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Title: preparation and care of diagnostic procedure gastrointestinal disorder


1
Topic 2 Preparation and care client for
diagnostic procedure
Prepared by Noor Mariana Sharif, RN Victoria
international college
2
Learning objective
  • At the end of the course, the student be able to
  • Identify the appropriate diagnostic procedure to
    determining the status of GIT
  • Describe the indication each diagnostic
    procedure determining the status of GIT
  • Explain health information and procedure teaching
    to patients and significant others.
  • Describe preparation needed before, during and
    after procedure
  • Identify abnormal finding that may indicate
    impaired in GIT function.
  • Explain instruction about post procedure care and
    activity restrictions.

3
  • Oral Gastroduodenoscopy (Esophagogastroduodenoscop
    y) / OGDS
  • Rectal Examination
  • Sigmoidoscopy, Colonoscopy And Biopsy
  • Abdominal paracentasis
  • Barium Meal And Barium Enema
  • Endoscopic Retrograde Cholangio-Pancreatography
  • Ultrasound
  • Oesophageal Ballon Tamponade
  • Cholecystography
  • Choleangiogram
  • Ultra sonography
  • Computed tomography (CT scan)
  • Liver Biopsy
  • Fractional test meal

4
EsophagogastroduodenoscopyDefinition
  • OGDS/ endoscopies/gastroscopy
  • (OGDS) is a procedure during which a small
    flexible endoscope is introduced through the
    mouth (or with smaller caliber endoscopes,
    through the nose) and advanced through the
    pharynx, esophagus, stomach, and duodenum
  • It considered a minimally invasive procedure.

5
Indication
  • Diagnostic evaluation for signs or symptoms
    suggestive of upper GI disease (eg, dyspepsia,
    dysphagia, noncardiac chest pain, recurrent
    emesis)
  • Investigation for upper GI cancer in high-risk
    settings (eg, Barrett esophagus)

6
Indication
  • Biopsy for known or suggested upper GI disease
    (eg, malabsorption syndromes, neoplasms,
    infections)
  • Therapeutic intervention (eg, retrieval of
    foreign bodies, control of hemorrhage, dilatation
    or stenting of stricture, ablation(removal) of
    neoplasms, gastrostomy placement)

7
Contraindication
  • Possible perforation, medically unstable
    patients, or unwilling patients.
  • Relative contraindications include
    anticoagulation, pharyngeal diverticulum, or head
    and neck surgery.

8
Complication
  • Aspiration pneumonia
  • Bleeding
  • Perforation
  • Cardiopulmonary problem

9
Equipment
  • Endoscope
  • Stack - light source
  • - insufflators
  • - suction
  • Instruments - biopsy forceps
  • - snares
  • - injecting needles

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Before procedure
  • Keep patient NBM (nil by mouth)
  • Obtain consent from the patient (risk for
    bleeding and perforation)
  • Take blood for investigation - complete blood
    cell count, blood cross matching, coagulation
    studies, BUSE, electrocardiogram, and chest
    radiographs.
  • Take vital sign for baseline

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During procedure
  • Placed patient in the left lateral position.
  • Administer topical and/or intravenous sedation to
    minimize gagging and to facilitate the procedure.
  • Place a bite block (mouth guard) to prevent
    damage to the endoscope and to ease its passage
    through the mouth.

15
  • Under direct vision, the endoscope will passed
    through the pharynx, esophagus, stomach and
    duodenum.
  • Liquid and particulate matter can be aspirated
    through the suction channel.
  • The procedure and findings will be documented
    with pictures or a video system. Biopsy specimens
    can be obtained by passing forceps and taking
    small mucosal samples for histology studies.
  • The procedure may last _at_ 5-30 minutes

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After procedure
  • Close monitoring of vital sign for 1 2 hours,
    or until the sedative or analgesia has worn off.
  • Keep patient nil by mouth until the local
    anesthetic has worn off (in the throat) and the
    gag reflex has returned (after two to four hours)
  • Patient may complaint of hoarseness and a mild
    sore throat - drink cool fluids or gargle to
    relieve the soreness

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Rectal examination
20
Definition
  • Rectal examination consists of visual inspection
    of the perianal skin, digital palpation of the
    rectum, and assessment of neuromuscular function
    of the perineum.

21
Indication
  • May be used to diagnosed
  • Rectal tumors
  • Prostatic disorders and benign prostatic
    hyperplasia
  • Appendicitis
  • Piles
  • Anyabnormalities

22
  • Indication
  • for the estimation of the tonicity of the anal
    sphincter
  • in females, for gynecological palpations of
    internal organs
  • for examination of the hardness and color of the
    feces (eg. in cases of constipation, and fecal
    impaction)
  • prior to a colonoscopy or proctoscopy.
  • to evaluate hemorrhoids
  • In newborns to exclude imperforate anus

23
Before the procedure
  • Provide privacy (is a very embarrassing
    examination)
  • Advice patient to take a deep breath during the
    actual insertion of the finger into the rectum.

24
During the procedure
  • Put patient in left lateral position with the
    buttocks near the edge of the bedside. Keep the
    right knee and hip in slight flexion.

25
During the procedure
  • Put patient in well lit room, with total privacy.
  • A chaperon is needed if the patient is female
  • Using a gloved hand, the examiner inspects the
    buttocks for fistulous tracts, the skin tags of
    hemorrhoids, excoriations, blood, and rectal
    prolapsed.
  • Next, using a generous amount of lubrication, the
    gloved index finger is inserted gently into the
    rectum.

26
Sigmoidoscopy, Colonoscopy And Biopsy
  • Definitions
  • Colonoscopy is the endoscopic examination of the
    colon and the distal part of the small bowel
  • Sigmoidoscopy is the medical examination of the
    large intestine from the rectum up to the sigmoid
  • A biopsy is a removal of tissue to determine the
    presence or extent of a disease.

27
Indication
  • COLONOSCOPY
  • Rectal bleeding
  • Iron deficiency anaemia
  • Cancer follow-up
  • Polyp follow-up
  • Abdominal pain
  • Abnormal bowel habit

28
  • SIGMOIDOSCOPY
  • Symptoms that suggest anorectal pathology,
    including colorectal neoplasia
  • Prior to anorectal procedures
  • To obtain biopsy of any bowel condition
  • To assess the true height (distance from anal
    verge) of rectal cancers
  • Conservative treatment of sigmoid volvulus
  • During anterior resection of rectum to gauge the
    lower resection margin

29
Before procedure
  • Stop
  • Aspirin and drugs for arthritis (ibuprofen,
    naproxen, etc.) A week before the procedure to
    prevent intestinal bleeding
  • Iron pills, because it may cause constipation
    difficult for colon cleansing
  • Barium swallow or enema, because barium can cover
    intestinal mucosa thus hiding it from doctors
    view 
  • Anticoagulants to prevent risk of bleeding
  • Insulin should not be taken during fasting

30
  • Bowel preparation
  • Low residue diet 2-3 days pre operatively
  • Administration of glycol-electrolyte solution
  • (Go-LYTELY) x 2 bottles / Foltran / fleet
    solution _at_ 1 day pre op (evening).
  • Clear fluids only after administration of
    Go-LYTELY
  • Bowel washout _at_ morning of operation day (if
    necessary)

31
During procedure
  • Lie on left lateral
  • Sedation will be given if necessary
  • Doctor will administer the colonoscope through
    your anus into the colon and advance it toward
    the end of the colon.
  • If necessary, doctor will perform a biopsy, stop
    the bleeding or remove the polyp.
  • Investigation lasts about 30-45 minutes

32
After procedure
  • Rest for 1 2 hours
  • Patient may experience some cramping or bloating
    (due to inflated air during the procedure) for
    the next day or 1-2 days
  • Biopsy results will be ready in a week

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  • Definition
  • Abdominal paracentesis is a bed side clinical
    procedure in which needle is inserted into
    peritoneal cavity nd ascitic fluid is removed.
  • TYPES-
  • 1)diagnostic small quantity of fluid is removed
    for testing.
  • 2) therapeuticgt5 litres of fluid is removed to
    reduce intraabdominal pressure and relieve the
    asso. Symptms like dyspnoea, abdominal pain

35
Indication
  • For evaluation of new onset ascites.
  • Testing of ascitic fluid.
  • For evaluation of pt with ascitis who has signs
    of clinical deterioration like fever,abd.pain,hepa
    tic encephalopathy,decreased renal function n
    metabolic acidosis.
  • Paracentesis can identify unexpected diagnosis
    such as chylous, hemorrhagic or eosinophilia
    ascites useful to know etiology n antibiotic
    susceptibility.

36
Patient preparation
  • Explain the procedure Obtain Consent
  • No fasting before Procedure
  • EQUIPMENT STAFF
  • Clinician Assistant
  • Bottles should be labelled for tests prior doing
    paracentesis
  • Bacterial culture is done in pts

37
Choice of needle
  • DIAGNOSTIC 1.5 Inch, 22 Gauge needle
  • For Obese 3.5 Inch, 22 Gauge spinal needle
  • THERAPEUTIC 15/ 16 Gauge needle to speed up the
    removal.
  • KIMBERLY CLARK QUICK TAP PARACENTESIS TRAY
    CONTAINS CADWELL NEEDLE which has a sharp inner
    trocar blunt outer metal cannula with side
    holes to permit withdrawal of fluid if end hole
    is occluded by bowel/ Omentum

38
Position
  • Mostly Supine
  • Head may be elevated
  • Knee elbow position for removal of minimal fluid
    in dependent area

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Why left ????
  • Abd. Wall is thinner.
  • Pool of fluid is more.
  • Pt can be rolled easily to left for drainage.
  • WHY NOT RIGHT???
  • Appedicectomy scar, caecum filled with gas in pts
    taking lactulose.
  • Care must be taken not to injure inferior
    epigastic artery which bleeds massively which
    is located near pubic tubercle

41
  • Sterilise with Iodine or Chlorhexidine
  • LA 1 Lignocaine
  • It is removal of gt5 lit of fluid.
  • In refractory ascites, removal of as much fluid
    as possible with sod.restricted diet n diuretics
    will extend the interval to next paracentesis.
  • REMOVAL OF NEEDLE
  • Needle is removed with one rapid smooth
    withdrawal motion.
  • Distract the pt by asking him to cough bcoz cough
    will prevent pain sensation.

42
Complication
  • Ascitic fluid leak
  • -improper Z track
  • -using large bore needle
  • -large skin nick
  • Rx keep ostomy bag over nick.
  • Bleeding
  • -artery or vein
  • In inferior epigastric bleed fig. of 8 suture is
    placed surrounding the needle site. Rarely
    laprotomy is needed to control bleeding in pts
    with renal failure n hyperfibrinolysis.
  • Bowel perforation
  • Infections
  • Catheter residue broken into adbominal.wall.

43
BARIUM MEAL / BARIUM ENEMA DEFINITION
  • A barium meal is a procedure in which radiographs
    of the esophagus, stomach and duodenum are taken
    after barium sulfate is ingested by a patient.
  • A barium enema is a procedure in which
    radiographs of the colon are taken after barium
    sulfate is infused into the colon

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INDICATION OF BARIUM MEAL
  • Dysphagia
  • Assessment of perforated region
  • Esophageal reflux
  • Carcinoma of esophagus

46
INDICATION OF BARIUM ENEMA
  • Changes in bowel habit
  • Colitis
  • Pain
  • Ulcerative colitis
  • Mass
  • Diverticulam
  • Neoplasm
  • Volvulus

47
BEFORE THE PROCEDURE
  • Bowel preparation (as in sigmoidoscopy)

48
DURING THE PROCEDURE
  • Lie on the x-ray table and preliminary x-ray is
    taken. Bowel preparation (as in sigmoidoscopy)
  • The doctor will gently insert a well-lubricant
    tube into the rectum.
  • The tube is connected to a bag that contains the
    barium. The barium flows into the colon.
  • The doctor will monitors the flow of the barium
    on an x-ray fluroscope screen
  • Client will need to move into different position
    and the table slightly tipped to get different
    views.

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AFTER THE PROCEDURE
  • Give bedpan or help client to toilet, so can
    empty bowels and remove as much of the barium as
    possible.
  • Advise patient to drink plenty of fluids for the
    next 24 hours to avoid constipation (Barium is a
    dense substance, which may not be completely
    cleared from toilet by normal flushing. It may be
    necessary to use a toilet brush, or to flush more
    than once to clear any residue from the toilet.

52
Endoscopic Retrograde Cholangio-pancreatography
DEFINITION
  • Endoscopic retrograde cholangiopancreatography
    (ERCP) is a technique that combines the use of
    endoscopy and fluoroscopy to diagnose and treat
    certain problems of the biliary or pancreatic
    ductal systems

53
INDICATION
  • Gallstones
  • Blockage of the bile duct
  • Jaundice
  • Undiagnosed upper-abdominal pain
  • Cancer of the bile ducts or pancreas
  • Pancreatitis

54
BEFORE THE PROCEDURE
  • Nil by mouth for 8 hours before procedure
  • Inform doctor if known allergy to any drug / food
  • Stop anticoagulant 1 week prior to procedure
  • Remove the eyeglasses and dentures.
  • Obtain the consent

55
PROCEDURE
  • Put patient in left lateral
  • The throat is anesthetized with a spray or
    solution, and the patient is usually mildly
    sedated.
  • The endoscope is then gently inserted into the
    upper esophagus to the main bile duct entering
    the duodenum.
  • Dye is then injected into this bile duct and/or
    the pancreatic duct and x-ray films are taken

56
PROCEDURE
  • If a gallstone is found, steps may be taken to
    remove it.
  • If the duct has become narrowed, an incision can
    be made using electrocautery to relieve the
    blockage / placement of stents
  • The procedure takes from 20 to 40 minutes

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AFTER THE PROCEDURE
  • Close monitoring for 1-2 hours
  • Do not drive or operate machinery for at least
    eight hours.

60
Ultrasound / SONOGRAPHYDefinition
  • Also called ultrasound scanning or sonography,
    involves exposing part of the body to
    high-frequency sound waves to produce pictures of
    the inside of the body.
  • Imaging is a noninvasive medical test that helps
    physicians diagnose and treat medical conditions.

61
Indication
  • Is a useful way of examining many of the body's
    internal organs e.g.
  • heart and blood vessels, including the abdominal
    aorta and its major branches
  • liver
  • gallbladder
  • spleen

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  • Pancreas
  • Kidneys
  • Bladder
  • Uterus, ovaries, and unborn child (fetus) in
    pregnant patients
  • Eyes
  • Thyroid and parathyroid glands
  • Scrotum (testicles)

63
Example images
64
Ultrasound is also used to
  • Guide procedures e.g. needle biopsies
  • Image the breasts and to guide biopsy of breast
    cancer.
  • Diagnose a variety of heart conditions and to
    assess damage after a heart attack or diagnose
    for valvular heart disease.

65
Ultra sound machine

transducer
66
Ultra Sonography
  • of the gallbladder provides a noninvasive means
    of studying the gallbladder and the biliary ducts
  • Advantages
  • No ionizing radiation
  • Detection of small calculi
  • No contrast medium
  • Less patient preparation

67
Before the procedure
  • Client should wear comfortable, loose-fitting
    clothing for the ultrasound exam.
  • Client may need to remove clothing and jewelry in
    the area to be examined.
  • They may be asked to wear a gown during the
    procedure.
  • Other preparation depends on the type of
    examination that the client will have.

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Before the procedure
  • For some scans the doctor may instruct not to eat
    or drink for 12 hours before appointment.
  • For others client may be asked to drink up to
    six glasses of water two hours prior to exam and
    avoid urinating so that bladder is full when the
    scan begins.

70
How the procedure performed
  • In an ultrasound examination, a transducer both
    sends the sound waves and records the echoing
    waves.
  • When the transducer is pressed against the skin,
    it directs small pulses of impossible to hear,
    high-frequency sound waves into the body.
  • As the sound waves bounce off of internal organs,
    fluids and tissues, the sensitive microphone in
    the transducer records tiny changes in the
    sound's pitch and direction.

71
Cont-
  • These signature waves are instantly measured and
    displayed by a computer, which in turn creates a
    real-time picture on the monitor.
  • One or more frames of the moving pictures are
    typically captured as still images.

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During the procedure
  • A clear gel is applied to the area to be examined
    to augment the ultrasound transmission and
    reception.
  • The sound waves produced by the transducer cannot
    penetrate air, so the gel helps to eliminate air
    pockets between the transducer and the skin.

74
  • Client will be asked to lie still and hold the
    breath from time-to-time to assist in acquisition
    of the best images.
  • Sometimes patients need to roll to different
    positions
  • Most ultrasound examinations are completed
    within 30 minutes to an hour.

75
After the procedure
  • Wiped off the gel from skin.
  • After an ultrasound exam, client should be able
    to resume the normal activities immediately.

76
Oesophageal Ballon Tamponade DEFINITION
  • Balloon tamponade usually refers to the use of
    balloons inserted into the esophagus or stomach,
    and inflated to stop refractory bleeding from
    vascular structures including esophageal varices
    and gastric varices in the upper gastrointestinal
    tract.

77
INDICATION
  • A balloon tamponade tube is used when the
    bleeding from oesophageal varices is dangerous
    and the tube is usually inserted during an
    endoscopy.

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  • EQUIPMENT
  • GEBT tube
  • Traction device or setup, including weights
  • Manual manometer or sphygmomanometer
  • Y-tube connector (if not already built into the
    tamponade balloon ports)
  • Vacuum suction device, tubing, and connectors
  • Soft restraints
  • Topical anesthetic (spray and jelly) and
    water-soluble lubricating jelly

79
  • 3 or 4 tube clamps
  • Large (e.g., 50 mL) catheter tip irrigating
    syringe
  • Surgical scissors for emergency balloon
    decompression
  • Standard NG tube (may not be required if GEBT has
    a built-in gastric aspiration port)

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PROCEDURE
  • Consider endotracheal intubation prior to GEBT
    placement.

82
  • If used, the NG tube should secured 3 cm proximal
    to the esophageal balloon.

83
  • Clamp the inflation tube after inflation.

84
  • Use of the sponge-rubber cuff to secure the tube.

85
  • Monitor the inflation pressure of the esophageal
    balloon with a manometer.

86
POST-PROCEDURE
  • After bleeding has been controlled for
    several hours, reduce the pressure in the
    esophageal balloon by 5 mm Hg every 3 hours,
    until an intraesophageal balloon pressure of 25
    mm Hg is achieved without ongoing bleeding.
  • If bleeding can be controlled with an
    intraesophageal balloon pressure of 25 mm Hg,
    maintain this pressure for the next 12 to 24
    hours.

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  • Once satisfactory positioning of the GEBT tube
    has been confirmed, do not disturb the tube for
    20 to 24 hours, unless necessary because of
    complications.
  • Provide the patient with analgesics and sedation.
  • Apply soft restraints to the patients arms.
  • If the bleeding does not remain controlled, other
    therapeutic interventions must be considered.

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  • COMPLICATIONS
  • Aspiration pneumonitis
  • Asphyxia due to airway obstruction. Keep scissors
    at the bedside so that the tube can be cut and
    quickly removed if this complication occurs.
  • Esophageal perforation or rupture

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  • Uncommon major complications include duodenal
    rupture, tracheobronchial rupture, and
    periesophageal abscess formation.
  • Common minor complications include pain,
    discomfort, local pressure effects of gastric or
    esophageal erosions or mucosal ulcers,
    regurgitation, chest discomfort, back pain, and
    pressure necrosis of the nose or lip.

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  • Choleangiogram
  • Radiographic examination of the biliary ducts
  •  special x-ray procedure that is done with
    contrast media to visualize the bile ducts after
    the a cholecystectomy (removal of the
    gallbladder). The bile ducts drain bile from the
    liver into the duodenum (first part of the small
    bowel).

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Computed tomography
  • is an imaging procedure that uses special x-ray
    equipment to create detailed pictures, or scans,
    of areas inside the body.
  • It is also called computerized
    tomography and computerizedaxial tomography (CAT)

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CholecystographyDefinition
  • Is a procedure that helps to diagnose gallstones.
  • In the test, a special dye, called a contrast
    medium, is either injected into patient body or
    is taken as special pills (oral
    cholecystography).
  • This contrast medium shows up the structure of
    the gallbladder and bile duct on x-ray.

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Before the procedure
  • Explain the procedure to patient.
  • Sign a consent form that gives permission to do
    the procedure.
  • Fasting prior to the procedure.
  • Notify the radiologic technologist if patient are
    pregnant or suspect patient may be pregnant.

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During the procedure
  • Remove any clothing or jewelry that may interfere
    with the exposure of the body area to be
    examined.
  • Patient may be given an enema prior to the
    procedure to clear the intestines of gas or feces
    that may interfere with imaging of the
    gallbladder.

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Cont..
  • Body parts not being imaged may be covered with a
    lead apron (shield) to avoid exposure to the
    x-rays.
  • Several x-rays will be taken while patient are in
    various positions.
  • If testing of the gallbladders ability to
    contract is requested, patient will be given some
    type of fatty intake to stimulate gallbladder
    contraction.

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After procedure
  • Generally, there is no special care following
    cholecystography.
  • Because the contrast dye is excreted from the
    body through the kidneys, sometime patient may
    feel some slight discomfort with urination for a
    day or so.

99
Liver biopsyDefinition
  • Liver biopsy is the biopsy (removal of a small
    sample of tissue) from the liver. It is a medical
    test that is done to aid diagnosis of liver
    disease, to assess the severity of known liver
    disease, and to monitor the progress of treatment.

100
Type of liver biopsy
  • Percutaneous Liver Biopsy
  • via a needle through the skin
  • Transvenous Liver Biopsy
  • through the blood vessels
  • Laparoscopic Liver Biopsy
  • technique that avoids making a large incision by
    instead making one or a few small incisions.

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Percutaneous Liver Biopsy
102
Laparoscopic Liver Biopsy
103
Indication
  • Liver biopsy Diagnostic purposes 
  • Alcoholic liver disease
  • Elevated liver enzymes of unknown cause 
  • Biliary tract obstruction/jaundice
  • Fatty liver disease
  • Hemochromatosis
  • Wilson disease
  • Autoimmune liver disease
  • Alpha1-antitrypsin deficiency

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  • Possible injury due to drug therapies
  • Hepatitis B
  • Hepatitis C
  • Hepatomegaly (liver enlargement) of undetermined
    cause
  • Cancers that originate in the liver
  • Cancers that spread (metastasize) to the liver
    from other sites
  • Noncancerous tumors or abnormalities in the
    liver 

105
  • Liver biopsy Monitoring therapy
  • Chronic viral hepatitis  
  • HIV/AIDS
  • Liver transplantation (to rule out rejection or in
    fection)

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Before procedure
  • Nil by mouth for 4 8 hours before the biopsy.
  •  Sign a consent form
  • Ask patient maybe have a allergy for medication.
  • Asked to empty the bladder so that he or she will
    be more comfortable during the procedure.
  • Check patient vital sign to identify any physical
    problem

108
During procedure
  • Patients lie on their back with their right hand
    resting above their head.
  • A local anesthetic is applied to the area where
    the biopsy needle will be inserted. If needed, an
    IV tube is used to give sedatives and pain
    medication.
  • The doctor makes a small incision in the abdomen,
    either toward the bottom of the rib cage or just
    below it, and inserts the biopsy needle.

109
  • Patients will be asked to exhale and hold their
    breath while the needle is inserted and a liver
    sample is quickly withdrawn.
  • Several samples may be collected, requiring
    multiple needle insertions.

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After procedure
  • lie on their right sides for 1-4 hours
  • Monitor patient's vital signs.
  •  Bed rest for a day is recommended, followed by a
    week of avoiding heavy work or strenuous exercise.
  • The patient can resume eating a normal diet.

112
Complications
  • Prolonged internal bleeding
  • Patient with liver cancer will develop a fatal
    hemorrhage from a percutaneous biopsy.
  • Leakage of bile 
  • Infection

113
Fractional test meal
  • Gastric analysis
  • Gastric acid stimulation test
  • pH monitoring
  • For zollinger-Ellison syndrome (tumor at
    pancreas/ duodenum)/ actropic gastritis

114
Preparation
  • NPO for 8 -12 h
  • Withhold medication that effect gastric secretion
    24-48h
  • Positioning in a semi fowlers
  • NGT insertion around 21, laying along the
    greater curve
  • Gastric sample are aspirate and collected every
    15m for next 1 hour.

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Thank you.
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