Upper endoscopy (EGD)

EGD is short for esophagogastroduodenoscopy, an endoscopic examination of the esophagus, stomach, and duodenum (the beginning of the small intestine). A thin, flexible tube (endoscope) equipped with a fiber optic camera and various instruments is used to examine the upper gastrointestinal tract.

When is an EGD performed?

Upper endoscopy is the most direct way to evaluate symptoms originating in the upper gastrointestinal tract, such as nausea, vomiting, heartburn, difficulty swallowing, and abdominal pain. It can determine the cause of bleeding in the upper GI tract. Beyond diagnosis, upper endoscopy is used for therapeutic intervention in a variety of conditions. The physician can pass instruments through a channel in the endoscope to stop bleeding, stretch narrowed areas, inject medication, or remove polyps for biopsy, among other techniques. These can all be done with little or no discomfort.

How is an EGD performed?

Fasting is required about six hours before the procedure. An IV will be started to administer sedative if desired, and blood pressure and pulse will be monitored throughout the procedure. The throat may be sprayed with anesthetic to prevent gagging.

The endoscope is inserted with the patient lying on his or her left side. Breathing will remain unobstructed. Carbon dioxide gas is introduced through a channel in the endoscope in order to expose the folds of the upper GI tract to the lens at the end of the endoscope. If necessary, treatment is performed and biopsies taken. The procedure lasts 15 to 30 minutes. Sedative will wear off within 30 to 60 minutes, after which feelings of bloat and sore throat may remain for a time. In most circumstances, the doctor can inform you of your test results on the day of the procedure.

Possible complications

EGD is a minimally invasive procedure, meaning it requires neither an incision nor significant recovery time afterward. Complications occur at a rate of 0.1%, but they are even rarer when a trained and experienced physician performs the procedure. Complications that can occur include bleeding, perforation, reaction to medication, and IV site reaction.

If sedatives were used, it is unsafe to drive after the procedure.

Colonoscopy

Colonoscopy is an endoscopic examination of the large intestine using a flexible tube (scope) equipped with a fiber optic camera and various instruments. It allows the physician to make a visual diagnosis of issues like polyps or ulceration, and to take biopsies.

When is a colonoscopy performed?

Colonoscopy is a routine screening test recommended for everyone over 50, to be repeated at least every 10 years. Earlier screening is best for those at higher risk for colon cancer due to family history or existing colon disorders.

Preparation

The colon must be completely clean for the procedure to be accurate and complete. Your physician will give you detailed instructions regarding the dietary restrictions to be followed and the cleansing routine to be used. In general, preparation consists of either consumption of a special cleansing solution and a day or two of clear liquids. Follow your doctor’s instructions carefully. If you do not, the procedure may have to be canceled and repeated later.

Most medications may be continued as usual, but some medications can interfere with the preparation or the examination. It is therefore best to inform your physician of your medications several days prior to the examination. Aspirin products, arthritis medications, anticoagulants (blood thinners), insulin and iron products should be discussed with your physician prior to examination.

The procedure

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

What if the colonoscopy shows something abnormal?

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

Polyps

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

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

After a colonoscopy

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

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

Possible complications

Colonoscopy and polypectomy are generally safe when preformed by experienced physicians. The risk of serious complications is 0.35%.

One rare albeit possible complication is a perforation or tear through the bowel wall that could require surgery. Across the US, the perforation rate is 0.08%. Bleeding may occur from the site of biopsy or polypectomy. It is usually minor and stops on its own or can be controlled through the colonoscope. Rarely, blood transfusions or surgery may be required. Other potential risks include a reaction to the sedatives used and complications from heart or lung disease.

Although complications after colonoscopy are uncommon, it is important for you to recognize early signs of any possible complication. Contact your physician who performed the colonoscopy if you notice any of the following symptoms: severe abdominal pain, fever and chills, or rectal bleeding. Bleeding can occur several days after polypectomy.

Capsule endoscopy

Capsule endoscopy utilizes a miniature camera to examine the three portions (duodenum, jejunum, and ileum) of the small intestine. The capsule, about the size of a large vitamin pill, is swallowed. It produces its own light and captures images of along the length of the intestine, most of which cannot be reached by upper endoscopy or colonoscopy. As the capsule travels through the intestine, sensors placed on the abdomen download the images and save them in a recorder unit worn on a waist belt. After 8 hours the sensors and recorder are removed. The capsule is excreted naturally.

Esophageal motility testing

Esophageal manometry (also called esophageal motility testing) is a procedure to measure the strength and function of the esophagus. It provides information about how the muscles in the mouth and esophagus contract to propel food and liquid toward the stomach (peristalsis).

When is a esophageal manometry performed?

• To evaluate the cause of reflux (regurgitation) of stomach acid into the esophagus (gastroesophageal reflux disease). Manometry often can identify weakness in the lower part of the esophagus that allows reflux.
• To determine the cause of difficulty swallowing. Manometry can diagnose several esophageal conditions that result in food sticking after it is swallowed.
• To determine the cause of non-cardiac chest pain.

Procedure

The procedure takes about 45 minutes. The nurse will verify that you had nothing by mouth in the last 6 hours prior to the test. A thin flexible catheter (about one-eighth inch in diameter) is then passed through the nostril, down the back of the throat into the esophagus and the stomach as you swallow water. The catheter has sensors that detect pressure along the length of the esophagus. With the tube inside the esophagus, you will lie down on your left side. The nurse will give you small sips of water during the test to record the pressures and the progression of the swallow. Pressure recordings are made and the tubing is slowly withdrawn. You may drive yourself home before and after the test since no sedation is involved.

The results of the manometry test are displayed as a graph with a wave pattern visualizing the contractile motions of the esophageal muscles.

pH monitoring

Esophageal pH monitoring is used to diagnose gastroesophageal reflux disease (GERD).

At the bottom of the esophagus, the lower esophageal sphincter guards the entrance to the stomach, protecting the lower esophagus from corrosive stomach acid. Refluxed stomach contents can linger in the esophagus due to an abnormally relaxed sphincter, impaired esophagus, or hiatal hernia, causing slow damage to the mucous membrane of the esophagus. This is felt as heartburn. pH monitoring uses a sensor to measure the acidity of the lower esophagus over a 24 or 48 hour period. 24 hour monitoring uses a catheter connected to a recording device, and 48 hour Bravo monitoring uses a wireless capsule sensor without a catheter.

Procedure

Before the procedure, an anesthetic gel may be applied to one end of the catheter to help with gagging which may occur when the catheter is positioned. This usually subsides shortly after the catheter is passed. No other anesthetic or sedative is used. While sitting, the end of the catheter which has the sensor is gently passed through your nose or mouth. The tube will not interfere with breathing. For 24 hour monitoring, the other end of the catheter is connected to the small recording device. For 48 hour monitoring, the capsule is attached to the wall of the esophagus and the catheter removed. The capsule is held in place against the lining of the esophagus with a tiny pin. The exact location is determined either during EGD or esophageal manometry.

Afterward

Once the sensor is in place, you will record your daily activities, such as eating, sleeping, and when your experience your typical symptoms. You should be as active as possible during the test to prevent a false negative result. The following day you will return to the hospital to have the catheter removed. The Bravo capsule naturally comes loose from the esophagus and is eliminated with body wastes a day or two after the test is completed.