Pedi GI Handbook
Endoscopy
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)
– 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)
Clinic
Budesonide is a steroid medication that is most often used for patients with asthma but is also a common treatment for people with Eosinophilic Esophagitis (EoE). Budesonide comes in a liquid respule (package) and is mixed with either Splenda, pancake syrup, formula, or other thickeners to create a slurry. A slurry is a semiliquid mixture, one that is thin enough to drink but thick enough to slowly trickle down the esophagus (the food pipe). The budesonide mixture works by coating the esophagus during the swallowing process which helps prevent and reduce inflammation caused by EoE. It’s similar to putting cream on a rash. Follow the steps below to make the Budesonide slurry:
1) Budesonide 0.5 mg/2 mL respule
2) Mix 1 mg (4 mL or 2 respules) with any one of the following:
– 7 packets of Splenda
– 1 teaspoon pancake syrup
– 1 teaspoon honey
– 1 teaspoon of vanilla Elecare Jr (you can also add a few drops of honey for taste)
– 1 teaspoon Neocate Nutra (you can also add a few drops of honey for taste)
3) Take this ___ per day
4) After administration, swish/rinse mouth (do not swallow) or brush your teeth
5) After administration nothing to eat or drink for 30 – 60 minutes
On call
-NPO
-CBC, LFTs, BMP (BUN), PT/INR, type and screen
-IV PPI 2 mg/kg bolus then 2 mg/kg divided twice daily
or
-IV PPI drip (2 mg/kg bolus max 80 mg, followed by 0.2 mg/kg/h max 8 mg/h)
-Fluid resuscitation (gentle!)
-Transfuse 15 mL/kg up to 2 units
-Consider vitamin K, FFP
-Consider octreotide drip: 1-2 mcg/kg bolus then start 1-2 mics per kilo per hour (max 50-100 mcg/hr)
-Consider IV erythromycin to empty stomach
- Loss of the airway is the first most dangerous complication.
- Do not induce vomiting or attempt to neutralize the ingested substance.
- Do not place NG tubes blindly.
- Check for injuries of the skin or eyes, remove clothing and irrigate skin or eyes if affected and consult Ophthalmology
- Consider googling the “safety data sheet” for the specific product pH
If algorithm leads to EGD:
Zargar Endoscopic classification of caustic injuries of the esophagus
Grade Features Prognosis
0 Normal Complete recovery
1 Superficial mucosal oedema and erythema Complete recovery
2 Mucosal and submucosal ulcerations
2A Superficial ulcerations, erosions, exudates Stricture unlikely
2B Deep discrete or circumferential ulcerations High stricture Low Perf risk
3 Transmural ulcerations with necrosis
3A Focal necrosis High stricture and Perf risk
3B Extensive necrosis High stricture and Perf risk
4 Perforations
- Grade 0 and 1 may be discharged if taking sufficient liquids by mouth.
- Grade 2A may be discharged on acid suppression if taking sufficient liquids by mouth.
- Grade 2B or 3 consider
- Steroid therapy methylprednisolone (1 g/1.73 m2 per day for 3 days)
- IV antibiotics
- IV PPI
- Carafate
- NG placement at endoscopy for nutrition
- Grade 3 ICU care as there is a high risk for developing perforation.
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