3.3 Therapeutic & Hemostatic Interventions

Why Therapeutic Endoscopy Is High-Yield

Therapeutic interventions convert a diagnostic exam into definitive treatment but introduce the highest bleeding and perforation risk in the unit. The CGRN exam expects you to match the technique to the clinical problem and to apply electrosurgical safety flawlessly.

Resection Techniques

Cold snare polypectomy is preferred for polyps under 10 mm because it avoids electrosurgical current and lowers delayed-bleeding and deep-thermal-injury risk. EMR uses a submucosal injection to lift the lesion and create a fluid cushion before snaring. ESD removes large lesions in one piece for accurate margin assessment but takes longer and carries the highest complication rate. CO2 insufflation is preferred over air for long resections because it is absorbed rapidly and reduces post-procedure bloating and the consequences of any perforation.

Hemostatic Interventions

Endoscopic hemostasis often combines modalities for durable control of nonvariceal bleeding (for example, a bleeding ulcer with a visible vessel):

• Injection therapy: dilute epinephrine, typically 1:10,000, for tamponade and vasoconstriction — effective initially but used as an adjunct, not a sole therapy, because rebleeding is common.
• Thermal/contact: bipolar/multipolar probe, heater probe, and argon plasma coagulation (APC), a noncontact method ideal for diffuse vascular lesions such as gastric antral vascular ectasia (GAVE) and radiation proctitis.
• Mechanical: through-the-scope clips and over-the-scope clips appose tissue, treat visible vessels, and can close small perforations; hemostatic powders/sprays cover diffuse oozing.
• Band ligation: endoscopic variceal band ligation (EVL) is the first-line endoscopic treatment for esophageal variceal hemorrhage and is preferred over sclerotherapy because of fewer strictures and ulcers.

During active GI bleeding the nurse anticipates the next device, manages irrigation and suction, tracks estimated blood loss, ensures large-bore IV access and type-and-cross, and continuously monitors hemodynamics and airway.

Luminal Dilation

Dilation treats strictures (peptic, anastomotic, Schatzki ring, achalasia) using a through-the-scope (TTS) balloon or bougie/wire-guided dilator. The "rule of three" limits passing no more than three progressively larger bougies once resistance is met, to reduce perforation. The principal complication is perforation; post-procedure the nurse watches for chest or abdominal pain, subcutaneous emphysema (crepitus in the neck), fever, and tachycardia.

PEG Placement and Care

Percutaneous endoscopic gastrostomy (PEG) places a feeding tube through the abdominal wall into the stomach under endoscopic guidance, indicated when long-term enteral nutrition is needed (dysphagia, stroke, neurologic injury, head and neck cancer).

Nursing care priorities:

• Site assessment: monitor for infection, leakage, hypergranulation, and skin breakdown; keep the site clean and dry.
• Avoid excessive external bolster tension — a tight bumper restricts blood flow and causes buried bumper syndrome, in which the internal bumper erodes into or through the gastric wall. Maintain a small gap (about 0.5 cm) between the external bolster and skin per protocol.
• Rotate and advance/retract the tube per facility protocol once the tract has matured (usually after the first week or two) to prevent buried bumper.
• Confirm placement and patency, flush with water before and after feeds and medications, and check residuals per protocol.
• Delay initial feeding per order (many protocols wait several hours after placement) and start at the ordered rate.

Electrosurgery Principles and Safety

Many therapeutic devices use electrosurgical current to cut and coagulate.

An improperly applied or partially detached dispersive pad concentrates returning current and can cause a patient burn — a frequently tested safety point. Document pad site and skin condition before and after the procedure, and remove the pad gently to avoid skin tears.

Matching the Technique to the Clinical Problem

A common exam pattern presents a clinical scenario and asks which therapeutic approach fits. Use this quick map:

• Small (<10 mm) pedunculated or sessile polyp → cold snare polypectomy (no electrosurgery needed).
• Large flat/sessile lesion, benign-appearing → EMR with submucosal lift; a non-lifting sign suggests deep invasion and may divert to surgery.
• Large lesion needing intact margins or suspected early cancer → ESD for en bloc removal.
• Bleeding peptic ulcer with a visible vessel → combination therapy (epinephrine injection plus a thermal or mechanical method).
• Bleeding esophageal varices → EVL; if the patient is hemodynamically unstable or banding fails, anticipate balloon tamponade and transjugular intrahepatic portosystemic shunt referral.
• Diffuse vascular bleeding (GAVE, radiation proctitis, angiodysplasia) → argon plasma coagulation.
• Symptomatic stricture → balloon or bougie dilation.

Periprocedural Bleeding Risk and Anticoagulation

Therapeutic endoscopy is classified as high-bleeding-risk, so antithrombotic management is a recurring topic. Per ASGE guidance the team weighs the thrombotic risk of stopping a drug against the bleeding risk of the intervention. Aspirin for secondary prevention is often continued; clopidogrel and direct oral anticoagulants are commonly held for a defined interval and may be bridged for very high thrombotic-risk patients. The nurse confirms the hold plan is documented, verifies the last dose taken, and ensures large-bore IV access and a current type and screen before high-risk resections.

Complication Watch After Therapeutic Endoscopy

The two dominant complications are bleeding (immediate or delayed up to two weeks after polypectomy/EMR/ESD) and perforation. Teach outpatients to report severe or worsening abdominal pain, fever, rectal bleeding more than minor spotting, dizziness, or black tarry stools. Post-polypectomy electrocoagulation ("postpolypectomy") syndrome — localized pain, fever, and leukocytosis from transmural thermal injury without frank perforation — is usually managed conservatively but must be distinguished from true perforation by imaging.