Gastrointestinal Procedures
An x-ray of the organs in the abdomen. An x-ray is a type of energy beam that can go through the body onto film, making a picture of areas inside the body.
Anorectal manometry is a test done to assess the function and strength of the muscles in the rectum and anus that control your bowel movements. This test is done on patients who suffer from constipation or faecal incontinence. The test is performed by placing a small, soft tube (the size of a drinking straw) into the back passage while lying on the side. It takes about 30 minutes to complete and the patient is awake for the test. There is no preparation needed.
An exam of the anus and lower rectum using a short, lighted tube called an anoscope.
Removal of the appendix.
A series of x-rays of the lower gastrointestinal (GI) tract. A liquid that contains barium (a silver-white metallic compound) is put into the rectum. The barium coats the lower gastrointestinal tract and x-rays are taken. This procedure is also called a lower GI series. A white substance which shows up on x-rays and is used in x-ray examinations called barium meals, where it is swallowed, or barium enemas, where it is inserted into the large bowel via a tube passed into the rectum via the anus.
Barium enema procedure. The patient lies on an x-raytable. Barium liquid is put into the rectum and flows through the colon. X-rays are taken to look for abnormal areas. Image courtesy of the National Cancer Institute.
A series of x-rays of the oesophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the oesophagus and x-rays are taken. This procedure is also called an upper GI series.
Barium swallow. The patient swallows barium liquid and it flows through the oesophagus and into the stomach.
X-rays are taken to look for abnormal areas. Image courtesy of the National Cancer Institute.
The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer.
Biopsy in the diagnosis of Gastrointestinal Disease
Biopsies are small samples of an organ, usually only a few millimetres in size. They may be used for chemical analysis, for example to detect enzyme deficiencies, or used to diagnose bacterial infection using culture methods. Mostly, biopsies are examined under the microscope by a specially trained pathologist, known as a histopathologist or an anatomical pathologist.
Biopsies are preserved in a fixative such as formalin, and then embedded in small blocks of paraffin wax. This allows very thin slices (about 0.005 millimetres thickness) to be cut with a microtome (a machine closely resembling a meat slicer). The slices (or ‘sections’) are transferred onto glass slides which are then immersed in dyes (‘stains’). Because the slices are so thin, individual cells and their relationships to each other can be visualised using a light microscope. Preparation of the slides typically takes about one working day. The tissue sections are routinely examined with a standard stain (haematoxylin and eosin). Further sections may be examined with various other stains to demonstrate particular features (such as helicobacter pylori organisms, important in the development of ulcers). Specific proteins may be demonstrated in the cells using antigen/antibody reactions, a technique termed immunohistochemistry. This technique is useful for classification of cancer cells and for demonstrating some organisms.
Biopsies are often taken at the time of endoscopy so that the gastroenterologist can more accurately determine the type of disease that is present. A fine cutting instrument is present at the end of the endoscope, allowing the gastroenterologist to sample areas of disease. Biopsies taken in the course of endoscopy are only useful if the disease involves the inner lining (mucosa) of the organ, as it is only this lining that is accessible to the biopsy instrument. Also, for a biopsy to be useful, the disease must have manifestations evident by microscopy. Examples of diseases that affect the bowel but cannot be diagnosed by mucosal biopsy are non-ulcer dyspepsia and diabetes. If deeper samples are required, other ways of obtaining them must be used. These include needle biopsies, usually performed by radiologists using –x-ray or ultrasound techniques to guide them. Otherwise tissue for diagnosis may be obtained by surgeons at the time of laparoscopy or open surgery.
Occasionally diagnosis may not be possible without the examination of a large sample or even a whole organ. After opening the abdomen, before embarking on a major surgical procedure, a surgeon may send a biopsy sample to the pathology laboratory for ‘frozen section’ examination. This allows a fast diagnosis, the procedure taking about 15 minutes, but the quality and detail is usually inferior to that obtained by conventional biopsy preparation.
Whilst biopsies often provide key information, particularly in the diagnosis of cancer, their proper interpretation requires correlation with all the other information gained in the course of investigating a patient's illness - assessment of a patient's symptoms, results of physical examination, findings at endoscopy, and radiological imaging.
Biopsies of the oesophagus or stomach may show –
- inflow of inflammatory cells and damage of normal cells, indicating inflammatory processes such as reflux oesophagi tis and peptic ulcer disease;
- infective organisms such as helicobacter pylori
- cancer;
- cellular changes suggesting increased likelihood of cancer development.
Biopsies of the small intestine may show –
- inflammation indicative of diseases such as coeliac disease or Crohn's disease;
- infective organisms such as Giardia;
- cancer.
Biopsies of the large intestine may show –
- inflammation, indicative of infective disease, or disease of uncertain cause such as Crohn's disease and ulcerative colitis;
- polyps - some of these are of no significance, whilst others will show changes suggesting potential for cancer development (adenomas);
- cancer arising in the bowel;
- cancer that has spread from another organ to the bowel.
A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it.
Your doctor checks for carcinoembryonic antigen (CEA) and other substances in the blood. Some people who have bowel cancer or other conditions have a high CEA level.
Bowel resection and anastomosis
Removal of the bowel tumour and a small section of healthy bowel on each side. The healthy parts of the bowel are then sewn together (anastomosis). Lymph nodes are removed and checked by a pathologist to see if they contain cancer.
A test that measures the level of CA 19-9 in the blood. CA 19-9 is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of gallbladder cancer or other conditions.
Carcinoembryonic antigen (CEA) assay
A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of gallbladder cancer or other conditions.
Chemotherapy in Gastrointestinal Malignancy
Chemotherapy for gastrointestinal cancer has become increasingly important in recent years. It has value in the treatment of gastrointestinal cancer at essentially all sites including oesophagus, stomach, small intestine, colon/rectum and pancreas.
Chemotherapy involves the administration of one or more drugs to patients with gastrointestinal cancer in an effort to either cure the cancer or maintain control and relief of symptoms. Chemotherapy is generally considered in conjunction with either surgery or radiotherapy as part of a combined treatment programme to provide for the best potential results for patients with these cancers.
Chemotherapy administered with curative intent will occur in circumstances where the patient has had initial surgery and/or radiotherapy and all evidence of obvious cancer has gone but significant risk of recurrence remains. Chemotherapy will then be administered in an effort to prevent recurrence and improve long term outcome. This is termed adjuvant chemotherapy. Such treatment is regularly considered for patients with colon and rectal cancer whose initial disease has been shown to place them at high risk of recurrence. In certain circumstances other cancers may also be suitable for consideration for the use of adjuvant chemotherapy.
Chemotherapy given in an effort to control disease or provide for symptom relief is generally undertaken in settings where the malignancy has already spread to other organs ie. metastatic, in which it is recognised that cure is not possible, but there is a very real potential for disease control. Such treatment may take the form of single drugs or in appropriate circumstances, combinations of drugs administered for various lengths of time until optimum control is achieved.
Chemotherapy may be administered either orally or intravenously, according to the nature of the drug. More drugs are only available in the intravenous form. Oral administration tends to be continuous ie. daily for a week or longer. Intravenous therapy tends to be intermittent, being administered weekly or less frequently according to the appropriate schedule.
There are nearly 50 different anticancer drugs currently available for the treatment of various cancers today.
Drugs of particular value for the treatment of gastrointestinal cancers include 5 fluorouracil with or without folinic acid (Leucovorin) which is a common component of combination treatments for gastrointestinal cancers of virtually all sites. Cisplatin and Carboplatin are regularly used in combination with 5 fluorouracil for the treatment of gastric and pancreatic cancers. Irinotecan and Oxaliplatin are new drugs recently tested for the treatment of colorectal cancers. Gemcitabine is a drug with definite activity in the treatment of pancreatic cancer and is of particular value in controlling symptoms and tumour activity of patients with metastatic pancreatic cancer.
Adverse effects are always of concern when chemotherapy is used in the treatment of cancer, either alone or in conjunction with surgery and radiotherapy. Modern treatments however are now able to minimise adverse effects to a very large extent. These include the use of very effective anti-nausea medications and the use of anti-diarrhoeals and special hormones (GCSF) to minimise blood count suppression. Most forms of chemotherapy for the treatment of gastrointestinal cancer are well tolerated by the vast majority of patients who receive them.
Medical Oncologists are consultant physicians who specialise in the management of patients with cancer. They are fully trained in the field of Internal Medicine and have undertaken specialised training in the understanding of the biology of cancer and management approaches for the treatment of these diseases. Medical Oncologists work in close collaboration with surgeons and radiotherapists to provide for treatment options. Medical Oncologists are particularly expert in the administration of chemotherapy, biological and immunological therapies. Medical Oncologists take their place alongside gastroenterologists, surgeons and radiotherapists in the evaluation, treatment and follow up of patients with all forms of gastrointestinal cancer.
Oncology clinics are ambulatory clinics which supervise the administration of chemotherapy, biological and immunological therapies. Highly trained Oncology nursing staff conduct these clinics under the supervision of Medical Oncologists to ensure optimum evaluation of patients and the highest standards of care in the administration of required treatments. Most patients are able to be treated in these ambulatory clinics where the atmosphere is relaxed and all effort is made to minimise fears and traumas of attending these clinics. Times required for attendance at these clinics will vary according to the nature of the chemotherapy being administered, but generally between 2 to 4 hours in duration. These clinics also provide opportunities for further support services including community nursing, palliative care, social work, nutritional advice, relaxation therapies and Cansupport.
An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer. A colonoscope (a thin, lighted tube) is inserted through the rectum into the colon. Polyps or tissue samples may be taken for biopsy. Polyps can be removed by a procedure known as polypectomy. A bowel preparation is given prior to the procedure and patients are sedated.
The patient will need to start the bowel preparation the day before the procedure. On the day of the procedure the patient must not have anything to eat or drink for 6 hours. The doctor should advise the patient if they need to stop taking any of their medications before the procedure. If the patient is diabetic they will need specific instructions for taking insulin.
After the procedure the patient will need to rest in the endoscopy unit until the sedation has worn off. Once the patient is fully awake refreshments will be given and discharge instructions for any follow up treatment needed. After sedation the patient is not allowed to drive for 24 hours.
Colonoscopy. A thin, lighted tube is inserted through the anus and rectum and into the colon to look for abnormal areas.
Image courtesy of the National Cancer Institute.
A procedure in which a sample of blood is drawn and checked for the following -
- The number of red blood cells, white blood cells, and platelets.
- The amount of haemoglobin (the protein that carries oxygen) in the red blood cells.
- The portion of the blood sample made up of red blood cells.
A treatment that uses an instrument to freeze and destroy abnormal tissues, such as carcinoma in situ. This type of treatment is also called cryotherapy. The doctor may use ultrasound to guide the instrument.
A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerised tomography, or computerised axial tomography. A spiral or helical CT scan makes a series of very detailed pictures of areas inside the body using an x-ray machine that scans the body in a spiral path.
Digital rectal examination (DRE)
An exam of the anus and rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual.
The body and the tail of the pancreas and usually the spleen are removed.
Endo-anal or endorectal ultrasound
A procedure in which an ultrasound transducer (probe) is inserted into the anus or rectum and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
A procedure in which an endoscope (a thin, lighted tube) with a laser attached is inserted into the body. A laser is an intense beam of light that can be used as a knife.
A procedure to insert a stent (a thin, expandable tube) in order to keep a passage (such as arteries or the oesophagus) open.
If the tumour is blocking the bile duct, surgery may be done to put in a stent (a thin, flexible tube) to drain bile that has built up in the area. The stent may be placed through a catheter that drains to the outside of the body or the stent may go around the blocked area and drain the bile into the small intestine.
A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
An investigation in which an endoscope is passed down via the mouth into the duodenum and then a fine tube is passed through the endoscope and into the tiny opening of the common bile duct into the duodenum. A special liquid known as dye or contrast is then injected with a syringe down through the fine pipe into the bile duct. The dye is radio opaque which means that it shows up clearly on x-rays that are taken at the time of the procedure. This enables the doctor doing the test to see the size of the bile duct and whether it contains things such as common bile duct stones.
Faecal Occult Blood Test (FOBT)
A test to check stool (solid waste) for blood that can only be seen with a microscope. Small samples of stool are placed on special cards and returned to the doctor or laboratory for testing.
Faecal Occult Blood Test (FOBT) kit to check for blood in stool. Image courtesy of the National Cancer Institute.
Use of an electric current to burn away the tumour using a special tool.
If a tumour is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.
Hepatic artery ligation or embolisation
A procedure to ligate (tie off) or embolise (block) the hepatic artery, the main blood vessel that brings blood into the liver. Blocking the flow of blood to the liver helps kill cancer cells growing there.
Surgery to remove part or all of the liver.
A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples for biopsy.
A surgical procedure in which an incision (cut) is made in the wall of the abdomen to check the inside of the abdomen for signs of disease. The size of the incision depends on the reason the laparotomy is being done. Sometimes organs are removed or tissue samples are taken for biopsy.
A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver disease that may be caused by gallbladder cancer or extrahepatic bile duct cancer.
The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells.
MRI (magnetic resonance imaging)
A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
A procedure to look inside the oesophagus to check for abnormal areas. An oesophagoscope (a thin, lighted tube) is inserted through the mouth or nose and down the throat into the oesophagus. Tissue samples may be taken for biopsy.
Esophagoscopy. A thin, lighted tube is inserted through the mouth and into the oesophagus to look for abnormal areas.
Image courtesy of the National Cancer Institute.
Oesophageal manometry is a test where a fine tube is placed through the nose or mouth into the swallowing tube (the oesophagus). This test looks at the pattern and strength of contractions (the squeezing) of the oesophagus. This test may be done in patients who have difficulty swallowing, or a feeling that the food gets stuck on the way down after eating. It may also be done in some patients with chest pain, and in some patients with acid reflux (gastro-oesophageal reflux disease). The test lasts about 30 minutes and is done while the patient is awake. The only preparation is to fast for 6 hours prior to the procedure. In some circumstances patients may need to stop certain medications for some time period before the test.
Removal of the part of the liver where cancer is found. The part removed may be a wedge of tissue, an entire lobe, or a larger portion of the liver, along with some of the healthy tissue around it. The remaining liver tissue takes over the functions of the liver.
Percutaneous transhepatic biliary drainage
A procedure done to drain bile when there is a blockage and endoscopic stent placement is not possible. An x-ray of the liver and bile ducts is done to locate the blockage. Images made by ultrasound are used to guide placement of a stent, which is left in the liver to drain bile into the small intestine or a collection bag outside the body. This procedure may be done to relieve jaundice before surgery.
Percutaneous transhepatic cholangiography (PTC)
A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body. This test is done only if ERCP cannot be done.
PET scan (positron emission tomography scan)
A procedure to find malignant tumour cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells.
An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
An exam of the rectum using a short, lighted tube called a proctoscope.
The use of a special probe with tiny electrodes that release high-energy radio waves (similar to microwaves) that kill cancer cells. The probe may be inserted through the skin or through an incision (cut) in the abdomen.
If the tumour is small and only in the bile duct, the entire bile duct may be removed. A new duct is made by connecting the duct openings in the liver to the intestine. Lymph nodes are removed and viewed under a microscope to see if they contain cancer.
Surgery to remove part or all of the organ that contains cancer. Resection of the tumour and a small amount of normal tissue around it is called a local excision.
A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumour cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumour markers. An increased level of alpha-fetoprotein (AFP) in the blood may be a sign of liver cancer. Other cancers and certain non-cancerous conditions, including cirrhosis and hepatitis, may also increase AFP levels.
A procedure to look inside the rectum and sigmoid (lower) colon for polyps, abnormal areas, or cancer. A sigmoidoscope is inserted through the rectum into the sigmoid colon. A sigmoidoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum and into the lower part of the colon to look for abnormal areas.
Image courtesy of the National Cancer Institute.
Removal of the part of the stomach that contains cancer, nearby lymph nodes, and parts of other tissues and organs near the tumour. The spleen may be removed. The spleen is an organ in the upper abdomen that filters the blood and removes old blood cells.
If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area.
Removal of the entire stomach, nearby lymph nodes, and parts of the oesophagus, small intestine, and other tissues near the tumour. The spleen may be removed. The oesophagus is connected to the small intestine so the patient can continue to eat and swallow.
Total hepatectomy and liver transplant
Removal of the entire liver and replacement with a healthy donated liver. A liver transplant may be done when the disease is in the liver only and a donated liver can be found. If the patient has to wait for a donated liver, other treatment is given as needed.
This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
A test in which a urine sample is checked to measure the amounts of certain substances, such as hormones. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it. The urine sample is checked to see if it contains a hormone produced by carcinoid tumours. This test is used to help diagnose carcinoid syndrome.
A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
(Also known as a gastroscopy) is a procedure to look at the inside of the oesophagus, stomach, and duodenum (first part of the small intestine, near the stomach). An endoscope (a thin, lighted tube) is inserted through the mouth and into the oesophagus, stomach, and duodenum. Tissue samples may be taken for biopsy.
Upper endoscopy is usually done on patients that have symptoms of persistent upper abdominal pain, nausea, vomiting, difficult swallowing or bleeding from the gastrointestinal tract. Prior to the procedure the patient must not have had anything to eat or drink for 6 hours. The stomach must be completely empty for the doctor to be able to examine it properly. The patient will need to discuss with their doctor if they need to stop taking any of their medications before the procedure.
After the procedure the patient will need to rest in the endoscopy unit until the sedation has worn off. Once the patient is fully awake refreshments will be given and discharge instructions for any follow up treatment needed. After having sedation the patient is not allowed to drive for 24 hours.
Esophagoscopy. A thin, lighted tube is inserted through the mouth and into the oesophagus to look for abnormal areas.
Image courtesy of the National Cancer Institute.
Upper GI series with small bowel follow-through
A series of x-rays of the oesophagus, stomach, and small bowel. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the oesophagus, stomach, and small bowel. X-rays are taken at different times as the barium travels through the upper GI tract and small bowel.
A procedure that uses a series of x-rays called computed tomography to make a series of pictures of the colon. A computer puts the pictures together to create detailed images that may show polyps and anything else that seems unusual on the inside surface of the colon. This test is also called colonography or CT colonography.
A surgical procedure in which the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
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Bowel cancer is something people don’t like to talk about; it’s a conversation killer. Our aim is to stop people dying of embarrassment.
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