1. When to use Adrenaline
2. How to set it up
3. How to actually use it once it is set up

When to use Adrenaline

1. Most commonly it is used as part of dual therapy (submucosal injection) to achieve haemostasis in ulcer bleeding, bleeding AVM, Dieulafoy lesion, MW tear, post polypectomy bleeding and post sphincterotomy bleeding.
2. Sometimes it is used to lift up the polyp base before snare polypectomy
3. It is not used in variceal bleeding.

How to set it up

Picture1: Adrenaline injection

1. Ten ml syringe filled with Adrenaline solution (1:10000 dilution, comes in 10ml ampoules)
2. Injector needle, primed with same solution. In most situations you probably will use a gold probe and use dual treatment with one device.

How to actually use it once it is set up

1. Inject adrenaline in four quadrants at the periphery of the lesion. This should be followed by injection at the centre of the lesion.
2. Assistant pushes the injection hub towards yellow injector stem when you say ‘advance needle’- don’t say ambiguous terms like needle out or needle in.


Picture2: Advance needle: injector hub is pushed towards the yellow stem

3. Inject in the submucosa and inject liberal amount (tamponade effect is probably as important as the vasoconstrictor effect) – 10-15ml should be the total amount. Studies show that at least 13 mls should be injected for optimum haemostasis.
4. After injection is given you say ‘needle back’ (don’t say needle out) and assistant withdraws the needle back in sheath by pulling the hub away from the yellow stem.


Picture3: Needle back: injector hub is pulled away from the yellow stem

5. Although at times when we inject adrenaline subcutaneously at times of giving local anaesthesia, we always aspirate before injecting to make sure we are not injecting in a blood vessel, we have not come across this practice but might not be a bad idea.
6. It should be followed by another modality of achieving haemostasis ( e.g. gold probe, endoclip etc)

Complications:

1. Cardiac tachyarrhythmia can occur particularly in the event of inadvertent intravascular injection
2. Local pressure necrosis (rarely)

Here is the link for Adrenalin injection video

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98

1. When to use APC
2. How to set it up- both the cable connection and the settings
3. How to actually use it once it is set up
4. The principle behind APC

When to use APC

1. Mainly in AVMs (particularly GAVE -gastric antral vascular ectasia) and bleeding tumours.
2. It can also be used in base of polyps after snare polypectomy.
3. Rarely used in bleeding gastric and duodenal ulcers.
4. Unblocking of occluded metal stents

How to set it up- both the cable connection and the settings

1. Turn on both the boxes: Top box is normal diathermy unit ERBE ICC200 and bottom box is APC 300
2. Connection of cables:

• Connect the plug of the nessy plate (patient electrode) to the neutral slot of the top box (top box left most plug)- picture1
  
  Picture1: Top box is normal diathermy unit ERBE ICC200 and bottom box is APC 300
• Three pronged connector from lower box goes to the Cut/Coag slot of the top box – picture2- (remove the single probe connector which we use most of the time i.e. polypectomy or hot biopsy)- operator holding it after taking it off -in the picture above (Picture1).
• If you forget to connect this, APC will not work – a frequent cause of ‘APC not working’


Picture2:The plug holes of the top box from left to right– 1) neutral 2) Cut/Coag- which takes the three pronged plug from the bottom box and 3) Bipolar- not important here

• Third plug socket on the top box called bipolar is not used in APC and we just leave the plug as it is
  
  Picture3:The plug holes of the bottom box from left to right-1) goes to the cut/coag hole of the top box- the three pronged cable 2) Not important for us 3) connects to the blue APC catheter
• The ash coloured cable from the bottom box ( furthest on the right- see picture 3 ) goes to the blue APC catheter
  
  Picture4: The APC blue catheter (coutesy www.erbe.nl)

3. The settings on the boxes:

• Set the current setting on the top box by repeatedly pressing the effect select button (bottom button which looks like a loop with an arrow) and the watt select button (middle up/down button)- See picture 5.
  
  Picture5:Finger on the effect settings- select forced and a second click on same button will make the watt A( A for Argon) and then make it 65 by using up/down button
• The setting for lesion in Stomach/Duodenum/Left colon :Auto Coag (Blue right panel) to Effect Forced and Watt A65
• The setting for lesion in right colon :Auto Coag (Blue right panel) to Effect Forced and Watt A40
• The setting for lesion in jejunum/ileum ( as in enteroscopy) :Auto Coag (Blue right panel) to Effect Forced and Watt A30
• We have checked with ERBE Engineers- the yellow Autocut panel is completely irrelevant and does not matter what you set as we use only blue Autocoag pedal (Some endosocpy nurses may insist on the ‘correct setting’ and set a value on the yellow autocut section. This is totally irrelevant).
  
  Picture6: Bottom box APC 300- programme 3, cylinder 2 is empty and see the Coag/Cut settings
• On the bottom box you don’t normally need to change current setting as mostly we don’t touch the settings –
  • Make sure the programme mode is set to 2-3
  • And the both the argon cylinders are not empty – in the picture cylinder 2 is empty
  • The setting for coagulation is normally 2.0L/min and is shown on the picture as selected option.For use of APC in small bowel/right colon reduce to 1.5L/min

4. Open the Argon tank valve
5. Purge (the button on the bottom box which says PUR- see picture 1) before using it and then test it by putting the catheter tip in jelly and press the blue foot pedal and see the gas bubble

How to actually use it once it is set up

1. The probe is passed through the accessory channel of the endoscope so that the blue tip hovers over the target tissue. A black stripe located a few centimetres proximal to the tip should be visualized to prevent damage to the endoscope.
2. The probe should be as close as possible to the lesion without actually touching the lesion. The best way is to actually touch the lesion with the probe and then withdraw a little and then give a burst
3. Bursts are controlled with the blue foot switch
4. If burst happens when the tip is in contact with the tissue- a submucosal bleb will form. This is a harmless event. But this can be dangerous when you are using deep in small bowel eg Double balloon enteroscopy.
5. For right colon use lower settings of CoagA40 in other areas of colon use Coag A65
6. Depth of burn is a function of time of burst and the power setting
7. Short bursts of 0.5secs to 2secs duration
8. Frequently suction off gas to avoid over-insufflations, particularly in the colon.

Advantage over conventional coagulation methods:

1. Depth of injury is limited – typically 3mm– better protection against perforation of thin-walled anatomy.
2. Can be used over relatively large areas using non contact method

Complications of the procedure:

1. Complications are rare. However, like any coagulation method, serious complications can occur, particularly in the right colon. Rare cases of perforations have been reported.
2. Other complications like subcutaneous emphysema and pneumoperitoneum have also been reported. These are likely caused by over distension within the right colon.

The principle behind Argon Plasma Coagulation

Picture7: The principle of APC (courtesy www.erbe.nl)

APC uses argon gas to deliver plasma of evenly distributed thermal energy to a field of tissue adjacent to the probe. A high voltage spark is delivered at the tip of the probe, which ionizes the argon gas as it is sprayed for a distance of 2-10mm from the probe tip in the direction of the target tissue. Current density upon arrival at the tissue surface causes coagulation. The application of the energy to the tissue is uniform, and contact free.

APC equipment thus combines argon gas with a monopolar power source. The electrode in the argon channel of the probe is connected to an electrosurgical generator.

The plasma beam has a tendency to turn away from already coagulated (high impedance) areas toward bleeding or still inadequately coagulated (low impedance) tissue in the areas receiving treatment. This automatically results in evenly applied, uniform surface coagulation.

Information regarding The Principle of Argon Plasma Coagulation: (courtesy www.erbe.nl)

Here is the link for APC Video:

Acknowledgement/Bibliography:

1. Rolachon A et al.Is argon plasma coagulation an efficient treatment for digestive system vascular malformation and radiation proctitis? Gastroenterol Clin Biol 2000;24(12):1205-10.
2. Grund KE et al. Argon plasma coagulation (APC) in flexible endoscopy Experience with 2193 applications in 1062 patients. Gastroenterolgy 1998; 114: A603
3. Wilson SA et al. Endoscopic treatment of chronic radiation proctopathy. Curr Opin Gastroenterol 2006;22(5):536-40.
4. ERBE: for kindly letting us use the information and pictures

1. When to use Gold probe
2. Different parts of the Gold probe
3. How it is set up and used
4. Other types of thermal devices in use

When to use Gold probe

1. Mainly in peptic ulcer bleeds
2. Bleeding polyp stalks
3. Dieulafoy lesions
4. Mallory-Weiss tears
5. Arterioveous malformations (AVMs)

Different parts of the Gold probe

Injection Gold Probe Catheter can be used to give injection therapy and also for electro haemostasis. It has also got irrigation capabilities.

Picture1: The gold probe

1. The catheter handle is a thick triangular portion- from its apex emerges the cable leading to the gold tip
2. From the base of the catheter handle arises
   1. The injection hub (with the red/green mark) and
   2. The cable which splits into two further cables
      1. One with the thicker, flange shaped end is the bipolar electrical connector- which is connected to the cable coming from the bipolar socket of the ERBE diathermy box (ICC 200)

      
      Picture2: The electrical connector/ irrigation hub

      2. The other cable takes a saline filled syringe to flush the tip after burning but alternatively you can exchange the adrenaline syringe with a saline filled syringe and flush.
3. The device is supplied in 7Fr (2.3mm) and 10Fr (3.2mm)- 7F and 10F probes require a minimum of 2.8mm and 3.7mm working channels respectively. So use 7F Gold probe if your endoscope is not a therapeutic one (yellow colour as opposed to salmon colour which is therapeutic)
4. The length of the gold probe is usually 210cm but 300cm and 350cm is also available to use in particularly deep in small intestine and colon if needed.

How is it set up and used

1. Connect the bipolar electrode end to the bipolar socket of the ERBE box


Picture3: The ERBE diathermy box ( ICC 200)

2. For gold probe:
   1. No patient plate/neutral cable is needed ( in the picture it is left connected from previous use but is not used)
   2. Accessory cable (gold probe in this case) is attached to the bipolar socket in the diathermy box (ICC 200)
   3. Nothing goes in the cut/coag socket (the middle socket in the diathermy box- we just left the plug of the APC in from previous use but it is not needed)
   4. Cutting panel is not needed at all and the setting on the autocut panel is irrelevant and the yellow pedal should not be used.
   5. Chose Autocoag with bipolar effect (as opposed to soft or forced which we used before), power to 15-30W for visible vessels/ Dieulafoy lesion/ Mallory Weiss lesion
   6. Choose power to 10-15W for colonic bleed (AVM/ diverticular bleed)
3. Connect a saline filled syringe to the irrigation hub and inject water until water is visible at the distal tip of the probe
4. Test the probe before passing it through the endoscope by touching the tip to a 1-2ml of saline / KY jelly and depressing the footswitch to activate the probe tip- saline bubbles are to be seen and steam should be emitted
5. Adrenaline filled syringe (1:10000 dilution adrenaline) is attached to the injection hub and pull back on the injection hub until hub locks into position to ensure that the injection needle is completely retracted into the probe tip
6. Turn off the electrosurgical generator during the insertion of the Gold Probe
7. Advance the tip until the gold tip is endoscopically visible through the endoscope
8. For lesions in the duodenum sometime you might find resistance in passing the gold probe when it’s tip reaches tip of the scope- then straighten the scope as much as possible and try again.

To use the gold probe to inject adrenalin

1. After positioning the tip near the lesion – slowly push the injection hub to the catheter handle until full extension of the needle is visible (4-6mm)
   
   Picture4: Pushing the handle in makes the needle to come out of the sheath
2. Under typical endoscopic configurations the green band on the injection hub should be partially visible.
3. Under some very tortuous configurations the green band and/or the red band may be completely hidden. But never push the injection hub past the proximal end of the red band
4. Insert the extended needle into the selected site and inject 1:10000 dilution adrenaline in 2-3ml aliquots and then completely withdraw the needle once finished.
5. Remember the volume of the adrenaline solution is important to exert tamponade effect.

To use the gold probe for electrohaemostasis

1. Identify and position the endoscope proximal to the intended cautery site.
2. Advance the probe until perpendicular or tangential contact is made with the site. Good apposition of the tip to the tissue is important (co-aptive pressure)
3. Using the Blue foot pedal activate the tip to cauterize the site- 2-5secs
4. Irrigate with saline before detaching the tip from the burnt area to avoid sloughing of devitalized tissue.

Other types of thermal devices in use

A) Heater probe ( Unipolar) – Teflon coated hollow aluminium cylinder with inner heating coil- heats tissue directly

B) Bipolar (Multipolar) – generates heat indirectly by passage of electric current. Two electrodes in the tip complete a circuit through non-desiccated tissue.

Types

• HEMArrest- Bard interventional products
• Gold Probe- Microvasive, Boston Scientific
• BICAP- Circon Acmi
• Quick silver- Wilson-Cook Medical Inc.

Here is the link for Gold probe Video:

Acknowledgement/Bibliography:

1. Gustavo A et al. Thermal probes alone or with epinephrine for the endoscopic haemostasis of ulcer haemorrhage Best Practice & Research Clinical Gastroenterology June 2000 :14 (3): 443-458
2. Jensen DM et al.CURE multicenter randomized, prospective trial of gold probe vs. Injection & gold probe for hemostasis of bleeding peptic ulcers. Gastrointestinal Endoscopy 1997:Volume 45 (4), Page AB92
3. Arasaradnam RP et al.Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding Postgrad Med J. 2005;81:92-98
4. Product guide of the respective companies- Boston Scientific

1. When to use endoclips
2. Different parts of the endoclip
3. How to set it up and fire the endoclip

When to use endoclips

1. Endoclip is a device commonly used to clip a bleeding vessel particularly in the context of a bleeding ulcer or a Dieulafoy lesion.
2. Other uses are to achieve haemostasis in bleeding from sphincterotomy and to stop bleeding from the base of a polyp after polypectomy.

Different parts of the endoclip

An Olympus QuickClip device has been shown, however the principles are the same for all types of endosclips. It comes both for upper GI and lower GI applications.

1. Starting with the tip/clip which is covered in a plastic sheath.
2. 

Picture1: The red stopper prevent the yellow slider to move so that the clip stays in side the sheath

2. Next is the handle with the yellow slider.

3.In between the two stays the red stopper

3. The thumb-rest ring
4. 
   Picture2: The yellow slider, red stopper and the firing handle
5. How to set it up and fire
6. This is mainly operated by the endoscopy nurse but you need to know the working of the endoclip.
7. Pass the tip of the endoclip which goes through the biopsy channel and make sure the red stopper is intact and the clip is retracted inside the sheath which is normally the case as you take it out of the packaging.
8. The red stopper prevents the clip coming out of the sheath accidentally.
9. When the endoscopist is in right position and ready to deploy the clip he will ask to open the clip. This is when you/assistant should remove the red stopper
10. Pull the yellow tube towards the slider and this would bring the clip out of the sheath.
11. 
    Picture3: The pulling of the yellow slider to the handle makes the clip to come out of sheath but it is not fully open to deploy yet
12. To get the clip in correct position the endoscopist might ask you to rotate the clip. Clip can be rotated by rotating the handle.
13. When everything is ready the endoscopist pushes the clip to the vessels and ask you to fire
14. Now before actually firing you will have to prime the clip
15. If you look carefully there is a waist at the bottom of the clip ( making the clip to look like X rather than V) and the clip in this stage is not completely open and there is less gripping power.
16. 
    Picture4: Olympus Quickclip: Courtesy Olympus
17. Before firing the waist need to vanish so that the clip is completely open and looks like letter V.
18. The same movement which fires the clip will get rid off the bottom waist but you have to be careful not to go all the way which than will fire the clip.
19. 
    Picture 5: Note that the bottom waist has vanished and clip looks like letter V
20. You will hear two distinct sound – the first faint click indicates the waist at the bottom is gone and the clip is ready to fire and the second louder click indicates that the clip has been fired.
21. Lastly fire by pulling the handle towards the thumb rest.

Picture 6: The firing grip and pull the handle towards the thumb-first click means the clip is primed and the second click means the clip is fired- second click is much louder and harder

Here is the link for Endoclip video:

1. Video 1
2. Video 2

Acknowledgement/Bibliography:

1. Tang SJ et al. Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery. Obesity surgery 2007; 17: 1261-1267
2. Ohta S et al. Hemostasis with endoscopic hemoclipping for severe gastrointestinal bleeding in critically ill patients. Am J Gastroenterol 1996;91:701-4.
3. Yoshikane H et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997; 46:464-6.
4. Product guide of the respective companies- Olympus