is miniaturized camera within a pill that is swallowed and takes video of the GI tract as it descends within the digestive tract. It transmits images wirelessly at a rate of two frames per second to a portable computer worn on the patient’s belt. The study duration is approximately 8 hours. The anatomy of interest is primarily the 20 or so feet of small bowel that can’t be reached by either an endoscope or colonoscope

Indications for the exam include the following:

• Obscure gastrointestinal blood loss
• Abnormal imaging of the gastrointestinal tract
• Chronic abdominal pain with reasonable suspicion of organic cause in the small intestine
• Chronic diarrhea
• Evaluation of Crohn’s disease
• Surveillance of polyposis syndromes

It is important not to eat or drink anything for at least six - eight hours before the exam. Anticoagulant therapy need not be discontinued.

Capsule endoscopy is usually performed first thing in the morning after an all night fast. Upon arriving to the office the morning of the capsule endoscopy study, the medical assistant will obtain an informed consent for the procedure. Next a sensory array (‘sticky patches’) is applied to the abdominal wall of the patient. The recorder device and battery pack is attached to a waist belt worn by the patient for the duration of the study. The capsule is then swallowed with water by the patient. The patient is given last minute instructions and then sent home. The patient can drink clear liquids after 2 hours; food and medications are permitted 4 hours after ingestion of the capsule. Later the same day, usually around 4:30 PM, the patient will be instructed to return to remove the recorder device so the video can be downloaded into the computer. The capsule should be spontaneously passed in the feces within 48 hours.

The video will be reviewed by the physician on a computer and a paper report generated, then sent to the referring physician. The patient will receive the results either over the phone or at a scheduled follow-up appointment.

Detailed videoscopic examination of the small bowel heretofore not possible. Sources of bleeding and anemia within the small bowel can be discovered, and although cannot yet be directly treated with the capsule, may lead to definitive medical or surgical treatment.

Alternative tests to Capsule Endoscopy include barium studies of the intestine. These tests are very insensitive for small bowel pathology..

Possible complications exist for any procedure. Capsule retention is the major concern and occurs with a frequency of 5%. Of these, < 1% require surgical retrieval. A second problem is delayed passage of the capsule resulting in termination of the recording before the capsule completes its journey through the small bowel.

A colonoscope is a long flexible tube that permits visualization of the lining of the large bowel utilizing a video monitor. The instrument is inserted via the rectum and guided through the length of the colon. If the doctor sees a suspicious area, a biopsy can be done to make a diagnosis. Polyps can also be removed by passage of a snare or biopsy forceps (depending upon the size of the polyp).

Colonoscopy is a valuable tool for the diagnosis and treatment of many diseases of the large intestine. Indications for this procedure include:

• the detection and removal of polyps, surveillance for new polyps in individuals with a past history of polyps or cancer of the colon
• those at risk for the development of colon polyps or cancer (such as individuals with a family history of colon cancer)
• assessment of abnormalities of the large bowel detected on a barium enema
• rectal bleeding
• changes in bowel habits
• inflammatory bowel disease
• therapeutic intervention such as in the setting of rectal bleeding, strictures of the colon, or abnormal
• distention of the large bowl
• abdominal pain

During the course of the examination, a polyp may be found. Polyps are abnormal growths of tissue which vary in size from a tiny dot to several inches. If your doctor feels that removal of the polyp is indicated, he will pass a wire loop or snare through the colonoscope and sever the attachment of the polyp from the intestinal wall by means of an electrical current. You should feel no pain during removal of the polyp. Polyps are usually removed because they can cause rectal bleeding, potentially grow larger and develop into cancerous growths, or contain cancer. Although the majority of polyps are benign (non-cancerous), a small percentage may contain an area of cancer in them or may develop into cancer. Removal of colon polyps, therefore is an important means of prevention and cure of colon cancer which is the second leading cause of cancer death in the United States.

Specific instructions will be provided to you regarding cleansing the bowel in anticipation of the colonoscopy examination. It is very important that the instructions be followed as outlined in order to insure a well prepared colon which will facilitate the colonoscopy. Please bring a list of medications you currently take, the dosage of these drugs, and any allergies you have to medications. If you are taking aspirin, coumadin, or "blood thinners”, please notify your doctor as the use of these drugs may need to be modified or discontinued temporarily. A companion must accompany you to the examination because you will be given medication (s) to sedate you during the procedure. You will feel drowsy and consequently you will need someone to take you home since driving an automobile is not allowed after the procedure. Even though you may not feel tired, your judgment and reflexes may not be normal.

A small catheter for intravenous (IV) medicines will be placed in an arm vein prior to the procedure. Sedating medicine will be injected through this catheter that will make you relaxed and sleepy. You will be placed in a comfortable position on your left side and the doctor will examine the rectum gently with a lubricated gloved finger. The colonoscope will then be placed into your rectum and advanced to permit examination of the colon. You may feel some cramping or gas from air that is introduced during the procedure although air can be suctioned from the colon during the examination. There may also be some discomfort as the instrument negotiates turns or bends In the colon. You may be placed into a different position during the examination (such as on your back) in order to facilitate passage of the instrument through the entire large bowel. The nurse who assists the doctor during this procedure may also compress the abdomen with their hand in order to reduce looping of the colonoscope and facilitate passage of the instrument through the colon.

The examination usually takes approximately 30 minutes to complete, however, more or less time may be utilized depending upon the specific colon anatomy and whether biopsies, polyp (s) removal, or specific intervention is indicated.

You will be kept in the endoscopy recovery area until most of the effects of the medication have worn off (30 - 60 minutes). You may feel somewhat bloated after the examination because of air that was introduced to perform the examination. You will be able to resume your diet after the examination but you may receive special dietary guidelines based upon the findings of the colonoscopy or if a polyp is removed. The findings of the examination will be reviewed with you and additional recommendations, if necessary will be discussed.

Colonoscopy and polypectomy are safe and are associated with very low risk. One possible complication is perforation in which a tear through the wall of the bowel may allow leakage of intestinal fluids. This complication usually requires surgery for treatment. Bleeding may occur from the site of biopsy or polyp removal. It is usually minor and stops on its own or can be controlled by cauterization (application of an electrical current) through the colonoscope. Rarely transfusions or surgery is required. Irritation of a vein at the site where medications were administered may also occur. Drug reactions may also occur despite careful review of an individual's medical history. Finally, like any test, pathology may be missed in a small number of cases leading to an error in diagnosis.

Upper GI endoscopy, sometimes called EGD (esophagogastroduodenoscopy), is a visual examination of the upper intestinal tract using a lighted, flexible fiberoptic or video endoscope. The upper gastrointestinal tract begins with the mouth and continues with the esophagus (food pipe) which carries food to the stomach. The J-shaped stomach secretes a potent acid and churns food into small particles. The food then enters the duodenum, or small bowel, where bile from the liver and digestive juices from the pancreas mix with it to help the digestive process.

Due to factors related to diet, environment, heredity and infection the upper GI tract is the site of numerous disorders. These can develop into a variety of diseases and/or symptoms. Upper GI endoscopy helps in diagnosing and often in treating these conditions:

• ulcers—which can develop in the esophagus, stomach or duodenum and occasionally can be malignant
• tumors of the stomach or esophagus
• difficulty in swallowing
• upper abdominal pain or indigestion
• intestinal bleeding—hidden or massive bleeding can occur for various reasons
• esophagitis (and heartburn)—chronic inflammation of the esophagus due to a back up of stomach acid and digestive juices
• gastritis—inflammation of the lining of the stomach

It is important not to eat or drink anything for at least eight hours before the exam. The physician instructs the patient about the use of regular medications, including blood thinners, before the exam.

Upper GI endoscopy is usually performed on an outpatient basis. The throat is often anesthetized by a spray or liquid. Intravenous sedation is usually given to relax the patient, deaden the gag reflex and even cause short-term amnesia. For some individuals who can relax on their own and whose gagging can be controlled, the exam is done without intravenous medications. The endoscope is then gently inserted into the upper esophagus. The patient can breath easily throughout the exam. Other instruments can be passed through the scope to perform additional procedures if necessary. For example, a biopsy can be done in which a small tissue specimen is obtained for microscopic analysis. A polyp or tumor can be removed using a thin wire snare and electrocautery (electrical heat). The exam takes from 15 to 30 minutes, after which the patient is taken to the recovery area. There is no real pain with the procedure and patients seldom remember much about it.

After the exam, the physician will explain the results to the patient and family. If the effects of the sedatives are prolonged, the physician may suggest an interview at a later date when the results can be fully understood. If a biopsy has been performed or a polyp removed, the results are not available for three to seven days.

An upper GI endoscopy is performed primarily to identify and/or correct a problem in the upper gastrointestinal tract. This means the test enables a diagnosis to be made upon which specific treatment can be given.

Alternative tests to upper GI endoscopy include a barium X-ray and ultrasound (sonogram) to study the organs in the upper abdomen. These exams, however, do not allow for a direct viewing of the esophagus, stomach and duodenum, removing of polyps or taking of biopsies. In addition, study of the stools, blood and stomach juice can provide indirect information about a gastrointestinal condition.

A temporary, mild sore throat sometimes occurs after the exam. Serious risks with upper GI endoscopy, however, are very uncommon. One such risk is excessive bleeding, especially with removal of a polyp. In extremely rare instances, a perforation, or tear, in the esophagus wall can occur. These complications may require hospitalization and, rarely, surgery. Quite uncommonly, a diagnostic error or oversight may occur. Due to the mild sedation, the patient should not drive or operate machinery following the exam. For this reason, a driver should be available.

ERCP stands for endoscopic retrograde cholangiopancreatography. As hard as this is to say, the actual exam is fairly simple. A dye is injected into the bile and pancreatic ducts using a flexible, fiberoptic video endoscope. Then x-rays are taken to outline the bile ducts and pancreas.

The liver produces bile, which flows through the ducts, passes or fills the gallbladder and then enters the intestine (duodenum) just beyond the stomach. The pancreas, which is six to eight inches long, sits behind the stomach. This organ secretes digestive enzymes that flow into the intestine through the same opening as the bile. Both bile and enzymes are needed to digest food.

Due to factors related to diet, environment and heredity, the bile ducts, gallbladder and pancreas are the seat of numerous disorders. These can develop into a variety of diseases and/or symptoms. ERCP helps in diagnosing and often in treating the condition.

• Gallstones, which are trapped in the main bile duct
• Blockage of the bile duct
• Yellow jaundice, which turns the skin yellow and the urine dark
• Undiagnosed upper-abdominal pain
• Cancer of the bile ducts or pancreas
• Pancreatitis (inflammation of the pancreas)

The only preparation needed before an ERCP is to not eat or drink for eight hours prior to the procedure. Alert the physician to any blood thinners (e.g. coumadin), aspirin, motrin, ibuprofen or similar medications you may be taking, for these should be stopped several days prior to the procedure.

An ERCP uses x-ray films and is performed in an x-ray room. The throat is anesthetized with a spray or solution, and the patient is usually mildly sedated. The endoscope is then gently inserted into the upper esophagus. The patient breathes easily throughout the exam, with gagging rarely occurring. A thin tube is inserted through the endoscope to the main bile duct entering the duodenum. Dye is then injected into this bile duct and/or the pancreatic duct and X-ray films are taken. The patient lies on his or her left side and then turns onto the stomach to allow complete visualization of the ducts. If a gallstone is found, steps may be taken to remove it. If the duct has become narrowed, an incision (papillotomy) can be made using electrocautery (electrical heat) to relieve the blockage. Additionally, it is possible to widen narrowed ducts and to place small tubing (stents) in these areas to keep them open. The exam takes from 20 to 90 minutes, after which the patient is taken to the recovery area. If a papillotomy is performed, the patient is routinely admitted to the hospital overnight for observation and discharged the following morning provided no complications are identified.

After the exam, the physician explains the results. If the effects of the sedatives are prolonged, the physician may suggest an appointment for a later date when the patient can fully understand the results.

An ERCP is performed primarily to identify and/or correct a problem in the bile ducts or pancreas. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a gallstone is found during the exam, it can often be removed, eliminating the need for major surgery. If a blockage in the bile duct causes yellow jaundice or pain, it can be relieved.

Alternative tests to ERCP include certain types of x-rays (CAT scan, CT) and sonography (ultrasound) to visualize the pancreas and bile ducts. In addition, dye can be injected into the bile ducts by placing a needle through the skin and into the liver. Small tubing can then be threaded into the bile ducts. Study of the blood also can provide some indirect information about the ducts and pancreas.

A temporary, mild sore throat sometimes occurs after the exam. Serious risks with ERCP, however, are uncommon. Inflammation of the pancreas also can develop in 7% of cases. There is approximately a 1% risk of excessive bleeding and perforation, or tear in the intestinal wall, especially when electrocautery is used to open a blocked duct. These complications may require hospitalization and, rarely, surgery. Complications from ERCP, although rare, and can in rare circumstances lead to death.

Due to the mild sedation, the patient should not drive or operate machinery for six hours following the exam. For this reason, a driver should accompany the patient to the exam.

Sigmoidoscopy is the visual examination of the inside of the rectum and sigmoid colon using a lighted, flexible fiberoptic or video endoscope. The colon, or large intestine, is 5 to 6 feet long. During a sigmoidoscopy, only the last 1 to 2 feet of the colon is examined. This last part of the colon, just above the rectum, is called the sigmoid colon.

Sigmoidoscopy is performed to diagnose causes of symptoms or as a preventative measure to detect problems at an early stage before they are even apparent to the patient.

Bleeding-Rectal bleeding is very common. It often is caused by hemorrhoids or a small tear at the anus, called a fissure. However, more serious problems can cause bleeding. Benign polyps can bleed. It is important to identify and remove polyps at an early stage before they become malignant. Rectal and colon cancers bleed and require immediate diagnosis and treatment. Finally, various forms of colitis and inflammation can cause bleeding.

Diarrhea - Persistent diarrhea should always be evaluated by Sigmoidoscopy There are many causes of diarrhea and the exam is of great help in tracking down the specific cause.

Pain - Hemorrhoids and fissures are some causes of pain around the anus or in the rectum. Discomfort in the lower abdomen can be caused by tumors as well as diverticuli. This condition is called diverticulosis. Small pockets or sacks project from the bowel in this condition.

X-ray Findings - A barium enema x-ray exam may show abnormalities that need to be confirmed or treated by Sigmoidoscopy

Detection - Colon cancer is the most common cancer in this country. it is highly curable if it is found early. This cancer may begin in the colon as a polyp that remains benign for many years. Therefore, it is generally advisable to have a surveillance exam after age 40. If there is a history of

colon polyps or cancer in parents or siblings, it is even more critical to have this exam because there is a definite hereditary aspect of colon cancer.

To obtain the full benefits of the exam and allow thorough inspection, the rectum and sigmoid colon must be clean. Preparation usually involves drinking clear liquids the day before along with taking enemas and/or laxatives. Specific instructions for preparation are always given by the physician’s office.

Flexible sigmoidoscopy is performed on an outpatient basis, usually in the doctor's office. It performed with the patient lying on the left side with the legs drawn up. A sheet is placed over the lower body. A finger or digital exam of the anus and rectum is performed. Then the sigmoidoscope is gently inserted into the rectum. Air is inflated into the bowel to distend it and allow for careful examination. The patient usually feels this distention of the rectum. The scope is then advanced under direct vision and moved around the various bends in the lower bowel.

The scope is advanced as far as possible without causing undue discomfort. When possible, the exam is continued to 25 inches (60 cm). Certain conditions, such as diverticulosis, irritable bowel syndrome or prior pelvic surgery, may produce discomfort when the sigmoid colon is entered by the scope. The exam is stopped if this occurs. The entire exam usually takes only 5 to 10 minutes. Sedation is not normally required.

The benefits of Sigmoidoscopy are considerable. A specific diagnosis can often be made. A condition, such as colitis, can be monitored following treatment. Polyps and tumors can be discovered at an early stage.

Alternative testing includes barium enema X-ray exams. Additionally, the stools can be examined in a variety of ways to uncover or study certain bowel conditions. However, direct visualization of the lower rectum and lower bowel is by far the best method of examining this area.

Bloating and bowel distention are common due to the air inflated into the bowel. This usually lasts only 30 to 60 minutes. If biopsies are done or if a polyp is removed, there may be some spotting of blood. This is rarely ever serious. Other very uncommon risks include a diagnostic error or oversight, or a tear (perforation) of the wall of the colon which might require surgery.

The liver is a very large organ in the right upper abdomen. In fact, most of the liver lies behind the ribs in the right-lower chest. The liver is remarkable, quietly making many proteins, eliminating waste products, and participating in the general metabolism and nutrition of the body. There are many different problems that can occur in the liver. These include virus infections, reactions to drugs or alcohol, tumors, hereditary conditions, and problems with the body's immune system.

The physician will always take a medical history and perform a physical exam. Blood studies, known as liver function tests (LFT), give an overview of the health of the liver. If LFT results are persistently abnormal, the physician will then perform additional medical studies to determine the exact cause of the problem. This is particularly important because there are now effective treatments for many chronic liver disorders. Finally, the physician will want to know not only the specific cause of the problem, but also the severity of it. The liver biopsy helps answer these questions.

A biopsy is a small sample of body tissue. This tissue is prepared and stained in a laboratory. The physician can then view it under a microscope. By so doing, he or she can often make a specific diagnosis and determine the extent and seriousness of the liver disease. This information is often vital in determining the treatment.

The liver biopsy is usually performed on an outpatient basis in the radiology department at the hospital. At times, an ultrasound or echo machine is used to identify the best location to make the biopsy. Usually, the physician can make this determination simply by examination. The patient lies quietly on the back or slightly to the left side. In some instances, the patient will be given some mild sedation at this point. The physician usually reaches the liver through the lower-right chest between the ribs. That area is first carefully cleaned. A local anesthetic agent like Novocain is used to numb the skin and tissue below. A specially designed thin needle is inserted through the skin. At this point, the physician will tell the patient how to breathe. The needle is quickly advanced into and out of the liver, taking only 1 or 2 seconds. This should not hurt due to the local anesthetic given to you. A slender core of tissue is thereby obtained which is then processed through the laboratory. The entire procedure from start to finish lasts only 15 to 20 minutes.

The patient is kept at rest for several hours following the exam. Medical personnel check the heart rate and blood pressure. At times, there is some discomfort in the chest or shoulder after the anesthetic wears off. This is usually temporary and medication is available if needed. The patient is given instructions regarding activity and eating before being discharged home. Activity is usually restricted for a day or so afterward.

In most instances, a liver biopsy is obtained quickly with no problems. As noted, there is occasionally some fleeting discomfort in the right side or shoulder. Internal bleeding can sometimes occur, as can a leak of bile from the liver or gallbladder. These problems are usually handled conservatively without the need for surgery.

A liver biopsy is a simple, rapid method of obtaining a sample of liver for analysis. This information is of great importance in guiding the physician in his or her evaluation and treatment. While some complications can occur, they are unusual. The benefits of the exam always outweigh the risk. With this biopsy information, effective and specific therapy can usually be provided to the patient.

If you need to have x-rays or other special radiologic studies performed, your doctor will explain what tests are necessary and why. Here is a summary of the four basic exams:

Barium is administered to highlight the GI tract when exposed to x-rays. Barium is an inert, harmless mineral that prevents the passage of x-rays - just as your hand blocks sunlight. During an Upper GI

Series, you are given a flavored "milkshake" of liquid barium to drink. The barium fills your stomach making it visible on the x-ray film. The standard Upper GI evaluates the esophagus, stomach, and first portion of your small intestine - called the duodenum. This takes about 30 minutes. If your doctor requests that the remaining twenty feet of small intestine also be evaluated, the test is termed a Small Bowel Series and takes an additional two to three hours to complete. Both examinations require fasting after midnight, but no laxative preparation is necessary. You may drive yourself to and from this exam.

A similar examination of the large intestine, or colon, is called Lower GI, or Barium Enema. Of course, in this instance, the barium is not swallowed, but is given rectally as an enema. You will be placed on an x-ray table and a small soft tube will be inserted into the rectum. Through this tube the technician will fill the colon with barium and air before x-rays are taken. This examination takes less than an hour and requires fasting as well as an unpleasant laxative and dietary preparation the day before. Prep instructions vary and will be provided by our staff. Be sure to follow them exactly so the test need not be repeated.

An Ultrasound test utilizes specialized sound waves that bounce off your internal organs to obtain images - much like the way a fisherman users sonar to find the fish.

The pitch, or frequency, of these sound waves is far above the range of human hearing, hence the name Ultrasound. An Ultrasound is also the examination that is given to pregnant women to check the size of their baby before delivery. This same exam can also be used to visualize certain digestive organs, such as the gallbladder, liver and pancreas as well as the main abdominal blood vessel, the aorta.

During an ultrasound, you will be positioned on an examination table and a gel will be applied to your abdomen. A small probe, called a transducer, will be passed over the surface of your abdomen. The test is quick, painless, and requires very little preparation. Fasting after midnight is usually required. If your doctor also requests an evaluation of the lower abdomen, or pelvis, a full urinary bladder is also required. You may drive yourself to and from this exam.

A CAT Scan, also known as CT Scan, uses a complex computerized x-ray scanner that takes multiple views of your abdominal organs as you lie on a flat table.

A high speed computer analyses the information to create cross sectional images of parts of your body. The radiologist can then view these images in sequence, like slices in a loaf of bread, and create a virtual three dimensional view of your abdominal organs. CT is best suited for viewing the more solid digestive organs like liver, pancreas and kidney, and less suited for viewing the tubular air field intestinal tract.

Preparation consists of drinking plenty of fluids up until four hours before the examination. During the last four hours, you should avoid all food and drink.

Since the contrast material can potentially damage poorly functioning kidneys, you may be asked to give a blood sample to test your kidney function.

To make the examination more accurate, you will be asked to drink an oral contrast solution before the scan. Additional contrast material may also be given by vein to enhance the images. Since this solution contains iodine, be sure to tell the doctor if you have ever had an allergic reaction to iodine, IVP or catheterization dye, or shellfish. Depending on the nature of your previous reaction, the solution will have to be modified or simply not used.

The CT scan itself is simple and painless, and usually takes less than an hour to complete. Serious side effects are rare, but a temporary feeling of warmth and mild nausea are common after the IV contrast injection. After the examination, you will be able to resume your normal activities and diet. You should drink plenty of fluids for 24 hours after the examination to help flush out your system.

In some instances, your doctor may request that you have a nuclear scan. Although the name sounds a little unsettling, a nuclear scan involves only a small "tracer" dose of radioactive material, and is not dangerous.

Once this tracer is injected into your system, it can be followed through your digestive organs as you lie directly underneath a large, flat nuclear camera. A nuclear scan is most often used to assess liver and gallbladder function. Other uses include measurement of stomach emptying and localization of intestinal bleeding. Nuclear scans require very little preparation. You may drive yourself to and from these exams.

Where Is The Test Performed?

X-ray, Ultrasound, CAT scan and Nuclear Scan exams require specialized equipment and highly trained technicians. They are usually performed in a hospital our specialized outpatient facility.

Who Performs The Exam?

In most cases, the examination will be performed by a specially trained technician who is expert in using the equipment. The radiologist may or may not be present depending on the circumstances. However, the radiologist will review the final films and dictate with an official result.

How Do I Schedule My Test?

Our office can assist you in obtaining all the necessary information to schedule your examination with your local outpatient radiology department. Any special preparation instructions will be provided.

What About Side Effects?

There are no known side effects to health from ultrasound. Nuclear scans, CAT scans, and barium x-rays expose your body to small amounts of radiation. Any woman who is pregnant, or thinks she might be, or is breastfeeding, should let her doctor know before scheduling the examination. Also, if you believe that you are allergic to iodine dyes and are scheduled for a CT scan, notify your doctor.

If barium was used for your test, you might want to take a mild laxative such as an ounce of Milk of Magnesia after the x-ray. This helps eliminate the barium from your system. If this is not done, the barium can harden, much like plaster of Paris, making elimination quite difficult.

How Do I Get The Results?

Once the test is completed, the films are developed and analyzed by the radiologist who then dictates a written report. Your doctor will contact you after reviewing the results in the context of your case. This may take about a week, but most reports arrive sooner.

In 1980, Dr. Jeffery Ponsky in Cleveland Ohio developed new non-operative technique called Percutaneous Endoscopic Gastrostomy, commonly called "PEG." Percutaneous means "going through the skin. So, this feeding tube bypasses the mouth and esophagus by passing through the skin and muscle of the abdominal wall directly into the stomach.

This technique can be done without the need for general anesthesia or a major abdominal incision. It is usually performed by a gastroenterologist. Using a endoscope to guide placement, a tunnel can be created between the skin and the stomach with only a 1/2" incision. PEG is particularly well suited for patients who have an increased risk for surgery. It can be performed in approximately 15

minutes, requires minimal sedation rather than general anesthesia, and can be accomplished at the bedside, if necessary. PEG has a low complication rate and is successful in over 95% of cases.

Liquid nutritional formulas are put into the tube and directly into the stomach - bypassing the disturbed swallowing function. These solutions can provide complete nutrition. Common solutions are Jevity and Ensure. The doctor and dietitian usually work together to determine which formula is best for each individual, and how much formula will be needed to meet that patient's nutritional needs. In addition, water and medications can be given through the tube.

PEG placement is not for everybody. It is still a surgical procedure with some risk and best serves those with a reversible problem or long term need for nutritional support. Poor candidates for a PEG would include:

• Patients with a terminal illness. It is not appropriate to use a PEG tube in those with a limited life expectancy. They can be treated with a NG tube or thin feeding tube inserted through the nose.
• Patients with a tight blockage of the esophagus. A PEG obviously can't be done if the endoscope cannot be passed through the esophagus into the stomach. This might happen in a case of a very narrow esophagus from cancerous invasion.
• Patient with a blockage of the digestive tract cannot be fed through a PEG tube - although a PEG is sometimes used in the circumstance to help deflate a blocked and swollen stomach.
• Patients with peritonitis - a serious infection within the abdomen sometimes caused by a ruptured organ like the appendix. (This can also result from premature PEG tube removal.)
• Patients with severe liver failure and massive abdominal fluid collection (ascites)
• Patients with poor blood clotting either from liver disease, a blood disorder, or due to a "blood thinner" such as Coumadin blood thinners. Clotting disorders must be corrected before PEG placement can be done.
• Patients with kidney failure on peritoneal dialysis
• Patients with a deformed stomach usually from a large hiatal hernia or prior stomach surgery
• Patients who are morbid obesity - over 100 pounds overweight.
• Patients with stomach cancer if the cancer is directly in the path of the PEG tube or if the cancer blocks the drain of the stomach (pylorus).

Typically, use of the PEG for medications can begin immediately after it is placed. After approximately 4 hours, it’s OK to initiate feeding with an eternal formula. The patient should be sitting upright or in a reclined position maintaining one’s head up at least 30 degrees while being fed through the tube.

In general, this is a relatively safe procedure, however, complications due occur. The most frequent complication is infection of the skin at the tube insertion site. This can occur is up to 20% of cases. The risk is minimized by giving prophylactic antibiotics at the time of tube placement. Other reported complications that occur with less frequency include peritonitis, aspiration pneumonia, bleeding and bowel perforation. Because these procedures are usually being performed on elderly or very ill patients, any of the complications could be associated with a poor outcome.

1. How do I unblock the tube?
   » Flushing tubes with water before and after feedings will prevent most blockages. If the formula, water, or medication will not go in, first check that the tube is not kinked. Occasionally, the tube will be blocked by residues from formula or medication. To remove the blockage, place a syringe into the blocked tube. Gently pull back on the plunger to remove the blockage. If the blockage remains, use the syringe to instill water into the tube. The tube may also be milked with the fingers. Place one hand holding the tube securely at the base. With the other hand run your thumb and forefinger down the tube to remove the blockage. If both methods fail, call your doctor.
2. What if the tube is pulled out?
   » Confused patients may try to remove the tube. It is very important NOT to pull out the tube in the first two weeks after PEG tube placement. Serious complications could occur. But, once the tract has healed, there is not much risk in removal of the tube. The opening in the abdominal wall will probably leak for a few days and then eventually seal itself - much like a pierced ear. If the patient pulls at the tube, do not panic. Cover the opening with a small, light dressing and call the patient's doctor.
3. What if the stoma looks infected?
   » Once the initial healing takes place infection of the stoma is uncommon. Clean the area several times a day as prescribed. If signs of skin irritation (redness, soreness, pain, swelling, unusual drainage) persist, call the patient's doctor.
4. What if there is leakage at the stoma?
   » Leakage may occur because the tube has pulled away from the abdominal wall or because the stoma site is enlarged. If the stoma site has enlarged, the doctor may need to replace the tube. Contact the doctor if the leakage does not stop.
5. What if the feeding tube becomes disconnected?
   » If the feeding tube becomes disconnected, estimate the amount of formula lost, reattach the feeding tube, and continue feeding, adding the estimated amount of lost formula.
6. What if the tube is shorter or longer than usual?
   » The length of the tube when originally placed is noted. Ask the patient's doctor or health care provider about marking the tube where it should be located. The tube should have a small amount of "play," but if the tube has become longer or shorter than the original length by more than the number of inches noted, it may be migrating (moving). Call the patient's doctor if there is a significant change in the tube's length.
7. What feeding solution is used?
   » There are many nutritional supplements on the market that can be given through the PEG tube. Nutritional prescriptions are usually provided by the physician or dietician.
8. How much feeding solution is given?
   » Every patient is given a unique nutritional prescription. Some patients can't eat at all and depend completely on the feeding tube for all of their nutrition. They may receive as many as 8 cans a day (2400 calories). Other just need a little help and require less.
9. Can the patient still eat and swallow once the PEG feeding tube is inserted?
   » For some patients, swallowing is either impossible or associated with high risk of aspiration pneumonia. These patients cannot take anything by mouth. Other patients, who still have an intact swallowing mechanism, may take nourishment orally and supplement any caloric deficits with tube feeding

The esophagus is the long, narrow food pipe (gullet) that carries food and liquid from the mouth to the stomach. It can become blocked or injured in a variety of ways. Esophageal dilatation is the technique used to stretch or open the blocked portion of the esophagus.

There are several causes of blockage or stricture of the esophagus. They all can make swallowing food and/or fluids difficult. The physician's first job is to find the reason for the stricture or narrowing. The answer can usually be provided by the medical history, physical exam, x-rays, and endoscopy (a visual exam of the esophagus using a flexible fiberoptic tube).

Acid Peptic Stricture - This condition is the most common of all. The stomach produces acid which, in turn, can reflux into the esophagus. This event is frequently worsened by the presence of a hiatus hernia. Over time, the acid and peptic stomach juices injure the esophagus, causing inflammation and then scarring. The fibrous scar then contracts and - narrows the esophageal opening.

• Schatzki's Ring - This condition is really exactly that, a narrow ring of benign fibrous tissue constricting the lower esophagus. Physicians still do not know how it develops.
• Ingestion of Caustic Agents - Children are particularly prone to swallowing liquid lye and other agents which can severely bum the esophagus, leaving it narrowed.
• Achalasia - This condition is uncommon and quite fascinating to physicians. The problem is a persistent and marked spasm of the lower esophageal muscle. This spasm just does not open up to allow food and fluid through. The result is a persistent blockage with subsequent slow trickling of the esophageal contents into the stomach.
• Tumors - Various forms of tumors, benign and malignant, can block the esophagus. This condition is obviously very important to diagnose and treat promptly.
• Heredity - The esophagus may be partially or completely blocked at birth.

In most instances, the problem is a mechanical one with an obstruction acting like a dam across a stream. Therefore, the treatment must be mechanical. The dam must be broken. After a diagnosis is made, the physician determines the method of treatment that is in the patient's best interest. The physician has a variety of techniques available. Each has benefits and is appropriate in specific cases. The physician will always discuss these options with the patient.

» Simple Dilators (Bougies) - These are a series of flexible dilators of increasing thickness. One or more of these are passed down through the esophagus at a setting. The bougie is the simplest and quickest method of opening esophagus.

» Guided Wire Bougie - In some instances, physician performs endoscopy and places a flexible wire across the stricture. The scope is removed and the wire left in place. A dilator with a hole through it from end to end is guided down the esophagus and across the stricture. One or more of these dilators are passed over the wire. At the end of the procedure the wire is removed. This type of treatment may be performed in the endoscopy department under fluoroscope.

» Balloon Dilators - Flexible endoscopy allot the physician to directly view the stricture Deflated balloons are placed through the scope and across the stricture. When inflated they become sausage shaped, stretch, and break the stricture.

» Achalasia Dilators - Achalasia is a special situation which requires a larger balloon dilator. The procedure is always done under x-ray control. In this situation, the spastic muscle fibers in the lower esophagus are stretched and broken, which in turn allows easier passage of food and liquid into the stomach.

As mentioned, there are a number of dilating techniques available to the physician. Simple bougie dilatation may be done in the office, in a sitting position, and with only an anesthetic spray of the throat. If endoscopy is performed at the same time, then it will be done in the endoscopy suite, usually under sedation. X-ray fluoroscope equipment may be needed. Simple bougie dilatation may take only a few minutes. The other techniques require 20 to 30 minutes. Recovery is usually quick and the patient can soon begin eating and drinking to test the effectiveness of the treatment.

Esophageal dilatation is usually performed effectively and without problems. However, some complications can occur. A small amount of bleeding almost always happens at the treatment site. At times, it can be excessive, requiring evaluation and treatment. An

uncommon but known complication is perforation of the esophagus. The wall of the esophagus is thin and, despite the best efforts of the physician, can tear. An operation may be required to correct this problem.