What is the pylorus?

The pylorus is the sphincter located at the end of the stomach, at its transition with the duodenum. With the stomach’s contraction movements, the pylorus opens and allows the stomach content to pass into the duodenum.

Pyloric stenosis

Pyloric stenosis is the partial or total narrowing of the pylorus that prevents the progression of the stomach content to the duodenum.

Pyloric stenosis can occur due to 3 main causes:

1- Hypertrophic pyloric stenosis: a condition that occurs in some newborns where the muscle of the sphincter becomes very “tight” and prevents the stomach content from passing into the intestine. In these cases, children have vomiting crises and become malnourished. The resolution of this problem is done by surgery through the pyloroplasty procedure.

2- Stomach tumors: some stomach tumors can grow to the point of causing obstruction of the pylorus, preventing the progression of the stomach content. In these cases, surgery is usually performed to remove the affected part of the stomach. In very advanced cases, an expandable stent can be passed through endoscopy for decompression.

In some cases where stent placement is not possible, the gastric bypass procedure is performed, connecting the stomach to the intestine.

3- Benign stenosis: some ulcers of the stomach or pylorus can, when healing, lead to retraction of the organ wall and closure of the pylorus. In these cases, endoscopic dilation of the region with a hydrostatic balloon type is performed.

In cases where there is no improvement with the dilations, surgical treatment of the problem is performed.

Complications

Pyloric dilation is generally performed effectively and without problems. Some complications that may occur are:

• A small amount of bleeding almost always occurs when the dilation is performed. If this bleeding is excessive, it may require more aggressive treatment.
• Another complication is perforation (a hole in the organ wall). If this happens, an operation may be necessary to repair the problem.
• Rarely, a small perforation can lead to infection, which can remain localized or even spread to neighboring organs.

During ERCP, after catheterization of the biliary tract and infusion of contrast, an X-ray is performed, which can show stones that may be obstructing the bile flow and causing symptoms in the patient.

After this diagnosis, an endoscopic sphincterotomy is performed to widen the exit of the bile duct. This allows for the removal of stones from the biliary tract and enables the normal return of bile drainage from the liver to the duodenum.

Usually, simply opening the exit of the bile duct is not enough for the stone to pass. In these cases, we need to insert instruments through the duodenoscope such as baskets or balloons to sweep the biliary tract from top to bottom and thus extract the stones.

When the stone is very large, we need to break it up to remove it, this procedure is called mechanical lithotripsy. This is performed by capturing the stone with a basket, which is then closed until the stone breaks.

Occasionally, if the stone does not break or is too large, a stent can be placed through the opening to drain the biliary tract and relieve the obstruction. Generally, the examination is repeated a few days later for another attempt at stone removal by endoscopy. If attempts by endoscopy fail, the patient is subjected to surgery to definitively resolve the problem.

Elastic band ligation is considered the best procedure for the treatment of esophageal varices. These arise in patients who have increased pressure in the portal vein (portal hypertension), which has several causes, with the main one being hepatic cirrhosis.

The procedure is performed to prevent the rupture of these vessels, thus avoiding episodes of gastrointestinal bleeding. It is also used to stop bleeding that has already been caused by a variceal rupture.

Every patient with esophageal varices should undergo periodic monitoring with their doctor, who, in addition to prescribing medications, may request elastic band ligation of the varices when necessary.

During the procedure, the patient is sedated as with all digestive endoscopies. A ligation device is then attached to the tip of the endoscope, with the elastic band trigger handle at the other end of the endoscope, where the endoscopist performs maneuvers with the device.

After the introduction of the device, the endoscopist identifies the dilated veins (varices) and sucks the point to be ligated into the device. After this, the ligation device is rotated, releasing the rubber band, which strangles the portion of the varix that was sucked in.

This strangulation causes the varix to decrease in size until it “dries up.” This process takes about 2 weeks. Sessions are usually repeated every 15 days until the varices disappear. Generally, 3 to 6 sessions are required for complete treatment.

After the procedure, the patient may feel some discomfort swallowing on the first day, which is normal and subsides in about 3 days. Therefore, during this period, the patient should have a liquid diet and then a soft diet. They should also avoid hot foods and liquids that can cause the rubber bands to come off prematurely and predispose to bleeding.

Guidelines for the exam:

• The presence of an adult companion from the time of arrival until the end of the procedure is an indispensable condition for the performance of variceal ligation. In the case of patients under 18 years of age, the companion must necessarily be a legal guardian.
• To undergo variceal ligation, the patient must have recent results of complete blood count, prothrombin time (PT), and platelet count. In addition, previous endoscopy reports must be presented.
• Medications with ASA (aspirin) and anticoagulants, such as warfarin (Marevan®, Coumadin®), clopidogrel (Plavix®), and ticlopidine (Ticlid®), should be discontinued ten days before the procedure, always under the supervision of the prescribing physician.

On the eve of the procedure

The patient should have a light dinner, avoiding fatty food.

On the day of the procedure

A fast of eight hours, even from liquids.

Attention: It is not possible to perform other invasive abdominal examinations on the same day (example: colonoscopy).

The procedure lasts, on average, 40 minutes, including preparation time.

At the end of the procedure, the patient needs to rest for about an hour.

Post-procedure care:

Due to the use of anesthesia, it is not possible to drive cars or other vehicles for the entire day after esophageal variceal ligation. For the same reason, for a period of approximately eight hours after the procedure, the individual cannot perform tasks that require attention, such as working with machinery and sharp objects.

The medication used in anesthesia can cause a short period of amnesia.

The patient should rest for the remainder of the day, eating as medically recommended.

For the 3 days following the procedure, the patient should have a diet consisting only of liquids and soft foods. They should also avoid hot food and liquids.

They should also not engage in physical activity or carry weight for at least 3 days.

What are gastric varices?

Some patients with portal hypertension may develop dilated veins (varices) in the stomach. These are usually located near the transition of the stomach to the esophagus or in the initial part of the stomach called the “gastric fundus”.

Gastric varices are generally large vessels that, when ruptured, cause high-volume gastrointestinal bleeding. Hence the need for their treatment.

Because they are voluminous, the substances that are used for the sclerosis of esophageal varices are not sufficient to “dry out” the varices of the stomach. Therefore, in these cases, we need to use a “biological glue” that when injected sticks to the tissue of the dilated vessel causing it to be obstructed.

This glue can be used during an episode of acute bleeding from these varices. In some cases, it can also be used to prevent this from occurring.

After a few weeks from the injection of the glue, the body expels it, and this process leads to the healing that “dries out” the dilated vein in that region.

Guidelines for the examination:

This procedure aims to treat gastric varices endoscopically.

The presence of an adult companion from the time the client arrives until the end of the procedure is an indispensable condition for the execution of the examination.

To undergo the procedure, the patient must have recent results of complete blood count, prothrombin time, and platelet count. In addition, previous endoscopies must be presented.

Medications with ASA (aspirin) and anticoagulants such as warfarin (Marevan®, Coumadin®), clopidogrel (Plavix®), and ticlopidine (Ticlid®), should be suspended seven to ten days before the procedure, evidently under the supervision of the attending physician.

On the eve of the procedure

The patient should have a light dinner, avoiding fatty food.

On the day of the procedure

Fasting for eight hours, even from liquids.

Attention: it is not possible to perform other invasive abdominal examinations on the same day, such as colonoscopy.

The procedure lasts, on average, 40 minutes, including preparation time.

At the end of the intervention, the patient needs to rest for about an hour.

Post-procedure care

Due to the use of sedatives, it is not possible to drive a car or other vehicles for the entire day after the examination. For the same reason, for a period of approximately eight hours after the procedure, the individual cannot perform tasks that require attention, such as working with machinery and sharp objects.

The medication used in anesthesia can cause a short period of amnesia.

The patient should rest for the remainder of the day, eating as medically recommended.

For the 3 days following the procedure, the patient should have a diet of only liquids and soft foods. They should avoid hot food and liquids.

They also should not engage in physical activity or carry weight for at least 3 days

1. Diagnosis
2. Treatment and Process
3. Stenoplasty
4. Complications

The esophagus is a long, narrow tube that carries food and liquids from the mouth to the stomach.

Esophageal dilation is the technique used to stretch a blocked or narrowed part of the esophagus. This procedure is used when a part of the esophagus has become so narrow that it becomes difficult, or even impossible and painful to swallow.

Dilation makes the passage of food and water into the stomach easier. This is usually a simple form of treatment but if it is not successful, surgery may be necessary. Surgery is a much more extensive form of treatment, with a longer recovery time.

Some of the most common causes of obstruction or narrowing of the esophagus are:

• Inflammation of the lower part of the esophagus. This usually happens due to constant exposure of the lower part of the esophagus to acid that returns from the stomach. Over time, this causes scarring and narrowing of the lower esophagus.
• Schatzki’s ring is a thin benign (non-cancerous) ring of fibrous tissue that constricts the lower esophagus. The reason for this is not well known.
• Achalasia is a change in the innervation of the end part of the esophagus and the lower esophageal sphincter. The lower esophageal sphincter is a muscle between the esophagus and the stomach that relaxes to allow food to pass into the stomach. After letting the food pass, it contracts to keep the food in the stomach. This change in innervation can be congenital (present since birth) or acquired by Chagas disease. This can cause irregular contractions of the lower esophageal muscle making the sphincter not open and thus not allowing food and liquids to pass. The result is a persistent blockage of the passage of esophageal content into the stomach.
• Stenoses can occur from ingesting substances that damage the esophagus. Some examples are acids or bases, such as caustic soda.
• Tumors, whether benign (non-cancerous) and malignant (cancerous) can also block the esophagus.

Diagnosis

Your doctor often suspects this problem through clinical history. He can prove his suspicion using X-rays and mainly endoscopy.

Treatment and Process

Esophageal stenosis is generally a mechanical problem, which can be treated with stretching (dilation). This can be done in different ways.

Flexible dilators: a series of graduated probes (increasing thickness) called thermoplastic probes can be used. These are tubes that pass through the esophagus to the stomach. The tubes used become progressively larger, until the desired size is reached.

Dilating balloons: esophageal dilation can be done using balloons during endoscopy. Flexible endoscopy allows the examiner to directly visualize the stenosis. A balloon is introduced through the device’s channel to the narrowing zone. It is then inflated with water to a certain pressure, which is pre-set for a given circumference. When inflated, it becomes sausage-shaped, stretched, and causes the stenosis to open.

Treatment of Achalasia

Achalasia requires a specific type of balloon, longer and larger, called a pneumatic balloon. In this situation, the spastic muscle fibers in the lower part of the esophagus are stretched.

In some cases of achalasia, treatment with botulinum toxin (botox) injection can be attempted.

In cases of achalasia that do not improve with endoscopic dilations, surgical treatment is indicated through a procedure called myotomy.

Stenoplasty

On some occasions, the narrowing (stenosis) is so great that even the dilation instruments cannot pass. In these cases and in some other situations, the stenoplasty procedure is performed. This consists of making small cuts in the region of the stenosis with the help of a stylet that is passed through the working channel of the endoscope. These small cuts help open the narrowing, facilitating the passage of the dilators and accelerating the treatment process. In some cases, after making the small cuts, some substances, such as corticosteroids, are injected into the region to prevent the narrowing from closing again easily.

Complications

Esophageal dilation is usually performed effectively and without problems. Some complications that may occur are:

A small amount of bleeding almost always occurs when dilation is performed. If this bleeding is excessive, it may require more aggressive treatment.

Another complication is perforation (hole in the organ wall). If this happens, an operation may be necessary to repair the problem.

Rarely, a small perforation can lead to infection, which can remain localized or even spread to neighboring organs.

1. What is a colonoscopy?
2. When is it used?
3. What is the preparation for the exam?
4. What will happen during the exam?
5. What are the risks of the procedure?
6. What should I do after the procedure?

What is a colonoscopy?

Colonoscopy is the endoscopic examination of the colon (large intestine) and often also of the terminal ileum (the final part of the small intestine). In addition to inspecting the intestinal surface, colonoscopy also allows for the performance of biopsies that can be useful in establishing a diagnosis. Therapeutic procedures can also be performed during colonoscopy, among which the most frequent is the removal of polyps (polypectomy).

When is it used?

Colonoscopy is the most direct and complete way to check the mucosa of the entire colon. It is generally done for one of the following reasons:

Prevention and early detection of cancer:

A colonoscopy can help find small warts (polyps), which can become cancer. Polyps can be removed before they become cancer. The exam can also allow your doctor to find cancerous tumors early, when cancer is easier to cure.

If you are over 50 years old, you should have a colonoscopy. If you have a personal or family history that increases your risk, your doctor may recommend that you start the exam at an earlier age.

Diagnosis of a disease:

If you have symptoms and still do not have a diagnosis, you may have to undergo this exam to try to find the cause. For example, if you are having abdominal pain, chronic diarrhea, change in bowel habits, or bleeding in the stool. Through colonoscopy, your doctor can check for any irritation of the mucosa or diverticula in the intestinal wall that may justify these symptoms.

What is the preparation for the exam?

For the performance of colonoscopy, it is very important to do an intestinal preparation so that the residues are removed from the inside of the colon and thus the exam can be done with maximum safety and efficacy. Usually, for intestinal preparation, a diet is recommended in the days preceding the exam, laxatives, and possibly enemas. Make sure to complete the intestinal preparation. The exam may not be performed if the colon still has feces. In addition, if the preparation is inadequate, small polyps or lesions may not be seen by the doctor, thus impairing the quality of the exam and consequently your health as well.

Drink plenty of clear liquids during the intestinal preparation to avoid dehydration. It is useful to drink liquids that help replenish electrolytes that you lose during the preparation. For example, you can drink “sports drinks” in any color, except red or purple.

The exam takes about 20 to 30 minutes. However, you will need to plan to stay at the clinic for about 2 hours for registration, examination, and recovery. The presence of an adult companion is mandatory.

What will happen during the exam?

After the colon preparation, the patient is taken to the examination room where they will be sedated. Sedation is performed intravenously and helps the patient to sleep and relax. The colonoscope is then inserted through the rectum to the cecum (initial portion of the colon) or to the terminal ileum (final portion of the small intestine). During the withdrawal of the device, a meticulous inspection is done identifying any changes.

If necessary, small tissue samples (biopsies) can be collected during the exam for detailed microscopic analysis. Don’t worry, it doesn’t hurt.

In the presence of elevated lesions (polyps), the doctor may perform, depending on the case, the removal of the lesion (polypectomy) during the exam. The samples removed during the exam (biopsies or polyps) are sent to the pathology laboratory for analysis. The result of the analysis should be collected directly from the laboratory where the material was analyzed and is usually ready in seven days.

What are the risks of the procedure?

Complications related to colonoscopy can result from the preparation of the colon, sedation, the exam itself, or complementary procedures performed. The preparation can cause gastric intolerance which will reflect in nausea, vomiting, and abdominal distension. As the preparation induces diarrhea, dehydration and an imbalance of the body’s electrolytes can occur. Complications related to sedation range from irritation of the punctured vein (phlebitis) to more serious situations with low blood pressure, bradycardia, respiratory depression, bronchoaspiration, and even cardiac arrest. Intestinal perforation can occur during the introduction of the colonoscope. However, this complication occurs in only about 0.05% of colonoscopies for diagnostic purposes. Resection of polyps can lead to two complications: perforation and hemorrhage. Such events are mainly related to the size of the resected polyps. Perforation can occur with a frequency of 0.03 to 1% of polypectomies and hemorrhage in about 0.02% of procedures, which can happen at the time of polyp resection or even days later.

What should I do after the procedure?

After the exam, you can rest until you are awake and alert enough to be taken home (you cannot drive vehicles). You should plan to continue resting for a few hours after you get home. It is normal to have gas and mild cramps for a few hours after the exam. After resting, you should feel like eating. The diet returns to normal again, but light meals are recommended. Make sure to drink plenty of fluids after the exams. If polyps or other tissue is removed, you may notice a little blood in your stool for a short time. In case of malaise, nausea and vomiting, intestinal bleeding, or severe abdominal pain, the patient should contact the endoscopy service or seek an emergency service with the exam report in hand.

1. What is Upper Digestive Endoscopy
2. When is it necessary?
3. What precautions should I take to undergo the exam?
4. What is the preparation for the Upper Digestive Endoscopy exam?
5. What is Upper Digestive Endoscopy
6. Upper Digestive Endoscopy: What are the risks of the procedure:
7. What should I do after the Upper Digestive Endoscopy procedure?

What is it?

It is an exam indicated for the diagnostic evaluation and treatment of diseases of the upper part of the digestive tube, including the esophagus, stomach, and the initial portion of the duodenum.

It is performed by inserting a flexible device with central lighting through the mouth, which allows the visualization of the entire examined path.

The exam is performed under sedation, using medication administered through a vein to allow you to relax and fall asleep, without pain or discomfort.

When is it necessary?

An endoscopy may be done if you have problems such as:

Heartburn

Problems swallowing

Abdominal pain

Burning chest pain

Anemia

Diarrhea

Gastrointestinal bleeding

Vomiting

This procedure helps your doctor make a more accurate diagnosis

What precautions should I take to undergo the exam?

Bring an adult companion. Plan for your care, find someone to give you a ride home after the procedure. It is forbidden to drive after the exam.

Bring documentation requested at the time of scheduling the exam. For example: identity card (ID); health insurance card and authorization; doctor’s order (exam request)

Some medications (such as aspirin and anticoagulants) may increase the risk of bleeding during or after the procedure. Ask your doctor if you need to avoid taking any medication before the procedure.

Inform your healthcare professional about all the medications and supplements you take.

Ask all the questions you have before the procedure. You should understand what the doctor will do and how long it will take to recover.

What is the preparation for the exam?

For the exam, it is necessary that your stomach is empty because if there are still food residues, they can come back and enter the lung, a very serious condition. Therefore, you must remain in complete fasting for 8 hours.

The use of most continuous-use medications can be postponed until after the exam. However, if there is a need to use any prescribed medication before the exam (for example, antihypertensives), you should take it with small sips of water. Do not use milk or antacids.

If you are diabetic, schedule the exam for the earliest possible time and leave to use insulin or oral hypoglycemic agents after the exam and close to the first meal of the day.

Avoid coming with painted nails, because the polish hinders the reading of blood oxygenation done by the digital oximeter.

The doctor will be available to explain the procedure and answer your questions.

Please inform if you have already undergone another endoscopy exam, if you had allergies or reactions to any medication.

You will need to remove your glasses and dental prostheses.

Before the exam, it is necessary to fill out the admission form and the informed consent form.

What will happen during the exam?

You will not feel pain, sometimes just a slight discomfort in the throat during the passage of the device and in the stomach during the inflation of the organ with air.

The sedative medication may also cause a burning sensation at the infusion site and along the punctured vein (phlebitis).

If necessary, small tissue samples (biopsies) can be collected during the exam for detailed microscopic analysis. Don’t worry, it doesn’t hurt.

In the presence of elevated lesions (polyps), the doctor may perform, depending on the case, the removal of the lesion (polypectomy) during the exam.

The samples taken during the exam (biopsies or polyps) are sent to the pathology laboratory for analysis. The result of the analysis should be collected directly from the laboratory where the material was analyzed and is generally ready in seven days.

If there are no complications, the average duration of the procedure is 10 minutes.

What are the risks of the procedure:

Upper digestive endoscopy is a safe exam. However, like any medical act, it is not without risks.

The most frequent complication is phlebitis (pain and swelling along the punctured vein) which can occur in up to 5% of cases, depending on the medication used for sedation.

More serious complications are very rare, occurring in less than 0.2% of cases, and may be related to the use of sedative medications or the endoscopic procedure itself.

The medications used in sedation can cause local and even systemic reactions of a cardiorespiratory nature, including respiratory depression with decreased blood oxygenation and changes in heart rhythm (bradycardia and tachycardia) and systemic blood pressure (hypotension and hypertension).

These side effects are constantly monitored during the exam with the use of blood oxygenation and heart rate monitors, and the team is trained to immediately treat any of these complications.

Other complications of upper digestive endoscopy, such as perforation and bleeding, are exceptional in diagnostic exams but may occur in therapeutic exams.

In therapeutic procedures such as the removal of a foreign body (fishbone, bone, etc.), dilation of stenoses (narrowings), elastic ligation or sclerosis of varices, removal of polyps (polypectomy), or flat lesions (mucosectomy), the risk of bleeding or perforation varies from about 0.5% to 5%.

Your endoscopist doctor is qualified to take all appropriate measures for the prevention and treatment of these adverse events as well as to better clarify them.

What should I do after the procedure?

You will remain in the recovery room for about 10-30 minutes until the main effects of the medications used for sedation wear off.

Your throat may be numb or slightly irritated, and you may feel a slight discomfort in your stomach. Sneezing or a feeling of nasal congestion may occur if you received oxygen during the exam.

Because you have been sedated, an adult companion must be available to help you back home.

Due to the effects of the medication, you should not drive cars, operate machinery, drink alcohol, or smoke until the next day after the exam, when you will be able to return to your routine activities.

After the exam, you can return to your normal diet and take your routine medications, unless otherwise instructed by your doctor.

The result of the exam should be interpreted according to your clinical history and physical examination. The doctor who requested the exam is the most qualified professional to guide you regarding the diagnosis found. Additional instructions regarding your problem and treatment will be given at your next clinical consultation.

If biopsies were obtained, the analysis will be performed by the pathology laboratory, with the result being delivered by the same laboratory usually in seven working days.

If you have undergone a therapeutic procedure, additional information will be provided by the endoscopist doctor.