INVESTIGATIONS
1. Plain X-rays mostly for acute abdomen. Used for:
If obstruction or perforation is suspected.
In assessment of the severity and extent of acute colitis.
To assess faecal loading in constipation.
Calcification may be seen in GBSs and in C. pancreatitis, though CT is more
sensitive for both.
2. Ultrasound
The first-line investigation for abdominal distension, e.g. ascites, mass or
suspected inflammatory conditions.
It can show dilated fluid-filled loops of bowel in obstruction, and thickening
of the bowel wall.
It can be used to guide biopsies or percutaneous drainage.
In the acute abdomen, ultrasound can diagnose cholecystitis, appendicitis,
enlarged mesenteric glands and other inflammatory conditions.
Endoscopic ultrasound (EUS). To diagnose lesions in the oesophageal or
gastric wall including the detailed TNM staging of oesophageal/gastric cancer
and for the detection and biopsy of pancreatic tumours and cysts.
Endoanal and endorectal ultrasonography are performed to define the
anatomy of the anal sphincters, to detect perianal disease and to stage
superficial rectal tumours.
3. Computed tomography (C.T)
Involves high-dose radiation. Intraluminal contrast may be positive (Gastrografin or
Omnipaque) or negative (usually water). The bowel wall and mesentery are seen
after intravenous contrast especially with negative Intraluminal contrast.
As the first-line for the acute abdomen. Such as a perforated viscus as well
as leakage of contrast from the gut lumen.
Inflammatory conditions such as abscesses, appendicitis, diverticulitis,
Crohn's disease and its complications. In high-grade bowel obstruction CT is
usually diagnostic of both the presence and the cause of the obstruction.
In cancer staging and as guidance for biopsy of tumour or lymph nodes.
CT pneumocolon/CT colonography (virtual colonoscopy) provides an
alternative to colonoscopy for diagnosis of colon mass lesions. It is being
evaluated as a screening test for colon pathology with sensitivity> 90% for >
10 mm polyps.
Unprepared CT is a good test for colon cancer in the frail (often elderly)
patient who would have problems with bowel preparation.
4. Magnetic resonance imaging.
MRI uses no radiation and is particularly useful in the evaluation of rectal cancers
and abscesses and fistulae in the perianal region. It is also useful in small bowel
disease and in hepatobiliary and pancreatic disease.
5. Positron emission tomography (PET)
Relies on detection of the metabolism of fluoro-deoxyglucose. It is used for staging
oesophageal, gastric and colorectal cancer and in the detection of metastatic and
recurrent disease. PET/CT adds additional anatomical information.
6. Contrast studies
I. Barium swallow examines the oesophagus and proximal stomach. Its main use
is for dysphagia. Barium is swallowed in both the upright and prone
positions. Anatomical lesions and motility disorders can be investigated.
Reflux, as demonstrated by the retrograde flow of barium from the stomach
into the oesophagus, is best observed with the patient tipped head down. It can
be provoked by asking the patient to drink water (water siphon test) and by
distension of the stomach with gas generated from swallowed effervescent
granules.
II. Double-contrast barium meal examines the oesophagus, stomach and
duodenum. Barium is given to produce mucosal coating. Effervescent
granules producing carbon dioxide in the stomach create a double contrast
between gas and barium. This test has a high accuracy for the detection of
significant pathology - ulcers and cancer - but requires good technique.
Gastroscopy is a more sensitive test for small superficial mucosal lesions and
for bleeding, and enables biopsy of suspicious areas.
III. Small bowel meal or follow-through Ingested barium reaches the right colon,
usually within an hour. The fold pattern and calibre of the small bowel are
assessed. Specific views of the terminal ileum are usually obtained using
compression with suspected Crohn's disease.
IV. Small bowel enema (enteroclysis) is an alternative specific technique for
small bowel examination. A tube is passed into the duodenum and a large
volume of dilute barium is introduced. It is particularly used to demonstrate
strictures or adhesions when there is suspicion of intermittent obstruction.
V. Barium enema examines the colon and is used for altered bowel habit.
Colonoscopy has largely replaced this examination for rectal bleeding, polyps
and inflammatory bowel disease. The colon is first thoroughly cleansed with
oral laxative preparations. Barium and air or CO2 are insufflated via a rectal
catheter and double-contrast views obtained of the entire colon. Rectal
examination and sigmoidoscopy should precede this examination.
VI. Absorbable water soluble (Gastrografin or Omnipaque) contrast agents
should be used in preference to barium when perforation is suspected
anywhere in the gut.
7. Radioisotopes
Some more common indications and techniques are to:
Detect urease activity of H. pylori - 13C urea breath test.
Assess oesophageal reflux.
Measure rate of gastric emptying.
Demonstrate a Meckel's diverticulum.
Assess the presence of inflammatory collections in IBDs.
Evaluate neuroendocrine tumours and their metastases.
assess obscure GIB : (only useful if the bleeding is at more than 2 mL/minute)
Measure albumin loss in the stools (in protein-losing enteropathy) - replaced
by intestinal clearance of α1 antitrypsin).
Assess bile salt malabsorption (in patients with unexplained diarrhoea).
Detect bacterial overgrowth in the small bowel - measure 14CO2 in breath.
8. Endoscopy
Oesophagogastroduodenoscopy (OGD, EGD, 'Gastroscopy') the
investigation of choice for upper GI disorders. Findings include reflux
oesophagitis, gastritis, ulcers and cancer. Relative contraindications include
Severe COPD.
A recent AMI.
Severe instability of the atlanto-axial joints.
The mortality for diagnostic endoscopy is 0.001% with significant
complications in 1: 1000, usually when performed as an emergency (e.g. GIB)
Colonoscopy the success rate for reaching the terminal ileum should be at least
90% after training. The most common findings are cancer, polyps and
diverticular disease. Perforation occurs in 1: 1000 examinations and in 2%
after polypectomy. The mortality is 0.02% for diagnostic colonoscopy.
Balloon enteroscopy can examine the small bowel from the duodenum to the
ileum. The indications are limited (mainly gastrointestinal blood loss), the
technique is time-consuming and the instruments are expensive so it is
available only in a few centres.
Video (wireless) capsule endoscopy is now used for the:
Evaluation of obscure GI bleeding (after -ve gastroscopy and colonoscopy).
Detection of small bowel tumours and occult IBD.
Practical Box 6.2 Gastroscopy and colonoscopy Gastroscopy (Important
notes)
1. Patient should be fasted for at least 4 hours.
2. Give oxygen and monitor O2sat with an oximeter.
3. Give Lidocaine throat spray or sedation (midazolam ± opiate
if required)
4. Gastroscopy takes 5-15 minutes, depending on the
indication and findings
5. Withhold fluid and food until LA/sedation wears off
6. Complications are rare: beware of over-sedation, perforation
and aspiration.
Colonoscopy
1. Stop oral iron a week before the procedure
2. Restrict diet to low residue foods for 48 hours; clear
fluids only for 24 hours
3. Use local bowel cleansing regime, usually starting 24 hours
beforehand (e.g. two sachets of Picolax and 2-4 bisacodyl
tablets, or Moviprep 2 litres, or KleanPrep 4 litres, or local
alternative; more if constipated)
4. Give oxygen and monitor O2 levels
5. Give sedation (midazolam ± opiate) if required by patient
6. Pass the colonoscope to the caecum or ileum under direct
vision
7. Detailed examination during withdrawal
8. Colonoscopy takes 15-30 minutes, depending on the colon
anatomy, indication and findings
9. Withhold fluid and food until sedation wears off
10. Observe patient for at least an hour after sedation given
11. Complications are rare: beware of over-sedation, perforation
and aspiration
12. Patient must be accompanied home if sedation given