# Therapeutic oesophagogastroduodenoscopy Therapeutic oesophagogastroduodenoscopy Appropriate patient selection and monitoring are essential to minimise complications. The most common therapeutic endo scopic procedure performed as an emergency is the control of upper gastrointestinal haemorrhage of any aetiology . Band ligation has replaced sclerotherap y in the management of oesophageal varices ( Figure 9.4 ), whereas sclerotherapy using thrombin-based glues can be used to control blood loss from gastric and duodenal varices. Injection therapy with adrenaline (epinephrine) coupled with a second haemostatic technique such as thermal coagula tion or endoclip application is the technique of choice for a peptic ulcer with active bleed ing or high-risk stigmata of haemorrhage ( Figure 9.5 ). Such high-risk bleeds should be followed by 72 /uni00A0 hours of intravenous proton pump inhibition. Chronic blood loss from angioectasia is most safely treated with APC because of the controlled depth of burn compared with alternative thermal tec hniques ( Figure 9.6 ) . Haemostatic powders provide a further way to arrest bleeding; these work best for di ff use bleeding or as salvage therapy . Norman Rupert Barrett , 1903–1979, sur geon, St Thomas’s Hospital, London, UK. - - Benign oesophageal and pyloric strictures may be dilated under direct vision with through-the-scope (TTS) balloon dila - tors or the more traditional guidewire-based systems such as Savary–Gilliard bougie dilators ( Figure 9.7 ) . On occasion, more di ffi cult benign strictures can be treated by the insertion of a fully covered removable stent, or with a biodegradable stent. Likewise, the non-relaxing lower oesophageal sphincter associated with achalasia can be treated by pneumatic balloon (a) (b) (c) (d) Figure 9.6 The classic appearance of gastric antral vascular ectasia, which is often treated with argon plasma coagulation. Figure 9.5 A gastric ulcer with active bleeding (a) is initially treated with adrenaline injection to achieve haemostasis (b) . Two haemoclips are then applied to prevent rebleeding (c and d) . dilatation with a 30- to 40-mm balloon. Endoscopic dissection techniques (see Therapeutic colonoscopy ) are now being employed to treat achalasia by natural orifice myotomy (pero ral endoscopic myotomy; POEM) with good follow-up results. An alternative in unfit patients is injection of botulinum toxin into the lower oesophageal sphincter, although this has a lim ited (3–6 /uni00A0 months) duration of benefit. There are a limited n umber of endoscopic techniques available to reduce gastro-oesophageal reflux, which rely on tightening the loose gastro-oesophageal junction by plication, by the applica tion of radiofrequency ablation or by mucosal resection techniques. These may have a role in some patients but are yet to demonstrate benefit over surgical fundoplication. Endoscopic bariatric therapies, such as intragastric bal loons, sleeve gastroplasty and duodenal resurfacing, may all provide alternatives to more established surgical options. In contrast, there is clear evidence that the insertion of a percu taneous endoscopic gastr ostomy (PEG) tube enhances nutri - tional and functional outcome in patients unable to maintain oral nutritional intake ( Figure 9.8 ). PEG insertion is often a - prelude to treatment of complex orofacial malignancy and y be used to support nutrition in patients with alternative ma malignant, degenerative or inflammatory diseases. - The deployment of self-expanding metal stents with or without a co vering sheath inserted over a sti ff guidewire leads to a significant improvement in symptomatic dysphagia and quality of life in patients with malignant oesophageal and gastric outlet obstruction ( Figure 9.9 ) . Covered stents are the mainstay of treatment for benign or malignant tracheo - oesophageal fistulae. It is now possible to endoscopically manage early oesoph - - ageal and gastric neoplasia with endoscopic m ucosal resec - tion (EMR) or endoscopic submucosal dissection (ESD). These techniques require specialist training but have allowed - Figure 9.7 A pyloric stricture (a) can be dilated using a through-the-scope balloon under direct vision to minimise complications (b) . (a) Figure 9.8 A schematic diagram of percutaneous endoscopic gastrostomy insertion. A standard endos - copy is performed to ensure that there are no contra - indications to gastr ostomy insertion. The stomach is insuf /f_l ated with air and a direct percutaneous needle puncture made at a point where the stomach abuts the abdominal wall. Lignocaine (c) is infused on withdrawal (a) . A trocar is inserted and a wire passed into the stom - ach, which can be caught with a snare (b) . The scope is withdrawn, pulling the wir e out through the mouth, at which point it is attached to the gastrostomy tube (c) . The gastrostomy is pulled through into the stomach and out through the track created by the trocar inser - tion (d) . (b) (d) endoscopic management of mucosal lesions that were previ ously subject to surgical intervention ( Figure 9.10 ). A prime example has been improved endoscopic treatment of Barrett’s high-grade dysplasia and early oesophageal adenocarcinoma. Destruction of residual Barrett’s epithelium in cases of or high-grade dysplasia is possible with endoscopic ablation, and has been shown to reduce risk of progression to cancer. The most commonly used technique for this purpose is radio- frequency ablation, where 360° ablation can be achieved with a balloon catheter, or more focused ablation with smaller probes. Cryotherapy and APC can also be used for ablation, but photodynamic therapy is now used much less often. Figure 9.10 Novel upper gastrointestinal therapeutic uses of oesoph agogastroduodenoscopy include the use of endoscopic mucosal resection to remove early gastric cancer leaving a clean base. Therapeutic oesophagogastroduodenoscopy Appropriate patient selection and monitoring are essential to minimise complications. The most common therapeutic endo scopic procedure performed as an emergency is the control of upper gastrointestinal haemorrhage of any aetiology . Band ligation has replaced sclerotherap y in the management of oesophageal varices ( Figure 9.4 ), whereas sclerotherapy using thrombin-based glues can be used to control blood loss from gastric and duodenal varices. Injection therapy with adrenaline (epinephrine) coupled with a second haemostatic technique such as thermal coagula tion or endoclip application is the technique of choice for a peptic ulcer with active bleed ing or high-risk stigmata of haemorrhage ( Figure 9.5 ). Such high-risk bleeds should be followed by 72 /uni00A0 hours of intravenous proton pump inhibition. Chronic blood loss from angioectasia is most safely treated with APC because of the controlled depth of burn compared with alternative thermal tec hniques ( Figure 9.6 ) . Haemostatic powders provide a further way to arrest bleeding; these work best for di ff use bleeding or as salvage therapy . Norman Rupert Barrett , 1903–1979, sur geon, St Thomas’s Hospital, London, UK. - - Benign oesophageal and pyloric strictures may be dilated under direct vision with through-the-scope (TTS) balloon dila - tors or the more traditional guidewire-based systems such as Savary–Gilliard bougie dilators ( Figure 9.7 ) . On occasion, more di ffi cult benign strictures can be treated by the insertion of a fully covered removable stent, or with a biodegradable stent. Likewise, the non-relaxing lower oesophageal sphincter associated with achalasia can be treated by pneumatic balloon (a) (b) (c) (d) Figure 9.6 The classic appearance of gastric antral vascular ectasia, which is often treated with argon plasma coagulation. Figure 9.5 A gastric ulcer with active bleeding (a) is initially treated with adrenaline injection to achieve haemostasis (b) . Two haemoclips are then applied to prevent rebleeding (c and d) . dilatation with a 30- to 40-mm balloon. Endoscopic dissection techniques (see Therapeutic colonoscopy ) are now being employed to treat achalasia by natural orifice myotomy (pero ral endoscopic myotomy; POEM) with good follow-up results. An alternative in unfit patients is injection of botulinum toxin into the lower oesophageal sphincter, although this has a lim ited (3–6 /uni00A0 months) duration of benefit. There are a limited n umber of endoscopic techniques available to reduce gastro-oesophageal reflux, which rely on tightening the loose gastro-oesophageal junction by plication, by the applica tion of radiofrequency ablation or by mucosal resection techniques. These may have a role in some patients but are yet to demonstrate benefit over surgical fundoplication. Endoscopic bariatric therapies, such as intragastric bal loons, sleeve gastroplasty and duodenal resurfacing, may all provide alternatives to more established surgical options. In contrast, there is clear evidence that the insertion of a percu taneous endoscopic gastr ostomy (PEG) tube enhances nutri - tional and functional outcome in patients unable to maintain oral nutritional intake ( Figure 9.8 ). PEG insertion is often a - prelude to treatment of complex orofacial malignancy and y be used to support nutrition in patients with alternative ma malignant, degenerative or inflammatory diseases. - The deployment of self-expanding metal stents with or without a co vering sheath inserted over a sti ff guidewire leads to a significant improvement in symptomatic dysphagia and quality of life in patients with malignant oesophageal and gastric outlet obstruction ( Figure 9.9 ) . Covered stents are the mainstay of treatment for benign or malignant tracheo - oesophageal fistulae. It is now possible to endoscopically manage early oesoph - - ageal and gastric neoplasia with endoscopic m ucosal resec - tion (EMR) or endoscopic submucosal dissection (ESD). These techniques require specialist training but have allowed - Figure 9.7 A pyloric stricture (a) can be dilated using a through-the-scope balloon under direct vision to minimise complications (b) . (a) Figure 9.8 A schematic diagram of percutaneous endoscopic gastrostomy insertion. A standard endos - copy is performed to ensure that there are no contra - indications to gastr ostomy insertion. The stomach is insuf /f_l ated with air and a direct percutaneous needle puncture made at a point where the stomach abuts the abdominal wall. Lignocaine (c) is infused on withdrawal (a) . A trocar is inserted and a wire passed into the stom - ach, which can be caught with a snare (b) . The scope is withdrawn, pulling the wir e out through the mouth, at which point it is attached to the gastrostomy tube (c) . The gastrostomy is pulled through into the stomach and out through the track created by the trocar inser - tion (d) . (b) (d) endoscopic management of mucosal lesions that were previ ously subject to surgical intervention ( Figure 9.10 ). A prime example has been improved endoscopic treatment of Barrett’s high-grade dysplasia and early oesophageal adenocarcinoma. Destruction of residual Barrett’s epithelium in cases of or high-grade dysplasia is possible with endoscopic ablation, and has been shown to reduce risk of progression to cancer. The most commonly used technique for this purpose is radio- frequency ablation, where 360° ablation can be achieved with a balloon catheter, or more focused ablation with smaller probes. Cryotherapy and APC can also be used for ablation, but photodynamic therapy is now used much less often. Figure 9.10 Novel upper gastrointestinal therapeutic uses of oesoph agogastroduodenoscopy include the use of endoscopic mucosal resection to remove early gastric cancer leaving a clean base. Therapeutic oesophagogastroduodenoscopy Appropriate patient selection and monitoring are essential to minimise complications. The most common therapeutic endo scopic procedure performed as an emergency is the control of upper gastrointestinal haemorrhage of any aetiology . Band ligation has replaced sclerotherap y in the management of oesophageal varices ( Figure 9.4 ), whereas sclerotherapy using thrombin-based glues can be used to control blood loss from gastric and duodenal varices. Injection therapy with adrenaline (epinephrine) coupled with a second haemostatic technique such as thermal coagula tion or endoclip application is the technique of choice for a peptic ulcer with active bleed ing or high-risk stigmata of haemorrhage ( Figure 9.5 ). Such high-risk bleeds should be followed by 72 /uni00A0 hours of intravenous proton pump inhibition. Chronic blood loss from angioectasia is most safely treated with APC because of the controlled depth of burn compared with alternative thermal tec hniques ( Figure 9.6 ) . Haemostatic powders provide a further way to arrest bleeding; these work best for di ff use bleeding or as salvage therapy . Norman Rupert Barrett , 1903–1979, sur geon, St Thomas’s Hospital, London, UK. - - Benign oesophageal and pyloric strictures may be dilated under direct vision with through-the-scope (TTS) balloon dila - tors or the more traditional guidewire-based systems such as Savary–Gilliard bougie dilators ( Figure 9.7 ) . On occasion, more di ffi cult benign strictures can be treated by the insertion of a fully covered removable stent, or with a biodegradable stent. Likewise, the non-relaxing lower oesophageal sphincter associated with achalasia can be treated by pneumatic balloon (a) (b) (c) (d) Figure 9.6 The classic appearance of gastric antral vascular ectasia, which is often treated with argon plasma coagulation. Figure 9.5 A gastric ulcer with active bleeding (a) is initially treated with adrenaline injection to achieve haemostasis (b) . Two haemoclips are then applied to prevent rebleeding (c and d) . dilatation with a 30- to 40-mm balloon. Endoscopic dissection techniques (see Therapeutic colonoscopy ) are now being employed to treat achalasia by natural orifice myotomy (pero ral endoscopic myotomy; POEM) with good follow-up results. An alternative in unfit patients is injection of botulinum toxin into the lower oesophageal sphincter, although this has a lim ited (3–6 /uni00A0 months) duration of benefit. There are a limited n umber of endoscopic techniques available to reduce gastro-oesophageal reflux, which rely on tightening the loose gastro-oesophageal junction by plication, by the applica tion of radiofrequency ablation or by mucosal resection techniques. These may have a role in some patients but are yet to demonstrate benefit over surgical fundoplication. Endoscopic bariatric therapies, such as intragastric bal loons, sleeve gastroplasty and duodenal resurfacing, may all provide alternatives to more established surgical options. In contrast, there is clear evidence that the insertion of a percu taneous endoscopic gastr ostomy (PEG) tube enhances nutri - tional and functional outcome in patients unable to maintain oral nutritional intake ( Figure 9.8 ). PEG insertion is often a - prelude to treatment of complex orofacial malignancy and y be used to support nutrition in patients with alternative ma malignant, degenerative or inflammatory diseases. - The deployment of self-expanding metal stents with or without a co vering sheath inserted over a sti ff guidewire leads to a significant improvement in symptomatic dysphagia and quality of life in patients with malignant oesophageal and gastric outlet obstruction ( Figure 9.9 ) . Covered stents are the mainstay of treatment for benign or malignant tracheo - oesophageal fistulae. It is now possible to endoscopically manage early oesoph - - ageal and gastric neoplasia with endoscopic m ucosal resec - tion (EMR) or endoscopic submucosal dissection (ESD). These techniques require specialist training but have allowed - Figure 9.7 A pyloric stricture (a) can be dilated using a through-the-scope balloon under direct vision to minimise complications (b) . (a) Figure 9.8 A schematic diagram of percutaneous endoscopic gastrostomy insertion. A standard endos - copy is performed to ensure that there are no contra - indications to gastr ostomy insertion. The stomach is insuf /f_l ated with air and a direct percutaneous needle puncture made at a point where the stomach abuts the abdominal wall. Lignocaine (c) is infused on withdrawal (a) . A trocar is inserted and a wire passed into the stom - ach, which can be caught with a snare (b) . The scope is withdrawn, pulling the wir e out through the mouth, at which point it is attached to the gastrostomy tube (c) . The gastrostomy is pulled through into the stomach and out through the track created by the trocar inser - tion (d) . (b) (d) endoscopic management of mucosal lesions that were previ ously subject to surgical intervention ( Figure 9.10 ). A prime example has been improved endoscopic treatment of Barrett’s high-grade dysplasia and early oesophageal adenocarcinoma. Destruction of residual Barrett’s epithelium in cases of or high-grade dysplasia is possible with endoscopic ablation, and has been shown to reduce risk of progression to cancer. The most commonly used technique for this purpose is radio- frequency ablation, where 360° ablation can be achieved with a balloon catheter, or more focused ablation with smaller probes. Cryotherapy and APC can also be used for ablation, but photodynamic therapy is now used much less often. Figure 9.10 Novel upper gastrointestinal therapeutic uses of oesoph agogastroduodenoscopy include the use of endoscopic mucosal resection to remove early gastric cancer leaving a clean base.