This is a procedure which allows the doctor to see inside your large bowel and examine the surfaces directly and take biopsies (samples of tissue) if needed. Treatment of conditions can also be undertaken. What to expect The colonoscope is a flexible plastic-coated tube a little thicker than a ballpoint pen which has a tiny camera attached that sends images to a viewing screen. You will be given a sedative (medicine that will make you sleepy but is not a general anaesthetic). The tube is passed into the rectum (bottom) and gently moved along the large bowel. The procedure takes from 10 minutes to 1 hour and your oxygen levels and heart rhythm are monitored throughout. The procedure is performed in a day stay operating theatre. Before the procedure You will need to follow a special diet and take some laxatives (medicine to make you go to the toilet) over the days leading up to the test. Risks of a colonoscopy are rare but include: bleeding if a biopsy is performed allergic reaction to the sedative perforation (tearing) of the bowel wall. For further information see Endoscopy Auckland website and Mercy Ascot Endosccopy

A flexible tube with a tiny video camera attached (endoscope) is inserted through the mouth into the stomach and small intestine while you are under sedation (you have been given medication to make you drowsy). A smaller tube is then moved through the first tube into the bile duct (the tube that connects your gallbladder to your intestines) through which dye is injected and an x-ray is taken to visualise the ducts. This procedure also enables the removal of stones from the ducts without the need for surgery. For further information see Mercy Ascot Endosccopy

This is a procedure which allows the doctor to see inside your oesophagus, stomach, and the first part of the small intestine (duodenum) and examine the lining directly. What to expect The gastroscope is a plastic-coated tube about as thick as a ballpoint pen and is flexible. It has a tiny camera attached that sends images to a viewing screen. During the test you will swallow the tube but the back of your throat is sprayed with anaesthetic so you don’t feel this. You will be offered a sedative (medicine that will make you sleepy but is not a general anaesthetic) as well. If the doctor sees any abnormalities they can take a biopsy (a small piece of tissue) to send to the laboratory for testing. This is not a painful procedure and will be performed at the day stay unit in a theatre suite (operating room) by a specialist doctor with nurses assisting. Complications from this procedure are very rare but can occur. They include: bleeding after a biopsy, if performed an allergic reaction to the sedative or throat spray perforation (tearing) of the stomach with the instrument (this is a serious but extremely rare complication). Before the procedure You will be asked not to eat anything from midnight the night before and not to take any of your medications on the day of the procedure. After the procedure You will stay in the day stay unit until the sedation has worn off which usually takes 1-2 hours. You will be given something to eat or drink before you go home. If you have been sedated, you are not to drive until the following day. If biopsies are taken these will be sent for analysis and results are available within 2-3 weeks. A report and copies of these are sent to your GP. For further information see Endoscopy Auckland website and Mercy Ascot Endosccopy

The best way to establish what type of liver disease is present and the extent of the disease, is a biopsy. It is usually performed by inserting a needle into the liver through the skin and taking a small sample of liver tissue. Examination of the sample under the microscope can demonstrate what damage or what type of disease is present. Before your doctor does this procedure, they will check whether or not you are at increased risk of bleeding by doing blood tests. Following the procedure, you will need to be monitored for several hours before you are discharged to go home. For further information see UpToDate Patient Information website.

Sometimes the diagnosis of acid reflux can be difficult to confirm or refute. Gastroscopy is the key test but this is often normal even when there are significant reflux symptoms. If the symptoms are typical and there is a good response to medication (usually Losec or Somac) then there is no problem. However if there continues to be uncertainties about the diagnosis and the treatment is not working then further testing can be useful. The most useful test is a 24 hour oesophageal pH/impedance study (sometimes abbreviated to 'pH test'). This involves directly measuring the acidity (or pH) in the oesophagus over a day. To do this a fine catheter is inserted through the nose (after local anaesthetic is applied to the nose) and passed into the oesophagus. This is done without sedation as full co-operation is needed to swallow the catheter: this usually only takes a few minutes. Initially there may be some discomfort in the back of the throat but perhaps surprisingly the catheter is tolerated well and normal activities can continue for the rest of the day. The catheter is taped to your nose to fix the position and the recorder is secured with a waist belt. Although most people do not go to work during the day of the study it is possible to continue your normal pattern eating, drinking and sleeping. The catheter is connected to a small recording device rather like a 'Walkman'. This records the pH every 6 seconds. At the end of the study this recording device is connected to a computer and a graph of pH over the day is produced. You will be asked to enter directly into the device the times of meals, sleeping and any symptoms. This will help determine if acid reflux is the main problem or perhaps if there is another explanation for your symptoms. The test requires careful interpretation and it is important to have a review by a gastroenterologist after the test to discuss the results and how the test might affect further treatment options. One important decision is whether to perform the test on treatment or off treatment. Please contact Auckland Gastroenterology to discuss details if booking this test.

What is a Wireless Capsule Endoscopy? Capsule endoscopy is a new and minimally invasive procedure to visualize the entire small intestine. Common indications for capsule endoscopy include the evaluation of obscure gastrointestinal bleeding and suspected small bowel disease including Crohn's disease. Your doctor has recommended a wireless capsule endoscopy to investigate your symptoms and determine the best course of treatment. This procedure involves swallowing a small capsule (the size of a large vitamin tablet) which will pass naturally through your digestive system while taking pictures of your intestine. The images are transmitted to sensors, which are placed on your stomach. These sensors are attached to the walkman-like data recorder that is fitted on a belt worn around your waist. The data recorder will save all the images. After about 8 hours the data recorder and sensors will be taken off for processing. Is Wireless Capsule Endoscopy Safe? You should not have a capsule endoscopy if you have any of the following: • Known stricture (narrowing) of the bowel • Gastrointestinal fistulae or known large diverticulae • Please inform the doctor if you have a pacemaker or other implanted electrical devices as special precautions may be required. Possible Complications of Wireless Capsule Endoscopy There is a very small risk that the capsule could get stuck in a previously unsuspected stricture or narrowing and cause an obstruction of the bowel. This is extremely unlikely to occur as most people coming forward for wireless capsule endoscopy have already undergone numerous bowel investigations, which would show up any such strictures within the bowel. How Should I Prepare? Your stomach and small bowel must be cleansed by drinking Klean-Prep. This is to ensure the doctors get the clearest view possible of your small bowel. Be aware, therefore, that Klean-Prep will induce diarrhoea. Please follow these instructions, starting the day before your appointment: 1. Have a normal sized breakfast. 2. Eat a light lunch. Do not eat after 12 midday. You may drink clear fluids (water, black tea/coffee without sugar). 3. Reconstitute Klean-Prep at midday. Dissolve the contents of the sachets in 2 litres of tap water and refrigerate. 4. Start drinking Klean-Prep between 5–7pm. You should drink 1 glass every 5–10 mins, aiming to complete 2 litres over two hours. • Feelings of bloating or nausea may occur after the first few glasses of Klean-Prep. Slowing the rate of drinking can decrease any nausea. Nausea should resolve after the bowel motions begin. • Keep warm while you are drinking Klean-Prep. • Drink unsweetened clear drinks during or after drinking the Klean-Prep to prevent dehydration. Drinks should be warm or hot if you feel cold. Have nothing to drink after 12 midnight the night before the procedure. Please STOP iron tablets 5-7 days before the wireless capsule endoscopy. Important medications may be taken up to 2 hours before your appointment time, with a mouthful of water, or 4 hours after swallowing the capsule. If you suffer from angina or asthma please bring your GTN spray or inhalers with you. If you are an insulin-dependent diabetic, please bring your insulin. For males: on the day prior to the capsule endoscopy, shave your abdomen 15 cm (6 inches) above and below the navel. The sensors and data recorder are a little bulky so you should wear loose fitting, comfortable clothing to your appointment (a large top and elasticated waist trousers are ideal. Dresses are unsuitable). What Should I Expect to Happen? Before swallowing the wireless capsule You should arrive at Auckland Gastroenterology Associates at the Mercy Specialist Centre by 7.45 am on the morning of your procedure. Before the examination you will be asked questions about your general health and about any medications you take. If you take several it is useful to bring a list of these with you. A doctor or nurse will answer any questions you have. You may be asked to take a Metoclopramide tablet shortly after arrival. Metoclopramide hastens gastric emptying and facilitates examination of the whole small intestine. The sensors will be applied to your abdomen with adhesive pads and will be connected to the data recorder, which will be worn on a belt around your waist. You will then swallow the capsule with a small amount of water containing Simethicone to reduce air bubbles. During the procedure The capsule endoscopy will last 8 hours during which time you will leave the Mercy Specialist Centre. After swallowing the capsule, do not eat or drink anything for 2 hours. After 2 hours you may drink a small glass of water. After 4 hours you may have a light lunch. After ingesting the capsule and until it is excreted, you should not go near any source of powerful electromagnetic field such as one created near a MRI (Magnetic Scanner) device at a hospital. Avoid any strenuous physical activity. Do not bend or stoop during the capsule endoscopy. Do not remove the belt at any time during this period. Every 15 minutes during the day you will need to verify that the small blue light on top of the data recorder is blinking. If for some reason it stops, it is likely that the battery pack will need replacing. Please record the time and contact the Mercy Specialist Centre. The data recorder holds the images of your examination, therefore you need to handle all the equipment carefully. Do not expose them to shock, vibration or direct sunlight, which may result in loss of important information. After the procedure You will return to Auckland Gastroenterology Associates at 4:30pm. The data recorder, belt and sensor array will be removed, and the information that you have recorded in the diary will be discussed. You may then eat and drink normally. The capsule is disposable and it will be excreted naturally in your bowel movement. Results from the wireless capsule endoscopy will take up to one week to review carefully. The results will be communicated directly to the doctor who referred you for the test. Any further discussions about the results should be directed to your usual doctor. More information ... www.givenimaging.com

Cirrhosis is the term used to describe a diseased liver that has been severely damaged, usually due to many years of injury. Many people who have developed cirrhosis have no symptoms or have only fatigue, which is very common. However, as the cirrhosis progresses, symptoms often develop as the liver is no longer able to perform its normal functions. Symptoms include: swollen legs and an enlarged abdomen easy bruising and bleeding frequent bacterial infections malnutrition, especially muscle wasting in the temples and upper arms jaundice (a yellow tinge to the skin and eyes). Cirrhosis is diagnosed using a number of tests including: blood tests, ultrasound scans and a biopsy of the liver. Treatment options depend on the severity of damage to the liver and include dietary changes and avoidance of substances such as alcohol that can further damage the liver. Medication may be given to prevent complications and treat symptoms of liver failure. There is no cure other than liver transplantation. For further information see National Digestive Disease Information Clearinghouse website.

Coeliac disease (also called gluten sensitive enteropathy) is a condition in which the lining of the small intestine is abnormal but improves once gluten (a protein found in wheat, rye and barley) is removed from the diet. Damage to the lining can lead to impaired absorption of nutrients. Symptoms vary from person to person and can include diarrhoea, weight loss, excessive gas and abdominal discomfort. In the mildest form no symptoms may be obvious. Blood tests that detect certain antibodies can suggest the diagnosis which needs to be confirmed by examining a sample of the lining of the small bowel under the microscope. The sample (biopsy) is taken during a gastroscopy (see above). Treatment involves complete avoidance of gluten. For further information see the Coeliac Society of New Zealand website.

For further information see the New Zealand Guidelines Group website: Bowel Cancer Consumer Resource Surveillance and Management of Groups at Increased Risk of Colorectal Cancer

What is fatty liver? Fatty liver is not a liver disease as such. It simply means there is more fat in the liver than normal. A person with a fatty liver is not necessarily ill. What causes fatty liver? Fatty liver can be caused by certain chemical compounds and by nutritional and endocrine disorders. Alcohol is by far the most common drug cause. Nutritional causes of fatty liver are starvation, obesity, protein malnutrition and intestinal bypass operations for obesity. The endocrine disorder diabetes mellitus often leads to fatty liver. These causes of fatty liver are called non-alcoholic fatty liver disease or NAFLD. In all of these conditions the fatty deposits are occasionally accompanied by some inflammatory changes and scarring of the liver. Doctors call this condition non-alcoholic steatohepatitis or NASH. Fatty liver of pregnancy is a serious condition occurring near term. Premature termination of pregnancy may be necessary. Delivery of the baby by Caesarean section may be a life-saving measure. What are the symptoms? Uncomplicated fatty liver does not usually produce symptoms because fat accumulates slowly. The liver may be enlarged on physical examination. In fatty liver of pregnancy there may be nausea, vomiting, abdominal pain and jaundice. How does fat get into the liver? Fat enters the liver from the intestines and from the tissues. Under normal conditions, fat from the diet is metabolised by the liver and other tissues. If the amount exceeds what is required by the body it is stored. In obesity some of the fat accumulates in the liver. Can fatty liver lead to other liver disease? Fatty liver in people who drink too much alcohol is sometimes followed by more serious liver damage in the form of alcoholic hepatitis. Serious liver damage is less common in diabetes and obese people who don’t drink but if the fat has progressed to NASH then further progression to scarring and even cirrhosis can occur. How is fatty liver treated? Treatment of fatty liver is related to the cause. Underlying conditions such as diabetes and elevated lipids require treatment. Fat is decreased by removal of any drugs or other chemical compounds thought to be responsible. In people with metabolic syndrome as the underlying cause a weight reduction and regular exercise program is recommended. How can I avoid fatty liver? Do not drink to excess: alcohol can decrease the rate of metabolism and secretion of fat, leading to fatty liver. Overweight patients may have fatty liver, and are also at risk for several more serious conditions such as high blood pressure, stroke, diabetes and heart disease. It is a good idea to watch your diet: starvation, excess dieting and protein malnutrition can also result in fatty liver. For further information see the Gastroenterological Society of Australia website.

Gastro-oesophageal reflux disease (GORD) is a disease in which acid from the stomach flows back (refluxes) into the oesophagus (gullet) causing irritation and sometimes damage to the lining of the oesophagus. The most common symptom is heartburn, but stomach pain and a taste of acid in the mouth can also occur. Treatment depends on the severity of the symptoms and may involve lifestyle changes and/or acid reducing medications. For further information see the Gastroenterological Society of Australia website.

Haemochromatosis is an hereditary condition in which excess iron is absorbed from the intestinal tract. This iron accumulates in tissues throughout the body including the liver, pancreas, heart and joints and can lead to symptoms and signs including joint pains, skin pigmentation, liver damage, heart failure, diabetes and sexual dysfunction. It is important to diagnose this condition as early treatment can help prevent complications. Tests include blood tests showing increased iron levels. Treatment consists of the removal of excessive iron from the body by repeated removal of a fixed amount of blood (therapeutic phlebotomy). This is very like repeated blood donations and is carried out at the blood donor centre. For further information see the Gastroenterological Society of Australia website.

This is inflammation of the liver, commonly caused by viruses. Hepatitis B and C are viruses that can cause chronic (long term) inflammation and damage to the liver. These viruses are passed from person to person through body fluids. For more information about Hepatitis B and C see The Hepatitis Foundation of NZ website and HepNet - The Hepatitis Information Network website.

There are two types of IBD, ulcerative colitis and Crohn’s disease. In these conditions, the immune system attacks the lining of the colon causing inflammation and ulceration, bleeding and diarrhoea. In ulcerative colitis this only involves the large intestine, whereas in Crohn’s disease areas within the entire intestine can be involved. Both diseases are chronic (long term) with symptoms coming (relapse) and going (remission) over a number of years. Symptoms depend on what part of the intestine is involved but include: abdominal pain diarrhoea with bleeding tiredness fevers infections around the anus (bottom) weight loss can occur if the condition has been present for some time. Diagnosis is made when the symptoms, examination and blood tests suggest inflammatory bowel disease, infection is ruled out, and you undergo a colonoscopy with biopsy. Treatment depends on the severity of the symptoms and what part of the intestine is affected. Medication is aimed at suppressing the immune system, which is harming the lining of the bowel. This is done via oral or intravenous medication as well as medication given as an enema (via the bottom). Other treatments include changes in the diet to optimise nutrition and health. Treatment in some cases requires surgery to remove affected parts of the bowel. For more information see http://crohnsandcolitis.org.nz/

Irritable bowel syndrome is a common disturbance of bowel motility that results in intermittent and recurrent pain / discomfort and altered bowel habit. There are considerable differences between individuals in the severity and consequences of symptoms. In severe cases it is a clinically important condition with potential to affect quality of life and productivity. Advances in research have led to increased understanding of the events that lead to symptoms, and development of symptom-based strategies that allow a confident diagnosis to be made. This process may rule out the need for invasive investigations in the majority of patients. A variety of simple measures, that may help to retrain the bowel, are usually recommended to patients with mild symptoms. These steps are usually not helpful in patients with severe symptoms who may benefit from specific interventions directed at the consequences of altered motility, or centrally acting treatments that reduce painful symptoms. For further information see the Gastroenterological Society of Australia website.

Peptic ulcers are sores or eroded areas that form in the lining of the digestive tract. They usually occur in the stomach (gastric ulcer) or in the duodenum (duodenal ulcer), which is the first part of the small intestine. People with peptic ulcers can have a wide variety of symptoms and signs, can be completely symptom-free or, much less commonly, can develop potentially life-threatening complications such as bleeding. Signs and symptoms of ulcers include: pain / burning or discomfort (usually in the upper abdomen) bloating an early sense of fullness with eating lack of appetite nausea vomiting bleeding, which is made apparent by blood in the stool, either in noticeable or microscopic amounts (very brisk bleeding will result in black and tarry stools that smell bad). Smoking, alcohol, anti-inflammatory medication and aspirin increase the risk of developing ulcers. Psychological stress and dietary factors (once thought to be the cause of ulcers) do not appear to have a major role in their development. Helicobacter pylori, a bacteria that is frequently found in the stomach is a major cause of stomach ulcers. If this is found you will be given a course of antibiotics. Diagnosis is made by the history, examination and sometimes blood tests. You may be asked to have a gastroscopy (see above) to clarify the diagnosis and aid with treatment. Treatment consists of medication to reduce the amount of acid in the stomach which aids in the healing of ulcers and avoidance of things that cause ulcers in the first place.