Endoscopy Specialist in Brisbane

Endoscopic Ultrasound

Endoscopic Ultrasound:

What is it?
- Endoscopic Ultrasound (EUS) is a minimally invasive procedure to assess digestive tract (gastro-intestinal) diseases. A special flexible endoscope, passed through your mouth or anus, uses high-frequency sound waves to produce detailed images of the lining and walls of your digestive tract, and nearby organs such as the pancreas, liver and lymph nodes.
- When combined with a procedure called fine-needle aspiration, EUS allows Dr. Nanda to sample (biopsy) fluid and tissue from your gastro-intestinal tract for analysis. In certain cases, EUS with fine-needle aspiration can be a minimally invasive alternative to exploratory surgery.

Why is it done?
- EUS is used to:
  - Find the cause of digestive tract symptoms such as abdominal pain
  - Determine the extent of diseases in your digestive tract such as:
    - Cancer of the colon, oesophagus, pancreas, stomach.
    - Bile duct stones
    - Pancreatitis and pancreatic cysts
  - Evaluate findings from imaging tests such as CT scan or MRI
- EUS Can also be used to provide treatment, it can:
  - Guide drainage of cysts, and other abnormal collections of fluid in the abdomen
  - Permit precise targeting for delivering medication directly into the pancreas, liver and other organs.
- EUS is performed on an outpatient basis, and is well tolerated by most people.

What are the risks?
- EUS is generally safe when performed by an experienced health-care provider such has Dr Nanda, and his team.
- Dr. Nanda will discuss in detail the nature and risks of complications from EUS. These risks are most commonly associated with the fine-needle aspiration component.
- Risks may include:
  - Bleeding
  - Infection
  - A Tear or perforation in the intestinal wall
  - Pancreatitis – if fine-needle aspiration of the pancreas is done.

What are the benefits?
- The benefits of endoscopic ultrasound include:
  - Minimal risk
  - No need for external incisions
  - Quick recovery
  - Enhanced diagnostic information about the gastro-intestinal tract

Endoscopic Mucosal Resection

Endoscopic Mucosal Resection

What is it:
- Gastro-intestinal endoscopic mucosal resection (EMR) is a procedure to remove early-stage cancer and pre-cancerous growths from the lining of the digestive tract.
- EMR is performed using a long, narrow tube (endoscope) equipped with a light and video camera. During EMR of the upper digestive tract, the endoscope is passed down your throat into your oesophagus, stomach or upper part of the small intestine (duodenum). To reach the colon, Dr. Nanda will guide the tube up through the anus. Instruments are then inserted through the endoscope to perform the procedure.
- EMR is generally performed under under sedation & local anaesthetic administered by an anaesthetist. You will feel relaxed and drowsy, but are able to co-operate if required, and are breathing by yourself. The local anesthetic will make the insertion of the endoscope more comfortable.
- There are a few versions of endoscopic mucosal resection. They are grouped into two general categories: Suction or Lift method. Both require a surgical cut to remove the abnormal tissue.

Why it’s done:
- EMR is a less invasive alternative to surgery for removing abnormal tissues from the lining of the digestive tract. Dr. Nanda, may recommend the procedure to remove certain early-stage cancers or pre-cancerous growths.
- Some of the conditions that EMR has been used to treat include:
  - Upper Digestive Tract:
    - Barrett’s Oesophagus
    - Oesophageal Cancer
    - Gastric Cancer
  - Lower Digestive Tract:
    - Colonic Polyps
    - Colorectal Cancer

What are the Risks:
- EMR is generally considered a safe procedure, though there are some risks:
  - Bleeding: This most common complication (2.5-5.0% of cases) can often be detected and corrected during the procedure.
  - Puncture (perforation): There is a slight risk of a puncture through the wall of the digestive tract, depending on the size and location of the lesion that is removed. If it occurs, it requires surgery to be repaired.
  - Narrowing (stricture): Removing certain oesophagus lesions increases the risk of scarring that narrows the oesophagus, which may lead to difficulty swallowing and require further treatment.
- This is why, EMR should be performed by a specialist such as Dr. Nanda, who has sub-specialty expertise and training in the various techniques.

What are the benefits:
- In appropriately selected patients EMR can achieve long-term cure and avoid a larger surgical procedure.

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

ERCP:

What is it?
- Endoscopic Retrograde Cholangio-pancreatography (ERCP) is a procedure that enables your physician to examine the pancreatic and bile ducts.
- A flexible endoscope, about the thickness of your index finger is placed through your mouth and into you stomach and first part of the small intestine (duodenum).
- In the duodenum a small opening is identified (ampulla), and a small plastic tube (cannula) is passed through the endoscope and into this opening.
- Dye (contrast material) is injected and X-rays are taken to study the ducts of the pancreas and liver.
- Small snares and baskets can also be passed through the tube to retrieve bile duct stones
- Balloons can be employed to dilate strictures (narrowings).

Why is it done?
- An ERCP is most commonly performed as a diagnostic procedure to help evaluate conditions of the:
  - Pancreas
  - Bile ducts
- An ERCP is also used to treat those conditions. Balloons can be used to dilate strictures, or small indwelling tubes can be placed to bypass a blockage of the bile duct. Snares and baskets can be used to remove stones.
- An ERCP is performed under sedation, and local anaesthetic, meaning that you will be awake and breathing by yourself, but very relaxed & drowsy.
- An ERCP can be performed as an outpatient procedure, and discomfort is usually minor, and you generally can resume your diet and regular medications once you have been discharged.

What are the risks?
- An ERCP is safe when performed by physicians, such as Dr. Nanda, who have had specific training and are experienced in this specialised type of endoscopic procedure.
- Complications are rare, but can include:
  - Pancreatitis – due to irritation of the pancreatic duct by the X-ray contrast material or the cannula. This is generally mild, though some patients require treatment and a hospital admission.
  - A Reaction to the sedatives administered
  - Irritation to the vein in which medications are given. This is uncommon and usually mild.
- If your ERCP includes a therapeutic procedure such as removal of stones or placement of a stent, there are additional small risks of:
  - Bleeding
  - Perforation
What are the benefits?
- Can provide superior diagnostic information, in addition to what is provided in a CT or MRI, or capsule endoscopy
- Minimally invasive, low risk and well tolerated.
- Possibility of both diagnosis and therapeutic measures at the same time.

Colonoscopy

Colonoscopy

What is it?
- Colonoscopy is a procedure to examine the internal aspect of the colon, rectum and often the last few cms of the small intestine (the terminal ileum).
- During a colonoscopy, a long, flexible tube (colonoscope), is inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the inside of the entire colon.
- If necessary, polyps or other types of abnormal tissue can be removed through the scope during a colonoscopy. Tissue samples (biopsies) can also be taken during a colonoscopy.
- Usually colonoscopy is performed under deep sedation administered by an anesthetist. The procedure may take 20-30 minutes, but you are in hospital for several hours. It requires bowel prep beforehand and 24 hours recovery before resuming responsible activities.

Why it’s done:
- Dr Nanda may recommend a colonoscopy to:
  - Investigate lower intestinal signs and symptoms or rectal bleeding.
  - Screen for bowel cancer in patients at risk or concerned about their risk
  - For surveillance of a known condition (e.g. Ulcerative colitis)
  - Therapeutic intervention (e.g. removal of a polyp, placement of a stent)

What are the Risks: Colonoscopy is generally a very safe procedure, the serious complication rate ranging from 1:1000 to 1:500. Rarely, complications may include:
- Bleeding: this may occur from the site where a tissue sample (biopsy) was taken or a polyp or other abnormal tissue was removed. Minor bleeding may occur in 1:20 cases, whereas major bleeding requiring treatment is rare, (1:500).
- Perforation: This where a tear occurs in the wall of the colon or rectum wall. This is very uncommon (1:>1000), but it can be serious, and requires an operation to repair the tear as soon as possible.
- Minor complications: such as transient abdominal pain, bloating, fainting, or minor bleeding can be more common (1:20) but generally require no intervention.

What are the Benefits:
- Colonoscopy is a low risk, minimally invasive procedure.
- Colonoscopy is a very accurate test for the detection of colorectal cancer, polyps and other diseases of the large intestine (sensitivity >95%). This makes it not only a very useful diagnostic tool for patients with symptoms but also beneficial in the asymptomatic , but “at risk” patient for the prevention of colorectal cancer.

Upper Endoscopy (Gastroscopy)

Upper Endoscopy:

What is it?
- Upper endoscopy (often called gastroscopy) is a procedure used to visually examine your upper digestive system with a tiny camera on the end of a long flexible tube.
- Tissue samples may be taken.
- An endoscopy is sometimes combined with other procedures, such as an ultrasound. An ultrasound probe may be attached to the endoscope to create specialised images of the wall of your oesophagus or stomach.
- Special tools can be passed through the endoscope to treat problems in your digestive system, such as burning a bleeding vessel to stop bleeding, widening a narrow oesophagus with a balloon, or clipping off a polyp or removing a foreign object.
- Many endoscopes allow Dr Nanda to use a technology called Narrow-Band-Imaging (NBI), which uses a special light to help better detect precancerous lesions.

Why it’s done:
- An upper endoscopy is used to diagnose and, sometimes treat conditions that affect the upper part of your digestive system, including the oesophagus, stomach and beginning of the small intestine (duodenum).
- Dr Nanda may recommend an endoscopy to:
  - Investigate upper gastro-intestinal symptoms such as nausea, vomiting, abdominal pain, difficulty swallowing and gastro-intestinal bleeding.
  - Treat problems in your digestive system such as bleeding, area of narrowing or a symptomatic polyp.
  - Follow-up a known disease – e.g. Barret’s Oesophagus
- Usually upper endoscopy is performed under deep sedation administered by an anaesthetist. The procedure may take 20-30 minutes, but you are in hospital for several hours. It requires an empty stomach beforehand so one need to cease eating 6 hours prior to the procedure. You will also require 24 hours recovery before resuming responsible activities.

What are the Risks: Upper Endoscopy is generally a very safe procedure, the serious complication rate ranging from 1:1000 to 1:500. Rarely, complications may include:
- Aspiration: This is where food or fluids are inhaled into the lungs during the procedure which can cause difficulty breathing and pneumonia. The risk is minimized by observing the recommended period of fasting
- Bleeding: this may occur from the site where a tissue sample (biopsy) was taken or a polyp or other abnormal tissue was removed. Minor bleeding may occur in 1:20 cases, wwhereas major bleeding requiring treatment is rare. (1:500).
- Perforation: This is where a tear or hole occurs in the wall of the area being examined. This is very uncommon (1:>1000), but it is a serious complication.
- Minor complications: such as transient abdominal pain, bloating, fainting, or minor bleeding can be more common (1:20) but generally require no intervention.

What are the Benefits:
- Upper Endoscopy is a low risk, minimally invasive procedure.
- It is a very accurate test for the detection of oesophageal and gastric cancer, polyps and other diseases of the upper gastro-intestinal tract (sensitivity >95%).
- It is a very useful diagnostic tool.

Nutritional Disorders

Nutrition:

What we eat and drink, normally travels the length of our gastro-intestinal tract. It provides us with all the key elements to sustain us, from carbohydrates, fats, & proteins, to vitamins and minerals, and other elements.
What we eat also has a key interaction with the millions of normal ‘healthy’ bacteria that reside in our digestive tract, and it also plays a role in almost all disorders that affect our gastro-intestinal tract. It is what sustains us, and at times, what ails us.

Science has an ever increasing understanding of these interactions, and thus, in managing both good gastro-intestinal health and disease, a close analysis and understanding of your nutrition is vital.

Working closely with dietitians and other specialists, Dr Nanda has particular expertise and fellowship training in nutrition management, and how it can improve your general and GI health. Call today to arrange an appointment.

Coeliac Disease:

Coeliac disease is a condition in which the immune system responds abnormally to a protein called gluten, which the leads to damage to the lining of the small intestine. Gluten is found in wheat, rye, barley, and numerous prepared foods. The small intestine is responsible for absorbing food and nutrients. Therefore, damage to the lining of the small intestines can lead to difficulty absorbing important nutrients; this problem is referred to as malabsorption. The cause of coeliac disease is not clear, but a combination of genetic and environmental factors is important. Symptoms vary from very mild, to more troubling symptoms including diarrhoea, weight loss, abdominal discomfort, excessive gas, and other symptoms caused by vitamin and nutrient deficiencies. Coeliac disease is difficult to diagnose on history and physical examination. Fortunately testing is available that can easily diagnose coeliac disease. This includes blood tests for antibodies and nutritional deficiencies, and taking a small intestine biopsy during upper endoscopy. Although coeliac disease cannot be cured, a gluten-free diet usually stops the damage to the intestinal lining and the malabsorption and symptoms that result. Families also need to be aware of their increased risk of coeliac disease, and first-degree relatives (parents, brothers, sisters, children) should consider being tested, especially if anyone has signs or symptoms of the condition. Testing is typically done with a blood antibody test.

Irritable Bowel Syndrome

Irritable bowel syndrome / functional bowel disorder

What is Irritable bowel syndrome?

Irritable bowel syndrome (IBS) is the commonest of the functional gastrointestinal disorders with an estimated prevalence of 10%. It accounts for up to 20 % of all GP visits and up to 50% of outpatient visits to a Gastroenterologist. It is a chronic, relapsing and often life-long disorder, characterized by the presence of abdominal pain/discomfort associated with defaecation, a change in bowel habit, the sensation of abdominal distension, and may include associated noncolonic symptoms. People with persistent symptoms of IBS have poor physical function, impaired quality of life and high healthcare costs.1

Incidence rates of IBS are seldom calculated, and prevalence estimates fluctuate both between and within countries. The pooled prevalence rate that one study cited for North America, Europe, Australia, and New Zealand was 8.1%.2 There appears to be a female predominance. IBS is common both in developed and developing countries.

The following physiologic and psychological variables have been proposed as potential factors in the aetiology and pathophysiology of IBS:

GI dysmotility
inflammation
visceral hypersensitivity
altered intestinal microbiota
diet
genetic predisposition
stress exposure (including early life events)

Disturbances in the brain–gut axis, including disruption of central and autonomic functions, peripheral hormones, amines, and peptides, have been documented in patients with IBS.3

Diagnosing IBS: Based on the Rome IV criteria

Characteristic	Rome IV criteria
Diagnostic time frame	Symptom onset at least six months prior Symptom activity during the last three months Symptom frequency at least one day per week
Symptom description	Abdominal pain
Symptom association (2 or more)	Related to defecation Associated with a change in the form of stool Associated with a change in the frequency of stool

The differential diagnosis of IBS should include coeliac disease, microscopic colitis, inflammatory bowel disease, bile acid malabsorption, colorectal cancer, and dyssynergic defecation. For the most part, patient diagnosis remains one of exclusion, with treatment being symptom driven.

Pharmacologic management of IBS focuses on the predominant bowel symptom (diarrhoea or constipation) and abdominal pain. Patient education, suggestions for lifestyle modifications, and reassurance should be provided with all IBS treatments.

Potential pharmacological interventions for IBS:

Abdominal pain/bloating	Constipation predominant IBS	Diarrhoea predominant IBS
Antispasmodics	Psyllium	Opioid agonist
Peppermint oil	Polyethylene Glycol	Antibiotics (Rifaximin)
Mibeverine	Chloride channel activators	Probiotics
SSRI or Tricyclic antidepressants		Bile acid sequestrants

While these pharmacological agents may transiently help symptoms, NONE alter the natural history of the condition apart from rifaximin (a nonabsorpable antibiotic). Rifaximin has been shown to improve symptoms and provide sustained relief.

References:

Akehurst RL, et al: Health-related quality of life and cost impact of irritable bowel syndrome in a UK primary care setting. Pharmacoeconomics 2002, 20:455–462.
Sperber AD, et al. The global prevalence of IBS in adults remains elusive due to the heterogeneity of studies: a Rome Foundation working team literature review. Gut 2016 Jan 27
Camilleri M. Physiological underpinnings of irritable bowel syndrome: neurohormonal mechanisms. J Physiol 2014; 592(14):2967-80.
Pimentel M, et al. Repeat Treatment With Rifaximin Is Safe and Effective in Patients With Diarrhea-Predominant Irritable Bowel Syndrome.
Gastroenterology. 2016 Dec;151(6):1113-1121.

Biliary System Disease

The biliary tree is the medical term for the gallbladder and the ducts (tubes) that lead from the gallbladder & liver down to the small intestine. These tubes carry Bile, which is produced in the liver, and concentrated in the gallbladder. The gallbladder is tucked up underneath the liver, and is located in the right upper quarter of the abdomen. Bile is a complex mixture that aids the body in digesting foods, especially fat.
Like most organ systems in the body, the biliary tree can also be affected by inflammation & infection, and by benign & cancerous growths. Biliary diseases can cause pain in the right upper corner of the abdomen, and cause jaundice, (yellow tinged skin & eyes, and pigment changes in the stool and urine), by a disruption to the normal drainage of bile. Gallstones are another common biliary disease which can range from being completely asymptomatic to causing severe pain, jaundice, pancreatitis and infection.

Biliary diseases are diagnosed through a comprehensive history, physical examination, imaging tests (e.g. CT scans), and advanced endoscopic procedures (e.g. ERCP).

Treatments of biliary disease can include, diet & lifestyle changes, specific medications, advanced endoscopic procedures and surgery

Dr Nanda has particular expertise and fellowship training in the assessment and management of pancreatic disease. Call today to arrange an appointment.

Pancreatic Disease

Diseases of the Pancreas and Biliary Tree

The pancreas is a solid organ in the abdomen that makes hormones (e.g. insulin) and enzymes (e.g. ) that help breakdown food. These substances are either secreted directly into the blood-stream, or join the secretions of the gallbladder, via a tube or duct, which eventually enters into the small intestine.
There are many conditions that can affect the pancreas. Some of these happen quickly (i.e. Acute), whilst others occur slowly (i.e. Chronic). An example of an acute condition is acute pancreatitis, in which the pancreas becomes inflamed, loses much of its function
Pancreatic disease can cause intense symptoms such as upper abdominal pain, sweats, jaundice (yellow tinged skin and eyes) & diarrhoea or it can be virtually silent, until it is fairly advanced.
Like most organs in the body, the pancreas can also be affected by benign and cancerous growths.

Pancreatic diseases are diagnosed through a comprehensive history, physical examination, laboratory testing, imaging tests and advanced endoscopic procedures (e.g. ERCP).

Treatments of pancreatic disease can include, diet & lifestyle changes, specific medications, advanced endoscopic procedures and surgery

Dr Nanda has particular expertise and fellowship training in the assessment and management of pancreatic disease. Call today to arrange an appointment.

Colorectal Cancer Screening

Colorectal Cancer Screening
Bowel Cancer – The Facts
Bowel cancer is the second leading cause of cancer related death in Australia, with 80 Australians dying from the disease every week. If you are over the age of 50, or have a family history of bowel cancer this places you at increased risk. It develops in the large intestine, where it can grow to form an abnormal lump of tissue, often called a ‘polyp’. Many of these polyps are not cancerous, but over many years, some may turn into bowel cancer. If left untreated, it can spread to other parts of the body. The good news is that bowel cancers that are caught early are treated successfully in 90% of patients.
Why Screening Works
Early testing for bowel cancer saves lives, and is being actively promoted by the Australian Government. Because bowel cancer often develops without symptoms, screening tests are the best way of detecting the disease when it is still early, and treatable. The test looks for any blood in the stool (often in microscopic quantities you can’t see) which can be an early sign of bowel cancer, and other bowel related conditions. The earlier you are diagnosed, the more effective the treatment. Extensive research studies have shown that bowel cancer screening reduces deaths from bowel cancer. The screening test for bowel cancer is a simple, non invasive test called Faecal Occult Blood Testing (FOBT). It is a test done in the privacy of your own home without the need to get your hands dirty, and is then sent via post to get a result.
If you want peace of mind, then contact the rooms for a free screening kit

Inflammatory Bowel Disease

Ulcerative colitis (UC) and Crohn’s disease (CD), collectively called inflammatory bowel disease (IBD) is a chronic inflammatory condition of the intestinal tract resulting from a dysregulated immune response. IBD affects around 85,000 people in Australia. Its incidence is rising in developing countries and is as common as type 1 diabetes or schizophrenia. The pathogenesis appears to suggest an underlying genetic susceptibility coupled with dietary, environmental and gut microbial changes leading to an ‘overdrive’ in immune response. IBD is characterised by a relapsing remitting course, which is variable amongst affected individuals.

Histologically, the inflammation in UC is does not extend beyond the submucosal layer of the bowel wall and in CD it affects all layers (transmural). Transmural inflammation causes complications such as strictures, fistulisation, perforation and abscess formation in CD. Smoking history is associated with adverse outcomes in CD but appears to be protective in UC.

Ileocolonoscopy and biopsy remain the gold standard for diagnosis of colonic and terminal ileal disease, and will usually confirm the diagnosis. Medical therapy is focussed on attaining clinical remission and achieving mucosal healing. A simplified step-up treatment pyramid is shown below:

Biologic agents are drugs directed against specific molecules in the inflammatory pathways involved in IBD. These agents have been a major game changer in the management of IBD patients.

What’s new?

Expanding field of biologic therapies with newer agents targeting alternative inflammatory pathway molecules with reduced systemic side effects
Promising early results of the use of faecal transplantation to improve gut inflammation

IBD medications considered safe to use in pregnancy are the corticosteroids, sulfasalazines, 5-ASA preparations, thiopurines and biologic agents. The best pregnancy outcomes occur in women whose IBD is in remission at conception and throughout the pregnancy.

Opportunistic infection is always a risk in patients treated with immunosuppressant medication. Appropriate vaccination is helpful in reducing this risk, but does not prevent it completely.

References:

Wilson J, Hair C, Knight R, Catto-Smith A, et al. High incidence of inflammatory bowel disease in Australia: a prospective population-based Australian incidence study. Inflamm Bowel Dis. 2010 Sep;16(9):1550-6.
Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2017 Oct 13 [Epub ahead of print]
Hindryckx P, Vande Casteele N, Novak G, et al. The expanding therapeutic armamentarium for inflammatory bowel disease: how to choose the right drug(s) for our patients? J Crohns Colitis. 2017 Aug 25 [Epub ahead of print]
Paramsothy S, Kamm MA, Kaakoush NO, et al. Multidonor intensive faecal microbiota transplantation for active ulcerative colitis: a randomised placebo-controlled trial. Lancet. 2017 Mar 25;389(10075):1218-1228

Brisbane Endoscopy Specialist

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Endoscopic Mucosal Resection

Endoscopic Ultrasound