INVASIVE PROCEDURES

ENDOSCOPY LIVER BIOPSY PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM OTHERS

ENDOSCOPY
Endoscopy is a nonsurgical procedure used to examine a person's digestive tract. Using an endoscope, a flexible tube with a light and camera attached to it, pictures of digestive tract can be viewed on the monitor.

 Upper endoscopy
an endoscope is easily passed through the mouth and throat and into the esophagus allowing the visualization of the esophagus, stomach, and upper part of the small intestine.

 Lower endoscopy
endoscopes can be passed into the large intestine (colon) through the rectum to examine this area of the intestine.

 Capsule endoscopy
capsule is the size and shape of a pill and contains a tiny camera. After a patient swallows the capsule, it takes pictures of the inside of the gastrointestinal tract. primary use is to examine areas of the small intestine that cannot be seen by other types of endoscopy such as colonoscopy or EGD

 Double-balloon enteroscopy
also known as push-and-pull enteroscopy is an endoscopic technique for visualization of the small bowel involves the use of a balloon at the end of a special enteroscope camera and an overtube, which is a tube that fits over the endoscope, and which is also fitted with a balloon

 Endoscopic retrograde cholangiopancreatography (ERCP)

combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on X-rays.

 Endoscopic ultrasound (EUS) or echo-endoscopy

is a medical procedure in endoscopy (insertion of a probe into a hollow organ) is combined with ultrasound to obtain images of the internal organs in the chest and abdomen. It can be used to visualize the wall of these organs, or to look at adjacent structures. Combined with Doppler imaging, nearby blood vessels can also be evaluated.

 Laparoscopy
is an operation performed in the abdomen or pelvis through small incisions (usually 0.51.5 cm) with the aid of a camera. It can either be used to inspect and diagnose a condition or to perform surgery.

PREPARATION Medication cessation like aspirin and sucralfate Fasting 6-8 hrs prior to procedure Laxative/enema Anesthesia

LIVER BIOPSY
biopsy (removal of a small sample of tissue) from the liver. It is a medical test that is done to aid diagnosis of liver disease, to assess the severity of known liver disease, and to monitor the progress of treatment.

PREPARATION
At least 1 week before a scheduled liver biopsy, patients may be asked to temporarily stop taking medications that affect blood clotting or interact with sedatives, which are sometimes given during a liver biopsy.
NSAIDs, such as aspirin, ibuprofen, and naproxen blood thinners high blood pressure medication diabetes medications antidepressants antibiotics asthma medications dietary supplements

 Prior to liver biopsy, blood will be drawn to determine its ability to clot. Clotting factor concentrates, reduces the risk of bleeding in patients with blood clotting abnormalities. NPO 8hrs Sedation no driving for 12 hrs

Types
Percutaneous LB Transvenous LB Laparoscopic LB

Types
Percutaneous Liver Biopsy
The most commonly used technique for collecting a liver sample is percutaneous liver biopsy. For this method, a hollow needle is inserted through the abdomen into the liver to remove a small piece of tissue. Right side 2hrs. Monitoring 2-4 hrs

 Transvenous Liver Biopsy

used when a person's blood clots slowly or when excess fluid is present in the abdomen patients lie on their back on an x-ray table and a local anesthetic is applied to one side of the neck. If needed, an IV tube is used to give sedatives and pain medication. 4-6 hrs monitoring

OTHERS
Bernstein test/acid perfusion test
Used to try to reproduce the symptoms of heartburn, to determine whether your heartburn symptoms are caused by acid coming up from the stomach and irritating the esophagus. NPO 8hrs

 Esophageal manometry
test that gauges how well esophagus works measures the rhythmic muscle contractions (peristalsis) that occur in esophagus when swallowing. also measures the coordination and force exerted by the muscles of esophagus.

 Advance Planning
Discontinue all motility drugs 24 hours before procedure, unless indicated Avoid narcotics for 24 hours before procedure. If taking insulin, consult with physician If taking cardiac (heart) or anti-hypertensive (high blood pressure) pills, take them with small sips of water.

On the Day Before

NPO after midnight. exception is medication taken with small sips of water. If for afternoon procedure, clear liquids up to 6 hours prior to arrival time.
CLEAR LIQUIDS: water, apple juice, ginger ale, sprite, beef or chicken broth WITHOUT noodles, coffee or tea WITHOUT cream or milk, most sodas, sherbet, pop-sicles, and Jell-O that is not red or orange. DO NOT DRINK ANYTHING RED OR ORANGE.

 Esophageal pH monitoring
measuring the reflux of acid from the stomach into the esophagus w/ GERD Small catheter passed through the nose or a capsule is inserted via catheter then clipped to the esophageal lining

Preparation for the test

Stop medications used for treating reflux and for treating stomach acid problems Stop these medications one week prior to the test.
Prilosec (omeprazole), Nexium (esomeprazole), Aciphex (rabeprazole), Prevacid (lansoprazole), Protonix (pantoprazole)

Stop for two days before the test.

Zantac (randitidine), Tagamet (cimetidine), Axid (nizatidine), and Pepcid (famotidine).

NPO after midnight Wear a shirt or blouse which opens in the front

 Exfoliative cytologic analysis

cells are collected after they have been either spontaneously shed by the body ("spontaneous exfoliation") or manually scraped/brushed off of a surface in the body ("mechanical exfoliation"). An example of spontaneous exfoliation is when cells of the pleural cavity or peritoneal cavity are shed into the pleural or peritoneal fluid. This fluid can be collected via various methods for examination.

 Gastric analysis
examination of the contents of the stomach, primarily to determine the quantity of acid present and incidentally to ascertain the presence of blood, bile, bacteria, and abnormal cells. sample of gastric secretion is obtained via a NGT.
The total absence of hydrochloric acid is diagnostic of pernicious anemia. Patients with gastric ulcer and gastric cancer may secrete less acid than normal whereas patients with duodenal ulcers secrete more.

consists of a series of tests

collecting residual gastric fluid from a fasting patient collecting basal secretions every 15 minutes for four hours IM administration of a drug that stimulates gastric acid output collecting stomach secretions every 15 minutes for 90 minutes

The appearance, blood, bile, pH, volume, millimoles of H+ per liter, millimoles of H+ per volume, and millimoles of H+ per hour of each specimen is then evaluated.

 Basal gastric acid secretion

NPO overnight (12 hours) prior to intubation. specimens are obtained every 15 minutes for a period of 90 minutes. no liquids during the test, and saliva must be ejected to avoid diluting the stomach contents. final four specimens collected during the test constitute the basal acid output. Each sample is titrated to pH 3.5 using 0.1 N sodium hydroxide. The millimoles of hydrogen ion in each sample are calculated from the amount of base used to neutralize the stomach acid of each. results are averaged and multiplied by four to give the millimoles of free hydrogen ions per hour. If analysis suggests abnormally low gastric secretion, the maximum acid output test is performed immediately afterward.

 Gastric acid stimulation test

After the basal samples have been collected, the tube remains in place for the gastric acid stimulation test. Pentagastrin injected subcutaneously. After 15 minutes, a specimen is collected every 15 minutes for one hour. specimens are called the post-stimulation specimens. The maximal acid output (MAO) is determined by titrating each of the four specimens and averaging the results. The average is used to determine the millimoles of hydrogen ion produced per hour. Alternatively, the peak acid output (PAO) is determined by titrating each specimen and using the average hydrogen ion concentration of the highest two to calculate the acid produced in millimoles per hour.

 Preparation
The patient should be fasting (nothing to eat or drink after the evening meal) on the day prior to the test, but may have water up to one hour before the test. Antacids, anticholinergics, cholinergics, alcohol, H2receptor antagonists (Tagamet, Pepcid, Axid, Zantac), reserpine, adrenergic blockers, and adrenocorticosteroids should be withheld for one to three days before the test, as the physician requests. If pentagastrin is to be administered for the gastric acid secretion test, medical supervision should be maintained, as possible side effects may occur. Additionally, because such external factors as the sight or odor of food, as well as psychological stress, can stimulate gastric secretion, accurate testing requires that the patient be relaxed and isolated from all sources of sensory stimulation.

 Paracentesis
procedure to take out fluid that has collected in the belly (peritoneal fluid); taken out using a long, thin needle put through the belly takes about 20 to 30 minutes up to 4 L (1 gal) of fluid is taken out Preparation
Medication history v/s Empty bladder

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM

an x-ray test that can help show whether there is a blockage in the liver or the bile ducts that drain it. Preparation
Assess for allergic reaction to lidocaine or the numbing medicine, pregnancy, taking insulin Assess for bleeding complications NPO on the morning of the test

LABORATORY RESULTS
BLOOD CHEM LYMPHOCYTE CT D-XYLOSE ABSORPTION TEST NITROGEN BALANCE FECAL ANALYSIS

 Amylase

BLOOD CHEM

enzyme that helps digest carbohydrates. produced in the pancreas & glands that make saliva. when the pancreas is diseased or inflamed, amylase releases into the blood. N: 23 to 85 (U/L) or 40 to 140 U/L. : infection : damage/cancer

Lipase
enzyme released by the pancreas into the SI helps the body absorb fat by breaking the fat down into fatty acids. normal: 0 to 160 units per liter (U/L) : Blockage of the bowel, Celiac disease, Cholecystitis, Duodenal ulcer, Gastroenteritis (severe), Macrolipasemia, Pancreatic cancer, Pancreatitis

 Proteins
measures the total amount of two classes of proteins found in the fluid portion of your blood: albumin and globulin. important parts of all cells and tissues e.g. albumin helps prevent fluid from leaking out of blood vessels & globulins are an important part of immune system. Normal: 6.0 to 8.3 gm/dL : chronic infection/inflammation :Agammaglobulinemia, Bleeding, Liver disease, Malabsorption, Malnutrition, Protein-losing enteropathy

 LYMPHOCYTE COUNT
a type of WBC present in the blood. White blood cells help protect the body against diseases and fight infections. help provide a specific response to attack the invading organisms Normal: 18 - 48 % : viral infection : infection after surgery/trauma; HIV

d-Xylose absorption test

measures the level of D-xylose, a type of sugar, in a blood or urine sample. help diagnose problems that prevent the SI from absorbing nutrients in food. Normal:
Infants (5-gram dose): Children (5-gram dose): >15 mg/dL or >1.0 mmol/L >20 mg/dL or >1.3 mmol/L

Adults (5-gram dose):

Adults (25-gram dose):

>20 mg/dL in 2 H or >1.3 mmol/L

>25 mg/dL in 2 H or >1.6 mmol/L

 Preparation
For 24 hours before a D-xylose test, do not eat foods high in pentose. These foods include fruits, jams, jellies, and pastries. Medicines such as aspirin and indomethacin can interfere with the results of a D-xylose test. NPO except water for 8 to 12 hours before the test. Children <9 yrs old NPO except water for 4 hours before the test.

How
a sample of first urine of the day and a sample of blood is collected. drink D-xylose solution. For adults, blood sample is usually taken 2 hrs after. For children, a blood sample may be taken 1 hr after. Another blood sample may be drawn 5 hours after. collect all of the urine produced for 5 hours after drinking the sugar solution. Sometimes urine is collected for 24 hours after drinking the sugar solution.

: interference in the absorption ability of intestine, inflammation of intestine lining, short bowel syndrome, parasitic infection, infection causing vomiting

 NITROGEN BALANCE
Nitrogen balance is the measure of nitrogen output subtracted from nitrogen input. Blood urea nitrogen can be used in estimating nitrogen balance, as can the urea concentration in urine. (+): periods of growth, tissue repair or pregnancy. (-): burns, fevers, wasting diseases and other serious injuries and during periods of fasting malnutrition

FECAL ANALYSIS
Preparation
assess medicines such as antacids, antidiarrheal medicines, antiparasitics, antibiotics, enemas, laxatives, or NSAIDs for 1 to 2 weeks before test. assess for barium enema, travel, menstrual period or active bleeding do not test a stool sample that has been in contact with toilet bowl cleaning products that turn the water blue
Normal: -appears brown, soft, and wellformed in consistency. -does not contain blood, mucus, pus, undigested meat fibers, harmful bacteria, viruses, fungi, or parasites. -shaped like a tube. -pH is 7.0-7.5. -contains <0.25 g/dL or <13.9 mmol/L of sugars called reducing factors. -contains 2-7 grams of fat per 24 hours (g/24h).

3 stool samples may be collected 4 to 7 days apart collected when the person is passing loose

 Abnormal values
High levels of fat may be caused by diseases such as pancreatitis, celiac disease, or other disorders affecting fat absorption. The presence of undigested meat fibers may be caused by pancreatitis. A low pH may be caused by poor absorption of CHO or fat. High pH may mean colitis, cancer, or antibiotic use. Blood may be caused by bleeding in the digestive tract. WBC may be caused by inflammation of the intestines or a bacterial infection. If diarrhea is present, testing may be done to look for rotaviruses in the stool. High levels of reducing factors may mean a problem digesting some sugars. Low levels of reducing factors may be caused by celiac disease, cystic fibrosis, or malnutrition. Medicine such as colchicine or birth control pills may also cause low levels.

METABOLIC FUNCTION TESTS (Liver)

AST (Aspartate Phosphatase) Lab Results
used to detect a liver injury or an active/chronic liver problem. AST levels can be dramatically affected by shock, low blood pressure or any other condition that deprives the liver of blood and oxygen. Normal Level:
Male: 8-46 units/liter Female: 7-34 units/liter

ALT (Alanine Aminotransferase) Lab Results

used to detect liver injuries and long-term liver disease. Highly elevated levels may indicate active hepatitis from any cause. Some prescription and OTC medications can cause an increase in ALT levels. ALT levels can be dramatically affected by shock, low blood pressure or any other condition that deprives the liver of blood and oxygen. Normal level: 5-40 units per liter of blood serum

 ALP (Alk Phos, Alkaline Phosphatase) Lab Results

ALP is a substance found in the bile ducts of the liver. Damage or obstruction of the bile ducts may result in ALP. Normal Level: 13-39 units/liter

Total Bilirubin (T. Bili) Lab Results

Bilirubin is produced during the normal process of blood cells dying and the liver excretes bilirubin through bile. Too much bilirubin in the blood results in jaundice. This detect elevated levels of bilirubin before jaundice is present. Normal Level: 1mg per 100 ml

Indirect Bilirubin (I. Bili) Lab Results

Indirect bilirubin does not dissolve in water. In order to dissolve in water, and be eliminated from the body, it must go to the liver where it is made into direct (water soluble) bilirubin. Indirect Bilirubin = Total Bilirubin Direct Bilirubin

 Direct Bilirubin (D. Bili) Lab Results

Direct bilirubin has been converted into a water soluble form of bilirubin by the liver. The proportion of indirect bili to direct bili may change if the liver has difficulty converting indirect into direct. Normal Level: .4 mg per 100 ml

Albumin Lab Results

Albumin is a protein made by the liver that is very common in blood plasma, which can be measured in the blood. If the liver has chronic or acute damage, the level of albumin in the blood will typically be low. A low level of albumin can also be caused by poor nutrition. Normal Level: 3.5-5 grams/100 ml

DIAGNOSTIC IMAGING
Radionuclide (radioisotope) imaging
uses a substance containing a radioactive tracer that, when injected intravenously into the body, collects in a particular organ. The radioactivity is detected by a gamma-ray camera, which is positioned over the upper abdomen and is attached to a computer that generates an image. A liver scan uses a radioactive substance that collects in liver cells.

 Cholescintigraphy (hepatobiliary scintigraphy or scan), another type of radionuclide imaging, follows the movement of a radioactive substance as it is secreted from the liver and passes into the gallbladder and through the bile ducts into the duodenum. This technique can detect a blocked cystic duct (which joins the gallbladder to the major bile duct). Such a blockage indicates acute inflammation of the gallbladder (cholecystitis).

 MRI
can detect diffuse liver disorders, such as hepatitis, hemochromatosis, and Wilson's disease, which affect all areas of the liver about equally. shows blood flow, providing info about blood vessel disorders. provide images of the bile ducts and nearby structures, using a technique called magnetic resonance cholangiopancreatography (MRCP). The images produced are as good as those produced by more invasive tests, in which dye is directly injected into the biliary and pancreatic ducts.