Getting ‘scoped’!

The gut, fascinating and complex as it is, is a part of the body that is more ‘camera shy’ than others. By which I mean, it does not show up clearly in tests such as x-rays, for instance, and for other imaging, like CT scans and MRIs, it requires that you swallow unpleasant contrasts to make it temporarily more visible, so that an image may be captured.

As a result, the gold standard when it comes to examining the various parts of our elaborate digestive tract, are the so-called scopes: gastrosocopy, ileoscopy, sigmoidoscopy and colonoscopy.

To brazenly misquote Jane Austen: It is a truth universally acknowledged that a patient with IBD, must be familiar with a scope of some sort!

The reason these are the ‘old faithful’ of testing, is both because they yield superior and clearer images, but also because they allow on-the-spot taking of tissue samples for biopsy (whether as a matter of course or because the doctor has spotted something that requires further investigation). They can also be great for minor interventions during the process of examination (eg removal of polyps).

To brazenly misquote Jane Austen: It is a truth universally acknowledged that a patient with IBD, must be familiar with a scope of some sort! While this post is most relevant to ostomates having an ileoscopy, it would be useful to first do a brief overview of the scope procedures, to clarify the differences between them.

Meet the Scopes

The purpose of any scope is essentially to directly view what is otherwise un-viewable, that being: the inside of the digestive system. This is so a doctor can more closely and accurately see and examine the mucosal lining of the stomach, small and large intestines, in order to spot and test for signs of inflammation or other abnormalities, for the purposes of diagnosis and disease monitoring. The vast majority of people with IBD will have been diagnosed following such a procedure.

The purpose of any scope is essentially to directly view what is otherwise un-viewable, that being: the inside of the digestive system.

All scopes involve the insertion of a thin flexible tube into the section of the digestive tract that is to be examined. Air is then pumped in (especially when examining the small and large intestine) in order to create a ‘stretching’ effect, so that the membrane is more clearly visible.

Gastroscopy: used to look at the oesophagus (the tube down which food travels from your mouth to your stomach), the stomach, and the beginning of the small intestine (duodenum).

Colonoscopy: examination of the entire large intestine (colon) and the very end of the small intestine (ileum), and the rectum.

Sigmoidoscopy: examination of the sigmoid colon (the lower part of the large intestine) and the rectum.

Ileoscopy: the examination of the end of the small intestine (ileum) during a colonoscopy OR directly through an ileostomy/stoma (an opening on the abdomen through which the end of the small intestine is surgically diverted).

The rest of this post relates specifically to the procedure of ileoscopy through a stoma.

WHY Do AN ILEOSCOPY?

An ileoscopy looks at the ileum (hence the name), which is the last and longest part of your small intestine (see the anatomical diagram above), and is often required to gather further information on what is going on in the small intestine, and/or with a person’s stoma. For IBD patients, an ileoscopy can be an important part of the disease-monitoring process, and for cancer screening.

For IBD patients, an ileoscopy can be an important part of the disease-monitoring process and for cancer screening.

In brief, having an ileoscopy serves several purposes, including:

Diagnosis (and differential diagnosis).
Monitoring for disease recurrence and degree of disease activity.
Diagnosis and monitoring of stoma anomalies or complications (hernia, retraction, prolapse, strictures, stenosis, frequent blockages, high ileostomy output etc).
Surveillance for dysplasia (for cancer-screening).
Delivery of endoscopic therapy, where applicable (for instance, endoscopic balloon dilation of a stricture).

HOW TO PREPARE FOR AN ILEOSCOPY

Your doctor will give you complete instructions for how to prepare for the procedure. This preparation may vary slightly depending on the individual, but it usually involves a specific diet and a period of fasting beforehand, and may include so-called ‘bowel prep’ (which is essentially a laxative preparation taken before a scope to ensure the intestine is as empty and clean as possible, to enable maximum visibility during the examination). You may also be required to stop certain medication ahead of your scope.

Be sure to ask all your questions at your doctor’s appointment.

Be sure to ask all your questions at your doctor’s appointment ahead of the procedure, including:

Details of the required dietary preparation.
Whether bowel prep will be necessary, and how to take it if so.
Whether you will be sedated or not (if you have a preference either way, this is the time to state it).
Whether you need to stop any medication you are taking, and when.
- Certain meds may need to be temporarily stopped ahead of the procedure, including:
  - Non-Steroidal Anti-Inflammatories (NSAIDs) like aspirin, ibuprofen etc
  - Blood thinners
  - Oral diabetes medication
  - Iron supplements
  - Fibre supplements

Dietary Prep

Ileoscopy through a stoma may not necessarily require full prep (including laxatives), but this will be decided by your doctor. Regardless, however, when it comes to your diet, here are some general guidelines for how to prepare:

3 days before ileoscopy

Start a low residue diet:
- No nuts, seeds, raw fruit/veg or fruit/veg skins, dried fruit, granola, popcorn or other high-fibre foods.
- Stick to easy-to-digest, ‘low residue’ foods, such as: steamed/boiled/puréed root vegetables, soup, lean chicken/turkey/fish, eggs, yogurt, plain crackers, pasta, bread (plain, without seeds, and not a high fibre option), nut butters (smooth/creamy, not crunchy) etc.

Suggestions:

2 days before ileoscopy

Continue as yesterday, but be sure to now also avoid red, blue or purple coloured foods (beetroot, blueberries, or red/purple sweets, jellies etc).

Day before ileoscopy

It’s usually acceptable to eat one small low residue meal in the morning, before 11:00 am (eg boiled egg, white bread/toast, chicken/turkey/fish with the skin removed) - confirm this with your doctor.
From 11:00 onwards, clear fluids only (ie liquids you can see through). This includes:
- Water, tea or coffee (black only, no milk), clear broth (with no ‘bits’ or herbs), electrolyte drinks, apple juice (clear), white grape juice, jelly/Jell-O, popsicles (but not red, purple or blue colours), soft drinks, coconut water (not coconut milk) etc.
- None of the following liquids: soup, alcohol, milk or non-dairy creamer, juice with pulp etc.

Suggestions:

(If you need to take some form of ‘bowel prep’, it will usually be in the afternoon/evening before your procedure. You will have increased stoma output as a result, so make sure you are drinking enough fluids to keep on top of your hydration, and maybe include a soluble oral rehydration solution to maintain your electrolyte balance).

Day of your ileoscopy

Nil-by-mouth for 6 hours before your appointment (only a small sip of water to take morning medication, if the doctor has said it’s ok, and not less than 3 hours before your appointment).
Stop drinking all liquids 3 hours before your procedure.
The stoma output should ideally be clear and yellow at this point, for optimum visibility during the scope.

*This is the exact prep that I have been instructed to follow (without laxatives) before my ileoscopies, and it has worked very well for me. Keep in mind that your doctor may give you different instructions based on your specific condition and circumstances, which you will need to follow.

WHAT TO EXPECT

When you arrive for your procedure you will be asked to change into a hospital gown and taken into the examination room. You will lie down and a canula will be placed intravenously for any sedative/anaesthetic that will be administered, to make you groggy and/or sleep. The doctor will slowly insert a thin tube into the stoma, through which air is pumped to help stretch the intestine for better visibility. A small camera is passed through this tube to capture images of the intestinal lining, and biopsies (tissue samples) will be taken for further testing. You will later have a follow-up appointment with your doctor to discuss the biopsy results and examination findings.

Be sure to take some extra ostomy supplies.

Important tips:

Be sure to take some extra ostomy supplies, including a bag and a flange/wafer (the flange/wafer you are wearing may or may not be removed for the procedure, but even if it is left on, it may get dirty and need changing).
You may want to take an extra pair of underwear, again in case the pair you are wearing is soiled.
Arrange to have someone pick you up when the procedure is over, to drive or escort you home, as you will be groggy.
Try to take it easy for the rest of the day. Go home and rest if possible.
Don’t be alarmed if you see blood in your ostomy pouch, this is quite normal and is a result of the biopsies that have been taken and should stop within a few hours, or by the next day at the latest.
You may feel a little bloated from the air that was used during the procedure, but this will gradually work its way out. Try a little gentle abdominal massage to help ease this.
Although you may feel hungry after your liquid fast and look forward to eating something, a gentle return to normal eating is best for your gut. Start with something simple, ‘soft’, and easy on the gut for your first post-scope meal (eg some scrambled eggs on toast, or a bowl of soup, or some chicken with boiled or mashed potatoes and carrots) – remember, your gut is irritated from the procedure and the biopsies, so don’t give it too much work to do just yet, if you can manage it.

ALTERNATIVE TESTS?

There are several other methods of testing when it comes to looking at the small intestine, however, none offer the possibility of on-the-spot tissue sampling that the ileoscopy does. Nevertheless, it is very possible that your doctor could suggest that you do one of more of these other tests, as well as an ileoscopy, or for monitoring in between ileoscopies.

There are several other methods of testing when it comes to looking at the small intestine.

These other testing methods include:

Faecal Calprotectin Stool Test – completely non-invasive, testing of stool sample to check for elevated calprotectin levels, indicative of inflammation in the intestine.
Capsule endoscopy - swallowing a capsule camera to record images of the entire small intestine.
Small bowel study (MRI) / MRI Enterography – where you drink a large volume of fluid with contrast material (gadolinium) during the 2 hours preceding the MRI.
CT Enterography - radiologic examination where you drink an iodine-based contrast material (gastrografin) ahead of the scan.
Small bowel follow through / CT Enteroclysis – radiologic examination of the small intestine using a barium-based contrast material, usually administered through a tube inserted through the nose or mouth into the stomach and into the beginning of the small intestine.
Small bowel endoscopy – specialised endoscopy using ‘balloons’ to be able to view entire small intestine (about 20 feet long).

SUMMARY

Check-ups, medical tests and appointments are never going to be fun, but they are necessary, especially when you live with a chronic condition like IBD. When it comes to having an ileoscopy, just focus on the fact that you are doing it for your well-being, to gather valuable information on your condition, and to ensure you are (and remain) as well and healthy as is possible. Being fully informed and having all your questions answered always helps, so be sure to discuss everything with your doctor to ensure you feel as comfortable as is possible.

Ileoscopy: What It Is, How To Prepare & What To Expect