Practical Gastrointestinal Endoscopy

THERAPEUTIC UPPER ENDOSCOPY 75
The heat probe (Fig. 5.16) provides a constant temperature of
250°C. First tamponade, then apply several pulses of 30·J.
The bipolar (or multipolar) probe (Fig. 5.17) provides bipolar
electrocoagulation, which is assumed to be safer than monopolar
diathermy (which produces an unpredictable depth of
damage). Use the larger 10 French gauge probe at 30–40·W for
10·seconds.
These treatment devices share some common principles. All
can be applied tangentially, but (apart from injection) are better
used face-on if possible. When the vessel is actively bleeding, direct
probe pressure on the vessel or feeding vessel will reduce the
flow and increase the effectiveness of treatment (Fig. 5.18). The
bipolar and heat probes incorporate a flushing water jet, which
helps to prevent sticking.
Clipping (Fig. 5.19). Metal clips can be applied endoscopically,
and are particularly useful for small bleeding ulcers (e.g. Dieulafoy
lesions), for Mallory–Weiss tears, and large visible vessels.
Know when to stop treatment! Treatment attempts should not
be protracted if major difficulties are encountered; the risks rise
as time passes. There are some patients and lesions in which
endoscopic intervention may be foolhardy, and surgery is more
appropriate, for example, a large posterior wall duodenal ulcer
that may involve the gastroduodenal artery. Angiographic treatment
is useful in selected cases.
Follow-through after treatment. A single endoscopic treatment
is not an all-or-nothing event. It is necessary to continue other
medical measures, to maintain close monitoring and to plan
ahead for further intervention (pharmacological, endoscopic,
radiological or surgical) if bleeding continues or recurs. The job
is not complete until the lesion is fully healed. Eradication of Helicobacter
pylori should reduce the risk of late rebleeding.
Fig. 5.16–Teflon-coated –
tip of
a heat probe with a water-jet
opening.
Fig. 5.17–The – tip of a multipolar
probe with a central water jet.
Fig. 5.19 –Hemostatic clip.
Treatment of bleeding vascular lesions
All of the endoscopic methods can be used to treat vascular
malformations such as angiomas and telangiectasia. The risk
of full-thickness damage and perforation is greater in organs
(a) (b) (c)
Fig. 5.18– (a) Bleeding ulcer. (b) Probe pressure stops the blood flow and coapts the vessel wall. (c) Coagulation.