Gastroscopy with oesophageal variceal banding or injection

Before your appointment

• All medications should be taken as normal with a little water.
• If you take Warfarin or Clopidogrel or other anticoagulant medication please contact the Endoscopy Nurses when you receive this information on 01223 216515. You may need to stop your medication prior to your procedure. If you take Aspirin only please continue.
• 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.

Why is variceal banding or injection needed?

You have been found to have oesophageal varices. These are swollen veins in your oesophagus (gullet), rather like varicose veins some people have in their legs. They are formed when blood flow through the liver is restricted. These veins could bleed, causing you to vomit blood, (possibly in large quantity), so it is important to try to reduce or shrink and obliterate them if possible. This can be done during a procedure called a gastroscopy.

A gastroscopy is a procedure that allows us to look directly at the lining of the upper gut. We use a gastroscope which is a long flexible tube (thinner than your little finger) with a light at the end It is passed through the mouth, into the oesophagus and then into the stomach and duodenum. The procedure can take between five and 15 minutes.

Treatment of oesophageal varices

This is either by compression or injection. The method used will be decided by the endoscopist and discussed with you.

Variceal banding (variceal ligation)

This is the preferred method for treating oesophageal varices using a similar technique that is used for the treatment of haemorrhoids (piles) using compression with tight rubber bands.

• A hollow tube loaded with small rubber bands is attached to the end of the gastroscope. This is passed into the oesophagus (gullet), the vein identified, suction applied and the elastic bands positioned. This is repeated as many times as is necessary at each procedure until all the veins have been eradicated.
• After a couple of days, a clot forms in each treated vein, which causes them to shrink. Several treatments may be required.

Injection of varices

• This procedure can be carried out using an injection needle, which is passed down the channel in the gastroscope whilst it is in your oesophagus (gullet).
• Through the needle, a drug can be injected into the varices, which creates a clot, blocking them off and causing them to shrink.
• In order to completely shrink the veins several injections may be needed. This may need to be repeated several times.

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, and explain the procedure to you.

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.

What happens during the procedure?

You will be collected from the changing room by the endoscopist and taken to a private bay to complete your consent form, when this has been completed they will escort you to the procedure room. The team in the procedure room will introduce themselves and ask you some questions; this is to confirm you are ready and prepared to continue with the procedure.

In the procedure room, we will ask you to remove false teeth, glasses and hearing aids in the left ear. We will make you comfortable on a couch lying on your left side. The endoscopist will give you the injection or throat spray. We will put a plastic guard into your mouth so that you do not bite and damage our instrument. We will also put a plastic ‘peg’ on your finger to monitor your pulse and oxygen levels. For your comfort and reassurance, a trained nurse will stay with you throughout.

As the gastroscope goes through your mouth you may gag slightly, this is quite normal and will not interfere with your breathing. During the procedure, we will put some air into your stomach so that we have a clear view; this may make you burp and belch a little. This is also quite normal but some people find this unpleasant. We will remove the air at the end of the procedure.

Minimal restraint may be appropriate during the procedure. However if you make it clear that you are too uncomfortable the procedure will be stopped.

Potential risks

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.

Ulcers usually form after banding or sclerotherapy and you should be given medication to help them heal. There is a small risk of bleeding in the few days following the procedure. Very rare complications include extension of thrombosis towards the liver after variceal injection, infection of ulcers with possible extension to the spinal cord, and when glue is used to inject the varices this can get into the circulation and affect the lungs (‘embolism’).

As with any procedure the potential benefits must be compared with any risks. Complications are generally less with the banding technique and this procedure is used preferentially. The injection treatment in the non emergency situation carries a complication rate of between one to two percent (1 to 2%).

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.

Afterwards, you may notice some chest discomfort and the back of your throat may feel sore for the rest of the day. 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 will 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.

Over the next few days

A soft diet is recommended for the first 24 hours particularly after banding. The action of the injection or banding will cause the veins to ulcerate over the next few days before healing. This can cause some soreness on swallowing for a few days. It is possible for a stricture (narrowing) to form in the oesophagus (gullet). This is more likely if the varices are large and repeated treatments (especially injection treatments) have been required. This may make swallowing difficult but can be treated. You may need to have a further procedure to ensure that varices have been completely eradicated.

After discharge

We will provide you with an information sheet on discharge which will detail who to contact if you require any assistance after the procedure.

Alternatives:

In some cases, depending on individual factors such as the symptoms present and the condition being treated, there may be alternatives to having injection or banding. These may include drug treatment.

For more information

Contact the endoscopy office between 09:00 and 17:00 Monday to Friday on 01223 257080.

Advice for patients with diabetes undergoing endoscopic procedures

Introduction

This information has been provided for patients with diabetes to help you understand how to manage your diabetes in preparation for your procedure:

• Gastroscopy
• Enteroscopy
• ERCP
• EUS

If you require further information or are unsure what guidance to follow please contact the endoscopy nurses on 01223 216515.

Patients having a gastroscopy, enteroscopy, ERCP or EUS

Ensure you follow the nil by mouth requirements in the procedure leaflet provided.

If you control your diabetes with diet alone:

No changes required.

Eat and drink after the procedure as normal

If you control your diabetes with tablets or non-insulin injectables:

Examples of non-insulin injectables include semaglutide (Ozempic), liraglutide (Victoza), dulaglutide (Trulicity), exenatide (Bydureon), lixisenatide (Lyxumia), Tirzepatide (Mounjaro)

On the day of the procedure only:

• If you have a morning appointment – omit all oral medication and non-insulin injectables on the day of your procedure
• If you have an afternoon appointment – take your usual morning dose only (oral medication or non-insulin injectable). If you normally take your medication at lunchtime or the evening do not move the missed doses to the morning before your appointment.

Resume all usual medications once eating and drinking normally

If you control your diabetes with insulin:

On the day of your procedure

• Test your blood sugar every 2 hours after waking
• Bring your glucose (+/- ketone) meter and medications (including insulin) with you
• Carry hypoglycaemia (low blood glucose) treatment with you. If you have a hypoglycaemic episode in the 3 hours before the procedure take 60mls of oral treatment or 4 glucotablets
• You can resume usual treatment when eating and drinking normally.

Please follow the guides below for your insulin regime:

If your diabetes medication or insulin is not listed above contact your usual Diabetes Specialist Nurse for advice.

Insulin adjustment guide: