What We Treat
Seek help from a provider for symptoms that affect your esophagus and stomach, including:
Achalasia
Difficulty swallowing because food being trapped in the esophagus.
Acid Reflux or Gastroesophageal Reflux Disease (GERD)
Burning sensation in the chest from stomach acid coming back up the esophagus.
Barrett’s Esophagus
Damage to the lining of the esophagus due to long-term GERD.
Hiatal Hernia and Paraesophageal Hernia
A hole in the diaphragm allowing organs from the abdomen to protrude into the chest cavity
Gastroparesis
Food gets trapped in the stomach longer than usual, causing nausea, vomiting, bloating, and feeling overly full after eating a small amount.
Strictures
Narrowing of the digestive tract caused by tumors or scar-tissue and can be cancerous or non-cancerous, resulting in painful swallowing, heartburn, vomiting, and frequent hiccuping or burping.
Zenker’s Diverticulum
A pouch that can form in the pharynx or esophagus allowing food to pool in the pouch causing difficulty swallowing and frequent regurgitation.
What We Do
Diagnostic Studies
Upper Endoscopy (EGD): A small telescopic camera is introduced through the mouth and advanced along the esophagus, stomach and first 2 parts of the duodenum (beginning portion of the small intestine). Patients are provided anesthesia so that they sleep through this 10-minute procedure. No special preparation is required but patients must have an empty stomach. This allows evaluation and photographing of the inner structure and appearance of the upper gastrointestinal system. Biopsies can be obtained if needed that can be analyzed for the presence of infections, inflammation, damage related to reflux, or cancerous cells.
Endoscopic Ultrasound (EUS): During an upper endoscopy with sedation, a special ultrasound device is used to assess the anatomy of the surrounding organs such as the esophagus, stomach, pancreas and liver and help guide biopsies of tissue when necessary.
EndoFLIP: During an upper endoscopy with sedation, a catheter is placed through the mouth into the esophagus. Fluid is passed through the catheter to inflate a balloon that contains specialized sensors. The pressure needed to distend the esophagus is measured and this allows measuring of the esophageal dispensability (stiffness). The patient experience of this test is similar to undergoing an upper endoscopy.
Manometry: A small catheter is placed through the nose into the esophagus which will measure the function of the esophagus by sensing the pressure that the esophageal muscle generates when swallowing. This is a study done to investigate the strength and muscle coordination of the esophagus. It is most useful to understand the cause of difficulty swallowing and to help determine what surgery can be done for reflux disease.
pH Monitoring: There are two versions of this test: Bravo pH monitoring and 24hr pH impedance-pH testing.
- Bravo pH monitoring: During an upper endoscopy with sedation, a small capsule is attached to the inner lining of the esophagus with gentle suction. This capsule will measure how much acid reflux is occurring. Signals from the capsule are wirelessly recorded by a monitor that you will wear over a two-day period. This test will measure the severity of the acid reflux and determine if the symptoms that the patient is having are associated to the reflux.
- 24hr pH-impedance testing: A small catheter is placed through the nose into the esophagus that will measure the amount of acid and non-acid reflux. The tube will be taped to your cheek, and connected to a small monitor for you to go home with and return 24hrs later. Similar to the Bravo testing, it measures the severity of the reflux and determines if the symptoms that the patient is having are associated to the reflux.
Esophagram (Upper GI Barium Swallow): Liquid contrast is swallowed and followed down through the esophagus, stomach and first portion of the small intestine with an x-ray. It is useful to show anatomic abnormalities such as hiatal hernias among others. Occasionally a solid substance such as a bagel or a marshmallow will be used during this test which can provide useful information in patients with difficulty swallowing.
Gastric Emptying Study: Is a nuclear medicine study which provides an assessment of the stomach's ability to empty. A labeled food is swallowed and the time it takes to empty from the stomach into the small intestine.
Endoscopic Interventions
Balloon Dilation: These are ERCP (endoscopic retrograde cholangio pancreatography) catheters fitted with balloons that can be placed across a narrowed area or stricture. The balloon is then inflated to stretch out the narrowing (dilation). A temporary stent may be placed for a few months to help maintain the dilation.
Radiofrequency Ablation: Using a small catheter inserted through an endoscope, Radiofrequency ablation delivers a short, controlled, burst of heat energy to the esophagus removing the diseased tissue and allowing for replacement with normal tissue.
Advanced Therapeutic Endoscopy: During an upper endoscopy (EGD) therapeutic maneuvers can also be performed. These include esophageal dilatation (stretching) and injection of medications. Swallowed foreign objects can be removed and bleeding can be addressed. Endoscopy is also used to remove early tumors from the esophagus, stomach, and duodenum. Endoscopic suturing can also be performed by use of the APOLLO device which is attached to the tip of an endoscope and can allow for closure or narrowing of abnormal bowel connections and perform Endoscopic surgery.
Endo Mucosal Resection (EMR): EMR is an endoscopic technique used to remove small pre-cancers and small early cancers for esophageal, stomach, or duodenal lesions. EMR involves removing a larger lesion and cutting deeper into the wall under which is curative for early cancers. It is best suited to smaller lesions, however, because multiple (piecemeal) resections would have to be performed with larger lesions and this is associated with higher risk of leaving abnormal tissue behind.
Endoscopic Submucosal Dissection (ESD): is a better technique for larger lesions because it allows larger lesions to be removed en-bloc (in one unbroken piece).
Endoscopic Surgery: Tumor Resection:
- Endoscopic Submucosal Dissection (ESD)
- Submucosal Tunneling Endoscopic Resection (STER)
- Endoscopic Full Thickness Resection (EFTR)
ESD, STER, and EFTR are endoscopic micro-surgical techniques to remove pre-cancers and early cancers using a standard endoscope (for esophageal, stomach, or duodenal lesions) or a colonoscope (for colonic lesions). These techniques allow large lesions to be removed in one unbroken (en-bloc) specimen thereby avoiding the need for surgery. En-bloc Resection allows a pathologist to know with certainty if a cancer resection has been curative. This contrasts with piecemeal (multiple piece) resection which is associated with a risk of accidentally leaving tumor behind as well as an increased risk of future recurrences. Assuming successful en-bloc resection ESD, STER, and EFTR do not have these risks. ESD is used for mucosal (surface) tumors along the wall of the esophagus, stomach, duodenum, and colon. STER is used for tumors within the middle (submucosal) layer of the same gut walls. EFTR allows for removal of certain types of tumors that involve the deep muscle layer and may involve the submucosal and surface (mucosal layers) above. Although this creates a “controlled” perforation a tight endoscopic closure of the resultant “hole” must be performed immediately following tumor removal. We usually close such defects by performing Endoscopic suturing or by clip placement.
Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is an endoscopic technique that uses a side-viewing endoscope which is advanced to the ampulla in the 2nd portion of the duodenum. The ampulla is the structure where the bile duct and pancreatic duct plug into the duodenum. The orifice to these ducts is extremely small (< 0.5 mm) but wires and catheters can be advanced through it into the desired duct. Dye injection with X-ray imaging allows for visualization of the ductal anatomy and identification of abnormalities. X-ray imaging also allow one to visualize wires and catheters advanced into the duct. Depending upon the type of catheter used stones can be crushed, destroyed, and removed. Strictures (a focal narrowing of the duct) can be stretched and stents (tubes) can be placed into the duct to allow drainage across sites of obstruction. In addition to X-ray imaging we can also evaluate the duct by using Intra-ductal Ultrasound (IDUS), an ultrasound probe that can be advanced into the duct. Direct imaging of the duct can be provided by advancement of a scope into the duct. Using this technique, we perform Choledochoscopy (direct visualization of the bile duct) and Pancreatoscopy (direct visualization of the pancreatic duct). These techniques also allow us to direct biopsy forceps and to destroy stones by use of Electrohydraulic Lithotripsy.
Endoscopic Ultrasound (EUS): Endoscopic ultrasound provides images similar to that of more standard “external/transabdominal” ultrasound. Air in bowel and in the lungs interferes with ultrasound of many internal sites when performed from the outside. EUS has the advantage of performing ultrasound immediately adjacent to these hidden areas where they are not blocked by air. Like ERCP EUS also involves use of a side-viewing endoscope. An upper EUS scope can be advanced to the 2nd portion of the duodenum to evaluate the esophagus, mediastinum (area around the esophagus), the stomach, pancreas, gallbladder, bile duct, part of the liver, and tissues around each of these organs. In so doing it can also evaluate lymph nodes in the chest and back of the abdomen. A lower EUS usually examines the rectum but can be advanced to the cecum if needed.
Diagnostic EUS is an examination to evaluate submucosal masses (masses within the wall of the GI tract but below the surface layer) and stages tumors of the esophagus, stomach, and pancreas. It can also be used to identify stones in the bile duct that were not previously seen by regular ultrasound, CT scan, or MRI. Diagnostic EUS also includes the potential for needle biopsy of any of these areas.
Therapeutic EUS takes advantage of the ability to visualize a needle advanced from the tip of the scope into visualized areas. Medications can be injected through the needle to temporarily numb or destroy nerve roots receiving messages of pain in persons with pancreatic disease (Celiac plexus block/Celiac plexus neurolysis). Medications or heat can be delivered via a needle to directly attack tumors. Contrast and wires can be delivered into bile ducts (Biliary rendez-vous) or the pancreatic duct (Pancreatic rendez-vous) to help fix an obstruction. Connections can be made between the stomach or duodenum and a pancreatic pseudocyst (Endoscopic Cyst-gastrostomy/Cyst-duodenostomy).
Enteroscopy: Enteroscopy is a procedure used to visualize and treat disorders of the small intestine. The small intestine is the longest portion of the digestive tract, averaging 20 feet long. It is also in the mid-portion of the digestive tract, which makes it difficult to reach with standard endoscopes.
When a small intestinal abnormality is suspected based upon less invasive imaging (see capsule endoscopy) then enteroscopy is often used for the purpose of biopsy or treatment. Standard enteroscopy consists of using an extra-long scope to enter the small intestine but even the longest scope cannot reach all the way through the small intestine. Deep Enteroscopy is a procedure that uses a combination of a long scope and a soft over-tube that helps reach much deeper into the small intestine. The type of deep enteroscopy available at CTGI is called Spiral Enteroscopy. Small intestinal conditions that may require deep enteroscopy include bleeding lesions, polyps, or tumors. It can also be used to help diagnose Crohn’s disease. Deep enteroscopy patients receive general anesthesia. The procedure takes anywhere from 20 minutes to 1 hour, and most patients are able to go home the same day.
POEM (Per Oral Endoscopic Myotomy):
- Achalasia (E-POEM)
- Gastroparesis (G-POEM)
- Zenker’s Diverticulum (Z-POEM)
POEM is a type of endoscopic surgery and a relatively recent advance. (See ESD, STER, and EFTR for other endoscopic surgeries.) In E-POEM (POEM in the esophagus) an endoscope is advanced from within the esophagus through the mucosal (surface) layer of the esophageal wall into the submucosal (middle) wall layer. The submucosal layer is then dissected to create a submucosal tunnel down the esophagus across the LES (lower esophageal sphincter) and another 2-3 cm further within the stomach wall. Once the submucosal tract is completed the underlying muscle layer is free to be safely cut (Myotomy). In most cases the myotomy usually begins approximately 5 cm above the junction of the esophagus and stomach and is also extended 2-3 cm further down within the stomach wall. By performing the Myotomy in this way spasm of the circular muscle of the lower esophageal sphincter (LES), a hallmark of achalasia, is eliminated. This allows food to more easily exit the esophagus into the stomach. Similarly, we have also performed G-POEM (POEM in the stomach) for non-relaxing spasms of the pyloric muscle (at the gastric outlet) in patients with gastroparesis and Z-POEM (Zenker’s diverticulotomy) for patients with difficulty swallowing due to a Zenker’s diverticulum. These new endoscopic surgical techniques are proving to have better efficacy than surgery and with less risk. Patients are often discharged from the hospital the very next day following surgery and with little/no pain.
Radiofrequency Ablation (RFA): Radiofrequency ablation uses a small catheter inserted through an endoscope to deliver a short, controlled, burst of heat energy to the esophageal lining. This removes the diseased tissue and allows for replacement with normal lining tissue. The ablation is performed with precise depth control, significantly reducing the risk of complications normally associated with other forms of ablation therapy. Ablation reduces the risk of progression to cancer reduces patient anxiety as it relates to “living with a premalignant condition.”
RFA candidates may have long or short segment Barrett’s and be diagnosed with dysplastic and non-dysplastic disease. Radiofrequency ablation is now used with curative intent to treat all patients with Barrett’s esophagus. In the largest study conducted with the HALO System, the system we use at CTGI, the AIM (Ablation of Intestinal Metaplasia) Trial, 98.4% percent of patients treated for non-dysplastic Barrett’s patients were disease-free (at thirty-month follow up). Durability testing found that 92% of patients remained disease free 5 years after initial treatment. The AIM-dysplasia Trial, similarly found that over 90% had complete remission.
CTGI has one of the largest experiences in the US with this technique and we have been serving as a teaching site for many years for other Gastroenterologists (from throughout New England) who want to learn it. (See section on GI neoplasms.) RFA can also be used for destruction of patches of superficial bleeding vessels in the stomach (Gastric Antral Vascular Ectasia (GAVE)) and in the rectum in the setting of Radiation Proctitis.
Variceal Band Ligation and Sclerotherapy: Persons with portal hypertension (see Liver Disease section) are at risk of life-threatening hemorrhage from engorged veins in the esophagus and elsewhere in the GI tract. These can be treated by upper endoscopy. The veins can be obliterated either by injection of a sclerosant (a scarring agent) or by capturing one or more of these distended veins in an elastic band. Patients are asleep throughout the procedure. Multiple sessions are usually required to obliterate the enlarged veins.
APOLLO Endoscopic Suturing: The APOLLO Endoscopic Suturing system enables advanced endoscopic surgery by allowing physicians to place full-thickness sutures from a flexible endoscope.
Surgical Interventions
Surgery for Acid Reflux and Hiatal Hernia Repair:
- Hiatal Hernia Repair: A hiatal hernia is the abnormal migration of the stomach from the abdomen to the thorax through the diaphragm muscle. Occasionally a hiatal hernia can lead to GERD and/or to difficulty swallowing. This is repaired minimally invasively (laparoscopically or robotically) under general anesthesia where the stomach is returned to its normal location in the abdomen bellow the diaphragm muscle and restoring the normal anatomy. This can be done in conjunction with a surgical procedure for Reflux Disease.
- Surgery for Reflux Disease:
- Fundoplication: This is minimally invasive surgical procedure to prevent acid reflux. Under general anesthesia, the upper part of the stomach is loosely wrapped around the lower esophagus to prevent heartburn and restore the function of the lower esophageal junction.
- Linx Device Placement: An implantable device made of small titanium magnets connected by a wire in a bracelet configuration is placed around the lower part of the esophagus. The magnetic attraction of the titanium beads prevents abnormal reflux by augmenting the strength of the lower esophageal sphincter. This procedure is also called magnetic sphincter augmentation.
Surgery for Gastroparesis:
- Pyloromyotomy: Gastroparesis is a neuromuscular stomach disorder in which food empties from the stomach more slowly than normal. Patients with gastroparesis retain significant amounts of food in the stomach hours after eating or longer causing symptoms. Pyloromyotomy is a minimally invasive procedure performed under general anesthesia that facilitates stomach emptying into the small intestine by splitting some of the muscle of the pylorus sphincter where the stomach connects into the small intestine.
- Gastric Stimulator Placement: Also known as Gastric Pacing is a minimally invasive surgery performed under general anesthesia where an implantable system that consists of two leads is placed in the muscle of the stomach. These leads are attached to a device that is placed under the skin which delivers a mild electrical stimulation to the lower stomach muscle and reduces the chronic nausea and vomiting associated with gastroparesis.
Surgery for Achalasia:
- Minimally Invasive Heller Myotomy: Achalsia is a disease in which the muscle of the esophagus, at the junction between the esophagus and the stomach, is abnormally tight impeding food from entering the stomach and causing difficulty swallowing. A Heller Myotomy is a minimally invasive (laparoscopy or robotic) surgical procedure for patients with Achalasia in which the abnormally thick esophageal muscle fibers are cut, allowing food and liquids to pass into the stomach.