Treatment of oesophageal and gastric varices A guide to the test Information for patients Endoscopy
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Welcome to the Endoscopy Suite Sheffield Teaching Hospitals NHS Foundation Trust has two Endoscopy Departments. One is at the Northern General Hospital and the other at the Royal Hallamshire Hospital. You may have your test at either hospital depending on current waiting lists. When you book your test you will be told which hospital you need to go to. It may not be your own consultant who undertakes the procedure. It may be another doctor. All doctors undertaking the procedure will have had appropriate training or will be supervised by a doctor who has. At the Northern General Hospital there are four Endoscopy rooms and at the Royal Hallamshire Hospital there are also four Endoscopy rooms (the fourth is based on P floor) in operation at any one time, performing different procedures; therefore other patients may be seen before you. Please feel free to write in your booklet where your appointment is and the date and time of it: Hospital Date Time page 3 of 20
If you are unable to keep your appointment, please tell the department you are attending as soon as possible. This will allow us to give your appointment to someone else and arrange another date and time for you. The Endoscopy Suite telephone number is: Northern General Hospital: 0114 226 9174 Royal Hallamshire Hospital: 0114 271 2990 You may get an answer machine, if so please leave a message and contact number and someone will get back to you. What are varices? Varices are dilated veins found in the gut and are most commonly seen in the oesophagus (gullet) or stomach. The most common cause is portal hypertension which is an increase in the blood pressure in the portal vein which feeds the liver. This increase in pressure could occur because of a clot in the portal vein or because the resistance in the liver is increased because of scarring (cirrhosis). This increase in pressure causes the blood to find another way back to the heart rather than through the liver. New vessels open up and some of these run along the lining of the gut. These veins (because of the pressure from the portal vein) protrude into the gullet and the stomach and can bleed. Bleeding from these veins can in some cases be life threatening, therefore it is essential to seek urgent medical attention in the event of a bleed. The symptoms of a bleed may include vomiting blood through the mouth or passing blood in the stool which may look black and sticky like tar. page 4 of 20
Why do I need this procedure? You have been found to have varices which your consultant feels need treating. There is a risk of them bleeding and the best way to treat them is through an endoscopic procedure. Varices don't always bleed, however it is best to treat them before they bleed. Treatment aims to reduce or shrink them resulting in a lesser chance of them bleeding in the future. There are different treatment options for varices and this depends on the site of the varix. Varices in the oesophagus (gullet) are usually treated with rubber bands although sometimes they are treated by injection. Gastric varices (stomach) are usually treated by injection. Oesophagus Stomach Duodenum page 5 of 20
How does banding work? Banding is a way to treat oesophageal varices. It involves having an endoscopy (camera test) in which a long flexible tube with a light on the end (an endoscope) is passed through your mouth into your gullet and stomach. If varices are seen and require treatment the doctor will remove the endoscope and attach a device which is loaded with rubber bands. The endoscope is then re-passed into your gullet and the swollen veins are sucked up into the device allowing the rubber bands to be placed. Once the bands are placed the endoscope is removed. These rubber bands hopefully reduce the blood flow in these veins, thereby reducing the chance of them bleeding. It is likely that this procedure will need to be repeated every 2-3 weeks until the varices are much smaller. This will not affect the normal blood supply to the gullet or stomach. The varices are simply extra veins that have developed. The banding procedure itself is not usually painful however the endoscopy procedure can be a little uncomfortable. Sometimes varices cannot be banded. Another type of treatment is to inject the varix with a chemical which causes them to thrombose (become hard). This procedure is similar to the banding procedure, however the endoscope does not need to be removed to attach a device. A fine tube is passed through the endoscope which has a needle on the end. The chemical can therefore be injected directly into the varix. Again this procedure is not usually painful. The doctor performing the endoscopy will decide which treatment is best for you. page 6 of 20
Gluing of gastric varices Injecting glue into varices is a way to treat gastric (stomach) varices. In the same way as the banding procedure, the endoscope is passed through your mouth into your gullet and stomach. If gastric varices are seen and require treatment a fine needle can be passed through the endoscope which has a needle on the end. The glue can be injected directly into the varix which causes the varix to thrombose (become hard). This procedure will almost certainly need to be repeated every 2-3 weeks until the varix is thrombosed. This procedure is not usually painful. Can there be complications or risks? Banding is a safe procedure with very rare complications, but occasionally the following can occur: Both banding and injecting varices can cause bleeding. If this does occur it can usually be treated through the endoscope. However, the banding treatment can cause bleeding which is usually easily treated through the endoscope. Injection of gastric varices carries a small risk of embolism (blood clot) to the lung, spleen or brain. This would require urgent admission to hospital. In a very few, rare cases the gullet can become narrowed as a result of scarring from the procedure. You may suffer from a sore throat or feel some wind in your stomach. These will settle in a few days. There is a small risk of damage to crowned teeth or dental bridge work. You may have occasional difficulty with swallowing due to swelling of the tissues. This should settle after a couple of days. page 7 of 20
Do I have to have this treatment? Your consultant will recommend the best treatment for you and this will have been discussed with you. The decision is yours as to whether you have an endoscopy and what treatment you have. Preparation for the test To allow a clear view, the stomach should be empty. If your test is in the morning, please have nothing to eat or drink from midnight of the day before. If your test is in the afternoon, please have nothing to eat or drink after a light early breakfast (e.g. toast and a drink only between 7.00am - 8.00am) on the day of test. Medication If you are taking anti-blood clotting medicines such as Warfarin, Rivaroxaban, Apixaban, Dabigatran or Clopidogrel (Plavix) please contact the Endoscopy Suite as soon as possible as these may need to be stopped before your procedure. If you take essential medication, for example for epilepsy or a heart condition, you may take these with a little water. Please try to take them as early as possible before your test as some tablets leave a residue in the stomach, which may affect the quality of the results. Do bring your other tablets or medicines with you so that you can take them after you have had your Gastroscopy. If you are diabetic, please refer to the 'Managing your diabetes' booklet, which you received with your appointment letter. page 8 of 20
The number to call is: Northern General Hospital: 0114 226 9174 Royal Hallamshire Hospital: 0114 271 2990 You may get an answer machine, if so please leave a message and contact number and someone will get back to you. Before your appointment Before you come to the Endoscopy Suite you should: Ensure you have completed your pre-assessment questionnaire and returned it to the Endoscopy Suite. Let us know if you are suffering from a cold or chest infection as it may be necessary to postpone your test. Bring with you any letters or cards you have received from the hospital. Bring any tablets you are currently taking. It is especially important to remember any asthma inhalers, angina sprays or diabetic medication. Follow all instructions included with this booklet. Come on time for your appointment. You should not bring valuables or large amounts of money into hospital, as we cannot accept responsibility for them. Do not drive yourself to or from hospital. Make sure someone is able to bring and collect you as you must have a responsible adult to accompany you home. How long will I be in hospital? This will depend on your individual procedure and on whether or not you choose to be sedated for your test. If you choose sedation, please allow for a stay of anything from 2-4 hours. If you choose not to be sedated, then your stay will be much shorter. Please note that your page 9 of 20
appointment time is for your pre-procedure assessment and not the time of your examination. You may find your test is delayed. We do sometimes have to deal with unexpected emergency cases and this can prevent us seeing you as quickly as we would like. We apologise if such delays happen to you. If they do we will try to keep them to a minimum and make sure you know the reason for the delay. Please be patient. When you arrive at the Endoscopy Suite On arrival at the hospital, please go to the reception desk in the Endoscopy Suite. Once checked in, you will be asked to take a seat in the waiting room. A nurse will call you in for pre-assessment. This involves checking your pulse and blood pressure, whether you have any allergies, and confirming your discharge arrangements. Please feel free to ask questions or voice any worries you may have regarding your test. The nurse will explain the options of sedation (injection) and local anaesthetic (throat spray). Both are available for this procedure. Throat spray This is a local anaesthetic spray to numb your throat. It has a slightly bitter banana taste. You may have the feeling of a 'lump 'in your throat or a gritty tongue, this is normal following throat spray and the sensation will wear off over about an hour. Throat spray is very safe and with it: You recover quickly You can hear and talk about the results of the test right away There is no delay in going home You can drive home You are more aware of discomfort page 10 of 20
Sedation This is a sedative injection, which may make you sleepy. It is not like a general anaesthetic so you may still be aware of having the procedure. It does however sometimes have a short term 'amnesic effect' which means you may not remember having the procedure. Having sedation means that you: Will be less anxious May be sleepy May not remember the test at all Will need to be monitored carefully Will take longer to recover Will not be able to drive home Will have to have an adult with you to take you home We advise you to refrain from taking any sleeping tablets on the day of your procedure if you have had sedation. If you choose to have the injection you must have a relative or friend with you who can also stay with you for 24 hours. After pre-assessment you will be called through for examination and the Endoscopist will discuss the procedure with you. Again, if you have any questions or are unsure about anything, please ask. It is necessary to remove any false teeth if you wear them. These will be placed in a denture pot and labelled. They will stay with you at all times. The consent form Before a doctor or healthcare professional examines or treats you, they will need to gain your consent. This will be required in writing. If you later change your mind, you are entitled to withdraw consent even after signing. A copy of the consent form will be offered to you. page 11 of 20
What should I know before deciding? The Endoscopist or health professional will ensure you know enough information about the procedure to enable you to decide about your treatment. They will write this information on the consent form as well as discussing choices of treatment with you. We encourage you to ask questions and inform us of any concerns that you may have. It may be helpful for you to write these down as a reminder. What are the key things to remember? It's your decision! It's up to you to choose whether or not to consent to what is being proposed. Ask as many questions as you like and please express any concerns about medication, allergies or past medical history. Can I find out more about giving consent? There is more information about consent on the NHS Choices website: www.nhs.uk/conditions/consent-to-treatment The Sheffield Teaching Hospitals Trust is a teaching organisation and has a responsibility to ensure that students (both medical and nursing) receive a high standard of training. The Endoscopy Unit is a regional Training Centre. Occasionally there may be students observing procedures in the department or the doctor may be a trainee under the supervision of an experienced Endoscopist. In either case you will be told of any student involvement beforehand. Please remember you do not have to let students be part of your care so please tell us if you do not want them involved. page 12 of 20
What happens during the test? You will be seated or laid on an examination trolley and a local anaesthetic will be sprayed onto the back of your throat. This will numb your throat and make the test easier. A nurse will be with you throughout the procedure. If you wish to have a sedative injection a needle will be put into your arm at this point. You will feel relaxed and may not remember the test but it will not put you to sleep. Many hospitals now find that the test can be performed without sedation as the gastroscopes have become much smaller and are easier to swallow. If you choose an injection you will be given oxygen through a plastic mouthguard. A small peg will be placed on your finger to measure your heart rate and oxygen level. It is necessary that you lie on your left side for the test. To keep your mouth open a plastic mouth guard will be placed between your teeth. When the Endoscopist passes the gastroscope into the gullet it may be uncomfortable but it will not cause you any pain, nor will it interfere with your breathing at any time. The swollen vein is identified and suction is applied to draw the vein up into the tube. Elastic bands are then placed. The whole procedure will take about 20-30 minutes. page 13 of 20
What happens when the procedure is finished? You will need to rest in the Endoscopy recovery area for approximately one hour. Whilst we endeavour to keep men and women separate in the recovery area, this is not always possible especially at peak time However, the staff will ensure that your privacy is maintained at all times. You may feel a little bloated with wind pains, these usually settle quickly once you have passed the wind and will not need any treatment. The action of the injection or banding causes the varices to ulcerate. This, in turn, can cause some soreness on swallowing for a few days after the procedure. You may also feel bloated with wind. Both of the discomforts will pass without medication. It is possible for a stricture (narrowing) to form in the gullet. This is more likely if the varices are large and repeated procedures are required, and is generally more common with the injection technique. Narrowing of the gullet can make swallowing difficult. You may find that you have some streaks of blood in your saliva for one to two days following your procedure. This is quite normal and should stop without any further treatment. If this continues for more than one to two days please contact the Endoscopy Department on the telephone numbers given to you on discharge. The effects of the sedation can last for at least twenty-four hours and even though you will probably feel perfectly recovered, your judgment can remain impaired during this time. It is essential that someone comes to pick you up. Once home, it is recommended that you rest quietly for the remainder of the day and that someone stays with you overnight. page 14 of 20
It is important that you do not: Drive a car Operate machinery or domestic appliances as your reaction times may be slowed Drink alcohol Sign legally binding agreements When can I get back to my normal activities? You should be ready to get back to your normal activities by the next day. Frequently Asked Questions 1. If my symptoms have stopped should I still come for the procedure? Yes. It is important that you still come for the test. Your doctor has organised this procedure to reduce the risk of the enlarged veins bleeding. 2. Will it hurt? No. You may feel some discomfort from the air that is pumped into the stomach to inflate it, but this should not hurt. You may also experience a sore throat for a few days. 3. Can I drive home after the procedure if I choose to have sedation? If you have sedation you will not be allowed to drive home and must arrange for someone to accompany you and drive you home. Medication given during the test will prohibit you from driving until 24 hours after your examination. Please do not plan to take public transport home. If you are unable to arrange transportation we can page 15 of 20
arrange a taxi to take you home, however, you are responsible for the fare. You will need a responsible adult with you for at least 12 hours. 4. What is the address for the Endoscopy Suite? Endoscopy Suite, Huntsman B floor, Northern General Hospital, Herries Road, S5 7AU Endoscopy Suite, B floor, Royal Hallamshire Hospital, Glossop Road, S10 2JS 5. Can I park at the hospital? Yes. We have car parks at both hospitals; these are indicated on the enclosed maps. The rates are as follows:- Northern General Hospital Up to 4 hours = 2.50 Over 4 hours = 3.70 All the disabled parking bays around Northern General Hospital are free of charge. Royal Hallamshire Hospital Up to 2 hours = 2.50 Up to 4 hours = 3.70 Over 4 hours = 8.40 Disabled parking bays in the multi-storey car park are charged at normal rate, however there are disabled parking bays on A and B roads which are free of charge. Car parking charges are correct at time of printing. Please ensure you check the rates before parking. page 16 of 20
6. Can I get public transport to the hospital? Yes. You may use public transport. See below for details of how to find out which bus routes serve the Endoscopy Suite you are visiting. Please remember if you have sedation you will not be able to travel home using public transport. Traveline 01709 515151 www.travelsouthyorkshire.com/timetables 7. Are there facilities for my relatives/friends to obtain refreshments while they are waiting for me? Yes. We have refreshments available at both hospitals. Northern General Hospital AMT Coffee Shop situated in the Huntsman main entrance C, Floor Royal Hallamshire Hospital WRVS situated on B road in the main entrance, B floor page 17 of 20
Please use this space to make a note of any questions you may have about your test page 18 of 20
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Produced with support from Sheffield Hospitals Charity Working together we can help local patients feel even better To donate visit www.sheffieldhospitalscharity.org.uk Registered Charity No 1169762 Alternative formats can be available on request. Please email: alternativeformats@sth.nhs.uk Sheffield Teaching Hospitals NHS Foundation Trust 2017 Re-use of all or any part of this document is governed by copyright and the Re-use of Public Sector Information Regulations 2005 SI 2005 No.1515. Information on re-use can be obtained from the Information Governance Department, Sheffield Teaching Hospitals. Email infogov@sth.nhs.uk PD5801-PIL2139 v5 Issue Date: November 2017. Review Date: November 2019