they apply to you.
Consider writing down all X-rays you get, including past scans and X-rays for other health reasons. Show this list to your provider. The risks of radiation exposure may be tied to the number of X-rays you have over time.
If you are pregnant or think you could be, tell your healthcare provider. Radiation exposure during pregnancy may lead to birth defects.
Tell your healthcare provider if you are allergic to or sensitive to medicines, contrast dyes, iodine, or latex.
Some possible complications may include:
- Inflammation of the pancreas (pancreatitis) or gallbladder (cholecystitis). Pancreatitis is one of the most common complications and should be discussed with your provider ahead of time. Keep in mind, though, that ERCP is often performed to help relieve the disease in certain types of pancreatitis.
- Infection
- Bleeding
- A tear in the lining of the upper section of the small intestine, esophagus, or stomach
- Collection of bile outside the biliary system (biloma)
You may not be able to have ERCP if:
- You’ve had gastrointestinal (GI) surgery that has blocked the ducts of the biliary tree
- You have pouches in your esophagus (esophageal diverticula) or other abnormal anatomy that makes the test difficult to perform. Sometimes the ERCP is modified to make it work in these situations.
- You have barium within the intestines from a recent barium procedure since it may interfere with an ERCP
There may be other risks depend based on your condition. Be sure to discuss any concerns with your healthcare provider before the procedure.
How do I get ready for ERCP?
Recommendations for ERCP preparation include the following:
- Your healthcare provider will explain the procedure and you can ask questions.
- You may be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
- Tell your healthcare provider if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.
- Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, or anesthesia.
- Do not to eat or drink liquids for 8 hours before the procedure. You may be given other instructions about a special diet for 1 to 2 days before the procedure.
- If you are pregnant or think you could be, tell your healthcare provider.
- Tell your healthcare provider of all medicines (prescribed and over-the-counter) and herbal supplements that you are taking.
- Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning medicines (anticoagulants), aspirin, ibuprofen, naproxen, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
- If you have heart valve disease, your healthcare provider may give you antibiotics before the procedure.
- You will be awake during the procedure, but a sedative will be given before the procedure. Depending on the anesthesia used, you may be completely asleep and not feel anything. You will need someone to drive you home.
Follow any other instructions your provider gives you to get ready.
What happens during ERCP?
An ERCP may be done on an outpatient basis or as part of your stay in a hospital. Procedures may vary based on your condition and your healthcare provider’s practices.
Generally, an ERCP follows this process:
- You will need to remove any clothing, jewelry, or other objects that may interfere with the procedure.
- You will need to remove clothes and put on a hospital gown.
- An intravenous (IV) line will be put in your arm or hand.
- You may get oxygen through a tube in your nose during the procedure.
- You will be positioned on your left side or, more often, on your belly, on the X-ray table.
- Numbing medicine may be sprayed into the back of your throat. This helps prevent gagging as the endoscope is passed down your throat. You will not be able to swallow the saliva that collects in your mouth during the procedure. It will be suctioned from your mouth as needed.
- A mouth guard will be put in your mouth to keep you from biting down on the endoscope and to protect your teeth.
- Once your throat is numbed and you are relaxed from the sedative. Your provider will guide the endoscope down the esophagus into the stomach and through the duodenum until it reaches the ducts of the biliary tree.
- A small tube will be passed through the endoscope to the biliary tree, and contrast dye will be injected into the ducts. Air may be injected before the contrast dye. This may cause you to feel fullness in your abdomen.
- Various X-ray views will be taken. You may be asked to change positions during this time.
- After X-rays of the biliary tree are taken, the small tube for dye injection will be repositioned to the pancreatic duct. Contrast dye will be injected into the pancreatic duct, and X-rays will be taken. Again, you may be asked to change positions while the X-rays are taken.
- If needed, your provider will take samples of fluid or tissue. He or she may do other procedures, such as the removal of gallstones or other blockages, while the endoscope is in place.
After the X-rays and any other procedures are done, the endoscope will be withdrawn.
What happens after ERCP?
After the procedure, you will be taken to the recovery room. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged home. If this procedure was done as an outpatient, plan to have someone drive you home.
You will not be allowed to eat or drink anything until your gag reflex has returned. You may have a sore throat and pain with swallowing for a few days. This is normal.
Many times, a rectal suppository of a certain medicine is given after the ERCP to decrease the risk of pancreatitis.
You may go back to your usual diet and activities after the procedure, unless your healthcare provider tells you otherwise.
Tell your healthcare provider if you have any of the following:
- Fever or chills
- Redness, swelling, or bleeding or other drainage from the IV site
- Abdominal pain, nausea, or vomiting
- Black, tarry, or bloody stools
- Trouble swallowing
- Throat or chest pain that worsens
Your healthcare provider may give you other instructions after the procedure, based on your situation.
Next steps
Before you agree to the test or the procedure make sure you know:
- The name of the test or procedure
- The reason you are having the test or procedure
- What results to expect and what they mean
- The risks and benefits of the test or procedure
- What the possible side effects or complications are
- When and where you are to have the test or procedure
- Who will do the test or procedure and what that person’s qualifications are
- What would happen if you did not have the test or procedure
- Any alternative tests or procedures to think about
- When and how will you get the results
- Who to call after the test or procedure if you have questions or problems
- How much will you have to pay for the test or procedure