Therapeutic endoscopy
Encyclopedia
Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy
, where the aim of the procedure is purely to visualise a part of the gastrointestinal
, respiratory
or urinary tract in order to aid diagnosis
. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding
, or the finding of polyp
s during colonoscopy
.
A number of different techniques have been developed to allow treatment to be carried out endoscopically, to treat disorders such as bleeding
, strictures
and polyps.
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 rebleeding.
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 This technique has now largely been superseded by variceal band ligation.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.
Argon plasma coagulation (APC) has been used to provide tissue coagulation and haemostasis since the early part of the 1990s. A stream of argon gas is passed through an endoscopic catheter; this is then ionized at the tip of the catheter by an electric current. The tip of the catheter is held close to the tissue to be treated, and the current arcs across to the tissue causing a superficial (2-3mm) burn. The lack of contact between the catheter and the tissue stops the tendency of the catheter to stick to the tissue, reducing unwanted tissue damage.
Its principal use is in providing haemostasis in gastrointestinal bleeding; angiodysplasia
, GAVE
, bleeding malignant tumours
and bleeding peptic ulcer
s can all be treated. Trials have also been carried out to assess its use in eradicating Barrett’s oesophagus, but have found that relapse is common.
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.
Endoscopic polypectomy has been carried out since the early 1970s by both endoscopic snare removal and fulguration of polyps with hot biopsy forceps.
Expandable mesh stents can be deployed in the oesophagus at endoscopy, primarily in patients with inoperable oesophageal cancer which is causing dysphagia
.
Plastic stents can also be used to relieve obstruction of the Common bile duct
at ERCP
.
) are at high risk for complications from anaesthesia and surgery
; the endoscopic technique usually requires mild sedation only.
.
as an alternative to laparoscopic Nissen fundoplication
.
, which aims to induce long-term weight loss in morbidly obese
patients.
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
, where the aim of the procedure is purely to visualise a part of the gastrointestinal
Gastrointestinal tract
The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. ....
, respiratory
Respiratory tract
In humans the respiratory tract is the part of the anatomy involved with the process of respiration.The respiratory tract is divided into 3 segments:*Upper respiratory tract: nose and nasal passages, paranasal sinuses, and throat or pharynx...
or urinary tract in order to aid diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding
Gastrointestinal bleeding
Gastrointestinal bleeding or gastrointestinal hemorrhage describes every form of hemorrhage in the gastrointestinal tract, from the pharynx to the rectum. It has diverse causes, and a medical history, as well as physical examination, generally distinguishes between the main forms...
, or the finding of polyp
Polyp
A polyp in zoology is one of two forms found in the phylum Cnidaria, the other being the medusa. Polyps are approximately cylindrical in shape and elongated at the axis of the body...
s during colonoscopy
Colonoscopy
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis and grants the opportunity for biopsy or removal of suspected...
.
A number of different techniques have been developed to allow treatment to be carried out endoscopically, to treat disorders such as bleeding
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
, strictures
Stenosis
A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.It is also sometimes called a stricture ....
and polyps.
Endoscopic haemostasis
Endoscopic injection of bleeding peptic ulcers with adrenalineEpinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
has been practised since the 1970s, endoscopic heater probes have been used since the 1980s, and Argon plasma coagulation
Argon plasma coagulation
Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain lesions in the gastrointestinal tract, and also sometimes to debulk tumours in the case of patients for whom surgery is not recommended...
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 rebleeding.
Injection sclerotherapy
Injection sclerotherapySclerotherapy
Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations...
has been used to treat oesophageal varices
Esophageal varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
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
Ethanolamine
Ethanolamine, also called 2-aminoethanol or monoethanolamine , is an organic chemical compound that is both a primary amine and a primary alcohol . Like other amines, monoethanolamine acts as a weak base...
or absolute alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
, 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
Cyanoacrylate
Cyanoacrylate is the generic name for cyanoacrylate based fast-acting adhesives such as methyl 2-cyanoacrylate, ethyl-2-cyanoacrylate , and n-butyl 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.
Argon plasma coagulation
Argon plasma coagulation (APC) has been used to provide tissue coagulation and haemostasis since the early part of the 1990s. A stream of argon gas is passed through an endoscopic catheter; this is then ionized at the tip of the catheter by an electric current. The tip of the catheter is held close to the tissue to be treated, and the current arcs across to the tissue causing a superficial (2-3mm) burn. The lack of contact between the catheter and the tissue stops the tendency of the catheter to stick to the tissue, reducing unwanted tissue damage.
Its principal use is in providing haemostasis in gastrointestinal bleeding; angiodysplasia
Angiodysplasia
In medicine , angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places...
, GAVE
Gastric antral vascular ectasia
*Please note that Wikipedia does not give medical advice, and that the information in this article is intended to be solely for informational purposes....
, bleeding malignant tumours
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
and bleeding peptic ulcer
Peptic ulcer
A peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
s can all be treated. Trials have also been carried out to assess its use in eradicating Barrett’s oesophagus, but have found that relapse is common.
Dilatation
Dilatation of benign oesophageal strictures
Esophageal stricture
Benign esophageal stricture is a narrowing or tightening of the esophagus that causes swallowing difficulties.-Causes:It can be caused by or associated with gastroesophageal reflux disease, esophagitis , dysfunctional lower esophageal sphincter, disordered motility, lye ingestion, or a hiatal hernia...
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
Achalasia
Achalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...
.
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.
Polypectomy
Endoscopic polypectomy has been carried out since the early 1970s by both endoscopic snare removal and fulguration of polyps with hot biopsy forceps.
Variceal banding
Oesophageal varices have been treated by band ligation since the late 1980s. This therapy is indicated for patients who are at high risk of bleeding from varices, and can be used in actively bleeding varices.Stenting
Expandable mesh stents can be deployed in the oesophagus at endoscopy, primarily in patients with inoperable oesophageal cancer which is causing dysphagia
Dysphagia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....
.
Plastic stents can also be used to relieve obstruction of the Common bile duct
Common bile duct
The common bile duct is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct . It is later joined by the pancreatic duct to form the ampulla of Vater...
at ERCP
Endoscopic retrograde cholangiopancreatography
Endoscopic retrograde cholangiopancreatography is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems...
.
Percutaneous endoscopic gastrostomy
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 strokeStroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
) are at high risk for complications from anaesthesia and surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
; the endoscopic technique usually requires mild sedation only.
Foreign body removal
Foreign bodies commonly impact in the lower oesophagus, and removal of these by pushing them into the stomach has been practised since the Middle Ages. Foreign body retrieval, using forceps and magnets, has been practised since the time of rigid oesophagoscopy and bronchoscopyBronchoscopy
Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for...
.
Anti-reflux procedures
A number of techniques are being developed for the endoscopic treatment of gastro-oesophageal reflux diseaseGastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...
as an alternative to laparoscopic Nissen fundoplication
Nissen fundoplication
Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure...
.
Treatment of Barrett’s oesophagus
Endoscopic circumferential radiofrequency ablation is being developed in an effort to obviate the need for long-term endoscopic surveillance in patients with Barrett’s oesophagus, and to reduce the risk of development of oesophageal carcinoma. Previous techniques, such as Argon plasma coagulation, have been unsuccessful because of incomplete removal of the Barrett’s mucosa and therefore relapse of part of the treated area. Newer techniques using circumferential radiofrequency ablation, which allows larger areas of the oesophagus to be treated at one time giving a more uniform area of treatment, are showing more promising short-term results.Transoral gastroplasty (TOGA procedure)
Early trials are under way to evaluate an endoscopic technique for gastric stapling, a type of bariatric surgeryBariatric surgery
Bariatric surgery includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device or through removal of a portion of the stomach or by resecting and re-routing the small intestines...
, which aims to induce long-term weight loss in morbidly obese
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
patients.