Part1: Gastrointestinal endoscopy revealed
What are the main types of gastrointestinal endoscopy that are often done by patients?
Dr. Li Chujun: Gastrointestinal endoscopy is a mirror that examines the digestive tract, and in general there are six major types: gastroscopy, colonoscopy (colonoscopy), small intestine endoscopy and capsule endoscopy for the small intestine, duodenoscopy for biliopancreatic diseases, and ultrasound endoscopy for ultrasound in the lumen.
What are the benefits of each of these endoscopes?
Dr. Li Chujun: Gastroscopy is mainly used to examine the upper gastrointestinal tract, including the esophagus, stomach and duodenum, which is called OGD or EGD in English.
Colonoscopy refers to colonoscopy, also called colonoscopy, which is used to examine the colon and rectum. The colonoscope also looks at the end of a small section of the ileum. The small intestine is what used to be called the relative blind spot of gastrointestinal endoscopy. Using small intestinal microscopy, it is possible to determine whether one should go in through the mouth to the upper section of the small intestine or through the anus to the lower section of the small intestine, depending on the possible location of the lesion. Theoretically, it is possible to achieve docking, but sometimes it is difficult, which is the relative blind spot of the small intestine. Later, a capsule endoscope, also called wireless endoscopy, was developed that allows natural access to the body, the ability to randomly select the mode of photographing, and the ability to retransmit the film to a receiver outside the body for easy interpretation by the physician to observe whether a lesion has occurred.
Duodenoscope as the name suggests is a mirror used to examine the duodenum, but its key role is not to examine the duodenum, but to make an image of the bile ducts and pancreatic ducts, its name is ERCP – retrograde cholangiopancreatography, which was the concept of diagnosis in the past. With the development of two decades, the mirror plays a greater role in the treatment nowadays, and its performance is mainly used in the treatment of bile duct stones, dilation of strictures, and drainage of stents.
The actual role of ultrasound endoscopy is mainly ultrasound, but different from the ultrasound we have outside the body. If a lesion is probed outside the body, it is disturbed by the action of intestinal gas, which may prevent us from seeing the lesion in a particular place, and is too far away to be examined with a very high probe.
If there is a probe that is close to the lesion, the frequency of the probe at the lesion can be adjusted to a higher and finer resolution, and the five layers of the digestive tract, including the mucosal interface reflection, the mucosa, the submucosa, the muscular layer, and the plasma layer, can be clearly observed. From this, it is possible to check which layer of the GI wall the lesion is in and then determine initially what the lesion is by its echogenicity to determine which treatment the patient will receive next.
Another advantage of ultrasound endoscopy is that it is used to examine lesions in the vicinity of the biliopancreatic area, which is complementary to CT and MR, thus making the examination of lesions in the vicinity of the biliopancreatic area more effective.
The endoscopist has to interpret the ultrasound images in addition to the endoscope. Ultrasound endoscopy started as a diagnostic concept and now has a more therapeutic connotation. After observing the lesion, the physician can perform some punctures to obtain cytopathological tissue for laboratory tests to make a definitive diagnosis.
In addition, for some lesions such as cysts, ultrasound endoscopy can be used to localize the puncture and then perform some subscopic drainage such as stenting and catheterization to achieve the therapeutic effect.
Part2: Does the patient feel painful during endoscopy?
Is endoscopy painful for patients? Is painless endoscopy dangerous?
Dr. Li Chujun: This is an issue of great concern to the people, and it also affects the promotion of endoscopy in the society, thus causing some people to delay the best time for diagnosis and treatment.
Compared with the current endoscope, the previous endoscope is indeed thicker and harder in material and lower in performance, in addition, there are also problems with the operation technique.
Patients do feel pain after endoscopy, but they usually magnify this pain and then tell others, so many people are resistant to this endoscopy situation.
Nowadays, there are two advantages of endoscopy: first, it is basically an electronic gastroscope, and the mirror is more ideal in terms of caliber and performance, and has reached a level acceptable to patients. Secondly, the operating techniques of doctors are getting better and better.
As there are more and more patients, the number of gastrointestinal endoscopists required has increased accordingly. Under greater pressure of work, endoscopists who are not yet senior grasp the opportunity to improve themselves, and for skilled endoscopists, patients who actively cooperate with the doctor’s examination can generally accept and complete the examination successfully, but there will inevitably be uncomfortable situations.
Gastroscopy can also be uncomfortable, because when the gastroscope passes through the throat will produce stimulation, vomiting slow release, but the patient is sedated with good cooperation can do, the doctor can give the patient some local anesthesia, so that the throat is not so sensitive.
The uncomfortable colonoscopy is mainly reflected in the mirror into the mirror and pumping, the patient will have the feeling of intestines being pulled, like eating the wrong thing to diarrhea, intestinal cramps uncomfortable feeling. Therefore, for colonoscopy, it is a great challenge to straighten out the intestines in the patient’s stomach to achieve the purpose of examination. Thus, training in colonoscopy is very demanding. Some people who are not professionals may think that endoscopy is easy – just insert a tube in and check, but in fact the requirements of gastrointestinal endoscopy operation are high.
There is an understanding that the discomfort generated by this examination is acceptable to most people when examined by a skilled doctor, because the doctor is skilled and will adjust the strength according to the patient’s reaction to make the patient feel better, but the tolerance of each patient is different and the discomfort will be different. However, most patients can complete the examination process while chatting with the doctor, but down a little discomfort. We have also tried to do gastroscopy for ourselves, and we feel that the level of discomfort should be acceptable to everyone.
If the doctor is very skilled and the patient is comfortable with the discomfort, and if the patient is so nervous about the test that it is difficult to perform the test, then the patient can be put under intravenous anesthesia. But the risks of anesthesia may be higher, mainly because: first, anesthesia itself has risks. As with air travel, it is generally safe, but the risks are still present. Second, the risk is higher after anesthesia. During the doctor’s examination, the patient will have the problem of sensitivity and insensitivity, and in terms of intensity, the patient will also have the problem of pain and painlessness. Having pain and feeling can be known and in fact is a protective response.
If the patient’s sensation is suppressed after anesthesia, the doctor cannot have a situation where he or she performs rough treatment because the patient will not feel discomfort. In addition, the damage caused by perforation after anesthesia is higher.
For patients who have received anesthesia, the examination must be done by a physician who is skilled in operation, because when the patient does not feel the situation will have to rely entirely on the surgeon, i.e., the endoscopist’s manual technique to judge, and only in this way can the risk be reduced. The risk comes from two aspects: one is the risk caused by anesthesia itself, and one is due to the patient doing endoscopy without feeling, part of the risk is more difficult to avoid.
Part3: Suspected lesions in the small intestine Preferred capsule endoscopy
Is it better to have another endoscopy than a capsule endoscopy if problems are found?
Dr. Li Chujun: Capsule endoscopy was originally developed to examine the small intestine. The small intestine itself has a blind spot, and for a relatively thin tube like the small intestine, the capsule endoscope can go more naturally and smoothly inside the small intestine, and the feedback view is clearer.
If a lesion is suspected in the small intestine, the first choice is to use capsule endoscopy to do a screening because, first, the patient is not in pain; second, the risk is relatively small and basically does not cause damage to the patient.
However, if the patient is found to be at risk of obstruction due to stricture that prevents the capsule endoscope from passing, the patient will require emergency surgery. The surgeon will assess whether the patient can tolerate the procedure in the event of an obstruction and whether the capsule endoscope can be removed if an obstruction occurs. Accordingly, the surgeon can find the site of the lesion, surgically remove it, and remove the capsule endoscope as well. However, if the patient is very poorly and an obstruction develops, the procedure cannot be performed.
For small bowel disease, capsule endoscopy is still used as the mirror of choice for screening. If the small intestine is examined with a small bowel scope, the procedure can be painful to the point of general anesthesia. The small intestine is subjected to several loops, which can cause more damage to the intestine than a gastroscope, so it is generally not the first choice for screening.
With the development of capsule endoscopy, there are now some capsule scopes trying to be applied to the examination of stomach and colon. For both, if you want to do a really meaningful and thorough and only one examination, patients are recommended to do routine gastroscopy enteroscopy. Secondly, if the lesion can already be seen or can be biopsied or even treated, it is not necessary to do it again because the cost of this is relatively high. Of course, patients who have no problem in terms of cost can also choose it as a screening test.
Is ESD a test or a treatment?
Dr. Li Chujun: It is a treatment, and its full name is endoscopic submucosal dissection, which is a procedure to remove mucosal lesions under endoscopy. This technique is used for larger mucosal lesions, and since previously only trap mucosal resection – EMR may be more difficult to remove such large lesions intact. And ESD would be able to strive to achieve a complete resection of a lesion no matter how large it is.
The real significance of complete mass resection is that for some lesions, especially in cases where cancer is suspected and is early, the whole mass can be biopsied after the complete mass resection, and the final result is that in addition to the characterization of the nature of the disease, it is most important to examine whether there is early cancer at the margins and base of the lesion, the extent of the cancer, and whether there is residual cancer at the margins and base.
ESD, not only does diagnosis and minimally invasive treatment, but also allows patients to achieve true minimally invasive treatment. Otherwise, if the lump is removed and then evaluated but pathological residue is found, the patient may have to undergo additional surgery.
We can take ESD further and use this technique to perform procedures such as submucosal tumor excavation – a “tunnel” under the mucosa of the GI tract where the mirror can “crawl” from underneath the mucosa to the site of the lesion. The mirror can “crawl” from under the mucosa to the site of the lesion until the tumor is removed. This technique can also be used to treat pancreatic dysenteria – the lower esophagus, the muscular layer of the cardia, is cut off through a submucosal tunnel to achieve treatment.
The development of ESD and its related technologies has changed the treatment mode of our GI diseases, making the scope of endoscopic treatment even further, and making many cases that originally required surgery not only non-invasive but also recovering quickly under the endoscopic technology.
Part4: Will endoscopic resection be clean?
Will endoscopic resection be clean?
Dr. Li Chujun: There is an assessment of this. When removing a lesion endoscopically, try not to divide the lesion into several parts, because dividing the lesion into several parts for removal will not be able to assess the condition of the lesion margin.
Assuming that a lesion is two centimeters in diameter, the resection should start at the outer edge of the two centimeters, where there is normal tissue outside the edge.
Different lesions will have different requirements for the distance, what is the margin of the lesion?
Dr. Li Chujun: The final endoscopic cut of these things, first of all, is a diagnostic excision, after the doctor removed the examined polyps, the entire polyp should be sent for pathological examination, if the pathological examination results are benign, then it is okay.
If the pathological examination is somewhat malignant, but the base is clean and well differentiated, and it is sufficient for endoscopic resection in medicine, then it is also OK. If there are residual cases, there are medical guidelines to define whether the procedure should be done by endoscopy or surgery, so patients should not worry.
If a polyp is found during colonoscopy, will it be treated directly under the endoscope?
Dr. Li Chujun: It depends on the situation. If the patient has no underlying medical history and the relative location and size of the polyp is optimistic, and the intestine is clean, the patient can have the polyp removed directly under the endoscope, and the patient and the patient’s family need to communicate well and obtain consent for the surgery.
The benefits of this approach are: one removal, no further examinations, and relatively low cost. For older patients with a history of underlying diseases or even anticoagulants and poor intestinal cleanliness as well as large tumors, there is a greater risk of surgery and the patient needs to be hospitalized and undergo the necessary preoperative tests before endoscopic resection, which is relatively safer.
Is it necessary to do a colonoscopy for people with high frequency of diarrhea?
Dr. Li Chujun: It is very important to have a change in stool habits. For example, if a young man in his twenties or thirties has diarrhea that is not the case in the last two days or recently, but has always been like this, it is possible that his stool habits have changed.
If he has been like this without change and there is no physical discomfort, it can be considered a functional problem rather than an organic one. Generally, diarrhea is not a particular problem after two days due to wrong food or acute enteritis.
However, if there is recurrence, change in bowel habits, mucus or blood in the excrement, it is important to go for examination. The most critical change is whether there are any abnormal components. Some people have a bowel habit of defecating once every three days for the rest of their lives, which can also be considered normal, but if there is a certain period of time two or three times a day defecation or even unclean, it is an abnormality, then we should be alert, it is best to go to the hospital to do a colonoscopy.