Gastroscopy, therapeutic

A therapeutic gastroscopy is a general term that is used to describe any type of procedure that is carried out inside the upper gastrointestinal tract that involves using an endoscope. Therapeutic gastroscopy is also known as therapeutic endoscopy of the stomach.

The gastrointestinal tract

The gastrointestinal (GI) tract is the medical term for the digestive system. The upper GI tract consists of:

• the mouth,
• the oesophagus (also known as the gullet) - which is a tube that runs from the mouth, down the throat, and into the stomach,
• the stomach, and
• the duodenum - which is the first section of the small intestine.

What is an endoscope?

An endoscope is a thin, flexible tube that is about the width of your little finger. It has a light and a camera on one end. The camera can relay images of the inside of your body to a monitor (screen). Tiny instruments can be passed down the endoscope to carry out a range of surgical procedures such as:

• repairing bleeding ulcers and veins,
• widening the upper GI tract if there are blockages,
• providing nutrition, in cases where a person is unable to eat food in the normal way, and
• removing non-cancerous growths (polyps), or early stage cancerous tumours.

An endoscope can also be used to diagnose problems with the upper GI tract. For more information about this see the Health A-Z topic about diagnostic gastroscopy.

How common are therapeutic gastroscopies?

A therapeutic gastroscopy is a very common procedure. There are an estimated 136,000 procedures carried out by the NHS each year in England, Wales, and Northern Ireland.

Due to the nature of the conditions that are treated using a therapeutic gastroscopy, most procedures are carried out in people who are 60 years of age, or over, with the average age being 74.

Complications

As with all surgery, a therapeutic gastroscopy carries a risk of complications, which are estimated to occur in 1 in every 100 cases.

Complications can include:

• perforation of the GI tract,
• bleeding, and
• infection.

See the 'risks' section for more information about complications and how they can be treated.

Common uses of therapeutic gastroscopy

The two most common uses of a therapeutic gastroscopy are:

• to stop bleeding inside the GI tract, and
• to widen a narrowed oesophagus that is causing pain and/or swallowing difficulties (dysphagia).

Bleeding

Common causes of bleeding in the upper GI tract include:

• peptic ulcers,
• gastro-oesophageal reflux disease (GORD), and
• varices - enlarged veins that can develop on the lining of the oesophagus and, less commonly, the stomach.

These are described in more detail below.

Peptic ulcers

Peptic ulcers are open sores that develop on the lining of the stomach and duodenum. Most peptic ulcers are caused by a type of bacteria called H. pylori, which damages the protective layer of mucus that coats the lining. Without this protection, the lining can become damaged by stomach acid and an ulcer can form.

If a peptic ulcer develops near the site of a blood vessel, it can damage the vessel and bleeding can occur.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is a chronic (long-term) condition where stomach acid leaks back out of the stomach and into the oesophagus. Over time, the acid can cause scarring of the oesophagus (oesophagitis) which can result in the formation of bleeding ulcers.

Varices

Varices are abnormally widened veins that develop under the lining of the stomach and oesophagus.

Most varices are caused by cirrhosis (scarring of the liver). When the liver becomes extensively scarred, your blood finds it harder to move through the liver.

The blood must find a new way to return to your heart and it does this by using other blood vessels. Due to the increase in blood flow, these vessels become swollen resulting in varices.

If the pressure of blood inside the varices becomes too high for the varices to cope with, the walls of the varices will split and bleeding will occur.

Narrowed oesophagus

There are a number of ways that your oesophagus can become narrowed, or an obstruction can develop. These include:

• mouth cancer or lung cancer,
• radiotherapy - radiation can cause the development of scar tissue, which can narrow the passageway in your throat and oesophagus,
• gastro-oesophageal reflux disease (GORD) - stomach acid can cause scar tissue to develop, and
• infections, such as tuberculosis,or herpes simplex, that lead to the inflammation of the oesophagus (esophagitis).

A gastroscopy that is used to widen the oesophagus is also known as a gastroscopy with oesophageal dilatation.

Other uses of therapeutic gastroscopy

Other uses of therapeutic gastroscopy include:

• treating cases of early-stage stomach, or throat, cancer by removing any tumours (more advanced cases will require more extensive surgery),
• removing non-cancerous growths (polyps) that are causing an obstruction,
• removing foreign bodies that have become lodged in the oesophagus, or stomach, and
• providing nutrients by way of a feeding tube, when a person is unable to eat in the normal way.

Preparing for the appointment

Before having a therapeutic gastroscopy, you will need to ensure that you have an empty stomach. You will be given the following instructions regarding your diet:

• if you have a morning appointment, you should eat nothing after midnight until the procedure is complete, or
• if you have an afternoon appointment, you can eat a normal breakfast before 8am and then no more food is allowed.

You can drink a small amount of water up to two hours before your appointment.

You can continue to take any essential medications as usual, but you should write a list of all the medications that you are currently taking, including over-the-counter (OTC) medications, such as ibuprofen and bring it with you.

A therapeutic gastroscopy will usually be carried out at the endoscopy unit at your local hospital (although some larger GP practices may also offer endoscopic services).

If you are taking any of the following medications, you should telephone the endoscopy unit before your appointment because special arrangements may need to be made:

• any medication that is used to treat diabetes, such as insulin, or metformin, and
• blood-thinning medication (medication that is used to prevent blood clots), such as warfarin, or clopidogrel.

You should not wear nail polish on the day of your appointment because it interferes with a device that is attached to your finger and is used to monitor your oxygen levels.

A therapeutic gastroscopy is usually performed under sedation. This means that you will not be unconscious, as with a general anaesthetic, but that you will be very drowsy during and after the procedure. You should therefore arrange for someone to bring you home and to stay with you for at least 12 hours after the procedure.

The procedure

A gastroscopy is usually performed by a nurse and an endoscopist (a health professional who specialises in performing endoscopies). You will be introduced to the nurse before the procedure who will be able to answer any questions that you may have.

You will be asked to remove any glasses, contact lenses, and false teeth. A nurse may then spray your throat with a local anaesthetic spray and insert a small plastic mouth guard to protect your teeth.

You will be asked to lie down on your left hand side. The nurse will attach a small probe to your finger that will be used to measure your oxygen and heart rates.

At this point, you will normally be given an injection of sedatives in your arm. This will make you feel very drowsy so that you will be mostly unaware of the procedure itself and will probably have no memory of it taking place. However, you will still be able to follow any instructions that are given to you by the endoscopist or nurse.

The endoscopist will insert the endoscope into your throat and you will be asked to swallow the endoscope to help move it down into your oesophagus.

Depending on the condition that is being treated, a gastroscopy usually takes between 20-40 minutes to perform.

The endoscope will then be removed and you will be taken to a recovery room to allow you to recover from the effects of the sedation.

Gastroscopy techniques

Listed below are some of the surgical techniques that can be carried out with a therapeutic gastroscopy.

Treating bleeding - varices

If you have bleeding varices, the endoscopist will first use the endoscope to locate the site of the bleeding.

If the bleeding varices are located in your oesophagus, they can normally be treated using a technique called band ligation. This involves passing a small rubber band down the endoscope which is used to seal the base of the varices and cut off the blood supply in order to prevent further bleeding.

If the bleeding varices are located in your stomach, the site of the bleeding will be injected with a chemical called cyanoacrylate. Cyanoacrylate is the active ingredient in the extra-strength glues ('superglues') that are sold in shops, and it has since proved to be very useful in sealing holes or tears in the tissues of the body.

Treating bleeding - ulcers

If you have bleeding ulcers, one of a number of techniques may be used to treat them. For example:

• a probe may be passed through the endoscope which is used to apply heat, or small clips, in order to staunch bleeding, or
• a weak solution of adrenaline may be injected around an ulcer in order to help activate the clotting process, narrow the arteries, and enhance blood clotting.

During these procedures, you may also receive an intravenous injection of a fast-acting, acid-reducing medication, called a proton-pump inhibitor, to prevent bleeding recurring.

Narrowed oesophagus

If you have a narrowed oesophagus, the endoscopist can pass instruments down the endoscope to stretch and widen it and/or to insert a rigid balloon or stent (a hollow plastic, or metal, tube) to hold the walls of your oesophagus open.

After having a gastroscopy, most people will recover from the effects of the sedation within two hours. It is likely that you will then be given a number of further tests to check if there are any immediate complications. These tests may include:

• a chest X-ray,
• a measure of your heart rate, and
• a blood pressure test.

Depending on your individual circumstances, after the tests, you will be transferred to a hospital ward, or you will be discharged (sent home).

Even if you feel very alert, the sedative can stay in your blood for 24 hours and you may experience further episodes of drowsiness during this time. Therefore, during this time, it is important that you do not:

• drive a vehicle,
• operate heavy machinery, and
• drink any alcohol.

Depending on what type of procedure you have had, it may be several days before you can resume a normal diet. The endoscopy nurse will give you more information about your specific dietary recommendations.

Serious complications arising from a therapeutic gastroscopy are uncommon, and they develop in approximately 1 in 100 cases. Possible complications include:

• adverse effects arising from sedation.
• infection,
• bleeding, and
• perforation (tearing).

Sedation

Sedation is usually a safe procedure but it can cause complications occasionally. Complications associated with sedation can range from mild to serious and include:

• nausea,
• vomiting,
• a burning sensation at the site of the injection,
• small particles of food fall into the lungs and trigger an infection (aspiration pneumonia),
• irregular heartbeat,
• breathing difficulties, and
• stroke.

Very rarely the complications arising from sedation can result in stroke, though this is extremely unlikely, occurring in 1 out of 25,000 cases.

Infection

Occasionally, during a gastroscopy, bacteria can enter the bloodstream through small tears and incisions in tissue that were formed during the procedure. In most cases, the bacteria do not cause serious problems and are killed by the immune system.

However, in rare cases, the bacteria can travel to the heart and infect the lining, muscles, and valves of the heart. This type of infection is known as endocarditis.

Symptoms of endocarditis include:

• high temperature (fever) of 38C (100.4F) or above,
• chills,
• an usual sounding heartbeat (murmur),
• fatigue,
• night sweats, and
• aching joints and muscles.

Endocarditis can be treated with injections of antibiotics and, in the most serious cases, surgery to repair the heart.

Bleeding

Sometimes, the endoscope can inadvertently damage a blood vessel resulting in bleeding.

Symptoms of bleeding can include:

• fatigue,
• breathlessness (dyspnoea)
• pale skin,
• vomiting blood, and
• passing stools that are very dark or 'tar-like'.

The source of bleeding can usually be repaired using a further gastroscopy, in the same way that a bleeding varices or ulcer is repaired. Blood transfusions may also be required to replace lost blood.

Perforation

During a gastroscopy, there is a small risk of the endoscope perforating the tissue inside your oesophagus, abdomen, and/or your chest.

Symptoms arising from a perforation include:

• neck pain,
• pain when swallowing,
• abdomen pain
• high fever, and
• breathing difficulties.

If your symptoms suggest that the perforation is not severe, it can normally be left to heal by itself. You may be given antibiotics to prevent an infection occurring at the site of the perforation.

If your symptoms suggest that the perforation is more extensive, such as severe pain that does not respond to painkillers, then surgery may be required to repair it.

We asked Ian Beckingham of the Queen's Medical Centre, Nottingham, what he would want to know if he needed a gastroscopy.

What are my treatment options?

In the past, bleeding peptic ulcers were treated with major abdominal surgery (when your stomach is opened up).

However, today, gastroscopy is the procedure of choice and major abdominal surgery is only used when gastroscopy fails to stop the bleeding, which occurs in around 10-20 per cent of patients.

What is the relative success of these operations?

Therapeutic endoscopy will stop bleeding in around 90% of ulcers, although sometimes it will need more than one session.

Will I need a blood transfusion?

If your bleeding has been severe, acute or you have become very anaemic, you may need a transfusion.

Will I need an anaesthetic?

Most patients can have a therapeutic endoscopy under sedation, but it may be necessary to have a general anaesthetic if there's a significant danger of breathing blood or other substances into the lungs.