MANUAL FOR ENDOSCOPY

TABLE OF CONTENTS

1... Amendment Log Blank sheet............................................................................... 3

2... Definitions & Abbreviations.................................................................................. 4
2.1. Definitions....................................................................................................... 4
2.2. Abbreviations................................................................................................... 5
3... Introduction..................................................................................................... 7
3.1. Objective........................................................................................................ 7
4... Department Structure........................................................................................ 8
4.1. Organogram.................................................................................................... 8
5... Department Procedures...................................................................................... 9
5.1. Scope of services.............................................................................................. 9
5.2. Overview of department function........................................................................ 11
5.3. Patient related procedures................................................................................. 12
5.4. Endoscopy room-related procedures.................................................................... 13
5.5. Room Preparation............................................................................................ 14
5.6. Pre-procedure Preparation................................................................................. 15
5.7. Receiving of Patient......................................................................................... 16
5.8. Endoscopic Equipment Preparation and Inspection.................................................. 17
5.9. Gastroscopy Protocol........................................................................................ 18
5.10 Colonoscopy Protocol....................................................................................... 20
5.11 ERCP protocol................................................................................................. 22
5.12 Hydrogen Breathing Test...........................................
5.13 Sclerotherapy/ Glue Injection/ Banding................................................................. 24
5.14 Colonoscopic Polypectomy or APC....................................................................... 26
5.15 Oesophageal Manometry................................................................................... 28
5.16 Anorectal manometry....................................................................................... 29
5.17 Urea breath test.............................................................................................. 30
5.18 Liver biopsy.................................................................................................... 31
5.19 Bio feedback.................................................................................................. 32
5.20 Transfer to Wards post procedure....................................................................... 33
5.21 Procedural sedation outside OR.......................................................................... 34
5.22 Incident Reporting........................................................................................... 37
6... Key Performance Indicators............................................................................... 38
7... Software User Guide........................................................................................ 39
8... Reports......................................................................................................... 40
9... List of forms, registers and other documentation.................................................... 41
10.. Appendix (as applicable)................................................................................... 42

AMENDMENT LOG BLANK SHEET

DEFINITIONS & ABBREVIATIONS

DEFINITIONS-
2.2. Abbreviations.
 3.INTRODUCTION
The word endoscopy is derived from the greek words endonand skopein (means to
examine).
Endoscopy is a direct visual examination of the internal body parts by means of an
endoscopes passed along the interior of hollow organs or cavities. Endoscopy is term
used for the visualization of more ten one organ with the same endoscope.

3.1. OBJECTIVE-after reading this manual staff will be able to-

1. Explain the importance of various endoscopy procedure.

2. Discuss the care of endoscope and there uses in general .
3. State the purpose, nurse's responsibility in the preparation and after care of the
patient .
4. Discuss the purpose, methods and nurse's responsibility in endoscopy.
5. Enumerate the purpose, of tissue biopsies and aspiration of body cavities.
6. Discuss the complications that can arise during the above stated biopsies and
measures used to treat ,as well as prevent complications.
7. Explain the nurse's responsibility in the collection and transportation of blood
,urine and other body fluids for investigation.
8. Differentiate normal and abnormal test results and its implication on the client's
treatment and recovery.
 4. Department Structure

4.1. Organogram....

5. DEPARTMENT PROCEDURES
1. opthalmoscopy - fundus of the eye
2. otoscopy - auditory canal and tympanic membrane
3. nasopharyngoscopy- naso pharynx
4. anthroscopy-maxillary sinus
5. laryngoscopy -larynx
6. bronchoscopy
7. tracheo broncheal tree
8. mediastinoscopy-mediastinal spaces in the chest.
9. pleuroscopy - pleural cavity
10. thoracoscopy-pleural surface in the thoracic cavity
11. oesophagoscopy- oesophagus
12. gastroscopy -stomach
13. duodenoscopy -duodenum
14. jejunoscopy- jejunum
15. clonoscopy-colon
16. sigmoidscopy -sigmoid colon and rectum
17. proctoscopy -rectum and anal canal
18. choledoscopy -common bile duct
19. nephroscopy -renal pelvis
20. Peritoneoscopy -abdominal and pelvis
21. laproscopy
22. culdoscopy
23. pelvic organs through the vaginal wall
24. hysteroscopy-uterus
25. urethroscopy-urethra
26. arthroscopy-a joint usually the knee
27. vascular endoscopy -arterial or venous lumen
5.1. SCOPE OF SERVICES-
 various invasive and non-invasive techniques in the diagnoses of diseases.
 care of the endoscopes and their uses in general.
 preparation and after care of the patient in bronchoscopy, laryngoscopy oespgo
duedenoscopy laproscopy, cystoscopy ,proctoscopy,and sigmoidoscopy.
 tissues biopsy and aspiration of body cavities .
5.5. Room Preparation
An endoscopy unit refers to a dedicated area where medical procedures are performed
with endoscopes, which are cameras used to visualize structures within the body, such
as the digestive tract and genitourinary system. Endoscopy units may be located within
a hospital, incorporated within other medical care centres, or may be stand-alone in
nature.

An endoscopy unit consists of the following components: trained and accredited endoscopists
(which are usually gastroenterologists or surgeons);
trained nursing and additional staff;
endoscopes and other equipment; preparation, procedural and recovery areas;
a disinfection and cleaning area for equipment;
emergency equipment and personnel; and, a program for quality assurance.
Procedures performed within an endoscopy unit may include
 gastrointestinal endoscopy (such as gastroscopy, colonoscopy, ERCP, and endoscopic
ultrasound), bronchoscopy, cystoscopy, or
 other more specialized procedures. Endoscopy units may be part of a hospital,
 where emergency procedures may be performed on ill patients admitted to hospital;
however, most endoscopies are performed on ambulatory patients in the outpatient
setting.
Endoscopy units consist of a number of areas:

 Reception and waiting area for patients and relatives.

 Consultation rooms.
 Changing areas.
 Procedure rooms.
 Recovery area.
 Decontamination area.
Procedure rooms

An endoscopy procedure room

These are the rooms where the endoscopic procedures are performed.
Procedure rooms should to contain:

 Patient trolley.
 Endoscopy 'stack' and video monitor(s) – this equipment contains the light source and
processor required for the endoscopes to produce images.
 Monitoring equipment to allow continuous monitoring of patient condition during procedures.
 suction equipment to allow both aspiration of airway secretions and to allow aspiration of
fluid through the endoscope.
 Piped oxygen supply.
 Medication used to provide procedural sedation.
 Ancillary equipment - endoscopy biopsy forceps, snares, injectors (see Instruments used in
gastroenterology).
 Diathermy and/or Argon plasma coagulation equipment.
 Computer(s) used to generate endoscopy reports.

An endoscopy recovery area

Recovery area
Since a number of patients undergoing endoscopy receive sedation, and a few emergency
patients may be unstable, there must be an area available for the observation of patients until
they have recovered. These areas also need to have piped oxygen, full monitoring facilities
(including pulse oximetry), suction, resuscitation equipment and emergency drugs.[3]

5.6. PRE-PROCEDURE PREPARATION

 Explain the procedure to the client in order to win his confidence and co-
operation.
 to prevent unnecessary gagging during the inspection of the larynx ,the
client is approached calmly.
 the room should be darkened so that the doctor can see more clearly the
structures lighted by the scope.
 for the direct laryngoscopy,the client should be prepared as for a surgical
procedure,-
 food and fluids are withheld for a period of 4to 6 hours to prevent
regurgitation and possible aspiration.
 the client is given a pre-operative sedation.
  the client's dentures are removed.
 if the laryngoscope is done under local anaesthesia the throat is sprayed
with a topical anaesthetic.
 if a biopsy or excision of tissues is expected the necessary articles are kept
ready
 the procedure is done under strict aseptic technique.

Patient related procedures.

5.8. ENDOSCOPIC EQUIPMENT PREPARATION AND

INSPECTION

5.9. GASTROSCOPY PROTOCOL

A gastroscopy is a procedure where a thin, flexible tube called an endoscope is used to

look inside the oesophagus (gullet), stomach and first part of the small intestine (duodenum).
It's also sometimes referred to as an upper gastrointestinal endoscopy. The endoscope has
a light and a camera at one end.

also called by various other names, is a diagnostic endoscopic procedure that

visualizes the upper part of the gastrointestinal tract down to the duodenum. It is
considered a minimally invasive procedure since it does not require an incision into
one of the major body cavities and does not require any significant recovery after the
procedure (unless sedation or anesthesia has been used). However, a sore throat is
common.

A GASTROSCOPY CAN BE USED TO:

 investigate problems such as difficulty swallowing (dysphagia) or

persistent abdominal (tummy) pain
 diagnose conditions such as stomach ulcers or gastro-oesophageal reflux disease
(GORD)
 treat conditions such as bleeding ulcers, a blockage in the oesophagus, non-cancerous
growths (polyps) or small cancerous tumours
Diagnostic

 Unexplained anemia (usually along with a colonoscopy)

 Upper gastrointestinal bleeding as evidenced by hematemesis or melena
 Persistent dyspepsia in patients over the age of 45 years
 Heartburn and chronic acid reflux – this can lead to a precancerous lesion called Barrett's
esophagus
 Persistent vomiting
 Dysphagia – difficulty in swallowing
 Odynophagia – painful swallowing
 Persistent nausea
 IBD (inflammatory bowel diseases)

A gastroscopy used to check symptoms or confirm a diagnosis is known as a diagnostic

gastroscopy. A gastroscopy used to treat a condition is known as a therapeutic
gastroscopy.

THE GASTROSCOPY PROCEDURE

 A gastroscopy often takes less than 15 minutes, although it may take longer if
it's being used to treat a condition.

 It's usually carried out as an outpatient procedure,

 Before the procedure, throat will be numbed with a local anaesthetic spray.

 patient can also choose to have a sedative, . This means he will still be
awake, but will be drowsy and have reduced awareness about what's
happening.

 The doctor carrying out the procedure will place the endoscope in the back of
mouth and ask to swallow the first part of the tube. It will then be guided
down oesophagus and into stomach.

 The procedure shouldn't be painful, but it may be unpleasant or uncomfortable

at times.

THERAPEUTIC

 Treatment (banding/sclerotherapy) of oesophageal varices

 Injection therapy (e.g. epinephrine in bleeding lesions)
 Cutting off of larger pieces of tissue with a snare device (e.g. polyps, endoscopic mucosal
resection)
 Application of cautery to tissues.
 Removal of foreign bodies (e.g. food) that have been ingested
 Tamponade of bleeding oesophageal varices with a balloon
 Application of photodynamic therapy for treatment of oesophageal malignancies
 Endoscopic drainage of pancreatic pseudo cyst
 Tightening the lower oesophageal sphincter
 Dilating or stenting of stenosis or achalasia
 Percutaneous endoscopic gastrostomy (feeding tube placement)
 Endoscopic retrograde cholangiopancreatography (ERCP) combines EGD with fluoroscopy
 Endoscopic ultrasound (EUS) combines EGD with 5–12 MHz ultrasound imaging.

RISKS

An endoscopy is a very safe procedure. Rare complications include:

 Bleeding. Your risk of bleeding complications after an endoscopy is increased

if the procedure involves removing a piece of tissue for testing (biopsy) or
treating a digestive system problem. In rare cases, such bleeding may require a
blood transfusion.

 Infection. Most endoscopies consist of an examination and biopsy, and risk of

infection is low. The risk of infection increases when additional procedures are
performed as part of your endoscopy. Most infections are minor and can be
treated with antibiotics. Your doctor may give you preventive antibiotics before
your procedure if you are at higher risk of infection.

 Tearing of the gastrointestinal tract. A tear in your esophagus or another part

of your upper digestive tract may require hospitalization, and sometimes
surgery to repair it. The risk of this complication is very low, but it increases if
additional procedures, such as dilation to widen your esophagus, are
performed.

 Reaction to sedation. Prior to your upper endoscopy, you'll likely be given

sedation so that you'll be better able to tolerate the procedure. The type of
sedation varies, and adverse reactions are possible, but rare. You will be
monitored closely during the procedure to reduce the risk of serious reaction.
5.10 COLONOSCOPY PROTOCOL
A colonoscopy (koe-lun-OS-kuh-pee) is an exam used to detect changes or
abnormalities in the large intestine (colon) and rectum.

During a colonoscopy, a long, flexible tube (colonoscope) is inserted into the rectum.
A tiny video camera at the tip of the tube allows the doctor to view the inside of the
entire colon.

If necessary, polyps or other types of abnormal tissue can be removed through the
scope during a colonoscopy. Tissue samples (biopsies) can be taken during a
colonoscopy as well.

PURPOSE

 Investigate intestinal signs and symptoms. A colonoscopy can help your

doctor explore possible causes of abdominal pain, rectal bleeding, chronic
constipation, chronic diarrhea and other intestinal problems.

 Screen for colon cancer. If you're age 50 or older and at average risk of colon
cancer — you have no colon cancer risk factors other than age — your doctor
may recommend a colonoscopy every 10 years or sometimes sooner to screen
for colon cancer. Colonoscopy is one option for colon cancer screening. Talk
with your doctor about your options.

 Look for more polyps. If you have had polyps before, your doctor may
recommend a follow-up colonoscopy to look for and remove any additional
polyps. This is done to reduce your risk of colon cancer.
RISKS

A colonoscopy poses few risks. Rarely, complications of a colonoscopy may include:

 Adverse reaction to the sedative used during the exam

 Bleeding from the site where a tissue sample (biopsy) was taken or a polyp or
other abnormal tissue was removed

 A tear in the colon or rectum wall (perforation)

After discussing the risks of colonoscopy with you, your doctor will ask you to sign a
consent form authorizing the procedure.

PREPRATION BEFORE COLONOSCOPY

Before a colonoscopy, need to clean out (empty) colon. Any residue in colon may
obscure the view of colon and rectum during the exam.

 Follow a special diet the day before the exam. Typically, patient won't be
able to eat solid food the day before the exam. Drinks may be limited to clear
liquids — plain water, tea and coffee without milk or cream, broth, and
carbonated beverages. Avoid red liquids, which can be confused with blood
during the colonoscopy. patient can not be able to eat or drink anything after
midnight the night before the exam.

 Take a laxative. doctor will usually recommend taking a laxative, in either pill
form or liquid form. instructed to patient to take the laxative the night before
colonoscopy, and asked to use the laxative both the night before and the
morning of the procedure.

 Use an enema kit. to clean the colon.

 Adjust your medications. medications at least a week before the exam —

especially if having diabetes, high blood pressure or heart problems or if take
medications or supplements that contain iron.

aspirin or other medications that thin the blood, such as warfarin (Coumadin,
Jantoven); newer anticoagulants, such as dabigatran (Pradaxa) or rivaroxaban
(Xarelto), used to reduce risk of blot clots or stroke; or heart medications that
affect platelets, such as clopidogrel (Plavix)

adjust dosages or stop taking the medications temporarily.

After a colonoscopy, tell to the client-

you'll eat and drink things that are gentle on your digestive system. Drinking lots of fluid and
fluid-based foods will help you avoid dehydration.

recommend you follow a soft, low-residue diet immediately after the procedure

If you experience any of the following problems:

• Severe abdominal pain (not cramp caused by wind).

• A sudden passing of a large amount of blood from your back passage (a very small amount of
blood is normal and needs no action).
• A firm and swollen abdomen.

• High temperature or feeling feverish.

• Vomiting.

Please contact your GP immediately, informing them that you have had a colonoscopy.

5.11 ERCP PROTOCOL

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines

the use of endoscopy and fluoroscopy to diagnose and treat certain problems of
the biliary or pancreatic ductal systems. Through the endoscope, the physician can see
the inside of the stomachand duodenum, and inject a contrast medium into the ducts in
the biliary tree and pancreas so they can be seen on radiographs.
ERCP is used primarily to diagnose and treat conditions of the bile ducts and main
pancreatic duct,[1] including gallstones, inflammatory strictures (scars), leaks (from
trauma and surgery), and cancer. ERCP can be performed for diagnostic and therapeutic
reasons, although the development of safer and relatively non-invasive investigations
such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic
ultrasound has meant that ERCP is now rarely performed without therapeutic intent.
Diagnostic[edit]
The following represent indications for ERCP, particularly if or when less invasive
options are not adequate or definitive:
Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the
distal common bile duct. A nasobiliary tube has been inserted.

Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation.
Endoscope is visible.

 Obstructive jaundice – This may be due to several causes

o Gallstones with dilated bile ducts on ultrasonography
o Indeterminate biliary strictures and suspected bile duct tumors[2]
o Suspected injury to bile ducts either as a result of trauma or of iatrogenic origin
o Sphincter of Oddi dysfunction
 Chronic pancreatitis is currently a controversial indication due to widespread
availability of safer diagnostic modalities including endoscopic ultrasound, CT,
and MRI/MRCP
 Pancreatic tumors no longer represent a valid diagnostic indication for ERCP unless
they cause bile duct obstruction and jaundice. Endoscopic ultrasound represents a
safer and more accurate diagnostic alternative
Therapeutic
ERCP may be indicated in the above diagnostic scenarios when any of the following are
needed:

 Endoscopic sphincterotomy (of the biliary or the pancreatic duct sphincter, or

Sphincter of Oddi)
 Removal of stones or other biliary debris
 Insertion of bile duct stent(s)
 Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures
after liver transplantation)[3]

Contraindications
 Hypersensitivity to iodinated contrast medium
 History of iodinated contrast dye anaphylaxis (although iodine-free contrast is now
available)
 Acute pancreatitis (unless persistently elevated or rising bilirubin suggests ongoing
obstruction)
 (Irreversible) coagulation disorder if sphincterotomy planned
 Recent myocardial infarction or pulmonary embolism
 Severe cardiopulmonary disease or other serious morbidity

Procedure
 The patient is sedated or anaesthetized.
 Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus,
into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the
union of the common bile duct and pancreatic duct) exists.
 The sphincter of Oddi is a muscular valve that controls the opening to the ampulla.
 The region can be directly visualized with the endoscopic camera while various
procedures are performed.

 A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is

injected into the bile ducts and/or pancreatic duct.
 Fluoroscopy is used to look for blockages, or other lesions such as stones.
 When needed, the sphincters of the ampulla and bile ducts can be enlarged by a cut
(sphincterotomy) with an electrified wire called a sphincterotome for access into either so
that gallstones may be removed or other therapy performed
 .
Other procedures associated with ERCP include the trawling of the common bile duct
with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist
the drainage of bile.
 Also, the pancreatic duct can be cannulated and stents be inserted.
 The pancreatic duct requires visualisation in cases of pancreatitis.
 In specific cases, other specialized or ancillary endoscopes may be used for ERCP.

RISKS
One of the most frequent and feared complications after endoscopic retrograde cholangio
pancreatograhy (ERCP) is
1. post-ERCP pancreatitis (PEP).
2. Intestinal perforation
3. risk associated with the contrast dye in patients who are allergic to compounds containing
iodine.
4. Over sedation can result in dangerously low blood pressure, respiratory depression, nausea,
and vomiting.
5. hospital acquired infection
 HYDROGEN BREATH TEST

A hydrogen breath test (or HBT) is used as a diagnostic tool for small intestine bacterial
overgrowth and carbohydrate mal absorption, such as lactose, fructose, and sorbitol mal
absorption. The test is simple, non-invasive, and is performed after a short period of fasting
(typically 8–12 hours).
A hydrogen breath test (or HBT) is used as a diagnostic tool for small intestine bacterial
overgrowth and carbohydrate malabsorption, such as lactose, fructose,
and sorbitol malabsorption.
 The test is simple, non-invasive, and is performed after a short period of fasting(typically
8–12 hours).
 Hydrogen breath tests are based on the fact that there is no source for hydrogen gas in
humans other than bacterial metabolism of carbohydrates.
 Even though the test is normally known as a "hydrogen" breath test, some physicians
may also test for methane in addition to hydrogen.
 Many studies have shown that some patients (approximately 35% or more) do not
produce hydrogen but actually produce methane. Some patients produce a combination
of the two gases
 Other patients, who are known as "non-responders", don't produce any gas; it has not
yet been determined whether they may actually produce another gas.
 In addition to hydrogen and methane, some facilities also utilize carbon dioxide (CO2) in
the patient's breath to determine if the breath samples that are being analyzed are
contaminated (either with room air or bronchial dead space air).
 Testing may be administered at hospitals, clinics, physician offices or if the
physician/laboratory has the proper equipment and breath collection kit, patients can
collect samples at home to then be mailed in for analysis.
 SCLEROTHERAPY/ GLUE INJECTION/ BANDING

Cyanoacrylates are a family of strong fast-acting adhesives with industrial, medical,

and household uses. They are various esters of cyanoacrylic acid. The acryl groups in
the resinrapidly polymerize in the presence of water to form long, strong chains. They
have some minor toxicity.
Specific cyanoacrylates include methyl 2-cyanoacrylate (MCA), ethyl 2-
cyanoacrylate (ECA, commonly sold under trade names such as "Super Glue" and
"Krazy Glue", or Toagosei), n-butyl cyanoacrylate (n-BCA), octyl cyanoacrylate and 2-
octyl cyanoacrylate (used in medical, veterinary and first aid applications). Octyl
cyanoacrylate was developed to address toxicity concerns and to reduce skin
irritation and allergic response. Cyanoacrylate adhesives are sometimes known
generically as instant glues, power glues or superglues. The abbreviation "CA" is
commonly used for industrial grade cyanoacrylate.
What is glue injection?
The needle is then removed from the vein. Slightly before injection, suction is
usually disconnected to ensure no aspiration of cyanoacrylate glue into the
endoscope channel. One millilitre of glue is injected at each injection site, with two
to three injections typically used per endoscopic therapy session.
Endoscopic therapy is a way of preventing and treating variceal bleeding without the
requirement for surgery. In the most common procedure
called endoscopic varicealbanding (or ligation), rubber bands are placed around varices in
the esophagus through a flexible endoscope which is used to visualize the vessels.

When these adhesives are mixed, a chemical reaction occurs, causing them to
harden. Cyanoacrylate is an acrylic resin that forms its strongest bond almost instantly. ...
Since almost every object has at least tiny amounts of water on its surface, super glue
does a super job of sticking most things together very quickly.

Esophageal varices are enlarged or swollen veins on the lining of

the esophagus.Varices can be life-threatening if they break open and bleed. Treatment is
aimed at preventing liver damage, preventing varices from bleeding, and controlling
bleeding if it occurs.

Gastric varices (GV) are present in approximately 20% of patients with portal hypertension. GVs
bleed less frequently than esophageal varices (EV), but bleeding is more severe and mortality is
higher. Risk factors for gastric variceal bleeding (GVB) include variceal location (particularly the
fundus), size, overlying red signs, and advanced liver disease.1

Management of Acute Bleeding and Prevention of Rebleeding General Considerations Similarly to

patients with EV, patients with suspected GVB should be managed in an intensive care unit with
careful blood volume resuscitation (target hemoglobin 8 g/dL), administration of prophylactic
antibiotics (intravenous ceftriaxone in high-risk patients), correction of significant clotting
abnormalities, and endotracheal intubation in patients at risk for aspiration. Despite the lack of
efficacy data for GVB, vasoactive agents (e.g., octreotide) are administered because of their
favorable safety profile and potential benefit. Variceal

tamponade with a large capacity balloon (e.g., a LintonNachlas tube) is used as bridge therapy in
patients with massive or uncontrollable bleeding. The optimal approach to GVB remains undefined
because of a lack of robust evidence-based data from large randomized trials and the inclusion of
different types of GV among studies. Several endoscopic, interventional radiologic, and surgical
treatment options are available. The selection of a particular treatment modality is influenced in
part by patient characteristics, type of GV, available expertise, technical/anatomical considerations,
and therapy-specific contraindications.

Endoscopic Intervention Band Ligation and Sclerotherapy.

The management of GOV1 is similar to that of EV, and endoscopic band ligation (EBL) is preferred to
sclerotherapy because of a lower risk of complications. However, EBL and sclerotherapy may be
ineffective therapies for fundal varices (GOV2 and IGV1) because of high rebreeding rates and the
potential for massive bleeding from large treatment-induced ulcers. EBL can be used to control
active fundal variceal bleeding if it is the only available endoscopic option, but referral to a center for
performance of more definitive therapy (e.g., cyanoacrylate injection) is recommended for
prevention of rebleeding (secondary prophylaxis). Cyanoacrylate Injection. Cyanoacrylate (glue)
injection is the recommended first-line therapy for GVB,3,4 with initial control of bleeding in 90% to
100% of patients and rebleeding rates complication rates.8-11 Cyanoacrylate is not approved by the
US Food and Drug Administration for intravariceal injection, but it is used off-label with increasing
frequency in the United States. Cyanoacrylate injection requires careful patient selection and
attention to technique for an optimal outcome. Dynamic computed tomography is recommended to
determine the presence of spontaneous large splenorenal or gastro renal shunts (GRS). These shunts
are associated with the risk for systemic glue embolism. A standardized injection protocol enhances
procedural safety and efficacy,6 although technical variations exist depending on the type of
cyanoacrylate used and local expertise (Table 1). Complete variceal obturation, including tributaries,
is attempted at the initial session, and repeat endoscopy is performed in 4 weeks to confirm GV
obliteration or treat residual varices (Fig. 2). Following variceal obliteration, surveillance endoscopy
is typically performed at 3- to 6-month intervals to monitor for variceal recurrence. A glue cast may
remain visible for weeks to months after injection. Beta-blocker therapy alone is inferior to
cyanoacrylate injection for secondary prophylaxis of GVB,12 and its use in conjunction with
cyanoacrylate provides no

additional benefit with regard to prevention of rebleeding and mortality.13 The incidence of
cyanoacrylate-related complications is low, which include bleeding from early glue cast extrusion,
sepsis, and distant glue embolism.14 The presence of intracardiac or intrapulmonary shunts (as
assessed by contrast echocardiogram) and a large GRS heighten the risk for systemic glue
embolization.1 The embolic risk may be minimized with the introduction of novel techniques, such
as EUS-guided coil/glue injection and the combined approach of endoscopic cyanoacrylate injection
with angiographic balloon occlusion of the GRS (Fig. 3), although additional appraisal of these
modalities is warranted.15,1

cyanoacrylate may be more cost-effective than TIPS,20,21 the latter is generally used as rescue
therapy after failed endoscopic intervention for acute GVB. Following the acute episode, either
cyanoacrylate or TIPS can be recommended for prevention of recurrent bleeding from fundal
varices.