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Pathology - Myocardial infarction with non-ST segment elevation (NSTEMI)
Pathophysiology
This is an Acute Coronary Syndrome (ACS) episode; NSTEMI or unstable angina are the most likely causes. Both NSTEMI and STMI, as well as unstable angina, fall within this category of conditions. Biochemical indicators and the presence or absence of ECG abnormalities are used to differentiate the illnesses. Substernal chest pain, heaviness, or pressure that may spread to the patient's left arm or left jaw region is the classic presentation of acute coronary syndrome (ACS). Though the illness usually progresses over time and may eventually lead to symptoms at rest, the discomfort is most frequently triggered by effort and relieved by rest. This patient's pulse and blood pressure have increased due to SNS activation and discomfort. Relatively low blood pressure in this context would be concerning as it would probably imply substantial ischemia left ventricular injury.
Another sign of the SNS's reaction to damage and pain is diaphoresis. This patient does not now exhibit any symptoms of ventricular ischemia, as evidenced by normal perfusion to the limbs, no abnormalities in the ECG, and no S3 or S4 heart sounds. Acute and without decompensation at this point, the patient shows no signs of heart failure (normal JVP and clean lung fields). Apart from the treatment with oxygen, nitrate, aspirin, and morphine, this patient requires additional assessment and constant observation to ensure that there is no progression to NSTEMI or STEMI. It is also recommended to evaluate biochemical markers, such as cardiac troponin and creatine kinase MB.
Pathophysiology
This is an Acute Coronary Syndrome (ACS) episode; NSTEMI or unstable angina are the most likely causes. Both NSTEMI and STMI, as well as unstable angina, fall within this category of conditions. Biochemical indicators and the presence or absence of ECG abnormalities are used to differentiate the illnesses. Substernal chest pain, heaviness, or pressure that may spread to the patient's left arm or left jaw region is the classic presentation of acute coronary syndrome (ACS). Though the illness usually progresses over time and may eventually lead to symptoms at rest, the discomfort is most frequently triggered by effort and relieved by rest. This patient's pulse and blood pressure have increased due to SNS activation and discomfort. Relatively low blood pressure in this context would be concerning as it would probably imply substantial ischemia left ventricular injury.
Another sign of the SNS's reaction to damage and pain is diaphoresis. This patient does not now exhibit any symptoms of ventricular ischemia, as evidenced by normal perfusion to the limbs, no abnormalities in the ECG, and no S3 or S4 heart sounds. Acute and without decompensation at this point, the patient shows no signs of heart failure (normal JVP and clean lung fields). Apart from the treatment with oxygen, nitrate, aspirin, and morphine, this patient requires additional assessment and constant observation to ensure that there is no progression to NSTEMI or STEMI. It is also recommended to evaluate biochemical markers, such as cardiac troponin and creatine kinase MB.
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Pathology - Atrial Fibrillation
Pathophysiology
As seen in the following example, this rather typical arrhythmia frequently begins with a subacute episode. This disruption of rhythm might be continuous or sporadic (paroxysmal). Breathlessness and palpitations are commonly observed. Laminar flow throughout the heart is disrupted by ineffective atrial contraction, which has multiple effects.
An inefficient flow can result in "stagnant" cardiac circulation, which puts the patient at risk for stroke and pulmonary embolus as well as atrial blood clots. The erratic and frequently quick ventricular response to erratic atrial activity results in dyspnea. An inadequate forward flow of blood to the systemic circulation results from ineffective ventricular pumping. Although various cardiac or pulmonary diseases might cause this illness, hypertension or valvular heart disease are the most common risk factors. The atrioventricular (AV) node is stimulated rapidly and randomly, leading to an abnormally irregular pattern of QRS complexes and the absence of P waves that make the diagnosis of atrial fibrillation easy to make.
Pathophysiology
As seen in the following example, this rather typical arrhythmia frequently begins with a subacute episode. This disruption of rhythm might be continuous or sporadic (paroxysmal). Breathlessness and palpitations are commonly observed. Laminar flow throughout the heart is disrupted by ineffective atrial contraction, which has multiple effects.
An inefficient flow can result in "stagnant" cardiac circulation, which puts the patient at risk for stroke and pulmonary embolus as well as atrial blood clots. The erratic and frequently quick ventricular response to erratic atrial activity results in dyspnea. An inadequate forward flow of blood to the systemic circulation results from ineffective ventricular pumping. Although various cardiac or pulmonary diseases might cause this illness, hypertension or valvular heart disease are the most common risk factors. The atrioventricular (AV) node is stimulated rapidly and randomly, leading to an abnormally irregular pattern of QRS complexes and the absence of P waves that make the diagnosis of atrial fibrillation easy to make.
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Pathology - Premature Atrial Contractions (PACs).
Pathophysiology
Common cardiac arrhythmias known as PACs are typically regarded as benign, rarely resulting in hemodynamic instability or other severe clinical signs. Premature ventricular contractions, or PVCs, can, however, frequently cause palpitations, anxiety, or psychosomatic chest discomfort, which can be distressing to patients. Although the exact cause of this disorder is unknown, high levels of stress, excessive coffee consumption, or insufficient sleep are frequently linked to the premature beats. It's interesting to note that both the irregular beats and the symptoms they produce usually go away with activity. The "fate" of a PAC is ultimately decided by intrinsic heart rate and the refractory time of the AV node or bundle branch fascicles. PACs are typically not routed through the AV node to the ventricles. A right bundle branch block may result from a PAC's ability to cross the AV node and reach the fascicular bundles because normal conduction pathways are slowed down.
Because PACs have an ectopic origin and follow a different conduction channel through the atria than typical sinoatrial (SA) nodal stimulation, their ECG waveforms may appear abnormal.
Pathophysiology
Common cardiac arrhythmias known as PACs are typically regarded as benign, rarely resulting in hemodynamic instability or other severe clinical signs. Premature ventricular contractions, or PVCs, can, however, frequently cause palpitations, anxiety, or psychosomatic chest discomfort, which can be distressing to patients. Although the exact cause of this disorder is unknown, high levels of stress, excessive coffee consumption, or insufficient sleep are frequently linked to the premature beats. It's interesting to note that both the irregular beats and the symptoms they produce usually go away with activity. The "fate" of a PAC is ultimately decided by intrinsic heart rate and the refractory time of the AV node or bundle branch fascicles. PACs are typically not routed through the AV node to the ventricles. A right bundle branch block may result from a PAC's ability to cross the AV node and reach the fascicular bundles because normal conduction pathways are slowed down.
Because PACs have an ectopic origin and follow a different conduction channel through the atria than typical sinoatrial (SA) nodal stimulation, their ECG waveforms may appear abnormal.
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Pathology - Multifocal Atrial Tachycardia
Pathophysiology
This disorder develops when the right atrium contracts at several locations other than the SA node. Many of these atrial beats, in contrast to PACs, are routed through the AV node, which raises the ventricular rate by as much as 200 beats per minute at times. If insufficient ventricular filling is caused by the tachycardia, symptoms and hemodynamic instability may arise. Cardiomyopathy can also result from the heart's increasing strain, particularly in patients who also have other long-term medical conditions. Patients with medical illnesses including COPD, lung cancer, bacterial pneumonia, or pulmonary embolism that diminish blood oxygen content are more likely to have MAT than individuals who are younger than 50. The best way to treat MAT is to assess and address any underlying medical issues. Forceful atrial contraction against a noncompliant left ventricle is the cause of the S4 heart sound heard in this patient, which is a common finding in COPD patients. The patient's prolonged systemic hypertension contributes to increasing afterload on the left ventricle, which eventually becomes hypertrophied and noncompliant.
Pathophysiology
This disorder develops when the right atrium contracts at several locations other than the SA node. Many of these atrial beats, in contrast to PACs, are routed through the AV node, which raises the ventricular rate by as much as 200 beats per minute at times. If insufficient ventricular filling is caused by the tachycardia, symptoms and hemodynamic instability may arise. Cardiomyopathy can also result from the heart's increasing strain, particularly in patients who also have other long-term medical conditions. Patients with medical illnesses including COPD, lung cancer, bacterial pneumonia, or pulmonary embolism that diminish blood oxygen content are more likely to have MAT than individuals who are younger than 50. The best way to treat MAT is to assess and address any underlying medical issues. Forceful atrial contraction against a noncompliant left ventricle is the cause of the S4 heart sound heard in this patient, which is a common finding in COPD patients. The patient's prolonged systemic hypertension contributes to increasing afterload on the left ventricle, which eventually becomes hypertrophied and noncompliant.
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Pathology -Accelerated Idioventricular Rhythm
Pathophysiology
The ventricles cause this arrhythmia, which happens when a typically suppressed ventricular "pacemaker" takes over as the primary heart rate regulator rather than the SA or AV nodes. When the intrinsic ventricular rate (IVR) reaches more than 40 beats per minute, the idioventricular rhythm is deemed to be "accelerated." As in the case vignette, the most frequent situation for this to happen is following coronary reperfusion, or the restoration of flow to ischemic heart tissue. Treatment is not necessary for this benign illness, which is typically invisible to the patient. After receiving reperfusion treatment, normal SA node function usually restores in 24 to 48 hours. ECG monitoring is essential because the illness must be distinguished from ventricular tachycardia, which can develop into the potentially fatal arrhythmia ventricular fibrillation. Idioventricular rhythm occurs at a rate of less than 120 beats per minute, more frequently at a rate of less than 100. Ventricular tachycardia typically occurs at a rate much higher than 120 beats per minute.
Pathophysiology
The ventricles cause this arrhythmia, which happens when a typically suppressed ventricular "pacemaker" takes over as the primary heart rate regulator rather than the SA or AV nodes. When the intrinsic ventricular rate (IVR) reaches more than 40 beats per minute, the idioventricular rhythm is deemed to be "accelerated." As in the case vignette, the most frequent situation for this to happen is following coronary reperfusion, or the restoration of flow to ischemic heart tissue. Treatment is not necessary for this benign illness, which is typically invisible to the patient. After receiving reperfusion treatment, normal SA node function usually restores in 24 to 48 hours. ECG monitoring is essential because the illness must be distinguished from ventricular tachycardia, which can develop into the potentially fatal arrhythmia ventricular fibrillation. Idioventricular rhythm occurs at a rate of less than 120 beats per minute, more frequently at a rate of less than 100. Ventricular tachycardia typically occurs at a rate much higher than 120 beats per minute.
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Pathology - Second Degree Heart Block Type I
Pathophysiology
Second-degree AV heart block, Type I, sometimes referred to as "Wenckebach periodicity" or "Mobitz I." This disorder is brought on by an irregularity in the heart's AV node, which leaves the ventricles without receiving all of the atrial impulses. The vignette describes the ECG pattern, which is characterized by prolonged PR intervals that continue until no single atrial impulse is passed via the AV node, resulting in a "dropped" ventricular beat. After that, the PR interval "resets," and the cycle is repeated. For the condition to be accurately diagnosed, the atrial rhythm needs to be regular, or alternative atrial disorders need to be taken into account. Most of the time, this illness doesn't cause noticeable symptoms and doesn't need to be treated. In contrast, nonconducted atrial activity occurs in second-degree AV block, Type II (sometimes referred to as "Mobitz II"), in a far less predictable manner (i.e., no PR interval lengthening and resetting). Cardiovascular pacemaker therapy is recommended for the treatment of Type II second-degree AV block since it has the potential to quickly develop into total (third-degree) heart block. When the ventricles and atria beat separately, it is known as complete heart block, and it also requires the use of an implanted cardiac pacemaker.
Pathophysiology
Second-degree AV heart block, Type I, sometimes referred to as "Wenckebach periodicity" or "Mobitz I." This disorder is brought on by an irregularity in the heart's AV node, which leaves the ventricles without receiving all of the atrial impulses. The vignette describes the ECG pattern, which is characterized by prolonged PR intervals that continue until no single atrial impulse is passed via the AV node, resulting in a "dropped" ventricular beat. After that, the PR interval "resets," and the cycle is repeated. For the condition to be accurately diagnosed, the atrial rhythm needs to be regular, or alternative atrial disorders need to be taken into account. Most of the time, this illness doesn't cause noticeable symptoms and doesn't need to be treated. In contrast, nonconducted atrial activity occurs in second-degree AV block, Type II (sometimes referred to as "Mobitz II"), in a far less predictable manner (i.e., no PR interval lengthening and resetting). Cardiovascular pacemaker therapy is recommended for the treatment of Type II second-degree AV block since it has the potential to quickly develop into total (third-degree) heart block. When the ventricles and atria beat separately, it is known as complete heart block, and it also requires the use of an implanted cardiac pacemaker.
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Clinical Procedures - Capsule Endoscopy
Indications
• Obscure gastrointestinal bleeding (in patients with negative gastroscopy and ileocolonoscopy), known or suspected small bowel Crohn's disease, assessment of coeliac disease, screening and surveillance for polyps in familial polyposis syndromes.
Contraindications
• Lack of informed consent, intestinal strictures, adhesions, obstruction
• Diverticula or fistulae that may block the passage of capsule endoscope
• Cardiac pacemakers or other implanted electronic devices
• Difficulty in swallowing tablets or known swallowing disorders
• Pregnancy (lack of available safety data)
• D Patients with obstructive symptoms or known or suspected inflammatory bowel disease should have either a small bowel follow-through or a patency capsule (dissolves after 36 hours), with an abdominal radiograph taken 24 hours after ingestion to identify whether capsule is retained within small bowel:
• If retained, capsule endoscopy is not appropriate
• D Capsule retention can occur even in the absence of strictures on barium or MR-enteroclysis study.
Procedure
• The capsule consists of a disposable, wireless, miniature video camera which can be swallowed and passes through the intestine by peristalsis
• Images taken by the capsule are transmitted, via sensors secured to the abdominal wall, to a battery-powered data recorder worn on a belt
• The capsule leaves the stomach within 30 minutes and the patient is allowed to drink after 2 hours and eat after 4 hours
• The external equipment is removed after 8 hours (approximate battery life) by which time the capsule has reached the caecum in 85% of cases
• The capsule is expelled naturally after 24 48 hours in the patient's stool
• Data from the recorder is downloaded onto a computer workstation which allows approximately 50,000 images to be viewed as a video.
Risks
• Capsule retention (may cause partial or complete intestinal obstruction; highest risk in patients with extensive small bowel Crohn's disease, chronic usage of non-steroidal anti inflammatory drugs, abdominal radiation injury, previous major abdominal surgery or small bowel resection)
• Capsule endoscopy may also fail in patients with dysphagia, gastroparesis, and anatomical abnormalities of the gastrointestinal tract.
The external equipment which the patient will wear, consisting of a data-recorder and electrodes.
Patient Preparation
• Iron supplements: stop taking 1 week prior to procedure
• Constipating agents: stop 4 days before the procedure
• Fasting: patients are fasted for 8-12 hours prior to the procedure and may receive bowel prep (taken day before procedure).
Other Information
• Incomplete examination in 10-25% of cases:
• Presence of dark intestinal contents in distal small bowel may impair visualization of mucosa
• Delayed gastric emptying and small bowel transit can lead to exhaustion of battery life before capsule reaches ileocaecal valve
• Capsules are being developed to screen for esophageal varices and may be more 'guided' in future as the technology develops
• Positive findings on capsule endoscopy may be reachable using either single- or double-balloon enteroscopy or spiral enteroscopy.
Indications
• Obscure gastrointestinal bleeding (in patients with negative gastroscopy and ileocolonoscopy), known or suspected small bowel Crohn's disease, assessment of coeliac disease, screening and surveillance for polyps in familial polyposis syndromes.
Contraindications
• Lack of informed consent, intestinal strictures, adhesions, obstruction
• Diverticula or fistulae that may block the passage of capsule endoscope
• Cardiac pacemakers or other implanted electronic devices
• Difficulty in swallowing tablets or known swallowing disorders
• Pregnancy (lack of available safety data)
• D Patients with obstructive symptoms or known or suspected inflammatory bowel disease should have either a small bowel follow-through or a patency capsule (dissolves after 36 hours), with an abdominal radiograph taken 24 hours after ingestion to identify whether capsule is retained within small bowel:
• If retained, capsule endoscopy is not appropriate
• D Capsule retention can occur even in the absence of strictures on barium or MR-enteroclysis study.
Procedure
• The capsule consists of a disposable, wireless, miniature video camera which can be swallowed and passes through the intestine by peristalsis
• Images taken by the capsule are transmitted, via sensors secured to the abdominal wall, to a battery-powered data recorder worn on a belt
• The capsule leaves the stomach within 30 minutes and the patient is allowed to drink after 2 hours and eat after 4 hours
• The external equipment is removed after 8 hours (approximate battery life) by which time the capsule has reached the caecum in 85% of cases
• The capsule is expelled naturally after 24 48 hours in the patient's stool
• Data from the recorder is downloaded onto a computer workstation which allows approximately 50,000 images to be viewed as a video.
Risks
• Capsule retention (may cause partial or complete intestinal obstruction; highest risk in patients with extensive small bowel Crohn's disease, chronic usage of non-steroidal anti inflammatory drugs, abdominal radiation injury, previous major abdominal surgery or small bowel resection)
• Capsule endoscopy may also fail in patients with dysphagia, gastroparesis, and anatomical abnormalities of the gastrointestinal tract.
The external equipment which the patient will wear, consisting of a data-recorder and electrodes.
Patient Preparation
• Iron supplements: stop taking 1 week prior to procedure
• Constipating agents: stop 4 days before the procedure
• Fasting: patients are fasted for 8-12 hours prior to the procedure and may receive bowel prep (taken day before procedure).
Other Information
• Incomplete examination in 10-25% of cases:
• Presence of dark intestinal contents in distal small bowel may impair visualization of mucosa
• Delayed gastric emptying and small bowel transit can lead to exhaustion of battery life before capsule reaches ileocaecal valve
• Capsules are being developed to screen for esophageal varices and may be more 'guided' in future as the technology develops
• Positive findings on capsule endoscopy may be reachable using either single- or double-balloon enteroscopy or spiral enteroscopy.
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Clinical Procedures - Esophagogastroduodenoscopy
Indications
• Diagnostic: haematemesis, dyspepsia (>55 years old), oesophageal and gastric biopsies (?malignancy), duodenal biopsies (?coeliac), surveillance (e.g. Barrett's oesophagus), persistent nausea and vomiting, iron-deficiency anemia, dysphagia
• Therapeutic: treatment of bleeding lesions, variceal banding and sclerotherapy, stricture dilatation, polypectomy, endoscopic mucosal resection, palliative intent (e.g. stent insertion, laser therapy), argon plasma coagulation for suspected vascular lesions.
Contraindications
• Absolute: lack of informed consent, possible perforation, haemodynamic instability, hypoxaemia with respiratory distress, uncooperative patient
•Relative: pharyngeal diverticulum, recent MI or PE.
Procedure
• Endoscopic examination of the mucosa of the esophagus, stomach, and proximal duodenum. Allows direct visualization, mucosal biopsies,
and other therapeutic procedures
• Dentures (if present) are removed
• Patient is given anaesthetic throat spray (lidocaine) ‡ IV sedation (e.g. midazolam)
• Patient lies on the couch in the left lateral position
• Hollow mouthpiece is inserted to protect the patient's teeth and facilitate instrument passage
• Endoscope (9.5-12.5mm diameter, max. 120cm long) is slowly advanced
and swallowed by the patient
• Scope advanced and manipulated by the endoscopist to allow
visualization of the target structures
• Procedure time varies but average 3-15 minutes.
Risks
• Minor throat and abdominal discomfort
• Cardiorespiratory: arrhythmias, MI, respiratory arrest, shock, death
Infection (uncommon, e.g. aspiration pneumonia)
Perforation (around 0.03% with a mortality of 0.001% during diagnostic procedures, higher with therapeutic procedures):
• Overall 2-3% perforation with esophageal dilatation; mortality 1%
• Bleeding (caution with low platelet counts and high INR)
• Medication effects including anaphylactic reactions and oversedation
• Dental trauma.
Patient Preparation
• Fasting: 4 hours prior to the procedure unless in an emergency situation
• Antibiotic prophylaxis: none for OGD. See other topics for comparison.
Other Information
• Dosages of benzodiazepines and opiates should be kept to a minimum
to achieve sedation, with lower doses being prescribed in elderly patients
• The pharynx is sprayed with local anaesthetic spray. There is some evidence that the combination use of local anesthetic spray and IV sedation increases the risk of aspiration pneumonia
• Patients who have had IV sedation should not drive, operate heavy machinery, or drink alcohol for 24 hours afterwards.
Indications
• Diagnostic: haematemesis, dyspepsia (>55 years old), oesophageal and gastric biopsies (?malignancy), duodenal biopsies (?coeliac), surveillance (e.g. Barrett's oesophagus), persistent nausea and vomiting, iron-deficiency anemia, dysphagia
• Therapeutic: treatment of bleeding lesions, variceal banding and sclerotherapy, stricture dilatation, polypectomy, endoscopic mucosal resection, palliative intent (e.g. stent insertion, laser therapy), argon plasma coagulation for suspected vascular lesions.
Contraindications
• Absolute: lack of informed consent, possible perforation, haemodynamic instability, hypoxaemia with respiratory distress, uncooperative patient
•Relative: pharyngeal diverticulum, recent MI or PE.
Procedure
• Endoscopic examination of the mucosa of the esophagus, stomach, and proximal duodenum. Allows direct visualization, mucosal biopsies,
and other therapeutic procedures
• Dentures (if present) are removed
• Patient is given anaesthetic throat spray (lidocaine) ‡ IV sedation (e.g. midazolam)
• Patient lies on the couch in the left lateral position
• Hollow mouthpiece is inserted to protect the patient's teeth and facilitate instrument passage
• Endoscope (9.5-12.5mm diameter, max. 120cm long) is slowly advanced
and swallowed by the patient
• Scope advanced and manipulated by the endoscopist to allow
visualization of the target structures
• Procedure time varies but average 3-15 minutes.
Risks
• Minor throat and abdominal discomfort
• Cardiorespiratory: arrhythmias, MI, respiratory arrest, shock, death
Infection (uncommon, e.g. aspiration pneumonia)
Perforation (around 0.03% with a mortality of 0.001% during diagnostic procedures, higher with therapeutic procedures):
• Overall 2-3% perforation with esophageal dilatation; mortality 1%
• Bleeding (caution with low platelet counts and high INR)
• Medication effects including anaphylactic reactions and oversedation
• Dental trauma.
Patient Preparation
• Fasting: 4 hours prior to the procedure unless in an emergency situation
• Antibiotic prophylaxis: none for OGD. See other topics for comparison.
Other Information
• Dosages of benzodiazepines and opiates should be kept to a minimum
to achieve sedation, with lower doses being prescribed in elderly patients
• The pharynx is sprayed with local anaesthetic spray. There is some evidence that the combination use of local anesthetic spray and IV sedation increases the risk of aspiration pneumonia
• Patients who have had IV sedation should not drive, operate heavy machinery, or drink alcohol for 24 hours afterwards.
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Clinical Procedures - Colonoscopy
Indications
• Diagnostic: gastrointestinal bleeding, iron-deficiency anemia, chronic diarrhoea, lower abdominal symptoms (chronic constipation, lower abdominal pain, bloating), evaluation of known inflammatory bowel disease (IBD), surveillance for cancer (in IBD patients/after colonic polypectomy/ after curative intent resection of colorectal cancer), screening for colorectal
cancer
• Therapeutic: polypectomy (including endoscopic mucosal resection techniques: EMR), angiodysplasia treated with argon plasma coagulation
(APC), decompression of volvulus or pseudo-obstruction, dilatation, or stenting of strictures or malignant colonic obstruction.
Contraindications
• Absolute: lack of informed consent, toxic megacolon, fulminant colitis, colonic perforation
•Relative: acute diverticulitis, symptomatic large abdominal aortic aneurysm, immediately post-op, recent MI or PE, severe coagulopathies:
• Colonoscopy can be performed safely in pregnancy but should be
deferred in most instances unless requiring immediate resolution.
Procedure
Colonoscopy is an endoscopic examination of the mucosal surface from the anal canal to the terminal ileum.
• Patient lies on the couch in the left lateral position with knees bent
• Endoscopist first performs a digital rectal examination
• Sedation (e.g. midazolam) may be given with monitoring of oxygen saturation. IV analgesia (e.g. pethidine) is also given:
• Increasing use of either no sedation (with improved techniques such as 'Scopeguide®') or inhaled nitric oxide
• Lubricated colonoscope (about 12mm wide and 185cm long) is passed rectally. Air is insufflated. Water-jet may also be used via the scope
• Aim is to pass to the terminal ileum
• Duration varies but averages at about 20 minutes.
Risks
• Perforation (0.2-0.4% diagnostic; higher with therapeutic procedures)
• Bleeding (1 in 1000)
• Abdominal distension, medication effects (allergic reactions, nausea vomiting hypotension, respiratory depression)
• Rarities: infection, postpolypectomy coagulation syndrome: (pain, peritoneal irritation, leucocytosis and fever), splenic rupture, small bowel obstruction.
Patient Preparation
• Iron and constipating agents: discontinue iron tablets 7 days and constipating agents 4 days prior to the procedure
• Anticoagulant and antiplatelet therapy: in the case of a planned polypectomy or other therapeutic procedure, refer to BS guidelines on the management of anticoagulant and antiplatelet therapy (www.bsg.
org.uk)
• Antibiotic prophylaxis: none for colonoscopy. See other topics for comparison
• Bowel preparation: the colon must be empty. Protocols vary but usually include prescribing 1 sachet of sodium picosulfate (Picolax®) for the morning and afternoon of the day before procedure.
Other Information
• The introduction of the bowel cancer screening programme has meant that endoscopists need to pass a 'driving test' to demonstrate high-level competency to perform safe screening colonoscopy
•EMR is used for larger or difficult flat polyps. The lesion is lifted by submucosal injection of gelofusin, adrenaline, and dye followed by snare resection. Polyps can then be retrieved by 'Roth' baskets for histological assessment.
Indications
• Diagnostic: gastrointestinal bleeding, iron-deficiency anemia, chronic diarrhoea, lower abdominal symptoms (chronic constipation, lower abdominal pain, bloating), evaluation of known inflammatory bowel disease (IBD), surveillance for cancer (in IBD patients/after colonic polypectomy/ after curative intent resection of colorectal cancer), screening for colorectal
cancer
• Therapeutic: polypectomy (including endoscopic mucosal resection techniques: EMR), angiodysplasia treated with argon plasma coagulation
(APC), decompression of volvulus or pseudo-obstruction, dilatation, or stenting of strictures or malignant colonic obstruction.
Contraindications
• Absolute: lack of informed consent, toxic megacolon, fulminant colitis, colonic perforation
•Relative: acute diverticulitis, symptomatic large abdominal aortic aneurysm, immediately post-op, recent MI or PE, severe coagulopathies:
• Colonoscopy can be performed safely in pregnancy but should be
deferred in most instances unless requiring immediate resolution.
Procedure
Colonoscopy is an endoscopic examination of the mucosal surface from the anal canal to the terminal ileum.
• Patient lies on the couch in the left lateral position with knees bent
• Endoscopist first performs a digital rectal examination
• Sedation (e.g. midazolam) may be given with monitoring of oxygen saturation. IV analgesia (e.g. pethidine) is also given:
• Increasing use of either no sedation (with improved techniques such as 'Scopeguide®') or inhaled nitric oxide
• Lubricated colonoscope (about 12mm wide and 185cm long) is passed rectally. Air is insufflated. Water-jet may also be used via the scope
• Aim is to pass to the terminal ileum
• Duration varies but averages at about 20 minutes.
Risks
• Perforation (0.2-0.4% diagnostic; higher with therapeutic procedures)
• Bleeding (1 in 1000)
• Abdominal distension, medication effects (allergic reactions, nausea vomiting hypotension, respiratory depression)
• Rarities: infection, postpolypectomy coagulation syndrome: (pain, peritoneal irritation, leucocytosis and fever), splenic rupture, small bowel obstruction.
Patient Preparation
• Iron and constipating agents: discontinue iron tablets 7 days and constipating agents 4 days prior to the procedure
• Anticoagulant and antiplatelet therapy: in the case of a planned polypectomy or other therapeutic procedure, refer to BS guidelines on the management of anticoagulant and antiplatelet therapy (www.bsg.
org.uk)
• Antibiotic prophylaxis: none for colonoscopy. See other topics for comparison
• Bowel preparation: the colon must be empty. Protocols vary but usually include prescribing 1 sachet of sodium picosulfate (Picolax®) for the morning and afternoon of the day before procedure.
Other Information
• The introduction of the bowel cancer screening programme has meant that endoscopists need to pass a 'driving test' to demonstrate high-level competency to perform safe screening colonoscopy
•EMR is used for larger or difficult flat polyps. The lesion is lifted by submucosal injection of gelofusin, adrenaline, and dye followed by snare resection. Polyps can then be retrieved by 'Roth' baskets for histological assessment.
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Clinical Procedures - Barium Swallow/Barium Meal
Barium swallows examine the oropharynx, oesophagus, and GO]; barium meals examine the stomach and first part of the duodenum. They are often performed together as described below.
Indications
• Investigation of esophageal and gastric pathology. Indications include dysphagia, odynophagia, dyspepsia, weight loss, anaemia, epigastric mass, partial obstruction
• I Always consider alternatives (e.g. OGD, MRI).
Contraindications
• Absolute: lack of informed consent, complete bowel obstruction, suspected perforation (a water-soluble contrast may be used instead)
• Relative: a large degree of patient cooperation is required so those unable to understand or follow instructions are unsuitable. Also, the patient must be able to stand for the duration of the examination and to lie supine if necessary.
Procedure
The patient drinks barium whilst the esophagus and stomach are imaged fluoroscopically. Usually performed by a radiologist.
• The patient stands in the fluoroscopy machine
• A gas-producing agent is ingested (e.g. Carbex®) and the patient is asked not to belch
• Images are taken as the patient swallows mouthfuls of barium. The patient must be able to hold the liquid in their mouth and swallow on command
• Once views of the esophagus have been obtained, the machine is tilted so the patient is supine. The patient is instructed to roll and tilt as images of the stomach are obtained from several angles:
• This requires a certain degree of patient fitness
• The time taken depends to a degree on how easily the patient follows the commands, although usually lasts 15-20 minutes
• After the procedure, the patient may eat and drink as usual but is advised to open their bowels regularly to avoid barium impaction.
Risks
• Leakage of barium through an unsuspected perforation:
• Intraperitoneal and intramediastinal barium has a significant mortality rate
• Barium impaction (causing large bowel obstruction) or barium appendicitis.
Patient Preparation
• Fasting: nil by mouth for 6 hours before the examination
• Bowel preparation: none required
• Smoking: patients are asked not to smoke for 6 hours before the procedure as this increases gastric motility.
Other Information
• A barium study will prevent a CT examination of the same area for a period of time as intestinal barium creates dense streak artefact.
Water-Soluble Contrast Examinations
• In the case of recent surgery, suspected perforation, or investigation of a leak, water-based iodinated contrast is used instead of barium.
Examples include Gastrografin®, Urografin®, Niopam®, Omnipaque®
• A single-contrast examination is performed (i.e. the gas-producing agent is not given and many of the 'standard' views are not included
• In contrast to the barium examinations, these studies can be carried out on patients who are frail and/or have recently had surgery
• Intraperitoneal or intramediastinal water-soluble contrast does not carry the risks of barium but aspiration of the contrast can result in pulmonary edema and lung fibrosis. Hypersensitivity is also a risk.
Barium swallows examine the oropharynx, oesophagus, and GO]; barium meals examine the stomach and first part of the duodenum. They are often performed together as described below.
Indications
• Investigation of esophageal and gastric pathology. Indications include dysphagia, odynophagia, dyspepsia, weight loss, anaemia, epigastric mass, partial obstruction
• I Always consider alternatives (e.g. OGD, MRI).
Contraindications
• Absolute: lack of informed consent, complete bowel obstruction, suspected perforation (a water-soluble contrast may be used instead)
• Relative: a large degree of patient cooperation is required so those unable to understand or follow instructions are unsuitable. Also, the patient must be able to stand for the duration of the examination and to lie supine if necessary.
Procedure
The patient drinks barium whilst the esophagus and stomach are imaged fluoroscopically. Usually performed by a radiologist.
• The patient stands in the fluoroscopy machine
• A gas-producing agent is ingested (e.g. Carbex®) and the patient is asked not to belch
• Images are taken as the patient swallows mouthfuls of barium. The patient must be able to hold the liquid in their mouth and swallow on command
• Once views of the esophagus have been obtained, the machine is tilted so the patient is supine. The patient is instructed to roll and tilt as images of the stomach are obtained from several angles:
• This requires a certain degree of patient fitness
• The time taken depends to a degree on how easily the patient follows the commands, although usually lasts 15-20 minutes
• After the procedure, the patient may eat and drink as usual but is advised to open their bowels regularly to avoid barium impaction.
Risks
• Leakage of barium through an unsuspected perforation:
• Intraperitoneal and intramediastinal barium has a significant mortality rate
• Barium impaction (causing large bowel obstruction) or barium appendicitis.
Patient Preparation
• Fasting: nil by mouth for 6 hours before the examination
• Bowel preparation: none required
• Smoking: patients are asked not to smoke for 6 hours before the procedure as this increases gastric motility.
Other Information
• A barium study will prevent a CT examination of the same area for a period of time as intestinal barium creates dense streak artefact.
Water-Soluble Contrast Examinations
• In the case of recent surgery, suspected perforation, or investigation of a leak, water-based iodinated contrast is used instead of barium.
Examples include Gastrografin®, Urografin®, Niopam®, Omnipaque®
• A single-contrast examination is performed (i.e. the gas-producing agent is not given and many of the 'standard' views are not included
• In contrast to the barium examinations, these studies can be carried out on patients who are frail and/or have recently had surgery
• Intraperitoneal or intramediastinal water-soluble contrast does not carry the risks of barium but aspiration of the contrast can result in pulmonary edema and lung fibrosis. Hypersensitivity is also a risk.
