About GI Conditions & treatments

For our patients comfort we have 12 specifically designed en-suite recovery bays which have been built in a traditional open-style recovery ward; increasing privacy and cleanliness for each patient.

In the centre itself we have three Endoscopy suites equipped with the very latest in videoscopy technology which provides the the GI team with high definition image capture, including still photography of any procedure undertaken. An integrated patient reporting and audit software system supports all our endoscopy procedures ensuring the highest standard of patient care and safety. Detailed reports, with high definition images are available for your consultant, in a number of formats, within minutes of the procedure.

The unit treats the full range of GI conditions including:

Upper GI conditions: Coeliac disease, Gall stones, Pancreatitis, Food intolerance and Achalasia

Lower GI conditions: Irritable bowel syndrome, Diverticular disease, Inflammatory bowel diseases and Polyps in the bowel

GI cancers including: Oesophageal cancer, Stomach cancer, Bowel cancer, Pancreatic cancer, Stromal tumours

As a result of the hard work from consultants, nursing staff, management and support staff, in 2014 our Endoscopy Centre was awarded JAG accreditation. This accreditation is annually reviewed and our endoscopy team continually work to maintain this status.

Appendicitis

The appendix is a small tube of tissue that is attached to part of the large intestine or colon. It sits in the lower right part of your abdomen and is about 5 to 10 centimetres long (that's about 2 to 4 inches).

Appendicitis means the appendix is inflamed. The causes are unclear but it is thought appendicitis occurs when the appendix gets blocked. Fluids, hard bits of stool or swollen lymph glands can get trapped in the appendix, and when this happens, the appendix becomes inflamed or infected. This leads to the painful symptoms of appendicitis. If the appendix is inflamed and it is not removed, the consequences can be fatal.

Symptoms

The symptoms of appendicitis begin with pain on the right-hand side of the lower abdomen. A lack of appetite and wanting to vomit are often experienced. In addition a patient might also experience the following:

  • cramp-like pain
  • a slight temperature
  • constipation, or more rarely, diarrhoea
  • pain that gets worse with movement or coughing
  • a need to go to the lavatory
  • it may be more comfortable bending over or lying with your knees drawn up.

Not everybody gets all of these symptoms, particularly those who are:

  • very young or very old
  • pregnant

or

  • have an appendix which is not in the usual place
  • have other medical problems such as diabetes or cancer

Treatment

The only treatment for appendicitis is surgery to remove the appendix.

If appendicitis isn't treated, the appendix can burst causing a serious infection inside the body. The Surgeon can either operate using the open surgery or keyhole surgical techniques.

Crohn's disease

Crohn's disease is an inflammatory disease that can affect any part of the alimentary canal between the mouth and the rectum. Symptoms depend on where the inflammation is present. Whilst all of the gut can be affected the commonest areas for problems to occur are in the lower small intestine (the ileum), the colon and the rectum where infections may occur.

People with Crohn's disease will often feel unwell in a non-specific way to begin with. This may involve weight-loss and appetite in addition to the abdominal symptoms. More specific intestinal symptoms are as follows.

Ileal Crohn's disease: Symptoms usually include lower abdominal pains often more to the right side. This is often worse after eating with abdominal swelling followed by diarrhoea.

Colonic Crohn's disease: This will cause symptoms very similar to ulcerative colitis with diarrhoea cramps and bleeding

Perianal crohns disease: This causes boils and abscesses in the perianal area. Some patients may develop a fistula where there is a discharge of mucous or blood to the skin

Crohn's disease of the stomach: This is much rarer and may present as an atypical form of indigestion.

This condition, in common with colitis, appears to be an abnormal reaction from the body's immune system against the gut. While there may be a contribution from our genes to this, the exact triggers for the condition are not known. In some families this condition is more common which raises the possibility of a genetic link.

Investigations and Diagnosis

A series of blood and stool tests will be needed in order to exclude other conditions that can give rise to similar symptoms.

The most important test, especially when rectal bleeding and diarrhoea is involved is an endoscopic examination of the colon. During the endoscopy a biopsy can be taken of the small intestine. Crohn's disease can also involve X-ray investigation. Ultrasound, MRI, and CT scans can aid diagnosis too.

Treatment

Treatment options will depend on the symptoms and where the gut is affected. If the inflammation is limited to the lower part of the colon this could be treated with suppositories or enemas. Usually patients will need medication which not only treats the inflammation but reduces the risk of recurrence.

For more serious symptoms you will be required a short course of steroid tablets which can have fast results. Side effects such as loss of bone density, which can occur with long term use, are reduced by keeping courses short, and giving supplements of calcium and vitamin D.

Steroids are not used as a long term treatment. For our patients who have a good response but whose symptoms return when the steroids are stopped there are other medications that are effective. The main treatment is with azathioprine. This has been used for many years and much is known about its safety and side effects.

Antibiotics are used where there is active inflammation and infection. These are usually used for short periods.

When none of these treatments give good control of symptoms, some of the newer ‘biologic treatments' are used. These are antibodies that are used to target specific sites in the immune system that are active in Crohn's disease. They can be very effective and have made a very significant difference to treating more complicated Crohn's disease. They are new treatments and all new treatments are undergoing a continuing process of evaluation regarding their safety, side effects and situations where they are best used.

For people with severe conditions, hospital admission may be required for treatment with intravenous steroids. Sometimes this and more potent drugs don't bring the condition under control and surgery may be necessary.

The Risk of Bowel Cancer

This is relevant to those patients who have predominant inflammation in the colon. The long term increase in risk is related to the extent of the inflammation, the amount of time that the condition has been present (decades) and the adequacy of control of the inflammation. Those who have very limited inflammation of just the lower part of the colon are not at a significantly increased risk. When the inflammation involves the entire colon, the disease has been active for more than 10 years and the inflammation has been difficult to control, this is when the risk of developing pre-cancerous changes is increased.

Good control of symptoms is very important. There is increasing evidence that taking regular asacol can not only reduce the frequency of relapses but also reduces the risk of precancerous changes. If you have extensive colitis your specialist may recommend 2 yearly colonoscopy after the condition has been present for 8 -10 years.

Fertility and Crohn's Disease
If well controlled the condition should not affect fertility and pregnancy. Most of the medications that are necessary to control this condition can continue to be used in pregnancy if your specialist feels this is necessary. Some medications may need to be discontinued. Men should not take azathioprine when trying to conceive.

Constipation

Constipation in adults is common, often causing pain in the lower abdomen and more trips to the lavatory than normal.

The causes include the following:

  • Eating too little fibre. Most people do not eat enough food containing fibre such as fruit, vegetables, and cereals
  • Drinking too little
  • Low fibre slimming diets
  • Some medicines can cause constipation, including pain killers containing codeine, some antacids, and iron tablets
  • Some medical conditions including: underactive thyroid, irritable bowel syndrome (IBS)
  • Pregnancy
  • Emotional upset
  • Unknown causes, known as "idiopathic", most common in women.

The treatment of constipation is simple and dietary changes are frequently advised.

No tests are required unless symptoms such as bleeding, weight loss, bouts of diarrhoea or symptoms are severe and recurring.

 

Ulcerative colitis

Ulcerative colitis is a condition that causes inflammation of the colon. It begins in the lower part of the colon and can spread all the way around the large bowel to the point where the large and small intestine joins. Symptoms include blood and diarrhoea with cramp pain.

The condition usually develops in both men and women and in patients between 20 and 40 years of age. There is usually no apparent reason why the condition develops when it does.

The most important test will be a direct examination of the colon. This will involve a colonoscopy or perhaps initially a colonoscopy (see link to endoscopic procedures). This not only allows the exclusion of other diseases but confirmation of the presence of colitis with biopsy.

Diagnosis


The tests for ulcerative colitis will involve blood tests and a stool examination for infection in order to exclude other conditions that could give similar symptoms.

Colitis appears to be a condition caused by the immune system which targets its inflammatory cells against the colon. The reason for this is unknown but theories include an abnormal response to the bacteria in the colon. Diet is not a factor in causing this condition.

Treatment


The type and level of treatment will depend on the symptoms and how much of the colon is inflamed. If the inflammation is limited to the lower part of the colon this could be treated with suppositories or enemas. Usually patients will need a medicine which not only treats the inflammation but reduces the risk of recurrence.

Patients with more serious symptoms are given a short course of steroid tablets which usually have a fast result. There can be side effects such as a loss of bone density but the risk is reduced by keeping courses short, supplementing calcium and vitamin D and using other medications when necessary that allow the steroids to be stopped.

It is possible to heal all the changes caused by colitis and return the lining of the colon to normal. Symptoms can also settle completely. Unfortunately there is no absolute medical cure so a return of symptoms and inflammation may occur at any time. The use of medication on a long term basis can reduce the frequency and severity of relapse in patients with colitis. The type of medication and the duration of treatment will depend on the severity of the initial problems.

In severe cases, some patients may need to be admitted to hospital and treated with intravenous steroids. Sometimes this and more potent drugs don’t bring the condition under control and surgery is necessary. This provides a cure for the condition. Whilst this cures the condition this does mean that a stoma is necessary for a period of months. Following this an artificial colon reservoir which is called a pouch can often be constructed restoring normal anatomy.

There is some risk of developing bowel cancer if a patient has severe symptoms over many years. But patients who have very limited inflammation of just the lower part of the colon are not at a significantly increased risk. When the inflammation has been involved the entire colon, the disease has been active for more than 10 years and the inflammation has been difficult to control, then the risk of developing pre cancerous changes is increased. Good control of symptoms is very important. There is increasing evidence that taking preventative medicines can not only reduce the frequency of relapses but will also reduce the risk of precancerous changes. If you have extensive colitis your specialist may recommend 2 yearly colonoscopy after the condition has been present for 8 -10 years.

There is a small chance that children may also develop the condition but this is low at about 6%.

Potential Affects on Fertility
If well controlled the condition should not affect fertility and pregnancy. Most of the medications that are necessary to control this condition can continue to be used in pregnancy if your specialist feels this is necessary. Some medications may need to be discontinued. Men should not take azathioprine when trying to conceive.

Achalasia

Achalasia is the condition where the muscle that controls the opening between the oesophagus and the stomach does not relax properly. This in turn leads to a build up of food in the oesophagus and stops it entering the stomach.

Damaged nerves in the gullet wall causes achalasia. Why the nerve becomes damaged is unknown, but it is thought that a viral infection might be to blame.

The symptoms of Achalasia can start at any time of life and usually come on gradually. Most people have difficulty, and find it painful to swallow their food (this is called dysphagia). Food may be regurgitated or vomited shortly after meals. The "vomit" may sometimes contain recognisable food eaten a long time previously, showing that it was held in the oesophagus for some hours.

Diagnostic Investigations

There are three main diagnostic tests:

  • Barium Meal and X-Ray: This involves swallowing a white liquid containing barium which allows the oesophagus to be seen clearly on an X-ray. In achalasia, the exit at the lower end of the bullet does not open properly and, together with a lack of the progressive contractions which force food down the gullet, delays the barium passing into the stomach. A chest X-ray will show whether the bullet is widened abnormally.
  • Endoscopic Diagnosis: A flexible tube with a camera on the end, called an endoscope, is used to look at the lining of the oesophagus and the stomach. Any food that hasn't entered the stomach can be seen. The doctor can also inspect the lining of the stomach to look for abnormalities.
  • Manometry Test: This test measures pressure waves in the oesophagus. A small plastic tube is passed into the gullet and pressure at different positions in the gullet is measured. In achalasia there are usually weak contractions of the upper gullet and sustained high pressure of the valve at the lower end of the gullet. It is this high pressure and the failure of the valve to relax in response to swallowing that causes food to remain in the lower oesophagus.

Treatment for Achalasia

The aim of treatment is to relax the valve at the base of the oesophagus so that food can pass easily into the stomach. The underlying causes of the condition cannot be cured, but there are various ways in which the symptoms can be improved. These include the following:

Drugs: The valve at the lower end of the gullet may be temporarily relaxed by drugs.

Stretching the Valve: This can be carried out after the patient takes a sedative, or under general anaesthetic. A small balloon (30mm; 1 ½ inches) is used to stretch the muscle fibres of the valve at the lower end of the gullet. This usually improves swallowing, but the process may need to be repeated after one or more years.

Botulinum Toxin ("Botox") Injection: This substance causes muscle fibres to relax. It can be injected painlessly into the valve through an endoscope. This is usually effective for a few months, sometimes for a few years, but this procedure normally has to be repeated. It is not a permanent treatment, but is useful for patients who are unable to have surgery.

Surgery: Under general anaesthetic, the muscle fibres that fail to relax are cut but and this results in a permanent improvement in swallowing. The operation is now often performed by key-hole surgery.

How you can reduce symptoms after treatment

You should always chew your food well. It is best to eat sitting upright and to drink fizzy drinks to ensure that the gullet is kept clear. Using several pillows or raising the head of the bed on wooden supports so that you sleep fairly upright can also be helpful. After dilation or surgery, acid may be able to rise from the stomach into the oesophagus through the weakened valve, causing heartburn. If heartburn develops after treatment it is important to consult your doctor who can give you medication. Any recurrence of swallowing difficulties or weight loss should be reported to your doctor. You may have some chest pain after treatment. This may be difficult to cure, but a drink of cold water often helps to reduce the pain.

Achalasia is not an inherited illness. Women with achalasia can have a normal pregnancy and their children will develop normally.

The risk of cancer for those people suffering from achalasia is slightly increased, so it is important to have treatment although the symptoms may not be severe.

Barrett's Oesophagus

The condition called Barrett's Oesophagus is damage to the oesophagus caused by acid reflux. The oesophagus carries food to the stomach and is lined by cells similar to those that form the skin. In Barrett's Oesophagus the lining at the lower end of the gullet changes from being skin-like to being like the lining of the stomach. Over a long period of time a small number of people with the condition (about 1 in 100) may develop a cancer of the oesophagus.

The Causes of Barrett's Oesophagus

The cause is believed to be linked to the 'reflux' of the acidic digestive juices from the stomach up into the gullet. Unlike the stomach, the oesophagus does not have a protective lining, so when it is repeatedly exposed to acid it may become inflamed and painful. Sometimes contents from the duodenum (the first part of the intestine after the stomach), particularly bile, may also reflux into the oesophagus and this mixture can be even more damaging than acid alone. The oesophagus usually heals with time and the lining returns to normal, but sometimes, if bile is present, the lining changes to appear more like the lining of the stomach or small intestine. The condition appears to be more common in men, and people who are overweight. Smoking can accelerate changes to Barrett's Oesophagus.

Symptoms

Most people diagnosed with Barrett's Oesophagus will have been examined because of symptoms associated with gastro-oesophageal reflux, which causes heartburn. Other symptoms may include a salty taste at the back of the mouth (sometimes called water brash), hoarseness due to acid damaging the vocal cords and chest pain. Barrett's Oesophagus can lead to complications such as ulcers in the gullet, bleeding, difficulty in swallowing due to a narrowing of the gullet, and occasionally cancer. The majority of people who have Barrett's Oesophagus have no serious, long term problems.

Diagnosis

An endoscopic examination using a thin flexible telescope passed through the mouth, into the gullet and on into the stomach is the common way of diagnosing the condition. A small biopsy sample is usually taken for examination. This will confirm the diagnosis and also highlight any complications.

Treatment

Three forms of treatment are available for Barrett's Oesophagus:

  • Medical Treatment Using Drugs
  • Medical treatment may be used to suppress the production of acid in the stomach and therefore reduce the amount of acid available to reflux into the oesophagus.
  • Laser or By Heat Energy: The abnormal lining may be destroyed by laser or by heat energy. This is done using an endoscope and it encourages the normal lining of the oesophagus to grow again.

Surgical Operation – Keyhole Surgery

The weakened valve at the lower end of the oesophagus, which allows reflux to occur, can be strengthened by an operation. Keyhole surgery is used. A small incision is made and a small camera is passed into the abdomen to let your surgeon view the affected area. Your surgeon will wrap the upper few centimetres of the stomach around the oesophagus to make a new valve. This prevents acid reflux and heartburn recurring. Permanent stitches are used to keep the stomach in place.

How to Help Prevent Acid Reflux

There are a number of ways that patients can prevent acid reflux, including the following:

  • Losing weight, if necessary;
  • Eating smaller meals and at regular intervals; Allowing time for food to be digested before going to bed; Avoiding tight clothes and bending down after meals;
  • Giving up smoking

Endoscopy

Endoscopy DiagramGastro-intestinal endoscopy is the process by which a doctor can look inside the upper part of your digestive system - your oesophagus (gullet), stomach and small intestine (bowel) by passing a tiny camera on the end of a very narrow and flexible tube called an endoscope. The tube is thinner than an index finger.

Endoscopy is used to investigate symptoms such as indigestion, heartburn, upper abdominal pains, difficulties in swallowing or to exclude other abnormalities. This provides a clear diagnosis.

There are other methods of examining the stomach, such as a barium meal, or a CT scan. Although gastro-intestinal endoscopy is less pleasant than a barium meal, it does allow biopsies and photographs to be taken. If you wish, please discuss with your doctor which is the best test for you.

Questions You May Have About Endoscopy

What preparation will I need?

The procedure must be performed on an empty stomach, so you cannot eat or drink for six hours before the test.

What should I bring on the day?

Please bring a list of your medication, and insurance details.

What about taking my medications?

If you are taking anti-inflammatory tablets (such as neurofen, brufen or voltarol) please stop taking them 5 days before your test.

Do not stop taking aspirin, clopidogrel or warfarin but please make sure that you have discussed this with your referring doctor before the test. There is a significant risk that a coronary stent will block if these medicines are stopped within one month of stent placement; and a slightly increased risk within the first six months. If the referring doctor thinks it is in your best interests to stop taking them, they should be stopped 10 days before the gastro-intestinal endoscopy.

If you are a diabetic, please let the unit know. We will give you more detailed information about your preparation.

What will happen to me on the day of the test?

Please book in with the endoscopy reception staff when you arrive. They will check a few of your personal details, such as your name and address. We try to ensure that all our patients are seen and have their tests within a short period of time of arriving in the unit, occasionally emergencies take precedence and you may need to wait longer than usual. The reception staff will keep you informed in the event that this happens.

One of the endoscopy nurses then sees you and asks you some further questions. Before you undergo the test, the doctor (endoscopist) who will be doing the procedure talks you through the consent form and the potential complications. It is important for you to think about these in advance so when you sign the form agreeing to the test you are comfortable that it is a test you really want. Remember, you can change your mind about having the procedure at any time. Please tell the doctor if you have heart valve disease or if you normally are given antibiotics when you visit the dentist.

The endoscopy is usually quick and often takes no more than 5 minutes to complete. It can be performed with a sedative injection administered through a drip in your arm. This will make you drowsy during the procedure and for up to sixty minutes afterwards. This is not a general anaesthetic. Alternatively, a local anaesthetic can be sprayed on to the back of your throat to make it numb. You are awake during the procedure but you will be able to leave the department as soon as the test is completed.

A plastic mouthpiece is placed between your teeth to keep your mouth slightly open. When the endoscopist gently passes the endoscope through your mouth you may gag slightly - this is quite normal and will not interfere with your breathing. The endoscope is thinner than an index finger.

During the procedure, air is put in to your stomach so that the endoscopist can have a clear view. This may make you burp a little. Some people find this uncomfortable. The air is removed at the end of the test. When the procedure is finished the endoscope is removed quickly and easily. Minimal restraint may be appropriate during the procedure. However if you make it clear that you are too uncomfortable the procedure will be stopped. During the test the doctor may take biopsies (tissue samples) and photographs of your bowel, even if it all looks normal. This does not hurt. In addition, it may be necessary to use thermal coagulation to remove small polyps or abnormal blood vessels; this is relatively safe. A nurse is present throughout the procedure to look after you.

What are the complications of gastro-intestinal endoscopy?

Complications are rare, but it is important that you know all the risks before you decide to go ahead with the test.

  • Minor complications: Despite sedation and pain killers some patients can experience abdominal discomfort or pain.
  • Major complications: There is a very small risk of bleeding, or of making a hole (perforation) in the intestine, which may require surgery. The risk of this happening is about 1 in 10,000. Other rare complications include aspiration pneumonia, damage to loose teeth or to dental bridgework.

Using sedation can cause breathing complications in up to 1 in 200 procedures, which usually are not serious. To reduce this risk, we monitor your pulse and oxygen levels at all times throughout the test.

If you have severe pain, black tarry stools or persistent bleeding, you should contact your nearest A&E Department for further advice and also inform your consultant through the endoscopy unit staff, or, if after hours, the hospital switchboard – 0207 586 5959.

What happens after the test?

If you choose to have sedation, you will be moved to the recovery area where nursing staff will monitor your condition for 1-2 hours. If you received local anaesthetic to your throat, you can leave the department immediately but will have to wait approximately half an hour before eating or drinking. You may experience a sore throat and may feel bloated due to air in your stomach. Both sensations are normal and will clear up quickly by themselves.

If you are going home the same day you must arrange for someone to escort you home as you may have been given a sedative. Be aware that parking at the hospital is very limited. If no escort is available, please bring enough money to pay for a taxi.

We strongly advise that you do not drink alcohol, operate machinery, drive or make important decisions for 24 hours after your procedure as sedatives can impair your judgment.

You can resume normal activities, work etc the following day.

How will I get the results?

The endoscopist will be able to tell you the results after the procedure. If you had sedation, it is a good idea to have someone with you when this occurs because the sedation can make you forget what is discussed. If biopsies were taken, you will be told the final diagnosis by you consultant at a follow-up appointment. Copies of your gastro-intestinal endoscopy report will be sent to your GP.

Any other questions?

Feel free to write down any other questions you may have. No question is ever too minor or too silly to ask, so please feel free to ask any member of the team caring for you if there is anything you wish to know.

If you have any problem understanding or reading any of this information, please contact the endoscopy team 0207 483 5164 or 5167.

Gallstones

The gallbladder is a small sac lying on the underside of the liver. Bile (also called gall) is a greenish-brown liquid produced by the liver. It is stored and concentrated in the gall bladder and passed into the small intestine through the bile ducts to help with digestion, mainly of fats.

Gallstones are hard pieces of stone-like material, round, oval, or faceted, commonly occurring in the gallbladder or the bile duct. Most gallstones are about the size of a pea, but in some cases there can be many very small stones, like fine gravel, or a single stone so large that it completely fills the gallbladder.

Gallstones cause symptoms in fewer than 20% of the people who have them. However, their presence may lead to the gallbladder becoming inflamed (cholecystitis), causing pain below the ribs on the right side. The pain may also be felt in the back and the right shoulder and patients may have fever, nausea and vomiting.

Gallstones may also block the bile duct, leading to obstructive jaundice. This causes yellowing of the skin and the whites of the eyes, darkening of the urine and pale clay coloured stools.

The passage of a gallstone down the bile duct into the duodenum is very painful, and is known as biliary colic. The pain is felt in the upper part of the abdomen, in the centre or a little to the right, and usually occurs about an hour after a meal, especially if the fat content has been high.

The Causes of Gallstones

Bile is a mixture of different chemicals. When the bile can no longer hold these chemicals in a liquid solution, gallstones start to form. Most gallstones are made up of cholesterol, chalk (calcium carbonate), calcium bilirubinate, or a mixture of these. They are more likely to occur if the composition of the bile is abnormal, if the outlet from the gallbladder is blocked or has a local infection, or if there is a family history of gallstones. The liver produces bile that is saturated with dissolved substances and has an excess of cholesterol in it. This may be caused by a relative reduction in bile salts.

Excessive cholesterol may be due to factors such as:

  • A high cholesterol diet
  • Advancing age
  • Excessive refined dietary carbohydrates such as white bread, cakes, and low-fibre cereals
  • The use of oral contraceptives
  • A genetic disorder featuring excessive cholesterol in the blood (hypercholesterolaemia)
  • Liver disease that reduces the levels of bile salts

Diagnosis

Your doctor would probably arrange for you to have some blood tests to look for signs of inflammation or jaundice. The best test for gallstones is an ultrasound scan. This is a very easy scan to have, as a little probe is moved over the upper abdomen in the region of the liver and gall bladder, and usually it is very easy to pick out gallstones on the screen. If the ultrasound scan does not give a clear result then other tests may be needed.

Treatment – Keyhole Surgery

Changes in diet have no effect on gallstones, but it is advisable to eat a well balanced healthy diet, and to control your weight.

Gallstones can be treated by surgical removal of the gallbladder (cholecystectomy) using Laparoscopic (keyhole) surgery also known as Minimally Invasive Surgery (due to the small incision). There is no question that, for most people, surgery is currently the best option for treating gallstones. Gall stones have to be physically removed with the gall bladder in order to get rid of them.

 

Gastroesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) occurs when there is a reflux of gastroduodenal contents into the oesophagus, causing symptoms that are sufficient to interfere with quality of life. People with GORD often have symptoms of heartburn and acid regurgitation.

This is a common condition with 20–25% of the population experiencing symptoms of GORD, and 7% have heartburn daily.

Obesity, smoking, and alcohol are all linked to the incidence of GORD. It is also said that some foods, such as coffee, mints, dietary fat, onions, citrus fruits, or tomatoes, may cause GORD. Drugs that relax the lower oesophageal valve, such as calcium channel blockers, may also cause GORD and it is a condition which can 'run in the family'.

Symptoms of GORD

The main symptom of GORD is heartburn. Heartburn often happens after a meal when your stomach is full, or when you lie down, which allows acid to flow upwards more easily. Heartburn is more common if you are a smoker, overweight or pregnant.

Other symptoms of GORD can include:

  • an acidic or sour taste in your mouth
  • burning pain in your throat
  • bloating and belching
  • stomach pains
  • burning pain in your throat and oesophagus when you swallow hot drinks
  • regurgitating food (when food comes out of your stomach and back up your oesophagus)
  • nausea and vomiting, and vomiting blood.

The Diagnosis of GORD

Endoscopic Examination – This is the most common test. A thin tube with a microscope on the end is passed down your oesophagus towards your stomach. It enables doctors to see whether the inside of your oesophagus is red and inflamed,
Acidity test on the inside of the oesophagus – the test is performed for a 24-hour period and involves a thin wire being passed through your nose and into your oesophagus. The wire measures how acidic your oesophagus is and displays the results electronically,
Barium swallow – a white liquid containing barium, which shows up white on an X-ray, is swallowed to enable doctors to identify any abnormalities in your oesophagus,

Radiolabelled technetium – in some hospitals radioisotope imaging may be used to demonstrate gastro-oesophageal reflux. The technique uses very small doses of technetium-sulphur colloid to help confirm a diagnosis.

The Treatment of GORD

GORD is a chronic condition, with about 80% of people relapsing once medication is discontinued. Many people therefore require long term medical treatment or surgery.

Medical Treatment

Proton Pump Inhibitors – Proton Pump Inhibitors (PPIs) reduce the amount of acid produced by your stomach, and are usually the first treatment for GORD.
H2 receptor antagonists – H2 receptor antagonists also reduce the amount of acid produced by your stomach. However, PPIs tend to be used more commonly to treat this condition.
Motility stimulants – These medicines speed up the rate at which your stomach empties. They also improve the squeezing of the valve muscle, to help stop stomach contents being brought back up into your oesophagus. Motility stimulants are normally used as an additional treatment to reduce symptoms such as bloating and a feeling of fullness soon after you start a meal.
Alginates and Antacids – Alginates and antacids are usually available without a prescription and are best taken when symptoms occur, such as after meals and at bedtime.
Surgical Treatment
If medicines do not help to control the symptoms of GORD, surgery may have to be considered. The operation is called ‘Fundoplication'. The aim of surgery is to make it harder for stomach contents to re-enter your oesophagus so that there is less reflux.

A number of different surgical procedures are available. You should discuss the alternatives with your specialist so that you are fully aware of what is required and understand the pros and cons of each procedure. The two main types of procedure are:

Open anti-reflux surgery – where a large incision is made to allow the surgeon to gain access to your oesophagus,
Keyhole surgery – for this procedure, a small incision is made and a small camera (telescope) is passed down your oesophagus to let the surgeon view the affected area.
Where there is a hiatus hernia, the surgeon will bring the stomach back into its original position under the diaphragm, then wrap the upper few centimetres of the stomach around the oesophagus to make a new valve. This prevents acid reflux and heartburn recurring. Permanent stitches are used to keep the stomach in place.

What Patients Can Do to Prevent GORD
There are some lifestyle changes you can make to help prevent GORD developing, or stop simple heartburn turning into GORD. These include:

Stop smoking
Avoiding foods that you find bring on heartburn,
Eating smaller, regular meals,
Changing your medication if you think it could be causing symptoms. Make sure you speak to your GP before stopping or starting any medication,
If you are overweight try losing weight, to reduce pressure on your stomach
Avoid altering your posture – don't wear tight belts and waistbands, and try not to leaning forward a lot during the day, and
If you have symptoms at night, try not eating three hours before going to bed, and not drinking two hours before. If you must have a drink, sip water or milky drinks, and avoid caffeine.

Pancreatitis

The pancreas is a large and important gland which helps to digest food and produces insulin, the main chemical for balancing the sugar level in the blood.

The pancreas is a solid gland about 10 inches (25cm) long behind the stomach and is shaped like a tadpole. Its head is just to the right of the mid-line and its body and tail point upwards at an angle so that the tail is situated just beneath the extreme edge of the left side of the ribs. The head is closely attached to the first part of the small intestine (duodenum), into which the stomach empties food and liquid, already partially digested. It is to this partially digested food that the pancreas adds its digestive enzymes.

The tube draining the liver of its bile (the bile duct) lies just behind the head of the pancreas and usually joins the bowel at the same place where the fluids from the pancreas enter the bowel.

Food consists of carbohydrates (e.g. starch), proteins (e.g. meat), and fat (e.g. butter), and digestion is not possible without the enzymes produced by the pancreas.

The pancreas makes a number of different enzymes each of which is responsible for breaking down the different types of food into small particles that can be absorbed. The enzymes are made in small glands within the pancreas and travel along increasingly large tubes until finally they reach the main pancreatic tube. This connects the gland to the first part of the bowel where food passes after it has gone through the stomach.

The enzymes are not active when they are first made within the pancreas (otherwise they would digest the pancreas as well) but when they pass into the bowel they are activated by the juices in the bowel. The main enzymes are called amylase (which digests carbohydrates), trypsin (which digests protein) and lipase (which digests fats). The bile which comes from the liver is also very important for the digestion of fat because it acts like a soap and breaks up the fat into minute droplets so that the pancreatic lipase can digest it.

Insulin and Glucose
All the body's cells use glucose (sugar) as an energy source. The level of sugar in the blood is kept constant by insulin, which is made by special cells in the pancreas. If the cells are not working properly and insulin is lacking then diabetes develops.

What is Pancreatitis?


Pancreatitis is inflammation of the pancreas and can be a very unpleasant and serious illness. There are two forms of it - the acute form which may be severe and life threatening with complications; and much less commonly, the chronic form which can cause continuing and severe pain and poor function of the pancreas, affecting digestion and causing weight loss.

Approximately 10,000 cases of acute pancreatitis occur in the United Kingdom every year. It occurs when the pancreas suddenly becomes inflamed and the two most common causes for it are drinking too much alcohol (alcohol induced pancreatitis) or gallstones within the bile tubes (gallstone pancreatitis). The symptoms of acute pancreatitis are severe upper abdominal pain and vomiting. The pain may be felt in the back and the patient feels very unwell. Fortunately, three out of four cases of pancreatitis cure themselves without any specific treatment.

It is best to rest the pancreas by not allowing the patient to eat anything until it has settled. However, one person in four will have a very bad attack (severe acute pancreatitis) which may require a prolonged stay in the intensive care unit and operations to remove parts of the gland that have been destroyed by the attack. Although excessive drinking of alcohol or gallstones are commonly identified causes of acute pancreatitis (two thirds of all cases), your doctor will want to do various tests when you have recovered from the attack to make sure that the diagnosis is definite and that you are unlikely to get another one.

The pancreas can return to normal after pancreatitis. Even if the pancreas has been inflamed and becomes scarred it will continue to work normally because there is so much more pancreatic tissue than we need. However, in some people the inflammation may continue and produce a condition called chronic pancreatitis.

Chronic Pancreatitis is a condition in which the pancreas is severely diseased and its function is impaired. It usually follows many years of alcohol abuse. Patients with chronic pancreatitis have pain, mal-absorption of food, leading to weight loss or diabetes. The condition is often painful and special treatment for the pain may be required. Eventually it may ‘burn out' leaving the sufferer pain free but requiring treatment for loss of pancreatic function.

Diagnosis

After your doctor has talked to you and made a physical examination he or she may wish to do some blood tests and special X-rays. A check on the level of amylase in the blood is a very helpful test for inflammation of the pancreas. Sometimes it may be necessary to check the motions to see whether there is an excess quantity of fat present, indicating that the pancreas is not producing its normal enzymes. A very useful test is an ultrasound scan which is a relatively simple and painless way of obtaining a ‘picture' of the pancreas gland. The pictures are made by using sound waves, which bounce off solid organs and can be recorded on a scanner (a sort of radar). In addition there are two further diagnostic procedures:

CT Scan

This is a type of X-ray in which the patient lies on a couch and moves through a large ‘doughnut' which carries out the X-ray as the patient moves through. This shows excellent pictures of the pancreas, which may be helped by drinking some liquid to outline the intestines around it.

ERCP (Endoscopic retrograde cholangiopancreatography)
This is a special investigation using a flexible telescope (endoscope) passed through the mouth and stomach so that it lies opposite the opening of the pancreas in the bowel. You are usually given heavy sedation for this test.

Once the endoscope is in the correct position, a tiny plastic tube is passed into the pancreas opening and some x-ray liquid is injected to outline the pancreatic tubes, after which X-ray pictures are taken. This procedure is very useful, since pictures of the inside of the pancreas can be obtained and also treatments can be given via the endoscope. For example, narrowing of the bile or pancreatic tubes can be widened and, most importantly, stones in the bile tubes can be removed. Although inflammation can occur after this examination, this is generally a safe procedure.

Treatments for a Failing Pancreas

There are many pancreatic enzyme preparations available and some are more effective than others. How much of the enzyme replacement you require will be determined by your doctor but sometimes up to 20-30 capsules every day are required. You may also need to take a tablet to reduce the level of acid in the stomach so that the pancreatic enzyme supplements can work better. The capsules are often taken with meals or snacks.

If you are diabetic because your pancreas does not work you will need insulin and this has to be given by injection. All diabetics who require insulin quickly learn how to inject themselves once or more daily. You will be under the care of a specialist team for this problem.

The pancreas is a very important gland and fortunately diseases that affect it are relatively rare compared with other digestive diseases.

Bowel Cancer

Bowel cancer is common in the UK with around 30,000 cases being diagnosed every year. It affects men and women equally and as always, early diagnosis is very important, giving a far greater chance of a cure. Most bowel cancers begin from pre-cancerous polyps, but in some cases the disease may be inherited.

Symptoms

The symptoms vary from no symptoms at all, to rectal bleeding, a change in bowel habits, weight loss, or anaemia. On occasions, a GP may detect an abdominal swelling.

Diagnosis

Diagnosis is almost always carried out with a colonoscopy using an endoscope which allows a consultant to see the entire length of the colon. Following the identification of a cancer, the consultant will arrange a CT or MRI scan to check whether the cancer has spread to other parts of the patient's body. When the results of all these tests are obtained, a multi-disciplinary team with often include a gastroenterologist, a surgeon, and an oncologist, will meet to decide on the best form of treatment.

Treatment

The most effective treatment for bowel cancer is the surgical removal of the affected part of the bowel. If the disease has spread, then chemotherapy and radio therapy may be used. Sometimes chemotherapy can be used to shrink a localised tumour before surgery to give a better chance of removing all of the affected tissue. If the cancer has spread to the liver or lungs, further surgery by relevant specialists may be needed. If the cancer is not treatable then the patient will be referred to the palliative care team.

Cancer of the Oesophagus

The oesophagus, or gullet, is a long, muscular tube that connects your throat to your stomach. It is at least 12 inches (30cm) long in adults. When you swallow food it is carried down the oesophagus to the stomach, and the walls of the oesophagus contract to move the food down. A tumour can occur anywhere along the length of the oesophagus.

Cancer of the oesophagus is becoming more common in Europe and North America with men affected more than women. It occurs generally in older people. The cause is unknown but one type of oesophageal cancer, known as adenocarcinoma, appears to be more common in people who have long-term acid reflux, which is the backflow of stomach acid into the oesophagus. Damage to the oesophagus caused by acid reflux is known as Barrett's oesophagus. Over a long period of time a small number of people with this condition, approximately 1 in 100, may develop a cancer of the oesophagus.

Another type of oesophageal cancer called squamous carcinoma is more common among smokers and people who drink a lot of alcohol, especially spirits, or those who have a poor diet. Other conditions affecting the oesophagus, such as achalasia, may also very occasionally lead to cancer.

For the most part, cancer of the oesophagus is not caused by an inherited faulty gene.

Symptoms of cancer of the oesophagus

Oesophageal cancer may cause no symptoms until it begins to obstruct passage of food and fluids down the gullet, or to make swallowing difficult. Difficulty in swallowing is the most common symptom. Often, there is a feeling that food is sticking on its way down to the stomach, although liquids may be swallowed easily at first. There may also be some weight loss, and possibly some pain or discomfort behind the breastbone or in the back. There may be indigestion or a cough. Many of these symptoms can be caused by conditions other than cancer, but you should always tell your GP, particularly if they do not go away after a couple of weeks.

Diagnosis

There are two main tests for diagnosing cancer of the oesophagus:

  • Endoscopy:Upper gastrointestinal endoscopy enables the consultant to look directly at the oesophagus using a thin flexible tube called an endoscope. The endoscope has a tiny camera and a light on the end. If necessary, the doctor can take a small sample of the cells (a biopsy) to be examined under a microscope. This can usually confirm whether or not there is a cancer.
  • Barium swallow and X-ray: A liquid barium solution is swallowed, which shows up on x-ray. The consultant can watch the barium as it flows down the oesophagus towards the stomach while at the same time x-ray pictures are taken of the oesophagus

Treatment

Cancer of the oesophagus can be treated using surgery, chemotherapy or radiotherapy. The choice of treatment will depend upon the exact type of oesophageal cancer, its stage of development, position and size, as well as age and general health. The treatments can be used alone or combined.

Other treatments may be used to ease any swallowing difficulties you may have. These include: intubation or stenting (inserting a tube into the oesophagus to keep it open), dilatation (stretching the oesophagus), laser treatment and photodynamic therapy.

Neuroendocrine (carcinoid) Tumours

Neuroendocrine tumours are relatively rare tumours however the incidence has increased over the last 20 years from approximately 2 per 100,000 to 4 per 100,000 per year. These tumours can be found anywhere in the body. They are classified according to their site of origin and whether they are functioning (hormone secreting) or non-functioning (non-hormone secreting). There are many types of neuroendocrine tumours including: medullary thyroid cancers, paragangliomas, phaeochromoctomas, bronchial carcinoids and the most common gastroenteropancreatic (GEP) tumours which encompass pancreatic islet cell tumours (e.g. insulinoma, gastrinoma, VIPoma, glucagonoma and non-functional tumours) as well as gastrointestinal carcinoid tumours originating in the foregut, midgut or hindgut.

For the optimal management of NETs, the following strategy is suggested:

(i) suspect the diagnosis

(ii) perform appropriate biochemistry profile including urine 24 hour 5 hydroxyindole acetic acid (5HIAA) and serum hormone including chomogranin A measurements

(iii) assessment of histopathology to confirm diagnosis and determine aggressiveness of the disease e.g. features of tumour differentiation, invasion and proliferation index

(iv) determine the presence of inherited disorder such as Multiple Endocrine Neoplasia type 1 (MEN-1) or the Von Hippel-Lindau syndrome

(v) determine the site and extent of disease using for example contrast CT or MRI, as well as the most sensitive modality the Indium-111 Octreotide scan

(vi) treat the symptoms or excessive hormonal state, usually involving somatatostatin analogue e.g. Octreotide or Lanreotide; (vii) treat the disease if possible with curative surgery otherwise consider surgical debulking. Non-surgical treatments of metastatic disease include: somatostatin analogues, interferon alpha, chemotherapy, hepatic artery embolization and radionuclide therapies such as I-131 MIBG and Yttrium-90 DOTA Octreotide; and (viii) all patients will require long term follow-up preferably within treatment protocols.

Pancreatic Cancer

Cancer of the pancreas is quite rare, developing in about 1 in 10,000 people each year in the UK. There are several types of pancreatic cancer, but the most common, more than 9 in 10 cases is called ductal adenocarcinoma.

Ductal adenocarcinoma of the pancreas develops from cancerous cells in the pancreatic duct. As the tumour grows it can block the bile duct or the main pancreatic duct. This stops the drainage of bile or pancreatic fluid into the duodenum.

The cancer then spreads deeper into the pancreas. It may even pass through the wall of the pancreas and affect nearby organs such as the duodenum, stomach or the liver.

In addition, some cells may break off into the lymph channels or bloodstream. The cancer may then spread to nearby lymph nodes or spread to other areas of the body (metastasise).

Symptoms

The pancreas is a large and important gland which helps to digest food and produces insulin, the main chemical for balancing the sugar level in the blood.

The pancreas is a solid gland about 10 inches (25cm) long behind the stomach and is shaped like a tadpole. Its head is just to the right of the mid-line and its body and tail point upwards at an angle so that the tail is situated just beneath the extreme edge of the left side of the ribs. The head is closely attached to the first part of the small intestine (duodenum), into which the stomach empties food and liquid, already partially digested. It is to this partially digested food that the pancreas adds its digestive enzymes.

The pancreas makes a number of different enzymes each of which is responsible for breaking down the different types of food into small particles that can be absorbed. The enzymes are made in small glands within the pancreas and travel along increasingly large tubes until finally they reach the main pancreatic tube. This connects the gland to the first part of the bowel where food passes after it has gone through the stomach.

In most cases, a tumour develops first in the head of the pancreas. A small tumour often causes no symptoms. As the tumour grows it tends to block the bile duct. This stops the flow of bile into the duodenum which leads to jaundice which makes a patient's skin turn yellow; turns urine a dark colour and turns faeces a pale colour. A patient may also experience generalised itching, caused by bile in the bloodstream.

As the cancer grows in the pancreas, further symptoms that may develop include:

  • Pain in the upper abdomen.
  • Pain in the middle of the back can also develop if the tumour spreads backwards.
  • General malaise and a loss of weight. These symptoms are often the first to develop if the cancer develops in the body or tail of the pancreas (when the bile duct is not blocked).
  • The patient may not digest food very well as the amount of pancreatic fluid will be reduced. This can cause smelly pale faeces, and weight loss.
  • Diabetes sometimes develops if nearly all the pancreas is damaged by the tumour.
  • A tumour can trigger also inflammation of the pancreas - 'acute pancreatitis' causing severe abdominal pain.

Diagnosis

If pancreatic cancer is suspected, a patient will be given blood tests and an ultrasound scan. This can be followed by a CT scan together with an Endoscopic Retrograde Cholargio Pancreatography (ERCP). ERCP uses an endoscope and X-rays to examine damage to the pancreas. The endoscope can also take a sample or biopsy to confirm the presence of cancer.

Treatment

Treatment options include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on a number of factors such as how large the cancer is, whether it has spread, and the general health of the patient.

Most cancers of the pancreas are advanced before they cause symptoms and are diagnosed. A cure is unlikely in most cases. However, treatment may slow down the progression of the cancer.

Rectal Cancer

Rectal cancers are common in the UK with a similar number of cases to cancer of the bowel.

Symptoms

The common symptoms of rectal cancer are bleeding combined with a change of bowel habits such as loose stools continuing for longer than six weeks together with the need to visit the toilet more frequently than normal. Rectal pain and sometimes constipation can also indicate a problem that needs early investigation.

Diagnosis

The diagnostic tests include blood and stool tests together with a sigmoidoscopy or colonoscopy carried out under local or general anaesthetic. The consultant will also take tissue samples for examination. If a cancer is discovered, then the consultant may request a CT or MRI scan to see if the cancer has spread.

Treatment

Once the size and particular stage of development of the cancer has been identified the patient may be given chemotherapy or radiotherapy to shrink the tumour before surgery.

Surgical techniques are now much more advanced than before with a far higher prevention of recurrent disease. There can still be some complications depending on the size of the tumour and complexity of the surgery.

Surgery can be followed by chemotherapy and/or radiotherapy.

Stomach Cancer

There are a number of different types of stomach cancer, each with different causes. Cancers may begin as a result of chronic inflammation, ulcers, large polyps or as a result of pernicious anaemia. Smoking or eating food with a high salt or high nitrite content are also associated with a higher incidence of stomach cancers but by and large, stomach cancer is not hereditary.

Symptoms

The earlier cancer is diagnosed, the better the chances of a cure and so recognising the symptoms and discussing this with your doctor right away is very important.

  • indigestion that does not go away
  • loss of appetite
  • difficulty in swallowing
  • loss of weight
  • feeling bloated after eating
  • feeling sick (nausea) or being sick (vomiting)
  • heartburn
  • blood in the stools or black stools
  • tiredness due to anaemia (from bleeding from the wall of the stomach)

Many of these can be caused by a number of illnesses other than cancer. Most people who see their GP with these symptoms will not have cancer. It is very important to have tests right away and to find the cause of the symptoms.

Diagnosis

Occasionally a lump can be felt in the abdomen, but other tests are always needed.

An endoscopy allows the doctor to see inside the stomach, and is the main diagnostic method. A camera is passed via the mouth and into the stomach under local anaesthetic. A small sample of tissue is taken for examination under a microscope (histology) and a test is taken for Helicobacter pylori, a bacterium which can infect the stomach and is thought to increase the risk of stomach cancer.

The second diagnostic tool is a CT scan, this is an X-Ray which takes 3D pictures of the chest, abdomen and pelvis areas. The scan allows a gastroenterologist to see whether a cancer has spread to other parts of the body.

Treatment

Once checks have been made that it has not spread anywhere else, most stomach cancers will be removed by surgery. Either a part of the stomach or the whole stomach is removed, with lymph glands that are close by. The stomach or gullet is then joined to the bowel. Once the cancer has been removed it is examined closely under the microscope to decide exactly what stage it is at.

If the cancer is at an early stage and has not spread through the stomach wall, then no further treatment may be necessary. If the cancer has spread through the wall, or involved lymph glands a patient may be offered further treatment such as chemotherapy, radiotherapy or a combination of both. Sometimes chemotherapy is given before surgery in order to shrink a tumour.

Obesity / Gastric Balloons

Gastric Balloon IllustrationManaging your weight is increasingly difficult with the pressures of modern society. Many of us have a weight problem and many of us find it impossible to manage our weight consistently despite the well known health dangers of being overweight.

Most people have heard of the surgical procedures now being used to restrict appetite and to bring bodyweight under control. But for many people the prospect of undergoing major surgery is not acceptable and now The Wellington can offer a new and increasingly popular non surgical alternative - the Intragastric Balloon Programme.

Our specialist endoscopy teams introduce a soft silicon balloon through the mouth and into the stomach and fill it with sterile saline solution. The procedure, carried out by a senior consultant, takes a matter of minutes and is assisted by a local anaesthetic to aid the passage of the balloon.

The balloon reduces the appetite by reducing the space for food and consequently leads to planned and consistent weight loss. During the time the balloon is in the patient's stomach, a course of medication may be needed to reduce the acid content in the stomach to preserve the balloon while its presence helps weight loss.

Our senior consultants work closely with our dieticians to help patients adjust their diet appropriately and to monitor the weight loss over a period of six months. After six months the balloon is removed and our consultants and dieticians review the patient's progress and discuss follow-up dietary and lifestyle regimes or other follow-up treatments.

This new method is internationally recognised as providing a successful non surgical method of bringing body weight under control and we have a full information pack explaining the expected results and all aspects of the treatment for those who would like to consider this option.

Gastric Banding

The Gastric Band operation is a type of weight loss surgery where the size of your stomach is reduced using an adjustable band so that you can only eat small meals.

Gastric banding involves placing an adjustable band around the top of the stomach creating a small egg sized stomach ‘pouch’, which restricts the food that can pass through into the bigger part of the stomach. If the ‘pouch’ is full and stretched, you feel full and don’t want to eat any more, however, if you try to ‘force’ eat, then you will be sick.

The size of the opening from the pouch determines how quickly food leaves your stomach and is adjusted by adding or removing fluid to/from the band. A thin tube connects the band to a ‘port’ that has been placed under the skin of your chest or below your ribs. To be effective, the band has to be tightened after 6 weeks under radiological control. It may have to be tightened or loosened later if required.

Changes

A strict diet will need to be followed together with some lifestyle changes in order to get the best results from this operation.

Complications

A Gastric band operation is commonly performed and generally safe, however, there is a 20% complication rate over the next 5 years. Sometimes the band may have to be removed if it slips out of place or leaks, which can occur in about 10% of people. Other problems are gastro-oesophageal reflux (heartburn) and band related problems. The required weight loss in not achieved in about 10% of patients who have a Gastric Band fitted and you surgeon may then recommend other alternatives. The exact risks are specific to every individual and the surgeon will explain how these apply to you.

Gastric Bypass

Gastric bypass diagramThe Gastric bypass procedure is the most common and standard weight loss surgery. This operation will make the stomach smaller and the digestive system (intestines) shorter, meaning that you absorb fewer calories when you eat.

Although there are a number of variations, one of the most commonly performed bypass procedures is called the Roux-en-Y gastric bypass. A small pouch, which only holds a few ounces, is created at the top of the stomach by stapling part of the stomach together – this limits how much food you eat. Then the small intestine (which carries food from the stomach) is cut and attached to the pouch to allow the food to bypass the duodenum, shortening the intestine and meaning that you have less time to absorb the food.

After the operation

Assuming that everything goes well, (and you have had a laparoscopic procedure) you will be discharged from hospital about 2 days after your surgery. It generally takes patients between two and four weeks to recover and resume normal activities.

Risks

As with any surgery, there are some risks associated with Gastric bypass procedures. This can include: internal or external hernias, or bleeding or leaking from the join between the stomach and intestine, although if you have had laparoscopic surgery the risk of external hernia complication is reduced. Not only does Gastric bypass result in reduced absorption of calories it may also reduce the absorption of important vitamins. So you will be required to take daily nutritional supplements to compensate for those that you will stop absorbing (ie vitamins, iron and calcium). You will also need to follow after-surgery guidance to ensure you maintain your diet and nutritional plans as this will reduce the risk of any problems occurring after surgery.

Benefits

For the seriously obese, the benefits of Gastric bypass surgery can outweigh the risks. The Gastric bypass operations allow greater weight loss with patients generally losing up to two-thirds (70%) of their excess weight within two years. There will also be major improvements to a whole range of weight-associated conditions including sleep apnoea, arthritis, joint pain, fatigue, shortness of breath plus most type II diabetics will be cured. There is no doubt that this surgery can be life-changing and life-saving, however, the decision to go ahead with surgery should always be discussed fully with your consultant. Further information and advice about this procedure will be made available to you at your consultations with our specialists.

Colonoscopy

ColonoscopyA colonoscopy is a test that allows the doctor to examine your large bowel with a fine flexible telescope. This test will review your bowel from the rectum to the cecum and the end of your small intestine called the terminal ileum. It is used to investigate some symptoms you have been having, such as a change in bowel habit, rectal bleeding; or to review a problem they may have found before, like polyps or colitis. This will benefit you by providing a clear diagnosis. If you prefer not to be investigated, we advise you to discuss the implications with your doctor.

There are other methods of examining the colon, such as a barium enema or a CT scan. Although colonoscopy is less likely to succeed than these methods (approximately 90 % vs. 98% success rate respectively), it does allow biopsies to be taken and procedures such as the removal of polyps to be performed. If the colonoscopy does not succeed, the doctor may recommend that you have a barium enema or CT scan so that a complete examination of the colon has occurred. If you wish, discuss with your doctor which is the best test for you.

Questions You May Have About Colonoscopy

When you book your appointment, the endoscopy staff will give you some preparation to take the day before your colonoscopy. The preparation may come in sachets or bottle form, and works as a powerful laxative to make your bowel completely clean. This allows the doctor to have a clear view of your bowel. We will give you instructions with the bowel preparation. You will not be allowed to eat any food for up to 24 hours before your procedure.

However you must drink lots of clear fluids, stopping 3 hours before the procedure. It is of great importance that this preparation works, or the test will not be possible.

What should I bring on the day?

Please bring a list of your medication, and insurance details.

What about my medications?

If you are taking iron tablets, please stop them 7 days before your test.

If you are taking anti-inflammatory tablets (such as Neurofen, Brufen or Voltarol) please stop taking them 5 days before your test.

Do not stop taking aspirin, clopidogrel or warfarin but please make sure that you have discussed this with your referring doctor before the test. There is a significant risk that a coronary stent will block if these medicines are stopped within one month of stent placement; and a slightly increased risk within the first six months. If the referring doctor thinks it is in your best interests to stop taking them, they should be stopped 10 days before the colonoscopy.

If you are a diabetic, please let the unit know. We will give you more detailed information about your preparation.

Women taking the oral contraceptive pill should be aware that taking bowel preparation might prevent the absorption of the pill. Additional contraceptive precautions should be taken until the next period begins.

What happens on the day of the test?

Please book in with the endoscopy reception staff when you arrive. Please do not have anything to drink for 3 hours before you arrive.They check your personal details, such as your name and address. We try to ensure that all patients are seen and have their tests within a short period of time of arriving in the unit, but occasionally emergencies take precedence and you may need to wait. The reception staff will keep you informed in the event that this happens.

Next, the doctor (endoscopist) who will be doing the procedure talks you through the consent form and the potential complications. It is important for you to think about these in advance so when you sign the form you are comfortable that it is a test you really want. Remember, you can change your mind about having the test at any time. Please tell the doctor if you have heart valve disease or if you are normally given antibiotics when you visit the dentist.

One of the endoscopy nurses then sees you, asks you some further questions, checks you have taken your preparation correctly and answers any questions you may have. Then the nurse asks you to get changed into a gown and you will be wheeled into the endoscopy room on a trolley.

The doctor or nurse puts a small needle into the back of your hand. This is to give you sedation and painkillers. These drugs are used together to reduce your discomfort and make you a little sleepy. This is not a general anaesthetic.

Once the medications have taken effect the doctor inserts a flexible tube (the endoscope) with a light on the end of it into your back passage. It is thinner than an index finger. Your bowel is inflated with air, and you may experience some bloating and discomfort. The tube is slowly moved along your colon whilst the doctor gets a good look at the wall of the bowel. The tube travels right around the colon to the cecum. The test can usually takes 20 – 30 minutes.

During the test the doctor may take biopsies (tissue samples) and photographs of your bowel, even if it all looks normal. There may be periods of discomfort as the tube goes around bends in the bowel. Usually these will ease once the bend has been passed. If you are finding the procedure more uncomfortable than you would like, please let the nurse know and you can be given some more sedative or painkiller. In order to make the procedure easier you may be asked to change position (for example, to roll onto your back).

There will be a nurse with you throughout the procedure explaining what is happening, monitoring your vital signs, level of comfort and assisting the doctor.

What happens if a polyp is found?

One of the aims of colonoscopy is to detect polyps. Polyps are very small growths that can occur on the bowel wall. Some are perfectly innocent, but others can develop into bowel cancer if they are not removed. Consequently, polyps are removed, which most of the time is entirely safe. This is termed a polypectomy. In addition, sometimes thermal coagulation is used to destroy polyps or abnormal blood vessels.

What are the complications of colonoscopy?

Complications are rare, but it is important that you know all the risks before you decide to go ahead with the test.

Minor complications

Despite using sedation and pain killers some patients can experience abdominal discomfort or pain.

In approximately 1 in 10 patients the procedure is difficult and the doctor finds it impossible to look right around the bowel. If this happens the doctor may organise another test.

Major complications

There is a very small risk of making a hole in the bowel wall (a perforation). This occurs in approximately 1 in 800 examinations. Perforations usually need to be repaired with an operation, and might require a temporary stoma (a surgical constructed opening, that permits the passage of waste).
If the doctor removes a polyp, then the risk of perforation, though still rare, increases slightly to about 1 in 600 occasions.

Bleeding from the rectum occurs in about 1 in 1500 cases, although if a polyp is removed it occurs in between 1 in 50 and 1 in 100 cases. It usually stops without any treatment but can occasionally need an operation to repair the area.

Using sedation can cause breathing complications in 1 in 200 procedures, which usually are not serious. To reduce this risk, we monitor your pulse and oxygen levels throughout the test.

If you have severe pain, black tarry stools or persistent bleeding, you should contact your nearest A&E Department for further advice and also inform your consultant either through the endoscopy unit staff, or, if after hours, through the duty manager on 0207 586 5959.

What happens after the test?

You are moved into the recovery area where a nurse monitors you for 1-2 hours whilst you sleep off the sedation. You may then eat and drink normally. You may feel a little discomfort due to the air in your abdomen - this is normal.

If you are going home the same day you must arrange for someone to escort you home. Be aware that parking at the hospital is very limited. If no escort is available, please bring enough money to pay for a taxi.

We strongly advise that you do not drink alcohol, operate machinery, drive or make important decisions for 24 hours after your procedure as sedatives can impair your judgment.

You can resume normal activities, work etc the following day.

How will I get the results?

The endoscopist will be able to tell you the results after the procedure. If you had sedation, it is a good idea to have someone with you when this occurs because the sedation can make you forget what is discussed. If biopsies were taken or polyps removed, you will be told the final diagnosis by your consultant at a follow-up appointment. Copies of your colonoscopy report will be sent to your GP.

Any other questions?

Feel free to write down any other questions you may have. No question is ever too minor or too silly to ask, so please ask any member of the team caring for you if there is anything you wish to know.

If you have any problem understanding or reading any of this information, please contact the Endoscopy Unit team on 0207 483 5164 or 5167.

Endoscopic Ultrasound

Endoscopic UltrasoundOne of the latest tools that the gastroenterologist has at his or her disposal is endoscopic ultrasound. This equipment is used both in diagnosis and in treatment.

A miniature ultrasound transmitter or transducer is fitted at the tip of an endoscope and introduced into the oesophagus (with the patient under sedation) just as a normal endoscope. With the ultrasound switched on and depending on the type of ultrasound transducer fitted, the gastro enterologist can see, on a screen, ultrasound pictures of the organs surrounding the oesophagus and the stomach and even into and around the pancreas. Both 360 degree directional scans can be carried out.

If the doctor identifies an abnormality he or she can take a sample using a needle in the tip of the endoscope and send this sample off for further investigation. The location and size of any abnormality can be pictured and mapped and with the result of the biopsy, doctors can make more precise decision over treatment regimes. After a short period of recovery a patient can leave and treatment can begin within a day or two of the test results being obtained.

This procedure is often far faster and certainly less distressing to a patient than open surgery carried out to obtain the same samples and diagnosis. The equipment can also be used to treat some conditions affecting the pancreas.

Two case histories to illustrate the capabilities of Endoscopic Ultrasound at The Wellington Hospital by Dr Ray Shidrawi.

Case History No 1

A 73 year old man from Switzerland was diagnosed with cancer of the stomach and underwent a subtotal gastrectomy in October 2005. Recently, he developed symptoms of gastro-oesophageal acid reflux and weight loss. He underwent two gastroscopies in Geneva that were reported as normal. An abdominal CT was also reported as normal. At preliminary endoscopy at the Wellington, he had a large gastric residue suggestive of gastric outlet obstruction and a stricture of the gastro-jejunal anastomosis without evidence of mucosal recurrence. A radial EUS examination identified thickening of the peritoneum resulting in extrinsic compression at the anastomosis. Subsequent biopsy of this thickened area confirmed a local recurrence of his disease and he underwent enteral stenting to allow feeding. He is now undergoing chemotherapy, is managing a pureed/soft diet and is maintaining his weight.

Case History No 2

A 52-year-old man complained of paroxysmal severe vomiting for the past two years. He has been extensively investigated in the past, including laboratory investigations during an attack, two CT scans, 4 gastroscopies, abdominal ultrasound, abdominal MRI scan and had been seen by several specialists over this period. Notably, he underwent a cholecystectomy eight years ago. Radial EUS confirmed the presence of a small gallstone impacted at the distal end of an undilated common bile duct. He subsequently underwent therapeutic ERCP and endoscopic sphincterotomy to extract gallstone debris that had accumulated within his biliary tree since his cholecystectomy. He has not had any further severe vomiting since his ERCP carried out at The Wellington GI unit.

Capsule Endoscopy

Capsule Endoscopy to scaleThis involves ingesting a small capsule (the size of a large vitamin tablet) which will pass naturally through your digestive system, taking pictures of the intestine.

These images are transmitted to sensors attached to a data recorder held in a harness, which you will wear. The capsule is disposable and will be excreted naturally in your bowel movement.

Are there any risks?

Very occasionally the capsule can become stuck in the intestine (less than 1%) in which case it may need to be removed surgically. In about 80% of such cases an operation is required anyway. In certain patients (eg those with intestinal fistulas or strictures, those with Crohn’s disease or with prior abdominal/pelvic surgery), your consultant will organise an x-ray test (eg a barium follow-through) before the capsule endoscopy to see whether capsule retention is likely to occur. Capsule endoscopy is not usually performed in patients who are pregnant.

Medication

Please continue to take your regular medication as usual. However, if you are prescribed iron tablets (ferrous sulphate) or non steroidal anti-inflammatory drugs (such as Ibuprofen, Diclofenac, Celecoxib) please stop for two weeks prior to your appointment. Do not take calcium channel blockers, Gaviscon, Maxalon, Motilium, or Codeine on the day of the test (if in doubt, check first with your doctor). Please contact the department if you have any questions about this.

The day before Capsule Endoscopy

If your consultant would like you to take a preparation to clear your bowel:
Breakfast - Eat a light breakfast at about 8am (ie white toast, omelette, eggs, yoghurt)
Lunch – Have a light lunch about midday (ie white toast, omelette, eggs, yoghurt, pasta or fish, cheese or chicken)
After lunch on the day before the capsule endoscopy - start a clear liquid diet (that can include jelly, clear broth, apple juice, squash, carbonated drinks, water, dissolved Bovril and Oxo, boiled sweets, tea and coffee with a small amount of milk if required).
In the early evening - In the box you have been given or sent, you will find a pack of Moviprep, which includes sachets A and B. Dissolve both sachets in 1 litre of water and drink over 1 – 2 hours. Flavouring can be added to this. Thereafter, continue with clear liquids. Have nothing further to drink from 10pm.

If your consultant would not like you to take bowel preparation: Eat a light breakfast and lunch of the suggested foods from the list above, thereafter drink clear liquids only. Have nothing further to drink from 10pm.

Please note: Abstain from smoking 24 hours prior to undergoing the procedure. Male patients may need to shave their abdomen 15cm above and below the navel on the day of the procedure.

Day of the Procedure

  • Do not take any medication for 2 hours before undergoing the procedure.
  • Please dress in loose fitting, two piece clothing as you will be wearing a data recorder in a harness.

What happens when I come to the unit?

When you attend the unit, you will be registered at reception (please bring your insurance details and authorisation number with you) and then taken into the endoscopy unit by a nurse. You will be given the opportunity to ask any questions you may have. During this time you will be given 2 ml of Infacol™, a non-prescription medication usually given to babies to prevent the accumulation of wind. This is safe.

You will then be taken to a cubicle and adhesive sensor pads will be applied to your abdomen. These will be connected to a data recorder which you will wear in a belt around your waist.

You will then be asked to swallow the capsule.

After swallowing the capsule

Inside an endoscopy capsule Once you have swallowed the capsule do not go anywhere near any source of powerful electromagnetic fields such as an MRI or amateur radio for at least 8 hours. We suggest you do NOT take public transport during this time, or go to crowded public places.
Do not eat or drink for at least 2 hours. After 2 hours you may have clear fluids. After 4 hours you may have a light snack. Contact the endoscopy unit immediately if you suffer from any abdominal pain, nausea, or vomiting during this time.

A capsule endoscopy lasts approximately 8 hours. Do not disconnect the equipment or remove the belt at any time during this period.
Handle the equipment carefully. Avoid sudden movements and avoid banging the (blue) data recorder. Do not expose it to shock, vibration or direct sunlight as this may result in the loss of information.

During the capsule endoscopy you will need to verify every 15 minutes that the small light on top of the data recorder is blinking twice per second. If it stops blinking at this rate, record the time and contact the endoscopy department.
You should also record the time and nature of any event such as eating, drinking, and any unusual activity on the capsule endoscopy event form (see the end of this document).

Avoid any strenuous activity, especially if this involves sweating, and do not bend over or stoop during the eight hour period.

After completing the capsule endoscopy

You will be given a time to return to the endoscopy unit to return the equipment with your capsule endoscopy event form. This is usually approx 4:30pm.

You may commence a normal diet once the test is completed. The capsule is normally passed in your stool after 24 to 72 hours. It can be flushed down the drain safely.

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

ERCP diagramAn ERCP is a procedure which enables the doctor to examine the common bile duct and the pancreatic duct. The doctor passes a tiny camera on the end of a narrow and flexible tube called an endoscope (or "scope") through your mouth, stomach and into your small intestine (bowel). Then diagnostic and therapeutic procedures can be performed and tissue or biliary samples obtained to detect infection, obstruction or any other abnormality.

The ERCP allows the doctor to establish reasons for jaundice (yellow skin), abnormal liver function, gallstones, biliary and pancreatic inflammation. This will benefit you by providing a clear diagnosis. Sometimes doctors will first perform an MRI scan of the bile ducts and pancreas called an MRCP. If you prefer not to be investigated, we advise you to discuss the implications with your doctor.

What preparation will I need?

This procedure must be performed on an empty stomach, so you must not eat or drink for six hours before the procedure.

What about my medications?
If you are taking anti-inflammatory tablets (such as neurofen, brufen or voltarol) please stop taking them 5 days before your test.

Do not stop taking aspirin, clopidogrel or warfarin but please make sure that you have discussed this with your referring doctor before the test. There is a significant risk that a coronary stent will block if these medicines are stopped within one month of stent placement; and a slightly increased risk within the first six months. If the referring doctor thinks it is in your best interests to stop taking them, they should be stopped 10 days before the ERCP.

If you are a diabetic, please let the unit know. We will give you more detailed information about your preparation.

What happens on the day of the test?

Please bring your medication, a dressing gown and an overnight bag in case you need stay in hospital after the test. Please book in with the endoscopy reception staff when you arrive. They check your personal details, such as your name and address. We try to ensure that all patients are seen and have their tests within a short period of time of arriving in the unit, but occasionally emergencies take precedence and you may need to wait. The reception staff will keep you informed in the event that this happens.

One of the endoscopy nurses then sees you and asks you some further questions. Before you undergo the test, the doctor (endoscopist) who will be doing the procedure will talk you through the consent form and the potential complications. It is important for you to think about these in advance so when you sign the form agreeing to the test you are comfortable that it is a test you really want. Remember, you can change your mind about having the procedure at any time. Please tell the doctor if you have heart valve disease or if you normally are given antibiotics when you visit the dentist. X-rays are taken during this procedure so please tell the doctor if you could be pregnant.

Before the test starts, the doctor or nurse puts a small needle into the back of your hand. This is to give you some sedation and some painkillers. These drugs are used together to reduce the discomfort you may feel and to make you a little sleepy. This is not a general anaesthetic.

An ERCP usually takes between 30 minutes and 1 hour, depending on what is done. Local anaesthetic is sprayed on to the back of your throat to make it numb. A sedative and analgesia (painkiller) are administered through a drip in your arm to make you drowsy.

A plastic mouthpiece is placed between your teeth to keep your mouth slightly open. When the endoscopist gently passes the endoscope through your mouth you may gag slightly - this is quite normal and will not interfere with your breathing. The endoscope is thinner than an index finger.

During the procedure, some air is put into your stomach so that the endoscopist can have a clear view - this may make you burp a little. Some people find this uncomfortable but it does not hurt or affect your breathing. The air is removed at the end of the test.

The procedure itself requires the doctor to pass the endoscope beyond your stomach into the small intestine (bowel). Water-soluble dye is injected into the bile ducts to allow the doctor to visualize the pancreas and common bile ducts. Photographs or video may be taken, and bile samples, brushings or biopsies (tissue samples) obtained. Often the doctor needs to perform therapeutic interventions like inserting a hollow tube, called a stent, into the bile duct; expanding a narrowed area (called dilating a stricture); removing gallstones or widening the entrance to the biliary system (called a sphincterotomy). Throughout the procedure a nurse cares for you and monitors your pulse and oxygen levels.

What are the complications of ERCP?

About 1 in 20 patients suffer from inflammation of the pancreas (called pancreatitis) after the procedure. This usually requires admission to hospital for several days, but occasionally may require longer stays.

Bleeding, cholangitis (infection of the bile ducts), or a hole (a perforation) occur about 1 in 500 times but are up to 10 times more common if a sphincterotomy is performed. If such a complication occurs, patients usually stay in hospital for a few days.

Using sedation can cause breathing complications in up to 1 in 200 procedures, which usually are not serious, but to reduce this we monitor your pulse and oxygen levels at all times throughout the test.

Other rare complications include aspiration pneumonia, damage to loose teeth or to dental bridgework.

The procedure has a 1 in 500 mortality rate.

If you have severe pain, black tarry stools or persistent bleeding, you should contact your nearest A&E Department for further advice and also inform us.

What happens after the test?

You are either moved back to the recovery area where a nurse monitors you for 1-2 hours whilst you sleep off the sedation, or you are returned to your ward.

You will be given fluids via a drip until you are able to eat and drink. You may experience bloating if there is still some air in your stomach, and a sore throat. Both sensations are normal.

If you are going home the same day you must arrange for someone to escort you home. Be aware that parking at the hospital is very limited. If no escort is available, please bring enough money to pay for a taxi. No escort is required if you are using hospital transport.

We strongly advise that you do not drink alcohol, operate machinery, drive or make important decisions for 24 hours after your procedure as sedatives can impair your judgement.

You can resume normal activities, work etc the following day.

How will I get the results?

The endoscopist will be able to tell you the results after the procedure. If you had sedation, it is a good idea to have someone with you when this occurs because the sedation can make you forget what is discussed. If samples were taken, you will be told the final diagnosis by your doctor within about 1 week. Copies of your ERCP report will be sent to your GP.

If you have any problem understanding or reading any of this information, please contact the Endoscopy team on 0207 483 5164.

Flexible Sigmoidoscopy

Flexible sigmoidoscopy diagramFlexible sigmoidoscopy is a test that allows the doctor to examine your bowel from the anus to the descending colon with a small, flexible endoscope.

The test is performed to investigate some symptoms such as a change in bowel habit, rectal bleeding; or to review a problem they may have found before, for example polyps or colitis. This will benefit you by providing a clear diagnosis. If you prefer not to be investigated, we advise you to discuss the implications with your doctor.

A flexible sigmoidoscopy is one of the simplest and safest methods to examine the lower part of the colon. Therefore, it is often the first test that the doctor requests. It may however be necessary to undertake further tests, such as a colonoscopy, barium enema, or a CT scan. If you wish, please discuss with your doctor which is the best test for you.

What preparation will I need?

You can eat and drink normally on the day of the test unless you choose to be sedated, in which case you should not eat or drink for 4 hours before the test. Shortly before your procedure, one of the nurses in the endoscopy unit will give you an enema. This is a liquid medicine that is given through your back passage. It works as a laxative that cleans the end of your bowel.

What should I bring on the day?

Please bring all your medication and insurance details.

What about my medications?

If you are taking iron tablets, please stop them 7 days before your test.

If you are taking anti-inflammatory tablets (such as nurofen, brufen or voltarol) please stop taking them 5 days before your test.

Do not stop taking aspirin, clopidogrel or warfarin but please make sure that you have discussed this with your referring doctor before the test. There is a significant risk that a coronary stent will block if these medicines are stopped within one month of stent placement; and a slightly increased risk within the first six months. If the referring doctor thinks it is in your best interests to stop taking them, they should be stopped 10 days before the procedure.

If you are a diabetic, continue your medication and eat normally.

What will happen to me on the day of the test?
Please book in with the endoscopy reception staff when you arrive. They check your personal details, such as your name and address. We try to ensure that all patients are seen and have their tests within a short period of time of arriving in the unit, but occasionally emergencies take precedence and you may need to wait. The reception staff will keep you informed in the event that this happens.

Next, the doctor (endoscopist) who will be doing the procedure talks you through the consent form and the potential complications. It is important for you to think about these in advance so when you sign the form you are comfortable that it is a test you really want. Remember, you can change your mind about having the test at any time. Please tell the doctor if you have heart valve disease or if you are normally given antibiotics when you visit the dentist.

One of the endoscopy nurses then sees you, asks you some further questions, and answers any questions you may have. You will then be asked to change into a gown, and a small enema will be administered.

Patients do not usually need to be sedated for this test. However, if a patient chooses to be sedated, the doctor or nurse puts a small needle into the back of their hand in order to give the sedative. This is not a general anaesthetic. Alternatively, short term pain-relief can be provided using an inhalation of Entonox™ ("laughing gas"), which is a mixture of nitrous oxide and oxygen (effects last for no more than 10 minutes).

The doctor inserts a thin flexible tube with a light on the end of it into your back passage. It is thinner than an index finger. Air is inserted into your bowel which may make you feel a little bloated. The tube is slowly moved up the left side of your colon whilst the doctor looks at the wall of the bowel. The test usually takes between 5 - 15 minutes.

During the test the doctor may take biopsies (tissue samples) and photographs of your bowel, even if it all looks normal. There may be periods of discomfort as the tube goes around bends in the bowel. Usually these will ease once the bend has been passed. If you are finding the procedure more uncomfortable than you would like, please let the nurse know. In order to make the procedure easier you may be asked to change position (for example, to roll onto your back).

There will be a nurse with you throughout the procedure explaining what is happening, monitoring your vital signs, level of comfort and assisting the doctor.

What are the complications of flexible sigmoidoscopy?

Complications are extremely rare, but it is important that you know all the risks before you decide to go ahead with the test.

Minor complications

Some patients can experience abdominal discomfort or pain.

Major complications

There is a very small risk of making a hole in the bowel wall (a perforation) or causing bleeding. This occurs in approximately 1 in 15,000 examinations. A perforation usually requires an operation to repair it.

Using sedation can cause breathing complications in up to 1 in 200 procedures, which usually are not serious. To reduce this risk, we monitor your pulse and oxygen levels at all times throughout the test.

If you have severe pain, black tarry stools or persistent bleeding, you should contact your nearest A&E Department for further advice and also inform your consultant through the endoscopy unit staff, or, if after hours, the hospital switchboard – 0207 586 5959.

What happens after the test?

You will be moved into the recovery area where a nurse will review you. If you have received no sedation, you may go home immediately after the procedure. You may feel a little discomfort due to the air inserted during the procedure - this is normal.

You must arrange for someone to escort you home as you may have been given a sedative. Be aware that parking at the hospital is very limited. If no escort is available, please carry enough money to pay for a taxi.

We strongly advise that you do not drink alcohol, operate machinery, drive or make important decisions for 24 hours after your procedure as sedatives can impair your judgment.

The endoscopist will be able to tell you the results after the procedure. If you had sedation, it is a good idea to have someone with you when this occurs because the sedation can make you forget what is discussed. If biopsies were taken or polyps removed, you will be told the final diagnosis by your consultant at a follow-up appointment. Copies of your flexible sigmoidoscopy report will be sent to your GP.

Any other questions?

No question is ever too minor or too silly to ask, so please ask any member of the team caring for you if there is anything you wish to know.

If you have any problem understanding or reading any of this information, please contact the Endoscopy team on 0207 483 5164 or 5167.

The C13-Urea Breath Test

The C13-urea breath test is designed to look for the presence of Helicobacter Pylori, a bacterium associated with a number of conditions affecting the stomach.

Helicobacter Pylori is a bacterium that lives in the lining of the stomach and gut. It may be a life-long infection that generally causes no problems. However, it is often associated with dyspepsia (indigestion) and peptic (stomach) ulcer. Treatment of the bacteria with medication can allow the ulcer to heal.

Helicobacter pylori breaks down urea, a common substance in many foods, into ammonia and carbon dioxide. Your test is based on this unique feature of the bacteria.

Urea that is high in a substance known as Carbon-13 (13C) is used (13C-urea). 13C can be measured by laboratory equipment. If the bacteria is present this 13C will appear in the carbon dioxide in your breath. Examination of samples of your breath taken before and after consuming the 13C-urea will show if the bacteria are present in your stomach.

Questions You May Have About the 13C-urea Test

  • 13C is a harmless naturally occurring substance that is present all around us. It is not radioactive.
  • Urea is a harmless substance found in food and in your body.

The amounts of these substances that you take during the test are very small compared to the amounts already present in your body or that you consume in your normal diet.

If you have any food allergies or intolerances you should tell your doctor before taking the test.

What will happen during the test?

A specialist nurse will be present to guide you through the test.

The test requires you to drink a "test meal" which will be a glass of orange-flavoured citric acid drink, or orange juice. If you are allergic to either of these or have difficulty drinking acidic drinks, please contact the test centre to arrange an alternative.

  • You will give samples of your breath by blowing into a set of tubes.
  • You will drink a small quantity of 13C-Urea dissolved in water (60ml) This is a colourless and tasteless liquid.
  • You will then be asked to sit quietly, without eating, drinking, or smoking for 30 minutes.

Finally, samples of your breath will be taken to complete the test.

When will I know the result?

The samples of breath have to be sent away to be analysed at a laboratory. You will be given a date to contact your doctor to learn the results of the test.

Is there anything I have to do before the test?

You will have to fast (not eat) before you take the test.

Some medications that you might take can affect the accuracy of the test. You will need to tell the GI Unit staff about these medications before you have the test.

Gastroscopy

A gastroscopy or gastro-intestinal endoscopy is so your doctor can look inside the upper part of your digestive system – your oesophagus (gullet), stomach and small intestine (bowel). A tiny camera is passed through theses areas on the end of a very narrow and flexible tube called an endoscope. The tube is thinner than an index finger.

Why am I having the procedure?

Your doctor has referred you for a gastro-intestinal endoscopy in order to investigate symptoms you have been having, such as indigestion, heartburn, upper abdominal pains, difficulties in swallowing or to exclude other abnormalities. This will benefit you by providing a clear diagnosis. If you prefer not to be investigated, we advise you to discuss the implications with your doctor.

There are other methods of examining the stomach, such as a barium meal, or a CT scan. Although upper intestinal endoscopy is less pleasant than a barium meal, it does allow biopsies and photographs to be taken. If you wish, please discuss with your doctor which is the best test for you.

What preparation will I need?

The procedure must be performed on an empty stomach, so you cannot eat or drink for six hours before the test.

What about taking my medications?

If you are taking anti-inflammatory tablets (such as neurofen, brufen or voltarol) please stop taking them 5 days before your test.

Do not stop taking aspirin, clopidogrel or warfarin but please make sure that you have discussed this with your referring doctor before the test. There is a significant risk that a coronary stent will block if these medicines are stopped within one month of stent placement; and a slightly increased risk within the first six months. If the referring doctor thinks it is in your best interests to stop taking them, they should be stopped 10 days before the gastro-intestinal endoscopy.

If you are a diabetic, please let the unit know. We will give you more detailed information about your preparation.

What will happen to me on the day of the test?

Please bring all your medication and insurance details. Please book in with the endoscopy reception staff when you arrive. They check a few of your personal details, such as your name and address. We try to ensure that all patients are seen and have their tests within a short period of time of arriving in the unit, but occasionally emergencies take precedence and you may need to wait. The reception staff will keep you informed in the event that this happens.

One of the endoscopy nurses then sees you and asks you some further questions. Before you undergo the test, the doctor (endoscopist) who will be doing the procedure talks you through the consent form and the potential complications. It is important for you to think about these in advance so when you sign the form agreeing to the test you are comfortable that it is a test you really want. Remember, you can change your mind about having the procedure at any time. Please tell the doctor if you have heart valve disease or if you normally are given antibiotics when you visit the dentist.

The endoscopy is usually quick and often takes no more than 5 minutes to complete. It can be performed with a sedative injection administered through a drip in your arm. This will make you drowsy during the procedure and for up to sixty minutes afterwards. This is not a general anaesthetic. Alternatively, a local anaesthetic can be sprayed onto the back of your throat to make it numb. You are awake during the procedure but you will be able to leave the department as soon as the test is completed.

A plastic mouthpiece is placed between your teeth to keep your mouth slightly open. When the endoscopist gently passes the endoscope through your mount you may gag slightly – this is quite normal and will not interfere with your breathing. The endoscope is thinner than an index finger.

During the procedure, air is put in to your stomach so that the endoscopist can have a clear view. This may make you burp a little. Some people find this uncomfortable. The air is removed at the end of the test. When the procedure is finished the endoscope is removed quickly and easily. Minimal restraint may be appropriate during the procedure. However if you make it clear that you are too uncomfortable the procedure will be stopped. During the test the doctor may take biopsies (tissue samples) and photographs of your bowel, even if it all looks normal. This does not hurt. In addition, it may be necessary to use thermal coagulation to remove small polyps or abnormal blood vessels; this is relatively safe. A nurse is present throughout the procedure to look after you.

What are the complications of gastro-intestinal endoscopy?

Complications are rare, but it is important that you know all the risks before you decide to go ahead with the test.

Minor complications

Despite sedation and pain killers some patients can experience abdominal discomfort or pain.

Major complications

There is a very small risk of bleeding, or of making a hole (perforation) in the intestine, which may require surgery. The risk of this happening is about 1 in 10 000. Other rare complications include aspiration pneumonia, damage to loose teeth or to dental bridgework.

Using sedation can cause breathing complications in up to 1 in 200 procedures, which usually are not serious. To reduce this risk, we monitor your pulse and oxygen levels at all times throughout the test.

If you have severe pain, black tarry stools or persistent bleeding, you should contact your nearest A&E Department for further advice and also inform your doctor through the endoscopy unit, or if after hours, the hospital switchboard – 0207 586 5959.

What happens after the test?

If you choose to have sedation, you will be moved to the recovery area where nursing staff will monitor your condition for about an hour. If you received local anaesthetic to your throat, you can leave the department immediately but will have to wait approximately 30 minutes before eating or drinking. In-patients will be transferred back to the ward. You may experience a slight sore throat and may feel bloated due to air in your stomach. Both sensations are normal and will clear up quickly by themselves.

If you are going home the same day you must arrange for someone to escort you home as you may have been given a sedative. Be aware that parking at the hospital is very limited. If no escort is available, please bring enough money to pay for a taxi.

We strongly advise that you do not drink alcohol, operate machinery, drive or make important decisions for 24 hours after your procedure as sedatives can impair your judgement. You can resume normal activities, work etc the following day.

How will I get the results?

The endoscopist will be able to tell you the results after the procedure. If you had sedation, it is a good idea to have someone with you when this occurs because the sedation can make you forget what is discussed. Results of biopsies are usually available within 1 week and will be discussed at a follow up appointment with you doctor. Copies of your gastro-intestinal endoscopy report will be sent to your GP.

Doctors

Browse doctors for this speciality, and find out more about their skills

Dr Akeel Alisa Consultant Gastroenterologist
Gastroenterology
Dr Akeel Alisa
Professor Qasim Aziz Professor of Neurogastroenterology
Gastroenterology
Professor Qasim Aziz
Dr Stuart Bloom Consultant Gastroenterologist
Gastroenterology
Dr Stuart Bloom
Dr Anton Bungay Consultant Gastroenterologist
Gastroenterology
Dr Anton Bungay
Professor Martyn Caplin Consultant Gastroenterologist
Gastroenterology
Professor Martyn Caplin
Dr Edward Despott Consultant Gastroenterologist
Gastroenterology
Dr Edward Despott
Dr Ameet Dhar Consultant Hepatologist
Gastroenterology
Dr Ameet Dhar
Dr Mark Hamilton Consultant Gastroenterologist
Gastroenterology
Dr Mark Hamilton
Dr Marcus W N Harbord Consultant Gastroenterologist
Gastroenterology
Dr Marcus W N Harbord
Dr Ailsa Hart Consultant Gastroenterologist
Gastroenterology
Dr Ailsa Hart
Professor Laurence Lovat Consultant Gastroenterologist
Gastroenterology
Professor Laurence Lovat
Dr Steven Mann Consultant Gastroenterologist
Gastroenterology
Dr Steven Mann
Dr Sara McCartney Consultant Gastroenterologist
Gastroenterology
Dr Sara McCartney
Dr Andrew Millar Consultant Gastroenterologist
Gastroenterology
Dr Andrew Millar
Dr Charles Murray Consultant Gastroenterologist
Gastroenterology
Dr Charles Murray
Dr Clive Onnie Consultant Gastroenterologist
Gastroenterology
Dr Clive Onnie
Professor Stephen Pereira Consultant Gastroenterologist
Gastroenterology
Professor Stephen Pereira
Professor Bobby Priyajit Prasad Consultant Gastroenterologist
Gastroenterology
Professor Bobby Priyajit Prasad
Dr Ray Shidrawi Consultant Gastroenterologist
Gastroenterology
Dr Ray Shidrawi
Dr Deepak Suri Consultant Gastroenterologist
Gastroenterology
Dr Deepak Suri
Dr Kwok Tang Consultant Gastroenterologist and Hepatologist
Gastroenterology
Dr Kwok Tang
Dr Douglas Thorburn Consultant Gastroenterologist
Gastroenterology
Dr Douglas Thorburn
Dr Christos Toumpanakis Consultant in Gastroenterology and Neuroendocrine
Gastroenterology
Dr Christos Toumpanakis
Dr Ana Wilson Consultant Gastroenterologist
Gastroenterology
Dr Ana Wilson
Dr Voi Shim Wong Consultant Gastroenterologist
Gastroenterology
Dr Voi Shim Wong