Page 151 - Medicine and Surgery

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Chapter 4: Clinical 147

able to stand. Apple-core lesions are classical of colonic not possible to obtain good views as far as the terminal
carcinoma. Features of colitis can be identified as well as ileum.
diverticular disease. Polyps can be biopsied or removed. Biopsies can also
In acute illnesses such as possible perforation or diver- be taken in suspected inflammatory bowel disease.
ticulitis, insufflation of air is avoided and a water-soluble Complications: Bowel preparation may cause dehy-
contrast is used. dration, electrolyte or fluid imbalance particularly in the
elderly, or those with cardiac or renal disease. Perfora-
tion and peritonitis occur approximately 1 in every 2000
Endoscopy
examinations and is more likely if biopsy or polyp re-
Endoscopic procedures use flexible fibre-optic tubes, moval takes place. Polyp removal also carries a 1 in 200
allowing direct vision and usually video imaging. The risk of bleeding. Overall colonoscopy has a mortality of
procedures are done under local anaesthetic and/or se- 1:100,000.
dation, so are usually a day case procedure.
Flexible sigmoidoscopy
Oesophagogastroduodenal (OGD) or upper
This is a generally well-tolerated procedure that requires
gastrointestinal (GI) endoscopy
only a phosphate enema to clear the lower part of the
The patient must be fasted at least 6 hours. Local anaes-
colon, it is inserted to 70 cm. All patients who have
thetic spray is used on the throat and sedation is some-
a barium enema, e.g. for possible malignancy, should
times required. The endoscope is passed through the
have a sigmoidoscopy, as barium enemas can miss low
pharynx, into the oesophagus, stomach and duodenum.
lesions.
Diagnoses which may be made include oesophagitis, oe-
sophageal candidiasis, Barrett’s oesophagus, carcinoma
Proctoscopy
of the oesophagus or gastric carcinoma, and peptic ulcer
Haemorrhoids are best seen with a proctoscope, which
disease. Mucosal biopsies can be made for histological
is a shorter, larger diameter tube gently inserted while
diagnosis and testing may be done for the presence of H.
the patient strains down. It is gently withdrawn whilst
pylori (see page 162).
thepatientcontinuestostraindown.Usingalightsource
In upper GI bleeding, varices or a bleeding ulcer can
haemorrhoids can be directly visualised and can be
be treated, e.g. by sclerotherapy, variceal banding, clips,
treated, e.g. with banding or injection of sclerosant.
glue,fibrinsealant(e.g.Beriplast)orlaserphotocoagula-
tion. Upper GI endoscopy should be repeated 4–6 weeks
after an endoscopic diagnosis of gastric ulcer has been Gastric surgery
made to repeat biopsies to exclude malignancy.
Complications of upper GI endoscopy include per- Surgery for uncomplicated peptic ulcer disease is rarely
foration (of oesophagus or stomach) and bleeding, but performed since the advent of proton pump inhibitors
these are uncommon. to reduce acid production and the discovery of H. py-
lori.However in life-threatening upper gastrointestinal
Colonoscopy bleeding, if gastric outflow obstruction develops or for
The patient has to have bowel preparation, which com- malignant gastric ulcers surgery is still indicated.
mences up to 2 days pre-procedure with a low-residue Vagotomy was previously used to reduce acid secre-
diet, then clear fluids. Osmotic laxatives or large vol- tion but caused decreased motility and thus a drainage
umes of electrolyte solutions are then taken to clear the procedure is required:
bowel 12 hours before the procedure (essentially causing Pyloroplasty in which a longitudinal cut is made in
watery, frequent diarrhoea). the pylorus, which is then closed transversely, estab-
Sedation and analgesia (usually with pethidine) is re- lishing an enlarged outlet from the stomach into the
quired. The instrument is passed via the anus and using intestine.
air insufflation to view the bowel, passed around as far Gastro-enterostomy in which a loop of small bowel
as the caecum and terminal ileum. In 20% of cases, due is linked to the stomach (the normal pyloric passage
to insufficient preparation or patient intolerance, it is remains intact).