Practical Gastrointestinal Endoscopy

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CHAPTER 5
Care after variceal treatments
The risks of variceal treatment include all of the complications of
emergency endoscopy (especially pulmonary aspiration).
Patients often have transient chest pain, odynophagia (pain
on swallowing) and dysphagia. They should maintain a soft diet
for a few days, avoid any medications that may irritate or cause
bleeding, and take acid-suppressing agents. Treatment should
be repeated in about a week in the context of acute bleeding, but
should be delayed for several weeks when elective, to allow the
lesions to heal. Delayed complications include esophageal stricturing,
which is more common after sclerotherapy. Strictures can
be dilated gingerly with standard methods.
Treatment of bleeding ulcers
Duodenal and gastric ulcers are still common causes of acute
bleeding. About 80% will stop bleeding spontaneously. It is important
if possible to predict those patients likely to rebleed and
select them for endoscopic treatment. We are guided by the size
of the initial bleed, the overall status of the patient, and by the
presence or absence of stigmata.
Ulcer stigmata
The following stigmata provide useful pointers when considering
treatment options.
• Active ‘spurters’ continue to bleed (or rebleed soon) in 70–80% of
cases.
• Ulcers with a ‘visible vessel’ have about a 50% chance of rebleeding.
• Clean ulcers do not rebleed.
An important question is whether it is appropriate to wash
clots off the base of an ulcer simply to check for these stigmata.
Most endoscopists will do so in high-risk patients provided they
are poised for treatment.
Treatment modalities
The most popular hemostatic methods currently are injection,
heat probe, bipolar probe and combinations. Clips are being used
increasingly.
Injection treatment. Epinephrine in saline (1·:·10·000) is applied
with a sclerotherapy needle in 0.5–1.0·mL aliquots around the
base of the bleeding site, up to a total of 10 ·mL. Some prefer to
use absolute alcohol in much smaller volumes (1–2·mL in 0.1·mL
aliquots) or combinations of epinephrine with alcohol, or with
thesclerosants used for the treatment of varices.