Pedi GI Handbook

BRAVO CAPSULE PLACEMENT:

• Confirm with RN that device is calibrated

• Patient in left lateral decub position

• Connect vacuum tubing to delivery device

• Perform vacuum pump check to verify gauge reaches 700 mmHg. 

• Perform EGD.  Identify the GE junction.  Remove the endoscope by 6 cm and note distances from incisors.  Capsule will be placed 6 cm proximal to the GEJ.

• With either direct endoscopic guidance or blind, deploy the capsule

  • Insert capsule through the mouth to 6 cm proximal to GEJ

  • Apply suction to the catheter until 700 mmHg is reached for 60 seconds. 

  • Depress plunger to advance pin. 

  • Release capsule by rotating the plunger clockwise. 

  • If done blind, repeat scope to confirm placement.  

• Begin pH recording.

See: https://youtu.be/AA-qzQAfLDs

Ref: Sofi et al Clin Exp Gastroenterol. 2010;3:147-51. PMID: 21694859

General Principles

-Do not treat: clean base with or without small flat spots 

-Do not treat: an overlying adherent clot unless you have appropriate back-up and/or feel confident in your ability to treat underlying lesion

-Do treat: active bleeding or a non-bleeding visible vessel

-For treatment: Inject with Epi and then clip or gold probe, depending on size, location, accessibility

Inject Epi:

– How to inject epi (skip to 5:40) 

– Diluted with saline to 1:10,000 is injected in 1 mL aliquots in four quadrants within 3 mm of the bleeding site

Clip

– How to clip (skip to 7:15)  

Gold probe (thermal coagulation)

– How to gold probe

– What to gold probe? An active bleeding and nonbleeding visible vessel

Gastric ulcer: Moderate to firm pressure, 15 to 20 watts, 10 seconds per pulse (prior to probe retraction), three to five pulses total

Duodenal ulcer: Light to moderate pressure, 10 to 15 watts, 10 seconds per pulse (prior to probe retraction), three to five pulses total

Irrigation via the probe is used to wash the ulcer base, to release the probe to prevent sticking after cautery, and to facilitate repositioning of the probe for further treatment if bleeding continues. Targeted irrigation and suctioning of excess blood or fluid are extremely important to identify the specific bleeding site and focus the treatment.

To prevent the probe from sticking to the area that has been treated, water irrigation via the probe can be applied after each application of cautery to gently separate the probe from the underlying area before retracting the device

band ligator set up (skip to 2:00)

• Duodenal Aspirate

• Order “culture, aerobic/anaerobic”

  • Under “body fluid” specify “duodenal aspirate” in the comments section, since there is no specific option for intestinal aspiration

• To collect, drive the scope straight to the second/third portion of the duodenum.  Do not suction on your way in!  Consider removing the suction so you’re not tempted. 
• Ask your endoscopy nurse to attach a sterile container trap to the scope suction.  Suction duodenal aspirate into the trap
• Send aspirate off to microbiology lab immediately.  Ideally should be received/plated within 30 min.  Send at room temperature.  
• If you’re having trouble getting adequate bile secretion, consider massaging the RUQ/liver to stimulate bile flow
• Interpretation: Duodenal aspirates in most individuals contain some lactobacilli,
  streptococcus, various fungi and rare Bacteroides sp. present in
  densities of 1000 cfu/mL or less.  Abnormal results: >100,000 cfu/mL.