Endoscopy webinar transcript

Zoe Andrews

Hello and thank you for joining us. I hope you're all well. My name is Zoe and I’m the Matron at Benenden Hospital. I’d like to welcome you to our webinar today on endoscopy. The presenter is Dr Lawrence Maiden, our Consultant Gastroenterologist.

His presentation will be followed by a Q&A session and, if you'd like to ask a question, please do so by the Q&A icon on the top right-hand side of your screen. This can be done with or without giving your name.

Just to remind you that this webinar is being recorded, although other attendees won't know that you're taking part unless you give your name when asking a question. If you’d prefer not to be part of the recording, now is your opportunity to leave.

I'll hand over now to Dr Maiden and you'll hear from me again shortly. Thank you all and enjoy the presentation.

Well thank you Zoe, and thank you ladies and gentlemen for joining us this afternoon. This is one of a series of webinars put on by Benenden Hospital. Today we're going to be talking all about endoscopy and this is what we're going to be covering over the next 30 to 40 minutes. As Zoe said, there's the opportunity to ask questions as well, so please do keep those questions coming in as we go along and then we'll be able to answer those towards the end of the presentation.

So how long has endoscopy been around? Well actually longer than some people may think and I think there's good evidence that that the Greeks and the Romans were trying to find various ways of looking into the body for a long time and archaeological digs in Pompeii have revealed what looks like a an old-fashioned endoscope in some form.

But really endoscopy probably had its start around the 1800s and a French clinician in the 1850s coined the term endoscopy; endo meaning inside and scope obviously to mean to look at. He made a bladder scope and looked into the bladder of a patient who’d died, and it was really a few years after that that a German physician actually came up with a scope and managed to look inside the stomach of a live person. It’s probably no great surprise that this was actually a sword swallower given that this was a rigid scope, and who else but a sword swallower might be able to manage such a scope!

But this clearly wasn't a practical thing. If we're trying to look inside the body, we want something which is a bit more flexible and it wasn't really till the start of the next century in the 1900s that the first flexible telescope was designed. Although it was flexible, it still had some limitations, and this was that first sort of rudimentary scope.

You can see it's got a flexible tip and there's a small light bulb at the end and one eyepiece, there really wasn't much way of manoeuvring this to look in different parts of the body.

But this is probably where we sort of first started off with endoscopy in its more traditional sense. A few years after that in Japan some of the physicians were working with Olympus cameras to try and work out how they might be able to take photos or actually record some of the images that we were seeing inside the scopes. And in the 1950s we came up with this sort of thing which looks roughly similar to what we're using nowadays, although it's been refined much more of course.

This was a flexible scope, and you can see it's got a light source and a camera at the end. The idea would be that this camera would take photographs and then we'd wind it onto the next picture and take another photograph. So, this really was very rudimentary. But really it was in the 1960s that that endoscopy took off and many of you may recall these lava lamps that you'd have, or these fibre optic lamps that you'd have in your living room in the 1970s.

The great thing about these glass fibres of course is that they carry light, and that means that you can carry an image if you have a light source as well. So, if you can imagine bundling some of these light fibres together and putting them in a flexible scope, that’s exactly what these first scopes were doing in the 1960s and 1970s.

This scope here isn't too far dissimilar to the scopes that we're using nowadays - you can see that there's a long shaft, which is flexible, and then at the other end are wheels which can move the tip of the scope up and down and left and right. The Endoscopist would roll the scope between his fingers, much like rolling a cigar, so that he could twist the scope into pretty much any position. Off the scope is a light source and this long thing is called an umbilicus, so that slots into a light source and the light would be shone down the scope. And there'd be an eye piece at the other end that the Endoscopist would have to squint through in order to see those images.

Of course, that'd get a little bit difficult. After an hour or two squinting down and seeing these small rudimentary images, we'd find that the scope would sometimes get dirty so we'd be able to wash the scope tip and we'd also blow air down this scope into the patient, so that the gastrointestinal tract can be distended with gas to optimise views, so we'll be able to suck things out with the scope, blow gas in to gently inflate the bowel and also wash the scope as well.

And then we added in a channel in the scope, so that we could put instruments down here to do various things, and you can see on this image here there's some biopsy forceps that are used to take tissue samples and we can also put snares down here or clips or injection devices. There's all sorts of things that we can do within this scope nowadays to perform therapeutic endoscopies if we need to do anything actually inside the patient, as well as just having a look or taking pictures.

So, these fibre optic scopes have been around since the 1960s, but around about the time I started doing endoscopies these were all replaced with the newer technology. These charged-couple devices, which are very much like the cameras that you have on your mobile phones now - these, and semi-oxide conductors.

And this has changed the way that we look at endoscopy. We no longer need the eyepiece and the fibreglass; in fact, everything's much more high definition.

And this is the typical setup of the scope that we'll have in most endoscopy units up and down the country nowadays. Rather than an eyepiece you can see that these digital images are actually displayed on a television, which is easier for all the team members in endoscopy to see.

Previously, with just the eyepiece, it would be the Endoscopist alone who'd be able to see the images and it’d be very difficult for the nurses to work out exactly what was going on. So now with the TV all the team members can see exactly what's going on, which means it's safer for the patient of course - and when we're trying to do something therapeutic the nurse knows exactly what it is that the Endoscopist is doing.

So, these setups have come a long way of course since the 1800s. High definition digital endoscope is what we're using nowadays, and there's lots of different applications that we can use. There's just a couple of slides here - these aren't too gruesome, so I hope people watching today aren't turned off by images of the body.

This is actually a photograph of the colon, or the large bowel. And this is the typical appearance here - it’s nice and shiny and healthy and clean; it looks like the inside of the mouth, like your cheek. It's the same sort of tissue that's lining the gut here.

And we can use different types of light; so traditional white light might make it difficult to see lesions sometimes, and by using narrow band imaging we can change the light to a more greeny-blue hue and lesions that might not necessarily be picked up then become more visible on these narrowband images. And really the definition that we're seeing nowadays with the high definition scopes is amazing, and actually we can get down to the microscopic level.

You can see these series of images, here at the bottom of the of the slide, show how we can magnify things and actually show up detail within the lining of the bowel that we just wouldn't have been able to see a few years ago - and certainly not with those traditional glass fibre scopes that we were using in the 60s and 70s. Some of you may have had ultrasounds in the past, ultrasounds of your abdomen - for example if you're pregnant and going to have a baby - and you have the scan in the antenatal clinic.

And nowadays we can use these ultrasound probes within the camera or within the endoscope and actually do ultrasound scans from within the body of the bowel as well. So, there's a lot of different applications that we can use for these scopes.

So, some of you may be saying “Well, do I need an endoscopy and why might I need an endoscopy?”.

So, if we look at each of these in turn, for an upper GI endoscopy - so looking at the upper gastrointestinal tract - we'd normally want to consider a gastroscopy or an upper GI endoscopy to look at any symptoms that might involve the food pipe or the stomach. And you can see on the image here in red we've got the upper GI tract. So, we have the oesophagus, and that's really about 40 centimetres from the teeth down through the chest and to the start of the abdominal cavity. And then we've got the stomach and - just to note here - that the stomach sits in the top part of the abdomen.

So often we refer to the belly or the abdomen as the stomach, and it's not actually. The stomach is a bag, or sac, which sits right at the top of the abdominal cavity, just under the ‘V’ of the ribs. So, if we have symptoms of acid reflux or indigestion that might be affecting the chest behind the breastbone or the top part of the abdomen - the solar plexus you may call it, or the epigastrium, your doctor may call it.

Now acid reflux, of course is very common. Probably about three quarters of the population are going to experience a reflux at some time in their lives. But if there is persistent acid reflux, then this may be an indication for having an endoscopy.

And what do we mean by persistent? Well, it's an arbitrary term really, but I think generally if something lasts for more than six weeks, we might consider that persistent. So if you've had symptoms of acid or discomfort behind your breast bone or that sore throat or that acidic taste in the mouth and that's gone on for six weeks or so, or may not be explained by anything particularly, I think we might want to consider doing an upper GI endoscopy.

Dyspepsia is the other common cause for an in an endoscopy and, by dyspepsia, I mean what you may call indigestion. Now indigestion may come in various shapes or forms; it's very difficult to describe pain sometimes. You may feel a burning sensation, or gnawing pain, or hunger pangs or even bloating or distension or fullness, And these are all subjective terms that mean the same thing really - just discomfort in the upper abdomen. And discomfort in the upper abdomen would correspond to where your stomach was, as I explained on the image here, and is what we call dyspepsia.

So acid reflux, or dyspepsia, would probably be the most common indications for an upper GI endoscopy. We'd certainly be concerned if there were other warning signs to go along with those symptoms, such as vomiting or unexplained weight loss or iron deficiency anaemia which would be picked up on a blood test.

So, iron deficiency anaemia, as I said, would only be picked up on a blood test - but you may experience symptoms of fatigue, or tiredness, or lethargy, or shortness of breath, or you may look pale of course - and a blood test might demonstrate that you're lacking in iron.

Iron is absorbed in the top part of the small bowel just after the stomach, and you also need acid in the stomach to help absorb iron as well. So, if there are problems in the stomach or the first part of the small bowel affecting absorption of iron, then we might need to do an endoscopy. But of course, if you're bleeding and losing blood more quickly than you can actually make new blood, then that will result in the net deficit in iron and that would manifest as anaemia as you need iron to make your red blood cells.

One of the common causes of iron deficiency anaemia in this country, and in fact in much of Europe, is celiac disease. And you may have heard of celiac disease or gluten allergy. Celiac disease is different to a wheat intolerance or a gluten intolerance; this is actually an immune-mediated disease where your immune system gets a bit confused and starts to attack wheat, thinking it's a virus or a germ.

And in all the battle that's going on between the wheat and your immune system, the lining of the bowel gets damaged to the extent that it can't absorb iron anymore. So, if you do have an iron deficiency anaemia, or symptoms of bloating or weight loss, then we might want to do an endoscopy and take some little tissue samples from the first part of your small bowel.

Other causes and other indications might include difficulty in swallowing. If there's reason why your food pipe isn't contracting properly, or there may be some narrowing or obstruction in the food pipe. And, of course, if there's disease that we already know about that warrants further follow-up - such as Barrett’s oesophagus or where the liver is swollen and scarred which we call cirrhosis - that can sometimes lead to dilatation of blood vessels at the bottom of the food pipe

And those varicose veins or varices at the bottom of the food pipe can be prone to bleeding sometimes in liver disease. And we'd want to know about that and start our patients on the right sort of treatment if either those were the case.

Bleeding is another indication for an upper GI endoscopy and that goes hand in hand with the iron deficiency anaemia that I mentioned earlier - and that blood of course might manifest as fresh blood, if you were if you were sick and vomited, but often the blood gets digested within the stomach and then it turns black because of the iron content in blood - and black stools or black poo might be an indication of bleeding from somewhere higher up in the gut.

And the other indication might be an abnormality if you've already had a scan, for example a CT scan, which might suggest there's some abnormality.

But by far the most common indications or reasons for having endoscopy would be persistent acid reflux or indigestion or dyspepsia.

And what about having a lower GI endoscopy?

So, this might be a full colonoscopy to look at the colon, or it might be just looking at the last part of the colon - the sigmoid colon - and we call that a sigmoidoscopy.

And again, much like bleeding in the top part of the stomach, if there's blood in the stools then that would be an indication for an endoscopy. That blood might either be visible red blood, where it might have been altered by the time that blood has passed through the gut, and again that black stool which doctors call melena may be an indication of bleeding somewhere in the upper part of the colon, indicating the need for a colonoscopy.

If there's been a change in your bowel habits, predominantly to a looser stool, then again that would also be a potential indication for an endoscopy to look at your colon - not so much constipation, more usually if the stool becomes looser and more frequent.

And as we discussed with the upper GI endoscopy, having anaemia would be an indication for having an endoscopy - especially if you're a man of any age or a post-menopausal woman.

Why post-menopausal? Well, of course women of reproductive age will be menstruating once a month, usually, and that would be a more common reason for an iron deficiency anaemia in younger women. But we’d still recommend that they had a celiac blood test to exclude the celiac disease as per British Society of Gastroenterology guidelines.

And again, as with surveillance for other diseases, abnormalities on imaging - or if we know that there are diseases such as colitis or history of polyps - these might warrant further surveillance colonoscopy over periods of time.

The other reasons for a lower GI endoscopy might be those who are of higher risk, either because of genetics or family history, and those we already know that have diseases, such as inflammatory bowel disease or polyps or cancer.

Now one thing I wanted to note was that you'll see all these different indications for having an endoscopy to look into the colon, and pain isn't actually an indication for having a colonoscopy. So, unlike an endoscopy to look into your stomach where pain or dyspepsia or indigestion is an indication, pain in your abdomen is not really a criteria for having a colonoscopy. It's more a change in bowel habits or blood or all those other criteria that I've listed.

Often patients are concerned that they have abdominal pain, and obviously everyone's always worried about cancer, and automatically people's minds go to “Is it cancer, doctor?” and invariably the answer would probably be ‘no’ in the absence of any of these other symptoms. And that's because cancers don't really present with pain until it's got to quite a late stage and they're actually large and pressing on something, or causing obstruction, by which time that have usually caused other symptoms such as bleeding or weight loss or changing bowel habits. So hopefully be reassured that pain is not an indication for any colonoscopy.

I'll just go to a tangent, just very quickly, just to talk about those high-risk groups again.

This isn't so much to do with endoscopy, but it's more to do with colonoscopy and surveillance. So screening is looking at patients who are well with no symptoms and investigating them - as opposed to surveillance where we know patients have disease, or at risk of developing disease, and ought to undergo ongoing monitoring.

So, screening might be involving groups who are well, but we think may be at future risk of developing serious disease such as cancer of course. And as you know, we have screening programs for breast, for lung, for bowel, for prostate cancer for example and the national bowel cancer screening program has been around for about 12 years now give or take - and was initially for those between the ages of 60 and 69 but has been extended to those of the age of 74.

We send out a kit through the letterbox to patients of those ages once every three years and those patients who are being screened then have the choice of submitting a stool sample, which undergoes an immunochemical test to look for any sign of bleeding.

And this has replaced our old faecal occult blood test where you may have been invited to put a sample of your poo on a special cardboard to look for the sign of blood. And this new FIT or faecal immunochemical test is much more sensitive at picking up blood - and we're using this test nowadays with a view to inviting patients for a colonoscopy if bleeding is picked up on that FIT, or on that stool sample

In addition to the national bowel cancer screening programme, patients on their 55th birthday or thereabouts might also be invited to come along for a flexible sigmoidoscopy - which we call a bowel scope - under the terms of the screening program, to look into the last part of their colon to make sure there isn't any sign of bleeding. And that might soon be superseded by this FIT test going forward in the future.

This is a program that's been running for, as I said, about 12 years now and runs in tandem with the NHS. And there are accredited bowel cancer screeners who undertake these colonoscopies for their patients - and indeed if you have been invited to submit a stool sample and are due to have a colonoscopy, then this is something that we can still do for you at Benenden.

This is a very fussy slide, and probably won't be able to pick it up in great detail, but I merely put it on just to illustrate the flow chart or the algorithm or the recommendations from the British Society of Gastroenterology guidelines for those patients who might be at higher risk.

Often I get patients in clinic asking me if they're at higher risk of developing bowel cancer, because their grandfather developed bowel cancer at the age of 75 or 80. And usually the answer to that specific scenario would be “No, you're not at any increased risk, other than the rest of the population”.

But there are some people who might be at slightly higher risk, for example, if they have two first-degree relatives who may be the age of over 60 and might be invited to have a colonoscopy at the age of 55 - or one first degree relative under the age of 50.

So, it really is more to do with those younger age groups because, unfortunately, bowel cancer - being quite a common cancer in the UK - is often age-related rather than genetic. So, for younger family members who were affected that might put you at slightly increased risk but for the most part, probably not.

We've discussed indications for upper GI endoscopy and lower GI. Well, that's the top bit and the bottom bit but, of course, there's about six or seven meters of small bowel in the rest of your abdomen that we haven't really talked about.

And the small bowel really is the holy grail of the endoscopist, actually. For a long time, we haven't been able to get to it because it's so inaccessible and so long and thankfully less than one in a hundred tumours in the gut arise in the small bowel. Most of them, by far, will be in the colon or the stomach or food pipe.

And the indications for having a small bowel endoscopy would again be iron deficiency anaemia, blood in the stools or suspected disease such as Crohn's disease or celiac disease where we know diseases can occur.

Now, these are the scopes that we use, which do admittedly look like instruments of torture, and aren't far off those endoscopes that we were looking at back in the 1850s and 80s/90s.

But you'll be pleased to know that it's seldom that we need to use these scopes and actually nowadays we can use something called capsule endoscopy. And, as the name implies, these capsules are small devices - about the size of a cod liver oil capsule - which our patients swallow and then these will wirelessly send pictures back to a receiver worn as a belt over a patient's abdomen and all the images are downloaded onto a data recorder.

The capsule itself is very small and consists of a light, a light source, a camera, a battery pack and a transmitter to send these images. And this technology, which has been around for about 20 years now, is really catching hold and transforming the way we look at the small bowel less invasively than our other traditional scopes. And the images of the small bowel we see are really quite amazing, but the definition of the lesions that we can see.

So, we move on to the next bit. Coming for an endoscopy, what to expect when you come for your endoscopy.

Well, the first thing to say is that usually you'll be in the outpatient department and be referred by your GP to see a clinician in the outpatient department. Sometimes people are a little disappointed, expecting to have their endoscopy on the day and, even if you've been referred to your local hospital for an endoscopy and the waiting time is such that you've been referred to Benenden, please do remember that you'll probably see a clinician first just to ensure you don't need any other tests as your symptoms may have changed. Or it might be that actually alternative investigations might be appropriate.

So, we'll always advise you as to what preparation to have before your endoscopy. So, if you're expecting one when you come to the endoscopy, be reassured that you'll probably see a clinician in the outpatient department first.

Once you've seen the clinician, you'll be directed to our clinical Ambulatory Unit and arrange a date for your procedure and, if applicable, pick up the bowel preparation that you might need to have a colonoscopy. And we'll give you information on explanatory leaflets about having those procedures at that time for you to take home and read as well.

If you're having a colonoscopy, for example, we'll need to make sure that you modify your diet - because we need to make sure that your bowel is empty, that there isn't any stool that may obscure our views. So, we'd ask you to avoid high fibre foods, just staying on low fibre diets for about three days before your endoscopy. And then two days before, just liquids, and then the day before have the bowel preparation to wash your bowel out.

What do I mean by avoiding high fibre foods? Well, low fibre food includes things like fish, chicken, rice and pasta and then moving on to just liquid foods as you approach your colonoscopy. And then the day before the colonoscopy you'll be given a solution similar to this, for example Picolax, but it might vary from centre to centre - for example, Moviprep or Plenvu or other preparations which will keep you very busy on the toilet as we wash out your colon to ensure that it's scrupulously clean when we come to have a look at your colon.

And if there are other patients who we need to take special consideration of it might be these listed here, for example diabetic patients, who we usually do first on the list - rather than towards the end, as they'll need to take their insulin or diabetic medication thereafter.

If you're taking anticoagulants, you probably need to stop those because we don't need bleeding if we're going to do anything therapeutic. Iron supplements tend to turn the stool rather dark in colour because of the iron being black - so we'd ask you to stop those for a few days before. And you'll be asked to stop any anti-acid medication like Omeprazole or Pantoprazole or Lansoprazole for example, or anything that might render you more constipated to counter the effects of the bowel preparation.

On the actual day of the test, be reassured that a nurse will accompany you every step of the way. You'll be invited to come in to the Ambulatory Unit and we'll see you in, check your blood pressure, run through a few questions, get you ready for the test and then the clinician doing the endoscopy will see you and run through the procedure - explain the procedure to you and all the risks and benefits and undergo the consent process.

You'll then actually have the test and, thereafter, recover in the in the recovery area, have a cup of tea and a light bite and the report will be explained. So, you'll probably be in the hospital for a good three or four hours. But, rest assured, that the endoscopy procedures really are only a very small part of that procedure.

So, having an upper GI endoscopy or an OGD (which is an esophagogastric duodenoscopy) - so that's looking at your food pipe, your stomach and your duodenum - well that procedure really only takes about five or six minutes. It doesn't take very long at all.

Invariably, you'll have a throat spray - which is a very light spray to coat the back of the throat - and that takes away the gag reflex, so it doesn't feel uncomfortable. You know, you'd literally be able to put a finger in the back of your mouth and touch the back of your throat and you wouldn't feel anything because it'd be numb.

So, most, if not all, patients for an endoscopy gastroscopy will have throat spray. Some also have a little light sedation to make them nice and relaxed; this is not a general anaesthetic - they'll still be awake- but much more relaxed and maybe slightly sleepy just to just to make it easier for you when we pop the telescope down.

Having the endoscopy, you'll be brought through to the endoscopy room lying on your left side, curled up in a ball, have a little mouth guard to protect your teeth. We'll put some oxygen probes and oxygen blood pressure cuff on to monitor you throughout.

The endoscopist would then gently pop the telescope over the tongue, down the food pipe and it's really like trying to swallow some food you haven't chewed enough times. So you might not feel ready to swallow but, if you just gently go through the motions of swallowing, the endoscopist will pop the telescope down and then insufflate the stomach with lots of gas so we can see where he's going, or she's going.

And that gas might make you feel a little bit bloated and, if you start burping that's quite normal, don't worry. And, as I said, the whole procedure will take five or six minutes. This is in contrast to a colonoscopy, which takes a little bit longer - perhaps 20 minutes, maybe 30 minutes for a diagnostic procedure or maybe longer for a therapeutic procedure if there are polyps that need to be removed, for example.

Again, patients will usually have sedation and some analgesia as well. It shouldn't be a painful procedure, but it might be a little bit uncomfortable - again because of the gas that's being inflated into the bowel to allow the endoscopist to see the whole of the colon clearly.

So, you'll certainly feel a little bit bloated, a little bit gassy or distended with all the gas that's being gently blown in from the telescope into the back passage, and the sedation and the analgesia will help with that.

For those patients who might be driving, or have to operate machinery, or work, then we don't recommend sedation because it does affect your ability and your judgment to make decisions. And there's always options, for example Entonox - or gas and air mix - or laughing gas, just to help with the analgesia as well.

The other procedure that we can undertake is a sigmoidoscopy. And this is the colonoscopy but just looking at the last part of the colon. And that procedure is much quicker – again, it usually takes about 10 minutes, if that, and - because it's so quick - we don't usually give sedation. But of course, if you opt to have sedation, then that's absolutely fine as well.

So those are the actual procedures, the time it takes. What sort of things might we find on doing an endoscopy? Many of you will have heard of a hiatus hernia before and wonder what a hiatus hernia is.

Well, these images here show the food pipe coming through the chest cavity into the abdomen and this thin sheet of muscle here is part of the diaphragm. And that diaphragm sits at the bottom of the chest and contracts and relaxes and sucks air in and out of the lungs.

But, of course, there has to be a hole in the diaphragm to allow the food pipe through and that's where the stomach is in the abdomen - just below there. And a hiatus hernia is where a little bit of the stomach has managed to push its way through that hole, back up into the chest cavity, so you actually have a small amount of stomach above the diaphragm and that can sometimes predispose to acid then refluxing back up into the food pipe.

At endoscopy, this is what it looks like. So, this black thing is the telescope going through the food pipe, and we've actually turned the tip of the telescope back round on ourselves like a ‘J’ shape to see where we've come from.

So, you can see the top of the stomach and you can see a hole here; the stomach should be gripping the telescope quite tightly, and it's actually quite loose. That's because that's the hiatus hernia; where the stomach has pushed its way above the diaphragm and there's a little bit of stomach just at the top of the abdomen, or the bottom part of the of the chest there.

And what sort of problems can that cause? Well, that can predispose to acid coming back up and you can see acid burning here. These sorts of lines are linear erosions at the bottom of the food pipe, and this is indicative of gastroesophageal reflux disease or esophagitis. And if this happens again and again and again, eventually it can become quite sore and all of these ulcers might all link up and you might get circumferential irritation or inflammation.

And if this carries on for many years, sometimes - not always - in fact, quite rarely, the food pipe gets a little bit tired of all this acid exposure and says to itself “Well why don't we be more like the stomach, because the stomach is acid resistant. And if we change to be more like the stomach lining, rather than the oesophagus lining, maybe that'll help us as well”

So, these oesophageal cells then turn into stomach cells and we call this Barrett’s oesophagus. Now this is a quite a rare occurrence but, of course, clinicians get a little bit twitchy when cells change from one type to another. We might want to keep an eye on this, just to make sure that the Barrett’s oesophagus doesn't progress into anything else. And, occasionally, it could be pre-cancerous or lead to cancer and again that's in exceptional circumstances, depending on the extent of the Barrett’s oesophagus and how far up the food pipe it stretches.

So, that's the top end. What about the sort of things we can see at the bottom end? Often, we see polyps and I've often had patients say to me “Exactly what are polyps?”

Well this is what they are. They're sort of fleshy lumps which grow from the lining of the bowel. And they can sometimes look like this image on the left - which looks like a mushroom, you can see there's a stalk and then there's a the red sort of polyp head at the top - and we can remove these by lassoing the polyp and burning the stalk with an electrical current that sears through the stalk, seals it off and seals any blood vessels that might be there. And we can then retrieve the polyp.

The other type of polyp are these sessile-like polyps which are pimples, which don't have a stalk. And this is a very small one that we're able to put a snare around and quite easily cut off.

Sometimes the large ones might need to be injected with a little layer of fluid to lift them up so that we can get the lasso all the way around the bottom of the polyp. This ensures that we remove it without leaving any remnants behind.

So of course, some people, who are due to have an endoscopy, might say “Well I’m not sure if I want to go through with this” but hopefully I've alleviated any concerns that you may have had about having a procedure.

But of course, there are alternatives. A barium swallow involves an x-ray, and this is harking back to the 1850s again like the original endoscopes that I talked about. This is really quite old technology, but still has its uses. It's not so good at detecting very shallow lesions, and certainly wouldn't detect something like those linear erosions or the Barrett’s oesophagus that I talked about, but it would show things that are a little bit deeper within the lining of the bowel. That would involve x-rays, so swallowing a contrast medium, and then taking x-rays to show up the contrast as it lines the lining of the food pipe in the stomach.

Nowadays, of course, we also have a CT scan which involves x-rays, taking x-ray slices through the abdomen and the pelvis and then reconstituting those images and coming up with the picture of your insides. Again, a CT scan can be designed to look at the chest if you're looking at your food pipe in your stomach, or your abdomen in your pelvis if we're looking at your small bowel or your large bowel.

We can also now do something called a virtual colonoscopy. And again, this is like a CT scan but slightly more high definition. You'd need to have gas inserted into the colon to inflate you like a balloon again, so you feel rather bloated with this, much like a colonoscopy. But this CT codogram is very good at picking up things probably anything from five or six millimetres or larger, but nothing smaller.

And, if we want to look at your small bowel for example, or the rectum, then an MRI might be an alternative.

So, the good things about having these alternatives is that they're less invasive, there's less preparation involved. You certainly don't usually need to take the bowel preparation like you would for a colonoscopy and, of course, you don't need sedation which means you'd be able to drive home, or you'd be able to return to work - unlike the sedation required in some cases for an endoscopy.

But the disadvantages would be that it's probably not as detailed. Certainly trying to follow the bowel, which loops around and twists and turns, can be quite difficult on a CT scan and, of course, you can't do anything therapeutic so you can't take biopsies, it's very difficult to take polyps off or do a polypectomy for example under this modality, and the CT and the barium swallow would involve radiation and not an insubstantial amount. For example, a CT codogram might be about two or three hundred chest x-rays’ worth of radiation.

So, there are alternatives, but I think the best way of looking at the gut usually would be with an endoscope; upper GI endoscopy for reflux and gastritis and a colonoscopy for looking at change in bowel habits or anaemia for example.

So, I think that brings us to the end of what I wanted to say with regards to endoscopy. Zoe, I’m not sure if we have any questions at all? Yes, we do.

Zoe Andrews

So, our first question was asking for a little bit more information about hiatus hernia and I think we probably covered that unless the person that's asked the question would like to add anything else? That’s fine.

I'll move on to the second question, and this is from Richard who says: would you conduct an endoscopy if you suspect non-celiac villus atrophy or extended gut permeability?

Dr Maiden

Well, good questions. Yeah so, of course, celiac disease is just one example of a cause of villus atrophy and, I think, was it Richard you were saying - so Richard was talking about villus atrophy.

So, the lining of the small bowel is a bit like a carpet. Like imagine a plush living room carpet that you can sink your feet into, and that pile there is very plush, and those villi are like little finger-like projections. And that's where nutrients are absorbed. And there's a lot of different reasons why those finger-like projections or villi might get worn away, so that instead of it looking like a living room carpet it ends up looking rather threadbare, like a hallway carpet.

Celiac disease would be the most common cause of that sort of villus atrophy, but there are other causes - for example tropical sprue or infection or even Crohn's disease or inflammation. And these might manifest as pain or bloating or weight loss, so that might be an indication for having an endoscopy in biopsies of the of the small bowel, rather than just celiac disease.

With regard to gut permeability, that's a slightly different kettle of fish and gut permeability may be an indication of inflammation within the gut and inflammation might manifest as ulceration or diarrhoea or bleeding. So, I think if we were concerned that there was inflammation within the bowel that might be an indication for an endoscopy, but not gut permeability per se, or a leaky gut syndrome which is a bit of a contentious issue which I won't go into just now.

Zoe Andrews

Thank you. Our next question is somebody asking: could you say something about a rolling hernia?

Dr Maiden

Okay yeah, so if we go back to the hiatus hernia again, I've got these images here for you to see.

So, we talked about the hole in the diaphragm which allows the food pipe to go through, then you've got the stomach just below. There are two types of hiatus hernia; there's a rolling hiatus hernia and there's a sliding hiatus hernia. And a sliding one is where, as the name implies, the stomach has slid through that hole back up into the chest cavity. And that can often reduce, so it might spontaneously push its way back down again and occasionally it might just stay up there particularly if it's a very large hiatus hernia, you've got the whole of the, you know, half the stomach up in the chest cavity.

And if that doesn't reduce that might then become incarcerated. It doesn't go back down again and that can lead to problems.

But a rolling hiatus hernia, as opposed to a sliding one, is where some of the stomach rolls up parallel to the to the top of the stomach. And you've got a bit of the stomach sort of trapped next to its own part of its body, like it folds over itself and overlaps.

So those are two types of hiatus hernias - sliding and rolling hiatus hernias. And, if they're causing problems, with difficulty in swallowing or significant pain - or the stomach is up in the chest cavity and can't reduce - then that can't be treated medically - sometimes needs to be treated surgically.

Zoe Andrews

Thank you. So, the next question is: how long after an endoscopy are the results actually available?

Well, almost immediately. I mean when we've done your endoscopy, we usually have answers to the questions that are being asked as patients are being wheeled through to the recovery area.

The endoscopist will usually be forming the report and we'll put some pictures on the report to show what they found, if there is anything to find, and explain what's been found and perhaps the next steps that might be involved.

That report will then be printed off in the recovery area and the recovery nurse will then allow the patient to recover from the sedation. And that might take, you know, half an hour or so while the effects of the sedation wears off - sometimes a little bit longer.

And once they've had something to eat and drink, and are alert, we can go through the report with them and explain the findings. Often though, those next steps or further management might be deferred back to the referring Consultant or the GP, but at least we've got the opportunity to go through the report with the patient on the same day, shortly after having had their test.

Zoe Andrews

The next question is about PPIs. How long can you safely take PPIs for?

Dr Maiden

That's a good question. It really depends on your symptoms and how severe the symptoms are. As with every medication that a GP or a doctor might prescribe, it's usually the lowest tolerable dose for the least amount of time - and it depends on your symptoms. So, for example, if you see the pictures that we've got up here still, you can see these ulcers here are quite sore.

But with acid suppression for perhaps four, maybe a little bit longer, weeks the acid production is inhibited and that might allow the damage here to settle down. Thereafter you can stop taking the tablet. Of course, there's also possibility that that acid might recur again, and damage might ensue again - and you might need to repeat a course of the PPI.

However, if you don't get any symptoms at all then you don't need to take the tablet. But if Barrett’s oesophagus, for example, progresses and - as I said before - occasionally this could be a precursor to cancer, then it's important that our patients stay on high-dose PPIs indefinitely, because I think the risk of cancer is outweighed by being on these PPIs for a long period of time.

Now of course there are side effects associated with PPIs - or proton pump inhibitors - as there are with all drugs, and one of the sequelae of long-term PPI use might be reduced calcium absorption, which can lead to osteoporosis. So for patients who - perhaps female, post-menopausal, older - who would be at risk of osteoporosis and a fractured hip for example - that has to be weighed up against the risk of discomfort from esophagitis or, arguably, the greater risk of developing something more serious like a cancer from Barrett’s oesophagus.

So, to answer the question, I think it depends on the setting and how severe the indication for the proton pump inhibitor was in the first place. The very young patients in their 20s or 30s, who might have severe ongoing symptoms, these patients might be looking at a lifetime of acid suppression with PPIs and that would increase their risk of osteoporosis. And it might be, therefore, that younger patients would want to consider alternative means of treatment for significant acid reflux - rather than being on lifelong acid suppression.

And the National Institute for Clinical Health and Excellence guidelines would suggest that the only role for anti-reflux surgery in the event of a, you know, large hiatus hernia, for example, might be in those younger patients with severe debilitating symptoms who might otherwise be facing a lifetime of PPIs.

So, I hope that answers the question.

Zoe Andrews

Thank you. The next question is from somebody that's already had an endoscopy and they're asking: they were diagnosed with a sliding hiatus hernia two years ago and esophagitis but the symptoms - although they went away at the time - they're now back so would you recommend having another endoscopy

Mr Maiden

Sorry Zoe just repeat that - when was the first endoscope?

Zoe Andrews

So, the first endoscopy was two years ago.

Dr Maiden

And the symptoms had gone away and then came back again? So often if the symptoms are similar and certainly aren't associated with any other sort of red flag symptoms, like persistent vomiting or weight loss or anaemia, it might not be necessary to repeat the endoscopy, especially if we know that there is a hiatus hernia or something that's predisposing to it.

But, if the symptoms again are persistent and haven't really responded to lifestyle modification or anti-acid tablets, or avoiding the typical food triggers - spicy food, acidic food, oily food, chocolate, coffee, those sorts of things and - as I said - if those anti-acid drugs or proton pump inhibitors haven't helped to settle symptoms down, then it might warrant another endoscopy.

But often, if the symptoms are similar, and hasn't been a great deal of time since their index endoscopy - like two years ago - then it might not be necessary to repeat an endoscopy quite so soon in the absence of any other symptoms.

Zoe Andrews

Thank you. Another question around potential causes for severe bloating in the belly after eating midday.

Dr Maiden

Severe bloating in the belly. So, bloating might be a sensation, and we talked about dyspepsia being a sort of a global term for discomfort in the tummy. So, if the bloating is a sensation of feeling full, then that might be termed dyspepsia and that could be due to acid irritation causing those symptoms.

Often though, bloating might imply that the bowel is actually bloated or distended, and the tummy may feel swollen - it might feel like there's a football sitting at the top of your tummy, just under the ribs, where I described before, is where the stomach is. And if that's due to gas distension and bloating sometimes this is due to gas rather than acid causing that discomfort.

Also remember of course when you're swallowing food that you swallow air, especially if people are busy and hectic lives are gulping their food down, gulping down big mouthfuls of air as well. We term that aerophagia. That can cause distension and bloating of the abdomen so, of course, taking time to slowly take your meals would be important in trying to alleviate that.

But often though, if it's gas bloating, it might be due to hyperacidity or excess acid producing the gas. Sometimes it's actually due to bloating further down in the bowel and loops of bowel trapping gas within them, which might cause the bloating, and it might not be anything to do with the stomach at all.

So, it really depends on where the bloating is - if it's in the top part of the tummy, whether it's associated with gas distension, or not might be due to indigestion or dyspepsia as I said.

Zoe Andrews

Thank you. How long would it take to see the results from a biopsy?

Dr Maiden

So typically, the biopsies would be sent off to the lab and normally it'd be around about 10 to 14 days, give or take, for a biopsy result to come back.

If there was something that the clinician was a little bit concerned about, and thought might be a bit more serious, for example, the turnaround time might be a little bit quicker. We'd usually try to accelerate those through to the top of the list - so these might come back - give or take - around about a week or so.

But of course, that will vary from centre to centre and hospital to hospital, but I think those would be about the ballpark figures to expect

Zoe Andrews

Thank you. And the last question is from Mary and she's written us a lovely message saying how much she's really enjoyed your presentation, how it's been really informative. And it sounds like Mary, you've been really unwell in the past and you've had to have an endoscopy. And there's just a few questions that Mary includes - and actually may have may have already been answered - about how the endoscopist reached down into to see her pancreas and how that progressed through her stomach and talking about is there a specific entrance into the pancreas? And just a big thank you for such an informative presentation.

Dr Maiden

Oh, that's nice to hear. So particularly with looking at the pancreas, this is a particular endoscopy which I didn't cover. It's called an endoscopic retrograde cholangiopancreatography so it's a bit of a mouthful - an ERCP.

It's not something we actually do at Benenden Hospital; it's usually done in in centres where it specialises in this procedure.

So, it's very similar to an upper GI endoscopy. This telescope has a side viewing scope, instead of a forward viewing scope, and again the patient will swallow the telescope like they do for a traditional upper GI endoscopy.

The scope then goes through the stomach, into the small bowel, and just in the second or third part of the duodenum is a small opening to the pancreatic duct called the ampulla. And there's a valve there - or sphincter - and that can sometimes be entered with a small guide wire and then the clinician is able to put special instruments over the top of that guide wire, into the pancreatic duct - or bile duct - and put a tube in there to keep them open, for example, or can put a balloon in there and inflate a balloon and pull out gallstones or something like that, for example. So that's an ERCP which I think she alludes to there.

Zoe Andrews

Thank you, Dr Maiden. And our last comment, another lovely message from Jo saying how much they've enjoyed the webinar and thank you for the really informative presentation, so thank you all for taking part.

So, if you'd like to book an endoscopy, as Dr Maiden has said, your initial consultation will cost around £200. That's payable at the time of your booking. In order to help our Consultants to give you the best possible treatment, we do require a referral from your GP prior to your appointment date.

Once you've had your consultation, and you've been listed for the most appropriate treatment, you'll then be notified of the exact costs. However, the guide price for our endoscopy procedures start from around £795.

If you want any further details around the prices, or this process, this can all be found on our website. Alternatively, if you'd like to be contacted by our Private Patient Team to book an appointment, or for any more details around pricing or process, you can message us with now your name and your phone number. And these are not seen by anybody else. Alternatively, you can contact the Private Patient Team on the information that's shown on the last slide.

Shortly you'll receive a survey from us and would be really grateful if you could spare a few minutes to let us have your feedback on how today's webinar has been for you.

Our next webinar is on Saturday the 5th of December which is bookable in the same way that you booked this webinar - via our website. This topic will be around hip replacement.

So, on behalf of Dr Maiden, myself and all the team at Benenden Hospital, I’d like to say a few a huge thank you for taking part in our webinar today. We look forward to you joining us again for another webinar very soon. Please all stay safe.

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