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Procedures We Perform

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Double Balloon Enteroscopy

Double Balloon Enteroscopy, also known as a push and pull enteroscopy, is an endoscopic technique for visualization of the small bowel. The technique for advancement, using the double balloon enteroscopy method, uses a push pull method with inflammation and deflation of two balloons and telescoping of the intestines onto an over tube. Double Balloon enteroscopy can be done in an antegrade (through the mouth) and /or retrograde (through the rectum) approach.

Through this technique, it is possible to biopsy tissue, dilate strictures, remove polyps and stop bleeding from the small bowel. Balloon assisted enteroscopy can be performed in an outpatient or inpatient setting and may require several hours (depending on the therapy required). It is often performed with general anesthesia or moderate sedation.

Double Balloon enteroscopy (DBE) is not used as a first line therapy and is performed after careful evaluation by a specialty trained gastroenterologist. In the event your gastroenterologist orders this test, he or she will discuss the procedure, benefits, potential risks and outcomes.

Endoscopic Ultrasound (EUS )

Endoscopic ultrasound (EUS) allows your doctor to examine the lining of your upper and lower gastrointestinal tract. The upper tract consists of the esophagus, stomach and duodenum (the first part of the small intestine). The lower tract includes your colon (large intestine) and rectum. EUS is also used to study other organs near the gastrointestinal tract, including the lungs, liver, gallbladder and pancreas.

Our EPGI physicians who perform EUS are highly trained specialists. To perform EUS, your doctor will use a thin, flexible tube called an endoscope that has a built –in miniature ultrasound probe. The endoscope will be passed through your mouth or anus to the area to be examined and ultrasound images will be taken.

Esophageal Dilation

The esophagus is a tube that connects the throat and the stomach. Within the esophagus, muscles contract to move food and fluids to the stomach. Esophageal dilation is a procedure to widen the part of your esophagus that is too narrow.

What is Esophageal Dilation?

Esophageal dilation is a procedure that allows your doctor to dilate, or stretch, a narrowed area of your esophagus [swallowing tube]. Doctors can use various techniques for this procedure. Your doctor might perform the procedure as part of a sedated endoscopy. Alternatively, your doctor might apply a local anesthetic spray to the back of your throat and then pass a weighted dilator through your mouth and into your esophagus.

Why is esophageal dilation done?

The most common cause of narrowing of the esophagus, or stricture, is scarring of the esophagus from reflux of stomach acid occurring in patients with heartburn. Patients with a narrowed portion of the esophagus often have trouble swallowing; food feels like it is “stuck” in the chest region, causing discomfort or pain. Less common causes of esophageal narrowing are webs or rings (which are thin layers of excess tissue), cancer of the esophagus, scarring after radiation treatment or a disorder of the way the esophagus moves [motility disorder].

Should you need an esophageal dilatation, your doctor will review how to prepare for the procedure, the type of dilatation being used, the procedure details and what to expect after the procedure along with potential risks and complications.

Esophageal Manometry Test

If you have symptoms such as difficulty swallowing or chest pain, your doctor might order an esophageal manometry. This test measures the function of the lower esophageal sphincter (the valve that prevents reflux of gastric acid into the esophagus), indicating if you are able to move food to the stomach normally.

What is esophageal manometry?

Esophageal manometry is a test used to measure the function of the lower esophageal sphincter (the valve that prevents reflux of gastric acid into the esophagus) and the muscles of the esophagus (see diagram). This test will tell your doctor if your esophagus is able to move food to your stomach normally. To know why you might be experiencing a problem with your digestive system, it helps to understand the swallowing and digestive processes.

The manometry test is commonly given to people who have:

  • Difficulty swallowing
  • Pain when swallowing
  • Heartburn
  • Chest pain

 

The swallowing and digestive processes

When you swallow, food moves down your esophagus and into your stomach with the assistance of a wave-like motion called peristalsis. Disruptions in this wave-like motion may cause chest pain or problems with swallowing.

In addition, the muscular valve connecting the esophagus with the stomach, called the esophageal sphincter, prevents food and acid from backing up out of the stomach into the esophagus. If this valve does not work properly, food and stomach acids can enter the esophagus and cause a condition called gastroesophageal reflux disease (GERD).

Manometry will indicate not only how well the esophagus is able to move food down the esophagus but also how well the esophageal sphincter is working to prevent reflux.

Eating and drinking

  • Do not eat or drink after midnight the night before the test.

 

The Day of the test

  • You may take any antacids up until 12 midnight the night before the test.
  • DO not smoke or drink alcohol after 10 pm the evening before the test.
  • You will be instructed by your doctor regarding the medications you can take the morning of your procedure.

 

 During the test

  • You are not sedated. However, a topical anesthetic (pain-relieving medication) will be applied to your nose to make the passage of the tube more comfortable.
  • A small, flexible tube is passed through your nose, down your esophagus and into your stomach. The tube does not interfere with your breathing. You will be seated while the tube is inserted.
  • You may feel some discomfort as the tube is being placed, but it takes only about a minute to place the tube. Most patients quickly adjust to the tube’s presence. Vomiting and coughing are possible when the tube is being placed, but are rare.
  • The end of the tube exiting your nose is connected to a machine that records the pressure exerted on the tube. Sensors at various locations on the tubing sense the strength of the lower esophageal sphincter and muscles of the esophagus. During the test, you will be asked to swallow a small amount of water to evaluate how well the sphincter and muscles are working. The sensors also measure the strength and coordination of the contractions in the esophagus as you swallow.
  • The test will take approximately 1 – 1.5 hours.

 

After the test

  • Your physician will notify you when the test results are available or will discuss the results with you at your next scheduled appointment.
  • You may resume your normal diet and activities and any medications that were withheld for this test.
  • You may feel a temporary soreness in your throat. Lozenges or gargling with salt water may help.
  • If you think you may be experiencing any unusual symptoms or side effects, call your doctor.

ERCP

What is an ERCP?

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and bile ducts.  The bile ducts are tubes that carry bile from your liver to your gallbladder and duodenum (the first part of your small intestines).  Pancreatic ducts are tubes that carry pancreatic juice from your pancreas to your duodenum. Small pancreatic ducts empty into the main pancreatic duct.  The common bile duct and main pancreatic duct join before emptying into your duodenum.

Doctors use ERCP to treat problems of the bile and pancreatic ducts.   Doctors also use ERCP to diagnose problems of the bile and pancreatic ducts if they expect to treat problems during the procedure. For diagnosis alone, doctors may use noninvasive tests instead of ERCP.  Noninvasive tests such as magnetic resonance cholangiopancreatography (MRCP), a type of MRI, are safer and can diagnose many problems of the bile and pancreatic ducts

Doctors perform ERCP when your bile or pancreatic ducts have become narrowed or blocked because of:

  • Gallstones that form in your gallbladder and become stuck in the common bile duct
  • Infection
  • Acute pancreatitis
  • Chronic Pancreatitis
  • Trauma or surgical complications in the bile of pancreatic ducts
  • Pancreatic pseudocysts
  • Tumors or cancers of the pancreatic or bile ducts

 

Should your doctor order an ERCP he/she will discuss how to prepare for the rest which includes:

  • Arrangements for transportation to and from the hospital
  • Discussion about your medical condition, medication, allergies, and over the counter medications including supplements.
  • A description of the ERCP procedure
  • And what to expect after the procedure

 

Your doctor will discuss your likelihood of complication with you before you undergo the test.

During the test, the Doctor:

  • Located the opening where the bile an pancreatic ducts empty into the duodenum
  • Slides a thin, flexible tube called a catheter through the endoscope and into the ducts
  • Injects a special dye, called a contrast, into the ducts thorough the catheter to make the ducts more visible on x-rays
  • Uses a type of x-ray imaging called fluoroscopy, to examine the ducts and look for narrowed areas or blockages.

 

The doctor may pass tine tools through the endoscope to:

  • Open blocked or narrowed ducts
  • Break up ore remove stones
  • Perform a biopsy or remove tumors in the ducts
  • Insert stents- tiny tubes that a doctor leaves in narrowed ducts to hold them open.

 

The procedure most often takes between 1-2 hours.

Fecal Transplant

Fecal Microbiotica Transplantation (FMT or stool transplantation) is a treatment for diarrhea that is caused by the Clostridium Difficile bacteria. The treatment includes the transfer (through a processed mixture of stool) of “healthy” bacteria from a donor into the intestines of the patient. The idea is to restore the proper balance of bacteria in the patient/recipients intestine so he or she can fight infection.

In order to be considered for FMT, the patient must have at least two stool samples that test positive for the clostridium difficile, even after treatment with antibiotics.

Flexible Sigmoidoscopy

Flexible sigmoidoscopy is the endoscopic examination of the rectum and sigmoid colon. This is not an examination of the entire colon. Flexible sigmoidoscopy 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. There is no sedation required, so you should be able to drive to and from your office visit the day of your procedure.

Preparation

The colon and rectum must be completely empty for flexible sigmoidoscopy to be thorough and safe. The night before the procedure, administer the FIRST Fleets enema at least one hour before bedtime. Administer the SECOND Fleets enema at least one hour before leaving for your procedure.

Your EPGI physician may give you other special instructions.

Hemorrhoid Banding

This highly effective, minimally invasive procedure is performed in our offices.

During the brief and painless procedure, our physicians place a tiny rubber band around the base of the hemorrhoid.

The procedure works by cutting off the blood supply to the hemorrhoid. This causes the hemorrhoid to shrink and fall off, typically within a day or so.

You probably won’t even notice when this happens or be able to spot the rubber band in the toilet. Once the hemorrhoid is gone, the wound usually heals within one to five days.

Procedure Information:

• Fast: This is a fast in office procedure which takes approximately one minute to perform.
• Painless: Banding is typically without much pain since it is an area without nerve endings.
• No Sedation: You will be able to drive yourself to and from the appointment since there is no sedation. You will also be able to return to work.
• No Bowel Prep: There is no fasting, no cleansing and no enemas needed for this procedure
• No Downtime: You can get right back to your daily activities and lifestyle. (You are asked to refrain from strenuous activity until the following day.)

The physicians at EPGI use a smaller, gentler disposable suction device to minimize discomfort and lesson the complication risk. During the first 24 hours, some patients may experience a feeling of fullness or a dull ache in the rectum. This can typically be relieved with an over-the-counter pain medication. However, more than 90% of patients treated with this method have no post-procedure pain.

PEG Tube

PEG stands for Percutaneous endoscopic gastrostomy and is a procedure through which a flexible feeding tube is placed though the abdominal wall and into the stomach. It allows nutrition, fluids and medications to be put into the stomach, bypassing the mouth and the esophagus.

How is the PEG Tube performed?

The doctor uses a lighted flexible tube called and endoscope to guide the creation of a small opening through the skin of the abdomen and directly into the stomach. This procedure allows the doctor to place and secure a feeding tube into the stomach. Patients generally receive a mild sedative and local anesthesia. Patients can usually go home the same day or the next day.

Patients who have difficulty swallowing, problems with their appetite or inability to take enough nutrition though the mouth can benefit from this procedure. Your provider will review care the peg tube, feeding and potential complications along with complete instructions.

RADIOFREQUENCY ABLATION

Radiofrequency ablation (RFA) is used in the treatment of Barrett’s esophagus. During radiofrequency ablation treatment for Barrett’s esophagus, the doctor uses an endoscope to insert a thin tube or catheter down your esophagus. The catheter has a balloon at the end, with electrodes on the outer surface. The balloon is inflated so the electrodes are touching the abnormal tissue in the lining of the esophagus. The electrodes deliver enough energy to destroy thin layers of the diseased or abnormal tissue.

Barrett’s Esophagus is a condition in which tissue that is similar to the lining of our intestine replaces the tissue lining in your esophagus. The procedure is usually done as an outpatient and during an upper endoscopy. It takes approximately 45 minutes to complete the procedure. If you are scheduled for an RFA, your physician will discuss the preparation, the procedure risks and expected outcome.

Screening and Diagnostic Colonoscopy

Screening
Did you know that colon cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death? And did you know that the average risk of being diagnosed is about one in 19?

Adults age 50 and older without any risk factors, and those with a family history of colon cancer, colon polyps, or inflammatory bowel disease should be screened every 10 years for colon cancer. Colon cancer can be prevented and is most easily treated when detected early.

At EPGI we are dedicated to the prevention and early detection of colon cancer and perform screening colonoscopies on a daily basis. Our highly trained physicians and clinical staff are available to answer any questions and walk you through the screening process. We have many valuable educational resources and perform the procedure in both the comfort of our outpatient ambulatory surgical center as well as the hospital setting.

Diagnostic
In addition to performing screening colonoscopy for the early detection of colon polyps and colon cancer, the physicians at EPGI perform diagnostic colonoscopy to help diagnose common gastrointestinal diseases.

If you’re experiencing gastrointestinal symptoms such as abdominal pain, rectal bleeding, diarrhea, blood in stool, constipation, unexplained weight loss, among other symptoms, you may be a candidate for a diagnostic colonoscopy.”

Diagnostic colonoscopies are performed by EPGI physicians at our endoscopy center, Lehigh Valley Hospital and Health Network – Cedar Crest, Lehigh Valley Health Network – Muhlenberg, and Sacred Heart Hospital.

Colonoscopy Preparation:

EPGI is pleased to have patterned with, yourPATIENTadvisor, a service that provides our patients with comprehensive colonoscopy preperations instructions, email and phone call reminders, and advisors who can help answer bowel preparation questions during extended hours when our office staff is not available.

Patients are automatically enrolled in the program when a colonoscopy is scheduled.  From there, patients will receive either a welcome email or phone call (patients will not receive a phone call if an email address is provided) and a welcome letter in the mail which will arrive in a bright blue envelope.  This welcomes patients to their patient advisor, provides contact information, and provides information about when, where, and with who their procedure is scheduled.

From there, patients will receive email and phone call reminders leading up to their procedure at:

4 weeks

14 days

7 days

3 days

1 day

 

A link to preparation questions is included in every email if an email address is provided.  A paper copy of preparation instructions will be mailed to the patient’s home 14 days prior to their scheduled procedure.  These instructions will also arrive in a bright blue envelope.

Any preparation questions leading up to the scheduled procedure should be directed to an advisor at (800) 349-0285 or support@yourpatientadvisor.com.  Advisors are available:  Monday – Friday 7:00am – 10:00pmEST, Saturday 10:00am – 6:00pmEST, and Sunday 12:00pm – 8:00pmEST.  Advisors are available in both English and Spanish.

TIF Procedure for Reflux

TIF (transoral incisionless fundoplication) is the latest treatment for safely and effectively treating chronic acid reflux disease, also known as gastroesophageal reflux disease (GERD). A completely incisionless procedure, TIF reconstructs the antireflux barrier to provide a solution to the anatomical root cause of GERD. The procedure is for patients who are dissatisfied with current pharmaceutical therapies or are concerned about the long-term effects of daily use of reflux medications.

What is GERD?

If you have heartburn or reflux twice a week or more, you may have GERD. Heartburn is the most common symptom, but you may also experience:

  • Hoarseness or sore throat
  • Frequent swallowing
  • Asthma or asthma-like symptoms
  • Pain or discomfort in the chest
  • Sleep disruption (unable to sleep lying down)
  • Bloating
  • Excessive clearing of the throat
  • Persistent cough
  • Burning in the mouth or throat
  • Intolerance of certain foods
  • Dental erosions or therapy-resistant gum disease or inflammation

Normally, after swallowing, a valve between the esophagus and stomach opens to allow food to pass, then it closes to prevent stomach contents from “refluxing” back into the esophagus, causing a burning sensation in the chest. For people who suffer from GERD, the valve is dysfunctional and unable to prevent acid from refluxing into the esophagus.

TIF procedure

TIF was developed to emulate more invasive surgical techniques, but from within and completely without incisions and visible scars. Using the FDA-cleared EsophyX device, the procedure is performed through the mouth, rather than through an abdominal incision. Typically lasting no more than 50-60 minutes, the procedure is performed under general anesthesia and reconstructs the antireflux barrier to restore the competency of the gastroesophageal junction.

FAQ’s
Is the TIF procedure effective?

Studies show that for up to three years after the TIF procedure, GERD symptoms are reduced and most patients are able to stop taking PPI medications to control symptoms.

Is the TIF procedure safe?

The TIF procedure has an excellent safety profile.  Clinical studies demonstrate that TIF patients rarely experience long term side-effects commonly associated with traditional antireflux surgery such as chronic dysphagia (trouble swallowing) gas bloat syndrome and increased flatulence.

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.

For the procedure the physician will use a thin, flexible, lighted tube called an endoscope. You will be sedated 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 15 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 30 to 45 minutes until the medication wears off. You will need someone to drive you home after your procedure.

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