Gastroscopy with botulinum toxin therapy

Important information

Before your appointment

• All medications should be taken as normal with a little water.
• If you take Warfarin or Clopidogrel or other blood thinning medication please read the ‘Alert’ on page 2 as you may need to have an INR test seven days before your procedure.
• If you have diabetes please read the advice further down the page
• If you have any questions about the procedure or find that you cannot keep this appointment, please contact the endoscopy office between 9:00 and 17:00 Monday to Friday on 01223 257080.

On the day

• Have nothing to eat for six hours and nothing to drink for four hours before your appointment.
• If you want to have sedation please ensure you have arranged an escort home. We cannot sedate you if you do not provide details of your escort.

At the hospital

• Please come to the endoscopy department on level 3 of the Addenbrooke’s Treatment Centre (ATC).
• Use the ‘Car Park 2’. The car park is busy early in the morning; please allow yourself enough time to arrive in time for your appointment. Take your parking ticket to the Endoscopy reception desk to have your ticket stamped; this will enable you to have discounted parking.
• Please note you need to arrive 30 minutes prior to your appointment time for your pre procedure check. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check.

Alert for endoscopy patients on Warfarin or Clopidogrel or other anticoagulant medication

You must read this guidance before your procedure.

If you have any questions or do not know whether to stop your medication before your endoscopy please phone 01223 216515.

Warfarin:

• You should stop Warfarin five days before the endoscopy.
• After the Endoscopy go back to your usual daily dose as soon as you are eating again (that will usually be the same evening).
• You should have your INR checked one week later to ensure you are adequately anticoagulated again.

If you have:

• metal mitral valve
• metal valve + previous stroke/thrombosis
• valvular heart disease

You may need Heparin injections instead of Warfarin. Please contact the endoscopy department for further advice.

Clopidogrel:

• You should stop Clopidogrel seven days before the endoscopy.

If you have:

• coronary artery stent

Please contact the endoscopy department for further advice.

Rivaroxaban, Apixaban, edoxaban, dabigatran:

• You should stop your medication 2 days before the endoscopy.
• The nursing staff will confirm when you need to restart your medication before you are discharged home.

Other anticoagulant medication: Acenocoumarol, sinthrome, phenindione, dindevan: If you are taking any of these please contact the endoscopy department 01223 216515.

What is botulinum toxin therapy?

You have been diagnosed with a disorder that affects the contraction of your oesophagus (gullet) and your doctor has decided to treat this condition with Botulinum toxin injection.

Botulinum toxin can be injected directly into the muscle of the oesophageal wall using a special needle which can be passed through the gastroscope during the procedure called gastroscopy.

A gastroscopy is an examination of the lining of the upper gut. The upper gut consists of the oesophagus, stomach and duodenum (part of the small intestine joining the stomach).

The procedure involves passing a narrow flexible tube through the mouth, into the oesophagus and then into the stomach and duodenum.

The toxin that is injected paralyses the muscle in the oesophagus and this effect can improve symptoms, sometimes for a few months. The procedure can take between five and 15 minutes.

The most common reasons for recommending this procedure are:

• Achalasia: This is a movement disorder of the oesophagus which, in particular, is characterised by a failure of the sphincter muscle, which lies at the end of the oesophagus at the entrance to the stomach. When this muscle fails to open during swallowing, it causes a delay of food passage through the oesophagus and into the stomach.
• Disorders of more widespread muscle spasm of the oesophagus: In these conditions the muscle of the oesophagus can go into spasm at various points along the length of the gullet. These contractions can be powerful and painful. The process of swallowing can be compromised.

Getting ready for the procedure

Wear loose fitting washable clothing and leave valuables at home.

On arrival to the department

Please register your arrival with the receptionist, they will ask for your pre-procedure questionnaire. Some patients may arrive after you but be seen quicker; we have seven procedure rooms all undertaking different procedures therefore patients are not seen in arrival order.

Before your procedure you will meet one of the nurses who will ask you some health questions, explain the procedure to you and ask you to sign a consent form. Once this is completed, you will be escorted to a single sex changing area. You are able to wear your own clothes for this procedure. Your escort cannot wait with you from this point and can leave the department until you are ready to go home. You can change your mind about having the procedure at any time.

Sedatives

For many people a gastroscopy is only minimally uncomfortable and sedation is not required. If you are worried about potential discomfort or would like sedation for other reasons then you can ask for it.

There are two options for this procedure:

1. No sedation: we will spray a local anaesthetic to the back of your throat. This will make it numb so that you cannot feel the gastroscope. The numbness will last for about half an hour. The advantage is that you can leave as soon as the procedure is finished and you have talked to the endoscopist. You may resume your normal activities such as working and driving. You will be fully aware of the procedure; most patients find this acceptable.
2. Intravenous sedation: this will be administered via a plastic tube called a cannula which is inserted into a vein, and will make you feel relaxed and sleepy but not unconscious (this is not a general anaesthetic). This option means you may not be aware of the procedure.

The disadvantages to this option are:

• You will need to stay whilst you recover which may take up to an hour or more.
• You will need to be escorted home; your procedure will be cancelled if you do not have an escort.
• The injection will continue to have a mild sedative effect for up to 24 hours and may leave you unsteady on your feet for a while.

If you choose sedation, you must arrange for a responsible adult to collect you from the department and take you home. You will not be able to drive yourself. You cannot be collected in a taxi without your escort present.

Please provide reception with the contact details of your escort, they need to be available to collect you from 90 minutes after your appointment time.

If you are entitled to use hospital transport, an escort is not required. Please inform the department prior to your appointment if you have arranged hospital transport.

Potential risks

Diagnostic gastroscopy procedures carry a very small risk (one in 10,000 cases) of haemorrhage (bleeding) or perforation (tear) of the gut following which surgery may be necessary. There may be a slight risk to teeth, crowns or dental bridgework. You should tell the nurses if you have any of these. Other rare complications include aspiration pneumonia (inflammation of the lungs caused by inhaling or choking on vomit) and an adverse reaction to the intravenous sedative drugs.

Adverse reactions to botulinum toxin are uncommon but include skin rashes and occasional chest pain or heartburn. Other rare complications include aspiration pneumonia (inflammation of the lungs caused by inhaling or choking on vomit) and an adverse reaction to the intravenous sedative drugs.

After the procedure

If you are given throat spray, you may go home immediately after the procedure. We advise you not to have anything to eat or drink until the numbness has worn off, which is usually about half an hour. After this, you can eat and drink normally.

If you had sedation, we will take you to a recovery area while the sedation wears off. When you are sufficiently awake, we will give you a drink before you get dressed. You can then go home; this may be up to an hour following the procedure.

We advise you not to drive, operate machinery, return to work, drink alcohol or sign legally binding documents for a 24-hour period after the procedure. We also advise you to have a responsible adult to stay with you for the next 12 hours. You can eat and drink as normal.

You may feel a little bloated and have some wind-like pains because of the air in your gut; these usually settle down quickly.

We will always do our best to respect your privacy and dignity, e.g. with the use of curtains. If you have any concerns, please speak to the department sister or charge nurse.

When do I know the result?

If you did not have sedation the endoscopist or endoscopy nurse will give you information during and immediately after the procedure. If you had sedation, we will tell you about the procedure in the recovery area when you are awake. If you would like more privacy, we will take you to a private room.

The sedation can affect your ability to remember any discussion. If you would like someone with you when you talk to the endoscopist or endoscopy nurse please inform the nurse looking after you who will arrange for you to be seen in a private room with your escort when they arrive.

The final results from biopsies or polyp removals will be given to you either by the healthcare professional who requested the procedure at a clinic appointment or by letter. These results can take several weeks to come through. You should discuss details of these results and any further treatment with that person.

After discharge

If you experience any severe pain or persistent bleeding you should contact your GP informing them that you have had a gastroscopy with botox injection. If you are unable to contact your GP: during working hours (08:00-18:00) contact the endoscopy department on 01223 216515, outside of these hours please attend your nearest emergency department informing them that you have had a gastroscopy with botox injection.

Alternatives

In some cases, depending on individual factors such as the symptoms present and the condition being treated, there may be alternatives. These will be discussed with you at the time your doctor advises you to have this therapy. These may include surgery or the use of endoscopic balloon distension to widen the oesophagus.

For more information:

• Contact the endoscopy office between 09:00 and 17:00 Monday to Friday on 01223 216546.
• See http://www.cuh.org.uk/consent (opens in a new tab)

Gastroscopy and botox injection: Morning appointment

Please follow these instructions if you have diabetes which is controlled with insulin or tablets.

If you have any questions related to your diabetes during this preparation, please contact your GP or the diabetes specialist nurse on 01223 245151 bleep 152078.

Food and drink

• Do not eat for six hours prior to your appointment.
• Do not drink for three hours prior to your appointment.
• Test your blood glucose regularly. If it drops below 4, please treat with a sugary drink such as lucozade 100ml, apple or grape juice 200ml, until your level is 5.
• After your procedure you may eat and drink normally unless specifically told otherwise.

Insulin and tablets: please adjust your normal insulin and tablet doses as instructed below:

If you take insulin once daily

• No change to insulin dose necessary

If you take insulin twice daily

• Do not have your morning insulin. Bring it with you, plus something to eat
• If you are able to eat before 11:00, have your normal morning dose with food
• If you are able to eat after 11:00, have half your normal morning dose with food
• Have your normal evening dose

If you take insulin four times daily

• Do not have your morning insulin. Bring it with you, plus something to eat
• If you are able to eat before 11:00, have your normal morning dose with food
• If you are able to eat after 11:00, omit your breakfast dose and have your normal lunchtime dose with food
• Have your normal tea time and bedtime evening doses

If you take tablets for diabetes

• Do not have your morning diabetic tablets
• After your procedure, re-start your tablets at the next dose time

Gastroscopy and botox injection: Afternoon appointment

Please follow these instructions if you have diabetes which is controlled with insulin or tablets.

If you have any questions related to your diabetes during this preparation, please contact your GP or the diabetes specialist nurse on 01223 245151 bleep 152078.

Food and drink

• Do not eat for six hours prior to your appointment
• Do not drink for three hours prior to your appointment
• Test your blood glucose regularly. If it drops below 4, please treat with a sugary drink such as lucozade 100ml, apple or grape juice 200ml until your level is 5.
• After your procedure you may eat normally unless specifically told otherwise.

Insulin and tablets: please adjust your normal insulin and tablet doses as instructed below:

If you take insulin once daily

• No change to insulin dose necessary

If you take insulin twice daily

• Have your normal morning insulin dose unless your breakfast is smaller than usual. If so reduce your normal dose by half.
• Have your normal evening dose

If you take insulin four times daily

• Have your normal morning insulin.
• Do not have your lunchtime insulin
• Have your normal tea time and bedtime evening doses

If you take tablets for diabetes

• Do not have your morning diabetic tablets
• After your procedure, re-start your tablets at the next dose time.