c

 


 

Stool fats, also known as fecal fats, or fecal lipids, are fats that are excreted in the feces. When secretions from the
pancreas and liver are adequate, emulsified dietary fats are almost completely absorbed in the small intestine. When a
malabsorption disorder or other cause disrupts this process, excretion of fat in the stool increases.



This test evaluates digestion of fats by determining excessive excretion of lipids in patients exhibiting signs of
malabsorption, such as weight loss, abdominal distention, and scaly skin.

 

Drugs that may increase fecal fat levels include enemas and laxatives, especially mineral oil. Drugs that may decrease fecal
fat include Metamucil and barium. Other substances that can affect test results include alcohol, potassium chloride,
calcium carbonate, neomycin, kanamycin, and other broad-spectrum antibiotics.

 

Excessive excretion of fecal fat is called steatorrhea, a condition that is suspected when the patient has large, "greasy," and
foul-smelling stools. Both digestive and absorptive disorders can cause steatorrhea. Digestive disorders affect the
production and release of the enzyme lipase from the pancreas, or bile from the liver, which are substances that aid
digestion of fats; absorptive disorders disturb the absorptive and enzyme functions of the intestine. Any condition that
causes malabsorption or maldigestion is also associated with increased fecal fat. As an example, children with cystic
fibrosis have mucous plugs that block the pancreatic ducts. The absence or significant decrease of the pancreatic enzymes,
amylase, lipase, trypsin, and chymotrypsin limits fat protein and carbohydrate digestion, resulting in steatorrhea due to
fat malabsorption.
Both qualitative and quantitative tests are used to identify excessive fecal fat. The qualitative test involves staining a
specimen of stool with a special dye, then examining it microscopically for evidence of malabsorption, such as undigested
muscle fiber and various fats. The quantitative test involves drying and weighing a 72-hour stool specimen, then using an
extraction technique to separate the fats, which are subsequently evaporated and weighed. This measurement of the total
output of fecal fat per 24 hours in a three-day specimen is the most reliable test for steatorrhea.

 

This test requires a 72-hour stool collection. The patient should abstain from alcohol during this time and maintain a
high-fat diet (100 g/day) for three days before the test, and during the collection period. The patient should call the
laboratory for instructions on how to collect the specimen.


 
Reference values vary from laboratory to laboratory, but are generally found within the range of 5-7 g/24 hr.
It should be noted that children, especially infants, cannot ingest the 100 g/day of fat that is suggested for the test.
Therefore, a fat retention coefficient is determined by measuring the difference between ingested fat and fecal fat, and
expressing that difference as a percentage. The figure, called the fat retention coefficient, is 95% or greater in healthy
children and adults. A low value is indicative of steatorrhea.


 
Increased fecal fat levels are found in cystic fibrosis, malabsorption secondary to other conditions like Whipple's disease
or Crohn's disease, maldigestion secondary to pancreatic or bile duct obstruction, and "short-gut" syndrome secondary to
surgical resection, bypass, or congenital anomaly.
 




 

The fecal occult blood test (FOBT) is performed as part of the routine physical examination during the examination of the
rectum. It is used to detect microscopic blood in the stool and is a screening tool for colorectal cancer.



FOBT uses chemical indicators on stool samples to detect the presence of blood not otherwise visible. (The word "occult"
in the test's name means that the blood is hidden from view.) Blood originating from or passing through the
gastrointestinal tract can signal many conditions requiring further diagnostic procedures and, possibly, medical
treatment. These conditions may be benign or malignant and some of them include:

O colon cancer, rectal cancer, and gastric cancers

O ulcers
O hemorrhoids
O polyps
O inflammatory bowel disease
O irritations or lesions of the gastrointestinal tract caused by medications (such as nonsteroidal anti-inflammatory
drugs, also called NSAIDs)
O irritations or lesions of the gastrointestinal tract caused by stomach acid disorders, such as reflux esophagitis

The FOBT is used routinely (in conjunction with a rectal examination performed by a physician) to screen for colorectal
cancer, particularly after age 50. The ordering of this test should not be taken as an indication that cancer is suspected.
The FOBT must be combined with regular screening endoscopy (such as a sigmoidoscopy) to detect cancers at an early
stage.

 

Certain foods and medicines can influence the test results. Some fruits contain chemicals that prevent the guaiac, the
chemical in which the test paper is soaked, from reacting with the blood. Aspirin and some NSAIDs irritate the stomach,
resulting in bleeding, and should be avoided prior to the examination. Red meat and many vegetables and fruits
containing vitamin C also should be avoided for a specified period of time before the test. All of these factors could result
in a false-positive result.

 

Feces for the stool samples is obtained either by the physician at the rectal examination or by the patient at home, using a
small spatula or a collection device. In most cases, the collection of stool samples can easily be done at home, using a kit
supplied by the physician. The standard kit contains a specially prepared card on which a small sample of stool will be
spread, using a stick provided in the kit. The sample is placed in a special envelope and either mailed or brought in for
analysis. When the physician applies hydrogen peroxide to the back of the sample, the paper will turn blue if an abnormal
amount of blood is present.

p
 
  
·emoccult is the most commonly used fecal occult blood test. The ·emoccult test takes less than five minutes to perform
and may be performed in the physician's office or in the laboratory. The ·emoccult blood test can detect bleeding from
the colon as low as 0.5 mg per day.

Tests that use anti-hemoglobin antibodies (or immunochemical tests) to detect blood in the stool are also used.
Immunochemical tests can detect up to 0.7 mg of hemoglobin in the stool and do not require dietary restrictions.
Immunochemical tests

O are not accurate for screening for stomach cancer

O are more sensitive than ·emoccult tests in detecting colorectal cancer
O are more expensive than ·emoccult tests.

·emoquant, another fecal occult blood test, is used to detect as much as 500 mg/g of blood in the stool. Like the
·emoccult, the ·emoquant test is affected by red meat. It is not affected by chemicals in vegetables.
Fecal blood may also be measured by the amount of chromium in the red blood cells in the feces. The stool is collected for
three to ten days. The test is used in cases where the exact amount of blood loss required. It is the only test that can
exclude blood loss from the gastrointestinal area with accuracy.
 Medicare coverage began on January 1, 2004, for a newer fecal occult blood test based on immunoassay. This technique
does not rely on guiaic, so it is not influenced by diet or medications used prior to the test. The immunoassay test also
requires fewer specimen collections. At a conference of gastroenterologists (physicians who specialize in diseases of the
stomach and related digestive systems), a company announced a new fecal occult blood test that was based on DNA and
appeared more sensitive than traditional tests. Widespread use of these new tests remains to be seen; the traditional
guiaic test has been in place for about 30 years.

 

For 72 hours prior to collecting samples, patients should avoid red meats, NSAIDs (including aspirin), antacids, steroids,
iron supplements, and vitamin C, including citrus fruits and other foods containing large amounts of vitamin C. Foods like
uncooked broccoli, uncooked turnips, cauliflower, uncooked cantaloupe, uncooked radish and horseradish and parsnips
should be avoided and not eaten during the 72 hours prior to the examination. Fish, chicken, pork, fruits (other than
melons) and many cooked vegetables are permitted in the diet.

 
Many factors can result in false-positive and falsenegative findings.

˜

It is important to note that a true-positive finding only signifies the presence of bloodȄit is not an indication of cancer.
The National Cancer Institute states that, in its experience, less than 10% of all positive results were caused by cancer.
The FOBT is positive in 1-5% of the unscreened population and 2-10% of those are found to have cancer. The physician
will want to follow up on a positive result with further tests, as indicated by other factors in the patient's history or
condition.



Alternatively, a negative result (meaning no blood was detected) does not guarantee the absence of colon cancer, which
may bleed only occasionally or not at all. (Only 50% of colon cancers are FOBT-positive.)



Screening using the FOBT has been demonstrated to reduce colorectal cancer. ·owever, because only half of colorectal
cancers are FOBT-positive, FOBT must be combined with regular screening endoscopy to increase the detection of pre-
malignant colorectal polyps and cancers. Since, through FOBT, cancer may be detected early, the benefits of possible early
detection must be considered along with the likelihood of complications and costs for additional studies.

* 
  

 
 


With the procedure known as gastrointestinal endoscopy, a doctor is able to see the inside lining of your digestive tract.
This examination is performed using an endoscope-a flexible fiberoptic tube with a tiny TV camera at the end. The camera
is connected to either an eyepiece for direct viewing or a video screen that displays the images on a color TV.
The endoscope not only allows diagnosis of gastrointestinal (GI) disease but treatment as well.

O Current endoscopes are derived from a primitive system created in 1806-a tiny tube with a mirror and a wax candle.
Although crude, this early instrument allowed a first view into a living body.

O The GI endoscopy procedure may be performed on either an outpatient orinpatient basis. Through the endoscope, a
doctor can evaluate several problems, such as ulcers or muscle spasms. These concerns are not always seen on other
imaging tests.

O Endoscopy has several names, depending on which portion of your digestive tract your doctor seeks to inspect.
  Colonoscopy: This procedure enables the doctor to see ulcers, inflamed mucous lining of
your intestine, abnormal growths and bleeding in yourcolon, or large bowel.

 Enteroscopy: Enteroscopy is a recent diagnostic tool that allows a doctor to see your small bowel. The procedure
may be used in the following ways:

´ To diagnose and treat hidden GI bleeding

´ To detect the cause for malabsorption

´ To confirm problems of the small bowel seen on an x-ray

´ During surgery, to locate and remove sores with little damage to healthy tissue

O Doctors do have other diagnostic tests besides GI endoscopy, including echography to study the upper abdomen and
a barium enema and other x-ray exams that outline the digestive tract. Doctors can study the stomach juices, stools,
and blood to learn about GI functions. But none of these tests offers a direct vision of the mucous lining of the digestive
tube.

O Endoscopy has little value for people with the following conditions:

 Severe coronary artery disease and acute or recent heart attack

 Ëncontrolled high or low blood pressure

 Shock

 Massive upper GI bleeding

 Acute peritonitis (inflammation of certain tissues in your abdomen)

 Injuries of the cervical spine

 ˜erforation of organs of the upper GI tract

 A history of respiratory distress

 Severe coagulopathy, a disease in which you continue bleeding because of inadequate clotting in your blood

 Recent upper GI tract surgery

 Long-standing and stable inflammatory bowel diseases (except for watching cancers)

 Chronic irritable bowel syndrome

 Acute and self-limiting diarrhea

 Bloody or tarry stools with a clear source of the bleeding

  ˜regnancy in second or third trimester

 ·istory of severe chronic obstructive pulmonary disease

 Recent colon surgery or past surgery of your abdomen or pelvis resulting in internal adhesions

 Acute diverticulitis

 Tear in a blood vessel in your abdomen

 Sudden colon inflammation

 Acute inflammation of the sac that lines your abdomen

 Noncorrectable coagulopathy, a disease in which you continue bleeding due to inadequate clotting factors in your
blood

 Massive gastrointestinal bleeding

olonoscopy or sigmoidoscopy

O âour rectum and colon should be cleaned of all fecal matter. Even a small amount of feces can reduce reliability of the
test.

O âou will change your diet prior to the test-no fibers or foods with small seeds for 5-6 days before the examination. âou
will drink liquids such as tea, fruit juices, and clear broth.

O âou may be given laxatives 12-15 hours before the test. âou will be asked to drink up to 4 liters (about 4 qt) of a
special cleansing solution to clean out the colon. Several medications are available for bowel cleansing,
including polyethylene glycol 3350 (GoLâTELâ, NuLâTELâ). Other laxatives to cleanse the bowel, such as magnesium
citrate(Citroma) or senna (X-˜rep), may also be prescribed.

O âou may be given 1 or 2 little enemas 2-3 hours before the procedure.

O The doctor may perform a rectal examination to detect narrowings, polyps or abnormal growth, or hidden bleeding
from your lower intestine.

  


O Ëpper GI endoscopy

 âou will be placed on your left side and have a plastic mouthpiece placed between your teeth to keep
your mouthopen and make it easier to pass the tube.

 The doctor lubricates the endoscope, passes it through the mouthpiece, then asks you to swallow it. The doctor
guides the endoscope under direct visualization through your stomach into the small intestine.

 Any saliva you have will be cleared using a small suction tube that is removed quickly and easily after the test.
  The doctor inspects portions of the linings of your esophagus, stomach, and the upper portion of your small
intestine and then reinspects them as the instrument is withdrawn.

 If necessary, biopsies and removal of foreign bodies and polyps may be performed.

 The procedure usually is completed within 10-15 minutes. Any surgical procedures will require several minutes,
depending on the type.

O Lower GI endoscopy

 âou will be placed on your left side with your hips back, flexed beyond your abdominal wall.

 The doctor lubricates the endoscope and inserts it into your anus and advances it under direct vision.

 âou may be asked to change position during the procedure to assist moving the endoscope. The doctor will study
your colon and rectum walls and reinspect them as the endoscope is withdrawn. If necessary, surgeries may be
performed.

 âou may feel uneasiness and abdominal pain. The procedure usually takes 15-20 minutes. Any surgeries will
require additional time, depending on the type.


  

O If you have been sedated, you will be moved to a recovery area to wake up.
O Once sedation has worn off, before you are discharged from medical center, you will be given instructions and told to
call your doctor if complications develop.
O âou should have someone there to take you home. âou should not drive a car or use other machinery or drink alcohol
for at least a day. âou may feel drowsy.
O At home, it would be best to have a light meal and rest for the remainder of the day

Ö



 
 


A colonoscopy is a test to look at the inside of your colon. The colon is the large intestine and the last part of
your digestive system. Its job is to dry, process, and eliminate the waste left after the small intestine has absorbed the
nutrients in food. The colon is about 3-5 feet long. It travels from the lower right corner of yourabdomen (where the
small intestine ends) up to your liver, across your body to thespleen in the upper left corner and then down to form
your rectum and anus.

The doctor will use an instrument called the colonoscope to perform a colonoscopy. It is a long (about 3 ft), thin (about 1
in), flexible fiberoptic camera that allows the doctor to visualize your entire colon.

O âour doctor may order a colonoscopy to investigate many different diseases of the colon.

 Colonoscopy is best known for its use as a screening tool for the early detection of colorectal cancer.

´ Colorectal cancer is the second leading cause of cancer deaths in the Ënited States.

´ Colon cancer develops from growths within the wall of the intestine such as polyps or tumors.
 ´ These growths often take 5-10 years to develop and may not cause many symptoms.

´ âou may not have any symptoms of colon cancer, but having a close relative with the disease increases your
risk for the disease compared to the general public.

´ Most people who develop polyps do so after age 50, so the American College of Gastroenterology (the digestive
specialists) recommends screening examinations every 5 years for early detection and removal of these cancer-
causing growths after that age.

 Colonoscopy is also used to investigate other diseases of the colon.

´ Colonoscopy may be used to find the place and cause of bleeding as well as to check areas for irritation or sores
in your colon.

´ These colon problems can cause unexplained changes in bowelhabits.

´ ˜ain, bloody diarrhea, and weight loss can be caused byinflammation of the bowel, which may be the result
of Crohn diseaseor ulcerative colitis.

´ These inflammatory digestive diseases tend to occur in young adults and, if undetected, can
produce chronic symptoms and increase the risk of colon cancer.

O Colonoscopy is used when there is concern that a disease of the colon may exist.

 âour doctor may recommend this test if other screening tests such as a manual rectal examination, a hemoccult
test to find hidden blood in yourfeces, or a barium enema (a test in which barium is used to make your colon
visible on an x-ray) suggest that further information is needed to make a diagnosis.

 A colonoscopy may be required when symptoms of digestive disease or other warning signs are present.

´ Rectal bleeding (which may appears as bright red, very dark, or black)

´ ˜ain in the lower abdomen

´ Changes in bowel habits

´ Nondietary weight loss

 Only doctors who specialize in the study of digestive disease, have special training in endoscopy, and are certified
to perform colonoscopy qualify to perform this procedure.

´ As with any skill, performance improves with experience.

 ´ The American Society for Gastrointestinal Endoscopy suggests that a doctor perform at least 200 procedures to
become technically competent at diagnostic colonoscopy.

Ö



  


A colonoscopy can be carried out in a hospital, clinic, or in a doctorǯs office, depending on the facility. âou will be given an
appointment and a set of instructions to follow before the test is performed.

O Although the exact instructions given may vary from clinic to clinic, their objective is the same: to clean out the
contents of the bowel before the test.

O This allows the bowel wall to be seen during the test.

O This system of cleaning the bowel is often called bowel preparation.

O âou will be given a combination of liquid diet, laxatives, or enemas for up to 2 days prior to the test with instructions
on how to use them. Several medications are available for bowel cleansing, includingpolyethylene glycol 3350
(GoLâTELâ, NuLâTELâ), magnesium citrate (Citroma), and senna (X-˜rep).

O These medications produce diarrhea, which can be uncomfortable, but unless the bowel is empty of stool, the test can
be limited and may need to be repeated at a later date.

O On the night before the test is to be performed, nothing should be taken bymouth (food or liquids) until after the test
is finished.

  


O On the day of the colonoscopy, you will most likely be asked to arrive at the clinic up to an hour before the test is due
to begin. This is to allow time to get ready for the test itself and to ask further questions. In addition, you will be asked
the following questions:

 When did you last eat?

 What allergies do you have?

 Did you remember to take all your bowel preparation medication?

O
O Once you are undressed and changed into an examination gown, your vital signs (blood pressure, heart
rate, respiration rate, and temperature) will be monitored and anintravenous line (IV) will be placed. This IV is
necessary to give you sedation and pain medication that may be required during the test. Although you will not be
fully asleep during the procedure, these medications will produce a sleepy state (sedation) and make the test more
comfortable.

O The procedure will begin with you lying flat on your left side. The equipment used, the colonoscope, is lubricated to
allow it to enter the anus. For a thorough investigation, air is required to gently open the folded colon. This may cause
a temporary uncomfortable bloated sensation. When the doctor applies gentle pressure, the colonoscope moves
further into the colon and is slowly advanced until the entire colon is seen.
 O The colonoscope has a tiny camera on the end of it, which is connected to a monitor. This allows the physician to see
the colon through the tip of the instrument even when it is far inside the body. As the scope passes the course of the
colon, the normal turns and contours of the colon may impede the passage of the scope. âou may be asked to change
positions for better visualization. It is common for fluid and gas to escape through the rectum and anus; this should be
expected. The entire procedure can take from 30 minutes up to 1 hour.

O In addition to simply viewing the bowel wall, the colonoscope has special attachments that allow the doctor to collect
tissue samples or biopsies, remove small growths, and stop bleeding with laser, heat, or medication.


  


When the colonoscopy is done as anoutpatient procedure (without checking into the hospital), you will go home later that
same day. But before you go home, you will be observed for some time and monitored until the effects of the medications
are gone. It is a good idea to make arrangements for someone to come to the clinic and take you home, because nausea,
bloating, and drowsiness can continue for some time after the procedure.



  A clotting test, the prothrombin time is done to test the integrity of part of the clotting scheme. The
prothrombin time is commonly used as a method of monitoring the accuracy of blood thinning treatment
(anticoagulation) with warfarin (Coumadin). Familiarly called the "pro time," the test is the time needed for clot
formation after a substance called thromboplastin (+ calcium) has been added to plasma.

˜rothrombin is a coagulation (clotting) factor needed for the normal clotting of blood.

There is a cascade of biochemical events that leads to the formation of the final clot. In this cascade, prothrombin is a
precursor to thrombin. Because prothrombin comes before thrombin, it is called prothrombin.

* 
  ! *"c

An upper gastrointestinal (ËGI) series looks at the upper and middle sections of the gastrointestinal tract . The test
uses barium contrast material,fluoroscopy, and X-ray. Before the test, you drink a mix of barium (barium contrast
material) and water. The barium is often combined with gas-making crystals. âour doctor watches the movement of the
barium through your esophagus, stomach, and the first part of the small intestine (duodenum ) on a video screen.
Several X-ray pictures are taken at different times and from different views.

A small bowel follow-through may be done immediately after a ËGI to look at the rest of the small intestine. If just the
throat and esophagus are looked at, it is called an esophagram (or barium swallow). See barium swallow images .

Ëpper endoscopy is done instead of a ËGI in certain cases. Endoscopy uses a thin, flexible tube (endoscope) to look at the
lining of the esophagus, stomach, and upper small intestine (duodenum).

# 

An upper gastrointestinal (ËGI) series is done to:

O Find the cause of gastrointestinal symptoms, such as difficulty swallowing,vomiting, burping up food, belly pain (including
a burning or gnawing pain in the center of the stomach), or indigestion. These may be caused by conditions such as hiatal
hernia.
O Find narrow spots (strictures) in the upper intestinal tract, ulcers, tumors, polyps, or pyloric stenosis.
O Find inflamed areas of the intestine, malabsorption syndrome, or problems with the squeezing motion that moves food
through the intestines (motility disorders).
O Find swallowed objects.
 Generally, a ËGI series is not used if you do not have symptoms of a gastrointestinal problem. A ËGI series is done most
often for people who have:

O A hard time swallowing.

O A history of Crohn's disease.
O A possible blocked intestine (obstruction).
O Belly pain that is relieved or gets worse while eating.
O Severe heartburn or heartburn that occurs often.