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HEPATOLOGY & GASTROENTEROLOGY

  • Upper GI Tract Endoscopy
  • GI Biopsy
  • ERCP – Endoscopic Retrograde Cholangio-pancreatography
  • MRCP – Magnetic Resonance Cholangio-pancreatography
  • Endoscopic Colonoscopy
  • Sigmoidoscopy
  • High resolution GI CT Scan
  • Virtual non-invasive  128 slice 3D-CT Colonoscopy
  • Gastroenterologist’s & Hepatologist’s consultation

Upper GI Tract Endoscopy

An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine called duodenum, through a thin, flexible viewing instrument called an endoscope. The tip of the endoscope is inserted through your mouth and then gently moved down your throat into the esophagus, stomach, and duodenum (upper gastrointestinal tract).

Since the entire upper gastrointestinal (GI) tract can be examined during this test, the procedure is sometimes called esophagogastroduodenoscopy (EGD).

Using the endoscope, your doctor can look for ulcers, inflammation, tumors, infection, or bleedingTissue samples can be collected (biopsy), polyps can be removed, and bleeding can be treatedthrough the endoscope. Endoscopy can reveal problems that do not show up on X-ray tests, and it can sometimes eliminate the need for exploratory surgery.

Why It Is Done

An upper gastrointestinal (UGI) endoscopy may be done to:

  • Find problems in the upper gastrointestinal (GI) tract. These problems can include:
  • Find the cause of vomiting blood (hematemesis).
  • Find the cause of symptoms, such as upper abdominal pain or bloating, trouble swallowing (dysphagia), vomiting, or unexplained weight loss.
  • Find the cause of an infection.
  • Check the healing of stomach ulcers.
  • Look at the inside of the stomach and upper small intestine (duodenum) after surgery.
  • Look for a blockage in the opening between the stomach and duodenum (gastric outlet obstruction).

Endoscopy may also be done to:

  • Check for an esophageal injury in an emergency (for example, if the person has swallowed poison).
  • Collect tissue samples (biopsy) for examination in the laboratory.
  • Remove growths from inside the esophagus, stomach, or small intestine (gastrointestinal polyps).
  • Treat upper gastrointestinal bleeding, including bleeding caused by engorged veins in the esophagus (esophageal varices).
  • Remove foreign objects that have been swallowed.
  • Look for bleeding that may be causing a decrease in the amount of oxygen-carrying substance (hemoglobin) found in red blood cells (anemia).

How To Prepare

Before having an upper gastrointestinal endoscopy, tell your doctors if you:

  • Are allergic to any medicines, including anesthetics.
  • Are taking any medicines.
  • Have bleeding problems or take blood-thinning medicine, such as warfarin (Coumadin).
  • Have heart problems.
  • Are or might be pregnant.
  • Have diabetes and take insulin.
  • Have had surgery or radiation treatments to your esophagus, stomach, or the upper part of your small intestine.

Do not eat or drink anything for 6 to 8 hours before the test. An empty stomach helps your doctor see your stomach clearly during the test. It also reduces your chances of vomiting. If you vomit, there is a small risk that your stomach contents could enter your lungs (aspiration). If the test is done in an emergency, a tube may be inserted through your nose or mouth to empty your stomach.

GI Biopsy

Overview

Patients undergoing endoscopy will be diagnosed on endoscopic visualization and pathological examination. The physician may take small tissue samples (biopsy) to look for infection, illness, and early signs of cancer. These samples may come from the esophagus, stomach, small intestine, or colon. Physicians may also remove polyps along the GI tract. Histopathologic evaluation is helpful to differentiate malignant, inflammatory and infectious processes. Therefore, biopsies should be taken of any suspect tissue or as a follow-up to an earlier endoscopic procedure to evaluate prior therapy. Obtaining samples via biopsy forceps is the most common GI technique.

Disposable Cold Biopsy Forceps

Single-bite biopsy cold forceps allow sampling of the GI tract. A variety of devices for all scopes can be utilized including designs such as our smooth cup and alligator jaw. Each device is designed with or without needles.

Disposable Hot Biopsy Forceps

The hot biopsy forceps technique involves the use of insulated monopolar electrocoagulating forceps to simultaneously biopsy and electrocoagulate tissue. This technique has been recommended for removal of diminutive polyps and for treatment of vascular ectasias of the GI tract.

Reusable

In addition to the single-use options provided, reusable forceps are offered in a variety of jaw types and channel sizes. These devices are constructed of easy-to-clean materials and can be reprocessed by ultrasonic cleaning and autoclave sterilization.

Endoscopic Retrograde Cholangio-pancreatography (ERCP)

An endoscopic retrograde cholangiopancreatogram (ERCP) is a test that combines the use of a flexible, lighted scope (endoscope) with X-ray pictures to examine the tubes that drain the livergallbladder, and pancreas.

The endoscope is inserted through the mouth and gently moved down the throat into the esophagusstomach, and duodenum until it reaches the point where the ducts from the pancreas (pancreatic ducts) and gallbladder (bile ducts) drain into the duodenum.

ERCP can treat certain problems found during the test. If an abnormal growth is seen, an instrument can be inserted through the endoscope to obtain a sample of the tissue for further testing (biopsy). If a gallstone is present in the common bile duct, the doctor can sometimes remove the stone with instruments inserted through the endoscope. A narrowed bile duct can be opened by inserting a small wire-mesh or plastic tube (called a stent) through the endoscope and into the duct.

Why It Is Done

ERCP is done to:

  • Check persistent abdominal pain or jaundice.
  • Find gallstones or diseases of the liver, bile ducts, or pancreas.
  • Remove gallstones from the CBD if they are causing a problem such as obstruction, inflammation or infection of the CBD (cholangitis), or pancreatitis.
  • Open a narrowed bile duct or insert a drain.
  • Get a tissue sample for further testing (biopsy).
  • Measure the pressure inside the bile ducts (manometry).

How To Prepare

Follow the instructions exactly about when to stop eating and drinking, or your test may be canceled. If your doctor has instructed you to take your medicines on the day of the test, please do so using only a sip of water.

If your doctor prescribed antibiotics before the test, take them as directed. You need to take the full course of antibiotics.

Tell your doctor if you:

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. You will be asked to empty your bladder and remove any dentures, jewelry, or contact lenses before having an ERCP.

How It Is Done

An endoscopic retrograde cholangiopancreatogram (ERCP) is done by a doctor trained in endoscopy, usually a doctor who specializes in diseases of the digestive system (gastroenterologist). A thin, flexible fiber-optic endoscope is used.

Magnetic Resonance Cholangio-pancreatography (MRCP)

Magnetic Resonance Cholangio-pancreatography (MRCP) is a technique that has evolved over the past two decades. It continues to have a fundamental role in the non-invasive investigation of many pancreatico-biliary disorders. The purpose of this review is to summarize the key concepts behind MRCP, the different techniques that are currently employed (including functional and secretin-stimulated MRCP), the pitfalls the reader should be aware of, and the main clinical indications for its use.

It has been exactly two decades since magnetic resonance cholangiopancreatography (MRCP) was first described. Over this time, the technique has evolved considerably, aided by improvements in spatial resolution and speed of acquisition. It has now an established role in the investigation of many biliary disorders, serving as a non-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP).

MRCP protocol

Patients are fasted for 4 h prior to the study in order to reduce fluid secretions within the stomach and duodenum, reduce bowel peristalsis and promote gallbladder distension. We do not routinely use an anti-peristaltic agent. Some centres use a negative oral contrast agent (e.g. iron oxide or blueberry juice) to reduce the signal intensity of overlapping fluid within the stomach and duodenum, although this is not part of our routine protocol.

At our institution, MRCP is performed on a 1.5-T GE MRI system, using a phased-array body coil. The protocol imaging parameters are shown in Table. We first perform an axial 2D breath-hold HASTE sequence. Two breath-hold acquisitions are obtained, so that the whole of the liver down to the duodenal ampulla is visualised.

The technique of MRCP has evolved considerably over the last 2 decades, with technological advances in both acquisition and post processing. It remains the investigation of choice for the non-invasive diagnosis of many pancreatico-biliary disorders. It is hoped that this review has helped remind the reader as to the basic concepts behind MRCP, the different sequences that can now be employed, the pitfalls one should be aware of, and why, even in modern day, it remains a test fit for purpose in the radiological investigation of biliary pathology.

Endoscopic Colonoscopy

Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (e.g. ulcerationpolyps) and grants the opportunity for biopsy or removal of suspected colorectal cancer lesions.

Colonoscopy can remove polyps as small as one millimetre or less. Once polyps are removed, they can be studied with the aid of a microscope to determine if they are precancerous or not.

Colonoscopy is similar to sigmoidoscopy, the difference being related to which parts of the colon each can examine. A colonoscopy allows an examination of the entire colon (1200–1500 mm in length).

A sigmoidoscopy allows an examination of the distal portion (about 600 mm) of the colon, which may be sufficient because benefits to cancer survival of colonoscopy have been limited to the detection of lesions in the distal portion of the colon.

Guidelines for the Early Detection of Cancer

The American Cancer Society “Guidelines for the Early Detection of Cancer” recommend, beginning at age 50, both men and women follow one of these testing schedules for screening to find colon polyps and cancer:

  1. Flexible sigmoidoscopy every 5 years
  2. Colonoscopy every 10 years
  3. Double-contrast barium enema every 5 years
  4. CT colonography (virtual colonoscopy) every 5 years

A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, often done in conjunction with a fecal occult blood test (FOBT). About 5% of these screened patients are referred to colonoscopy.

Virtual colonoscopy, which uses 2D and 3D imagery reconstructed from computed tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is also possible, as a totally non-invasive medical test, although it is not standard and still under investigation regarding its diagnostic abilities. Furthermore, virtual colonoscopy does not allow for therapeutic maneuvers such as polyp/tumour removal or biopsy nor visualization of lesions smaller than 5 millimetres. If a growth or polyp is detected using CT colonography, a standard colonoscopy would still need to be performed.

Medical uses

Conditions that call for colonoscopies include gastrointestinal hemorrhage, unexplained changes in bowel habit and suspicion of malignancy. Colonoscopies are often used to diagnose colon cancer, but are also frequently used to diagnose inflammatory bowel disease. In older patients (sometimes even younger ones) an unexplained drop in hematocrit (one sign of anemia) is an indication that calls for a colonoscopy, usually along with an esophagogastroduodenoscopy (EGD), even if no obvious blood has been seen in the stool (feces).

Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn’s diseaseulcerative colitis), colon cancer, or polyps. However—since its development by Dr. Hiromi Shinya and Dr. William I. Wolff in the 1960s—polypectomy has become a routine part of colonoscopy, allowing for quick and simple removal of polyps without invasive surgery.[7]

Colonoscopy has become a primary routine screening test for people  who are over 50 years of age, but flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years, or double-contrast barium enema every 5 years, or CT colonography (virtual colonoscopy) every 5 years are all equally recommended. Subsequent rescreenings are then scheduled based on the initial results found, with a five- or ten-year recall being common for colonoscopies that produce normal results. Patients with a family history of colon cancer are often first screened during their teenage years. Among people who have had an initial colonoscopy that found no polyps, the risk of developing colorectal cancer within five years is extremely low. Therefore, there is no need for those people to have another colonoscopy sooner than five years after the first screening.

Procedure

Indications

Medical societies recommend a screening colonoscopy every 10 years beginning at age 50 for adults without increased risk for colorectal cancer. Research shows that the risk of cancer is low for 10 years if a high-quality colonoscopy does not detect cancer, so tests for this purpose are indicated every ten years.

Preparation

The colon must be free of solid matter for the test to be performed properly. For one to three days, the patient is required to follow a low fiber or clear-liquid only diet. Examples of clear fluids are apple juice, chicken and/or beef broth or bouillonlemon-lime soda, lemonade, sports drink, and water. It is very important that the patient remain hydrated. Sports drinks contain electrolytes which are depleted during the purging of the bowel. Orange juiceprune juice, and milk containing fiber should not be consumed, nor should liquids dyed red, purple, orange, or sometimes brown; however, cola is allowed. In most cases, tea(no milk) or black coffee (no milk) are allowed.[14]

The day before the colonoscopy, the patient is either given a laxative preparation (such as PicosalaxBisacodylphospho sodasodium picosulfate, or sodium phosphate and/or magnesium citrate) and large quantities of fluid, or whole bowel irrigation is performed using a solution of polyethylene glycol and electrolytes. Often, the procedure involves both a pill-form laxative and a bowel irrigation preparation with the polyethylene glycol powder dissolved into any clear liquid, preferably a sports drink that contains electrolytes.

In this case, a typical procedure regimen then would be as follows: in the morning of the day before the procedure, a 238 g bottle of polyethylene glycol powder should be poured into 64 oz. of the chosen clear liquid, which then should be mixed and refrigerated. Two (2) bisacodyl 5 mg tablets are taken 3 pm; at 5 pm, the patient starts drinking the mixture (approx. 8 oz. each 15-30 min. until finished); at 8 pm, take two (2) bisacodyl 5 mg tablets; continue drinking/hydrating into the evening until bedtime with clear permitted fluids. A common brand name of bisacodyl is Dulcolax, and store brands are available. A common brand name of polyethylene glycol powder is MiraLAX. It may be advisable to schedule the procedure early on a given day so the patient need not go without food and only limited fluids the morning of the procedure on top of having to go through the foregoing preparation procedures the preceding day.

Since the goal of the preparation is to clear the colon of solid matter, the patient should plan to spend the day at home in comfortable surroundings with ready access to toilet facilities. The patient may also want to have at hand moist towelettes or a bidet for cleaning the anus. A soothing salve such as petroleum jellyapplied after cleaning the anus will improve patient comfort.

The patient may be asked to skip aspirin and aspirin-like products such as salicylateibuprofen, and similar medications for up to ten days before the procedure to avoid the risk of bleeding if a polypectomy is performed during the procedure. A blood test may be performed before the procedure.

Investigation

Schematic overview of colonoscopy procedure

During the procedure the patient is often given sedation intravenously, employing agents such as fentanylor midazolam.

The average person will receive a combination of these two drugs, usually between 25 to 100 µg IV fentanyl and 1–4 mg IV midazolam. Sedation practices vary between practitioners and nations; in some clinics, sedation is rarely administered.Some endoscopists are experimenting with, or routinely use, alternative or additional methods such as nitrous oxide and propofol, which have advantages and disadvantages relating to recovery time (particularly the duration of amnesia after the procedure is complete), patient experience, and the degree of supervision needed for safe administration. This sedation is called “twilight anesthesia“. For some patients it is not fully effective, so they are indeed awake for the procedure and can watch the inside of their colon on the colour monitor. Substituting propofol for midazolam, which gives the patient quicker recovery, is gaining wider use, but requires closer monitoring of respiration.

meta-analysis found that playing music improves patient tolerability of the procedure.

The first step is usually a digital rectal examination, to examine the tone of the sphincter and to determine if preparation has been adequate. The endoscope is then passed through the anus up the rectum, the colon(sigmoid, descending, transverse and ascending colon, the cecum), and ultimately the terminal ileum. The endoscope has a movable tip and multiple channels for instrumentation, air, suction and light. The bowel is occasionally insufflated with air to maximize visibility (a procedure which gives one the false sensation of needing to take a bowel movement). Biopsies are frequently taken for histology. Additionally in a procedure known as chromoendoscopy, a contrast-dye (such as Indigo carmine) may be sprayed via the endoscope onto the bowel wall to help visualise any abnormalities in the mucosal morphology.

In most experienced hands, the endoscope is advanced to the junction of where the colon and small bowel join up (cecum) in under 10 minutes in 95% of cases. Due to tight turns and redundancy in areas of the colon that are not “fixed”, loops may form in which advancement of the endoscope creates a “bowing” effect that causes the tip to actually retract. These loops often result in discomfort due to stretching of the colon and its associated mesentery. Manoeuvres to “reduce” or remove the loop include pulling the endoscope backwards while torquing the instrument. Alternatively, body position changes and abdominal support from external hand pressure can often “straighten” the endoscope to allow the scope to move forward. In a minority of patients, looping is often cited as a cause for an incomplete examination. Usage of alternative instruments leading to completion of the examination has been investigated, including use of pediatric colonoscope, push enteroscope and upper GI endoscope variants.

For screening purposes, a closer visual inspection is then often performed upon withdrawal of the endoscope over the course of 20 to 25 minutes. Lawsuits over missed cancerous lesions have recently prompted some institutions to better document withdrawal time as rapid withdrawal times may be a source of potential medical legal liability. This is often a real concern in clinical settings where high caseloads could provide financial incentive to complete colonoscopies as quickly as possible.

Suspicious lesions may be cauterized, treated with laser light or cut with an electric wire for purposes of biopsy or complete removal polypectomy. Medication can be injected, e.g. to control bleeding lesions. On average, the procedure takes 20–30 minutes, depending on the indication and findings. With multiple polypectomies or biopsies, procedure times may be longer. As mentioned above, anatomic considerations may also affect procedure times.

After the procedure, some recovery time is usually allowed to let the sedative wear off. Outpatient recovery time can take an estimate of 30–60 minutes. Most facilities require that patients have a person with them to help them home afterwards (again, depending on the sedation method used).

One very common aftereffect from the procedure is a bout of flatulence and minor wind pain caused by air insufflation into the colon during the procedure.

An advantage of colonoscopy over x-ray imaging or other, less invasive tests, is the ability to perform therapeutic interventions during the test. A polyp is a growth of excess of tissue that can develop into cancer. If a polyp is found, for example, it can be removed by one of several techniques. A snare device can be placed around a polyp for removal. Even if the polyp is flat on the surface it can often be removed. For example, the following shows a polyp removed in stages:

Pain management

The pain associated with the procedure is not caused by the insertion of the scope but rather by the inflation of the colon in order to do the inspection. The scope itself is essentially a long, flexible tube about a centimetre in diameter, i.e. as big around as the little finger, which is less than the diameter of an average stool.

The colon is wrinkled and corrugated, somewhat like an accordion or a clothes-dryer exhaust tube, which gives it the large surface area needed for digestion. In order to inspect this surface thoroughly the physician blows it up like a balloon, using an air compressor, in order to get the creases out. The stomach, intestines and colon have a so-called “second brain” wrapped around them, which autonomously runs the chemical factory of digestion. It uses complex hormone signals and nerve signals to communicate with the brain and the rest of the body. Normally a colon’s job is to digest food and regulate the intestinal flora. The harmful bacteria in rancid food, for example, creates gas. The colon has distension sensors that can tell when there is unexpected gas pushing the colon walls out—thus the “second brain” tells the person that he or she is having intestinal difficulties by way of the sensation of nausea. Doctors typically recommend either total anaesthesia or a partial twilight sedative to either preclude or to lessen the patient’s awareness of pain or discomfort, or just the unusual sensations of the procedure. Once the colon has been inflated, the doctor inspects it with the scope as it is slowly pulled backwards. If any polyps are found they are then cut out for later biopsy.

Some doctors prefer to work with totally anesthetized patients inasmuch as the lack of any perceived pain or discomfort allows for a leisurely examination. Twilight sedation is, however, inherently safer than general anesthesia; it also allows the patients to follow simple commands and even to watch the procedure on a closed-circuit monitor. For these reasons it is generally best to request twilight sedation and ask the doctor to take his or her time despite any discomfort which the procedure may entail. Tens of millions of adults annually need to have colonoscopies, and yet many don’t because of concerns about the procedure.

It is worth noting that in many hospitals (for instance St. Mark’s HospitalLondon, which specialises in intestinal and colorectal medicine) colonoscopies are carried out without any sedation. This allows the patient to shift his or her body position to help the doctor carry out the procedure and significantly reduces recovery time and side-effects. Although there is some discomfort when the colon is distended with air, this is not usually particularly painful and it passes relatively quickly. Patients can then be released from hospital on their own very swiftly without any feelings of nausea.

Ultrasound

Duodenography and colonography are performed like a standard abdominal examination using B-mode and color flow Doppler ultrasonography using a low frequency transducer — for example a 2.5 MHz — and a high frequency transducer, for example a 7.5 MHz probe. Detailed examination of duodenal walls and folds, colonic walls and haustra was performed using a 7.5 MHz probe. Deeply located abdominal structures were examined using 2.5 MHz probe.

All ultrasound examinations are performed after overnight fasting (for at least 16 hours) using standard scanning procedure. Subjects are examined with and without water contrast. Water contrast imaging is performed by having adult subjects take at least one liter of water prior to examination. Patients are examined in the supine, left posterior oblique, and left lateral decubitus positions using the intercostal and subcostal approaches. The liver, gall bladder, spleen, pancreas, duodenum, colon, and kidneys are routinely evaluated in all patients. With patient lying supine, the examination of the duodenum with high frequency ultrasound duodenography is performed with 7.5 MHz probe placed in the right upper abdomen, and central epigastric successively; for high frequency ultrasound colonography, the ascending colon, is examined with starting point usually midway of an imaginary line running from the iliac crest to the umbilicus and proceeding cephalid through the right mid abdomen; for the descending colon, the examination begins from the left upper abdomen proceeding caudally and traversing the left mid abdomen and left lower abdomen, terminating at the sigmoid colon in the lower pelvic region. Color flow Doppler sonography is used to examine the localization of lesions in relation to vessels. All measurements of diameter and wall thickness are performed with built-in software. Measurements are taken between peristaltic waves.

Results

A 2009 study published in the Annals of Internal Medicine implies that colonoscopy screening prevents approximately two thirds of the deaths due to colorectal cancers on the left side of the colon, and is not associated with a significant reduction in deaths from right-sided disease. This study examined people with colon cancer diagnosed between 1996 and 2001 in Ontario who died of colon cancer by 2003, and hence studied colonoscopies done in the early to mid-1990s. (Since the procedure continues to evolve, more recent colonoscopies may be more effective). The summary result, according to table 3 of the report, show approximately a 37% reduction in the death rate from colorectal cancer, with a significantly lower reduction in death for “incomplete” colonoscopies.

A 2011 study published in Annals of Internal Medicine, on the other hand, showed that in people who had colonoscopy in the previous 10 years “the risks for early and more advanced stages of cancer were reduced by more than 50%. A lower risk for CRC [colorectal cancer] was seen for both cancer on the left side of the colon (closer to the anus and thus easier to reach during colonoscopy) and for cancer on the right side (which is harder to reach).”

Risks

This procedure has a low (0.35%) risk of serious complications. In a 2006 study of colonoscopies done from 1994 to 2002, Levin et al., found serious complications occurred in 5.0 of 1000 colonoscopies, comprising 0.8 in 1000 colonoscopies without biopsy or polypectomy, and a rate of 7.0 per 1000 for colonoscopies with biopsy or polypectomy; although McDonell and Loura criticize this rate as being unacceptably high.

The rate of complications varies with the practitioner and institution performing the procedure, as well as a function of other variables.

The most serious complication generally is the gastrointestinal perforation, which is life-threatening and requires immediate major surgery for repair. A 2003 summary study of 25,000 patients showed a perforation rate of 0.2%, and a death rate of 0.006% on a total of 84,000 patients. The 2006 study by Levin et al. showed a perforation rate of 0.09%; while a 2009 study quoted a similar perforation rate of 0.082%. Appendicitis has been associated with either perforation or colonoscopy, in case reports in Korean, Italian and English journals.

According to a study published in the Annals of Internal Medicine, for which researchers reviewed colon cancer screening data from 1966 to 2001, the most severe complications from colonoscopy are perforation (that occurred in 0.029% to 0.72% of cases), heavy bleeding (occurring in 0.2% to 2.67% of colonoscopies) and death (occurring in 0.003% to 0.03% of colonoscopy patients).

A 2003 analysis of the relative risks of sigmoidoscopy and colonoscopy, brought into attention that the risk of perforation after colonoscopy is approximately double that after sigmoidoscopy (consistent with the fact that colonoscopy examines a longer section of the colon), even though this difference appeared to be decreasing.

Bleeding complications may be treated immediately during the procedure by cauterization via the instrument. Delayed bleeding may also occur at the site of polyp removal up to a week after the procedure and a repeat procedure can then be performed to treat the bleeding site. Even more rarely, splenic rupture can occur after colonoscopy because of adhesions between the colon and the spleen.

As with any procedure involving anaesthesia, other complications would include cardiopulmonarycomplications such as a temporary drop in blood pressure, and oxygen saturation usually the result of overmedication, and are easily reversed. Anesthesia can also increase the risk of developing blood clots and lead to pulmonary embolism or deep venous thrombosis. (DVT) In rare cases, more serious cardiopulmonary events such as a heart attackstroke, or even death may occur; these are extremely rare except in critically ill patients with multiple risk factors. In very rare cases, coma associated with anesthesia may occur.

Virtual colonoscopies carry risks that are associated with radiation exposure.

Severe dehydration caused by the laxatives that are usually administered during the bowel preparation for colonoscopy also may occur. Therefore, patients must drink large amounts of fluids during the days of colonoscopy preparation to prevent dehydration. Loss of electrolytes or dehydration is a potential risk that can even prove deadly. In rare cases, severe dehydration can lead to kidney damage or renal dysfunction under the form of phosphate nephropathy.

Colonoscopy preparation and colonoscopy procedure can cause inflammation of the bowels and diarrheaor even bowel obstruction.

During colonoscopies where a polyp is removed (a polypectomy), the risk of complications has been higher, although still very uncommon, at about 2.3 percent. One of the most serious complications that may arise after colonoscopy is the postpolypectomy syndrome. This syndrome occurs due to potential burns to the bowel wall when the polyp is removed. It is however a very rare complication and as a result patients may experience fever and abdominal pain. The condition is treated with intravenous fluids and antibiotics while the patient is recommended to rest.

Bowel infections are a potential colonoscopy risk, although very rare. The colon is not a sterileenvironment as many bacteria live in the colon to assure the well-functioning of the bowel and therefore the risk of infections is very low. Infections can occur during biopsies when too much tissue is removed and bacteria protrude in areas they do not belong to or in cases when the lining of the colon is perforated and the bacteria get into the abdominal cavity. Infection may also be transmitted between patients if the colonoscope is not cleaned and sterilized properly between tests, although the risk of this happening is very low.

Minor colonoscopy risks may include nauseavomiting or allergies to the sedatives that are used. If medication is given intravenously, the vein may become irritated. Most localized irritations to the vein leave a tender lump lasting a number of days but going away eventually. The incidence of these complications is less than 1%.

On very rare occasions, intracolonic explosion may occur. High frequency ultrasound duodenography and colonography do not carry the risks associated with a traditional colonoscopy.[citation needed]

Although complications after colonoscopy are uncommon, it is important for patients to recognize early signs of any possible complications. They include severe abdominal pain, fevers and chills, or rectal bleeding (more than half a cup).

Sigmoidoscopy

Flexible Sigmoidoscopy is a routine outpatient procedure in which the inner lining of the lower large intestine is examined. Flexible Sigmoidoscopy is commonly used to evaluate gastrointestinal symptoms, such as abdominal pain, rectal bleeding, or changes in bowel habits. It is also performed to screen people older than age 50 for colon and rectal cancer.

During the procedure, a doctor uses a Sigmoidoscopy, a long, flexible, tubular instrument about 1/2 inch in diameter, to view the lining of the rectum and the lower third of the colon (the sigmoid colon).

How Do I Prepare for a Flexible Sigmoidoscopy?

Before having a flexible Sigmoidoscopy, make sure you tell your doctor about any medical conditions you may have that he or she may not know about.

You should always tell your doctor if you:

  • Are pregnant
  • Have a lung or heart condition
  • Are allergic to any medications
  • Have diabetes or take drugs that may affect blood clotting

Adjustments to these medications may be required before the sigmoidoscopy procedure.

Never stop taking any medication without first consulting with your doctor.

You may need to take antibiotics before the sigmoidoscopy if you:

  • Have an artificial heart valve
  • Have ever been told you need to take antibiotics before a dental or surgical procedure

Do I Have to Stop Eating and Drinking Before a Flexible Sigmoidoscopy?

There are no diet or fluid restrictions before a flexible sigmoidoscopy. But, your bowel must be cleansed in order for sigmoidoscopy to be successful. You will receive two enemas before the procedure since the rectum and lower intestine must be empty so that the intestinal walls can be seen. You will need to try to hold the enema solution for at least five minutes before releasing it.

How Is a Flexible Sigmoidoscopy Performed?

A flexible sigmoidoscopy is performed by a doctor experienced in the procedure, and usually lasts from 10 minutes to 20 minutes. No sedation is required. Your doctor will have you lie on your left side, with your knees drawn up. The sigmoidoscope is inserted through the rectum and passes slowly into the sigmoid colon. A small amount of air is used to expand the colon so the doctor can see the colon walls. You may feel mild cramping during the procedure. You can reduce the cramping by taking several slow, deep breaths during the procedure. When the doctor has finished, the sigmoidoscope is slowly withdrawn while the lining of your bowel is carefully examined.

What Happens After a Flexible Sigmoidoscopy?

After the procedure your doctor will discuss the results of your flexible sigmoidoscopy with you.

You may feel some cramping or a sensation of having gas, but this usually passes quickly.

You may resume your normal diet and activities.

If growths, or polyps, are found during the procedure, a biopsy (removal of tissue) of the polyp, or polyps, may be taken, or you may be advised to have a complete colon exam, by colonoscopy with polyp removal.

Puncture of the colon is a serious — although rare — possible complication of sigmoidoscopy. If you experience any of the following, call your doctor immediately:

  • Severe abdominal pain
  • Fever and chills
  • Heavy rectal bleeding (greater than 1 teaspoon at a time)

Rigid sigmoidoscopy

Rigid sigmoidoscopy may be useful in ano-rectal diseases such as bleeding per rectum or inflammatory rectal disease, particularly in the general practice and pediatrics.

For performing the examination, the patient must lie on the left side, in the so-called Sims’ position. The bowels are previously emptied with a suppository, and a digital rectal examination is first performed. The sigmoidoscope is lubricated and inserted with obturator in general direction of the navel. The direction is then changed and the obturator is removed so that the physician may penetrate further with direct vision. A bellows is used to insufflate air to distend the rectum. Lateral movements of the sigmoidoscope’s tip negotiate the Houston valve and the recto-sigmoid junction.