Endoscopic therapy

Anti-reflux surgery or endoscopic therapies offer an alternative treatment for refractory GERD or when pharmacologic management is undesirable. 

Nonpharmacologic treatment of GERD includes lifestyle modifications, anti-reflux surgery, or endoscopic therapies. 

Panloprazole 40 mg including those with persistent atypical symptoms, may be candidates for anti-reflux surgery or endoscopic therapies. 

Assess the risk for variceal bleeding and begin pharmacologic prophylaxis where indicated, reserving endoscopic therapy for high-risk patients or acute bleeding episodes. 

EBL is the recommended form of endoscopic therapy for acute esophageal variceal 1A... 

EBL is the recommended form of endoscopic therapy for acute variceal bleeding, although endoscopic injection sclerotherapy (injection of 1 to 4 mL of a sclerosing agent into the lumen of the varices) may be used if the ligation is technically difficult. EBL is often used for upper GI tract hemorrhage secondary to portal hypertension and varices. 

Ranitidine 150 mg four times daily Antireflux surgery or endoscopic therapies... 

Khan S, Tudur Smith C, WUhamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev 2006. 

Acute non-variceal upper gastrointestinal (GI) bleed 80 mg i.v. bolus followed by continuous infusion at 8 mg/h. for 72 h. after endoscopic therapy... 

EBL is the recommended form of endoscopic therapy for acute esophageal variceal bleeding and should be used in conjunction with vasoactive drug therapy Secondary prophylaxis of variceal bleeding... 

Nonvaticeal Endoscopic therapy Proton pump inhibitors... 

Vasopressin is rapidly cleared from the circulation and must be given by continuous i.v. infusion. The synthetic ancJogue, terlipressin (triglycyl-lysine-vasopressin) is now preferred. This prodrug (or hormogen) is converted in vivo to the vasoactive lysine vasopressin which has biological activity for 3-4 hours, and is effective by bolus injections 4-hourly, usually for 48-72 hours. It is a useful adjunct to endoscopic therapy and reduces rebleeding. 

Endoscopic therapy as (above), preferably by band ligation, and repeated at weekly intervals until all varices are obliterated, is currently the treatment of choice it reduces the incidence of rebleeding by 50-60%. 

If a blood clot is found at the bleeding site, it should be removed with the help of a probe or loop. This is followed by endoscopic therapy. In this way, the risk of rebleeding can be markedly reduced. 

Cook, D.J., Guyatt, G.H., Salena, B.J., Laine, L.A. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage A metaanalysis. Gastroenterology 1992 102 139-148... 

Dowidar, N., El-Sayad, M., Osman, M., Salem, A. Endoscopic therapy of fasciohasis resistants to oral therapy Gastrointest. Endosc. 1999 50 345-351... 

All reconstructive or resective interventions of the bile-duct system (as well as all abdominal operations) have the disadvantage that subsequent orthotopic liver transplantation is rendered more difficult or even impossible. (300, 352) Intrahepatic cholangiojejunostomy, the influence of which on the survival rate was not confirmed, should also be mentioned in this respect. (340) There is a significantly high perioperative risk with increased mortality regarding all of these surgical interventions, particularly in the late stages of PSC. For this reason, all possibilities of endoscopic therapy should be exhausted first. 

Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis. Gastrointest. Endosc. 2001 53 308-312... 

Craig, PJ., Hatfiled, A.R.W. Endoscopic therapy in primary sclerosing cholangitis. Eur. J. Gastroenterol. Hepatol. 1992 4 284-287... 

Some clinicians believe that patients should be offered the newer endoscopic interventions instead of proton pump inhibitors for long-term maintenance of GERD. While the newer endoscopic therapies provide good results and less recovery time than surgery, the long-term effects are still not known. Conversely, many patients prefer not to have to take medication indefinitely, and in some cases still complain of symptoms despite drug therapy. 

Johnson DA. Endoscopic therapy for GERD—baking, sewing, or stuffing An evidence-based perspective. Rev Gastroenterol Disord 2003 3 142-149. 

Sung JJY, Chan EKL, Lau JYW. The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots. Ann Intern Med 2003 139 237-243. 

Band ligation/sclerotherapy Octreotide Endoscopic therapy Proton pump inhibitors Antibiotics Paracentesis Discontinue diuretics Eluid and electrolyte replacement Discontinue sedatives/tranquilizers Consider reversal (flumazenil/ naloxone)... 

The severity and frequency of abdominal pain should be assessed periodically in order to determine the efficacy of the patient s pain control regimen. Most patients with abdominal pain can be adequately controlled with acetaminophen, NSAIDs, or selective COX-2 inhibitors. A trial of pancreatic enzymes and either an H2-receptor antagonist or proton pump inhibitor may relieve pain in patients with mild to moderate disease. Patients with severe pain will require narcotics. In these patients, pain should be monitored daily and medications adjusted accordingly. Some patients will require endoscopic therapy or pancreatic surgery. 

ERCP is useful in the evaluation of a small mass causing obstruction of the ductal system. MRCP is as sensitive as ERCP and may prevent inappropriate explorations of the pancreatic and bile ducts in patients with suspected pancreatic carcinoma in whom interventional endoscopic therapy is unlikely (Gazelle et al. 1998 Chung 2006). 

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