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Digestive Diseases and Nutrition

USF Health is pleased to announce the new Inflammatory Bowel Disease Center. A team of specialized healthcare providers trained in the field of IBD - ulcerative colitis and crohns disease have come together as a community to offer complete care for our patients. Visit the Inflammatory Bowel Disease Center page to discover the innovative approach USF Health is taking in making life better for those living with IBD.  

From routine screenings to rare and complex conditions, our digestive disease experts are specially trained to provide high quality, comprehensive care for patients with a wide variety of gastrointestinal ailments. We welcome patients who have not found relief from past treatments for their digestive or swallowing problems – diagnosing and treating these difficult conditions are what sets USF Health apart. 

By connecting with USF Health – this region’s only academic medical center – you are accessing a level of care unmatched in the Tampa Bay area. Our team includes nationally renowned gastroenterologists who have a complete understanding of the normal function and diseases of the esophagus, stomach, small intestine, colon and rectum, pancreas, gallbladder, bile ducts and liver. We also offer comprehensive consultative care in various complex gastrointestinal, hepatobiliary and pancreatic disorders, as well as clinical nutrition – our highly respected team accepts referrals from all over the country.

Our services include:

Breath tests Barrx ® Barrett Ablation
Bravo ® pH Testing
Colonoscopy
ERCP
Endoscopic Ultrasound (EUS)
Esophageal Motility
Flexible Sigmoidoscopy
Liver Biopsy
Single Balloon-Assisted Deep Enteroscopy
SpyGlass ® Cholangioscopy
Upper Endoscopy
 
To learn more about the services listed above scroll down to the Patient Education section.

 

To find a location near you click here for Digestive Diseases and Nutrition Locations.

 

 

 


Patient Education

Breath testing is used as an ancillary diagnostic tool for certain medical conditions presenting with symptoms such as diarrhea, bloating and abdominal distension, and abdominal pain, alone or as part of irritable bowel syndrome (IBS). These symptoms can be the result of small intestinal bacterial overgrowth (SIBO), food intolerances such as lactose or fructose intolerance, and certain infections such as H. pylori. SIBO is not an acquired infection (from eating or drinking). The small numbers of bacteria that normally reside in the small intestine grow, for a number of reasons, beyond the normal limits. The result is an increase in bacterial fermentation of some of the ingested food that creates gases and other compounds causing the symptoms associated with SIBO (mainly diarrhea, bloating, and abdominal pain). These gasses include hydrogen (H2), carbon dioxide (CO2), and methane (CH3) that can be measured in breath samples after the test substance is administered to the patient. SIBO is a treatable condition with remarkable improvement seen in as little as few days after initiating the appropriate antibiotic(s). SIBO is also one of the causes of vitamin B12 deficiency and it is important to check for this condition in a patient with this deficiency.

For each medical condition, a different test substance is given to a patient to swallow. For example, lactulose (an indigestible synthetic sugar) is used as test substance for SIBO, the sugar lactose for lactose intolerance, and urea in a capsule form for H. pylori. Breath tests are simple, non-invasive, and are performed after a short period of fasting (typically 8–12 hours). Certain dietary restrictions are necessary prior to the test and will be provided to you as the test when the test scheduled. It is also important not to take antibiotics for 14 days prior to the test.

At the Division of Digestive Diseases and Nutrition at USF Morsani College of Medicine, we offer the lactulose breath test for SIBO. We utilize the latest gas chromatograph equipment, the QuinTron BreathTracker™ SC Digital MicroLyzer. The test is administered in the clinic area on the 6th floor and it will take up to 3 hours starting at 8:00 o’clock in the morning. While a driver is not needed, we suggest that you bring some reading material or good music to keep yourself entertained.A baseline breath sample is collected, and then additional samples are collected at 20 minute intervals for up to 3 hours. Once positive results are reached, the test is terminated. A rise in breath hydrogen or methane of 20 parts-per-million (ppm) or greater over baseline within the first two hours indicates bacteria in the small intestine. A delayed response may be caused by colonic bacterial fermentation. The results will be conveyed to you within 3-5 business days and treatment will be initiated, if appropriate, accordingly.

Barrett’s esophagus (BE) or intestinal metaplasia (IM) is a visible change in the normal lining (or mucosa) of the esophagus (the muscular tube that transfers food from the throat to the stomach). The diagnosis is suspected visually at the time of upper endoscopy (see upper endoscopy tab for details) and confirmed by biopsy (samples) of the suspicious mucosa. BE develops as a result of chronic exposure of the esophagus to stomach acid, enzymes and bile, collectively known as gastroesophageal reflux disease (GERD). Patients with reflux disease present with symptoms of heartburn and regurgitation. Risk factors may include the presence of a hiatal hernia, a condition that renders the lower esophageal sphincter (muscle valve) less competent in preventing gastroesophageal reflux.

Barrett’s esophagus increases the risk of esophageal cancer. Once Barrett’s esophagus is detected at the time of initial upper endoscopy, periodic surveillance and biopsies of this abnormal mucosa is recommended. Before cancer develops from Barrett’s esophagus, a pre-cancerous condition called high grade dysplasia (HGD) can be detected by biopsies of Barrett’s esophagus. Since HGD will likely lead to esophageal cancer, elimination (ablation) of this condition will likely prevent the development of cancer.

One of techniques used to achieve this goal is called radiofrequency ablation (RFA). This endoscopic technique provides a controlled-depth burn of Barrett’s esophagus which results in its elimination. The HALO system (previously Barrx®) is the most advanced and commonly used system for this purpose.The ablation catheter or devise can be circumferential (HALO360) or a quarter of a circle (HALO90).Your physician will decide on the proper devise to use based on the length and extension of Barrett’s esophagus. This will not change what you should expect during or after the procedure. 

The preparation and recovery for the procedure are not different from those for upper endoscopy (see upper endoscopy tab) but the duration of the procedure is longer.The procedure is done on an outpatient basis under general anesthesia at Tampa General Hospital GE (GastroEnterology) Center.The potential risks of the procedure are not different from those mentioned for upper endoscopy, but chest pain and difficulty swallowing may also occur. Also, a stricture (narrowing) of the esophagus and fluid build-up around the lung(s) has also been reported. Your doctor will prescribe you with pain medications if necessary and may ask you to be on liquid diet for 2-3 days afterwards.After the initial procedure, surveillance endoscopies are needed to monitor the results of the treatment and the decision to repeat the procedure in the future.

Patients with heartburn or regurgitation may have acid reflux, also known as gastroesophageal reflux disease (GERD).Other symptoms of GERD may include chest pain of non cardiac origin, hoarseness, cough or asthma. The diagnosis can be made on clinical grounds by history however, confirmation is important in many instances to assure proper treatment and avoid unnecessary medications. This can be achieved by pH monitoring. Since acid reflux measurement is the hallmark of the test, your doctor will ask you to stop taking any prescription or over-the-counter (OTC) acid reducers (e.g. Prilosec®, Protonix®, AcipHex®, Prevacid®, Nexium®, Dexilant®, Zegerid®, Tagamet®, Pepcid®, and Zantac®) for 7 days prior to the test and the 48-hour recording period. Before the procedure commenses, you will be instructed to record on a diary not only your symptoms, but also meals and sleep times.


BRAVO® pH monitoring is a wireless, small capsule-based, patient-friendly test for identifying the presence and severity of acid reflux. The capsule is inserted by carefully advancing a thin, flexible, blunt-tip insertion device (figure on the left) through the mouth then attached to the lower end of your esophagus or swallowing tube (figure on the right). This procedure can be done at the time of upper endoscopy (with sedation) or by itself (with numbing medication to the throat). Bravo EndoThe capsule records acid exposure information and transmit them wirelessly to a recording device (receiver) for 48 hours (figure on the lower right).Bravo ReceiverThe receiver can be worn on a shoulder strap or a waistband but can also be taken off for shower or sleep as long as it is within 5 feet from your person. Because BRAVO pH monitoring is wireless (nothing will stick out of your mouth or nose), it allows you to maintain your regular activities and the convenience to record any symptoms. 

The capsule will eventually fall into the stomach and pass painlessly in the stool in 10-14 days. Once the recording period is over, you will be asked to return the recording device so the doctor can analyze it (figure below) and evaluate reflux symptoms by determining the frequency and duration of acid flowing back up into the esophagus.Bravo Recording

BRAVO pH has the potential to provide a more accurate picture of acid exposure, compared to data collected using catheter-based systems where normal activities may be limited.

There is some discomfort and gagging if the device is placed without sedation. Trauma to throat can also occur very rarely from the passage of the insertion device. Some people may have a foreign body sensation in their esophagus but this will not interfere with normal swallowing.

The colonoscopy procedure is a real-time visual examination of the lining of the colon, rectum and at times, the small bowel (known as the terminal ileum). The procedure is performed by board-certified gastroenterologists (stomach and liver specialists) or by their trainees (also known as Fellows) who work under their direct supervision.The instrument used for this procedure is called the colonoscope, a thin but long flexible tube that carries a high definition wide-angle camera, a bright light source and working channels at its tip. The colonoscope allows the physician not only to take a look but also obtain tissue samples known as biopsies. Biopsies are then examined by a pathologist.The procedure is pain free as you will receive sedatives/pain medications to ensure your comfort. 

The instrument is inserted through the anal canal into the rectum and on to the colon. Colonoscopy can also be through a stoma, an artificial opening of colon to the skin.Colonoscopy helps your gastroenterologist evaluate and treat multiple gastrointestinal symptoms such as abdominal pain, gastrointestinal hemorrhage, diarrhea to name a few. An important function of colonoscopy is to look for and remove colon polyps that can potentially become colon cancer. It can be done on an outpatient or inpatient basis.

In preparation of the procedure, your physician may ask you to stop certain medications before your procedure. Otherwise, detailed preparation instructions for the procedure will be provided to you by one of our staff members. You will need to be on clear liquid diet the entire day before the procedure and drink a cleansing solution.

Colonoscopy is usually safe. The risks associated with this procedure are commonly related to sedation such as transient respiratory depression (slowness of breathing) and minor change in vital signs (blood pressure and heart rate). Infection is extremely uncommon (1-5 per 10 million); bleeding 1-6 per 1,000; perforation (tear) risk is 5-7 per 10,000; and risk of death is 7 per 100,000 (to give a perspective, the risk of being randomly shot at is 6 in 100,000). These risks are increased with interventions such as biopsies, polypectomy (polyp removal), and others. 

When you wake up from sedation you will be monitored for any adverse events for a period up to one hour. You may feel a little bloated from the air that is introduced through the instrument, but this will wear off in a short period of time. You will be permitted to carry on any normal activity for the remainder of the day except for driving a motorized vehicle so you will need an adult driver to pick you up that day.

Endoscopic Retrograde Cholangio Pancreatography (ERCP) procedure is a real-time radiolgraphic examination of the bile ducts (small draining tubes), gallbladder and/or pancreatic duct. The procedure is performed by board-certified gastroenterologists (stomach and liver specialists) or by their trainees (also known as Fellows) who work under their direct supervision. 

The instrument used for this procedure is called the side-viewing endoscope, a thin but long flexible tube that carries a high definition wide-angle side camera, a bright light source and working channels at its tip. The instrument allows the physician to insert a thin tube known as a cannula into the bile duct and/or pancreatic duct. Dye is injected through the cannula under x-ray imaging (fluoroscopy) so a picture of the bile/pancreatic ducts is obtained and tissue samples known as biopsies/brushings are taken.

The procedure is pain free as you will receive sedatives/pain medications to ensure your comfort. The instrument is inserted through the mouth.

ERCP helps your gastroenterologist evaluate and treat multiple biliary disorders such as bile duct obstruction due to stones or cancer, or pancreatic disorders such as pancreatitis or pancreatic cancer. It is an essential part of the evaluation of abdominal pain and abnormal liver tests. The procedure can be done on an outpatient or inpatient basis.

In preparation of the procedure, your physician may ask you to stop certain medications before your procedure. Otherwise, a period of 12-hour fasting is needed.

ERCP harbors some risk. The risks associated with this procedure can be related to sedation such as transient respiratory depression (slowness of breathing) and minor change in vital signs (blood pressure and heart rate). Pancreatitis (inflammation of the pancreas) occurs in 1-7% of patients depending on multiple factors. Infection rate is 1%; bleeding 7-20 per 1,000; perforation (tear) risk is 3-6 per 1,000; and risk of death is 1 in 500.

When you wake up from sedation you will be monitored for any adverse events for a period up to one hour. You may feel a little bloated from the air that is introduced through the instrument, but this will wear off in a short period of time. You will be permitted to carry on any normal activity for the remainder of the day except for driving a motorized vehicle so you will need an adult driver to pick you up that day.

Endoscopic ultrasonography (EUS) is an examination of the upper and lower digestive tract. Upper EUS examines the esophagus, stomach, small bowel and surrounding organs such as the pancreas, liver, gallbladder and bile ducts. Rectal EUS examines the anal canal, rectum, and surrounding structures. Unlike conventional endoscopy that focuses on direct viewing of the lining of the intestinal tract organs, EUS uses ultrasound waves to indirectly look at the wall and adjacent structures beyond the lining of the gastrointestinal tract.

Your physician (also known as the endoscopist) uses a thin, flexible tube called an endoscope that has a built-in miniature camera and ultrasound probe. Your doctor will pass the endoscope through your mouth (or anus) to the area to be examined. Your doctor then will use the ultrasound to use sound waves to create visual images of the digestive tract.

EUS is only done at our affiliate institution, Tampa General Hospital. Upper EUS is done under sedation. For this reason, an adult driver is required to take you back home that day. Rectal EUS can be done comfortably without sedation. Immediately after the procedure, you may have mild sore throat but you should have no other symptoms. Diet and most medications can be resumed unchanged later that day. Your doctor will provide you with the results of the exam in the recovery area as you wake up from sedation; however, the results of any biopsies might take up to one week.

EUS is used to evaluate symptoms such as abdominal pain or abnormal weight loss, potential diseases of the pancreas, bile duct and gallbladder, or known abnormalities such as lumps or lesions which were detected at a prior endoscopy or were seen on x-ray tests such as a computed tomography (CT) scan. In the latter instance, the endoscopist can also sample the lump or lesion by directly inserting a small needle into the lesion to be later examined under the microscope. This is called fine needle aspiration (FNA) biopsy. Finally, EUS helps your doctor determine the extent of spread of certain cancers of the digestive and respiratory systems into adjacent lymph glands or nearby vital structures, such as major blood vessels. Most blood thinners such as heparin, Coumadin, and Plavix will need to be stopped for 5-7 days prior to EUS and FNA due to increased risk of bleeding. Other medications can be continued including aspirin and other non-steroidal anti-inflammatory medications (NSAIDs) prior to EUS and FNA. Antibiotics are usually not needed prior to EUS/FNA but your doctor will clarify that with you prior to the test.

Bleeding might occur at a biopsy site, but it’s usually minimal and rarely requires follow-up. Other potential but uncommon risks of EUS include a reaction to the sedatives used, aspiration of stomach contents into your lungs, infection, and complications from heart or lung diseases. One major but very uncommon complication of EUS is perforation. This is a tear through the wall of the digestive tract that might require surgery to repair. The possibility of complications increases slightly if a needle biopsy is performed during the EUS examination.

Esophageal motility or manometry is used to evaluate patients with symptoms of difficulty swallowing solid and liquid foods (or both), chest pain that is not of cardiac origin, and occasionally heartburn. The test measures the pressures and the pattern of muscle contractions (motility) in your esophagus. The esophagus is a muscular tube that connects your throat to your stomach. With each swallow, the esophagus muscles contract and push food downward into the stomach. At the lower end of the esophagus, a special muscle (sphincter) remains closed except when food or liquid is swallowed or when you belch or vomit. Abnormalities in the contractions and strength of the muscle or in the sphincter at the lower end of the esophagus can result in the above mentioned symptoms.

High resolution manometry (HRM) is the latest and most sophisticated version of esophageal manometry. It allows for the detection of most complex esophageal motility disorders. Our highly trained doctors usually perform the test at our Joy McCann Culverhouse Center for Swallowing Disorders (CSD) at the Morsani clinic building but occasionally at Tampa General Hospital.The test is done on an empty stomach for 6 hours before the test to allow for the best and safest examination. Since many medications can affect esophageal pressure and the natural muscle contractions required for swallowing, be sure to discuss with your healthcare professional each medication you are taking. Your doctor may ask that you temporarily stop taking one or more medications before your test.

A numbing medication is applied to the inside of your nostril(s). Then a thin, flexible, lubricated tube (manometry catheter) "figure on the left" will be passed through your nose and advanced into your stomach while you swallow sips of water. Mild, brief gagging may occur while the tube is passed through the throat. When the tube is in position, you will be sitting upright while the tube is connected to a computer. You will be instructed to breathe slowly and smoothly, remain as quiet as possible and avoid swallowing unless instructed to do so. You will be given a cup of liquid to have ten wet swallows and if satisfactory results are obtained, the manometry catheter is removed and the test is finished. Since you have to make intentional swallows, sedation cannot be administered 6 hours before or during testing. You can continue your daily meals, medications, and activity for the remainder of the day unless you were instructed otherwise. No adult driver is needed to take you home. The test will take approximately 30 minutes to complete and the results will be sent to your doctor’s office in 5-7 days.

While serious side effects of this procedure are extremely rare, it is possible that you could experience irregular heartbeats, aspiration (when stomach contents flow back into the esophagus and are breathed into the lung), or perforation (a hole in the esophagus). During insertion, the tube may be misdirected into the windpipe before being repositioned. Precautions are taken to prevent such risks, and your physician believes the risks are outweighed by the benefits of this test. In some situations, correct placement of the tube may require passage through the mouth or passing the tube using endoscopy (a procedure that uses a thin, flexible lighted tube). Your physician will determine the best approach.

Flexible sigmoidoscopy (in short Flex Sig) procedure is a real-time visual examination of the lining of the last part of the colon (sigmoid) and rectum. The procedure is performed by board-certified gastroenterologists and trained internists or family physicians.

The instrument used for this procedure is called the flexible sigmoidoscope, a thin flexible tube that carries a high definition wide-angle camera, a bright light source and working channels at its tip. The instrument allows the physician not only to take a look but also obtain tissue samples known as biopsies. Biopsies are then examined by a pathologist.

The procedure carries minimal discomfort and usually is performed without any sedation. Sedation can be provided if requested by the patient and will necessitate that an adult driver takes the patient home that day.

Flexible sigmoidoscopy helps your gastroenterologist evaluate and treat lower gastrointestinal symptoms such as rectal bleeding. Colonoscopy, for the most part, has replaced flexible sigmoidoscopy as a screening tool for colon polyps and cancer. The procedure can be done on an outpatient or inpatient basis.

In preparation of the procedure, your physician may ask you to stop certain medications before your procedure. Otherwise, two Fleet’s enemas taken the morning of the procedure suffice. You will need to be on clear liquid diet for eight hours if sedation is required.

Flexible sigmoidoscopy is very safe. The risks associated with this procedure are rare and including anal or abdominal discomfort, bleeding, and perforation.

If you require sedation you will be monitored for any adverse events for a period up to one hour. You may feel a little bloated from the air that is introduced through the instrument, but this will wear off in a short period of time. You will be permitted to carry on any normal activity for the remainder of the day except for driving a motorized vehicle so you will need an adult driver to pick you up that day.

A liver biopsy is a procedure that is intended to obtain a small sample or piece of the liver so it can be examined under the microscope. The purpose for the biopsy is for one or more of the following reasons:Establish the presence (or absence) of disease entity in the context of elevated liver enzymes undiagnosed by blood testsEstablish the nature of an incidental liver lesion (a mass or a tumor) that is seen on liver imaging tests (ultrasound or CT scan), with or without abnormal liver enzymesAssess the degree of liver damage (staging) in a previously diagnosed liver disease such as hepatitis C or fatty liver disease.

Once the above is achieved, a specific treatment can be initiated accordingly, if applicable.Liver biopsy is done as an outpatient procedure at Florida Hospital Tampa or Tampa General Hospital. All three main types of liver biopsy remove liver tissue with a needle that has a built-in automatic mechanism (that is, after needle insertion, you will hear clicking sound as the needle removes a tissue sample); however, each takes a different approach to needle insertion. Liver biopsy can be performed through the skin (percutaneous route), the jugular vein in the right side of the neck (transjugular route), and during an abdominal surgery (laparoscopic route).

Prior to liver biopsy, blood will be drawn to determine its ability to clot. Certain medications that inhibits normal clotting function such as oral warfarin sodium (Coumadin®), or injection ardeparin (Indeparin®), dalteparin (Fragmin®), enoxaparin (Lovenox®, Clexane®, Cutenox®), fondaparinux (Arixtra®), should be avoided for 3-5 days prior to liver biopsy (you will be instructed). Also, medications that inhibit platelets function should be avoided for one week prior to liver biopsy. These include oral medications such as anagrelide (Agrylin®), clopidogrel (Plavix®), dipyridamole/aspirin (Aggrenox®), cilostazol (Pletal®), dipiridamole (Persantine®), ticlopidine (Ticlid®), and aspirin or injection medications such as abciximab (Reopro®), tirofiban (Aggrastat®), eptifabatide (Integrilin®). A telephone or face-face interview at the performing facility will also be conducted to further explain the procedure and answer any questions. Patients with severe liver disease often have blood clotting problems that can increase the risk of bleeding after the procedure. This problem can be addressed on the morning of the procedure by giving certain blood products to temporarily improve the clotting problems.

Patients who desire sedation for the procedure should not eat or drink for 8 hours before the liver biopsy. All patients should arrange a ride home, as driving is prohibited for the 24-hour period after the procedure. Mild sedation is sometimes used during liver biopsy to help patients stay relaxed. Unlike general anesthesia where patients are unconscious, patients can communicate while sedated and able to hold their breath momentarily while the actual biopsy is obtained. Sedatives are often given through an intravenous (IV) catheter placed in a vein. The IV can also be used to give pain medication, if necessary, after the procedure. Transient pain at the IV and liver biopsy sites is expected. There is always a risk of medication reaction to the sedatives or the topical anesthetic (numbing medications).

For the percutaneous route (most often route), the performing physician often uses ultrasound, computerized tomography (CT), or other imaging techniques to help find the liver and avoid sticking other organs with the biopsy needle. For this reason, a specialized radiologist (x-ray doctor) is the one performing the procedure.

During the procedure, the patient lies on his/her back on a table with their right hand resting above their head. A local anesthetic (numbing medication) is applied to the area where the biopsy needle will be inserted. This will cause transient burning sensation. An IV tube is used to give sedatives during, and pain medications during or after the procedure. The doctor makes a tiny incision (less than a quarter of an inch) on the right side of the chest wall between the ribs where the liver exists (see image) but sometimes in the abdomen, and inserts the biopsy needle. Patients will be asked to exhale and hold their breath while the needle is inserted and a liver sample is quickly withdrawn. Several samples may be collected, requiring multiple needle insertions. After the biopsy, patients must lie on their right side for up to 2 hours to reduce the risk of bleeding. Patients are then monitored an additional 2 to 4 hours after the biopsy before being sent home.

Transjugular liver biopsy provides smaller liver samples so it is not the preferred method of liver biopsy. It is reserved for patients with significant blood clotting disorders or when excess fluid is present in the abdomen, a condition called ascites. Transjugular biopsyDuring the procedure, patients lie on their back on an x-ray table and a local anesthetic is applied to the right side of the neck (see image). If needed, an IV tube is used to give sedatives and pain medication. A small incision is made in the neck and a specially designed hollow tube called a sheath is inserted into the jugular vein as a conduit. The doctor threads the sheath down the jugular vein, along the side of the heart, and into one of the hepatic (liver) veins, which are located above the liver. To see the veins, the doctor injects liquid contrast material into the sheath. The contrast material lights up when seen under x-ray, highlighting the blood vessels and showing the proper location of the sheath. The doctor threads a biopsy needle through the sheath and into the liver and a liver sample is quickly withdrawn. Several samples may be collected, requiring multiple needle insertions. The sheath is carefully withdrawn and the incision is closed with a bandage. Patients are monitored for 4 to 6 hours for signs of bleeding. 

Laparoscopic liver biopsy is done at the time of surgery for another indication, e.g. gallbladder removal, etc. There is no special preparation or this procedure apart what you should do for the surgery itself.

Pain at the biopsy site is the most frequent risk of percutaneous liver biopsy, occurring in about 20 percent of patients. The risk of excessive bleeding, called hemorrhage, is about 1 in 500 to 1 in 1,000. Risk of death is about 1 in 10,000 to 1 in 12,000. If hemorrhage occurs, a blood transfusion may be necessary and bleeding may stop on its own. If it does not, a procedure called angiography (visualization of blood vessels with contrast injection under x-ray to identify the bleeding site) and embolization (deployment of a special plug), can be used to stop the bleeding. In extreme cases, surgery can also be used to stop a hemorrhage. Other risks include puncture of other internal organs such as the lungs or bile ducts, infection, leakage of bile inside the abdomen at the biopsy site, and spread of cancer cells (if biopsy was directed at a suspected or known tumor), called cancer seeding. Transjugular liver biopsy carries an additional risk of adverse reaction to the contrast material. For any concerns or potential complication post-liver biopsy, you will need to notify the facility where the biopsy had taken place to properly and expediently address any concerns.

Single balloon assisted enteroscopy (SBE) is an examination of the lining of the esophagus, stomach, and deep small intestine (duodenum, jejunum and ileum) with a small camera (flexible endoscope) which is inserted down the throat with the assistance of an overtube/balloon system (see image). On the tip of the overtube is a balloon that can be blown up and deflated. The balloon when blown up is used to anchor the overtube within the intestine. While the overtube is anchored, the endoscope can be advance further into the small intestine. By withdrawing the overtube the small intestine can be shortened and straightened to make the passage of the inner endoscope easier. The balloon may then be deflated so that the overtube can be inserted further and the endoscope advanced again. The endoscope itself is a longer than the standard endoscope (200 cm or 8 feet) with working channels that allow the intestine to be inflated with air, rinsed with water, or to guide biopsy or electrocautery instruments to the tip of the endoscope. The procedure is pain free as you will receive a sedative and pain medications to ensure your comfort. A local anesthetic may be sprayed into your mouth to suppress the cough or gag reflex when the endoscope is inserted. A mouth guard will be inserted to further protect your teeth and the endoscope during the procedure.

Your physician may ask you to stop certain medications before your procedure. Otherwise, the only preparation for the procedure is a period of fasting ranging from 8-10 hours prior to the procedure.

SBE is safe. The risks associated with the procedure are commonly related to sedation such as transient respiratory depression (slowness of breathing) and minor change in vital signs (blood pressure and heart rate).

Risks of SBE are similar and slightly higher than a standard upper endoscopy due to insertion depth and prolonged procedure time. Infection is extremely uncommon with diagnostic SBE (1-5 per 10 million); perforation (tear) risk is 3 per 10,000, and risk of death is 1 per 100,000 (the risk of randomly being shot at is 6 in 100,000). Bleeding risk from diagnostic SBE is extremely rare. These risks are increased with interventions such as biopsies (sampling), dilation (stretching of tight spots), cautery and others.

When you wake up, you may feel a little bloated from the air that is introduced through the endoscope, but this will wear off in a short period of time.

SpyGlass® direct visualization system is used in conjunction to ERCP (see ERCP tab for details). The instrument is attached to the standard ERCP equipment as seen in the diagram. After ERCP is performed, the SpyGlass procedure will follow. Your preparation and recovery for this procedure are not different from those for ERCP. The duration of the procedure is longer but is still considered an outpatient procedure that is done at Tampa General Hospital GE (GastroEnterology) Center.

While ERCP provides adequate diagnostic x-ray imaging of the bile and pancreatic duct systems as well as the necessary treatment, SpyGlass® enables the endoscopist (the physician performing your procedure) to directly visualize the bile ducts and obtain better biopsy (sample) specimens of suspicious lesions or tumors. Also, the system allows for direct fragmentation of bile or pancreatic duct stones (lithotripsy) using laser beam or other methods not usually performed during standard ERCP. Although ERCP is usually an adequate first step to diagnosis and treat most bile and pancreatic ducts diseases, SpyGlass® can later be suggested if ECRP falls short of providing this information. Your physician will discuss this option with you during your consultation.

Upper endoscopy procedure or EsophagoGastroDuodenoscopy (EGD) is a real-time visual examination of the lining of the esophagus, stomach, and upper small intestine (duodenum). The procedure is performed by board-certified gastroenterologists (stomach and liver specialists) or by their trainees (also known as Fellows) who work under their direct supervision.

The instrument used for this procedure is called the upper endoscope, a thin but long flexible tube that carries a high definition wide-angle camera, a bright light source and working channels at its tip. The endoscope allows the physician not only to take a look but also obtain tissue samples known as biopsies. Biopsies are then examined by a pathologist.

The procedure is pain free as you will receive sedatives/pain medications to ensure your comfort. A local anesthetic may also be sprayed into your mouth to suppress the cough or gag reflex when the endoscope is inserted. A plastic mouth guard will be inserted to further protect your teeth and the endoscope during the 5 – 20 minute procedure. The endoscope is inserted through the mouth and will not interfere with your breathing.

EGD helps your gastroenterologist evaluate and treat multiple gastrointestinal symptoms such as abdominal pain, nausea and vomiting, esophageal reflux, gastrointestinal hemorrhage, to name a few. It can be done on an outpatient or inpatient basis.In preparation of the procedure, your physician may ask you to stop certain medications before your procedure. Otherwise, the only preparation for the procedure is a period of fasting ranging from 8-10 hours prior to the procedure. Detailed instruction will be provided through our staff members.

EGD is usually very safe. The risks associated with this procedure are commonly related to sedation such as transient respiratory depression (slowness of breathing) and minor change in vital signs (blood pressure and heart rate). Infection is extremely uncommon with diagnostic EGD (1-5 per 10 million); perforation (tear) risk is 3 per 10,000; and risk of death is 1 per 100,000 (to give a perspective, the risk of being randomly shot at is 6 in 100,000). Bleeding risk from diagnostic EGD is extremely rare. These risks are increased with interventions such as biopsies, dilation (stretching of tight spots), and others.

When you wake up from sedation you will be monitored for any adverse events for a period up to one hour. You may feel a little bloated from the air that is introduced through the instrument, but this will wear off in a short period of time. You will be permitted to carry on any normal activity for the remainder of the day except for driving a motorized vehicle so you will need an adult driver to pick you up that day.

Capsule endoscopy (CE), also known as capsule enteroscopy or video capsule endoscopy lets your doctor examine the lining of your small intestine that is unreachable by standard upper endoscopy. This includes the portions of the small intestine called the jejunum and ileum which extend beyond its first portion also known as the duodenum. 

This camera has its own light source and takes pictures of your small intestine as it passes through. These pictures are sent to a small recording device (receiver) that you have to wear on your body for 8 hours. At the end of the procedure you will return to the office and the data recorder is removed so that images of your small bowel can be put on a computer screen for physician review. The procedure is painless and you do not need to have an adult driver to take you home since you will not receive any sedation for the procedure.

Your doctor will be able to view these pictures at a later time and might be able to provide you with useful information regarding your small intestine. Although examination is possible, the test is not intended to examine the stomach or the colon.The most common reason for doing capsule endoscopy is to search for a cause of bleeding from the small intestine. It may also be useful for detecting polyps, inflammatory bowel disease (Crohn’s disease), ulcers, and tumors of the small intestine.You should have nothing to eat or drink, including water, for approximately twelve hours before the examination.

Your doctor may determine that you drink a bowel cleansing solution the day before the procedure.It is very important that you tell your doctor of the presence of a pacemaker or defibrillator, trouble swallowing, previous abdominal surgery, or previous history of bowel obstructions in the bowel, inflammatory bowel disease, or adhesions since these conditions may cause the capsule to get stuck at a narrowed area of the small intestine causing bowel obstruction (blockage). It is important to recognize obstruction early. Signs of obstruction include unusual bloating, abdominal pain, nausea or vomiting. You should call your doctor immediately for any such concerns. Be careful not to prematurely disconnect the system as this may result in loss of pictures being sent to your recording device.

Your doctor will give you a pill-sized video camera for you to swallow. In preparation for the examination, a sensor device may be attached to your abdomen with adhesive sleeves (similar to tape). The capsule endoscope is about the size of a large pill. After ingesting the capsule and until it is excreted in your stool, you should not be near an MRI device or schedule an MRI examination.

You will be able to drink clear liquids after two hours and eat a light meal after four hours following the capsule ingestion, unless your doctor instructs you otherwise. You will have to avoid vigorous physical activity such as running or jumping during the study. Your doctor generally can tell you the test results within the week following the procedure; however, the results of some tests might take longer.

There are limitations to capsule endoscopy. The capsule is pushed by intestinal motility (movement). At times, it may idle for a long time in the stomach or parts of the small intestine, and at times it may rush quickly preventing thorough evaluation. The capsule lacks the ability to remove debris that can be found in the intestine hence decreasing the visibility of lesions and is unable to put air to distend the intestine for better visualization. Finally, the capsule lacks the ability to obtain samples of lesions (biopsies) or provide any treatment (e.g. treatment of an area of bleeding)...

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