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SPECIALTIES & SERVICES

Gastroenterology & Hepatology



The Gastroenterology & Hepatology unit of Khoo Teck Puat Hospital treats both local and international patients who present to us with digestive and liver related problems. We also routinely perform gastric and colorectal cancer screening for people who have significant risk factors.

Our team comprises of dedicated specialists, nurses and medical technologists.

We utilise an array of diagnostic tools such as laboratory tests, modern scanners and advanced endoscopic imaging modalities to aid in the management of our patients’ complex medical conditions.

The Gastroenterology and Hepatology unit provides:

  • Outpatient consultations
  • Direct access endoscopy
  • Direct access urea breath test
  • Inpatient care to patients who require hospitalization.

Our doctors engage in medical education and clinical research as well. In addition, we contribute to the hospital’s multidisciplinary nutrition support service, which advises on enteral and parenteral nutrition related issues.

Patients with complex Gastrointestinal and Liver diseases at KTPH are managed holistically through our collaborations with specialists such as the Gastrointestinal surgeons and radiologists. This ensures that our patients are managed seamlessly in an integrated, multi-disciplinary manner. We also partner external hospitals in the training of junior residents and in the referral of patients who may require a liver transplant.

At the KTPH Endoscopy Center, our specialists perform a high volume of endoscopic procedures annually. We endeavor to adhere to international standards of quality assurance in our daily procedures, so as to continuously achieve the best outcomes for our patients. It is our aim to provide specialised, cost-effective and high quality care.


Our core services are divided into:

Liver Disease Service (Hepatology)

The KTPH Liver service comprises of outpatient specialist clinics and an inpatient service. Patients who have abnormal liver function tests are commonly referred to our clinics.

Liver diseases may be silent or may present as:

  • Jaundice
  • Water retention
  • Impaired immunity
  • Increased risk of bleeding
  • Problems with blood clotting
  • Confusion and reduced alertness
  • Swelling of the legs and abdomen
Liver Diseases

Liver diseases which we manage in our specialist clinics include:

  • Viral hepatitis (e.g. Hepatitis A, Hepatitis B, Hepatitis C)
  • Fatty liver
  • Liver cancer
  • Abnormal liver lesions seen on scans (e.g. suspected cancer)
  • Cirrhosis or ‘hardening’ of the liver
  • Metabolic liver diseases (e.g. Wilson’s disease)
  • Drug related liver disease, including alcoholic liver disease
  • Autoimmune liver disease, primary biliary cirrhosis, sclerosing cholangitis

Our specialists have an interest in the treatment of viral hepatitis. With advancements in medicine, Hepatitis C which was once an incurable disease can now be cured. New drugs (e.g. protease inhibitors) may be used to treat Hepatitis C when appropriate. In addition, there are also new medications available to treat patients with abnormal liver function tests and Hepatitis B.

The liver cancer treatments which are available at KTPH include:

  • Trans-arterial chemoembolization, TACE (including doxorubicin coated beads, if necessary)
  • Radiofrequency ablation, RFA
  • Liver resection

We collaborate with Liver surgeons, interventional radiologists and oncologists in the management of liver cancer. Our Liver service is supported by modern scanners and elastography to detect early liver disease. In selected patients with a failing liver, we may recommend a liver transplant through our partnership with a transplant center.

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Digestive Disease Service (Gastroenterology)

The KTPH Digestive Disease service treats patients with problems of the digestive tract (esophagus, stomach, small intestine, colon and rectum). This also includes problems of the pancreas, liver and gallbladder, which are involved in producing digestive secretions.

Diseases of the digestive tract may result in symptoms such as:

  • Acid reflux and heartburn
  • Loss of appetite
  • Swallowing problems
  • Unintentional weight loss
  • Anemia (low blood count)
  • Sensation of bloating or indigestion
  • Pain in any area of the abdomen
  • Bleeding from the gastrointestinal tract (e.g. blood seen or detected in stool samples)
  • Change in one’s usual bowel habit
  • Chronic diarrhea or constipation
Advanced EndoscopicProcedures

We provide both outpatient clinics and inpatient care. Our doctors also perform cancer screening (gastric cancer and colorectal cancer) as a form of preventive medicine.

The common conditions which we treat are:

  • Peptic ulcer disease
  • Polyps of the stomach
  • Investigation of anemia
  • Irritable bowel syndrome
  • Gastro-oesophageal reflux disease
  • Helicobacter pylori infection
  • Colorectal cancer / colon polyp screening and surveillance
  • Cancers of the oesophagus, stomach, colon, pancreas and gallbladder
  • Inflammatory bowel disease (Ulcerative colitis, Crohn’s disease )
  • Pancreatic diseases (pancreatitis, tumors, cysts)
  • Evaluation of elevated cancer markers (Alpha-fetoprotein (AFP), Carcinoembryonic Antigen (CEA) and Ca19-9)
  • Hemorrhoids

Gastrointestinal diseases are evaluated with the use of abdominal scans and endoscopy. Abdominal scans include computed tomography (CT) scans, magnetic resonance imaging, magnetic resonance cholangio-pancreatography, CT enteroclysis, CT colonography (virtual colonoscopy) and contrast studies.

Another frequently performed test is the Urea Breath Test, which screens for the presence of an infection in the stomach called Helicobacter pylori.

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Endoscopy Service

Endoscopy involves the examination of the digestive tract using a slim and flexible tube with a tiny camera mounted at the end.

Endoscopic procedures are performed at the KTPH Endoscopy Center. These can be divided into routine procedures and advanced procedures. Advanced procedures are more complex and require special equipment and skills.

We perform endoscopy for cancer screening in patients whom have an increased risk of gastrointestinal cancers (e.g. history of polyps, more than 50 years old, family history of gastrointestinal cancers). These procedures include:

  • Gastric cancer screening with gastroscopy
  • Colon cancer screening with colonoscopy
  • Colon polyp follow up / surveillance with colonoscopy

Routine endoscopic procedures which we perform include:

  • Oesophagogastroduodenoscopy (OGD) or gastroscopy
  • Colonoscopy
  • Polypectomy
  • Piles (hemorrhoid) ligation
  • Percutaneous endoscopic gastrostomy (PEG) insertion

The advanced endoscopic procedures which are available include:

  • Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
  • Endoscopic Ultrasound (EUS)
  • Small Bowel Endoscopy (Capsule endoscopy and balloon Enteroscopy)
  • Endoscopic Management of Strictures
  • Insertion of Self-Expandable Metal Stents (SEMS)
  • Endoscopic Dilation

The KTPH Endoscopy Centre is equipped with a variety of modern endoscopes to provide a better patient experience and an accurate examination. Our endoscopes come with high definition imaging to ensure a clear image. When necessary, advanced imaging techniques such as narrow band imaging and zoom magnification may be used to further characterise any abnormal findings.

We also have special endoscopes such as dual channel and multi-bending endoscopes to examine difficult-to-reach corners of the digestive tract. Our range of slim to ultra-slim gastroscopes and colonoscopes will ensure a pleasant experience, customised to our patient’s individual needs.

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Below is a brief description of the following endoscopic procedures which are performed at KTPH.

Routine endoscopic procedures:

Advanced endoscopic procedures:

ENDOSCOPIC ULTRASOUND (EUS)

Oesophago-Gastro-Duodenoscopy or Gastroscopy (OGD)

OGD or Gastroscopy is a procedure frequently performed for the following reasons:

  • Indigestion
  • Gastric / upper abdominal pain
  • Unintentional weight loss
  • Loss of one’s appetite
  • Anemia
  • Swallowing problems
  • Acid reflux symptoms
  • Stomach cancer screening

This test is performed under light sedation and usually requires only about 10 minutes. Gastroscopy allows the diagnosis of disorders of the upper digestive tract such as gastro-oesophageal reflux disease, stomach ulcers, gastritis, Helicobacter pylori infection, varices, and cancers of the oesophagus and stomach.

In patients who decline sedation during gastroscopy, the ultra-slim endoscope which is inserted via the nose, may be used to examine the stomach.

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Colonoscopy

A colonoscopy is an endoscopic procedure used to examine the large intestine from the rectum to the lower end of the small intestine. This is usually performed after the bowel has been cleansed with medication.

Your doctor will perform this procedure for the following reasons:

  • Presence of blood in the stools
  • Chronic diarrhea
  • Chronic constipation
  • Unexplained weight loss
  • Anemia
  • Change in bowel habit
  • Colon cancer screening
  • Follow up of colon polyps

Our endoscopes are equipped with high definition technology to examine the lining more accurately and peristaltic flushing pumps to cleanse the bowel for a better examination. In addition, zoom magnification and narrow band imaging allow our doctors to scrutinize and predict a polyp’s potential risk of cancer, even before it is removed.

In order to ensure a comfortable examination, doctors may select a variety of modern techniques such as using variable stiffness colonoscopes, carbon dioxide insufflation instead of air, an ultra-thin colonoscope with passive bending technology or a balloon enteroscope. These methods have enhanced our ability to complete the colon examination even in patients with previous unsuccessful colonoscopies due to bowel scaring.

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Polypectomy

Polyps found in the digestive tract may have a potential risk of cancer or future progression to cancer. Large polyps detected in the colon (larger than 1 centimeter) carry a higher risk of harboring cancer than smaller polyps which may be benign (non-cancerous).

During endoscopy, polyps identified are removed by a procedure called a polypectomy. A polypectomy leaves no scars on the skin as it is removed within the digestive tract. It involves putting a loop of wire around the polyp base and cutting it. Small polyps may be removed by biopsy forceps, which snips off small pieces of tissue. Other polyps may be ablated with electrical energy that generates heat. All of these procedures are painless and you may not be aware that they are being performed.

Our doctors also perform endoscopic mucosal resection which is an advanced polypectomy technique used to remove large, flat polyps detected at colonoscopy. This technique obviates the need for surgery even though they may be relatively large.

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Piles Ligation

Bleeding piles (hemorrhoids) is a commonly encountered problem which may not always resolve with medication and increased dietary fiber intake. Rubber band ligation can be used to treat internal piles which bleed frequently.

Piles ligation is performed as an outpatient procedure and does not require hospitalization. The procedure involves placing a small rubber band at the base of the hemorrhoid with a special applicator. The rubber band cuts off the blood supply to the hemorrhoid, which falls off after a few days. Piles ligation reduces bleeding episodes and leads to a more comfortable experience during defecation.

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Percutaneous Endoscopic Gastrostomy (PEG)

Difficulty in swallowing arises as a result of muscular weakness or an obstruction to the passage of food in the segment of the digestive tract leading to the stomach (oesophagus). This may occur in patients with a stroke, cancer or a narrowing of the oesophagus.

In patients with chronic swallowing problems, feeding tubes are inserted to provide nutrition. The PEG is a procedure which establishes a direct feeding route into the stomach, bypassing any problem in the mouth or oesophagus.

During this procedure, a short flexible feeding tube is inserted using the assistance of an endoscope and passed through the abdominal wall. This establishes a direct communication between the tube externally and the stomach internally. It allows nutrition, fluids and medication to be administered with ease.

In patients who require long term naso-gastric feeding tubes, the placement of a PEG tube instead will reduce the risk of accidental dislodgement. PEG tubes are more comfortable and better tolerated as compared to feeding tubes which are placed through the nose. In addition, PEG tubes have a longer lifespan and do not require replacement as frequently.

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Endoscopic Ultrasound (EUS)

Endoscopic ultrasound combines the use of an ultrasound probe and an endoscope.

It allows our doctors to evaluate abnormalities beyond or deep within the lining of the gastrointestinal tract by utilizing sound waves. Therefore, EUS is frequently used to evaluate abnormal growths which have been identified on other scans or at prior endoscopy.

During EUS, ultrasound waves enable the doctor to visualize structures through the abdominal wall in real-time. This allows examination of internal structures such as the gallbladder, bile duct, pancreas, lymph nodes and adrenal glands. In addition, abnormal growths or cysts can be further characterized and the presence of stones (in the gallbladder, bile duct, pancreatic duct) may be identified.

EUS can be used to obtain tissue samples from any organ in close proximity to the digestive tract. This includes lesions or lymph nodes within the chest / abdomen. Samples are obtained as cells or tiny strips and processed in the laboratory, providing doctors with valuable information.

In addition, EUS can be used to assess the degree of spread of cancer before surgery, drain cysts and perform pain relieving nerve blocks in patients with pancreatic cancer or chronic pancreatitis. In those who experience fecal incontinence, EUS can be used to assess the muscles of the anus for injury.

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Enodoscopic Retrograde Cholangio-Pancreatography (ERCP)

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an advanced endoscopic technique which combines the usage of X-ray together with a special side-viewing endoscope. It is used to treat diseases of the bile duct and the pancreas.

Diseases of the bile duct may present with recurrent episodes of pain in the upper right abdomen or jaundice, while diseases of the pancreas may present with pain in the central upper abdomen that radiates to the back.

During ERCP, X-rays are used to guide the insertion of instruments into either the bile duct or pancreatic duct to treat stones, tumours or strictures. Stones may be crushed and removed, or stents (either plastic or metal stents) may be inserted with rapid relief of symptoms. In patients with cancers causing obstruction of the bile duct (e.g. cancer of the bile duct or pancreas), ERCP can be use to relieve the blockage.

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Small Bowel Endoscopy

Diseases of the small intestine may present with abdominal pain, bleeding, a low blood count, chronic diarrhea or an obstruction to the passage of food. Occasionally, abnormal thickening or cancers of the small intestine may be identified on abdominal scans.

Evaluation of the small intestine represents a unique challenge to doctors as it is extremely long, tortuous and deep within the digestive tract. The two modalities frequently used to examine the small intestine include:

1. Wireless video capsule endoscopy
2. Small intestine enteroscopy

1. Wireless video capsule endoscopy

Capsule endoscopy is a painless diagnostic procedure that uses a tiny camera to inspect the digestive tract. The camera sits inside a transparent pill which is swallowed by the patient with water, just as one would swallow a tablet.

As the capsule travels through the digestive tract, the camera takes thousands of pictures over the next 8 to 10 hours which are transmitted wirelessly to a recording device and converted into a video. Once the recording is complete, the capsule is passed out from the bowels in the next few days.

The video is then screened by a doctor who examines the small intestines for any problems. If abnormalities are seen, then further evaluation with an enteroscopy may be required.

2. Enteroscopy

The small intestine may be examined with the use of a specially designed endoscope called an enteroscope.

An enteroscope is an ultra-flexible endoscope, which is longer and more flexible than the standard endoscope. The single balloon enteroscopy performed at KTPH uses a specially designed over-tube to assist in deep small bowel insertion, either via the mouth or the anus.

Balloon enteroscopy at KTPH is performed using carbon dioxide insufflation instead of air for a more comfortable experience. This procedure enables the direct visualization of abnormalities of the small intestine, biopsies to be obtained for further analysis and the treatment of intestinal disorders beyond the reach of the conventional endoscopes.

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Endoscopic Management of Strictures

The digestive tract can be conceptualized as a long hollow tube with a lumen of varying diameters. The digestive tract starts from the mouth and continues as the oesophagus, stomach, small intestine, large intestine and ends as the anus. There are also tiny ducts which function as conduits supplying digestive secretions to the gastrointestinal tract. These ducts are the pancreatic duct and the bile duct.

Diseases of the digestive tract may result in luminal obstruction. The consequence of this is a failure to absorb nutrients, digest food and excrete secretions. This may result in vomiting, inability to eat, malnutrition, malabsorption, pain and infection.

Strictures of the digestive tract may be treated with either surgery or endoscopy. Endoscopic treatment consists of dilatation therapy or the insertion of stents to maintain patency.

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Insertions of Self-Expandable Metal Stents (SEMS)

The ability to take food orally may be hampered by the growth of a cancer. In patients with cancers of the oesophagus, stomach, pancreas or colon, narrowing of the lumen may obstruct the passage of food.

Cancers can also obstruct the bile duct or pancreatic ducts causing pain, jaundice and inflammation.

For patients who experience these problems, the insertion of metal stents using an endoscope will allow the restoration of nutrition and flow of digestive secretions. Placement of a metal stent is usually performed if:

  • Immediate surgery is not possible
  • Cancer is unsuitable for an operation

In these cases, insertion of a stent represents one aspect of cancer treatment and may be accompanied by further chemotherapy or radiotherapy.

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Endoscopic Dilation

Luminal obstruction of the digestive tract may be due to non-cancerous causes such as:

  • Accidental ingestion of caustic liquids
  • Excessive gastric acid exposure
  • Post-surgery scaring
  • Radiation therapy
  • Inflammation

Some patients may have swallowing difficulties due to a rare problem called Achalasia. It is a condition in which the muscles of the lower oesophagus fail to relax, preventing food from entering the stomach.

Endoscopic dilation therapy may be performed as an alternative to surgery in patients with these problems. Dilation utilizes special balloons or dilating catheters to stretch the narrowing. Several sessions are usually required before the obstruction can be successfully relieved.

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