Gastroscopy with Banding of Oesophageal Varices or injection therapy

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Diagram of the endoscopy procedure

You have been advised to have a procedure known as Banding of Oesophageal Varices or Injection Sclerotherapy. This procedure requires your formal consent. This booklet has been written to enable you to make an informed decision in relation to agreeing to the investigation. You will be required to sign a consent form on the day of the procedure, which is a legal document, therefore please read this booklet carefully beforehand.

If you are unable to keep your appointment, please notify the endoscopy unit as soon as possible. This will enable staff to give your appointment to someone else and to re-arrange another date and time for you.

You need to understand all the information, including the possibility of complications. There will be the opportunity to speak to a health care professional about anything that you do not understand on the day of the procedure before you sign the consent form.

 What is an endoscopic treatment of Oesophageal varices?

Oesophageal varices are dilated (enlarged) veins in the oesophagus (gullet), which if left untreated run the risk of bleeding, as the larger they become the greater the risk of heavy bleeding.

Banding is a procedure that is performed, by passing a flexible scope down into your gullet with a device attached to the tip of the scope. This device contains several rubber bands that can be used to capture the protruding veins and “strangle” them thus reducing the risk of bleeding. It may take more than one treatment over a few months to ensure that the risk of bleeding is reduced.

Sclerotherapy is sometimes needed for treatment of varices. It involves passing a gastroscope (flexible endoscope) down into your gullet to look at the varices. A long thin tube is then passed down the gastroscope, which has the ability to inject a sclerotherapy agent. This agent will cause the large veins to thrombose (become hard) and will reduce the risk of them bleeding. It may take more than one treatment to ensure that the risk of bleeding has been greatly reduced by destroying the dilated veins.

There is no alternative treatment option for this procedure.

How do I prepare?

To get a clear view of the oesophagus and stomach it is important that the stomach is empty. Please do not eat or drink anything for at least 6 hours before the procedure.

What about my medication?

• Routine Medication: If you are on any medication, especially blood pressure tablets, you should take these with a sip of water as usual.
• Diabetes: If you have diabetes and control this with insulin or tablets, please ensure that the Endoscopy Unit is aware so that your procedure can be booked for the beginning of the morning list. You will need to stop your diabetes medication during your “Nil By Mouth” phase. Your usual medication can be recommenced after the procedure once you are eating again. You may want to bring a sandwich with you to eat after the procedure with your usual diabetes medication. If you have any further concerns, please contact your diabetic specialist nurse well in advance of the procedure for advice.
• Anticoagulants/ Antiplatelets: If you are taking blood- thinning medicines, such as Warfarin, Dabigatran, Heparin, Dalteparin, Apixaban Clopidogrel, the dose of these may need to be altered or stopped before your procedure. You may also need to have blood tests before your procedure. If the referring doctor did not give you instructions, you may be referred to the bridging clinic for advice on stopping your medication. If this is required, this will be arranged for you by the referring clinician or the endoscopy booking coordinator.

What to bring with you

Along with your appointment letter you will have received a health questionnaire. Please complete it and bring it with you. You will also find enclosed a copy of your consent form; please read this carefully but do not sign it. This is just an example for you to read carefully prior to your appointment. The endoscopist will meet with you prior to your endoscopy to discuss what is going to happen, any risks and any serious or common side effects. At this point you will be given the opportunity to ask any questions and then you will sign the ‘actual’ consent form.

How long will I be in the Endoscopy Unit?

You should expect to be in the unit for approximately five hours. Please note that the time of your appointment is not the time that the procedure will be performed. How long you will be in the unit will depend on how quickly you recover from the procedure, the sedation you may have had and also on how busy the unit is.

The unit also looks after emergencies, and these can sometimes take priority over outpatient procedures. You should be kept informed of any delays, but if you have any questions or concerns, please ask a member of the staff.

What happens when I arrive?

After checking in at reception, a qualified nurse will welcome you and take you to the admissions area where you will have a brief medical assessment.

Please note that the endoscopy unit operates a same sex environment and your relative may not be able to accompany you past the waiting area unless there are exceptional circumstances.

In the admission room, you will be asked some questions regarding your medical and surgical history to confirm that you are fit to undergo the procedure and about your arrangements for getting home. The nurse will make sure that you understand the procedure and discuss any questions you may have. Your blood pressure, heart rate, respiration and oxygen levels will be recorded. If you have diabetes, your blood sugar level will also be checked and recorded.

If you wear spectacles or dentures you will be asked to remove them when you enter the procedure room. All your belongings will be kept with you during your procedure to prevent anything being lost. You are advised to leave your valuables at home as we do not accept responsibility for them.

Some people decide to have this procedure with a local anaesthetic throat spray to make the throat numb. However, some need a little bit more help to keep them relaxed. If you have decided that you want sedation, which will be given later, the nurse will insert a cannula (a small plastic tube) into a vein in your hand or arm.

Sedation

Usually, an intravenous sedation is offered for this procedure, you can discuss this with the endoscopist before the procedure.

A sedative (usually Midazolam) and/or a painkiller (Fentanyl or Pethidine) may be offered which will be administered through an IV cannula (a plastic tube) which is inserted in a vein in your arm/hand. This will make you slightly drowsy and relaxed, but not make you go to sleep like a general anaesthetic. You will still hear what is said to you and therefore, will be able to carry out simple instructions during the procedure. Some people do not remember anything about the procedure once the effects have worn off.

Whilst you are sedated, we will monitor your breathing, respiration, and pulse rate via a finger probe, so that any changes can be recorded and dealt with accordingly. You will also be given some oxygen via a nasal sponge into your nostril. Your blood pressure may also be checked and recorded.

If you are having sedation, you must arrange for a responsible adult to collect you and stay with you overnight. If you have not been able to make these arrangements, you will not be able to have the procedure with sedation.

You should not drive, return to work, operate machinery, or drink alcohol for 24 hours after the procedure, nor should you make any important decisions. The reason for this is that the sedation may, even though you may feel perfectly normal, still be in the body and may impair your judgement.

The procedure

After signing your consent form in the admission area, you will be escorted to the procedure room, you will be introduced to the team and a verbal safety checklist (called “WHO”) will be done.

Your throat will be made numb by using the local anaesthetic spray; you will then be asked to lie on your left side. A “probe” will be placed on your finger which can read your pulse and the amount of oxygen in your body (pulse oximeter). Oxygen will be given, usually via a sponge which is placed into one of your nostrils. A mouth guard is placed lightly between your teeth.

During the test, photographs may be taken if appropriate. The procedure should take about 20 minutes.

Milton Keynes University Hospital is a teaching hospital and there may be a student and/or a trainee present in the room or a supervised trainee may be doing your procedure.  If you have any concerns or objections, please contact the Endoscopy Unit prior to your test or make the nurse admitting you aware of this.

Aftercare

After the procedure, you will remain in the Endoscopy Unit for between 2 – 4 hours for observation.  You may feel some abdominal bloating due to the air which will have been pumped into your stomach during the procedure.

When can I eat and drink again?

You will need to remain nil by mouth (no drink or food) for 1 hour after your procedure. You will be given written advice on what you can eat and drink when you are discharged.

 When will I know the results?

Usually, the doctor or nurse will be able to tell you the results straight after the test, or if you have been sedated, when you are discharged. A nurse will discharge you, discuss any aftercare and follow up needed and answer any questions you may have. Before leaving you should receive written information on your procedure and a copy of the consent form.

Details of results and any necessary treatment should be discussed with your general practitioner (GP) or the consultant who referred you to have the test.

Being collected after the procedure

If you are having sedation, the person collecting you must come to the unit to collect you.  We advise that they park in the multi-storey car park or cark park C before reporting to the Unit.

Are there any risks or complications?

Banding and sclerotherapy do have some risks associated with it. These occur infrequently, but we wish to draw your attention to them to help you make your decision. The doctor or specialist nurse who has requested the test will have considered this already.

The risks must be compared with the benefit of having the procedure carried out. The possible complications are listed below. Any numbers which relate to risk are from studies of patients who have had this procedure. Your doctor will tell you if the risk of complications is higher or lower for you.

• Sore throat, which gets better quickly.
• You may be experiencing discomfort like indigestion which can be treated with medication.
• Allergic reaction to equipment, materials, or sedative. The endoscopy team is trained to detect and treat any reaction that may happen. Let the admitting nurse and endoscopist know if you have any allergies or you have reacted to any drugs or tests in the past.
• Breathing difficulties or heart irregularities, as a result of a reaction to sedation or inhaling secretions such as saliva. To help prevent this from happening, your respiration and oxygen levels will be monitored, and a suction device will be used to clear any secretions. Rarely, a heart attack or stroke (loss of brain function resulting from an interruption of the blood supply to the brain) can happen if you have serious medical problems.
• Aspirating fluid in airway (minor risk)
• Perforation – making a hole in the oesophagus, stomach, or duodenum (risk: between 2% and 5%). The risk is higher if there are any abnormal narrowing (stricture) which is stretched (dilated). If a hole occurs, you will need to be admitted to hospital for further treatment which may include surgery.
• Damage to teeth and bridgework. The nurse will place a plastic mouthpiece in your mouth to help protect your teeth. Let the endoscopist and nurse know if you have any loose teeth or dentures.
• Bleeding from minor damage caused by the endoscope is rare and usually stops on its own. The risk of bleeding from banding is small; it can occur in about 1:100 patients. You must seek medical advice if you vomit blood or pass black stools up to two weeks after the procedure.
• There is a small risk of developing a chest infection following the procedure.
• Incomplete procedure. This can happen due to a technical difficulty, food or blockage in the upper digestive system, complications during the procedure, or discomfort.
• Sedation. This can occasionally cause problems with breathing, heart rate and blood pressure. If these problems do occur, they are usually short lived. Careful monitoring by the endoscopy team ensures that any potential problems can be identified and treated quickly. Older patients and those with significant health problems, such as breathing difficulties due to a bad chest, may be assessed by a doctor or specialist nurse before having the procedure.
• Complications can happen. Some of these can be serious and can even cause death (risk: 1 in 25,000).

You should discuss these possible complications with your doctor if there is anything you do not understand.

What to do if you feel unwell once at home?

If you ever have any signs of bleeding such as dark stools and vomiting blood, you must inform your GP immediately.

If any of the above symptoms persist or worsen after your procedure – such as bleeding, pain, temperature, and shortness of breath, you must then seek urgent advice from the Endoscopy Department between 09:00 and 17:30 (01908 996 460) Monday to Saturday.

Outside these hours, please call a nurse on Ward 22 (01908 996 455) for advice or go to your nearest A&E department.