ENDOSCOPIC THERAPY

Endoscopic injection of bleeding peptic ulcers with adrenaline has been practised since the 1970s, endoscopic heater probes have been used since the 1980s, and Argon plasma coagulation has been used since the 1990s. More recently, adrenaline injection tends to be combined with either heater probe coagulation or argon plasma coagulation to minimise the chance of an ulcer re-bleeding. The disadvantage of this treatment is a low risk of perforation of the gastric wall and a low risk of peritonitis. Combined therapy may work better than epinephrine alone. However, there is no evidence that one kind of treatment is more effective than the other.

Injection sclerotherapy has been used to treat oesophageal varices since the 1960s. A sheathed needle is passed through a channel in the endoscope, unsheathed and pushed into a varix. A sclerosing agent, such as ethanolamine or absolute alcohol, is then injected into the varix to cause scarring and constriction of the varix with the aim of obliterating the varix (or varices). This technique has now largely been superseded by variceal band ligation.

Sclerotherapy has also been used in the treatment of gastric varices since the late 1980s. In this case Histoacryl glue (cyanoacrylate) is commonly used as the sclerosant. This technique is favoured over band ligation because the position of the varices in the stomach, most often in the gastric fundus, makes the placing of bands very difficult.

Dilatation of benign oesophageal strictures using semi-rigid bougies existed long before the advent of flexible endoscopes. Since that time oesophageal dilatation has been carried out using either bougies or endoscopic balloons, and can be used to treat benign oesophageal strictures and achalasia.

Initially, bougies were used to dilate benign strictures of the oesophagus. These could be passed alongside the endoscope, allowing visualisation of the bougie passing through the stricture, but the technique of passing a guidewire through the stricture endoscopically, then removing the endoscope and passing the bougie over the guidewire was more commonly used.

More recently, balloon dilatation of the oesophageal strictures has become more common. It is thought that this technique carries a lower complication rate than the use of bougies, and since endoscopy balloons are single use items there are no concerns about equipment sterilization. In addition to oesophageal dilatation, endoscopic balloons can also be used to dilate pyloric strictures.

Oesophageal varices have been treated by band ligation since the late 1980s.

Non variceal indications include bleeding peptic ulcers. Banding allows clamping of bleeding vessels and achieves mechanical sealing without affecting the ulcer’s depth or size. These bands dislodge spontaneously and pass through the gastrointestinal tract safely within 3 weeks.

A method for inserting a feeding gastrostomy tube without the need for surgery was first described in 1980. This endoscopic technique is of particular use as many patients who require feeding tubes (such as after patients with swallowing difficulties after a stroke) are at high risk for complications from anaesthesia and surgery; the endoscopic technique usually requires mild sedation only.