• Upper gastrointestinal (GI) hemorrhage is a relatively common, potentially life-threatening emergency that requires rapid assessment and resuscitation.¹¹ Esophagogastroduodenoscopy (EGD) is the diagnostic and therapeutic modality for nonvariceal and variceal upper GI bleeding.^2,3,12 Endoscopic therapy reduces the rate of rebleeding, blood transfusion requirements, and the need for surgery.^2,3

• Endoscopic therapies are the interventions of choice for many upper and lower GI bleeding lesions. Upper endoscopic therapies include injection therapy, ablative therapy, such as heater probe, and mechanical therapy, such as endoclips or endoscopic banding.²

• For all upper endoscopic interventions, a fiberoptic endoscope is passed through the esophagus and into the stomach and duodenum to identify the site of bleeding. The nurse assisting the endoscopist prepares all of the equipment potentially needed during the procedure. Once the site of bleeding is found, any of the endoscopic techniques identified previously may be used.

• Endoscopic variceal ligation (EVL) is the preferred endoscopic method for control of acute esophageal bleeding and for prevention of rebleeding, unless excess bleeding prevents effective band placement and ligation.¹¹ Endoscopic sclerotherapy (EST), which involves injection of a sclerosant into or adjacent to a varix, may be used. EST has largely been replaced by the use of EVL, which is a type of mechanical therapy.^1,4,9,12

• For gastric varices, a promising intervention is gastric variceal occlusion (GVO) with tissue adhesives such as N-butyl-cyanoacrylate. Studies are ongoing, but tissue adhesives are not yet approved for use in the United States.^9,12

• Injection therapy is used for hemostasis for bleeding from peptic ulcer disease, Mallory-Weiss tears, and other lesions and for postprocedure related bleeding.¹¹ Epinephrine is the injection agent of choice for these maladies in the United States.²

• The several proposed mechanisms of action of the various sclerosing agents include vasoconstriction, esophageal or vascular smooth muscle spasm, compression of the bleeding vessel by submucosal edema or by the volume of sclerosing agent used (tamponade effect), and actual coagulation of the vessel. Ultimately, vessel thrombosis occurs.

• A variety of sclerosing agents are available (Table 111-1). The physician or advanced practice nurse who performs the endoscopy prescribes the agents to be used.

• Endoscopic therapy can combine a number of interventions to promote hemostasis, including esophageal band ligation, injection therapy, laser therapy, thermal coagulation, and transjugular intrahepatic portosystemic shunt (TIPS), a radiologic intervention.^2,11,12

• Ablative therapies, such as the use of a heater probe or bipolar electrocoagulation, are other endoscopic techniques for the management of bleeding from peptic ulcer disease and other nonvariceal causes of upper GI bleeding. These therapies are effective as they result in coagulation of a bleeding vessel.^2,8

• Passage of the large-bore therapeutic endoscope may stimulate the vagal response in the patient and precipitate bradydysrhythmias.

• As a result of the sedation and topical anesthetic used, the patient’s gag reflex may be diminished or absent, putting the patient at risk for aspiration.

• Sedation can put the patient at risk for respiratory depression. A moderate sedation protocol is recommended for use to guide monitoring of the patient. This protocol should include the use of recommended monitoring and emergency equipment.

• Therapeutic large-caliber endoscope (rigid or flexible; however, the flexible scope is the usual type used for upper endoscopy)

• Endoscopic injector needle (23- to 26-gauge, 2- to 5-mm needle; as ordered by physician)

• Three 10-mL syringes filled with sclerosing agent, as prescribed by physician

• Additional therapeutic equipment should be available for management of nonvariceal upper GI bleeding (i.e., laser or thermal equipment, endoloops or endoclips)

• Esophageal bands should be available for management of known or suspected variceal upper GI bleeding

• Suction setup with connecting tubing

• Rigid pharyngeal suction-tip (Yankauer) catheter

• Safety goggles for each healthcare provider and the patient

• Nonsterile gloves

• Barrier gowns

• Nonsterile 4-inch gauze or washcloth

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