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    Procedural Services

    PAMF gastroenterologists perform a variety of diagnostic and therapeutic procedures. A brief discussion of each category follows.

    Diagnostic Procedures

    The total types and numbers of diagnostic procedures performed at PAMF are shown in Table 2 by year, from 2007 through 2011. Of these procedures, colonoscopy predominated (Table 2), with 81,557 colonoscopies performed during that period.

    TABLE 2

    The total types and numbers of diagnostic procedures performed at PAMF by year from 2007 to 2011. Of these procedures, colonoscopy predominated with 81,557 colonoscopies performed during that period, followed by upper endoscopy, then sigmoidoscopy.

    Liver Biopsy
    Percutaneous liver biopsies are done by inserting a needle into the liver under ultrasound guidance. A sample is obtained and then reviewed by a pathologist to assist in the diagnosis of liver diseases. Important uses of liver biopsy include evaluating patients with increased liver enzymes to make a diagnosis and determining the extent of liver damage from HBV and HCV infections and other chronic liver diseases. The role of liver biopsy has become less important with the advent of noninvasive diagnostic tools.

    Upper Endoscopy
    In upper endoscopy (esophagogastroduodenoscopy/EGD), a flexible endoscope is used to visualize inside the upper part of the GI tract (the esophagus, stomach and duodenum). Upper endoscopy is useful in diagnosing and evaluating abdominal pain, nausea, vomiting, swallowing difficulties and gastric reflux. In addition, EGD can be used to understand unexplained weight loss, anemia and bleeding in the upper GI tract.

    Esophageal Manometry
    Esophageal manometry is performed by passing a tube through the mouth or nose and into the stomach in order to measure the muscular function of the esophagus. After it is in place, the tube is pulled back into the esophagus and the patient swallows. Then the pressure of the muscle contractions are measured along several sections of the tube. Esophageal manometry is used to see if the esophagus is properly contracting and relaxing. This procedure is used to evaluate difficulty swallowing and GERD symptoms. It can help diagnose specific esophageal diseases, such as achalasia or nutcracker esophagus, and is needed prior to the surgical treatment of GERD, a procedure known as Nissen fundoplication.

    Anorectal Manometry
    Anorectal manometry is performed by inserting a small tube into the rectum in order to measure the pressure and electrical activity of the muscles around the anus and sensation in the rectum. It is often performed to evaluate patients with constipation and fecal incontinence.

    Small-Bowel Capsule Endoscopy
    In small-bowel capsule endoscopy, a patient swallows a small pill camera that takes pictures of the small intestine and sends the images to a device worn on the patient’s body. Capsule endoscopy is used to search for a cause of bleeding in the small intestine and to evaluate for polyps, Crohn’s disease, tumors and ulcers.

    Catheter-Based 24-Hour pH Testing
    Catheter-based pH testing is done by passing a thin plastic catheter through one nostril, down the back of the throat and into the esophagus as the patient swallows. The tip of the catheter has a sensor that detects acid (low pH). This procedure is used to diagnose GERD, determine the effectiveness of medications that are given for acid reflux, and to find out if acid reflux is causing chest pain. Monitoring the esophageal pH is a useful way to learn if stomach acid is reaching the pharynx, causing a cough, sore throat or hoarseness.

    Bravo 48-Hour pH Testing
    Bravo 48-hour pH testing is done by attaching a small capsule to the esophageal wall during an upper endoscopy. The capsule measures the pH in the esophagus and sends data by radio waves to a receiver on the patient’s belt or waistband. Bravo 48-hour pH testing is used for the same indications as catheter-based pH testing.

    Impedance Testing
    Impedance testing is performed by inserting a catheter transnasally through the esophagus into the stomach. The procedure detects intraluminal bolus (esophageal contents) movement; it is often performed in combination with pH testing, allowing for detection of GERD.

    Hydrogen Breath Testing
    Hydrogen breath testing measures hydrogen gas in the breath. This procedure is used to diagnose lactose intolerance, bacterial overgrowth of the small bowel and the rapid passage of food through the small intestine. Recently, it has been recognized that overgrowth of normal bacteria in the intestinal tract can lead to symptoms of gas and bloating that are commonly associated with irritable bowel syndrome. This condition can be diagnosed with the use of hydrogen breath testing.

    Sigmoidoscopy is used to look inside the last third of the colon. Gastroenterologists use this process to look for early signs of cancer and identify causes of unexplained changes in bowel habits, abdominal pain, anal bleeding and weight loss.
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    Therapeutic Procedures

    From 2007 through 2011, PAMF’s gastroenterology departments performed a total of 7,930 therapeutic procedures. The types and numbers of procedures performed by year are shown in Table 3.

    TABLE 3
    FROM 2007 TO 2011

    The total number of therapeutic procedures performed in 2007 being Hermorrhoid Banding, with a decrease each year until 2011. Only 1 ablation therapy procedure in 2007 & increasing to 14 in 2011. For double balloon endoscopy, 21 procedures were done in 2007 & about the same number until 2011. For endoscopic ultrasound, 322 in 2007 & increasing steadily until 586 in 2011. For GI stenting, 7 in 2007 with a slight increase in the years 2008, 2009, 2010 but a decrease back to 8 in 2011. ERCP was 236 in 2007 and increasing steadily to 361 in 2011.

    Ablation Therapy
    Recent studies have shown an increase in the incidence of cancer of the esophagus over the last few years. Cancer of the esophagus is often preceded by Barrett epithelium, which in turn is caused by GERD. With Barrx ablation therapy, the precancerous tissue in the lower part of the esophagus is destroyed with a catheter, which reduces the likelihood of esophageal cancer development.

    Double-Balloon Endoscopy
    In double-balloon endoscopy, an endoscope is inserted through the mouth, beyond the stomach and into the small intestine. The performing physician can take tissue samples, remove small tumors or polyps, treat bleeding problems and dilate strictures.

    Endoscopic Ultrasound
    Endoscopic ultrasound (EUS) combines endoscopy and ultrasound to obtain images and information about the GI tract, including the pancreatobiliary system. This procedure may be used to drain pancreatic pseudocysts and evaluate cystic lesions of the pancreas and subepithelial lesions. Our physicians are experts in performing advanced endoscopic procedures, including EUS, with some of the highest local volumes for these complex therapeutic procedures.

    Gastrointestinal Stenting
    Gastrointestinal stenting uses stents to treat various colorectal, esophageal and gastroduodenal conditions. Colorectal stents may be used to treat acute malignant colonic obstructions in nonsurgical patients. Esophageal stents can be used to treat inoperable esophageal and gastric cardia cancers. Finally, gastroduodenal stents can be used to treat advanced cancers of the stomach, pancreas and upper small intestine.

    Endoscopic Retrograde of Cholangiopancreatography
    Endoscopic retrograde of cholangiopancreatography (ERCP) combines the use of X-rays and an endoscope to diagnose and treat conditions of the liver, bile ducts, pancreas and gallbladder. These conditions include gallstones, infl ammatory strictures, leaks from trauma and surgery, and pancreatobiliary cancers.
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