Gastroenterology Services & Procedures

What is Celiac Disease?

Celiac disease is a genetic autoimmune condition. With autoimmune diseases, a person’s own immune system attacks a healthy part of the body by mistake. Celiac disease mainly affects the small intestine, but it can impact other parts of the body, too.

People with celiac disease cannot eat gluten because it damages the lining of the small intestine and affects digestion. Gluten is the general name for the protein found in wheat, rye, and barley.

Damage to the small intestine can cause inflammation. This irritation makes it more difficult to absorb or take in vitamins and minerals. Strictly avoiding gluten can help reverse the damage and control symptoms, such as gas, bloating, diarrhea, and constipation. But following a strict gluten-free diet (GFD) is tough for many people, and not always effective at treating symptoms.

Diagnosis and Treatment

Sometimes it is difficult to diagnose celiac disease. Our specialists are skilled at ruling out other conditions with symptoms similar to celiac disease. Genetic testing, blood work and endoscopy help diagnose celiac disease.

During an endoscopy, doctors use an endoscope (a thin, flexible tube with a light and camera that is inserted through the mouth) to view the esophagus, stomach, and the first part of the small intestine. Through the endoscope, they take tissue samples (biopsies) from the small intestine to confirm whether the patient has celiac disease.

What are Colon Polyps?

Polyps in the colon are growths that may be benign (not cancerous) or pre-cancerous (may develop into cancer if not removed).

Diagnosis and Treatment

Most colon polyps are discovered during routine screening tests such as a sigmoidoscopy or a fecal occult blood test (test for blood in the stool). Treatment for colon polyps is based on the size and the type of the polyp. Polyps that are likely to become cancerous should be removed. Some can be removed safely during a colonoscopy. Others may need to be removed surgically.

What are Gallstones?

Gallstones are hard stones that form in the gallbladder. They consist of cholesterol and other substances from bile. Gallstones range in size from barely measurable to 2.5 inches. Some of the factors that increase the risk of gallstones include being female, being over age 55, being obese, having a family history of gallstones, having multiple pregnancies, being of Native American or Mexican American descent, and taking female hormones such as birth control pills or hormone replacement therapy.

Many people with gallstones do not experience any physical symptoms and do not require any medical treatment. These people have "silent" gallstones. Others feel pain in the abdomen which may be intermittent or continuous, dull or sharp, and is generally located in the upper abdomen, particularly on the right side where the gallbladder is located. If pain is accompanied by a fever, nausea and vomiting, the gallbladder may be infected. In some cases, a gallstone can block the bile duct, which is indicated by symptoms such as fever, jaundice (yellowing of the skin), dark-colored urine and light-colored stools. Gallstones in the bile duct can cause other complications such as pancreatitis.

Diagnosis and Treatment

Tests often used to diagnose gallstones include blood tests, abdominal ultrasound, hepatobiliary (liver and gall bladder bile ducts) scan, and Endoscopic Retrograde Cholangiopancreatogram (ERCP). If the gallbladder is infected, it is usually removed in a procedure called a cholecystectomy. Gallstones sometimes pass into the common bile duct, causing jaundice or inflammation (cholangitis). Treatment for stones in the bile duct is based on the patient's history and the severity of his or her symptoms. Most often, treatment involves utilizing ERCP.

What is GERD?

Gastroesophageal reflux disease is a condition in which the valve between the lower end of the esophagus and the stomach (lower esophageal sphincter, or LES) does not close properly. This causes stomach acid and juices to flow back to the upper esophagus and throat. Symptoms of GERD include heartburn on a regular basis, a bitter or sour taste in the mouth, painful swallowing, difficulty swallowing, nausea, throat problems, and respiratory problems.

GERD Treatment

Treatment for GERD usually begins with dietary changes. Foods such as chocolate, coffee, onions, and peppermint may cause the LES to relax and not close tightly. Other foods can irritate the esophagus once it is affected by GERD. These include spicy foods, tomato products, and citrus fruits. Acid reducers, antacids, or prescription medications may be recommended, as well as simple lifestyle changes such as eating smaller meals and raising the head of the bed while sleeping.

More chronic cases of GERD may require more extensive testing and treatment. An endoscopy may be performed to look for possible complications of GERD such as swelling, bleeding or strictures in the esophagus.

What is Crohn’s Disease?

Crohn's disease is a chronic disorder of unknown origin characterized by inflammation of the gastrointestinal (GI) tract. Although any part of the GI tract can be affected by Crohn's disease, from the mouth to the anus, the area where the small intestine (terminal ileum) and colon (cecum) meet is the site most commonly involved. Inflammation can affect all the layers of the bowel wall and can lead to a variety of symptoms, including:

• Abdominal pain
• Diarrhea
• Intestinal bleeding
• Weight loss

These symptoms are non-specific and can be present in many other disorders, including ulcerative colitis and gastrointestinal infection.

Diagnosis and Treatment

A physician will make the diagnosis of Crohn's disease after speaking with and examining the patient, and performing a number of diagnostic tests: blood tests, X-rays, and often a colonoscopy.

Once a diagnosis of Crohn's disease is made, patients are treated with a variety of medications, often immunomodulators or biologics (drugs that affect the immune system), with the goal of controlling the patients' symptoms and making them feel well.

There is no cure for Crohn's disease; it is a chronic illness, so the goals of therapy are to get the patient feeling back to normal, keeping the patient feeling normal, and reducing the number of recurrent flares. The hope is that by achieving those goals patients are able to live normal lives without any limitations related to their disease; however, in a number of situations, surgery is required.

Because Crohn's is a chronic disease, patients need to take an active role in their treatment. Most importantly, they should not be afraid to ask questions.

What is Ulcerative Colitis?

Ulcerative colitis is a disease characterized by chronic inflammation of the colon (large intestine) accompanied, in severe cases, by ulcers in the lining of the colon. It is most often diagnosed in people between the ages of 15 and 30, although it can develop at any age, in both children and adults.

The majority of patients have inflammation in their rectum, which spreads along the colon to varying extents. The inflammation may be limited to the:

• rectum (proctitis)
• rectum and sigmoid colon (distal colitis)
• rectum, sigmoid and descending colon (left-sided colitis)

When more than just the left colon is affected, it is termed "extensive colitis." "Pancolitis" is the term used when the entire colon is inflamed.

Ulcerative colitis is a chronic condition in which individuals experience both periods of active disease (flares/relapses) and periods of mild or inactive disease (remission). Typical symptoms include:

• Frequent loose and often bloody stools
• Abdominal pain or cramping
• Nighttime awakenings
• Urgency
• Incontinence

Diagnosis and Treatment

The most accurate way to diagnose ulcerative colitis is by examining the colon with a fiber-optic endoscope inserted into the rectum. A sigmoidoscopy examines the lower third of the colon and requires minimal preparation. A colonoscopy examines the full colon and requires a thorough bowel cleansing to ensure complete visualization of the lining of the colon. When ulcerative colitis is present, the lining of the colon appears swollen and inflamed, with surface bleeding and ulcers (if severe enough) usually in a continuous pattern. Tiny samples (biopsies) of the lining of the colon are taken during the procedure, so that a pathologist may examine them under the microscope for inflammatory changes (histology).

The majority of patients diagnosed with ulcerative colitis respond to conventional medical therapy. Typical treatments involve anti-inflammatory medications (5-aminosalicylates) or immunomodulators (medications that modulate or suppress the immune system). Occasionally, medical treatment fails and surgical removal of the diseased colon becomes necessary.

What is Irritable Bowel Syndrome?

Irritable bowel syndrome is a common condition. Its symptoms include abdominal pain or discomfort associated with diarrhea, constipation, or both symptoms alternating.

The cause of irritable bowel syndrome is not known. In some cases, irritable bowel syndrome begins after an intestinal infection or a significant life stressor.

Diagnosis and Treatment

The diagnosis of irritable bowel syndrome often requires tests such as blood tests, colonoscopy, and imaging studies to exclude other causes of chronic pain and diarrhea.

Treatment for irritable bowel syndrome may include dietary changes, exercise, stress management, and medications to control symptoms and reduce pain, and alternative therapies.

The diagnosis of liver fibrosis (scarring)—which is the common pathway leading up to cirrhosis and other serious liver conditions—traditionally requires a liver biopsy, an invasive procedure in which a small piece of liver tissue is removed with a needle or through surgery.

Gastroenterology at Beth Israel Deaconess Hospital–Plymouth offers a non-invasive diagnostic testing by use of a fibroscan that can reveal any fibrosis and fatty deposits in the liver, allowing your doctor to quickly determine whether you are at risk for progression to cirrhosis. The quick and simple test is similar to ultrasound and is available in Plymouth.

What is Capsule Endoscopy?

Capsule endoscopy is a new technique to examine the small intestine. The upper endoscope and colonoscope are not able to visualize the 15-20 foot length of the small intestine to any significant extent. The capsule endoscopy allows a much more detailed view than afforded by the traditional Upper GI series X-ray. We do a capsule study to look for unexplained causes of gastrointestinal bleeding, anemia, or diarrhea.

The capsule is the size of a multi-vitamin tablet. It contains a miniature camera and a tiny battery and it takes two pictures per second as it travels through the small bowel. The images are recorded on a receiver that is worn around the waist. At the conclusion, these transmitted pictures are downloaded into the computer for viewing. The capsule will pass harmlessly in the stool.

On the day of your procedure, you will arrive at the Endoscopy Unit on an empty stomach. Sedation is not necessary. You will be asked to return 8 hours later to return the recorder. You will be allowed to drink some clear liquids two hours after swallowing the capsule and eat a light meal 4 hours after swallowing the capsule.

Risks and Complications

There are two major reasons why a capsule endoscopy should not be performed. A pacemaker would be an absolute contra-indication as pacemaker function might be disturbed by the capsule. Another would be the known presence of an obstruction as 1 to 2 percent of capsules have been found to lodge.

What is Colonoscopy?

The colonoscope is a thin flexible fiber optic tube that allows the physician to view the inside of the colon or large intestine. The lining is examined for abnormalities such as polyps or growths, inflammatory conditions called colitis, potential causes of gastrointestinal bleeding or changes in bowel habits. The procedure generally takes 30 minutes to perform. There is an operating channel in the colonoscope which allows the doctor to pass instruments to obtain biopsies or to remove polyps.

Before the Procedure

There will be a preparation to take at home the evening before the exam to clean you out. Simply put, this is, at minimum, an inconvenience and no one likes it, but this is a very important step. The more complete and thorough the cleansing process, the more accurate the procedure will be.

At the Endoscopy Unit, your medical history will be obtained and an intravenous line will be started. It is helpful if you bring a list of medications you are currently taking. You will also meet the Anesthesia team who will provide the sedation for the procedure.

After the Procedure

You will be taken to a recovery area after the procedure is completed and will be observed by the nursing staff as the sedation wears off, a process that generally takes 30 to 45 minutes. You will hear the initial results or findings of the colonoscopy while in recovery. If there are biopsies done, the results will take 3 to 5 days. It is required that all patients have a friend or relative available to drive them home.

Risks and Complications

Many patients feel gassiness or cramping immediately after the procedure. This results from the air introduced into the colon during the procedure so that the physician can see. As this gas is passed, patients feel much better. Bleeding might occur from a biopsy or the removal of a polyp. It is usually minor. A few patients might have delayed bleeding from a polypectomy up to 10-14 days later. The major complication of colonoscopy is perforation of the colon wall. Such a tear or puncture is fortunately rare, but may require emergency surgery to repair.

Every patient’s heart rhythm, blood pressure, and oxygen level are monitored continuously during the procedure to ensure the safety of the sedation.

What is Esophageal Dilation?

Esophageal dilatation is a technique that allows the physician to dilate or stretch a narrowed area of the patient’s esophagus or "food pipe". This is generally done under sedation at the time of an upper endoscopy to visualize the esophagus. Your throat is numbed with a local spray or gargle to eliminate choking or gagging. Esophageal dilatation is done to help patients who experience food sticking in the chest while eating, particularly solid food. It often results from a stricture or narrowing as a result of acid-reflux disease. Other causes might include a lower esophageal ring related to a hiatal hernia, or possibly tumor of the esophagus. Some people suffer from poor motility or peristalsis of the esophagus as food or liquids are transported downstream to the stomach.

There are a number of different techniques or pieces of equipment to carry out esophageal dilatation. A tapered tube might be passed orally through the esophagus and into the stomach. Another option the physician might choose is an inflatable balloon which is passed through the endoscope’s operating channel, much like angioplasty of a blocked blood vessel.

Risks and Complications

You may experience a sore throat for a day or two following endoscopy or dilatation which should resolve shortly. Bleeding may occur briefly, but is not usually noticed. The most serious potential risk is esophageal or gastric perforation, but fortunately this is quite rare. Esophageal dilatation is a safe and much appreciated procedure by those who have difficulty swallowing.

What is Flexible Sigmoidoscopy?

A flexible sigmoidoscopy is essentially a shorter version of a colonoscopy. The sigmoidoscope is a thin flexible fiber optic tube that is passed through the rectum into the lower third of the large intestine.

While it may have been replaced by colonoscopy for the most part as a form of colon cancer screening, flexible sigmoidoscopy may still be used for that purpose if preferred by the patient. Sigmoidoscopy is often helpful to assess for potential causes of rectal pain, sources of rectal bleeding, or extent of inflammation from colitis.

The procedure itself may take 5 to 10 minutes. There is a minimal prep. It is generally performed without sedation, with the patient lying on his or her left side. The procedure should not cause significant discomfort. The physician will introduce some air into the scope in order to see, and this may result in mild abdominal pressure or discomfort. This sensation will pass after the procedure is over. Patients are expected to be able to eat and resume all normal activities following the procedure.

Risks and Complications

Should an abnormality be detected, the physician may take a biopsy through the operating channel in the scope. This is painless but may result in minimal bleeding. The other potential complication of flexible sigmoidoscopy is perforation, or puncture of the bowel wall. However, it is extremely unusual.

What is Liver Biopsy?

There are many causes of liver disease and abnormal liver blood tests. A liver biopsy is often helpful to distinguish among various conditions. In so doing, appropriate treatment can be started. A liver biopsy may also help the physician stage the degree of involvement, particularly in chronic viral hepatitis.

A liver biopsy allows the physician to obtain a sample of the liver for microscopic analysis. It is generally performed on an outpatient basis, and the procedure itself may only take about 15 minutes. A portable ultrasound machine may be used to select the best spot for biopsy. The patient lies on his or her back, the skin is scrubbed with an antibiotic swab, and local anesthesia is used to numb the skin and underlying tissue. A special thin needle is passed into the liver to obtain the specimen.

Following the biopsy, you will be taken to the recovery unit for observation. You will be lying on your right side for several hours to provide compression, and continued bed rest for an additional two hours. Blood pressure and pulse will be checked frequently. There may be some discomfort at the biopsy site and this may also radiate to the shoulder. This generally resolves in a short period of time. A blood count is checked prior to being discharged home.

At home, you may resume your diet. You will be asked to restrict vigorous physical activity for several days after the biopsy, and avoid aspirin and non-steroidal anti-inflammatory agents such as ibuprofen or naproxen for a brief time. The results of the biopsy should be available in 3 to 5 days.

Risks and Complications

Complications are fortunately rare. Aside from discomfort as noted, bleeding can occur. The liver is a highly vascular organ, rich in blood supply. Any bleeding should be limited, and the need for a blood transfusion is very unusual. Nicking of an organ other than the liver has been described. Great care is taken to avoid this, and ultrasound certainly reduces the risk.

What is Paracentesis?

Fluid that accumulates in the abdominal cavity is termed ascites. It may develop as a result of infection, tumor, or from cirrhosis of the liver. Paracentesis is the procedure which allows needle drainage of the fluid for analysis and comfort.

It is generally performed as an outpatient procedure. The patient is generally lying on their back. The physician will select a site, and the spot will be scrubbed with an antibiotic swab. Local anesthesia is used to numb the skin and underlying tissue. A special needle will cross the abdominal wall into the abdominal space to drain the fluid. A small amount of fluid might be obtained for diagnostic purposes, but often much more is removed to relieve any abdominal pressure or distention. In such cases, an intravenous line will be started to maintain blood pressure.

Risks and Complications

Paracentesis should not be painful, and sedation is not required. There may be some stinging as the local anesthesia is applied. There is a risk of introducing infection or bleeding from the needle, but this is rare. Perforation of the bladder wall or a loop of bowel might occur, but is also very rare. A few patients may develop a leak of fluid afterwards, which should resolve in a day or two. Generally, paracentesis should be considered a safe and valuable procedure.

What is Upper Endoscopy?

The upper endoscope is a flexible fiberoptic tube that allows the physician to directly view the upper GI tract which includes the esophagus (the “food pipe”), the stomach, and the duodenum (the first part of the small intestine). Upper endoscopy allows the physician to check for any ulcers, inflammation, or possible growths, to investigate causes of pain or obstruction, and to look for and possibly treat sources of gastrointestinal bleeding. The procedure is performed under intravenous sedation to keep the patient comfortable, and generally takes 15 to 20 minutes to perform. The scope is passed orally and then advanced into the stomach. The endoscope has an operating channel which allows the physician to pass instruments to take biopsies. The lining of the GI tract does not have nerve fibers, which prevents patients from having any sensation of samples being taken.

Before the Procedure

You will need to arrive at the Endoscopy Suite on an empty stomach. This would mean no solid food for at least six hours prior to the procedure, and no clear liquids for at least 3 hours. At the Endoscopy Suite, your medical history will be obtained, and an intravenous line will be started. You should bring a list of medications you are currently taking. You will meet the Anesthesia team who will be providing the sedation to maintain comfort during the procedure. A local spray or gargle for the back of the throat will be given, which will numb the back of the gag reflex so choking or gagging will be controlled. A bite block will be placed in your mouth to protect your teeth.

After the Procedure

You will be taken to the recovery area after the exam is completed and observed by the nursing staff as the sedation wears off, a process that may take 30 to 45 minutes. When you are able to swallow, you may have something to drink and then eat. If biopsies were obtained during the procedure, the results may take 3 to 5 days. You must have a friend or relative available to drive them home.

Risks and Complications

You might experience a mild sore throat for a day or two following the procedure. There might be a sense of bloating, which can be relieved by burping or belching. A biopsy may cause some bleeding, which is rarely noticed. The major complication of upper endoscopy is perforation of the esophagus or stomach. Such a tear or puncture is very unusual, but may require surgery to repair. Every patient is monitored for their blood pressure, heart rhythm, and oxygen level during the procedure to ensure the safety of the sedation.