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Disclaimer: Any answers provided are for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor immediately. Always seek the advice of your doctor before starting or changing treatment.

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Disclaimer: Any answers provided are for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor immediately. Always seek the advice of your doctor before starting or changing treatment.




























































Endoscopy & Gallstones

Endoscopy & Gallstones

A DxD Session with Dr Quan Wai Leong

Ended on Sun Mar 31 2019
Have a question to ask?

Get Dr Quan Wai Leong's opinions on your questions! Only approved questions are displayed.

Top Answers

Hi Ding Lee,

Endoscopy is a technique widely employed by different medical specialties to investigate problems arising from the different organ systems in our body. These organ systems include the nose & throat by ENT specialists, the urinary tract by urologists and most common of all, the digestive tract by gastroenterologists.

So it is understandable to get a little mixed up with the different types of endoscopes available. I will highlight the commonly used endoscopes below and try to explain more on their functions. 

Routine gastroscopes used for the upper digestive tract, for example, can help to diagnose stomach ulcers, inflammation, tumour growth and to arrest bleeding from ulcers.

Colorectal cancer, being the no. 1 cancer in Singaporean males, can be detected accurately and even effectively prevented through the use of colonoscopy and the removal of polyps.

Besides the routine endoscopes, specialised endoscopes are used to diagnose and treat different and more complex digestive diseases.

Some different types of specialised endoscopes and its functions:

  • Ultrasonic endoscope (EUS scope) - This can detect growth outside the digestive tract and obtain tissue for diagnosis through fine needle aspiration.

endoscopy singapore

Bile duct stone seen under EUS

  • Duodenoscope (ERCP scope) - This used to remove stones from and to insert stents into the bile duct.

endoscopy singapore

Bile duct stone removed by ERCP

  • Balloon enteroscope (single or double balloon enteroscope) is for conditions located deeper in the small intestine normally out of reach of the routine endoscopes.
  • Video Capsule Endoscope (VCE) is a wireless, self-powered camera system which one swallows to investigate problems in the small and large intestines.

All of these endoscopes are designed for very different and specific purposes. Selection of the right tool will be determined by the objective of the examination and underlying medical conditions.

In general, specialised endoscopes are operated by Interventional Endoscopists who are trained to handle them safely and effectively while routine gastroscopes and colonoscopes can be operated by most digestive surgeons and gastroenterologists.

If you have a digestive condition which you think may benefit from an endoscopy, consider getting a formal advice from your gastroenterologist to determine the approach which suits you best.

31 Aug 2018

Besides clinching diagnoses such as gastric ulcers, colonic polyps, or cancers, modern endoscopes can certainly be used to treat many different digestive conditions. 

endoscopy singapore endoscopy singapore endoscopy singapore

Gastric Ulcer           Small Intestine Polyp  Bleeding gastric varices

By removing a growth known as polyp in the large intestine through the process of Colonoscopy and Polypectomy, colon cancer death rates has been shown to be reduced by more than 50%.

In cases with active bleeding from the digestive tract, endoscopy is now the first line treatment to arrest the bleeding. Gallstones which have migrated into the bile duct can now be removed by a special endoscope through a process called ERCP. (Find out more about ERCP here

Chronic pain from inflammation of the pancreas can be managed through a nerve block via Endoscopic Ultrasound-guided injection. These are just some examples of what modern endoscopes can achieve.

In patients with early gastric cancer, endoscopic resection may be a possible option without open surgery. On the other hand, advanced obstruction of the oesophagus due to cancer may be overcome by special feeding tubes or stents inserted through endoscopy.  

In recent years, more sophisticated endoscopic methods have been developed to tackle difficult stones in the bile duct through the use of lasers. 

So you can see, endoscopy is very much a diagnostic as well as a therapeutic tool for many digestive conditions. Do speak with your gastroenterologist to find out more if you or your loved ones have conditions involving the digestive system which endoscopy may help.

31 Aug 2018

Hi Si Yi,

Endoscopy is minimally invasive. The risk of endoscopy is much lower than most surgery and most, if not all procedures, are carried out under some form of sedation or anaesthesia.

This means that patients would sleep through the entire procedure and therefore not be aware or have no recollection of the procedure upon completion.

The risk of endoscopy varies according to the type of procedure. A straightforward upper digestive endoscopy, for instance, can be completed in 15 minutes and carries very low risk of 1 in 10 thousand while colonoscopy carries a risk of 1 in a thousand.

The possible complications range from mild pain to bleeding and perforation. Based on our experience, serious complications rarely happen with routine upper and lower endoscopy.

Do note that there are more advanced and sophisticated endoscopic procedures which carry a higher risk of serious complications. These procedures are usually carried out by endoscopists who have undergone special training in interventional endoscopy.

Procedures such as ERCP (Endoscopic Retrograde CholangioPancreatography), for example, carry a risk of pancreatitis which can potentially be life threatening. Stent placement within the digestive tract may result in bleeding and perforation if not done optimally.

There are many other endoscopic procedures with their corresponding risks and complications which you should discuss with your endoscopist in detail before agreeing to undergo the procedure.

31 Aug 2018

Endoscopy is recommended only if there is a strong reason to do so. The type and urgency of an endoscopic procedure depends on the nature and severity of your medical condition, which may be reflected in your presenting symptoms, medical history, family history or abnormal blood tests or scans.  

Common indications for endoscopy include persistent abdominal pain, suspected blood in your stools, raised serum tumour markers, personal or family history of colonic polyps and so on. Other indications include cancer screening and abnormal scan findings discovered incidentally, and the list goes on.

What I would advise you to do is to discuss with your gastroenterologist on the reason(s) for the procedure and find out on the urgency to do so and possible outcomes for not undergoing the procedure. If you are still not convinced, do get a second opinion and do some research on your own.

Ultimately, you have to understand why you are undergoing the procedure and accept the risk(s) of endoscopy and be convinced of the benefits you will get from undergoing the procedure.

31 Aug 2018

I am sorry to hear that. This is indeed a tough question and I am not sure if I can provide a satisfactory answer. You must be aware that despite undergoing the same rigorous training which qualifies a doctor to perform a particular procedure, each of us has different skill-sets and strengths, which defines our ability to perform procedures in the safest and most comfortable manner.

In my humble opinion, just be mindful that a “popular” name on magazines or provided by some insurance agents may or may not be the best person who will perform the procedure with utmost care and compassion.  

Do speak with your friends or relatives and ask for their feedback. Find out from the “inner circle” if you happen to have a doctor friend who has no vested interest in that area. You may be surprised to find information that could turn out to be very different from what you already know.

Next, consider going online to check on the credentials and past histories on the lists of doctors you shortlisted and you may come across pertinent information which can help you make your final decision. Find out more about the procedure you intend to undergo and you can gauge your doctor’s skill level and knowledge on the topic with questions you prepared before the consultation.

Lastly, there is always the option of second opinion if you are not convinced that you have the best choice at hand.

I would like to emphasise that even in the best of hands, complications do still occur and one has to be realistic about possible undesirable outcomes of any procedure he or she undertakes.

May I wish you the best luck with your quest!

31 Aug 2018

Hi Wai Ma, 

Endoscopy is carried out by doctors who are competent to do the procedure. The level of complexity depends on the reason for the endoscopy and the type of endoscopical procedure you plan to undergo. Diagnostic upper digestive endoscopy, for instance, is relatively easy and safe to perform.

Endoscopy of the bile ducts (e.g. Spyglass Cholangioscopy), on the other hand, can be challenging and carries much higher risks of complications, thereby requiring more years of training to master.

 endoscopy singapore

SpyGlass Cholangioscope for laser stone fragmentation

Although it is true that restructured hospitals need to conduct training for their resident doctors, these trainings are done under direct supervision of a competent endoscopist most if not all the time.

This is necessary so that our resident doctors can have adequate training to be competent endoscopists in future to guide new trainees in the public domain.

In case you are wondering, the resident doctors in public hospitals are qualified doctors registered under Singapore Medical Council and undergoing their final training phase to become a specialist. As such, they are not the first- or second- year fresh-out-of-medical-school junior doctors that you are concerned about.

In any case, even in the best of hands, complications can still happen, especially for more complex cases. As such, do consider your options carefully and try asking your friends or relatives about their experiences before drawing your own conclusion.

In my opinion, word-of-mouth is likely a more reliable gauge of the endoscopists’ experience and work ethics. Lastly, do expect a longer wait time if you choose to have your scopes done in public hospitals due to the sheer number of cases they have to handle.

31 Aug 2018

Depending on the type of endoscopy you plan to have, the preparations can be merely a 6 to 8 hour fasting to drinking 2 to 3 litres of bowel prep fluid overnight. In general, most doctors have their own advice on how to prepare you for the endoscopy process. Please follow their advice closely so that you will get the best outcome from your endoscopy.

One simple tip that I provide my own patients for colonoscopy is to chill their bowel prep solution in the fridge after preparing. A few drops of lime juice may go a long way in making the drink more palatable. 

Do pay attention to your doctor’s advice on whether to stop any medication before the procedure. This is especially important if you are taking diabetic medicines or any blood thinning agent to minimise possible complications during the procedure.

Lastly, have a good rest before the procedure and try to relax your mind and not to get too worried. Most of my patients are surprised to find out how comfortable the entire process is after completing the endoscopy.

31 Aug 2018

Hi Yoke Peng, 

First, you need to understand that capsule endoscopy was first designed to allow doctors to look into problems arising from the small intestine where routine endoscopy fails to reach, due to the length of the entire small bowel.

Over time, newer capsule endoscopes were developed to study the oesophagus and large intestine for cases when routine endoscopy cannot be carried out. This system powers itself and takes pictures at variable rates and wirelessly transmits the signals back to the data collector.

The doctor will then retrieve the many thousands of pictures taken and run through them quickly like a movie clip to detect any pathology in the digestive tract. 

Let me start by assuring you that there is nothing to be afraid of for routine upper and lower digestive tract endoscopy. They are carried out with sedation almost all the time, making it a comfortable experience for most people. The risk of routine endoscopy is also low.

If you have a condition suspected to originate from your stomach or large intestine, I will personally advise you to consider routine endoscopy over capsule endoscopy and I am going to tell you why.

Capsule endoscopy is purely diagnostic in nature, which means it is incapable of collecting tissue samples for histological analysis when required. It cannot be used to treat any condition such as bleeding in the digestive tract, while routine endoscopes are expected to be able to do so.

As the current capsule endoscopy system is designed to be passive in its movement, it literally tumbles down the digestive tract, subjected to normal bowel movements. We are not able to control its speed of movement and direction of view. This means that we cannot stop to observe a suspicious area one second longer and cannot direct the view to any area we want to study closely.

Besides the high cost there is also the potential risk of a capsule being retained in your intestines if there is an area of narrowing in your intestine. Under that circumstance, surgery may be required to retrieve the capsule.

However, if your problem is suspected to originate from the deeper portions of your small intestine, then capsule endoscopy may be recommended as a first line, less invasive investigational tool, since routine endoscopes may not reach that area.

Do speak with your gastroenterologist in greater detail to pinpoint the most suitable procedure which suits your needs best.

31 Aug 2018

Hi Jun Kai, 

For routine upper and lower digestive endoscopy, the recovery period is fast and estimated to be completed within 1 to 2 hours. One may experience some light headedness and unsteady gait for a short period of time, until the sedatives wear off.

Depending on what is done, there may be a sensation of gas in the abdomen and a mild throat discomfort, especially after a gastroscopy.

Most people can resume their normal diet after the procedure unless there are findings during endoscopy which requires a change. Just be prepared to spend half a day at the endoscopy centre, since the entire process involves preparations before the procedure and monitoring after the scopes.

Do arrange for someone to send you home after the procedure because one may still feel slightly sleepy for the rest of the day. Most doctors will be happy to issue you a medical certificate so that you can rest well at home after the procedure.

31 Aug 2018

Endoscopy is only recommended when there is reason to do so. The reason for endoscopy may be related to personal past history (e.g. colonic polyps), family history (e.g. history of digestive cancer within the family), abnormal scan or blood results found incidentally or when one reaches a certain age which qualifies him or her to have a cancer screening colonoscopy done (e.g. > 50 yrs).

All the above reasons are not related to the presence of any symptom and they are by no means exhaustive.

However, if you are referring to having a scope done just to be sure, you will have to discuss with your endoscopist in detail regarding the risks involved and whether the risk is worth taking in your case. Most doctors will weigh the risks versus the benefits before performing any procedure.

In Singapore, screening colonoscopy is recommended for anyone above 50 years of age as the risk of colon cancer increases around the same time.

It has been shown that colonoscopy and polypectomy can reduce colon cancer-related deaths by more than 50%, making colonoscopy the screening method of choice in many developed countries around the world.

31 Aug 2018

The cost of an endoscopy in Singapore can range anywhere from $500 to $11,000. It varies a great deal depending on the type of procedure you plan to do. In general, there are a few components which will affect the final bill size for endoscopy.

The common components are:

  • Doctor’s professional fee
  • Hospital facility fee, sedation fee (if applicable)
  • Fee for tissue samples taken for examination and related accessories (if applicable)
  • Miscellaneous fees for other items used in relation to the procedure, e.g. gauze

You can also refer to the MOH website for more detail.

It is difficult to tag a price to one single endoscopy procedure and it is best for you to speak with your doctor directly to get a ballpark figure.

The amount claimable from Medisave is $650 for gastroscopy and $950 - $1,550 for colonoscopy depending on whether any polyp has been removed and the number and size of the polyps.

You do not need to worry about the Medisave component as most endoscopy centres will help you to make the claim once you have indicated you wish to do so.

31 Aug 2018

I am sorry to hear that. Failure in completing any endoscopic procedure may be due to unavoidable reasons such as anatomical changes after a surgery, narrowing of the intestinal lumen due to scarring or tumour growth, or other medical reasons when patient’s health may be at risk during the procedure.

Rarely, patients with especially sensitive intestines may not be able to tolerate the discomfort or bloating and the procedure may have to be postponed to another day with an anaesthetist to provide support for deeper sedation.

Putting the above reasons aside, one may be able to avoid repeating the procedure by adhering to the pre-procedure advice given by his or her doctor and to clarify any doubts they have before the procedure.

Some common problems resulting in a repeat procedure include failure to fast for the required time, unable to complete the bowel preparation given or failure to stop certain medicine your doctor requested you to do so before the procedure. So please go through the instructions carefully with your doctor before the procedure.

In addition to the above, the procedure may have to be repeated because of high risk findings in the specimen taken or unexpected discovery during the index endoscopy such that the procedure cannot be completed at one go.

Do speak with your endoscopist about your concerns so that he or she can advise you on the most appropriate way to avoid repeating the procedure unnecessarily.

31 Aug 2018

The most common investigation to detect the presence of gallstones is an ultrasound scan of the abdomen. Your doctor may also recommend some blood tests to look for problems related to the stones.

At times, a CT scan may be proposed to you if your doctor is also looking out for possible tumour growths in your abdomen.

When there is a suspicion of a gallstone being migrated into the bile duct, a special MRI scan known as MRCP may be required to study the bile ducts specifically.

This will help your doctor to decide the next course of action, including the option of using a special endoscope to remove the migrated stone through a process known as ERCP (Endoscopic Retrograde Cholangio-Pancreatography).

Just as a side note, gallbladder stones found incidentally without any symptoms do not need to be removed most times. Those stones which induce pain or discomfort will require surgical removal in general.

Having said that, gallbladder polyps, which carry a risk of cancer, may be mistaken as gallbladder stones from time to time. If you are found to have any gallstones, do speak with your doctor regarding the proper follow up plan.

31 Aug 2018

In general, gallstones do not disappear easily without any treatment. In fact, once gallstones developed, they tend to increase in size and numbers over the years.

The good news is that most patients with gallstones remained well without symptoms and the current recommendation for these cases is to maintain vigilance. 

In approximately 10 to 15% chance, people with gallstones develop abdominal discomfort or pain. If there is no other plausible explanation for the pain, surgical removal of the gallstones and the gallbladder is the recommended treatment.

This is because, once gallstones become symptomatic, the risks of complications such as gallbladder inflammation (cholecystitis) or bile duct infection (cholangitis) increase. These are serious complications not to be taken lightly. 

The real problem in managing gallstones is in ascertaining that the pain is really due to the presence of gallstones and nothing else. This remains challenging since many people do have concurrent medical conditions such as gastritis or abdominal cramps and surgical removal of the gallbladder in these cases will not help.

Speak with your gastroenterologist and discuss on the likely cause of your pain to see if further treatment is indeed required.

31 Aug 2018

For symptomatic gallbladder stones, the right approach is surgical removal of the gallbladder together with the stones. This method is time proven and offers the best long term outcome, provided the patient is both fit and also keen for surgery.

Unfortunately, there is no effective, alternate method of removing gallstones at the moment. In selected cases with only a few small gallstones, medical treatment to dissolve the stone may be possible. This treatment requires oral medication for a long time and the result is not guaranteed, making it less attractive to both doctors and patients.

Rarely, the gallstones may move out of the gallbladder and threaten to obstruct the bile duct. Under such circumstances, an endoscopic procedure known as ERCP (Endoscopic Retrograde Cholangio-Pancreatography) may be employed to remove the bile duct stones.

Since this procedure also enlarges the bile duct opening during stone removal, it may potentially minimise future chances of bile duct obstruction and infection.

Do suggest to your uncle to discuss with his surgeons on the risks and benefits of the surgery. He should also understand the risk of not removing the diseased gallbladder so that he can make an informed decision.

31 Aug 2018

The primary function of the gallbladder is to temporarily store and, at the same time, concentrate the bile juice within. Unknown to many, bile juice is secreted by the liver and not the gallbladder. After leaving the liver, the bile juice enters and leaves the gallbladder through the cystic duct which connects the liver ducts to the gallbladder.

We now understand that the gallbladder functions very similarly to a store room for spare bile. As such, removing the gallbladder will not have a great impact on one’s health and certainly should not cause a drastic deterioration.

One may expect some loose stools especially after a fatty meal shortly after removal of one’s gallbladder. This is usually transient and should not have any long term effect.

Sometimes, people with their gallbladder already removed continue to have pain at a later time. Besides the possibility of retained stones and new stones formation in the bile duct, one common reason for such pain is wrongly attributing the initial pain or discomfort to the gallstones.

Many people have concurrent digestive problems together with asymptomatic gallstones detected on a routine scan. Removing the gallbladder surgically in such cases will not address the pain. This is why one should always be confident that the pain is related to the gallstones before undergoing surgery. 

31 Aug 2018

The most important deciding factor for surgery is the presence or absence of symptoms related to the gallstone. It is common to pick up incidental gallstones on routine scans intended for other reasons. However, up to 80% of such gallstones are not producing any symptoms and are best left alone. For stones which are causing pain or discomfort, the current recommendation is surgical removal. 

The reason for the above recommendation is essentially a balance between the potential benefit and harm with the surgical approach versus that of leaving the gallstones alone. If the benefit outweighs the risk, (as in gallstones causing symptoms) surgery is generally recommended. 

One common challenge doctors face is attributing the symptoms to the gallstones to justify taking the surgical route. This is because problems such as gastritis, bloating and indigestion can some times mimic milder symptoms related to the gallstones. Having too low a threshold for surgery will risk over treatment and unnecessary complications. As such, many doctors may choose to watch over a period using medication until he or she is reasonable convinced the stone need to be taken out.

- Dr Quan

26 Jan 2019

Liver cysts are common incidental findings on routine ultrasound scan of the abdomen. In general, small and simple liver cysts are benign and need no intervention. In fact, such cysts are also commonly found in the kidneys and occasionally in the pancreas. 

If your mom's liver function test is normal and she does not have other liver related problems such as viral hepatitis, there is very little you need to worry about.

Although the liver cysts may grow in size slowly and more cysts may be found over time, most patients remain healthy throughout. She can keep a watch by repeating her liver function and ultrasound scan say in a year's time. 

One ward of caution is the present of cysts with complex internal wall or structures or cysts which grows quickly. Such cysts may not be entirely friendly and carry the risk of transformation to something nasty over time. In such a case, surgical resection may be an option to consider.

-Dr Quan 

29 Jan 2019