v ERCP (Endoscopic Retrograde Cholangiopancreatography)

Endoscopic retrograde cholangiopancreatography (ERCP) enables the physician to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin. ERCP is used primarily to diagnose and treat conditions of the bile ducts including gallstones, inflammatory strictures (scars), leaks(from trauma and surgery), and cancer. ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube. Through it, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays. For the procedure, you will lie on your left side on an examining table in an x ray room.

You will be given medication to help numb the back of your throat and a sedative to help you relax during the exam. You will swallow the endoscope, and the physician will then guide the scope through your esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. At this time, you will be turned to lie flat on your stomach, and the physician will pass a small plastic tube through the scope. Through the tube, the physician will inject a dye into the ducts to make them show up clearly on x rays. X rays are taken as soon as the dye is injected.

If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing.

Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days. 

ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for 1 to 2 hours until the sedative wears off. The physician will make sure you do not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

Preparation

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home–you will not be allowed to drive because of the sedatives. The physician may give you other special instructions.

v Liver Biopsy In a liver biopsy (BYE-op-see), the physician examines a small piece of tissue from your liver for signs of damage or disease. A special needle is used to remove the tissue from the liver. The physician decides to do a liver biopsy after tests suggest that the liver does not work properly. For example, a blood test might show that your blood contains higher than normal levels of liver enzymes or too much iron or copper. An x ray could suggest that the liver is swollen. Looking at liver tissue itself is the best way to determine whether the liver is healthy or what is causing it to be damaged. Preparation Before scheduling your biopsy, the physician will take blood samples to make sure your blood clots properly. Be sure to mention any medications you take, especially those that affect blood clotting, like blood thinners. One week before the procedure, you will have to stop taking aspirin, ibuprofen, and anticoagulants. You must not eat or drink anything for 8 hours before the biopsy, and you should plan to arrive at the hospital about an hour before the scheduled time of the procedure.

 Your physician will tell you whether to take your regular medications during the fasting period and may give you other special instructions.

Procedure

Liver biopsy is considered minor surgery and so it is done at the hospital. For the biopsy, you will lie on a hospital bed on your back with your right hand above your head. After marking the outline of your liver and injecting a local anesthetic to numb the area, the physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue. In some cases, the physician may use an ultrasound image of the liver to help guide the needle to a specific spot.

You will need to hold very still so that the physician does not nick the lung or gallbladder, which are close to the liver. The physician will ask you to hold your breath for 5 to 10 seconds while he or she puts the needle in your liver. You may feel pressure and a dull pain. The entire procedure takes about 20 minutes.
Two other methods of liver biopsy are also available. For a laparoscopic biopsy, the physician inserts a special tube called a laparoscope through an incision in the abdomen. The laparoscope sends images of the liver to a monitor. The physician watches the monitor and uses instruments in the laparoscope to remove tissue samples from one or more parts of the liver. Physicians use this type of biopsy when they need tissue samples from specific parts of the liver.

Transvenous biopsy involves inserting a tube called a catheter into a vein in the neck and guiding it to the liver. The physician puts a biopsy needle into the catheter and then into the liver. Physicians use this procedure when patients have blood-clotting problems or fluid in the abdomen.

Recovery

After the biopsy, the physician will put a bandage over the incision and have you lie on your right side, pressed against a towel, for 1 to 2 hours. The nurse will monitor your vital signs and level of pain.

You will need to arrange for someone to take you home from the hospital since you will not be allowed to drive after having the sedative. You must go directly home and remain in bed (except to use the bathroom) for 8 to 12 hours, depending on your physician’s instructions. Also, avoid exertion for the next week so that the incision and liver can heal. You can expect a little soreness at the incision site and possibly some pain in your right shoulder. This pain is caused by irritation of the diaphragm muscle (the pain usually radiates to the shoulder) and should disappear within a few hours or days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after surgery. These medicines decrease blood clotting, which is crucial for healing.

Like any surgery, liver biopsy does have some risks, such as puncture of the lung or gallbladder, infection, bleeding, and pain, but these complications are rare.

v Colonoscopy

Colonoscopy (koh-luh-NAH-skuh-pee) lets the physician look inside your entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to look for early signs of cancer in the colon and rectum. It is also used to diagnose the causes of unexplained changes in bowel habits. Colonoscopy enables the physician to see inflamed tissue, abnormal growths, ulcers, and bleeding. For the procedure, you will lie on your left side on the examining table. You will probably be given pain medication and a mild sedative to keep you comfortable and to help you relax during the exam. The physician will insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a colonoscope (koh-LON-oh-skope). The scope transmits an image of the inside of the colon, so the physician can carefully examine the lining of the colon. The scope bends, so the physician can move it around the curves of your colon. You may be asked to change position occasionally to help the physician move the scope. The scope also blows air into your colon, which inflates the colon and helps the physician see better. If anything abnormal is seen in your colon, like a polyp or inflamed tissue, the physician can remove all or part of it using tiny instruments passed through the scope.

That tissue (biopsy) is then sent to a lab for testing. If there is bleeding in the colon, the physician can pass a laser, heater probe, or electrical probe, or inject special medicines through the scope and use it to stop the bleeding.

Bleeding and puncture of the colon are possible complications of colonoscopy. However, such complications are uncommon.

Colonoscopy takes 30 to 60 minutes. The sedative and pain medicine should keep you from feeling much discomfort during the exam. You will need to remain at the endoscopy facility for 1 to 2 hours until the sedative wears off.

Preparation

Your colon must be completely empty for the colonoscopy to be thorough and safe. To prepare for the procedure you may have to follow a liquid diet for 1 to 3 days beforehand. A liquid diet means fat-free bouillon or broth, strained fruit juice, water, plain coffee, plain tea, or diet soda. Gelatin or popsicles in any color but red may also be eaten. You will also take one of several types of laxatives the night before the procedure. Also, you must arrange for someone to take you home afterward—you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions. Inform your physician of any medical conditions or medications that you take before the colonscopy.

v Virtual Colonoscopy Virtual colonoscopy (VC) uses x rays and computers to produce two- and three-dimensional images of the colon (large intestine) from the lowest part, the rectum, all the way to the lower end of the small intestine and display them on a screen. The procedure is used to diagnose colon and bowel disease, including polyps, diverticulosis, and cancer. VC can be performed with computed tomography (CT), sometimes called a CAT scan, or with magnetic resonance imaging (MRI).  VC Procedure While preparations for VC vary, you will usually be asked to take laxatives or other oral agents at home the day before the procedure to clear stool from your colon. You may also be asked to use a suppository to cleanse your rectum of any remaining fecal matter. VC takes place in the radiology department of a hospital or medical center. The examination takes about 10 minutes and does not require sedatives. During the procedure,

After the examination, the information from the scanner must be processed to create the computer picture or image of your colon. A radiologist evaluates the results to identify any abnormalities.

You may resume normal activity after the procedure, although your doctor may ask you to wait while the test results are analyzed. If abnormalities are found and you need conventional colonoscopy, it may be performed the same day.

Advantages of VC 

VC is more comfortable than conventional colonoscopy for some people because it does not use a colonoscope. As a result, no sedation is needed, and you can return to your usual activities or go home after the procedure without the aid of another person. VC provides clearer, more detailed images than a conventional x ray using a barium enema, sometimes called a lower gastrointestinal (GI) series. It also takes less time than either a conventional colonoscopy or a lower GI series.

Disadvantages of VC

The doctor cannot take tissue samples or remove polyps during VC, so a conventional colonoscopy must be performed if abnormalities are found. Also, VC does not show as much detail as a conventional colonoscopy, so polyps smaller than 10 millimeters in diameter may not show up on the images.

v Flexible Sigmoidoscopy Flexible sigmoidoscopy (SIG-moy-DAH-skuh-pee) enables the physician to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid or descending colon. Physicians may use the procedure to find the cause of diarrhea, abdominal pain, or constipation. They also use it to look for early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum. Flexible sigmoidoscopy is not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon). For the procedure, you will lie on your left side on the examining table. The physician will insert a short, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a sigmoidoscope (sig-MOY-duh-skope). The scope transmits an image of the inside of the rectum and colon, so the physician can carefully examine the lining of these organs. The scope also blows air into these organs, which inflates them and helps the physician see better.

If anything unusual is in your rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing. Bleeding and puncture of the colon are possible complications of sigmoidoscopy. However, such complications are uncommon.

Flexible sigmoidoscopy takes 10 to 20 minutes. During the procedure, you might feel pressure and slight cramping in your lower abdomen. You will feel better afterward when the air leaves your colon.

Preparation

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe, so the physician will probably tell you to drink only clear liquids for 12 to 24 hours beforehand. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. The night before or right before the procedure, you may also be given an enema, which is a liquid solution that washes out the intestines. Your physician may give you other special instructions.

v Lower GI Series A lower gastrointestinal (GI) series uses x rays to diagnose problems in the large intestine, which includes the colon and rectum. The lower GI series may show problems like abnormal growths, ulcers, polyps, and diverticuli, and colon cancer. Before taking x rays of your colon and rectum, the radiologist will put a thick liquid called barium into your colon. This is why a lower GI series is sometimes called a barium enema. The barium coats the lining of the colon and rectum and makes these organs, and any signs of disease in them, show up more clearly on x rays. It also helps the radiologist see the size and shape of the colon and rectum. You may be uncomfortable during the lower GI series. The barium will cause fullness and pressure in your abdomen and will make you feel the urge to have a bowel movement. However, that rarely happens because the tube used to inject the barium has a balloon on the end of it that prevents the liquid from coming back out.

You may be asked to change positions while x rays are taken. Different positions give different views of the intestines. After the radiologist is finished taking x rays, you will be able to go to the bathroom. The radiologist may also take an x ray of the empty colon afterwards.

A lower GI series takes about 1 to 2 hours. The barium may cause constipation and make your stool turn gray or white for a few days after the procedure.

Preparation

Your colon must be empty for the procedure to be accurate. To prepare for the procedure you will have to restrict your diet for a few days beforehand. For example, you might be able to drink only liquids and eat only nonsugar, nondairy foods for 2 days before the procedure; only clear liquids the day before; and nothing after midnight the night before. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. To make sure your colon is empty, you will be given a laxative or an enema before the procedure. Your physician may give you other special instructions.

v Upper GI Series The upper gastrointestinal (GI) series uses x rays to diagnose problems in the esophagus, stomach, and duodenum (first part of the small intestine). It may also be used to examine the small intestine. The upper GI series can show a blockage, abnormal growth, ulcer, or a problem with the way an organ is working. During the procedure, you will drink barium, a thick, white, milkshake-like liquid. Barium coats the inside lining of the esophagus, stomach, and duodenum and makes them show up more clearly on x rays. The radiologist can also see ulcers, scar tissue, abnormal growths, hernias, or areas where something is blocking the normal path of food through the digestive system. Using a machine called a fluoroscope, the radiologist is also able to watch your digestive system work as the barium moves through it. This part of the procedure shows any problems in how the digestive system functions, for example, whether the muscles that control swallowing are working properly. As the barium moves into the small intestine, the radiologist can take x rays of it as well.

An upper GI series takes 1 to 2 hours. X rays of the small intestine may take 3 to 5 hours. It is not uncomfortable. The barium may cause constipation and white-colored stool for a few days after the procedure.

Preparation

Your stomach and small intestine must be empty for the procedure to be accurate, so the night before you will not be able to eat or drink anything after midnight. Your physician may give you other specific instructions.

v Upper Endoscopy Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy (eh-SAH-fuh-goh-GAS-troh-doo-AH-duh-NAH-skuh-pee). For the procedure you will swallow a thin, flexible, lighted tube called an endoscope (EN-doh-skope). Right before the procedure the physician will spray your throat with a numbing agent that may help prevent gagging. You may also receive pain medicine and a sedative to help you relax during the exam. The endoscope transmits an image of the inside of the esophagus, stomach, and duodenum, so the physician can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for the physician to examine the stomach.

The physician can see abnormalities, like inflammation or bleeding, through the endoscope that don’t show up well on x rays. The physician can also insert instruments into the scope to remove samples of tissue (biopsy) for further tests or treat bleeding abnormalities.

Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure.

The procedure takes 20 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 1 to 2 hours until the medication wears off.

Preparation

Your stomach and duodenum must be empty for the procedure to be thorough and safe, so you will not be able to eat or drink anything for at least 6 hours beforehand. Also, you must arrange for someone to take you home—you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions.