Diagnostic Procedures

Therapeutic Procedures

Liver Biopsy

Ascitic Tap

Esophageal pH Monitoring 

Structure Dilatation

Foreign Body Removal

Endoscopy

Manometry

Diagnostic Procedures

Upper GI Endoscopies

An upper endoscopy (also called esophagogastroduodenoscopy or EGD) is a test done by a doctor to examine the esophagus, stomach, and upper intestine for possible causes of problems with your child’s digestive tract. Symptoms that may require an upper endoscopy include:

Vomiting
Trouble swallowing
Trouble growing
Diarrhea
Belly pain
Taking out food, coins or other things that get stuck

What will the procedure involve?
Your child will be given medicine that will help him go to sleep. Then the doctor will use a very narrow, bendable tube with a tiny camera and light on the end which is called endoscope to look inside your child’s body. The doctor may also take a small tissue sample from esophagus or duodenum or both for biopsy to help him/her to find out why your child is not feeling well.

Before the Test
Your child should not eat or drink anything 6 to 8 hours before this test in order to avoid problems with the medicine that will be used to help your child sleep during the procedure. However, if your child is under 1 year of age intravenous fluids will be started.

Enteroscopies

Alternative Names
Small bowel biopsy; Push enteroscopy; Double-balloon enteroscopy; Capsule enteroscopy; Sonde enteroscopy

Definition of Enteroscopy:
Enteroscopy is a procedure used to examine the small intestine (small bowel).

How the test is performed:
A thin, flexible tube that is endoscope is inserted through the mouth or nose and into the upper gastrointestinal tract. During a double-balloon enteroscopy, balloons attached to the endoscope can be inflated to allow the doctor to view a large part of the small intestine.In a colonoscopy, a flexible tube is inserted through your rectum and colon. The tube usually can reach into the end part of the small intestine (ileum).

Tissue samples removed during enteroscopy are sent to the laboratory for examination.

Therapeutic Procedures

Variceal Banding

Endoscopic band ligation is the use of elastic bands to treat the varices. It is also known as Endoscopicvariceal ligation (EVL). It was developed in an effort to find an effective means of treating esophageal varicesendoscopically with fewer complications than endoscopic sclerotherapy (ES).The concept was based upon many years of experience treating hemorrhoids with rubber band ligation in patients with and without portal hypertension. EVL works by capturing all or part of a varix resulting in occlusion from thrombosis. The tissue then necroses and sloughs off in a few days to weeks, leaving a superficial mucosal ulceration, which rapidly heals.EVL avoids the use of sclerosant and thus eliminates the deep damage to the esophageal wall that occurs after ES.Another interesting finding is that during acute variceal bleeding, the hepatic venous pressure gradient (which correlates with the risk of variceal bleeding) increases after ES, but not after EVL.
Endoscopic variceal ligating devices are placed on the tip of standard endoscopes. The device has a soft sheath portion that fits over the tip of the endoscope and a hard plastic portion. Bands are stretched over the hard portion at the distal end of the device and later deployed onto the varices.

Sclerotherapy
Sclerotherapy for esophageal varices(also called endoscopic sclerotherapy) is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.

Various sclerosing agents are sodium morrhuate, sodium tetradecyl sulfate, and hypertonic saline or glucose.

Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. The sclerosant injected into the vein causes blood clots to form and stops the bleeding. The sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel.

Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective.

Once bleeding has been stopped, the treatment can be used to significantly reduce or destroy the varices.

Polypectomy
Polypectomy is the medical term for removing Polyps. Colonic polyps are abnormal like growths that protrude into the lining of the bowel. Small polyps can be removed by an instrument called a biopsy forceps, which snips off small pieces of tissue. Larger polyps are usually removed by putting a noose, or snare, around the polyp base and burning through the tissue with electric cautery. Neither of these procedures is painful, and you will usually not be aware that they are being done. Rarely will a polyp be too large to remove by colonoscopy and require surgery for removal.

Liver Biopsy

A liver biopsy is a short procedure to remove a small piece of liver tissue. It can then be examined under a microscope and tested chemically in the laboratories. A percutaneous liver biopsy is carried out by inserting a needle through the skin (percutaneously). The liver is the largest organ in the body and is located in the top right hand side of the abdomen.

A liver biopsy is a procedure in which a small needle is inserted into the liver to collect a tissue sample. This is performed as an office or outpatient procedure or during surgery. The tissue is then analyzed in a laboratory to help doctors diagnose a variety of disorders and diseases in the liver.

Why does child need this procedure?
A liver biopsy is usually suggested when a child has an abnormally large liver or abnormal blood results, which indicate that the liver is not working properly. The doctors can tell a certain amount by examining your child’s blood, but there are some diseases that can only be diagnosed by a liver biopsy – for example some metabolic disorders. The reason for your child’s biopsy will be discussed with you fully by your child’s doctors.

What happens before the biopsy?
If your child is taking certain medicines on a regular basis, these will need to be stopped a few days before the liver biopsy is due to take place. Ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs) need to be stopped three days beforehand.

Your child will need to come into hospital the day before the procedure and should be able to go home the day after the procedure, unless he or she needs any further investigations or treatment.

Your child’s doctor will see you when you arrive at the hospital to explain the procedure in more detail, discuss any questions you may have and ask you to sign a consent form. Your child will need to have a mild general anaesthesia or sedation. This means that your child will not be able to have any food or milk for six hours before the procedure, although he or she can have clear fluids up to three hours beforehand infants are started with intravenous fluids to prevent hypoglycaemia.
Your child will need a test to check his or her blood clotting the day before the biopsy like PT/APTT/INR For this your child will have a small plastic tube (a cannula) inserted into a vein.
Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective.

What does the biopsy involve?
The doctor will use an ultrasound scan to find the best place from which to take the biopsy. When this has been located, a local anaesthetic injection will be used to numb the area, before the needle is inserted through the skin into the liver. The needle will then be removed containing a small ‘plug’ of liver tissue. This will then be sent to the laboratories for detailed examination.
The incision site will be closed by appropriate dressing. There might be some bleeding straight after the procedure, but this will stop when pressure is applied to the site. The biopsy itself only takes a few minutes.

Are there any risks involved?
Every anaesthetic carries a risk of complications, but this is very small. Sometimes after a general anaesthetic, a child may feel sick and could actually vomit. Your child may also complain of a headache, sore throat and feeling dizzy and may be upset. These side effects are usually short lived.
Liver biopsy carries some specific risks; pain is the most common side effect of liver biopsies. There is also a small risk of bleeding. If this occurs, it usually starts within a few hours of the biopsy.

What happens after the biopsy?
Your child will be able to recover from the biopsy on the ward and may be sleepy for a few hours as the anaesthetic wears off. Your child’s blood pressure, pulse and breathing rate will be monitored every 15 minutes initially, then less frequently as your child recovers. The local anaesthetic given during the procedure will start to wear off a few hours after the biopsy, but we will give your child pain medicines to keep the area comfortable.
Your child should remain in bed for 24 hours after the biopsy and ideally, he or she should lie on the right hand side as much as possible.
The results of the biopsy are usually available within a 3 days, but more complicated tests can take longer. All the biopsy results will be given to you at your child’s next outpatient appointment, but if there is a need to change your child’s treatment before this time, you will be contacted directly.

Ascitic Tap

Ascitic tap or Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes.

Characterization of ascites

Ascitic fluid may be used to help determine its etiology as well as to evaluate for infection or presence of cancer. Transudative ascites occurs when a patient’s SAAG level is greater than or equal to 1.1 g/dL (portal hypertension). Exudative ascites occurs when patients have SAAG levels less than 1.1 g/dL.

Causes of ascites
Causes of transudative ascites include the following:
Cirrhosis
Heart failure
Fulminant hepatic failure
Portal hypertension
Portal vein thrombosis

Causes of exudative ascites include the following:
Peritoneal carcinomatosis
Inflammation of the pancreas or biliary system
Nephrotic syndrome
Peritonitis
Ischemic or obstructed bowel

Esophageal pH Monitoring

Esophageal pH monitoring can help diagnose a condition called “oesophageal reflux” or gastroesophageal reflux disease. This is when the stomach valve is not tight enough, and the stomach contents come up the oesophagus (food pipe) and your child vomits. This test measures the amount of acid refluxing or backing up from the stomach into the esophagus (food pipe).and helps the doctor decide on any further treatment. Esophageal pH monitoring is used in several situations to assess for gastroesophageal reflux disease (GERD). The first is to evaluate typical symptoms of GERD such as heartburn and regurgitation that do not respond to treatment with medications. In this situation, there may be a question whether the patient has gastroesophageal reflux disease disease or whether anti-acid medications are adequate to suppress the acid production. The second is when there are atypical symptoms of GERD such as chest pain, coughing, wheezing, hoarseness, sore throat. In this situation, it is not clear if the symptoms are due to gastroesophageal reflux. Occasionally, this test can be used to monitor the effectiveness of medications used to treat GERD. The test is often used as part of a pre-operative evaluation before anti-reflux surgery. IA doctor will pass a fine soft tube in your child’s nose down into their oesophagus. The tube is connected to a small portable machine called a “Mouse” for 24 hours. You can feed, change, and play with your child as usual.

Impedance Study
This new technology allows us to further evaluate the esophagus (feeding tube in the chest) when patients have symptoms that may or may not be related to acid reflux. This will help your doctor determine the cause of your symptoms. There are other movements of air/gas and liquid (or a mixture) within the esophagus that may give you symptoms but are not caused by acid reflux. Impedance testing can tell us whether it is that (or acid reflux) that is causing your symptoms.You will carry a recording device with you and you will receive instructions on how to use that. The messages from the Impedance catheter/tube are sent to the recording device and once you return next day we remove the tube and download the information from the recorder into the computer for the doctor to review.

Structure Dilatation

An esophageal stricture is a gradual narrowing of the esophagus, which can lead to swallowing difficulties. The strictures are caused by scar tissue that builds up in the esophagus. When scarring occurs, the lining of the esophagus becomes stiff. In time, as this scar tissue continues to build up, the esophagus begins to narrow in that area. The result then is swallowing difficulties.Scarring will result after repeated inflammatory injury and healing, re-injury and rehealing. This scarring will produce damaged tissue in the form of a ring that narrows the opening of the esophagus.The causes of stricture dilatation are corrossive ingestion, Gastroesophagesl reflux disease,viral or bacterial infestion, prolong use of nasogastric tube etc.The dilation are performed by passing a dilator or air-filled balloon of different size through a endoscope under fluoroscopic guidance. Repeated dilation may be necessary to prevent the stricture from returning.The child is kept nil orally and a post-procedure chest X-ray is performed.Feeding is usually started on instruction of doctors some time after the procedure.

Foreign Body Removal

Patients with foreign bodies in the gastrointestinal (GI) tract commonly present to the emegency department. Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally.

The child may accidentally ingest foreign bodies (i.e. foreign objects such as coins, batteries, toys, pins, dentures etc., and food items such as pieces of meat or bones [chicken or fish]). These items may get stuck or lodged at various locations in the gastrointestinal tract and all require removal. Other objects require removal even if they are not stuck due to their potential to cause injury. Examples include batteries lodged in the esophagus, and sharp or large foreign bodies of any kind.

In some cases, the presence and location of a foreign body may be determined by X-ray. In other cases foreign bodies are not visible by X-ray and require an endoscopic procedure for diagnosis. In addition to diagnostic purposes, endoscopy is used as a minimally invasive alternative to surgery for removal of foreign objects in the GI tract. Foreign bodies may be removed by both upper endoscopy (EGD) and colonoscopy depending on their location. Some foreign bodies do not require removal and may pass on their own under supervision of the treating physician. The child is kept fasting prior to endoscopic procedure and is allowed to eat after removal of foreign body as advised by the doctor.

Endoscopic Ultrasound

An endoscopic ultrasound scan uses an endoscope with an ultrasound probe attached to create detailed pictures of internal organs and structures. An endoscopic ultrasound scan (known as EUS) combines two types of test – endoscopy and ultrasound. The doctor uses an endoscope with an ultrasound probe attached to look inside your gut (gastrointestinal tract). By putting the endoscope into the upper part of the gut, EUS can create pictures of the surrounding structures, not just inside the gut. The ultrasound probe is used to create detailed pictures of the body, including the lungs, pancreas, liver, gallbladder and stomach. EUS can also look at other structures lower down in the body by inserting the endoscope through the rectum into the lower part of the gastrointestinal tract. The tip of the endoscope contains a light and a tiny video camera so the operator can see inside your gut. In an endoscopic ultrasound scan the endoscope also contains an ultrasound probe.

The procedure and preparation are similar to upper gastrointestinal endoscopy or lower gastrointestinal colonoscopy. The endoscope also has a ‘side channel’ down which instruments can pass. These can be manipulated by the doctor to take a small sample (biopsy) by using a thin ‘grabbing’ instrument or a fine needle which is passed down a side channel.

Manometry

Manometry is measurement of pressure within various parts of the GI tract. It is done by passing a catheter containing solid-state or liquid-filled pressure transducers through the mouth or anus into the lumen of the organ to be studied.
Manometry typically is done to evaluate motility disorders in patients in whom structural lesions have been ruled out by other studies.
Manometry is used in the esophagus, stomach and duodenum, sphincter of Oddi, and rectum.
Aside from minor discomfort, complications are very rare.

Esophageal manometry: This test is used to evaluate patients with dysphagia, heartburn, or chest pain. It measures the pressure in the upper and lower esophageal sphincters, determines the effectiveness and coordination of propulsive movements, and detects abnormal contractions. Manometry is used to diagnose achalasia, diffuse spasm, systemic sclerosis, and lower esophageal sphincter hypotension and hypertension.
Anorectalmanometry: This test evaluates the anorectal sphincter mechanism and rectal sensation in patients with incontinence (and sometimes constipation) by means of a pressure transducer in the anus. It can help diagnose Hirschsprung’s disease and provide biofeedback training for fecal incontinence.

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