Diagnostic Procedures And Tests

Question 1

What are the different types of endoscopes

Answer 1

1. A flexible forward-viewing or side-viewing (oblique) endoscope used to visualize the esophagus, stomach, and proximal duodenum in the Esophagogastroduodenoscopy (EGD), to cannulate the biliary tract in endoscopic retrograde cholangiopancreatography (ERCP0 or to cannulate beyond the ligament of Treitz in small bowel enteroscopy (SBE)
2. An anoscope, which is a rigid plastic or metal speculum, used to inspect the anal canal
3. A proctosigmoidoscope, or recto-sigmoidoscope, a rigid endoscope that is used to examine the rectum and sigmoid colon
4. A flexible sigmoidoscope, used to examine the rectum, sigmoid, and descending colon
5. A colonoscope, used to visualize the entire lower GI tract from the rectum to the ileocecal valve and the terminal ileum

Question 2

What are the common parts that are included in all endoscopes

Answer 2

1. A flexible insertion tube that is usually 8-12mm in diameter. The insertion tube contains air, water, and biopsy channels; fiberoptic bundles; and cables. The tube extends from the distal end of the scope to the control head
2. A universal cord (also called an umbilical cord or light guide tube) that extends from the control head and inserts into the light source
3. An optic system, which consists of fiberoptic bundles that conduct light through the shaft and transmit the image to the eye using a lens system that focuses the image at the eyepiece. In a video endoscope, the optic system consists of a one-piece, solid-state video camera (including the camera head, coupler, and focusable optics), which transmits the image to a video monitor without the need for fiber optics
4. A control head that houses the lenses, which includes controls for maneuvering the tip up and down and left and right; valves that regulate irrigation, air, or carbon dioxide insufflation; and suction
5. Cables that extend the length of the insertion tube and serve to control the movement of the flexible tip
6. Channels for air and water flow
7. A suction biopsy channel. The channel allows the passage of accessories, such as biopsy forceps, cytology brushes, polypectomy snares, laser fibers, electrocautery devices, banding equipment, aspiration and injection needles, prostheses (stents) and minimally invasive surgical equipment. The channel also allows suctioning of fluid that obstructs the endoscopist’s vision
8. Optimal cameras that can be attached to the endoscope to allow the taking of still 35mm or instant photographs or video recordings

Question 3

What are the different types of sedation used for GI procedures

Answer 3

1. Minimal sedation (anxiolysis)—is a drug-induced state during which cognitive function and coordination may be impaired, by patients are able to maintain ventilator and cardiovascular functions and respond normally to verbal commands
2. Moderate sedation/analgesia (conscious sedation)—is a drug induced state of depressed consciousness in which patients can still respond to verbal commands, perhaps accompanied by light tactile stimulation, are are able to maintain a patent airway and spontaneous ventilation and cardiovascular function
3. Deep sedation/analgesia—a drug-induced depression of consciousness during which patients cannot be easily aroused but respond with repeated or painful stimulation. Patients may require assistance to maintain a patent airway and ventilatory function, but cardiovascular function is usually maintained
4. General anesthesia—is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation, require assistance maintaining a patent airway and ventilation, and may have impaired cardiovascular function

Question 4

What are the indications for moderate sedation in endoscopic procedures

Answer 4

1. Maintain intact protective reflexes
2. Allow relaxation to allay anxiety and fear
3. Minimize changes in vital signs
4. Ensure cooperation
5. Provide decreased pain perception
6. Ensure easy arousal from sleep
7. Maintain patient ability to respond to commands
8. Provide some degree of retrograde amnesia

Question 5

What medications are used for moderate sedation

Answer 5

Diazepam and midazolam
1. Both diazepam and midazolam must be slowly titrated in small incremental doses until the desired endpoint is reached, usually exhibited by onset of slurred speech and decreased responsiveness
2. Respiratory use of an analgesic, emphasizing the need to reduce the amount of incremental doses and closely monitor the level of consciousness and respiratory function
3. Individual response varies with age, physical status, and current medications. Particular care must be taken with pediatric, elderly and debilitated patients

Propofol
1. The ASA has specific guidelines for the administration of drug agents that can provide the sudden onset of deep sedation such as propofol (Diprivan) due to the rapid and profound changes in sedation and anesthetic depth and the lack of antagonist medications

Question 6

What type of monitoring does the person administering anesthesia needs to be done during the procedure

Answer 6

1. A register nurse (RN) trained in moderate sedation administration is responsible for monitoring and assessing the patient receiving moderate sedation and analgesia throughout diagnostic and therapeutic endoscopic procedures
2. The moderate-sedation trained RN administers the sedation and analgesia during endoscopic procedures in the presence of and by the order of a physician
3. In procedures that are complicated by the severity of the patient’s illness, age, and/or complex technical requirements of the procedure, a second gastroenterology nurse may be needed to assist the physician while the first gastroenterology nurse assesses and monitors the patient
4. The anesthesia department may need to assess and monitor pediatric or high-risk patients, as determined by the physician. This may be standard practice in some institutions

Question 7

What patients need special consideration for increased risk during moderate sedation and analgesia

Answer 7

1. Over age 60
2. With a history of severe cardiac, pulmonary, hepatic, renal, or central nervous system (CNS) disease
3. Who are morbidly obese or pregnant
4. With sleep apnea, a recent history of drug or alcohol abuse, metabolic imbalance, or airway difficulties
5. Who have not been properly prepared for the procedure such as with an emergency procedure

Question 8

Before administration of sedation and analgesia, it is important that the GI RN assess the patient for

Answer 8

1. Communication barriers or developmental stage factors
2. Cultural or religious needs
3. Age, height, and weight, blood pressure, pulse, respiratory rate, oxygen saturation level, electrocardiogram (ECG), and circulation perfusion
4. Allergies, including drug and latex allergies
5. Current medications
6. Alcohol and recreational or illegal drug use history
7. Relevant medical-surgical history
8. Level of comfort
9. Level of consciousness and cognitive ability
10. Mobility and associated safety measures, include a fall risk assessment
11. Type of bowel preparation and results, if indicated
12. Laboratory results, including pregnancy testing if indicated

Question 9

What are other pre-procedure responsibilities of the GI nurse

Answer 9

1. Verify signed informed consent
2. Verify current history and physical (complete and on chart)
3. Verify post-procedure transportation with a responsible adult (for outpatients)
4. Establish venous access
5. Provide patient education, including what to expect during all phases of the procedure, as well as discharge instructions
6. Verify NPO status to reduce the risk of aspiration. Institutional policies for length of fasting should be followed
7. Administer pre-procedure medication as ordered

Question 10

What is the purpose of a time-out prior to the procedure

Answer 10

1. It is standardized as defined by the institution
2. It is initiated by a designated member of the team. The provider performing the procedure assumes responsibility fro the time-out and engages the entire procedural team
3. During the time-out, the team members agree (at a minimum) on the correct patient identity, the correct site, and the correct procedure to be done

Question 11

What documentation should be performed during the procedure

Answer 11

1. Diagnostic or therapeutic techniques used
2. Any unusual events, including interventions and subsequent patient response
3. Status of the patient after completion of the procedure
4. All drugs, fluids and blood products administered, including dose or amount, router time given, and patient response

Question 12

What are the GI nurses responsibilities after the procedure

Answer 12

1. Monitor the patent’s vital signs and level of consciousness. The patient is observed for signs of malignant hyperthermia, which is a rare but life-threatening reaction to certain triggering anesthetics
2. Continue to observe and document any further unusual events or post-procedural complications and their nature. Patients who receive reversal agents require longer periods of observation became the half-life of the offending agent may exceeds that of the reversal medication and lead to resedation
3. Review with the patient and responsible caregiver the written post-procedure instructions that address diet, medications, safety-focused activity restrictions according to age or level of mobility, follow-up care, and course of action if a post-discharge complication develops
4. Ensure that institutional discharge criteria are met. These usually include return to pre-sedation and analgesia oxygen saturation, vital signs, and level of consciousness; no nausea, vomiting or abdominal pain; and steady ambulatory

Question 13

What are indications for an Esophagogastroduodenoscopy (EGD)

Answer 13

1. Dysphagia or odynophagia
2. Dyspepsia
3. Anemia
4. Esophageal reflux that persists despite appropriate therapy
5. Persistent unexplained vomiting
6. Upper GI x-ray showing lesions that require biopsy
7. Acute or chronic upper GI bleeding (hematemesis or Melena)
8. Suspected esophageal or gastric varices
9. Suspected esophageal stenosis, esophagitis, hiatal hernia, gastritis, obstructive lesions, and gastric or peptic ulcers
10. Epigastric or chest pain
11. Chronic abdominal pain
12. Suspected polyps or cancer
13. Follow-up of patients with Barrett’s esophagus; large, indeterminate ulcers, or previous gastric or duodenal surgery
14. Removal of ingested foreign bodies
15. Caustic ingestion
16. Oral aversion
17. Dilation of the upper GI tract
18. Placement or removal of a feeding tube
19. Pre-surgical screening

Question 14

When would a EGD be contraindicated

Answer 14

1. Suspected perforated viscus
2. Shock
3. Seizures
4. Recent myocardial infarction
5. Severe cardiac decompensation
6. Thoracic aortic aneurysm
7. Respiratory compromise
8. Severe cervical arthritis
9. Acute oral or oropharyngeal inflammation
10. Acute abdomen
11. Known Zenker’s diverticulum
12. Unwillingness or inability to cooperate
13. Noncompliance with NPO guidelines

Question 15

What must be complete prior to the EGD procedure

Answer 15

1. The patient must be NPO before the procedure to decrease the risk of aspiration. Guidelines for fasting before sedation should be followed
2. A thorough and current medical and drug history and physical examination are important, with special attention given to any history of drug reactions, bleeding disorders, or associated cardiac, pulmonary, renal, hepatic, or central nervous system disease
3. The mouth should be inspected for loose teeth and orthodontic appliance that could become dislodged
4. If ordered, a topical anesthetic may be applied to the oropharynx to suppress the gag reflex
5. A bite-block should be placed into the patient’s mouth to protect the patient’s teeth and to prevent damage to the endoscope

Question 16

What occurs during the EGD procedure

Answer 16

1. The patient is placed in the left lateral position. The chin should. Be tilted toward the chest, keeping the head in the midline. Reassure the patient and hold his or her head and shoulders to help maintain the proper position. Keeping the chin tilted toward the table allows secretions to drain
2. Before insertion, the endoscope is lubricated with a water-soluble lubricant
3. The endoscope is passed in stages, examining each structure as the scope advances
4. To obtain the best possible view, mucus or other secretions are suction and air is instilled to distend structures. CO2 is an alternative to room air for insufflation. CO2 insufflation has been associated with decreased post-procedure pain, flatus, and bowel distention
5. As the endoscope passes through the pylorus the patient may experience some abdominal discomfort or may retch. At this time, it may help to have the patient breath deeply and slowly to help relax the abdominal muscles. The patient may also experience a feeling of fullness or an urge to defecate as air passes into the stomach and duodenum
   —occasionally, duodenal spasm makes visualization of this area difficult. Administration of a smooth muscle relaxant such as glucagon decreases contractions so the mucosa and contour of the duodenum can be examined thoroughly

Question 17

What are potential adverse events that could occur with EGD procedures

Answer 17

1. Respiratory depression or arrest
2. Perforation of the esophagus, stomach or duodenum
3. Hemorrhage related to trauma or perforation
4. Pulmonary aspiration of blood, secretions, or regurgitated gastric contents
5. Infection
6. Cardiac arrhythmia or arrest
7. Hypotension
8. Vasovagal response
9. Allergic reaction to the topical anesthetic or IV medications

Question 18

What are indications for an ERCP procedure

Answer 18

1. Evaluation of signs or symptoms suggesting pancreatic malignancy when results of ultrasonography and/or a computerized tomography (CT) scan is not normal or equivocal
2. Evaluation of acute, recurrent, or chronic pancreatitis of unknown etiology
3. Before therapeutic endoscopy procedures of the biliary tree such as removal of retained common bile duct stones, endoscopic sphincterotomy, balloon dilation of strictures, or placement of a stent or biliary drain
4. Unexplained chronic abdominal pain of suspected biliary or pancreatic origin
5. Evaluation of jaundiced patients suspected of having treatable biliary obstruction
6. Evaluation of patients without jaundice whose clinical presentation suggest bile duct disease
7. Preoperative or postoperative evaluation to detect common duct stones in patients who undergo laparoscopic cholecystectomy
8. Manometric evaluation of the ampulla of Vater and the common bile duct

Question 19

When is an ERCP contraindicated

Answer 19

1. In patients who are unable or unwilling to cooperate
2. In patients who are unable to tolerate the procedure
3. It is also contraindicated in patients with recent myocardial infarction
4. Severe pulmonary disease
5. Coagulopathy
6. Pregnancy
7. In patients with acute pancreatitis unless the clinical situation necessitates the procedure

Question 20

What is done during the ERCP procedure

Answer 20

1. The patient is placed in either the prone or left lateral position
2. A bite block is placed into the patient’s mouth to protect the patient’s teeth and to prevent damage to the endoscope
3. A side-viewing Duodenoscope is passed into the second part of the duodenum
4. Glucagon may be injected intravenously to suppress duodenal peristalsis and enhance visualization
5. When the endoscope s in the proper position to view the ampulla of Vater, the patient is moved to the prone position
6. The endoscopist passes a plastic cannula through the endoscope and maneuvers it into the orifice of the ampulla of Vater. Further adjustment of the cannula using the endoscope’s elevator control allows it to enter the pancreatic duct or the common bile duct
7. To be certain that the contrast medium is free of air bubbles, the cannula must be primed with contrast before being inserted into the endoscope. Radiocontrast material is injected through the cannula. When the contrast medium is injected, the amount injected should be stated verbally. Contrast should be injected slowly to avoid overfilling the duct
8. X-ray films are taken to identify the configuration of the appropriate ductal system
9. The patient is observed for any allergic reactions to the radiocontrast dye
10. Before the scope is withdrawn, a biopsy examination or cytology brushing may also be done

Question 21

What are the responsibilities of the GI nurse after the ERCP procedure

Answer 21

1. Assess, monitor, and document oxygen saturation and vital signs
2. Observe the patient for abdominal distention and signs of pancreatitis such as chills, low-grade fever, pain, vomiting, and tachycardia
3. Maintain NPO status until the patient’s gag reflex returns or further orders are written
4. Administer antibiotics as ordered
5. Check the patient’s temperature every 4 hours for 48 hours for a possible sign of perforation or infection
6. Offer a light meal 2-4 hours after the procedure. The day after the procedure, a full diet may be resumed

Question 22

What are potential complications of ERCPs

Answer 22

1. Pancreatitis—it usually occurs within 2-4 hours after the procedure
2. Sepsis
3. Injury to the pancreas can be the result of mechanical, chemical, enzymatic, microbiological, thermal or hydrostatic factors
4. Aspiration
5. Bleeding
6. Perforation
7. Respiratory depression or arrest
8. Cardiac arrhythmia or arrest
9. Ascending cholangitis

Question 23

What are indications for a small bowel enteroscopy (SBE)

Answer 23

1. GI bleeding of suspected small bowel origin, with continued or intermittent blood loss, in whom a GI bleeding site has not be found despite exhaustive research
2. Small bowel tissue sampling for the diagnosis of celiac disease

Question 24

What are the contraindications for a small bowel enteroscopy

Answer 24

The same as an EGD

Question 25

What are the techniques for a small bowel enteroscopy

Answer 25

1. Small bowel enteroscopy
2. Balloon-assisted enteroscopy
3. Sonde enteroscope peristalsis methods

Question 26

What are the potential complications of a small bowel enteroscopy

Answer 26

1. Perforation
2. Pancreatitis
3. Gastric mucosal stripping

Question 27

What are the indications for an anoscopy

Answer 27

1. Evaluation of bright red rectal bleeding in adults and children. The most common causes are hemorrhoids and fissures, although hemorrhoids are not common in children
2. Suspected protein allergy, the most common cause of rectal bleeding in neonates
3. Before sigmoidoscopy or colonoscopy

Question 28

What is the positioning for an anoscopy and what are potential complications

Answer 28

1. The sims left-lateral position or knee-chest postion
2. Severe spasm induced by digital examination usually signifies low-lying inflammatory bowel disease such as proctitis or ulcerative colitis

Question 29

What are the indications for a proctosimiodoscopy (rectosigmoidoscoy)

Answer 29

1. Melena or bleeding from the Anorectal area
2. Persistent diarrhea
3. Change in bowel habits
4. Passage of pus and mucus
5. Suspected in chronic inflammatory bowel disease
6. Bacteriology and histological studies
7. Surveillance of known rectal disease
8. Rectal pain
9. Screening for suspected polyps or tumors
10. Foreign body removal
11. As an adjunct to a barium enema
12. Surveillance following rectal surgery

Question 30

What are contraindications for proctosigmoidoscopy

Answer 30

1. Severe necrotizing enterocolitis
2. Toxic mega colon
3. Painful anal lesions
4. Severe cardiac arrhythmia
5. Patients who are unwilling to cooperate

Question 31

What is done during the proctosigmoidoscopy procedure

Answer 31

1. While the patient bears down, the instrument is easily passed into the rectum, the obturator is removed, and the instrument is passed slowly into the colon. If spasm or difficulty is encountered, the scope should be withdrawn until the full lumen is seen, the a second attempt is made
2. During insertion, the patient should breathe deeply with the mouth open to keep the abdominal muscles relaxed. Cramping or a desire to defecate can be relieved by having the patient relax and take deep breaths or pant
3. If air is insufflation into the lumen to enhance visualization, the patient will typically experience some flatulence as the air moves down the bowel and escapes
4. Once the desired depth is reached, the proctosigmoidoscope is gradually withdrawn, thus allowing examination of all sides of the bowel
5. A large cotton swab or suction may be used to remove any fecal matter, blood, or mucus that is obscuring vision
6. The examiner notes the color and friability of the mucosa, bleeding sites, petechiae and ulcers. Mucosal friability is established if pinpoint bleeding is noted immediately after application of mechanical pressure with a cotton swab or cytology brush
7. If a biopsy examination is indicated, the site of the lesion or specimen and its distance from the anus should be recorded

Question 32

What are potential complications of rigid proctosigmoidoscopys

Answer 32

1. Perforation—prompt surgical intervention is needed
2. Minimal bleeding for lacerations—(PT,PTT) should be checked and biopsy site reexamined. Silver nitrate or electrocautery will usefully stop the bleeding
3. Transient abdominal discomfort
4. Cardiac arrhythmias

Question 33

What are indications for flexible sigmoidoscopy

Answer 33

1. Routine screening of adults over age 45
2. Inflammatory bowel disease
3. Chronic diarrhea
4. Pseudomembranous colitis
5. Radiation colitis
6. Sigmoid volvulus
7. Foreign body removal
8. Lower GI bleeding

Question 34

What are contraindications for a flexible sigmoidoscopy

Answer 34

1. Patients who have fulminant colitis
2. Toxic mega colon
3. Severe, acute diverticulitis
4. Peritonitis
5. Inability or unwillingness to cooperate

Question 35

What occurs during a flexible sigmoidoscopy procedure

Answer 35

1. After a visual and digital rectal examination, the patient is instructed to breathe slowly and deeply to relax the anal sphincters while the well-lubricated endoscope is inserted
2. While the endoscope is being advanced to the rectosigmoid junction, air is insufflation to facilitate passage into the sigmoid and descending colon
3. While the instrument is slowly withdrawn, the physician examines the sigmoid colon, and then the rectal and anal mucosa. Suction may be used to remove residual matter, blood, or mucus that obscures vision

During the procedure the GI RN monitors the patient’s vital signs; color, warmth and dryness of the skin; abdominal distention; level of consciousness, pain tolerance, and vagal response

Question 36

What are potential complications of a flexible sigmoidoscopy

Answer 36

1. Bleeding
2. Perforation

Question 37

What are indications for colonoscopy

Answer 37

1. Active or occult lower GI bleeding, such as hematochezia, Melena, with a negative upper GI investigation, unexplained fecal occult blood, and unexplained iron-deficiency anemia
2. Abnormalities found on Radiographic examination
3. Suspected cecal or ascending colonic disease
4. Surveillance for colon neoplasia in patients who have had previous colon cancer or previous colon polyps
5. Screening in patients 45 years of age or older. Patients with an increased or high risk of colorectal cancer may need to start colorectal cancer screening, before age 45 and be screened more often
6. Surveillance in patients with chronic UC of several years duration
7. Diagnosis or management of chronic inflammatory bowel disease
8. Chronic, unexplained abdominal pain
9. Suspected polyps, rectal or colonic strictures, or cancer

Question 38

When is a colonoscopy contraindicated

Answer 38

1. Fulminant ulcerative colitis
2. Acute ischemic colitis
3. Acute radiation colitis
4. Suspected toxic mega colon
5. Suspected perforation
6. Acute, severe diverticulitis
7. The presence of barium
8. Imperforate anus
9. Massive colonic bleeding
10. Shock
11. Acute surgical abdomen
12. A fresh surgical anastomosis
13. Patient who are physically unable to tolerate the procedure

Relative contraindications
1. Massive hematochezia
2. Infectious bowel disease
3. Pregnancy
4. Coagulation abnormalities
5. Unstable cardiovascular status
6. Patients who are unable or unwilling to cooperate

Question 39

What occurs during a colonoscopy procedure

Answer 39

1. The patient is given an opportunity to urinate before the procedure
2. Because colonoscopy takes longer and is more uncomfortable than a flexible sigmoidoscopy, it is typical to administer IV moderate sedation and analgesia to promote relaxation and diminish discomfort. General anesthesia is used in pediatric patients
3. Colonoscopy is usually begun with the patient in the left lateral decubitus position
4. After a visual and digital examination, the lubricated colonoscope is inserted into the rectum while the patient breathes slowly and deeply
5. The physician insufflates a small amount of air to help dilate the bowel lumen
6. During insertion of the colonoscope, the objective is to reach the cecum as quickly and safely as possible
7. When appropriate, the GI nurse assist the physician in repositioning the patient smoothly to facilitate passage through the splenic flexure, the transverse colon, the hepatic flexure, the ascending colon and the cecum. In addition, the GI nurse may apply pressure to areas of the abdomen as requested by the physician to assist with passage of the instrument
8. During withdrawal, the objective is meticulous inspection. The mucosa is scanned by changing the position of the flexible tip while the instrument is withdrawn. The bowel wall is examined for abnormalities such as ulcerations, bleeding sites, polyps, inflammations or tumors
9. Direct visualization allows fore therapeutic procedures such as polypectomy, dilation, decompression, and fulguration of bleeding sites

Question 40

What are potential complications of a colonoscopy

Answer 40

1. Bleeding
2. Vomiting
3. A change in vital signs
4. Severe or persistent abdominal pain and/or distention
5. Abdominal rigidity
6. Perforation

Question 41

What is a capsule endoscopy

Answer 41

It’s useful to help diagnose difficult and challenging esophagus and small bowel conditions where conventional methods have failed

Question 42

What is a capsule enteroscopy

Answer 42

1. A diagnostic tool approved for imaging of the small intestine.
2. Capsule enteroscopy is indicated for diagnosis of diseases of the small bowel, including obscure bleeding, irritable bowel syndrome, Crohn’s disease, celiac disease, chronic diarrhea, malabsorption and small bowel cancer

Question 43

What is a capsule esophagoscopy

Answer 43

1. A diagnostic tool approved for imaging of the esophagus.
2. Capsule esophagoscopy is indicated for diagnosis of diseases of the esophagus, including gastric esophageal reflux disease (GERD)

Question 44

What are the indications for an endoscopy through an ostomy

Answer 44

1. Evaluation of an anastomotic site
2. Identification of recurrent disease (e.g., Crohn’s disease or cancer)
3. Visualization and/or treatment of GI bleeding

Question 45

When is endoscopy through an ostomy contraindicated

Answer 45

1. A recent ostomy or bowel surgery
2. Poor bowel preparation
3. Suspected bowel perforation
4. Presence of a large Peristomal hernia
5. Massive lower GI bleeding

Question 46

What are indications for endoscopic ultrasonography

Answer 46

1. EUS offers better-quality resolution, which enhances evaluation of the histological structure of targeted lesions
2. Esophageal wall thickness may be evaluated and assessed
3. The walls of the esophagus, stomach, duodenum, and colon may be visualized, as well as the structure of several contiguous organs
4. The act of scanning through the gastric wall, combined with changes in the patient’s position, enables the study of the gastric wall, the gallbladder, the pancreas, the kidneys, the left lobe of the liver, the spleen ,the aorta, the inferior vena cava, and various tributaries of the extrahepatic portal vein system

Question 47

What are the different types of manometry catheters

Answer 47

1. Solid-state catheters
2. Disposable air-filled catheters
3. Water-perfused pressure sensors
4. High-resolution Anorectal manometry (HRAM) catheters

Question 48

What are solid-state catheters

Answer 48

1. Contain small, direct intraluminal transducers
2. Solid-state catheters are available in several configurations, ranging from 3 to 38 sensors
3. The sensors positioned in the UES and LES are circumferential sensors that provide an average sphincter pressure
4. Solid-state catheters are very accurate for UES and pharyngeal studies as they are not position-dependent
5. The patient can sit up for a more accurate study, and the response time is faster to record the rapid pharyngeal upslope

Question 49

What are disposable air-filled catheters

Answer 49

1. Connected to external transducers
2. These catheters are configured with four circumferential sensors
3. The advantages of air-filled catheters are that they have a smaller diameter, are single-patient use, and require minimal equipment maintenance

Question 50

What are water-perfumed pressure sensors

Answer 50

1. Connected to external transducers on a water-perfusion pump
2. Compressed air pushes water through capillaries—the pressure transducers—and the catheter at a steady rate
3. The number of sensors and the spacing vary with catheter models
4. There is added maintenance and nursing responsibilities with the water perfusion system
5. This includes changing the water reservoir daily, ensuring that no air bubbles are in the transducers or catheter lumens, checking that the system capillaries and catheter are patent, and confirming that the pump maintains a constant pounds per square inch (psi)

Question 51

What is high-resolution Anorectal manometry (HRAM) catheters

Answer 51

1. Have approximately 23 sensors spanning the entire sphincter length
2. This allows visualization of the entire sphincter length and rectum, requiring the catheter to be position only once
3. This configuration is often more comfortable for the patient, as they don’t feel movement of the catheter with the station pull-through
4. HRAM catheters also allow visualization of the entire sphincter and rectal dynamics
5. Colors are assigned to the pressures to allow clear visualization of the multiple pressure channels on a color plot

Question 52

What are indications for esophageal manometry

Answer 52

1. Evaluation of dysphagia after a mechanical obstructing lesion has been excluded by barium Esophagram or endoscopy
2. Evaluation of chest pain after previous cardiac testing has ruled out a cardiac origin
3. Preoperative evaluation for anti-reflux, hiatal hernia repair, and bariatric surgeries to assess peristaltic pressure in the esophageal body
4. Evaluation of gastroesophageal reflux disease (GERD) to help define the mechanism for the reflux (e.g. low LES pressures, weak or absent peristalsis in the distal esophagus) and the degree of reflux-related changes in the esophagus body
5. Determination of the location of the LES for placement of reflux detecting probed, which require placement of the pH sensor 5cm above the proximal LES border for pH impedance and 6cm above the proximal LES border for BRAVP probe placement
6. Exclusion of esophageal involvement in generalized GI tract diseases, such as scleroderma and pseudo-obstruction

Question 53

What are contraindications of esophageal manometry

Answer 53

1. Are unwilling or unable to cooperate
2. Have cardiac instability, severe coagulopathy, suspected complete or near complete obstruction or recent gastric surgery

Question 54

What are potential complications of esophageal manometry

Answer 54

1. Aspiration
2. Vagal stimulation, resulting in slowing of the heart rate —that could cause faintness, dizziness and syncope

Question 55

What are the different types of esophageal manometry testing and what care and maintenance needs to be taken with the equipment

Answer 55

1. High-resolution manometry (HRM)
2. Impedance manometry
3. High resolution manometry with esophageal pressure topography plotting
4. Lower esophageal sphincter (LES)—esohagogastric junction pressure
5. Integrated relaxation pressure
6. Distal contractile integral
7. Peristaltic breaks
8. Distal latency

Manometry equipment and protocols vary depending on the type of manometry catheter used
—systems consist of a manometric catheter with several pressure sensors that interface with a transducer cable and conditioning circuitry to convert the electrical signal to a digital display
—a specific computer program is used to display, edit, and analyze the measurements
— a report is generated from the measurements obtained
—after the procedure, non-disposable catheters and catheters not using a sheath require an initial cleaning with enzymatic detergent, followed by high-level disinfection and rinsing with water

Question 56

What is high-resolution manometry (HRM)

Answer 56

1. Uses multiple pressure sensors (32-38) spaced 1cm apart to enable visualization of the entire esophagus and the sphincters
2. HRM has the advantage of displaying the dynamics of the entire esophagus
3. The catheter stays at the same position throughout the study, simplifying the procedure, decreasing the procedure time and increasing patient tolerance
4. Colors are assigned to the pressures to allow clear visualization of the multiple pressure channels
5. This color system graphic is called the “Clouse plot” in honor of the innovator Dr. Ray Clouse

Question 57

What is Impedance manometry

Answer 57

1. A combination of impedance testing and manometry
2. It provides simultaneous information on esophageal pressure changes and bolus movement with test swallows
3. This technology measures changes in resistance to lather acting current between two metal electrodes
4. Intraluminal impedance (resistance) rapidly decreases as the high-ionic content (saline swallow) of the bolus passes between the electrodes and rapidly increases as the bolus clears the electrodes
5. Multiple impedance channels span the esophagus to determine the direction and bolus transit
6. Normal bolus transit is <12 seconds
7. The esophagus is also challenged with viscous swallows to assess bolus transit

Question 58

What is High resolution manometry with esophageal pressure topography plotting

Answer 58

1. High resolution manometry (HRM) with the evolving technology of esophageal pressure topography (EPT) plotting has introduced new types of pressure measurements and classifications of manometry abnormalities
2. The Chicago classification version 3.0 terminology and values listed below has worldwide acceptance
3. As this is evolving technology, new parameters and values may change
4. These measurement parameters can be obtained with systems using HRM

Question 59

What is Lower esophageal sphincter (LES)—Esophagogastric junction (EGJ) pressure

Answer 59

1. This is a measure of LES competency
2. The high pressure zone (HPZ) of the LES is measured over three respiration cycles
3. The measurement is obtained in a quiet data-acquisition area of the esophagus that is free of artifact such as spontaneous esophageal contractions, swallowing, belching or coughing

Question 60

What is integrated relaxation pressure (IRP)

Answer 60

1. A measure of LES relaxation in response to liquid test swallows
2. Mean EGJ pressure is measured in all sensors spanning the LES over four contiguous or noncontiguous seconds of lowest pressure over a 10-second window of relaxation
3. IRP normal values are catheter-technology specific
4. A medium value among the test swallows is calculated
5. The upper limit of normal is 15-20mmHg, depending on the catheter technology

Question 61

What is distal contractile integral (DCI)

Answer 61

1. A measure of the distal esophageal contractile vigor
2. This measurement is the segment spanning from the end of the proximal pressure through to the EGJ, with a calculation of amplitude multiplied by duration, multiplied by length (mmHg x sec x cm)
3. The DCI measurement identifies hypercontractility and hypocontractility conditions
4. A DCI <100 is a failed contraction, 100-450 us a weak (ineffective) contraction and >8000 defines hypercontractility
5. A measurement between 450 and 8000 is considered a normal result

Question 62

What are peristaltic breaks

Answer 62

1. Peristaltic wave integrity is assessed by measuring gaps in the contour plot of the peristaltic contraction between the UES and EGJ with a 20mmHg isocontour line
2. A break >5vm is considered fragmented and is associated with incomplete bolus transit

Question 63

What is distal latency (DL)

Answer 63

1. This is a measure of peristaltic timing from the onset of the swallow (UES relaxation) to an identifiable point in the distal peristalsis sequence, the contractile deceleration point (CDP)
2. This is an important measurement to assess distal esophageal spasm (DES)
3. A value <4.5 seconds is defined as a premature contraction

Question 64

What should be done prior to an esophageal manometry procedure

Answer 64

The patient should be fully informed:
1. Purpose of the test
2. Positioning to be used
3. Effective relaxation methods
4. Procedure techniques to be used
5. Approximate length of the procedure
6. Sensations likely to be experienced
7. Risks of the procedure
8. Importance of patient cooperation
9. Need to remain NPO for 6 hours prior to the procedure

The GI Nurse should
1. Obtain a patient history as to presenting symptoms
2. Provide and document post-procedure instructions and recommendations for follow-up care
3. Document patient education and comprehension
4. Verify the patient has had nothing but mouth (NPO) for at least 6 hours
5. Provide information as reassurance to decrease the patient’s anxiety regarding the procedure
6. Ensure the equipment is functioning properly
7. Adhere to protocol
8. Pass the catheter into the nostril of the patient’s choice
9. Gently advance the catheter into the nasopharynx
10. Give the patient swallows of water to ease passing of the catherter

Question 65

How is the manometry catheter intubated

Answer 65

1. The catheter is usually inserted transnasally but may be inserted orally if not using a solid-state catheter where the sensors can be damaged by biting
2. The lubricated catheter is introduced in a sitting position.
3. The catheter is gently advanced over the nasal floor with the patient’s chin parallel to the floor
4. Resistance is felt as the tip of the catheter reaches the posterior nasopharynx
5. When the catheter passes into the hypopharynx (10-15cm), the patient’s head is tilted toward the chest, and the pateint is asked to take several sips of water
6. The catheter is advanced quickly past the gag reflex point and then advance continuously to a depth per catheter system protocol
7. Verification that the distal sensors are in the stomach is dome by asking the patient to take a deep breath
8. Increased pressure will be seen if the sensors are below the diaphragm
9. The patient is then positioned on his or her side or back with the head of the bed <30 degrees
10. The patient should be allowed time to accommodate to the catheter before continuing with the procedure

Question 66

What are the areas of measurement in esophageal manometry

Answer 66

1. LES
2. Esophageal body
   3 UES

Question 67

What happens during a LES study

Answer 67

1. The LES is a Toni ally contracted smooth muscle about 3-5cm in length
2. The LES relaxes in response to swallowing to allow passage of the bolus into the stomach
3. LES pressure, length, location relative to the nares and diaphragm, and relaxation in response to liquid swallows are assessed
4. The distal sensors are placed in the HPZ of the LES to measure and assess LES resting pressure
5. LES relaxation is assess by by giving the patient a 5ml bolus of room temperature water or normal saline if measuring impedance
6. The sphincter pressure decreases close to gastric pressure in response to the swallows and remains relaxed as the esophageal contractions progress through the esophagus
7. LES relaxation is assessed with 10 swallows, allowing a 20-30 second interval between swallows
8. With conventional catheters, a slow station pull through is performed
9. The catheter is pulled in 0.5cm increments to identify the distal border of the LES, the pressure inversion point (PIP) and the proximal border of the LES
10. With HRM, the LES dynamics are visualized without catheter movement

Question 68

What happens during an esophagus body study

Answer 68

1. The esophagus body study evaluates the esophageal muscle response to controlled swallows
2. Ten liquid swallows of 5ml of room temperature water (5ml of normal saline with impedance studies) are given at 20-30 second intervals
3. At least two sensors are positioned in the distal esophagus at 5cm and 10cm above the LES
4. A normal swallow produces contractions beginning in the proximal esophagus and moving distally with a DCI value between 450-8000
5. Abnormal findings in the esophagus include
   
   • simultaneous contractions, where the upslope of the contractions occur at the same time (DL>4.5 seconds)
   • retrograde contractions, which progress from the distal to the proximal esophagus
   • repetitive contractions with three or more peaks
   • failed contractions (DCI<100)
   • weak (ineffective) contractions (DCI<450)
   • hypercontractile contractions (DCI>8000)
6. It may be necessary to assess the striated muscle in the proximal esophagus in patients with a smooth muscle disorder such as scleroderma or a skeletal muscle disorder such as Parkinson’s disease
7. The proximal sensor is positioned 1cm below the UES, and 5 to 10 liquid swallows are performed
8. It is not necessary to wait 20 seconds between swallows, as the striated muscle recovers quickly

Question 69

What happens during an UES study

Answer 69

1. The final step of esophageal manometry involves assessing the UES, including UES resting pressure, UES relaxation and pharyngeal contractions
2. The UES and pharynx are composed of striated muscle
3. Pharyngeal contractions and UES relaxations are very rapid, requiring solid-state catheters to accurately record their function
4. A circumferential sensor is positioned in the UES, and one to two sensors are positioned in the pharynx
5. A sensor is positioned in the proximal border of the UES and five 5-ml liquid swallows are given to assess UES and pharyngeal coordination
6. The UES should be relaxed while the pharynx is contracting
7. It is necessary that the measuring sensor is in the proximal boarder of the UES because the UES moves toward the mouth on swallowing
8. The UES will move up onto the sensor, and accurate UES relaxation can be recorded
9. This movement will produce an M configuration
10. Normal UES resting pressure is 30-120mmHg, and pharyngeal contraction amplitude is >60mmHg
11. With HRM, several pressure sensors encompass the UES and pharynx, and a separate UES pull-through is not necessary
12. A long esophageal length may prevent enough sensors from spanning the UES or pharynx, requiring the catheter to be withdrawn a couple of centimeters
13. Then five quick additional swallows are performed
14. It is not necessary to wait 20 seconds between swallows as striated muscle recovers quickly

Question 70

What are the manometric findings in Achalasia

Answer 70

1. Failed peristalsis or spasm in the esophageal body
2. Elevate IRP
3. Hypersensitive LES, elevated intraesophageal pressure relative to gastric pressure, poor bolus transit, and low distal baseline impedance (DBI) are also common findings

Achalasia subtypes
1. Type 1 is identified by 100% failed swallows
2. Type 2 is identified by >20% of swallows with panesophageal pressurization
3. Type 3 is identified by >20% of swallows with premature (spastic) contractions

Question 71

What happens if the catheter will not pass through the LES

Answer 71

1. Due to the esophagus being dilated or the LES is hypersensitive
2. The catheter is withdrawn to about 30cm and reinserted slowly while the patient is swallowing
3. If the catheter cannot be passed into the stomach, the catheter can be positioned in the esophagus and esophageal swallow data obtained with 10 liquid swallows
4. This would be a failed manometry because the stomach measurements cannot be obtained
5. A direct placement of the manometry catheter under sedation, with visual confirmation or assistance of catheter placement with the endoscope, would be considered for a complete study

Question 72

What are the manometric findings of distal esophageal spasm

Answer 72

1. Normal IRP
2. Reduced distal latency with >/=20% premature swallows (DL<4.5 seconds)

Question 73

What is ineffective esophageal motility

Answer 73

> /=50% weak or failed contractions in the distal esophagus
Patients typically present with symptoms of dysphagia
IEM is often associated with GERD

On the manometry —the first swallow has normal amplitude and propagation, while the nest four are ineffective or non-transmitted

Question 74

Manometric findings of jackhammer esophagus

Answer 74

1. An abnormality of contraction wave amplitude identified by >/=20% hypercontractile swallows (DCI >8000)
2. May present with elevated IRP
3. Patients with this disorder complain of chest pain and/or dysphagia
4. The duration of contractions may be prolonged, but peristaltic progression and bolus transit is normal

Question 75

What does hypertensive lower esophageal sphincter look like manometrically

Answer 75

1. Characterized by abnormally high resting LES pressure of >45mmHg
2. LES relaxation may be normal or show elevated IRP (EGJ outflow obstruction)
3. Peristaltic progression is normal
4. Patients complain of chest pain or dysphagia

Question 76

What are the manometric findings for scleroderma

Answer 76

1. Shows reduced esophageal contractions or aperistalsis in the distal esophageal body and low to absent LES pressure
2. The striated upper body contractions, the UES, and pharyngeal contractions are normal
3. Poor bolus transit is typically demonstrated in the impedance channels

Question 77

What are the manometric findings of intestinal pseudo-obstruction

Answer 77

May demonstrate esophageal aperistalsis

1. Incomplete LES relaxation
2. Abnormal esophageal contractions (simultaneous and repetitive) and absent peristalsis

Question 78

What are the manometric findings of GERD

Answer 78

1. Decreased LES pressure
2. Lower peristaltic amplitude in the esophageal body

Question 79

What is Anorectal manometry

Answer 79

1. Measures pressures throughout the anal canal and rectum to determine abnormalities in the mechanisms of defecation and continence

Question 80

What are indications for Anorectal manometry

Answer 80

1. In chronic constipation, in fecal and/or flatus incontinence, for preoperative evaluation prior to ileo-anal pouch, for colorectal anastomosis, before and after rectal surgery, in suspected scleroderma and dermatomyositis, and to rule out Hirschsprung’s disease
2. As a screening procedure in newborns who have not passed meconium stool within 48 hours
3. As an operant conditioning (biofeedback) technique to improve bowel control in patients with incontinence secondary to previous Anorectal surgery, obstetrical trauma, spinal injury, irritable bowel syndrome, diabetic neuropathy, rectal prolapse, multiple sclerosis, scleroderma, and dyssnergic defecation
   - dyssynergic defecation refers to a problem coordinating the muscles and nerves of the pelvic floor in order to pass stool

Question 81

When is Anorectal manometry contraindicated

Answer 81

1. Patients suffering from infectious diarrhea
2. Anal obstruction
3. Anal stricture
4. Severe anal pain
5. In patients unwilling or unable to cooperate

Question 82

What should the GI nurse do prior to Anorectal manometry

Answer 82

1. Verify informed consent
2. Review the patient’s medical and surgical history and results of the physician’s physical examination
3. Provide the patient with a thorough explanation and instruction regarding the procedure and catheter insertion in order to decrease anxiety, including the amount of time the procedure will take, that it is generally a well-tolerated procedure, and there will be the occasional sensation of the need to defecate
4. Encourage the patient to have a bowel movement before the procedure. The use of enema preps is determined by the referring physician

Question 83

What happens during Anorectal manometry procedure

Answer 83

1. The procedure is typically performed with the patient in the left lateral position.
2. The catheter is positioned with the pressure sensors in the anal canal and the rectal stimulation balloon in the rectum
3. Allow the patient a 3-minute wait time to adjust to the sensation of the catheter before obtaining the study measurements
4. Anorectal manometry in infants and older children who are able to understand the procedure and cooperate can usually be performed without sedation
5. Toddlers and children who are highly anxious or fearful will likely need sedation to accomplish the procedure and obtain interpretable data
6. The study has several different components including resting, squeeze, recto anal inhibitory reflex (RAIR) and rectal sensation, push and rectal compliance studies
7. Not all components are performed during the procedure, depending on the patient age (an infant cannot voluntarily squeeze), physician preference, and the type of catheter used

Question 84

What is done during the resting study of Anorectal manometry

Answer 84

Obtained over a period of 1 minute, with the patient relaxed and not moving or talking

The resting study evaluates
1. Anal sphincter resting pressure:
A. The internal anal sphincter, external anal sphincter muscle, and puborectalix muscle contribute to this pressure
B. Normal resting pressure is 33-101mmHg in females and 38-114 mmHg males
2. Sphincter length:
A. Normal sphincter length in females is 2.3-5.0cm
B. Normal sphincter length in males is 2.4-5.1cm
3. Resting symmetry:
A. Directional sensors are used to assess symmetry
B. Similar resting pressures are demonstrated on all four quadrants: positive, left, anterior, and right

Question 85

What is done during the Squeeze study of Anorectal manometry

Answer 85

—The patient is asked to voluntarily squeeze tightly for 5 seconds, as if trying to prevent the passage of stool
—The entire length of the sphincter is assessed in a pull-through with the conventional catheters or at one location with a high-resolution manometry catheter
—A prolonged squeeze (squeeze duration) is also performed to assess for sphincter fatigue

1. External anal sphincter response
   A. The external anal sphincter and puborectalis muscle contribute to the increased pressure
   B. Normal maximum squeeze pressure is 90-397mmHg above rectal pressure in females and 94-590mmHg above rectal pressure in males
2. Squeeze duration
   A. The patient should be able to maintain 50% of the initial squeeze pressure for 30 seconds

Question 86

What is done during the RAIR and rectal sensation study during Anorectal manometry

Answer 86

—Inflation of the rectal balloon results in an autonomic relaxation of the internal anal sphincter in order to measure the rectoanal inhibitory reflex (RAIR)
—This reflex allows stool or gas to enter the anal canal and provides a signal to make the maneuver to defecate or withhold defecation

—Increasing volumes of air are instilled into the rectal stimulation balloon to determine rectal sensation
The RAIR and rectal sensation study is performed
1. As a screening for Hirschsprung’s disease. Absence of ganglion cells prevents inhibition of the internal anal sphincter, resulting in an outlet obstruction
2. To determine rectal sensation. Normal rectal sensation threshold can vary among individuals, but is generally 10-30mL

Question 87

What is done during the Push study of Anorectal manometry

Answer 87

—with the sensors in the high-pressure zone (HPZ) of the anal canal, the patient is instructed to bear down for 5 seconds, as if trying to pass stool
—the puborectoalis muscle and external anal sphincter muscle should relax to allow the stool to pass

1. To determine if there is a paradoxical response (increased pressure) in response to pushing. If present, this indicates a fecal outlet obstruction (dyssynergic defecation), resulting in symptoms of incomplete evacuation, excessive pushing, and constipation
2. With the cough maneuver
   A. With the sensors in the HPZ of the anal canal, the patient is instructed to forcefully cough once, and then a second time
   B. Increased pressure is seen in the patient with normal pressure response

Question 88

What is done during the rectal compliance study portion of Anorectal manometry

Answer 88

—Increasing volumes of air, usually in 50ml increments in the adult patient, are instilled into the rectal stimulation balloon
—Intrarectal pressures are measured after each inflation to determine how well the rectum expands to accommodate the volume

The test evaluates rectal capacity
1. The rectum should be able to tolerate 200ml of inflation before the patient experiences an urgent need to defecate that does not subside
2. Poor rectal compliance indicates a decreased storage ability, resulting in fecal incontinence and pain

Question 89

What is neuromuscular retraining

Answer 89

1. Neuromuscular retraining or biofeedback, is an instrument-assisted process that increases the awareness of the pelvic muscles’ response and improves the muscle functions that control continence and the ability to defecate in a normal manner

Question 90

What is done during a neuromuscular retraining procedure

Answer 90

1. The patient learns to manipulate his or her muscles through trial and error to improve the voluntary control of muscles
2. The muscle function is demonstrated by either electromyogram (EMG) or pressure sensors positioned in the anal canal
3. The response is displayed on a computer monitor where the patient can immediately see his or her effort
4. The healthcare provider coaches the patient to recognize muscle response and produce the correct response and provides encouragement

Neuromuscular retraining sessions require 4-6 visits over 4-6months and are supplemented by home exercise practiced several times a day. Each session is approximately 45 minutes in length, with the patient actively working his or her muscles about 20 minutes.
The majority of the session time is spent providing patient education regarding the patient’s disorder, assessing the patient’s progress, and providing emotional support

—Directional sensors are necessary to determine sphincter symmetry. A rectal stimulation balloon on the end of the catheter is inflated with a 60ml syringe attached to the inflation port during the RAIR and rectal sensation studies and the rectal compliance study. Some of these catheters use a latex rectal stimulation balloon

Question 91

What is the goal of neuromuscular retraining

Answer 91

1. Increase the number of muscle fivers innervated by existing nerves
2. Increase the patient’s awareness of anal and rectal sensations
3. Improve motor skills

Creation of new neural pathways is not possible

Question 92

What nursing considerations need to be taken for Anorectal manometry

Answer 92

1. Obtain patient history pertain to the defecation complaint
2. Determine if the patient has a latex allergy
3. Provide patient education, including the:
   A. Purpose of the test
   B. Positioning that will be used
   C. Effective relaxation methods
   D. Techniques to be used
   E. Approximate length of the procedure
   F. Sensations likely to be experienced
   G. Risks of the procedure
   H. Importance of patient cooperation
   I. Post-procedure instructions and recommendations for follow-up care
4. Document patient education and comprehension
5. Obtain verbal consent (and written consent if required by the organization)
6. Provide information and reassurance to decrease the patient’s anxiety regarding the procedure
7. Ensure equipment is functioning properly
8. Adhere to protocol

Question 93

What is antroduodenal manometry

Answer 93

1.Measures gastric and small intestinal contractions
2. Measuring contraction coordination and contraction amplitudes allows assessment of neural control and the smooth muscle response

Question 94

What are indications for antroduodenal manometry

Answer 94

1. Unexplained nausea and vomiting
2. Delayed gastric emptying
3. Chronic intestinal pseudo-obstruction
4. Gastric arrhythmias are associated with
   A. Clinical conditions including idiopathic gastroparesis, gastroparesis secondary to diabetes mellitus or anorexia nervosa, gastric ulcer disease, and gastric adenocarcinoma
   B. The effects of certain drugs and hormones, including anticholinergics, methionine-enkephalin, beta-endorphin, epinephrine, glucagon, prostaglandin E2, secretin and insulin

Question 95

What is done during an antroduodenal manometry procedure

Answer 95

1. The patient is NPO for 8 hours prior to the procedure to provide a baseline and to decrease the chance of aspiration during catheter placement
2. Medications that affect motility, including metoclopramide, erythromycin, narcotics and anticholinergics, should be discontinued prior to the procedure
3. The catheter is passed transnasally and positioned with endoscopic guidance or guide wires
4. Placement is certified with fluoroscopy
5. A fasting period, often 3 hours, is recorded, followed by stimuli from a meal or drugs with a 1-hour recording
6. Study time varies, up to 24 hours
7. The patient’s mobility is limited to a few feet from the manometry system
8. Normal gastric contractions are 3 (contractions per minute)CCM, 11cpm in the duodenum
9. Duration of the MMC, propagation velocity and contraction amplitude are measured in the fasting and fed state

Question 96

What is the care and maintenance for antroduodenal manometry catheters

Answer 96

1. Water-perfused catheters and solid-state catheters are used for antroduodenal manometry
2. Water-perfused require the patient to remain in a recumbent position during the entire procedure
3. The solid-state theaters have a faster response time and are not position-dependent
4. The spacing of the sensors varies, with closer sensor spacing at the pylorus
5. A catheter longer than 20cm is necessary to measure propagation of the MMC

Question 97

What considerations need to be taken by the GI nurse during the antroduodenal manometry procedure

Answer 97

1. Ensure that the patient is comfortable and adhere to the physician’s protocol for testing
2. Should be prepared to address patient discomfort after a meal and potential nausea and vomiting

Question 98

What is sphincter of Oddi manometry

Answer 98

1. The sphincter of Oddi is a circular, smooth muscle that surrounds the ampulla of Vater, the distal common bile duct and the pancreatic duct
2. During fasting, it exhibits peristaltic-like contractions that propel bile and pancreatic fluids into the duodenum and prevent reflux of duodenal contents
3. Food causes the release of cholecystokinin from the duodenum, which inhibits contraction of the sphincter of Oddi and lowers the basal pressure

Question 99

What are indications for sphincter of Oddi manometry

Answer 99

1. For diagnosis of papillary stenosis and motility disorders of the sphincter of Oddi, which may be associated with choledocholithiasis, biliary pain, abdominal pain, or pancreatitis
2. Possible factors causing obstruction of bile flow including spasm of the sphincter of Oddi and retrograde contractions
3. Sphincter of Oddi manometry is usually obtained during ERCP

Question 100

When is sphincter of Oddi manometry contraindicated

Answer 100

1. Are unwilling or unable to cooperate
2. Have had a recent myocardial infarction
3. Have acute pancreatitis
4. Have coagulopathy
5. Have barium in the GI tract
6. Are pregnant
7. Have severe pulmonary disease

Question 101

What is done prior to the sphincter of Oddi manometry procedure

Answer 101

Before the procedure, the GI nurse should

1. Verify informed consent and 8 hour NPO status
2. Review the patient’s medical history and laboratory results
3. Establish a patient intravenous (IV) line
4. Remove dentures
5. Administer antibiotic prophylaxis, as ordered
6. Record baseline vital signs

The patient is mildly sedated with Anticholinergic drugs. Opiates are not used before manometry because they can alter sphincter pressures

Question 102

What is done during the sphincter of Oddi Manometry procedure

Answer 102

Usually obtained during ERCP

1. The catheter is inserted over a guide wire, through the biopsy channel of a side-viewing Duodenoscope, into the duodenum
2. A duodenal baseline recording and measurement is obtained
3. If possible, this measurement should be obtained in a quiet period without contractions
4. The ampulla of Vater is identified and cannulated with the manometry catheter, which is passed though the sphincter of Oddi into the common bile duct
5. As the catheter is withdrawn slowly at 1mm increments, a normal tracing will show sphincter basal pressure <40mmHg, with peristaltic-like phasic waves
6. If a motility disorder is confirmed (high basal pressure), the physician may choose to perform an endoscopic sphincterotomy

—inject sterile water through the biopsy channel prior to inserting the guidewire to ease the passage of the wire and catheter
—tape the water-perfumed catheter to the patient’s shoulder to prevent the catheter from hanging below the water-perfumed transducers
—attempt to obtain more than a 30-second sphincter pressure for assessment

Question 103

Once the sphincter of Oddi manometry procedure is complete what does the GI nurse do

Answer 103

1. Monitor and document the patent’s vital signs
2. Observe for abdominal distention and signs of pancreatitis
3. Maintain NPO status until change of status ordered by physician
4. Administer antibiotics, as ordered
5. Remove the IV line
6. Provide written discharge instructions
7. Ensure that outpatients have someone to drive them home

Question 104

What care and maintenance needs to be performed for sphincter of Oddi Manometry

Answer 104

1. In addition to the ERCP equipment, a manometry recording system and a sphincter of Oddi catheter is necessary
2. Water-perfused catheters with two to three channels are used
3. When using water-perfused catheters, the water chamber is filled with sterile water, and a floating disc is placed on top of the water column. This will decrease air bubbles getting into the tubing
4. Setting the pressure to 7.5psi prevents a forceful flow of water into the ducts
5. Water is perfused through the catheter, ensuring no air bubbles are in the catheter, extension tubing, or perfusion capillaries
6. The components are kept sterile or as clean as possible
7. The system is calibrated before every patient per the manufacturer’s instructions to ensure that the system is in good working order

Question 105

What considerations need to be taken for sphincter of Oddi manometry

Answer 105

The most common complication of sphincter of Oddi manometry is pancreatitis, which may present as
1. Mild to incapacitating pain, beginning in the midepigastrium and radiating to the patient’s back
2. Nausea and vomiting
3. Fever
4. Distended abdomen
5. Decreased bowel sounds

Less likely complications are
1. Perforation, which may present with abdominal rigidity, rebound tenderness, an increase in pulse rate, and shallow and rapid respirations
2. Bleeding, which may present as a decrease in blood pressure and increased pulse rate

Question 106

What are indications for endoscopic biopsies

Answer 106

—includes confirmation of normal or abnormal mucosal tissue in any portion of the GI tract and/or assessment of tissue response to therapy

Question 107

What are contraindications for endoscopic biopsies

Answer 107

1. Severe coagulopathy or active bleeding
   —caution should be exercised in patients who are currently taking
   A. Antithrombotics- including warfarin, heparin, and low molecular weight heparin
   B. Antiplatelet agents - including aspirin, NSAIDs, plavix, and glycoprotein IIb/IIIa

Question 108

What are the different ways that specimens are sent out

Answer 108

1. Fixative—10% buffered formalin, which provides excellent tissue fixation and allows staining by routine histologic study with optimal results
   —complete immersion of biopsies in formalin should always occur immediately on collection
   —up to 1 hour is often needed to adequately fix a specimen with a diameter >1.0
2. Non-fixation fluids—specimens obtained for specific tests such as tissue culture, molecular tests, and electron microscopy may not require fixative
   —specimens that require placement in non-fixation fluids should be handled with a tissue-capture device that has not been previously placed in fixative
3. Frozen section—if urgent denial or confirmation of malignancy us required, the endoscopic biopsy specimen in the form of a frozen section may be sent to the laboratory for immediate microscopic examination by a pathologist
   —no fixative of any kind is used for a frozen section. Instead the specimen is placed on mounting material, labeled and immediately transported to the laboratory

Question 109

What are considerations taken for endoscopic biopsies

Answer 109

Endoscopy-directed diagnostic biopsies are extremely safe. The risk of perforation after diagnostic or therapeutic colonoscopy is extremely low. Excessive bleeding and perforation are the most likely complications of endoscopic biopsy

Post-biopsy patient discharge instructions should include
1. Notifying the physician of signs and symptoms of bleeding or perforation, which include fever or pain
2. Avoiding the use of aspirin or aspirin-containing products for a period of time as recommended by the physician
3. Resuming antithrombotic medications as recommended by the physician

Question 110

What is endoscopic mucosal resection

Answer 110

1. An established technique for the endoscopic removal of precancerous and early-stage malignant lesions in the mucosal and submucosal layers of the esophagus, stomach, duodenum and colon.
2. EMR can remove larger histologic specimens compared with the standard biopsy forceps
3. The endoscopist may remove the lesion in a piecemeal fashion or attempt an en bloc resection with the potential to completely resect an early malignant lesion of more than 1.5-2cm in diameter
4. EUS is often used to assess the depth of a particular lesion before performing EMR

Question 111

What are the indications for an endoscopic mucosal resection

Answer 111

1. In the esophagus
   A. Barrett’s esophagus-associated neoplasia
   B. Intermucosal carcinoma
   C. Superficial esophageal cancer
2. In the stomach
   A. Early gastric cancer
   B. Type 1 gastric carcinoids (associated with chronic Atrophic gastritis)
3. In the duodenum
   A. Nonampullary duodenal adenomas
   
   • has a thin wall and increased vascularity—increased risk of bleeding and perforation
4. In the colon
   A. Large or flat lesions

Question 112

What are the different endoscopic techniques used for EMRs

Answer 112

1. Injection-assisted EMR
2. Cap-assisted EMR
3. Underwater EMR
4. Ligation-assisted EMR

Question 113

What is an injection-assisted EMR

Answer 113

1. Allows snaring and resection of lesions after injection of a substance to lift the specimen
2. This technique minimizes mechanical or electrocautery damage to the deeper layers of the GI wall

Question 114

What is cap-assisted EMR

Answer 114

1. Uses a cap mounted on the tip of a forward-viewing endoscope
2. To decrease the potential risk of perforation, a submucosal injection is used to separate the mucosa from the muscle layer
3. A specially designed snare is then pre-looped in the cap
4. After the endoscope is positioned over the target lesion, suction is used to retract the mucosa into the cap
5. The snare is closed to capture the lesion
6. Electrocautery is then applied to resect the lesion, which is then removed by maintaining suction inside the cap

Question 115

What is underwater EMR

Answer 115

1. A newer technique that is particularly useful for salvage EMR
2. Filling the bowel lumen with water, rather than air, allows “floating” the mucosa and submucosa away from the deeper muscularis propria layer to allow EMR without requiring submucosal injection.
3. This technique theoretically eliminates any risk of tracking Neoplastic cells into deeper layers of the GI tract wall by the injection needle and making capture of flat lesions easier
4. This method has also been reported to be effective in managing recurrences after previous EMR, as well as avoiding submucosal fibrosis in patients with previous partial resections and biopsies of lesions, which makes lifting the lesion with submucosal injection difficult

Question 116

What is a ligation-assisted EMR

Answer 116

1. Uses a band ligation device attached to the endoscope and connected to a banding cap set on the distal tip of the scope
2. The device is positioned over the target area with or without previous submucosal injection
3. Suction is applied to retract the lesion into the banding cap, creating a pseudo polyp
4. A band is then deployed to capture the lesion, after which an electrocautery snare is used to resect the pseudo polyp above or below the band
5. Available multi and ligation kits allow potential resection of many mucosal sites without changing the device after respecting each lesion

Question 117

What considerations need to be taken when performing an EMR

Answer 117

1. Major complications
   A. Bleeding (the most common)
   B. Perforation
   C. Strictures

Question 118

What is endoscopic submucosal dissection (ESD)

Answer 118

1. An established effective treatment modality for premalignant and early stage malignant lesions of the stomach, esophagus and colorectum
2. Allows for en bloc removal of mucosal lesions >2cm; flat lesions, and lesions in deeper submucosal layers in the stomach, esophagus, and colorectum that cannot be removed by other endoscopic methods

Question 119

What are indications for an endoscopic submucosal dissection

Answer 119

1. Using EMR to resect tumors >2cm often results in piecemeal resections, which is associated with higher local recurrence rates
2. Compared with EMR, ESD is generally associated with higher rates of en bloc and curative resections and a lower rate of local recurrence
3. Oncologic outcomes with ESD compare favorably with competing surgical interventions
4. Also, ESD can serve as a T-staging tool to identify non curative resections requiring further treatment

Question 120

What is the Endoscopic submucosal dissection procedure

Answer 120

1. A substance is injected under the submucosa of the targeted lesion to act as a cushion
2. Then the submucosa is carefully dissected under the lesion with a specialized electrocautery knife
3. Adding dye such as indigo carmine or methylene blue to the injection solution can help in identifying the submucosal layer to determine margins of the dissection
4. The specimen is prepared and sent for histologic study

Question 121

What considerations need to be taken for an endoscopic submucosal dissection (ESD) procedure

Answer 121

1. Because of the technical difficulty of ESD, there is a higher rate of adverse events, including bleeding, perforation, and esophageal stricture, compared to other endoscopic procedures such as EMR
2. In esophageal ESD strictures may develop in 12-17% of cases
   A. Strictures are often prophylactically managed by serial dilation, steroid injection or topical steroid gel and placement of a fully-covered, self-expandable metal stent

Question 122

What are indications for endoscopic esophageal biopsies

Answer 122

Diagnosis and/or evaluation of
1. Radiographically demonstrated stricture
2. Suspected esophageal carcinoma
3. Barrett’s esophagus
4. Dyspepsia
5. Chronic or acute esophagitis
6. Gastroesophageal reflux disease (GERD)
7. Eosinophilic esophagitis (EOE)
8. Esophageal ulcer
9. Infectious esophagitis, such as herpes simplex virus (HSV) or cytomegalovirus (CMV)
10. Esophageal candidiasis—cytologic brushing may be more sensitive than histology for diagnosis

Question 123

What is evident with endoscopic biopsy of patients with suspected GERD

Answer 123

1. Esophageal biopsy specimens from patients with chronic esophageal reflux often show thickening of the squamous epithelium
2. An established biopsy protocol for GERD in the absence of recognized Barrett’s metaplasia does not exist
3. Biopsies of normal-appearing distal esophageal mucosa in patients with GERD symptoms may reveal nonspecific changes, but biopsy of endoscopically normal mucosa in GERD, when other diagnoses are not suspected, is not recommended

Question 124

What is evident in endoscopic biopsies for esophagitis

Answer 124

1. Findings of polymorphonuclear leukocytes, eosinophils, and ulceration in esophageal biopsy specimens provide strong support for a diagnosis of active esophagitis
2. For Eosinophilic esophagitis (EOE), two to four biopsy samples should be obtained from both the proximal and the distal esophagus, even if the esophageal mucosa appears normal
3. Biopsy samples should also be taken from the gastric antrum and duodenum when there is a suspicion of Eosinophilic gastroenteritis

Question 125

What is evident with endoscopic biopsies of Barrett’s esophagus

Answer 125

1. In patients with suspected Barrett’s esophagus, obtaining at least eight random biopsies is recommended
2. This provides the best results to identify intestinal metaplasia
3. If the area of suspected Barrett’s esophagus is short and eight biopsies are unattainable, it may be necessary to take fewer specimens at specific intervals and from specific tissues
4. The American College of Gastroenterology provides specific recommendations for biopsy sample collection in endoscopic surveillance for Barrett’s esophagus
5. Mucosal abnormalities should be sampled separately, preferably with EMR

Question 126

What is evident with endoscopic biopsies of esophageal cancer

Answer 126

1. To accurately diagnose esophageal cancer, any strictured lesions should be dilated sufficiently to allow passage of the endoscope to its distal margin
2. Numerous biopsy specimens should be obtained from tissue that is clearly abnormal but not necrotic
3. High-definition endoscopes, chromoendoscopy, and EUS may be used to help identify biopsy sites
4. Brush cytology can also be helpful in some cases
5. Specimens for cytology may be obtained by using a sheathed brush that is inserted through the endoscope

Question 127

What is evident with endoscopic biopsies from cytomegalovirus (CMV)

Answer 127

1. CMV infects mesenchymal and columnar cells, causing as ulcerative lesions in the esophagus
2. Samples for biopsy should be taken from the ulcer base for diagnostic accuracy

Question 128

What is evident with endoscopic biopsies for herpes simplex virus (HSV)

Answer 128

1. This virus infects squamous epithelial cells found at the outer margins of ulcers and erosions
2. Biopsy samples taken from the ulcer margin have the highest diagnostic accuracy
3. Culture and polymerase chain reaction can aid in diagnosing herpes simplex virus esophagitis

Question 129

What is evident with endoscopic biopsies for esophageal candidiasis

Answer 129

1. The optimal diagnostic technique for esophageal candidiasis has not been established, but samples are generally taken from the creamy patches that appear on the esophageal mucosa
2. Taking cytologic brushing, rather than biopsy, may be more sensitive for diagnosis

Question 130

What are indications for endoscopic gastric biopsy

Answer 130

In the diagnosis of
1. Gastric mucosal abnormalities associated with active and chronic gastritis
2. Metaplastic (chronic) Atrophic gastritis (e.g., environmental metaplastic atrophic gastritis, autoimmune atrophic metaplastic gastritis
3. Gastric epithelial polyps
4. Malignancy
5. Gastric ulcers
6. Gastric lymphoma
7. Evaluation of dyspepsia
8. Helicobacter pylori (H.pylori) gastritis

Question 131

What is evident with endoscopic gastric biopsies of gastric polyps

Answer 131

1. All polyps of the stomach, especially those polyps >5mm, should be examined by endoscopic biopsy
2. Choice of biopsy technique depends on the type and size of the protruding lesion and the risks inherent to removal for the individual patient
3. If possible, polyps should be removed endoscopically
4. If polyps cannot be removed, biopsies should be performed
5. Adenomatous polyps, large Hyperplastic polyps, and any polyp with a stalk should be removed using an endoscopic snare technique

Question 132

What is evident with endoscopic biopsies of gastric neoplasms

Answer 132

1. Most neoplasms of the stomach are adenocarcinomas
2. For patients with suspected gastric adenocarcinoma, the appearance of the lesion is assessed and biopsied
3. It is possible to detect lesions as small as 2-3mm in diameter and to obtain a histological diagnosis
4. For submucosal tumors, the mucosa overlying the tumor can be lifted off with biopsy forceps, but this will not always provide a positive diagnosis of the tumor itself
5. ESD, a large-particle biopsy, or a lift-and-cut biopsy employing a snare may also be used to obtain submucosal tissue
6. Fine needle aspiration or FNA or fine needle biopsy (FNB) with ultrasound guidance may be used to obtain tissue from submucosal nodules

Question 133

What is evident with endoscopic biopsy of gastric ulcers

Answer 133

1. The benign appearance of a gastric ulcer should always be confirmed as benign by multiple biopsies and exfoliative brush cytology
2. Biopsies of the ulcer edges are necessary to ascertain whether or not the lesion is malignant
3. When endoscopy is performed, six to ten biopsy specimens should be obtained from the ulcer margin in a circumferential pattern

Question 134

What is evident from endoscopic biopsy for H.pylori

Answer 134

1. Endoscopic tests for patients with suspected H.pylori infection include tissue urease activity, histologic examination, and microbial culture
2. A standard biopsy forceps may be used to obtain the specimen from the dependent portion of the antrum along the greater curvature.
3. Using a rapid urease test, a sample can then be inserted into an agar gel test kits that contains urea, a pH indicator, buffers, and a bacteriostatic agent
4. A rapid color change indicates the presence of the urease enzyme typically produced by H.pylori
5. Tissue may also be sent to the pathology lab and stained for H.pylori
6. The gastroenterology nurse should request appropriate laboratory staining per organization protocol
7. The sensitivity of these tests may be decreased by proton pump inhibitors, bismuth compounds, antibiotics, and acute GI bleeding
8. In situations in which test sensitivity is reduced, a negative urease test result should be confirmed with a different test for H.pylori infection, such as sending sample tissue to the pathology lab for staining
9. H.pylori culture allows identification of the bacterial strain and antimicrobial resistance patterns but is difficult to obtain and performed at only a few centers

Question 135

What considerations need to be taken for endoscopic biopsies of the stomach

Answer 135

The patient should be observed for signs and symptoms of complications such as bleeding and perforation
1. Symptoms include:
A. Abdominal pain
B. Tenderness
C. Distention
D. Nausea and vomiting
E. Chills
F. Hypotension
G. Temperature elevation

Question 136

What are indications for endoscopic small bowel biopsies

Answer 136

For evaluation of abnormal tissue and differential diagnoses of conditions such as:
1. Celiac disease
2. Whipple’s disease, which gives rise to highly specific lesions
3. Malabsorption syndromes
4. Unexplained steatorrhea
5. Small intestinal bacterial overgrowth (SIBO), a syndrome of diarrhea and nutritional deficiencies
6. Tropical spru
7. Eosinophilic gastroenteritis (rare)
8. Intestinal lymphangiectasia
9. Amyloidosis
10. Scleroderma and other conditions that cause chronic diarrhea or weight loss
11. Agammaglobulinemia, severe hypogammagloblinemia, and abetaliproproteinemia
12. Giardia

Question 137

What are indications of enteroscopy evaluation

Answer 137

1. Abnormal GI bleeding or GI bleeding when the small intestine has been identified as the source of bleeding
2. Suspected small bowel malignancies (e.g. adenocarcinoma, lymphoma, GI stromal tumors, metastatic tumors)
3. Suspected small intestinal bleeding with objective evidence of recurrent or obscure GI bleeding (e.g. iron deficiency anemia, positive fecal occult blood test or visible bleeding) in patients who have had upper and lower GI endoscopies (EGD and colonoscopy) that failed to identify a bleeding source
4. Elevated white blood cell count
5. Small bowel obstruction
6. Unexplained diarrhea
7. Abdominal x-ray
8. Known or suspected Crohn’s disease

Question 138

What are requirements for small bowel biopsy specimens to be of maximum diagnostic values

Answer 138

1. Precise localization of the biopsy site
2. Proper orientation and prompt fixation of biopsy specimens
3. Careful study of serial secretions of the central half or two-thirds of each biopsy specimen
4. Obtaining the specimen from the region of the duodenal bulb and more distal duodenum, including in the area of the ligament of Treitz

Question 139

What different instrument can be used for small bowel biopsies

Answer 139

1. Upper endoscope
2. Small bowel push enteroscope
3. Deep balloon-assisted enteroscope
4. Endoscopic ultrasound (EUS)

Question 140

What are deep balloon-assisted and push enteroscopy procedures

Answer 140

They are done under direct visualization for both diagnostic and therapeutic intervention to the entire small bowel

1. Deep balloon-assisted enteroscopy uses an antegrade and/or retrograde approach to examine the small bowel, including the jejunum and ileum. This procedure requires a specially designed 200cm-long balloon enteroscope in conjunction with an Overtube to advance the scope
2. Push enteroscopy is commonly performed using a 160-180cm colonoscope or with a dedicated 220-250cm enteroscope. Push enteroscopy evaluates the esophagus, stomach, duodenum, and proximal jejunum approximately 50-150cm beyond the ligament of Treitz

Question 141

What are considerations that need to be taken for small bowel biopsies

Answer 141

1. Capsule endoscopy is typically the next step for patients with unexplained overt GI bleeding and negative upper endoscopy and colonoscopy results
2. Push enteroscopy can be performed if capsule endoscopy reveals a lesion in the proximal jejunum
3. Deep balloon-assisted enteroscopy can be performed if a lesion is found in the mid small intestine

Question 142

What are indications for endoscopic diagnosis of biliary and pancreatic neoplasms

Answer 142

1. Cytologic brushing, biopsy forceps and/or bile aspiration may be used to sample suspected bile duct tissue during ERCP

Question 143

What is brush cytology

Answer 143

1. The most commonly used method for tissue sampling during ERCP
2. Recent studies estimate that cytologic brush sensitivity ranges from 35-70% and that specificity generally exceeds 90%
3. Tumor type influences the accuracy of brush cytology
4. Typically primary biliary tumors demonstrate higher sensitivity than those that do not originate form the biliary tract resulting from mucosal changes that facilitate cell collection
5. The endoscopist’s technique and the cytologist’s interpretation of results can also influence the accuracy of brush cytology

Question 144

What is forcep biopsy for the diagnosis of biliary and pancreatic neoplasms

Answer 144

1. Forceps biopsy can be used to acquire tissue during ERCP
2. Reports estimate that the sensitivity of biopsy forceps ranges from 43-88% and that specificity generally exceeds 90% comparable to brush cytology
3. Specially designed forceps are used to obtain samples from biliary strictures
4. However, the location and characteristics of the tumors and strictures can affect the adequacy of tissue collection
5. Additionally, it is often difficult to properly position and control the forceps to sample the target area

Question 145

What considerations need to be taken when trying to obtain biopsies of biliary and pancreatic neoplasms

Answer 145

1. Because of the difficulty obtaining adequate biopsy samples, brush cytology remains the technique of choice to obtain tissue samples during ERCP
2. Gallbladder lesions observed on ERCP may be amenable to endoscopic biopsy, although this is rarely performed in clinical practice

Question 146

How can cytologic interpretation of FNA samples be affected

Answer 146

1. The site and size of the lesion
2. Difficulties in obtaining an adequate aspirate
3. The presence of blood and benign epithelial cells
4. The availability of a cytopathologist to offer an onsite diagnosis

Question 147

What are indications for FNAs and FNBs

Answer 147

1. Obtain biopsy and cytology specimens of mucosal and submucosal lesions
2. Aspirate fluid from cystic lesions, pseudocysts, and fluid collection for both diagnosis and therapy

Question 148

What is the procedure for FNAs and FNBs

Answer 148

1. After both endoscopic and EUS evaluation, the needle may be passed into the targeted tissue
2. In EUS-guided FNA, the assistant id often responsible for the aspiration of the cytological or histological material. This is necessary because of the endoscopists needs to maintain the position of the endoscope with the transducer in contact with the GI wall during needle puncture
3. Under ultrasound guidance, the needle punctures the targeted lesion, the stylet is removed, and suction is applied when directed by the physician
4. While maintaining contestant suction, the needle is moved back and forth within the lesion
5. Suction is released while the needle is within the lesion to reduce the risk of aspiration of surrounding tissue
6. The entire needle assembly is removed for the endoscope
7. Specimens, including salvage wash, are prepared according to institution policy and procedure
8. FNB samples may also be fixed before and sent to the lab for further histologic examination

Question 149

What considerations are taken when obtaining an FNA or FNB

Answer 149

1. The presence of a cytopathologist in the procedure suite greatly improves the accuracy of diagnosis
2. When the cytopathologist is present, fewer passes may be needed to obtain adequate specimens for diagnosis
3. Most EUS=FNA procedures are performed on an outpatient basis. When they are combined with other procedures such as EGD and ERCP, however, patients may need additional recovery time

Question 150

What are indications for endoscopic colorectal biopsies

Answer 150

1. Suspected Neoplastic lesion of the rectum and colon
2. Suspected collagenous or microscopic colitis
3. Inflammatory bowel disease
4. As an adjunct to cultures and smears of rectal mucosa for detecting an infectious process in men and women who engage in anal intercourse and may be at risk for acquiring HIV
5. Diagnosis of a suspected neuronal lipidoses or unexplained signs of a degenerative nervous system disorder
6. Suspected schistosomiasis
7. Suspected amebiasis
8. Assessment of progress in patients who are undergoing therapy

Question 151

What is evident with colorectal biopsies with suspected Crohn’s disease

Answer 151

1. The typical mucosal biopsy shows a focal ulcerative and inflammatory process, rather than the diffuse abnormality seen with ulcerative colitis
2. Histological documentation of granulomatous inflammation of bowel mucosa argues strongly for a diagnosis of Crohn’s disease, particularly when discrete noncaseating granulomatous are found and other causes of granulomatous disease have been excluded

Question 152

What is evident in endoscopic biopsies of suspected ulcerative colitis

Answer 152

1. Biopsy shoes characteristic inflammation of the colonic mucosa, with changes ranging from mild degrees of inflammation to microscopic erosions of the epithelium and crypt abscesses
2. A complete colonoscopy with biopsy is especially useful when prior sigmoidoscopic findings are equivocal

Question 153

What is evident with endoscopic biopsies of suspected pouchitis

Answer 153

1. This is a complication in patients with ulcerative colitis
2. Symptoms include abdominal cramps, urgency, night incontinence, and fever
3. Crohn’s disease should be considered if macroscopic changes are present in the afferent loop
4. The diagnosis can be confirmed by histology
5. Treatment of pouchitis is proctocolectomy with ileoanal anastomosis

Question 154

What is evident with endoscopic biopsy when taken as an adjunct to cultures and smears of rectal mucosa for detecting an infectious process in men and women who engage in anal intercourse and may be at risk for acquiring HIV

Answer 154

1. Mucosal biopsy may demonstrate focal crypt epithelial cell degeneration, which has been described as a characteristic pathological feature in AIDS
2. When performing culture for AIDS-related diseases, the tissue is also examined for CMV, HSV, other sexually transmitted diseases, cryptosporidium micrococus and amoeba

Question 155

What is evident in endoscopic biopsies of a suspected neuronal lipidoses or unexplained signs of a degenerative nervous system disorder

Answer 155

1. Morphological and histochemical staining characteristics of the biopsy specimen can help diagnose certain neuronal diseases including:
   A. Niemann-Pick disease
   B. Tay-Sachs disease
   C. Hurler syndrome

Question 156

What is evident in endoscopic biopsies for suspected schistosomiasis

Answer 156

1. In which characteristic ova of the parasite can be identified in the biopsy material
2. However, because the eggs may go undetected, a serologic test may also be required

Question 157

What is evident from endoscopic biopsies of suspected amebiasis

Answer 157

Volcano-like lesions —the center of the volcano may have organisms

Question 158

What needs to be done to obtain useful diagnostic information from a colorectal biopsy specimen

Answer 158

1. Intestinal location of the biopsy specimen(s) must be clearly defined by anatomical area (e.g. rectum, descending colon, splenic flexure). Centimeter designation is not usually accurate, especially if that number will be used to subsequently return to the location of the area in question
2. Separate containers must be used for tissue specimens from different biopsy sites
3. Specimens sent to pathology must stipulate that multiple sections should be made of all specimens for examination
4. All specimens must be clearly labeled according to the organizations policies

Question 159

What considerations need to be taken for obtaining endoscopic biopsies of the colon

Answer 159

It is important to note that significant and poetically diagnostic abnormalities may be present in tissue obtained by colorectal biopsy, despite a normal endoscopic appearance of the mucosa

Question 160

What is rectal suction biopsy

Answer 160

1. Most intraluminal biopsies of the GI tract go no deeper than the muscularis mucosa, which is adequate for most diagnoses
2. Suction biopsy more consistently penetrates the submucosa

Question 161

What are indications for rectal suction biopsy

Answer 161

Rectal suction biopsy is obtained for suspected Hirschsprung’s disease in which evidence of the myenteric ganglia is sought within the submucosa

Question 162

What is the procedure for a rectal suction biopsy

Answer 162

1. Rectal biopsy is the definitive diagnostic test for Hirschsprung’s disease, which demonstrates the absence of ganglion cells in the submucosal and myenteric plexuses
2. The biopsy specimen is obtained from above the dentate line and below the peritoneal reflection to reduce the chance of perforation
3. Specialized mechanical suction biopsy device kits have been developed that offer the advantage of reproducibly obtaining a standard volume of tissue sample
4. Suction mucosal biopsies can be done without anesthesia at the patient’s bedside
5. The capsule of the biopsy tool is placed within the rectum and held against the rectal wall
6. Using a manometer to measure suction pressure, the tissue is suctioned into the capsule’s side hole
7. While the suction is maintained, the trigger id fired, and the tissue is cut in a guillotine fashion
8. The specimen is sent to pathology per the organizational policies

Question 163

What considerations need to be taken for rectal suction biopsy

Answer 163

1. Suction biopsy offers a low risk of perforation or bleeding, but complications may include bleeding.
2. Rectal biopsy is not recommended in premature infants due to poor diagnostic specificity and higher risk complications
3. Endoscopic rectal biopsies may not provide sufficient submucosal tissue to diagnose Hirschsprung’s disease and may require sedation in a surgical or endoscopy suite
4. Open rectal biopsy, in which a surgical excision of a segment of the rectal wall is required to obtain a specimen, is performed in an operating room with the patient placed under general anesthesia
5. Punch biopsies and full-thickness biopsies obtain a deeper tissue specimen

Question 164

What is a Percutaneous liver biopsy

Answer 164

1. A needle aspiration of liver tissue for histological analysis
2. In most cases, liver biopsy is performed Percutaneously, guided by imaging such as ultrasonography
3. It can also be done under direct vision via laparoscopy or surgery or via EUS guidance

Question 165

What are indications for Percutaneous liver biopsy related to evaluation

Answer 165

1. Abnormal liver tests of unknown etiology
2. Fever of unknown origin
3. Focal or diffuse abnormalities on imaging studies
4. Viral hepatitis and its sequelae
5. Alcoholic hepatitis
6. Evaluation of a liver mass that does not exhibit typical imaging features of hepatocellular carcinoma (HCC)
7. Quantitative estimation of iron in hemochromatosis
8. Quantitative estimation of copper in Wilson’s disease
9. Estimation of the severity of alcoholic liver disease
10. Evaluation of drug toxicity
11. Evaluation of the suitability of a donor liver for transplantation
12. Diagnosis and staging of nonalcoholic fatty liver disease (NAFLD), including nonalcoholic steatohepatitis (NASH)
13. Evaluation of unexplained jaundice
14. Diagnosis of cholestatic liver disease
15. Evaluation of infiltrative or granulomatous disorders
16. Evaluation of liver injury from immunosuppressive agents (e.g., methotrexate)

Question 166

What are indications for Percutaneous liver biopsy related to prognosis include

Answer 166

1. Staging of known parenchyma liver disease

Question 167

What are indications for Percutaneous liver biopsy related to management/surveillance during treatment include

Answer 167

1. Developing treatment plans based on histologic analysis
2. Follow-up evaluation while on antiviral treatment for chronic hepatitis C (rare)
3. Monitoring of disease activity of autoimmune hepatitis during treatment (may assist in determining if therapy can be discontinued)

Question 168

What are indications for Percutaneous liver biopsy relevant to the patient who has undergone a liver transplant include

Answer 168

1. Diagnosis of acute cellular rejection
2. Diagnosis of chronic rejection
3. Diagnosis of recurrent hepatitis C
4. Diagnosis of post transplant lymphoproliferative disorder
5. Diagnosis of CMV hepatitis
6. Protocol biopsies to monitor for fibrosis or inflammation (particularly in patients who received liver transplants to treat liver failure in chronic hepatitis C)

Question 169

Percutaneous liver biopsies may be absolutely contraindicated in patients who

Answer 169

1. Are unable or unwilling to cooperate or are confused
2. Have severe coagulopathy or thrombocytopenia (Uncorrectable prior to the liver biopsy)
3. Have infection of the hepatic bed
4. Have extrahepatic biliary obstruction
5. Have suspected vascular lesions (e.g. hemangioma, vascular tumor, echinococcal cyst)
6. Have not discontinued NSAID use (including aspirin) within the last 7-10 days
7. Are not able to have the biopsy site identified by percussion and/or ultrasound
8. Refuse blood transfusion or support
9. Have hepatoma

Question 170

What are relative contraindications to Percutaneous liver biopsies

Answer 170

1. Ascites
2. Morbid obesity
3. Amyloidosis (because of possible risk of liver rupture)
4. Cystic echinocccosis (Hydatid disease)
5. Infection within the right pleural cavity and/or below the right hemidiaphragm

Question 171

What does the GI nurse need to do prior to the Percutaneous liver biopsy procedure

Answer 171

1. Establish proper clotting factors, adequate blood volumes, and absence of infection. Laboratory studies commonly done before performing Percutaneous liver biopsy include (CBC, PT, INR_ and in some organizations an aPTT
2. Review medication history. Medications that prolong bleeding time, such as clopidogrel, aspirin, and NSAIDs, should be discontinued at least 1 week prior to the liver biopsy. Alternative and complimentary therapies, such as ginkgo biloba and fish oil, should also be stopped at least 1 week prior to the liver biopsy. Patients who inadvertently took aspirin or other NSAIDs during the week before the procedure can be rescheduled, or the liver biopsy can be performed if the patient has a normal bleeding time immediately before the procedure
3. Review anticoagulant use. For patients on pharmacologic anticoagulation antiplatelet medications, and anticoagulant medication, these medications should discontinued up to 10 days prior to the procedure. There is a question about whether new oral anticoagulants such as dabigatran (Pradaxa), rivaroxaban (Xarelto), and Eliquis with a much shorter half-life than warfarin could be discontinued closer to the procedure, but clinical guidelines are lacking. Management of specific agents should be individualized and carefully weighed against the need for liver biopsy and the potential risk of bleeding during during or after liver biopsy. May be restarted 48-72 hours after liver biopsy
4. Complete a nursing admission database that also may include obtaining baseline vital signs, blood typing and crossmatching for blood transfusion, administration of prophylactic vitamin K and chest and abdominal radiographs and scans
5. Determine NPO status

Question 172

What should be included when preparing a patient for a Percutaneous liver biopsy

Answer 172

1. Education about the procedure
2. Written informed consent
3. Review of patient history
4. Determination on laboratory studies
5. Medication maintenance

Question 173

What does the GI nurse do on the day of the Percutaneous liver biopsy procedure

Answer 173

1. An IV line may be started in order to provide sedation or analgesia
2. Administer any ordered blood products prior to procedure
3. Draw blood for type and cross-match as ordered

Question 174

How is the Percutaneous liver biopsy procedure performed

Answer 174

1. The patient is placed in a supine position near the right side of the bed with a pillow under the right side. The right arm us placed comfortably under the head, and the head is turned toward the left. Because the pediatric patients cannot be expected to cooperate, the must be adequately sedated. Infants may be restrained on a pediatric immobilizer or held by assistants
2. To identify the biopsy site, the physician percusses over the right Hemithorax at the mid-axillary line in order to recognize, then mark, the area of maximum liver dullness, typically found between the sixth and ninth intercostal space. A bedside ultrasound is often used to confirm the location
3. The surrounding skin is prepped. Sterile drapes are arranged around the biopsy site
4. The skin, subcutaneous tissues, and deeper intercostal muscles at the insertion site are infiltrated with a local anesthetic, such as lidocaine, assuming the patient has no known allergy to local anesthetics. A small scalpel incision is made in the skin over the biopsy site
5. Biopsy needles are selected massed on physician preference, technique used, and/or patient factors. Three types of needles are available to obtain a Percutaneous liver biopsy
   A. Suction needles (Menghini, Klatskin, Jamshidi,)—for suction biopsies, a suction biopsy needle is attached to a syringe containing a small amount of sterile saline
   B. Spring-loaded cutting needles with trigger mechanisms (various vendors). When using a spring-loaded or automated needle, the device is passed through the skin incision and advanced into the liver to obtain the biopsy specimen
   C. Cutting needles (Vim-Silverman, Trucut). Like suction needle biopsies, cutting needles utilize a similar approach but do not require a saline flush
6. The needle attached to the syringe is pushed through the skin incision and advanced into the intercostal muscles. A trochar may be used to create the tract. Pain with insertion of the biopsy needle indicates inadequate local anesthesia. The saline is injected to expel any tissue fragments from the needle
7. To prevent pleural cavity or diaphragm puncture, the patient is asked to hold his or her breath at full expiration while the biopsy needle is advanced into the liver. For pediatric patients, the biopsy should be timed to the respiratory cycle
8. While constant aspiration suction is maintained, the needle is advanced 4-5cm and then quickly withdrawn. During the procedure the needle is actually in the liver for only a fraction of a second. The patient may resume breathing 5-10 seconds after the specimen is obtained. A second biopsy through the same incision at a slightly different angle may be necessary

The biopsy sample is expelled from the needle and then sent to the laboratory for analysis per organization protocol. If lymphoma is suspected, accurate diagnosis requires that a portion of the biopsy specimen be placed in saline, not formalin. The minimal amount of tissue necessary for evaluation by the pathologist is usually a core sample longer than 1cm

Question 175

What are the orders for post Percutaneous liver biopsy procedure

Answer 175

1. After the procedure is completed, an adhesive bandage is applied to the insertion site, and the patient is turned onto his or her right side against a firm support
2. The patient maintains that position for the first 1-2 hours, followed by a supine position for another hour
3. Vital signs should be monitored at least every 15 minutes for the first hour
4. The recommended observation time is 2-4 hours, depending on local expertise and protocol
5. The risk of bleeding is greatest immediately after liver biopsy
6. If bleeding from the site persists, a pressure dressing may be needed.
7. The insertion site must be observed closely for any changes to condition

Question 176

What are the typical liver biopsy discharge instructions

Answer 176

1. Must be accompanied by a reliable person the first night after the procedure
2. Cannot drive until the day after the biopsy anesthesia was given
3. Cannot shower for 24 hours after the biopsy. If desired, the patient can take a bath with a sponge or washcloth, but cannot get the biopsy dressing wet. When able to shower, the biopsy site should not be scrubbed. The area may be gently washed and patted dry
4. Can remove the bandage covering the biopsy site 48 hours after procedure
5. Should not engage in strenuous exertion and exercise for 5-7 days following the biopsy to allow the body to heal
6. May not lift anything heavier than 10 pounds for up to 1 week after the procedure to avoid increasing intra-abdominal pressure, which could cause bleeding from the puncture site
7. Should discuss with the physician when it would be appropriate to return to work. Barring evident complications or significant pain that requires a narcotic, patients typically should be able to return to work the day after the procedure
8. May not start taking an antithrombotic without clear instructions from the physician

Question 177

What considerations need to be taken post Percutaneous liver biopsy where the physician should be notified immediately

Answer 177

1. Increased pulse and decreased systolic blood pressure
2. Prolonged pain that radiates to the back, abdomen, or shoulder
3. Abdominal distention or obvious bleeding or drainage from the biopsy site
4. Increased temperature
5. Dizziness or lightheadedness
6. Shaking chills
7. Yellow eyes or skin
8. Vomiting of blood
9. Sudden chest pain or increased shortness of breath

Question 178

What are potential complications post Percutaneous liver biopsy

Answer 178

1. Intreperitoneal hemorrhage (the most common)
2. Hematoma
3. Hemobilia
4. Infection—local or systemic (bacteremia, abscess, sepsis)
5. Pneumothorax
6. Hemothorax
7. Bile peritonitis
8. Malignant tumor track seeding
9. Needle breakage
10. Liver laceration

Question 179

What are other methods of obtaining a liver biopsy

Answer 179

1. EUS-FNB
2. Transjugular liver biopsy
3. Surgical/laparoscopic liver biopsy

Question 180

What are indications for cytology and culture of the GI tract

Answer 180

Cytology
1. Suspected malignancy
2. Suspected infection

Cultures
1. Symptoms of infection
2. Abnormal x-ray
3. Endoscopic image suspicious for infection

Question 181

How is brush cytology obtained and what is FISH testing

Answer 181

1. The brush is passed through the endoscope, lined up with the suspicious area and rubbed across the mucosa.
2. After the brushing is complete it is withdrawn in the sheath and removed
3. The brush is gently rotated on a slide and then the brush is put in cytology and both are sent to the lab
4. Fluorescence in situ hybridization (FISH) is an increasingly used technique that can detect chromosomal aneuploidy in specimens from biliary brushing
   
   • obtained from patients with suspected pancreaticobiliary cancer or primary sclerosing cholangitis, who are at increased risk for cholangiocarcinoma

Question 182

What is the washing technique for cytology

Answer 182

1. Washing is indicated for cell collection for cytology or culture analysis
2. A specimen trap is attached to the endoscope suction port
3. When collecting a washing for cytology, 20-30ml sterile saline is injected through the endoscope biopsy channel onto the lesion
4. The specimen is then collected by aspirating the fluid through the endoscope into a specimen trap.
5. The specimen is immediately sent to the lab to prevent lysis of the cells
6. Alternatively, an amount of fixative is added to the specimen equal to the fluid aspirated or in a volume determined by the organization’s policy and procedure

Question 183

What is the washing technique for culture

Answer 183

1. When collecting a washing for culture, a specimen trap is attached to the endoscope suction port, and the specimen is aspirated through the endoscope into the trap
2. If difficulty obtaining the specimen is encountered, 10-20ml of sterile saline is injected through the biopsy channel
3. The specimen is immediately sent to the lab with or without fixative, according to the organization’s policy and procedure and the test that is ordered

Question 184

What is the procedure for needle aspiration for cytology and culture

Answer 184

1. A catheter is inserted through the endoscope biopsy channel with a syringe attached and closed
2. The specimen is aspirated, injected into a sterile specimen container, and sent for analysis according to the organization’s policy and procedure
3. An aspiration needle can be used to retrieve cytological material from the upper GI tract
4. As previously discussed, using EUS-FNA, aspiration cytology is indicated for pancreatic masses and neuroendocrine tumors, pancreatic cystic lesions, peri-intestinal and mediastinal lymphadenopathy, mucosal and submucosal tumors or infiltrating malignancy in the gastric wall

Question 185

How and why is a rectal culture performed

Answer 185

1. Used to isolate and identify organisms that can cause symptoms or disease in this area of the GI tract
2. It may be performed initially or when a stool sample is difficult to obtain
3. The main pathogens that are isolated are bacterial or parasitic enterocolitis, gonorrhea infection, and vancomycin-resistant enterococci (VRE)
4. A rectal culture is a simple to perform and quick and normally painless to the patient
5. A cotton swab is generally inserted into the rectum and rotated completely, then removed
6. A smear from the swab is placed in culture media to grow microorganisms for evaluation
7. As growth occurs, organisms can be identified
8. Colonic tissue can be biopsied during colonoscopy and sent to the lab for culture

Question 186

What are the different types of Radiographic and non-Radiographic imaging done in gastroenterology

Answer 186

1. Barium swallow
2. Upper Gastrointetinal series
3. Enteroclysis
4. Barium enema
5. Capsule endoscopy
6. Esophageal capsule endoscopy
7. Wireless motility capsule testing
8. MRI
9. Percutaneous Transhepatic Cholangiography
10. Abdominal ultrasonography
11. Oral cholecystography
12. Arteriography
13. CT scan
14. Scintigraphy
15. Transjugular intrahepatic portosystemic shunt (TIPS)

Question 187

What are the different types of contrast

Answer 187

1. Barium
2. Iodinated water-soluble contrast media
3. Intravenous iodine-based (iodinated) contrast media
4. Gadolinium

Question 188

What are the different ways that contrast media can be administered

Answer 188

1. Orally
2. By enema
3. Through intestinal accesses (e.g., intestinal stomas, catheters, G-tubes)
4. By injection per vein or artery
5. Endoscopically during a procedure, such as ERCP

Question 189

The approach to patients about to undergo a contrast-enhanced examination has four general goals

Answer 189

1. To ensure that the administration of contrast is appropriate for the patient and the indication
2. To balance the likelihood of an adverse event with the benefit of the examination
3. To promote efficient and accurate diagnosis and treatment
4. To be prepared to treat a reaction should one occur

Question 190

In relation to contrast what is barium

Answer 190

1. The most common contrast material for Radiographic tests for GI disorders is barium sulfate
2. Barium is a chalky, radiopaque, inert, nonallergenic substance that enables fluoroscopic examination and x-ray of the esophagus, stomach, and small and large intestines
3. It’s available in several forms: powder(which is mixed with water), liquid, paste, and tablet
4. It can be administered orally, rectal, or via intestinal stoma
5. Is contraindicated in patients with digestive tract obstruction or perforation

Question 191

What is the education provided to a patient after undergoing barium studies

Answer 191

1. Report failure to pass the barium within 2-3 days, so cathartics or enemas may be prescribed to avoid constipation or obstruction. An enema or a laxative may be given routinely after barium studies
2. Increase intake of oral fluids
3. Expect stools to be chalky and light-colored for 24-72 hours after the barium study

Question 192

What are examples of iodinated water-soluble contrast media

Answer 192

1. Diatrizoate meglumine (Gastrografin)
2. Diatrizoate sodium (MD-gastroview)

Question 193

What is Gadolinium

Answer 193

An MRI contrast

Question 194

What is a barium swallow

Answer 194

It permits Radiographic examination of the pharynx, esophagus, and lower esophageal sphincter after ingestion of a thick barium solution

Question 195

What are indications of barium swallow

Answer 195

Can reveal the presence or absence of:
1. Foreign bodies
2. Diverticula
3. Ulcerations
4. Varices
5. Polyps
6. Tumors
7. Hiatal hernia
8. Motility disorders

It may discover but is not sensitive for, esophagitis or Barrett’s esophagus

Question 196

When is a barium swallow contraindicated

Answer 196

1. In patients with intestinal obstruction
2. In patients with suspected perforations, a water-soluble agent such as Gastrografin is the preferred contrast media

Question 197

In a barium swallow procedure what is done prior to the procedure

Answer 197

The patient may be given these instructions
1. Fast before the exam for a given period of time
2. Consult the ordering physician to determine, which, if any oral medications should be taken prior to the procedure

Question 198

What occurs during the barium swallow procedure

Answer 198

1. During the test the patient swallows a barium mixture while in a supine position
2. The Trendelenburg position may be used to detect gastric reflux or a sliding hiatal hernia
3. For patients with dysphagia, a barium tablet or a food or marshmallow bolus should be used in addition to the liquid barium so that strictures can be identified

Question 199

What considerations need to be taken with a barium swallow

Answer 199

1. Potential allergies to solution. Barium is nonallergenic, but various ingredients are added to improve coating, flow, taste and color
2. Possible constipation
3. Accidental aspiration into the trachea in children and patients with swallowing disorders
4. Barium leakage into the thoracic cavity or peritoneum

The presence of bowel obstruction may increase the potential for complications
Barium swallow testing should be avoided in pregnant women, if possible, due to radiation exposure during x-ray

Question 200

What is an upper gastrointestinal series

Answer 200

With small bowel follow through

1. The esophagus, stomach and the entire length of the small intestine are examined after ingestion of a barium solution

Question 201

What are indications for an Upper GI series

Answer 201

Can be used to aid in diagnosis of
1. Hiatal hernia
2. Diverticula
3. Varices
4. Strictures
5. Ulcers
6. Tumors
7. Crohn’s disease
8. Malabsorption syndromes
9. Motility disorders

Gastric x-ray films may shoe masses or ulcers
Films of the small intestine may indicate obstruction, regional ileitis or diverticula

Question 202

What is done prior to and Upper GI series procedure

Answer 202

Prior to the procedure the patient may be instructed to
1. Remain NPO after midnight before the procedure
2. Follow a low-residue diet for 2-3 days
3. Avoid Anticholinergic or narcotic medications for 24 hours
4. Refrain from smoking after midnight
5. Avoid antacids for several hours before the test

Question 203

What is done during an Upper GI series procedure

Answer 203

1. After swallowing the barium, the patient assumes various positions on the X-ray examination table so that the barium will outline all parts of the gastric wall
2. In addition, the abdomen may be palpated or compressed
3. The patient may be asked to swallow a gas-producing substance in the form of powder, pills, or a carbonated beverage
4. This will introduce air into the GI tract to improve visualization of small lesions that can be missed when using barium alone
5. This is called a double-contrast UGI

Question 204

What considerations need to taken when an upper GI series is performed

Answer 204

1. Complications
   A. Potential allergies to solution. Barium is nonallergenic, but various ingredients are added to improve coating, flow, taste, and color
   B. Possible constipation
   C. Accidental aspiration into the trachea in children and patients with swallowing disorders
   D. Barium leakage into the thoracic cavity or peritoneum

Should be avoided with a bowel obstruction
Pregnant would should also avoid due to x-ray

Question 205

What is enteroclysis

Answer 205

An imaging study that shows how contrast material moves through the small intestine

Question 206

What are indications for enteroclysis

Answer 206

1. When small bowl follow-through fails to provide a satisfactory study, enteroclysis may be used to detect subtle small intestine disease
2. CT scan provides visualization of features of the GI wall, while conventional enteroclysis can distend the small intestine for better visualization of the lumen
3. CT enteroclysis combines the advantages of both procedures
4. CT enteroclysis is particularly useful in evaluating symptomatic Crohn’s disease, particularly in the detection of a fistula, an abscess, skip lesions, lymphadenopathy, and conglomeration of small intestine loops
5. MRI enteroclysis is also available

Question 207

What is done prior to the enteroclysis procedure

Answer 207

The patient scheduled for enteroclysis should
1. Receive a bowel prep (enemas are not recommended as some fluid may be retained in the small intestine)
2. Have someone present to drive home, if sedation is needed

Question 208

What is done during the enteroclysis procedure

Answer 208

1. Sedation may be necessary to ensure patient comfort during the examination
2. A flexible feeding tube is placed either intranasally or orally. The tip of the tube is positioned in the duodenum
3. Barium is injected through the tube into the small intestine under fluoroscopic guidance
4. Barium is then followed by an injection of water and/or methylcellulose solution to give a double contrast effect
5. Multiple spot films of the various segments of the small intestine are obtained, including the ileocecal valve

Question 209

What considerations need to be taken during an enteroclysis procedure

Answer 209

Complications
1. Potential refusal to allow tube placement
2. If sedating the patient, medication reaction or complications
3. Potential allergies to solution
4. Possible constipation
5. Barium leakage into the peritoneum through any leaks or perforations

Not done with bowel obstruction
Pregnant women should not do due to x-ray

Question 210

What is a barium enema

Answer 210

1. A common and a valuable diagnostic test for patients with colon disorders
2. Both single-contrast and double-contrast barium enemas are generally safe and well-tolerated without premedication, although double contrast enemas are generally the method of choice
3. In double-contrast studies, a thicker barium solution is used
4. After rotation by the patient to cover the bowel wall, air is introduced into the bowel so that smaller lesions can be seen

Question 211

What are indications for a barium enema

Answer 211

Evaluation of
1. The large intestine
2. Inflammatory disease
3. Detection of polyps, masses, diverticula and structural changes

Question 212

What are contraindications of a barium enema

Answer 212

Patients with fulminant ulcerative colitis associated with systemic toxicity, toxic mega colon, or suspected perforation or obstruction

Question 213

What is done prior to the barium enema procedure

Answer 213

The patient schedule for the enema should
1. Receive complete information about the procedure and expectations, as full cooperation is essential for a successful exam
2. Follow a clear liquid diet for 1-2 days prior to the exam
3. Complete a bowel-cleaning regiment to allow for adequate examination of the bowel

Unprepared barium enema examination is indicated for children when Hirschsprung’s disease is suspected d

Question 214

What is done during the barium enema procedure

Answer 214

1. The barium is administered as an enema, and the patient is encouraged to retain the barium, despite any cramping or urge to defecate
2. In some cases, the barium is administered through a foley-type catheter, and the balloon is inflated slightly to prevent the patient from expelling the solution
3. The use of a catheter, however, may increase the urge to defecate and exacerbate patient discomfort
4. The patient is instructed to move about to allow the barium to spread through the colon
5. In some cases, a tilt table may be used to achieve a semi-erect or Trendelenburg position that will allow the barium to cover all areas of the colon

Question 215

What is to be done post-procedure for a barium enema

Answer 215

1. A conventional cathartic and enema preparation or a balance electrolyte lavage solution is given after the procedure to ensure elimination of the barium
2. Defecation of barium should be monitored, and laxatives given if barium is not passed within 2-3 days

Question 216

What considerations need to be taken for a barium enema procedure

Answer 216

Complications
1. Constipation
2. Rectal trauma
3. Barium leakage into the peritoneum through any leaks or perforations

Should be avoided in pregnant women due to x-ray

Question 217

What is a capsule endoscopy

Answer 217

A technique that employs a disposable video capsule swallowed by the patient, allowing visualization of much of the small intestine not within reach of a standard upper and lower endoscopy

Question 218

What are indications for a capsule endoscopy

Answer 218

1. Aiding in the diagnosis of GI bleeding, especially when upper endoscopy and colonoscopy are negative
2. Evaluation of conditions of the small intestine that cause diarrhea, pain or weight loss (Crohn’s disease_

Question 219

What should be done prior to ingesting a capsule endoscopy

Answer 219

The patient should be instruction
1. Avoid iron tablets for 7 days prior to the procedure, as iron will turn the stool dark, making it harder to visualize the bowel during the procedure. Some physicians may also request no vitamins for the same time frame
2. Complete a bowel prep per the physicians order
3. Shave the abdomen 6 inches above and below the naval the night before the procedure, if hairy. This helps to ensure that the sensors applied to the abdomen with adhesive pads will stick. These sensors are connected to the recorder that is worn in a belt around the waist
4. Take simethicone prior to the procedure to decrease gas bubbles and increase visualization if ordered
5. Do not undergo and MRI before the capsule has been verified as excreted from the body, as undergoing an MRI with the capsule still in the intestine can result in serious damage to the intestinal tract or abdominal cavity

The GI nurse should explain that the capsule is disposable and should be evacuated naturally in a bowel movement

Question 220

During the capsule endoscopy procedure what is done

Answer 220

The patient swallows the pill with a sip of water and the images captured are transmitted to the belt

The patient should be instructed to
1. Remain NPO for at least 2 hours after ingesting the capsule. After 4 hours, have a light meal. After completion of the study, return to a normal diet
2. Contact the facility immediately for any abdominal pain, nausea or vomiting any time after ingesting the capsule
3 avoid any strenuous physical activity to avoid sweating, bending, or stooping during the procedure. This helps to prevent the adhesive pads from coming off
4. Treat the data recorder with care. The belt should remain secure throughout the procedure. The recorder is a small computer
5. During capsule endoscopy, verify every 15 minutes that the small light on top of the data recorder is blinking. If, for some region it stops blinking, record the time and contact the facility for instructions
6. Record the nature and time of any activity or event such as eating, drinking, or feeling unusual sensations. Give these notes to the staff at the time the equipment is returned

The capsule is expected to have progressed through the small intestine approximately 8 hours after ingestion

Question 221

What is done after the capsule endoscopy is completed

Answer 221

The data is downloaded to a workstation, and software processes the images to produce a video of the small intestine for interpretation by the physician

The patient is instructed to
1. Watch for excretion of the capsule in the stool
2. Report development of unexplained abdominal pain, vomiting, or other symptoms of obstruction
3. Report the inability to positivity verify excretion of the capsule

If the patient cannot verify excretion, the MD will do an evaluation and may order an abdominal x-ray to determine if the capsule is still present in the GI tract

Question 222

What are considerations that need to be taken for a capsule endoscopy

Answer 222

A history of Crohn’s disease, obstructions, narrowing of the bowel, and precious bowel surgery could prevent an accurate test result

Question 223

What is an esophageal capsule endoscopy

Answer 223

1. Similar to the small bowel video endoscopy capsule in many ways; although it possesses an imaging unit on both ends of the capsule

Question 224

What are indications for an esophageal capsule endoscopy

Answer 224

1. To diagnose esophageal diseases when EGD is not possible
2. Contraindications are similar to those of the small bowel capsule endoscopy procedure

Question 225

What instructions is a patient given prior to an esophageal capsule endoscopy

Answer 225

1. Abstain from food and fluids after midnight before the procedure
2. Take routine medications with a sip of water the morning of the procedure, up to 2 hours before the exam time
3. Not to apply lotions or powders to the chest area so that the recording device can be securely applied
4. Refrain from applying lipstick, lip gloss, or other facial lotions or treatments to prevent accidental smearing on the capsule lens when it is ingested
5. Wear lose-fitting, two-piece clothing to facilitate the application of the recording device
6. Do not undergo an MRI before the capsule has been verified as excreted from the body, as undergoing an MRI with a capsule still in the intestine can result in serious damage to the intestinal tract or abdominal cavity

Question 226

What will the patient do during the esophageal capsule endoscopy procedure

Answer 226

1. Stand in an upright position while drinking 100ml of water to cleanse the mouth of salvia
2. Lie in a lateral right-side position with the head on a pillow
3. Swallow the capsule with a minimal sip of water using a 10ml syringe
4. Take additional sips of water (15ml) from the syringe every 30 seconds for 7 minutes
5. After 7 minutes, sit upright and drink another sip of water
6. Remain seated in the examination room or move to the waiting room for 20 minutes, with no eating or drinking during this time

Question 227

What us done after the esophageal capsule endoscopy

Answer 227

The recording system may be removed when the indicator lamp stops blinking (about 30 minutes) the data is then downloaded

Before discharge, the patient is instructed
1. To monitor his or her stool for the elimination of the capsule
2. Not to schedule and MRI until passage of the capsule has been confirmed with certainty
3. Seek medical attention if unexplained nausea, abdominal pain or vomiting develops

Question 228

What considerations need to be taken for an esophageal capsule endoscopy

Answer 228

1. The examination may be incomplete due to technical difficulties, any food retention in the esophagus, or any esophageal abnormalities
2. No test, including esophageal capsule endoscopy, can offer 100% accuracy for diagnosis

Question 229

What is wireless motility capsule testing

Answer 229

1. The wireless motility capsule is an ingestible device that uses sensor technology to measure pH, pressure, temperature, and transit time within the entire GI tract
2. Before administering the wireless motility capsule, a physiological or mechanical GI obstruction must be ruled out as a cause of the patient’s symptoms

Question 230

What are indications for wireless motility capsule testing

Answer 230

1. Indications for wireless motility capsule testing include
   A. Gastroparesis
   B. Postprandial fullness
   C. Nausea
   D. Early satiety
   E. Vomiting
   F. Delayed chronic transit
   G. Irritable bowel syndrome (IBS)
   H. Chronic abdominal pain
   I. Chronic bloating
   J. Fecal incontinence
   K. Constipation
2. The wireless motility capsule system provides valuable diagnostic information, including
   A. Gastric emptying time
   B. Small intestine transit time
   C. Colonic transit time
   D. Whole gut transit time
   E. Pressure patterns from the antrum and duodenum

Question 231

What instructions are the patient given prior to the wireless motility capsule testing procedure

Answer 231

1. Discontinue proton-pump inhibitors (PPIs), histamine 2 (H2) blockers, antacids, and drugs that affect GI motility (pain medications, sedatives, tranquilizers, antispasmodics and promotility medications)
2. Refrain from smoking the day before the examination
3. Remain NPO after midnight or 8 hours before testing
4. In the morning, take other medications with a sip of water

Question 232

What is done during the procedure for wireless motility capsule testing

Answer 232

The test involves application of a recording device, eating a specific meal or food bar prior to the examination, swallowing the capsule, and returning the appliance in 3-5 days

1. Immediately after the test meal is ingested; the capsule is ingested
2. The patient is advised not to eat for 6 hours after consuming the test meal. Small sips of water, up to 4 ounces, may be taking during the initial 6 hours
3. After the 6 hours another test meal or drink may be ordered
4. A normal diet may be started 8 hours after the capsule is ingested
5. The patient is instructed to
   A. Not use laxatives, bowel cathartics, and antidiarrheal medications until the capsule is passed
   B. Avoid vigorous exercise and prolonged aerobic activity greater than 15 minutes throughout the testing period
   C. Keep the data receiver within 5 feet of him or herself at all times to ensure the information is recorded
   D. Not get the data receiver wet when showering or bathing
   E. Maintain a diary for the test interval, as well as to use the event button to mark bowel movements and other occurrences and symptoms that may be useful to the physician when reviewing the test data

Question 233

What instructions are given to the patient after wireless motility capsule testing

Answer 233

1. Monitor his or her stool for elimination of the capsule
2. Schedule any MRIs only after the passage of the capsule has been confirmed with certainty
3. Seek medical attention if unexplained nausea, abdominal pain or vomiting develops

Question 234

What considerations need to be taken when performing a wireless motility capsule test

Answer 234

1. The examination may be incomplete due to technical difficulties
2. No technology, including a wireless motility capsule, can offer 100% accuracy for diagnosis
3. Significant data dropout can occur in patients who are severely obese (>40BMI)
4. The risks of the capsule testing include capsule retention and aspiration

Question 235

What is magnetic resonance imaging (MRI)

Answer 235

1. A noninvasive diagnostic imaging test that uses an external magnetic field to create a picture of soft tissue in the body
2. The test does not use radiation
3. An injection of a gadolinium-based contrast may be given in order to improve imaging

Question 236

What is Magnetic Resonance Cholangiopancreatography (MRCP)

Answer 236

1. An application of MRI
2. This test evaluates the patient’s hepatobiliary and pancreatic ductal systems for strictures, stones, and neoplasms using radio waves and a magnetic field with special software
3. Intravenous contrast-enhanced MRCP may be performed using gadolinium-based contrast agents excreted into the bile
4. Agents such as gadobenate dimeglumineor gadoxetate disodium are used for this purpose
5. The use of gadolinium-based MRI contrast agents requires precautions in patient selection and renal function screening to preclude later development of nephrogenic systemic fibrosis

Question 237

What are indications for MRCP

Answer 237

1. Can produce images similar to those obtained from a more invasive approach using ERCP without the added risk of pancreatitis, sedation or perforation
2. MRCP also can be used in preoperative anatomic mapping of the biliary tree prior to living donor liver transplantation and in detection of postoperative biliary leak assessments of patients who have received liver transplants
3. The procedure does not allow for therapeutic intervention
4. The patient would require an ERCP if therapeutic intervention can treat the diagnosis that is obtained by MRCP

Question 238

What is done prior to the MRCP procedure

Answer 238

1. The patient’s medical and surgical history, medication allergies, medication history, required labs, and pervious MRI or other radiology films are obtained if available
2. Confirm whether the patient has any of the following
   A. Cardiac pacemaker or artificial heart valves
   B. Metal plate, pin or other metal implant
   C. Insulin pump or other infusion pump
   D. Aneurysm clips
   E. Stents
   F. Intrauterine device (IUD)
   G. Inner ear implant
   H. Tattoo history
   I. Piercings in any location
   J. Any other internal or external device

Question 239

What is done during the MRCP procedure

Answer 239

1. The patient is injected with gadolinium intravenously, dosed at 1mL for every 10 pounds of body weight
2. Preparation for imaging includes
   A. Having the patient remove all metal.
   B. Positioning the patient on the exam table, lying supine
   C. Providing earplugs or headphones with music for patient comfort
   D. Informing the patient to hold his or her breath when instructed
3. The exam usually takes between 20 and 30 minutes
4. An MRCP may be enhanced by the use of synthetic secretin. Secretin can be administered to stimulate pancreatic fluid and bicarbonate secretion during the test
5. This improves ductal delineation, as the increased generated ductal fluid volume results in greater ductal distention
6. Secretin also relaxes the sphincter of Oddi and opens pancreatic duct orifices
7. Secretin is injected intravenously at the tine of the MRCP
8. Images are then taken every 30 seconds for 10 minutes
9. Maximum output of pancreatic fluid is optimal between 6 and 8 minutes

Question 240

What are the post procedure instructions given to the patient post MRCP

Answer 240

The patient can return to normal activity

Question 241

What considerations need to be taken prior to MRCP

Answer 241

1. In a patient with previous moderate or severe allergic-like reactions to a specific gadolinium
2. It may be prudent to use a different gadolinium and pre-medicate for subsequent MRI examinations
3. Secretin is safely administered to most patients, but its use should be avoided in patients with acute pancreatitis, as symptoms can be exacerbated
4. Other immediate side effects may be encountered, with the most common symptoms including
   A. Flushing of the face, neck and chest
5. Less commonly
   A. Some patients may develop vomiting
   B. Diarrhea
   C. Fainting
   D. Blood clot
   E. Fever
   F. Tachycardia
6. Allergic-like reactions are rare by symptoms such as
   A. Hives
   B. Redness of the skin
   C. And even anaphylaxis have been reported

Question 242

What is magnetic resonance enterography (MRE)

Answer 242

1. Uses MRI technology to create images of the intestinal tract
2. MRE can pinpoint inflammation, bleeding and other problems in the intestinal tract and create detailed images of organs

Question 243

What are indications for magnetic resonance enterography (MRE)

Answer 243

1. MRE can evaluate various GI disorders and inflammatory bowel disease such as Crohn’s disease
2. Because it is a noninvasive imaging test, it also can be used in patients with GI bleeding
3. MRE does not use radiation, making it a good choice for young patients or for patients who may need to have other studies that use radiation

Question 244

What is Percutaneous transhepatic cholangiography

Answer 244

A procedure used to visualize the biliary ductal system

Question 245

What are indications for a Percutaneous transhepatic cholangiography

Answer 245

1. Purely diagnostic, Percutaneous transhepatic cholangiography is performed when other less invasive methods of imaging the biliary tree (e.g. MRCP. ERCP. CT cholangiography) have failed
2. PTC may also be done to:
   A. Distinguish between obstructive and non obstructive jaundice
   B. Determine the location, extent, and cause of mechanical bile duct obstruction, which may be caused by stones, tumors, inflammation, stenosis or structure
   C. Place a drainage catheter for the treatment of obstructive jaundice
   D. Delineate bile leaks
   E. Place a Percutaneous binary stent
   F. Dilate postoperative stricture
   G. Remove stones

Question 246

What needs to be done prior to the Percutaneous transhepatic cholangiography procedure

Answer 246

1. The patient’s medical and surgical history, medication allergies, medication history (in particular, blood thinners), required labs (coagulation in particular), and previous procedural and radiological reports related to this procedure are obtained
2. Antibiotics are administered per the physician’s order

Question 247

What is done during the Percutaneous transhepatic cholangiography procedure

Answer 247

1. Under fluoroscopic visualization, a “skinny” or fine needle is introduced into the liver through the locally-anesthetized seventh or eighth intercostal space, parallel to the plane of the table
2. The needle is slowly withdrawn until a green fluid is aspirated, indicating that a bile duct has been entered
3. A radiopaque iodine dye is then injected, and radiographs are taken to define the site, cause, and extent of bile duct obstruction

Question 248

What needs to be done after the Percutaneous trans-hepatic cholangiography procedure is completed

Answer 248

1. Carefully observe the patient. Vital signs should be checked regularly, and the patient should be observed for signs of hemorrhage from the site. Signs and symptoms of hemorrhage include a decrease in blood pressure, and increase in pulse rate and respirations, restlessness, pallor, or diaphoresis
2. Position the patient on the right side for the time ordered
3. Monitor the patient for pain, temperature elevation, chills, abdominal distention, peritonitis, bile leakage, or septicemia
4. Administer antibiotics per the physician’s order

Question 249

What considerations need to be take for a Percutaneous transhepatic cholangiography procedure

Answer 249

Bleeding may result following PTC and can be massive

Question 250

What is abdominal ultrasonography

Answer 250

1. Ultrasonography is noninvasive, does not involve patient preparation or radiation, and is simple to perform and interpret
2. It is indicated to shoe the size and configuration of organs
3. It identifies abnormalities of the structures and spaces within the abdomen or pelvis through the transmission of sound waves
4. Sound waves are used to create images of organs

Question 251

What are the indications for abdominal ultrasonography

Answer 251

1. The optimal test for the detection of gallstones
2. Screening for biliary dilation
3. Detecting changes caused by appendicitis, such as a dilated appendix, thickened wall, or periappendiceal fluid accumulation
4. Acute Cholecystitis

Question 252

What is entailed with the abdominal ultrasound procedure

Answer 252

1. The skin over the area to be studied is exposed and lubricated to seal out air pockets and keep the transducer from rubbing the patient’s skin
2. While the patient lies still, a microphone transducer is slowly rubbed over the skin surface for approximately 20-30 minutes
3. Images of the structures within the target area are produced on a screen throughout the test

Question 253

What considerations need to be taken for abdominal ultrasonography

Answer 253

1. Ultrasound waves are disrupted by air or gas; therefore ultrasound is not an ideal imaging technique for air-filled bowels or organs obscured by the bowel
2. Large patients are more difficult to image by ultrasound because greater amounts of tissue attenuate the sound waves as they pass deeper into the body and return to the transducer for analysis
3. For standard diagnostic ultrasound, there are no known harmful effects on humans

Question 254

What is oral cholecystography

Answer 254

1. An x-ray procedure used to evaluate the gallbladder
2. The test has largely been superseded by ultrasonography

Question 255

What are indications for oral cholecystography

Answer 255

1. Although ultrasonography is the initial diagnostic procedure of choice for the detection of gallstones, oral cholecystography is an acceptable alternative when ultrasonography is unavailable, not diagnostic, or when the cholecystogram will be performed in conjunction with an UGI series
2. Oral cholecystography may be superior to ultrasonography for demonstrating the patency of the cystic duct, assessing gallbladder function, and showing the apparent density of stones
3. It is also necessary before oral dissolution therapy of gallstones to be certain that the cystic duct is open

Question 256

What instructions should be give to the patient about the oral cholecystography procedure

Answer 256

1. The test involves oral administration of pills containing iodinated radiocontrast material
2. Films are taken 10-14 hours after ingestion of the pills
3. Fat may be ingested following the initial gallbladder films in order to cause contraction of the gallbladder, filling the common bile duct
4. Radiography takes 30-45 minutes
5. After the test, a normal diet may be resumed and prescribed medications may be continued
6. After the test, the patient should drink plenty of fluids for several days, unless otherwise contraindicated

Question 257

what considerations need to be taken for oral cholecystography

Answer 257

This test exposes the patient to iodine and x-ray

Question 258

What is arteriography

Answer 258

1. Also called angiography
2. It involves the catheterization of selected arteries, followed by injection of an iodinated dye via the catheter

Question 259

What are examples of GI arteriography tests

Answer 259

1. Aortic angiography (chest or abdomen)
2. Mesenteric angiography (colon or small intestine)
3. Pelvic angiography (pelvis)

Question 260

What are indications for arteriography (Angiography)

Answer 260

1. X-ray films taken after injection can help to locate the source of GI bleeding, investigate poor blood supply, evaluate cirrhosis and portal hypertension, or determine the extent of vascular damage to the liver and spleen after abdominal trauma
2. Vascular tumors may be located by selective celiac and superior mesenteric arteriograms
3. Selective arteriography can also be therapeutic
4. Autologous clots or vasoconstricting drugs can be injected into appropriate vessels to control bleeding, or chemotherapeutic agents can be delivered directly to a tumor
5. Arteriography is used to detect several conditions and abnormalities, including
   A. Aneurysms
   B. Blockages
   C. Hemorrhages
   D. Inflammation
   E. Narrowing of blood vessels
   F. Thrombosis
   G. Tumors

Question 261

What is done during the arteriography procedure

Answer 261

1. The specific procedure for an arteriogram will depend on the body part or system being studied. Generally, the procedure includes:
   A. A small incision made in the arm or groin into which a small catheter will be inserted
   B. A small catheter inserted into an artery in the patient’s arm or groin
   C. Contrast dye given through catheter
   D. X-rays taken as dye runs through the vessels
   E. The catheter removed and a pressure dressing applied over the insertion site

Question 262

What is done after the arteriography procedure is completed

Answer 262

1. The patient will remain flat in bed for a designated time
2. Instruct the patient how to monitor for bleeding and to report any unusual pain, discoloration, or temperature change of the extremity with the puncture site
3. Instructions regarding physical activity and wound care will be procedure-specific, but in general the patient should avoid strenuous physical activity for up to a week
4. The patient should keep the bandage on the insertion site dry for approximately 2 days

Question 263

What considerations need to be taken for the arteriography procedure

Answer 263

Risks of an arteriography include
1. Pain
2. Bleeding
3. Infection at the insertion site
4. Blood clots
5. Damage to blood vessels
6. Allergic reaction to the contrast dye

Question 264

What is a computerized tomography scan (CT)

Answer 264

1. A noninvasive, radiological scanning technique that relies on difference in tissue density to reflect organ configurations
2. Because it gathers information in all three dimensions, CT scans provide a more detailed and precise view of the area being scanned than does abdominal ultrasonography
3. However, CT scan can also require more personnel and expensive equipment to operate than ultrasonography, and it uses ionizing radiation
4. CT scan may be done with or without contrast, although the diagnostic accuracy of the CT scan can be enhanced by IV injection of contrast material to visualize the biliary system or by oral ingestion of a contrast agent to delineate the GI system
5. Dosages, contrast median and application of contrast depends on the specific procedure
6. Orally administered contrast media are used for GI opacification during routine abdominopelvic CT scan
7. Ct scan has several options for opacifying the GI tract of the abdomen and pelvis, with barium-based and iodine-based contrast media being the most commonly used

Question 265

What are indications for a CT scan

Answer 265

Evaluation of
1. Gallbladder carcinoma
2. Common bile duct stones
3. Liver masses
4. Pancreatic adenocarcinoma
5. Intra-abdominal abscess
6. Intestinal obstruction
7. Crohn’s disease
8. Aortic aneurysms
9. Appendicitis
10. Abdominal tumors
11. Complications of acute pancreatitis

Question 266

What is entailed with the CT scan procedure

Answer 266

1. Prep depends on the reason for CT scan
2. The patient may be given oral contrast of a liquid containing barium or a water soluble media
3. The patient may be given intravenous iodine-based contrast if the CT is to highlight blood vessels, organs and other structures

Question 267

What considerations need to be take with CT scans

Answer 267

1. Radiation exposure is much higher than with regular x-ray
2. Safety precautions related to x-ray, especially with regard to children and pregnant women, should be observed

Question 268

What is scintigraphy

Answer 268

1. A nuclear medicine diagnostic test
2. Radioactive isotopes or radiopharmaceuticals are administered to the patient, and the emitted radiation is captured by external detectors or a gamma camera to form two-dimensional images of the target organs
3. The hepatobiliary (HIDA) scan, also known as cholescintigraphy and hepatobiliary scintigraphy, is an imaging procedure used to diagnose problems of the liver, gallbladder and bile ducts

Question 269

What is hepatic scintigraphy

Answer 269

1. Hepatic scintigraphy with technetium 99m sulfur colloid is widely used for noninvasive evaluation of the liver
2. Kupffer cells and other phagocytic cells in the liver and spleen absorb the radiolabeled chemical
3. Because most intrahepatic masses appear as “cold” spots on the hepatic scintigram

Question 270

What are indications for hepatic scintigraphy

Answer 270

1. The most common use of hepatic scintigraphy is for diagnosing and following the progression of metastatic disease
2. In addition, its sensitivity for hepatocellular dysfunction or diffuse infiltrating diseases, including alcoholic liver disease, cirrhosis, lymphoma, Amyloidosis, or infiltrating metastatic disease, may be higher than other imaging methods

Question 271

What is biliary scintigraphy or cholescintigraphy

Answer 271

1. In patients with normal biliary function, a technetium 99m labeled iminodiacetic acid derivative is taken up by the hepatocytes and excreted into bile
2. Scans outline the bile ducts, gallbladder, and proximal small bowel

Question 272

What are indications for biliary scintigraphy or cholescintigraphy

Answer 272

1. This test is performed to detect obstruction of the bile ducts
2. This test may also be ordered to detect a bile leak

Question 273

What does the biliary scintigraphy or cholescintigraphy procedure entail

Answer 273

1. For biliary scintigraphy, the patient must be NPO after midnight before the procedure
2. A technetium 99m-labeled iminodiactic acid derivative is administered IV
3. Scans are obtained continuously with a 4- to 6-minute images for filming or digital display, viewed for up to 60 minutes for most procedures
4. For biliary leaks, hepatocellular dysfunction, common bile duct obstruction or suspected biliary atresia, delayed images up to 24 hours may be obtained after radionuclide injection

Question 274

What are indications for radionuclide evaluation of gastric emptying

Answer 274

1. For evaluation of gastric emptying, radionuclide testing is preferred over intubation methods
2. Gastric emptying studies may also be done without radionuclides, however, the ability of radionuclides to tag a solid test meal offers quantitative results that are not possible with barium radiography

Question 275

What does the radionuclide evaluation of gastric emptying procedure entail

Answer 275

1. Either egg salad or chicken liver is labeled with 99mTC, which serves as a marker of the solid of the meal
2. The liquid component of the meal is labeled with indium 111(111In)
3. Following ingestion of the radiolabeled solid and liquid meal, the patient reclines under a scintiscanner that measures the initial level of intragastric radioactivity and the rate of passage of radioactivity out of the stomach (i.e. gastric emptying)
4. In this manner, differential rates of solid and liquid emptying can be detected

Question 276

What is gastrointestinal bleeding scintigraphy (GIBS)

Answer 276

1. A diagnostic radionuclide imaging study performed with 99mTC-labeled red blood cells using the patient’s own blood to detect active bleeding into the GI lumen
2. Historically, GI bleeding was diagnosed through the use of one of two scintigraphic scanning techniques use it technetium
   A. Using 99mTc-labeled sulfur colloid
   B. Using 99mTc-labeled red blood cells using the patient’s own blood
3. Using 99mTc-labeled red blood cells is the radiopharmaceutical of choice for performing GIBS, because of an intravascular half-life that allows for continuous imaging over many hours providing superior studies
4. Inflammatory foci may be identified using 99mTc-labeled white blood cells

Question 277

What are indications for gastrointestinal bleeding scintigraphy (GIBS)

Answer 277

1. Clinical signs of GI bleeding include hematochezia, Melena, or hematemesis, obvious bright red bleeding during endoscopy procedure, current and recent hemoglobin, hematocrit and blood urea nitrogen changes, number of recent transfusions needed, current blood pressure and heart ranges, and presence of orthostatic vital signs
2. Scanning for GI bleeding is helpful in diagnosing active GI bleeding as a result of such conditions as diverticulosis, post polypectomy bleeding, arteriovenous malformations, malignancies, colitis, radiation proctitis, angiodysplasias, and inflammatory foci

Question 278

What does the Gastrointestinal bleeding scintigraphy (GIBS) procedure entail

Answer 278

1. After injection with the labeled substance, the patient is placed in a supine position, and rapid images of the abdomen and pelvis are obtained at intermittent intervals
2. When the labeled substance enters the bleeding site, its location is identified through nuclear scanning
3. Images are obtained over 20 to 60 minutes
4. Active hemorrhage is seen within the first 5 to 10 minutes
5. Bleeding in the splenic flexure or transverse colon regions is difficult to visualize due to intense uptake by the liver and spleen
6. Inflammatory foci may be identified using labeled white blood cells and employing a similar technique as that of labeled-red-blood cell studies
7. The patient’s white blood cells are isolated, and technetium is added before the substance is administered via IV
8. Nuclear scanning techniques allow for identification of inflammatory foci (as seen in inflammatory bowel disease(IBD)) in areas where the labeled white blood cells cluster

Question 279

What considerations need to be taken for the Gastrointestinal bleeding scintigraphy (GIBS) procedure

Answer 279

1. GIBS is only reliable if the patient is actively bleeding at the time of the procedure
2. The most common false positive results occur when there is rapid transit of luminal blood that is detected in the colon, although it originated in the upper GI tract
3. If no bleeding site is identified on the initial images, delayed images can be acquired by rescanning the patient for up to 24 hours, especially if recurrent GI bleeding is evident

Question 280

What is a transjugular intrahepatic portosystemic shunt (TIPS) procedure

Answer 280

1. A Percutaneously created low-resistance channel between the portal vein and the hepatic vein
2. The goal of TIPS is to reduce portal pressure by shunting blood from the portal to the systemic circulation, bypassing the liver

Question 281

What are indications for a TIPS procedure

Answer 281

1. Complications of portal hypertension, including variceal bleeding uncontrolled by medical or endoscopic management that normally drains the stomach, esophagus, or intestines into the liver
2. Portal gastropathy in the wall of the stomach
3. Severe ascites and/or hepatic hydrothorax
4. Budd-Chiari syndrome

TIPS should not be performed in patients who have severe heart failure or pulmonary hypertension, due to an increased risk of life-threatening pulmonary congestion
Other contraindications are multiple hepatic cysts, uncontrolled systemic infections or sepsis, and unrelieved biliary obstruction

Question 282

What is to be done before the TIPS procedure begins

Answer 282

1. The procedure is explained to the patient, and informed consent is obtained
2. Moderate sedation is provided to the patient
3. The GI nurse or physician preps and drapes the right side of the neck

Question 283

What does the TIPS procedure entail

Answer 283

The procedure is performed EGD under fluoroscopic guidance
1. A wire is introduced into the right hepatic vein via the right internal jugular vein
2. The catheter is replaced by a sheath, through which contrast is injected to confirm entry into the portal vein
3. The parenchyma tract is dilated with a angioplasty balloon
4. The balloon is deflated, and a wall stent catheter is advanced over a wire across the hepatic vein to the portal vein
5. The metallic stent is left in place
6. Venography is performed and shows hepatoportal flow to the inferior vena cava with collapse of the varices

Question 284

What must be done immediately post procedure in recovery from a TIPS procedure

Answer 284

1. The patient must be monitored for possible compilations following the procedure
2. Such complications include inadvertent puncture of the gallbladder, colon, or other abdominal organ; blood loss and infection
3. Doppler ultrasound is used to monitor shunt patency approximately every 3 months

Question 285

What considerations need to be taken for a TIPS procedure

Answer 285

1. Two main limitations of TIPS are shunt dysfunction and hepatic encephalopathy, which is the main symptom of treatment failure
2. Complications related to the puncture site include intraperitoneal hemorrhage, portal vein perforation, and hepatic artery or bile duct injury, which may lead to fistula formation

Question 286

What are secretory studies

Answer 286

They evaluate secretion of bile and various GI enzymes, with or without external stimulation

Question 287

What is pancreatic stimulation

Answer 287

1. Exocrine pancreatic insufficiency occurs in any condition that blocks the pancreatic ducts or damages the cells that produce elastase
2. Pancreatic stimulation involves the determination of the volume, bicarbonate content, and pancreatic enzyme concentration in the duodenal juice before and after direct IV stimulation of the pancreas with the hormones secretin and/or cholecystokinin (CCK)
3. Indirect pancreatic (stool elastase) test is used to measure the exocrine pancreas responsible for producing elastase along with other enzymes.
4. This testis only positive in patient with exocrine pancreatic insufficiency, as seen with chronic pancreatitis and pancreatic cancer

Question 288

What are indications for pancreatic stimulation

Answer 288

1. Evaluation of possible early exocrine dysfunction in patients with abdominal pain
2. The determination of the etiology of steatorrhea
3. Increases in duodenal secretion (volume and/or bicarbonate level) may occur with chronic alcoholism, hepatic or biliary cirrhosis, Gastrinomas, or hemochromatosis
4. Decreases in secretions are associated with pancreatic carcinoma, collagen disease, diabetes mellitus, and Bilroth I and II surgeries
5. Patient with cystic fibrosis has a substantial reduction in volume and bicarbonate and an 80-90% reduction or absence of enzymes
6. Normal to slightly reduced volume, reduced bicarbonate concentration, and greatly reduced enzyme secretions are found in patients with pancreatic exocrine insufficiency not caused by cystic fibrosis
7. Indirect pancreatic (stool elastase) test is indicated for
   A. A decrease in elastase, associated with chronic pancreatitis and sometimes pancreatic cancer. In children, a decrease in elastase is mostly associated with cystic fibrosis or Shwachman-Diamond syndrome

Question 289

How is the pancreatic stimulation test performed

Answer 289

It can be performed by two methods
1. An orally passed radiopaque duodenal tube is guided under fluoroscopic control through the duodenum to the ligament of Treitz. Secretin or CCK is administered intravenously over a one-minute period, and samples of duodenal fluid are collected in ice-cooled flasks for over approximately 50 minutes. Each specimen is examined for volume; bicarbonate concentration; pH; and the enzymes trypsin, chymotrypsin, lipase and amylase

2. A secretin endoscopic pancreatic function test advances the endoscope to the post-bulbar duodenum. The first specimen is collected prior to secretin or CCK, and then secretin or CCK is administered intravenously over a 1-minute period. Samples of duodenal fluid are collected through upper endoscope every 15 minutes for 1 hour. 2.5cc of duodenal fluid is collected in a trap, with each specimen collected separately and kept on ice as soon as collected. The tip of the scope is kept in the post-bulbar duodenum

Indirect test, the pancreatic elastase test, collects stool samples

Question 290

What considerations need to be taken for a pancreatic stimulation test

Answer 290

1. If the patient is taking pancreatic enzymes they must be discontinued a week prior to either test
2. Pancreatic stimulation results are approximate because the duodenal aspirates consist of pancreatic and duodenal juices and bile. In addition, not all of the secreted juice will be aspirated. A finding of less than 90mEq/L of bicarbonate is 74-90% sensitive and 90-90% specific for chronic pancreatitis
3. For indirect pancreatic test, the stool must be formed, not watery, and not contaminated with urine or water
4. Both of these tests share one major drawback
   A. They will usually not be positive until the pancreas has developed pancreatic insufficiency, a process that takes years
   B. The tests are likely to be inaccurate in the early or less-advanced stages of the disease
5. This type of testing is not standardized, and each of the few facilities that perform the test has to develop a protocol and normal ranges

Question 291

What is gastric analysis

Answer 291

the purpose of gastric analysis is the objective measure of gastric acid secretions

Question 292

What are indications for gastric analysis

Answer 292

In patients with
1. Intractable peptic ulcer symptoms
2. Suspected Zollinger-Ellison syndrome (hypersecretory disease)
3. Achlorhydria
4. In the presence of elevated gastrin, which indicates impairment of acid output such as occurs in
A. Pernicious anemia
B. Atrophic gastritis
C. Menetrier disease
5. After inhibition of gastric acid secretion by potent antisecretory drugs

Gastric analysis may be indicated to assess the efficacy of treatment regimens in peptic ulcer disease
For patients with suspected achlorhydria or gastric hypersecretory states, it may also be helpful to obtain a serum gastrin level

Question 293

When is gastric analysis contraindicated

Answer 293

1. In patients with gastric outlet obstruction
2. Recent upper GI tract bleeding
3. Allergy to the stimulating agent; when there is an inability to freely pass a nasogastric tube lobe when food particles or fresh blood are present in the gastric aspirate

Question 294

What is the patient required to do prior to a gastric analysis test

Answer 294

1. Remain NPO for 12 hours
2. Withhold H2-receptor antagonists, anticholinergics, tricyclic antidepressants, sucralfate (Carafate), and antacids for 48 hours before testing
3. Withhold PPIs for a minimum of 72 hours before testing
4. Refrain from smoking for 2 hours before the test
5. If the test is being done to check the effectiveness of the medications, the medications should be continued until 12 hours prior to the test

Question 295

What occurs during the gastric analysis procedure

Answer 295

1. After lubricating the tube, a radiopaque polyethylene nasogastric tube is passed—fluoroscopy may be used if needed—so that the tip lies in the most dependent part of the stomach and along the greater curvature. Proper placement is confirmed by instilling 30ml of water with immediate recovery of at least 80%
2. With the patient lying on the left side, suction is used to aspirate the stomach contents as completely as possible, then the aspirate is discarded. Pentagastrin, the usual drug of choice to induce gastric secretions, is given either intravenously or subcutaneously. Four separate 15 minute basal acid output samples are then obtained. Each sample is analyzed for volume, pH, free acid, color, consistency, and occult blood

Question 296

What considerations need to be taken for a gastric analysis test

Answer 296

Complications of gastric analysis are rare but may include nosebleeds, tube miss placement, or an adverse reaction to the gastric stimulant

The patient’s nose and throat may feel irritated, so gargling with warm salt water or sucking on throat lozenges may help

Question 297

What is multichannel intraluminal impedance (MII)

Answer 297

1. A technique usually done in combination with esophageal manometry to detect intraluminal bolus movement and esophageal contractions during typical eating and drinking
2. MII calculates the bolus transit parameters, evaluates the bolus clearance, and investigates the relationship between bolus transit and LES relaxation in the esophagus
3. When done with pH testing, MII allows for the detection of Gastroesophageal reflux independent of pH, including both acid and non-acid reflux

Question 298

What are indications for multichannel intraluminal impedance

Answer 298

Evaluation of patients with
1. Dysphagia
2. Non-cardiac chest pain
3. Heartburn and regurgitation
4. Preoperative evaluation before antireflux procedures
5. Location of the LES prior to pH catheter placement

In patients with non-obstructive dysphagia, MII may offer better sensitivity for detection of motility disturbances than standard manometry

Question 299

What does the multichannel intraluminal impedance procedure entail

Answer 299

1. An impedance catheter, a thin wire with sensors, is inserted through the nose and down the esophagus
2. The external end is hooked into an external recorder box for approximately 18-24 hours
3. The catheter measures changes in resistance to alternating electrical current when a bolus passes by a pair of metallic rings mounted on the catheter
4. The level of electric current alternates in response to different substances based on their electrical conductivity
   A. For example, liquid-filled boluses passing by the impedance measuring segments show a lower impedance value, and gas will produce a rise in impedance
5. The patient continues his or her usual daily routine and pushes a button on the recording device during certain designated activities such as eating or lying down
6. Upon completion of the test, the patient returns to the facility to have the catheter and recorder removed and the data downloaded

Question 300

What considerations need to be taken for the multichannel intraluminal impedance procedure

Answer 300

1. Complications of esophageal manometry are rare but may include
   A. Nosebleed
   B. Tube misplacement
2. The patient’s nose and throat may feel irritated, so gargling with warm salt water or sucking on throat lozenges may help post-procedure

Question 301

What is 24-hour pH monitoring

Answer 301

1. Measuring the pH using ambulatory pH monitoring will show the degree of acidity or alkalinity of gastric secretions
2. Prolonged esophageal pH monitoring is the most sensitive method of directly detecting esophageal reflux, quantifying it, and correlating symptoms with reflux events

Question 302

What are indications for 24-hour pH monitoring

Answer 302

1. Suspected pulmonary complications of esophageal reflux
2. Atypical presentations of esophageal reflux such as non-ulcer dyspepsia, wheezing and hoarseness
3. Typical presentation of esophageal reflux with a negative work up
4. Esophageal reflux after medical or surgical therapy
5. Episodes of apnea or bradycardia to determine if they are associated with reflux—in infants
6. Chest pain to determine a noncardiac source for pain

Ambulatory pH monitoring may be performed in patients before proposed anti-reflux surgery to prevent incessant surgery in patients with atypical symptoms who do not have esophageal reflux

Ambulatory pH monitoring is contraindicated for patients with any esophageal condition that would prevent correct placement of the probe

Question 303

What does the patient need to do prior to the 24-hour pH monitoring procedure

Answer 303

1. Remaining NPO after midnight or at least 6 hours before the procedure for adults; in children, fasting for 2-4 hours before the procedure
2. Discontinuing H2 2-receptor antagonist for 24 hours before the procedure
3. Discontinuing PPIs for at least 72 hours before the procedure
4. Discontinuing antacids 6 hours before the procedure

Sometimes pH monitoring is done to assess the adequacy of acid suppression
In these cases, the patients should not discontinue medication before the procedure

Question 304

What is done during the 24-hour pH monitoring procedure

Answer 304

The pH probe and equipment must be calibrated for each patient. For the test
1. A pH probe is inserted through the patient’s nostril to a position 5cm above the LES. The patient may be asked to take a few sips of water to help advance the probe
2. The LES is located by esophageal manometry, fluoroscopic placement, endoscopic visualization or by measuring the pH in the stomach and withdrawing the probe until it enters the esophagus where the pH is higher. The proper position of the probe in children may be estimated by a calculation based on the child’s height. Proper placement of the probe may need to be confirmed by Radiographic examination
3. The tube is taped securely to the nose and side of the face
4. Some types of pH monitoring equipment require the use of an external reference electrode secreted to a flat area of skin surface (usually the chest or back) the area may need to be shaved before the electrode is applied to allow optimal conduction
5. The probe is connected to an external recording device
6. The patient proceeds with his or her daily routine while wearing the device for 24 hours

The patient is instructed to
1. Not take a tub bath or shower until the equipment is removed. The equipment cannot get wet
2. Record symptoms (i.e., chest pain, heartburn, or coughing) and activities in a diary, along with pressing a button to mark the even on the recording device. Children may need to be hospitalized overnight if the parent or guardian is unable to record events accurately
3. Avoid strenuous activities because of the possibility of damaging the monitor, dislodging the probe, or disrupting the recording

Question 305

what is to be done after the 24-hour pH monitoring procedure is finished

Answer 305

1. At completion of the monitoring period, the stored data are downloaded into a computer that analyzes the information and prints a graphical display of esophageal pH over the recording period, along with a summary of these values
2. Norma pH in the esophagus ranges between 6.5 and 7.9. Acid reflux is defined as a fall in intraesophageal pH below 4

Question 306

What considerations need to be taken for the 24-hour pH monitoring procedure

Answer 306

1. Complications of 24-hour pH monitoring are rare but may include nosebleeds or tube misplacement
2. The patient’s nose and throat may feel irritated, so gargling with warm salt water or sucking on throat lozenges may help post-procedure

Question 307

What is wireless pH monitoring

Answer 307

1. A wireless, catheter free pH monitoring system is designed to minimize the discomfort associated with transnasal catheters, which are uncomfortable, induce social embarrassment, and interrupt daily activity during the pH monitoring and impede the sensitivity of the test
2. A wireless pH sensing capsule, which is attached to the mucosa of the distal esophagus, shows improved patient tolerability, enables the patient to perform daily activities, and has the capacity to record extended period of monitoring up to 96 hours. An advantage of wireless pH monitoring is the ability to study pH levels both off and on PPIs during the 96-hour monitoring

Question 308

What are the indications for wireless pH monitoring

Answer 308

Refractory GERD

Question 309

What does the wireless pH monitoring procedure entail

Answer 309

1. The preparation for the procedure is the same as for upper endoscopy
2. A small transmitter is placed at the end of the esophagus and attached to the surface of the esophagus
3. This may be done with endoscopic assistance
4. The transmitter sends signals to a belt clip recorder for up to 96 hours and the passes out of the body naturally
5. Patients are monitored while they go about their daily routine
6. They are asked to keep a journal and press one of the three buttons on the recorder to indicate if they deal heartburn, when they start and stop eating, and when they lie down

Question 310

What are considerations that need to be taken before a wireless pH monitoring procedure is done

Answer 310

1. Complications of wireless pH monitoring are rare
2. Some patients may experience a vague sensation that something is in the esophagus, especially when eating or drinking
3. Some may experience discomfort, and endoscopic removal may be required
4. The capsule may cause a tear in the lining of the esophagus causing bleeding and may require endoscopic intervention
5. Perforation is possible
6. The capsule may dislodge early, or it may not completely pass on its own, requiring intervention to remove it
7. The capsule contains a small magnet; therefore, the patient should not have an MRI study within 30 days of undergoing placement

Question 311

Why would blood test be ordered for gastroenterology patients

Answer 311

1. To test for coagulopath
2. To reveal alterations in basic metabolic functions
3. And/or to indicate the severity of a disorder

Question 312

What is the normal range for a hematocrit

Answer 312

Female— 38-47%
Male—40-54%

Question 313

What is the normal range for hemoglobin

Answer 313

Female—12-16g/dl
Male—13.5-18g/dl

Question 314

What is the normal prothrombin time

Answer 314

11-14 seconds

Question 315

What is the normal activated partial thromboplastin time

Answer 315

32-47 seconds

Question 316

What is the normal INR

Answer 316

<1

Question 317

What is the normal platelet count

Answer 317

150,000-350,000mm3

Question 318

What is the normal albumin level

Answer 318

3.6-5.1g/dl

Question 319

What is the normal globulin level

Answer 319

2.1-3.8g/dl

Question 320

What is the normal albumin/globulin ratio

Answer 320

1:2

Question 321

What is the normal total protein level

Answer 321

6.4-8.3g/dl

Question 322

What is the normal glucose level

Answer 322

65-115mg/dl

Question 323

What is the normal cholesterol level

Answer 323

150-240mg/dl

Question 324

What is the normal total cholesterol level

Answer 324

<200

Question 325

What is the normal LDL level

Answer 325

Optimal is <100mg/dl
Borderline high is 100-159mg/dl
High is >160mg/dl

Question 326

What is the normal HDL level

Answer 326

Men—>37mg/dl
Women—>47mg/dl

Question 327

What is the normal triglyceride level

Answer 327

<150mg/dl

Question 328

What is the normal VLDL

Answer 328

2-30mg/dl

Question 329

What is the normal AST level

Answer 329

6-41mU/ml

Question 330

What is the normal ALT level

Answer 330

8-50mU/ml

Question 331

What is the normal alkaline phosphatase level

Answer 331

0-15 years —50-300IU/ml
Adults—30-115IU/ml

Question 332

What is the normal amylase level

Answer 332

23-85u/1

Question 333

What is the normal lipase level

Answer 333

0-160u/1

Question 334

What is the normal total bilirubin level

Answer 334

0.1-1.3mg/dl

Question 335

What is the normal indirect bilirubin level

Answer 335

0.0.4mg/dl

Question 336

what is the normal CEA level

Answer 336

O-2.5mcg/1

Question 337

What is the normal Ca19-9 level

Answer 337

1-36u/ml

Question 338

What is hemoglobin and hematocrit

Answer 338

1. Hemoglobin is the iron-containing, oxygen-transport protein in red blood cells
   A. It is formed by the developing red blood cells in bone marrow
2. Hematocrit or packed cell volume (PCV) refers to the volume percentage of erythrocytes in whole blood

Question 339

Why would a hemoglobin and hematocrit be drawn

Answer 339

1. Both hemoglobin and hematocrit levels are decreased when the patient is anemic
2. And increased wren the patient is dehydrated
   Resulting in a concentration of cells proportionate to fluid volume

Question 340

What is a Prothrombin level

Answer 340

1. A glycoprotein in the plasma that is normally converted to thrombin on activation
2. A deficiency in the factor leads to hypoprothrombinemia

Question 341

Why is a prothrombin level drawn

Answer 341

1. Decreased prothrombin levels may be associated with impaired absorption of vitamin K from the intestine
2. It also may be related to decreased availability of vitamin K, resulting from the absence of bile salts or a decrease in intestinal flora caused by antibiotic suppression
3. Lo levels of prothrombin are seen in infectious hepatitis, cirrhosis, biliary tract obstructions and small bowel disorders

Question 342

What is prothrombin time

Answer 342

1. Measures the rapidity of blood clotting through examination of factors I,II,V,VII,and X

Question 343

Why is a prothrombin time drawn

Answer 343

1. A prolonged PT is seen in patients with poor nutrition, vitamin K deficiency from decreased absorption, liver disease leading to decreased synthesis of clotting factors, warfarin sodium (Coumadin, Jantoven, etc) therapy, and inherited blood disorders

Question 344

What is an activated partial thromboplastin time (APTT)

Answer 344

1. Measures the rapidity of blood clotting
2. It reflects clotting time by examining factors I,II,V,VIII,IX,X,XI, and XII

Question 345

Why is an activated partial thromboplastin time drawn

Answer 345

1. A pronged APTT is observed in patients who are taking heparin and in those with liver disease or inherited coagulopathies

Question 346

What is the International Normalized Ratio

Answer 346

1. The ratio of the patient’s PT compared to the mean PT for a group of individuals

Question 347

Why is an INR drawn

Answer 347

1. Allows physicians to determine the level of anticoagulation in a patient independent of the laboratory reagents used

Question 348

What is a bleeding time

Answer 348

1. If the platelet count is extremely low, clotting mechanisms may be impaired
2. To assess platelet function, bleeding time is measured by making small cuts in the patients arm and monitoring the time until bleeding stops

Question 349

Why would a bleeding time be checked

Answer 349

1. Aspirin products and NSAIDs such as Ibuprofen can prolong bleeding time for up to 14 days after ingestion

Question 350

What is a platelet count

Answer 350

1. They play an important role in blood clotting
2. A platelet count measures the number of platelets present in the blood

Question 351

Why would a platelet count be drawn

Answer 351

Indicated for possible platelet disorders
1. Thrombocythemia (overproduction of platelets dye to Myeloproliferative neoplasm) and reactive thrombocytosis (overproduction of platelets due to inflammatory disorder)
2. Thrombocytopenia (decrease in platelets dye to decreased production, increased splenic sequestration, increased platelet destruction or consumption and dilution
3. Platelet dysfunction (may be hereditary or acquired)

Question 352

What are serum albumin, globulin and albumin/globulin ratio

Answer 352

1. They occur in inverse proportion to one another
   A. As one increases the other decreases

Question 353

Why would a serum albumin, globulin and albumin/globulin ratio be drawn

Answer 353

1. These tests are indicated for patients who are experiencing
   A. Significant sudden weight loss
   B. Symptoms of kidney or liver disease
   C. Edema: ascites, peri-orbital edema, pleural effusion, and/or anasarca
2. A low albumin/globulin ratio can indicate conditions causing overproduction of globulins, Luke an autoimmune disease (lupus), or conditions causing underproduction or loss of albumins (nephrotic syndrome, liver disease, malabsorption, malnutrition, carcinomas, etc.)
3. A high albumin/globulin ratio indicates conditions causing under production of globulins (leukemia, hypothyroidism, some genetic disorders, etc)

Question 354

What is total protein

Answer 354

Measures the total amount of albumin and globulin found in the fluid portion of the blood

Question 355

Why would a total protein level be drawn

Answer 355

1. These tests are indicated for patients who are experiencing
   A. Significant or sudden weigh loss
   B. Symptoms of kidney or liver disorder
   C. Edema: ascites, peri-orbital edema, pleural effusion and.or anasarca
2. Low total protein levels indicate serious malnutrition, conditions producing malabsorption of proteins (celiac disease, inflammatory bowel disease, etc.) and kidney or liver related disorders
3. High levels of total protein indicate kidney or liver disease, chronic inflammations and/or infections (viral hepatitis, HIV, etc) and bone marrow disorders (multiple myeloma, etc)

Question 356

What is a galactose tolerance test

Answer 356

1. This liver function test is based on the ability of the liver to convert galactose to glycogen
2. Following oral ingestion of 40g of galactose, less than 3g should appear in the urine within 5 hours after the ingestion
3. In the IV galactose tolerance test, galactose is administered intravenously, and blood is drawn at half-hour intervals for 2 hours
4. In a normal test result, all galactose will have been eliminated from the blood 45 minutes after its injection

Question 357

Why would a galactose tolerance test be done

Answer 357

The presence of large amounts of galactose in the serum after the specified periods of time is indicative of liver disease failure of the liver to convert galactose to glycogen

Question 358

What are possible causes got an abnormal ALT and AST level

Answer 358

Cirrhosis or hepatitis, depending on the degree of alcoholism

Question 359

What are possible causes of abnormal red blood cell count, hemoglobin and hematocrit

Answer 359

GI bleeding resulting in iron deficiency

Question 360

What are possible causes of an abnormal platelet count

Answer 360

Impaired platelet production because of toxic effects of alcohol on the bone marrow

Question 361

What are the possible causes of abnormal PT and APTT

Answer 361

Liver disease impairs the production of protein synthesis

Question 362

What are possible causes of abnormal urinary bilirubin

Answer 362

Normal to elevated, depending on the degree of bleeding and the stage of liver disease (the liver converts the hemoglobin from the red cells to bilirubin)

Question 363

What are the causes for an abnormal fecal occult blood test

Answer 363

Positive for blood in the stool due to GI bleeding

Question 364

What are hydrogen/methane breath tests

Answer 364

1. The objective is to measure the volume of hydrogen that is produced in the colon, absorbed from the colon into the blood, and expelled in the breath
2. Methane is also measured because there are patients with severe malabsorption issues who do not produce hydrogen but methane
3. Hydrogen/methane is produced in the body by bacterial fermentation of carbohydrates
   A. Under normal circumstances lactose is broken down into glucose and galactose and is absorbed in the small intestine, which has virtually no anaerobic bacteria
   B. In patients who are deficient in lactase or who have delayed transit times, mucosal damage or colonic flora in the upper GI tract, hydrogen gas evolves when lactose comes into contact with the fermenting bacteria in the colon

Question 365

Why would a hydrogen/methane breath test be indicated

Answer 365

Used in the diagnosis of
1. Small intestinal overgrowth (SIBO)
2. Short bowel syndrome (rapid transit of food through the small bowel)
3. Sugar intolerance (lactose, lactulose, fructose, or sucrose)
4 and tests for fat absorption
Also used for other GI disorders
1. Bloating
2. Cramps
3. Diarrhea

Contraindicated in patients who are unwilling to cooperate

Question 366

How is the hydrogen/methane breath test done

Answer 366

1. The patient must be NPO for 12 hours and follow other specific diet instructions prior to the test, and they must refrain from smoking or second-hand smoke exposure after midnight before the test
2. End-expired tidal air is collected twice before the test and at designated times for 3 hours after ingestion of a carbohydrate drink.
3. Hydrogen gas concentration is determine by gas-liquid chromatography
4. Test results are normal if the patient expires <20 parts per million of hydrogen
5. Patients with malabsorption syndromes expire >i-ppm
6. To avoid false positive results a positive lactose test may be followed by a glucose breath test to differentiate between true lactose intolerance and bacterial overgrowth
   A. A portion of the population lacks hydrogen-producing bacteria in the colon
   B. To avoid false negative diagnosis, a negative lactose test may be followed by a lactulose test to confirm the present of hydrogen-producing colonic bacteria

Question 367

What considerations need to be taken before a hydrogen/methane breath test

Answer 367

1. Patients should have at least 28 days between a breath test and any procedure that involves a bowel prep
2. Antibiotic and probiotics should be discontinued at least 4 weeks before test
3. Laxative should not be taken for at least 1 week prior to test