Gastrointestinal (GI) Endoscopy

Who Needs An Endoscopy?

Endoscopy is often performed on patients who have unexplained or persistent gastrointestinal symptoms that warrant investigation. A patient who presents with chronic abdominal pain, ongoing heartburn, difficulty in swallowing, or unexplained weight loss may need an endoscopy to look for possible causes. This may also be used in assessing the abnormal findings from other tests or evaluating chronic conditions like inflammatory bowel disease and cancer screening. Apart from diagnosis, endoscopy can also be used for therapeutic purposes, for example, polyp removal, stopping of bleeding, or dilating strictures. A decision regarding endoscopy is made based on symptoms, past medical history, and diagnostic findings.

What Diseases Can Be Found By Endoscopy?

This is the list of some diseases that can be diagnosed by endoscopy:

1. Gastroesophageal Reflux Disease (GERD)

   Classical changes in the esophagus from GERD are better assessed with endoscopy. It may reveal conditions like inflammation of the esophagus, that is, oesophagitis, erosion, ulceration. It may also delineate complications like strictures or Barrett's esophagus, which involves a change in the lining of the esophagus from its normal appearance due to chronic acid exposure. The procedure essentially requires a flexible tube with a camera passed through the mouth to have a look at the esophagus.

2. Peptic Ulcer Disease

   Endoscopy is very useful in confirming a diagnosis of peptic ulcers, whether the ulcer is located in the stomach or duodenum. The most definite way to determine the presence of peptic ulcers is through the use of endoscopy since it can provide direct visualization of ulcers and assessment of their severity. In addition, this will enable biopsies of the ulcer to test for Helicobacter pylori infection infections, which may have been the cause of the ulcer, and for signs of malignancy if needed.

3. Esophageal Cancer

   Abnormal growths in the esophagus or lesions indicative of cancer can thus be identified. The supple tube in endoscopy permits a close and detailed view of the lining of the esophagus, where some irregularities, tumors, or masses can be identified. Biopsy samples can be taken during the procedure for histological examination to confirm cancer diagnosis and its staging.

4. Barrett's Esophagus

   In Barrett's esophagus, because of chronic acid reflux, the lining of the esophagus is replaced with tissue similar to the intestinal lining. Endoscopy can identify this abnormal tissue change, and it will also explain the extent of involvement. Biopsies taken during endoscopy will be useful for deciding the existence of dysplasia, or precancerous changes, and determining the degree of risk for developing esophageal cancer.

5. Inflammatory Bowel Disease (IBD)

   IBD can be evaluated with endoscopy, including conditions that go under the name of Crohn's Disease and Ulcerative Colitis. Colonoscopy would reveal examination of the colon and the rectum, showing inflammation, ulceration, and other characteristic changes. Enteroscopy or capsule endoscopy may be used in examining involved areas of the small intestine with Crohn's disease that are out of reach of the colonoscope.

6. Colorectal Cancer

   It is one of the most important ways to diagnose colorectal cancer. Colonoscopy allows the proper visualization of the colon and rectum; hence, helps in detecting cancers in the form of tumors or precancerous polyps. During the procedure, polyps can be removed and examined to prevent cancer development.

7. Diverticulitis

   Endoscopy can detect diverticula, or pouches in the colon, and inflammation that occurs with diverticulitis. While a colonoscopy can detect diverticula, and also some of its complications like bleeding or abscesses, imaging studies are often obtained to better outline the extent of disease.

8. Celiac Disease

   Endoscopy with biopsy of the small intestine can help diagnose celiac disease by displaying damage to the villi (small finger-like projections) in the intestine. It is an immune reaction against gluten, and biopsy can identify this damage, helping in diagnosis and monitoring.

9. Gastroparesis

   Endoscopy may be performed to examine the stomach for physical obstructions or structural abnormalities that could account for symptoms of gastroparesis. Because endoscopy does not directly assess the contractions of the stomach muscle, it is a test to rule out other causes of symptoms that may overlap with those of gastroparesis.

10. Polyps

    Endoscopy is utilized to detect and excise polyps in the digestive tract. Polyps are described as unusual outgrowths protruding from the lining of the colon, stomach, or small intestine. If the polyps are removed and later examined during an endoscopy, the potential of being malignant for cancer can be analyzed.

11. Peptic Stricture

    Peptic stricture refers to the narrowing in the esophagus and stomach. It generally occurs through scar tissues that have chronic ulcers or inflammation. From an endoscopic examination, stricture can be seen and its proportion and significance can be judged. It also allows for interventions like dilation to relieve symptoms.

12. Hemorrhoids and Anal Fissures

    Anoscopy can check the rectum and anus for other diseases, including hemorrhoids and anal fissures. Endoscopy can offer direct vision and treatment for such diseases, which may be responsible for bleeding and abdominal pain.

13. Small Bowel Diseases

    For diseases of the small intestine, special specialized endoscopic techniques are applicable:

    • Capsule Endoscopy: A small capsule that encases an incorporated camera is swallowed for taking pictures of the small bowel while it progresses along it. The procedure is useful in the diagnosis of conditions such as Crohn's disease, sources of bleeding, and neoplasms in the small intestine.
    • Enteroscopy: Enteroscopy is the examination of the small intestine using a long, flexible endoscope. It can be used for direct viewing and the application of treatment for diseases of the small bowel, such as polyps, tumors, or sites of bleeding.

What Are The Various Endoscopic Diagnostic Tests Performed For Gastroenterological Disorders?

Some of the endoscopic diagnostic tests done in gastroenterological disorders are as follows:

1. Esophagogastroduodenoscopy (EGD)

   This is a diagnostic procedure in which a flexible endoscope is used to view the interior of the esophagus, stomach, and duodenum-commonly known as the first part of the small intestine. They are passed through the mouth and are used to observe the structures mucosal lining, evaluating for abnormalities like inflammations, ulcers, tumors, and hemorrhages. EGD is crucial for the diagnosis of diseases such as gastroesophageal reflux disorders, peptic ulcers, Barrett's esophagus, and esophagus cancer. The test also allows therapeutic procedures like the taking of a biopsy, removal of a foreign body/ polyp.

2. Sigmoidoscopy

   Sigmoidoscopy is the process to analyze the sigmoid colon and rectum using a flexible tube, fitted with a camera, where the tube is called a sigmoidoscope. The scope is inserted through the rectum to see the lower part of the colon. It is one of the investigative tools for the patients who present with symptoms of rectal bleeding, chronic diarrhea, or abdominal pain. It can make the diagnosis of colorectal cancer, colorectal polyps, Ulcerative colitis, and sometimes can help in diagnosing Crohn's disease. Sigmoidoscopy helps in making a diagnosis and carries out removal of the lesion (polyp, malignant lesion) or biopsy for pathology.

3. Full-Length Colonoscopy (LGI Endoscopy)

   This procedure is also known to many people as LGI (lower gastrointestinal) endoscopy that helps in examining the complete colon and rectum. This thorough process allows the detection and diagnosis of a variety of different conditions, including colorectal cancer, polyps, diverticulosis, and inflammatory bowel disease (IBD). The endoscope, when passed through the rectum, provides a complete inspection of the colonic mucosa, enabling direct visualization, and intervention including biopsy and removal of polyps. It is one of the important ways to screen and survey colorectal cancer.

4. Ileoscopy

   Ileoscopy is an endoscopic examination of the ileum, which is the terminal portion of the small intestine. The endoscope advances through the rectum, up to the colon, and further along to the ileum. This procedure is extremely valuable for diagnosing diseases that involve the ileum, such as Crohn's disease, tumors, and sources of gastrointestinal bleeding.

5. Enteroscopy (Anterograde and Retrograde)

   Enteroscopy is the special type of endoscopy in which the mucosa of the small intestine is examined. There are two types of enteroscopy, namely anterograde and retrograde. Anterograde enteroscopy involves inserting the endoscope through the mouth and advancing it through the stomach and into the small intestine. Retrograde enteroscopy, on the other hand, is performed by the insertion through the rectum and then advancing the endoscope back into the small bowel. These two procedures focus on the determination and treatment of any conditions affecting the small bowel, including bleeding, polyps, and growths.

6. Endoscopic Ultrasound (EUS), Fine Needle Aspiration, and Biopsy (FNB)

   Endoscopic Ultrasound (EUS) yields the precise views of all layers of the digestive tract, noting the pictures of surrounding structures. EUS utilizes an endoscope with an ultrasound probe at its tip, giving high-resolution images of the wall of the gastrointestinal canal and other organs including the pancreas and lymph nodes. EUS is an important procedure in staging cancers, the evaluation of pancreatitis as well conditions of the bile ducts. Fine Needle Aspiration (FNA) and Fine Needle Biopsy (FNB) are techniques in which EUS can be supplemented to sample tissue from suspicious locations to make a histological diagnosis of malignant and other pathologies.

7. Mucosal Enhancing Techniques: Chromoendoscopy, NBI, i-Scan, FICE
   • Chromoendoscopy is a process that involves applying specific dyes or contrast in a targeted area such that the disparities in mucosa can easily be seen. This technique will hence increase dysplasia and early cancer detection by highlighting subtle changes that could be missing for detection with standard endoscopy.
   • Narrow Band Imaging is an illumination technique that uses specific wavelengths of light to better visualize the blood vessels and mucosal patterns. It enables the detection of many abnormalities such as early-stage cancer and precancerous lesions by good contrast between normal and abnormal tissues.
   • I-Scan's image-enhancement technology advances mucosal visuality by sharpening the surface and vascular patterns. It aids in identifying disease and determining the stage of diseases like cancer and inflammatory conditions.
8. Another image-enhancement technology is the Flexible Imaging Color Enhancement (FICE) that enlarges the color spectrum of the endoscopic image to emphasize mucosal features. This increases the detection of early cancer and precancerous lesions by enhancing contrast and texture features of the tissues.

What Are The Various Therapeutic Endoscopy Services Provided At Marengo Asia Hospitals?

Below is a quick overview of some of the therapeutic endoscopy services, keyed to specific areas of concentration:

1. Upper and Lower GI Therapeutic Endoscopy
   • Variceal Ligation & Sclerotherapy: This deals with the treatment of esophageal varices, which are enlarged veins in the esophagus, usually caused due to liver cirrhosis. Variceal ligation involves the placement of rubber bands around the varices to prevent bleeding, while sclerotherapy involves the injection of a sclerosing agent into the varices to shrink and seal them.
   • Glue Injection for Gastric Varices & EUS-guided Coagulation with Glue: In glue injection for gastric varices, some unique adhesive is introduced in a way to occlude the bleeding veins to minimize the risk of hemorrhage. On the other end, EUS-guided coagulation with glue combines imaging and targeted injection in the management of bleeding varices.
   • Stricture Dilatation (Esophageal & Intestinal): Narrow portions of the esophagus or intestines are dilated by balloon dilation or other techniques. This is normally carried out for effective management of conditions such as esophageal strictures or intestinal stenosis.
   • Achalasia Dilatation: Achalasia is a condition that causes food to move sluggishly from the esophagus to the stomach. The stretching of the balloon, in dilatation, helps to release tension in the lower esophageal sphincter, which enhances the ability to swallow and also improves symptoms of achalasia.
   • Argon Plasma Coagulation of Mucosal Lesions: This involves the use of activated argon gas, which coagulates to treat any mucosal abnormality in the GI tract. It's particularly useful for bleeding control and managing lesions like polyps or precancerous areas.
   • Polypectomy (UGI and Colonic Polyps): Polypectomy refers to the surgical procedure of getting rid of a polyp in the UGI ( upper gastrointestinal) colon. It is typically done by several techniques, among them are snare resection for the prevention of cancer development and as treatment for polyp removal after polyps are encountered during endoscopic procedures
   • Foreign Body Removal from GI Tract: This is the process by which the endoscope can be used to remove things that might have been ingested by consumption of food and non-food stuff. This process involves removing an object through the endoscope hence permitting safe removal of objects and preventing complications such as blockage and perforation.
   • Endoscopic Placement of Feeding Tubes (PEG/PEJ/Nano Gastric Tubes): PEG, PEJ, and Nano Gastric Tubes represent modalities of the localization of feeding tubes directly into the stomach or small intestine. These are particularly critical for individuals who, because of a large number of pathologies, are unable to eat orally.
   • Polypectomy with Hybrid EMR: Hybrid endoscopic mucosal resection is a method born from endoscopic resection and mucosal removal to remove larger or more complex polyps. It treats both benign and precancerous lesions.
   • Endoscopic Hemostasis for Bleeding Lesions: These techniques for endoscopic hemostasis use the endoscope tools to control the bleeding of gastrointestinal lesions. The techniques include cauterization, clipping, or banding of the lesion to prevent bleeding and their consequences.
   • SEMS Placement for Malignant Colonic Strictures: SEMS is utilized for the management of malignant colonic strictures by providing a scaffold that keeps the narrowed area open, thereby improving bowel function and symptom relief in patients with colorectal cancer.
2. Therapeutic Endobiliary & Pancreatic ERCP
   • ERCP for Bile Duct Stones, Strictures, and Leaks: ERCP, or endoscopic retrograde cholangiopancreatography, is the diagnostic and therapeutic modality applied to problems in the bile ducts due to stones, strictures, and leaks. It combines endoscopy and fluoroscopy for the visualization and treatment of these disorders.
   • Biliary Stents (Plastic and SEMS): This is where plastic or metal self-expanding stents are inserted into the bile ducts. These will keep the duct open and reestablish the flow of bile if there is a blockage caused by stones, tumors, or strictures within the ducts.
   • ERCPs for Post-Liver Transplant Conditions (Strictures and Leaks): This may also be indicated in the management of bile duct strictures or leaks that consequently develop after liver transplantation due to surgical alterations or rejection.
3. Cholangioscopy
   • Diagnostic: Spy Bite for Mucosal Lesions:
     Spy Bite is a technique for cholangioscopy, the visualization of the bile duct for mucosal lesions. This diagnostic tool allows for identification and characterization of abnormalities that may require additional intervention.

   • Therapeutic: LASER Lithotripsy, Post-Transplant ERCPs:

     Laser lithotripsy attempts to turn the stones in the bile duct into dust using laser treatment. These resultant stones are easily removed. In post-transplant ERCPs, complications such as strictures and leaks of the bile ducts after liver transplantation are managed.

4. Pancreatoscopy
   • ERCP for Stones, Strictures, and PD Leaks: Pancreatoscopy is the use of ERCP for diagnosis and treatment of problems in the pancreatic duct, like stones, strictures, and leaks. This technique helps manage conditions affecting pancreatic function.
   • Pancreatoscopy, Enteroscopy-guided ERCP for Bile Duct and Pancreatic Duct Obstruction (Post-Whipple’s, Post-Roux-en-Y): These are modalities for the treatment of complicated obstructions in bile and pancreatic ducts, especially after procedures like Whipple's or Roux-en-Y that can affect the anatomy.
   • Minor Duct ERCP: This is an ERCP performed in the smaller pancreatic ducts for problems not shown in imaging or not amenable to the standard methods of performance of ERCP.
5. Endoscopic Mucosal Dissection

   EMR, ESD, and Submucosal Tumor Removal: Endoscopic mucosal resection and endoscopic submucosal dissection are techniques for the removal of early-stage cancers or precancerous lesions of the mucosa in the gastrointestinal tract. EMR provides a technique whereby the mucosa can be removed in piecemeal fashion, and ESD allows for the en bloc resection of larger lesions. Submucosal Tumor Removal treats tumors beneath the mucosal layer, providing a minimally invasive alternative to classical surgery.

What is Therapeutic Endoscopic Ultrasound (EUS)?

Therapeutic Endoscopic Ultrasound is a minimally invasive procedure in which the endoscopy procedure is associated with ultrasound imaging to diagnose different gastrointestinal and pancreatic diseases, with options for both imaging and therapeutic procedures. The types of Therapeutic Endoscopic Ultrasound include:

• Cystogastrostomy for Pseudocyst, Walled-off Pancreatic Necrosis (WOPN), and Collections Related to the Stomach: A cystogastrostomy is an opening created between a pancreatic cyst or pseudocyst and the stomach. This is done for the drainage of fluid collections or necrotic tissue that might have resulted from pancreatic diseases.
• Cystoduodenostomy for Pseudocyst, WOPN, and Collections Related to the Duodenum: The cystoduodenostomy is similar to the cystogastrostomy, but rather, an anastomosis is created with the duodenum—the first part of the small intestine. It's indicated when a pancreatic cyst or pseudocyst is adherent to or abutting the duodenum.
• Hepatogastrostomy (Stomach to Bile Duct): In this process, the stomach is anastomosed to the bile duct. It bypasses or relieves the obstruction of the bile duct.
• Cholecystoduodenostomy (Gallbladder to Stomach): Cholecystoduodenostomy is a direct anastomosis of the gallbladder with the duodenum. It is done for relief from conditions like obstruction of the bile duct or diseases of the gallbladder.
• Choledochoduodenostomy (Gallbladder to Duodenum): Choledochoduodenostomy is a surgical anastomosis of the bile duct and the duodenum, commonly performed in either obstruction of the duct or some complex problems related to that.
• EUS Pancreaticogastrostomy or Pancreaticoduodenostomy: Pancreatic Drainage in Failed ERCP or Altered Anatomy: Pancreaticogastrostomy and pancreaticoduodenostomy refer to the creation of a pathway for pancreatic drainage into the stomach or duodenum. These procedures are performed in the event of failure of conventional endoscopic techniques, such as ERCP, or in the presence of altered anatomy complicating drainage.
• EUS-guided Gallbladder Drainage: Cholecystogastrostomy or Cholecystoduodenostomy: Cholecystogastrostomy or Cholecystoduodenostomy: EUS-guided gallbladder drainage is an endoscopic ultrasound-guided placement of drainage stents from the gallbladder to the stomach or duodenum. It is performed to palliate acute or chronic conditions in the gallbladder with respect to infection and obstruction.
• EUS-guided Coil & Glue Placement for Gastric Varices: Coil and glue placement is a procedure where, under EUS guidance, coils and glue are placed to manage gastric varices, which could be a complication of portal hypertension.
• EUS-guided RFA for Bile Duct Cancer or Pancreatic Lesions: RFA is a technique that kills cancer cells with high-energy waves. EUS-guided RFA for bile duct cancer or pancreatic lesions is aimed at dispatching the high-energy waves right down to the tumor or abnormal tissue through the scope.
• EUS-guided Pelvic Abscess Drainage: This is a process in which EUS is used to guide the drainage of abscesses—collections of pus—in the pelvis area, often for treatment of an infection or other complications.
• Biliary Drainage for Failed ERCPs or Difficult Anatomy: Enteroscopic Drainage or EUS-guided Choledochoduodenostomy or Hepatogastrostomy: If ERCP fails or if the anatomy is difficult, then biliary drainage by other modalities may be done with Enteroscopic Drainage, that is using the endoscopy to access the bile ducts through the small intestine or with EUS guided Choledochoduodenostomy or Hepatogastrostomy.