Frequently Asked Questions

As trained Gastroenterologists we routinely perform the following procedures:

A. EGD (esophagogastroduodenoscopy): also called Upper Endoscopy. A small tube with a light and camera mounted at the end is passed through the mouth in to the stomach and up to the duodenum (small bowel). During this procedure we can take biopsies, remove polyps, perform dilation of strictures, and stop bleeding from ulcer or vessels.

• Common indications: Abdominal pain, reflux, nausea, vomiting, diarrhea, weight loss.
• Time: The procedure is done under moderate sedation with the help of nurse anesthetists, and generally takes 15 - 20 minutes.
• Complications:We rarely encounter a complication during the procedure. However, while completing a consent we tell patients that there is a risk of bleeding, perforation and reaction to the medication.

B. Colonoscopy: A small tube with a light and camera mounted at the end is passed through the rectum up to cecum which is the last part of the (colon) large bowel.

• Common indications: Screening (to look and remove polyps which are precursors for cancer), abdominal pain, diarrhea, bleeding, anemia, weight loss.
• Time: The procedure is done under sedation with the help of nurse anesthetists, and generally takes 15 - 30 minutes.
• Complications: We rarely encounter a complication during the procedure. However, while completing a consent we tell patients that there is a risk of bleeding, perforation and adverse reaction to the sedating medications.

Yes, both doctors are University trained Hepatologists. We treat all kinds of hepatitis - ranging from auto-immune and alcohol induced to viral hepatitis (hepatitis C and B). Recently, the introduction of the protease inhibitor (Incevik ad Victrelis) to Pegylated Interferon and Ribavirin (Triple therapy) has helped patients with hepatitis C genotype 1 patients erradicate the virus in nearly 80%, a turnaround from the previous response of 40%. www.incivek.com

In addition to diseases of the esophagus, stomach, duodenum, colon and liver, we also diagnose and treat diseases of the gallbladder (gallstones) pancreas (pancreatits, cancer), small intestine (celiac disease, ulcers). We also perform a variety of other tests:

1. Capsule Endoscopy:(Video Link) You swallow a small capsule (capsule is a device that has a camera and a flash at its tip) and takes pictures of the Small Bowel that cannot be satisfactorily examined by any other method. This method has revolutionized how easily we are able to diagnose small bowel diseases (like Crohn’s disease, AVMs, Celiac disease, rarely cancer) and treat them effectively. Over the last few years, we have diagnosed many patients with small bowel Crohn’s disease using Capsule Endoscopy who otherwise were not diagnosed and were not receiving the correct treatment.
2. Endoscopic Retrograde Cholangio Pancreatography (ERCP): An endoscope is inserted under sedation into the duodenum and contrast injected into the bile ducts and pancreas. We can remove gallstones from the bile duct, open up strictures (narrowings) and place stents (plastic tubes) across strictures.
3. Esophgeal Motility Testing: By means of this test we can determine how the esophagus contracts.
4. Twenty four hour pH testing: By placing a pH meter (determines the amount of acid reflux) in the distal esophagus, either with a tube or tubeless (Bravo capsule) we can determine if you have GERD and its severity and thus direct treatment appropriately.

Most visits can be completed in a total of 2-3 hours. We ask our patients to check in at the Bay Area Houston Endoscopy Center 1 hour before the scheduled time. During this period, a nurse would ask you questions regarding your health, place an IV line and dress you in a gown for the procedure. The average time for single procedure (EGD or colonoscopy) is 15-30 minutes, and when doing both of the procedures it can take up to 30-45 minutes. The patient spends about 30 minutes in recovery. Soon after the procedure, Dr. Subramanyam or Dr. Malhotra will briefly talk to the family regarding the findings. Please do not consider this to be a substitute for the follow up appointment in the office that you need to keep for getting the biopsy results and further management.

We generally use TIVA (Total intravenous anesthesia - intravenous drugs Versed, Fentanyl, Propofol) to sedate patients that do not require airway intubation (placement of a breathing tube). In most cases, a Nurse anesthetist administers the drugs and monitors the patient closely during the procedure. The patient breathes on his own but is sedated enough not to have any discomfort, pain or recollection of the procedure.

In some cases MCS (Moderate Conscious Sedation - Fentanyl, Versed but no Propofol) is used that leads to a lesser degree of sedation but again the patient generally do not experience pain or discomfort during the procedure.

With both forms of sedation, patients generally cannot recall what is said after the procedure and hence it is important for a family member to be present so that the doctor can explain the result of the procedure after it is completed.

Yes. Its okay to take your medications with sip of water at least 1 hour before the start of the procedure.

We perform colonoscopy using 2-3 liter of Golylely or 2 liter Half-Lytely Prep. Golytely has Tier I coverage (costs about $4) compare to Half-Lytely which has Tier II coverage with co-pay between $10-50. Both of these products work really well. However, Half-Lytely is slightly more palatable than the Golytely. If the procedure is scheduled for the afternoon, the prep can be taken in the morning and is well tolerated in our experience. Morning procedures usually require the prep be taken the day before the procedure.

We always check with your insurance and obtain an authorization if required before the procedure. Insurance companies generally cover most of the the cost. Most policies have a deductible and a co-pay and your part of the costs depend on your coverage. Generally, the deductible is 20%. Many policies cover Screening Colonoscopy at 100% with no deductible. If a polyp is removed during the procedure you might have to pay a part of the costs.

It is recommended that all asymptomatic patients with normal laboratory studies over 50 years undergo a Screening Colonoscopy. If no polyps are found then follow up exam at 5-10 year interval is recommended. If polyps are found, a more frequent schedule may be necessary depending on the size, nature (stalk or no stalk) and histology (pathology) of the polyp.

In symptomatic patients (rectal bleeding, abdominal pain, change in bowel habits etc) or in those with abnormal labs (anemia), EGD and/or Colonoscopy is indicated regardless of age or when the last endoscopic exam was performed as these patients are likely to have lesions discovered at the exam.

We are providing general guidelines for follow up exam. Please understand that these are guidelines only and the interval may have to be tailored according to the findings.

Guidelines for Colonoscopy Intervals:

1. No Polyps in the past and during first colonoscopy: 5-10 years. Scientific literature reports a waiting time of 10 years. However, we have realized that it is also determined by the quality of the prep and the percentage of missed polyp that could be as high as 5-10% during colonoscopy. By taking in to consideration these two factors, we suggest 5 years although waiting 10 years could be acceptable in may cases.
2. Personal history of polyps : 3-5 years.
3. Flat, large polyp or abnormal findings at pathology : 6 month -1 year.

Guide lines for Upper Endoscopy (EGD) Intervals:

1. Gastroesophageal Reflux Disease (GERD) : Patients with long standing or severe GERD require an endoscopy (Index Exam) to exclude Barrett’s Esophagus (because of cancer risk and need for frequent Endoscopic Exams) or Esophageal ulcerations so as to be able to tailor therapy and determine the need for follow up.
2. Barretts Esophagus with no dysplasia (means cells are healthy, no cancer cells): 2-3 years.
3. Barretts Esophagus with low grade dysplasia (slightly altered cells): 1 year
4. Barrett’s Esophagus with high grade dysplasia: we recommend ablation therapy (BARRX) ti burn the cells. www.barrx.com
5. Gastric polyps: Most gastric polyps are benign (hyperplastic) and require no further endoscopic follow-up. However, if the polyps are pre-cancerous (tubular adenoma) follow up endoscopies may be needed.

Yes, we like to see patients in the office before scheduling any endoscopic procedure. The visit serves many purposes - to obtain a medical history , perform a medical examination to determine the risk during procedure and provide detailed instructions about the preparation for the procedure.

Generally we are able to schedule the procedures soon after the office visit (2-10 days) and in urgent cases, even the next day. However, most insurance approvals take a few days (2-3 days).