Interventional Procedures and Extended Endoscopic Examination Methods

Overview of Interventional Endoscopy

Table 4.1 Interventional procedures in esophagogastroduodenoscopy (EGD)
Endoscopic hemostasis Specimen collection Endoscopic treatment of precancerous lesions and early carcinoma Endoscopic tube placement Foreign body removal Endoscopic treatment of stenoses Dye methods

Fig. 4.1 Bleeding gastric ulcer

Fig. 4.2 Endoscopic biopsy

Fig. 4.3 Polyp removal

Fig. 4.4 PEG placement

Fig. 4.5 Foreign body removal: coins

Fig. 4.6 Stent insertion for a malignant esophageal stricture

Fig. 4.7 Methylene blue staining of Barrett esophagus

Upper Gastrointestinal Bleeding: Incidence and Signs

Incidence

Acute gastrointestinal bleeding is the most common emergency in gastroenterology. Ninety percent of all acute hemorrhages arise in the upper gastrointestinal tract, approximately 9 % in the colon, and approximately 1 % between the ligament of Treitz and the ileocecal valve (Figs. 4.8, 4.9). The incidence is age-dependent, ranging from approximately 30:100 000 in young individuals to as much as 400:100 000 in persons over age 75 according to published reports. The overall mortality rate is approximately 15%; it is markedly lower in young patients, rising to 40% in elderly patients with multiple morbidity.

Causes

The most frequent cause is ulcer bleeding associated with the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs). This type of bleeding usually occurs early during NSAID use and may occur even at low doses. The concomitant use of corticosteroids significantly increases the risk, and concurrent anticoagulant use can increase it dramatically.

Fig. 4.8 Relative frequency of acute bleeding at different levels in the gastrointestinal tract

Fig. 4.9 Location and relative frequency of acute upper gastrointestinal bleeding

Symptoms

The main symptoms of upper gastrointestinal bleeding are hematemesis, melena, and signs of hemorrhagic shock.

The major problems associated with upper gastrointestinal bleeding are hemorrhagic shock and aspiration pneumonia (bleeding and vomiting). They dictate the priorities that are followed in primary treatment:

Hemodynamic stabilization
Maintenance of adequate respiration
Identifying the source of bleeding and hemostasis
Prevention of rebleeding

Table 4.2 Upper gastrointestinal bleeding
Cardinal symptoms and likelihood of massive bleeding
Hematemesis 20% Melena 5–10% Hematochezia (red blood in the stool)
General symptoms
Dizziness Syncope Dyspnea Angina pectoris Hemorrhagic shock

Upper Gastrointestinal Bleeding: Primary Treatment

Hemodynamic Stabilization

Is there impending or frank hemorrhagic shock (Table 4.3)?

Caution: Symptoms may be masked by:

– Beta-blocking drugs

– Vasovagal bradycardia

– Preexisting hypertension

Note:

– An orthostatic rise in the heart rate by more than 20 bpm suggests a blood loss greater than 500 mL

– A blood pressure differential > 15-20 mmHg between sitting and lying down suggests a blood loss greater than 1000 mL

Treat for shock before performing endoscopy!

– Place two large-caliber i. v. lines as soon as possible.

– Augment the circulating volume (preferably with a crystalloid such as 100 mL physiological saline solution or Ringer lactate).

– Goal: Heart rate < 100 bpm, blood pressure > 100 mmHg

Necessary laboratory tests

– Blood for typing, cross-matched blood, blood count, coagulation values, electrolytes

Table 4.3 Impending hemorrhagic shock
Heart rate > 100 Blood pressure < 100 systolic Cool extremities Cold sweat Obtundation Angina pectoris

Maintaining Adequate Respiration

Clear the airway (Caution: vomited blood).

Suction the airway as needed.

Administer O₂ by nasal catheter.

Intubate if necessary (Table 4.4).

Table 4.4 Indications for intubation
Frank hemorrhagic shock Patient somnolent before endoscopy Patient uncooperative before endoscopy

Identify the Source of Bleeding and Stop the Bleeding

Preendoscopy checklist

– Adequate treatment for shock?

– Need to intubate before endoscopy?

– Time for blood replacement? (If Hb < 8, try to transfuse before endoscopy.)

– Open surgery instead of endoscopy (Table 4.5)

Identify the source of bleeding

– Always perform complete esophagogastroduodenoscopy (EGD) according to standard protocols.

– If one bleeding site is detected, always look for another potential source of bleeding.

– It is not unusual for multiple sources of bleeding to coexist.

Hemostasis

– The most frequent sources of upper gastrointestinal bleeding are ulcers and varices (Fig. 4.9).

– Hemostatic modalities include pharmacological therapy, balloon catheter insertion, injection therapy, thermal methods, banding, and transjugular intrahepatic portosystemic shunting (TIPS). The method of choice is determined by customary recommendations and by the technical capabilities and interests of the endoscopy department.

– The goals of endoscopic treatment are always to control active bleeding and prevent rebleeding. Endoscopic techniques are appropriate for the sources of bleeding listed in Table 4.6. Necessary instruments and equipment are listed in Table 4.7.

Prevent rebleeding

Table 4.5 Indications for open surgery instead of endoscopy
Refractory shock Recurrent bleeding from a known ulcer on the posterior wall of the duodenal bulb Recurrent bleeding in an elderly patient with comorbidity Recurrent bleeding in a patient with high initial bleeding activity

Table 4.6 Indications for endoscopic hemostasis
Esophageal varices and fundic varices Gastric and duodenal ulcer Reflux esophagitis Mallory-Weiss syndrome Erosions

Table 4.7 Necessary emergency instruments and equipment
Endoscope with a large working channel High-performance suction pump Second suction pump for the pharynx Water pump for irrigation Sclerotherapy needles Injection needles for Histoacryl Clips with applicators Argon plasma coagulation Multiband ligator set Epinephrine 1 :1000 Histoacryl Lipiodol Polydocanol 1 % Fibrin glue (optional)

Bleeding Esophageal Varices and Fundic Varices: Medications and Tubes

The mortality rate due to variceal bleeding (Fig. 4.10) is high, at 15-30%. The recurrence rate after an initial bleed is approximately 60% during the first two weeks. One third of varices will stop bleeding spontaneously.

Fig. 4.10 Bleeding esophageal varices

Treatment Methods

The following treatment methods are used:

Pharmacological

– Terlipressin plus nitrate

Balloon tamponade

– Sengstaken-Blakemore tube (for esophageal varices)

– Linton-Nachlas tube (for fundic varices)

Endoscopic

– Sclerotherapy

– Banding

TIPS

Operative treatment

Besides the control of bleeding and prevention of rebleeding, additional therapeutic measures may be taken depending on the clinical situation (Table 4.8).

Table 4.8 Additional measures for variceal bleeding
PPI i.v. Antibiotic therapy (lowers risk of rebleeding and of spontaneous bacterial peritonitis) Lactulose 3×50 mL Neomycin 2-4g/day Protein restriction Fresh frozen plasma Packed red blood cells Volume replacement

Pharmacological Therapy of Bleeding Esophageal Varices

Principle and Key Characteristics

Principle: medication to lower the portal venous and intravenous pressure

Vasopressin and terlipressin are the only two medications that have been approved for the treatment of bleeding esophageal varices.

– Terlipressin is superior to vasopressin owing to its longer half-life.

– Terlipressin should be combined with nitrates due to possible side effects (ischemia and necrosis).

Pharmacologic therapy is an acceptable alternative to balloon tamponade if emergency endoscopy cannot be performed.

Materials

Terlipressin

Glyceryl nitrate

Intravenous access

Perfusor and perfusor tubing

Syringes

Technique

Terlipressin, 2 mg by i. v. bolus

Repeat at 1 mg every four to six hours

Duration: two to three days

Always combined with glyceryl nitrate i.v. by perfusor, 14 mg/hour