Our seminars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, entitled acute management of GI bleeding. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started just a few housekeeping items. We want to make sure the session is interactive. So feel free to ask any questions at any time by clicking the q amp a feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit. Please note that this presentation is being recorded and will be posted within two business days on GI leap. You will have ongoing access to the recording and GI leap as part of your registration. Now it is my pleasure to hand over the presentation to our two GI fellow moderators, who will help with the incoming questions, Dr. Jamie Bering, and Dr. Khushboo Ghala. I will now hand the presentation over to them. Thank you, Marilyn. Hello everyone and Happy New Year. My name is Jamie Bering. I'm a third year chief GI fellow at Mayo Clinic Arizona. Thank you to the ASGE for hosting this educational webinar tonight to our incredible panelists for their commitment to fellow education. And thank you to all of you for joining us. Hi everyone. Good evening and Happy New Year. My name is Khushboo. I'm a first year fellow at Mayo Clinic Rochester. It's a pleasure to be here. I'm looking forward to the session. It's my pleasure to introduce our main moderator for tonight's session, Dr. Alon Kahn. Dr. Kahn is a senior associate consultant and assistant professor of medicine in the division of gastroenterology and hepatology at Mayo Clinic Arizona. He specializes in caring for patients with esophageal disorders and has a particular expertise in clinical focus in Barrett's esophagus and esophageal cancer. He also cares for patients with complex and refractory esophageal strictures using novel techniques and he directs the esophageal self dilation program in Arizona. It is my distinct honor to introduce our amazing panelists for today. We have Dr. Nina Abraham. Dr. Abraham is a professor of medicine and consultant in the division of GI and hepatology at Mayo Clinic Arizona. She completed her medical school training at Dalhousie University in Canada and then did her internal medicine residency, GI fellowship, advanced therapeutic endoscopy fellowship and postdoctoral research at McGill in Canada. She's a federally funded PI at the intersection of cardiology and GI disorders, focusing her research agenda on health services and outcomes research. She's the director of the Mayo Clinic gastroenterology clinic. She has served in many leadership roles at ASG and is currently serving her second term on the board of trustees of the ACG. We also have with us tonight Dr. Andy Tao. Dr. Tao is a GI hospitalist and partner at Austin gastroenterology. He graduated from Harvard University where he played football and met his wife and spent the next 11 years at Baylor College of Medicine Houston, where he completed his MD, internal medicine residency, chief residency and GI fellowship. Dr. Abraham actually taught him as a student and resident while in Houston. Dr. Tao received the prestigious Henry D. McIntosh award for the best medicine resident in his graduating class. In 2021, he was named Travis County Medical Society young physician of the year. Dr. Tao currently serves as the chief of gastroenterology of Ascension Seton Medical Center in Austin, Texas, which is a tertiary referral center in central Austin. His interests include hemostasis and perforation closure. All right. Well, thank you so much to Dr. Baring and Dr. Gallup for your excellent introductions. Thank you to all the participants for being here tonight and those who are going to watch this later on GI leaf. We thank you for your interest in this session. I also want to thank Marilyn and Lyle who have been instrumental in setting this up tonight. Thank you. And to the ASG for hosting us. So, you know, just in terms of housekeeping, I want to explain that, you know, tonight's session is intended to be interactive. We don't want to just give you a didactic lecture. We want this to be interactive. And we really prioritize the audience questions and making sure that we address the questions you have. So if there's something you've always meant to ask, some question that our cases trigger, something you were either afraid to ask or didn't want to ask, you know, the questions are anonymous. We really want you to get the answers that you are seeking today and get the education that you want. I chose the particular participants very carefully today. You know, Dr. Tao, because he has some of the best cases I've ever seen in videos that he shares online. And he has a GI hospitalist, so he's dealing with acute GI bleeding every single day. Dr. Abraham, who, as you know, is an international expert in managing GI bleeding, especially in patients on complex antithrombotic therapy. So I'm really excited to have them talk tonight and hope that you'll participate with questions. So Dr. Tao is going to take it away and show us some cases and then we will have some discussions as we go through. Thanks so much, guys. It's really an honor. So the goal of my presentation is to be very, very practical. I want, after tonight, all the fellows to go home and be able to use something tomorrow in the hospital on call. So it's going to be very practical. I'm not going to go through a lot of studies. I'm going to really just show you how I do things. Maybe it's not the right way, but it's the way I do it. And I do a lot of bleeding cases. So this is the sum of my experience, and I hope to share these pearls with you. I think they're quite useful. I have a few disclosures. So the pregame. So before the endoscopy begins, risk stratification, resuscitation, timing, and some classifications are worth mentioning. In terms of resuscitation, when I see a patient who's having an active GI bleed or at least some type of a GI bleed, I touch their skin first. I see if they're cold and clammy and clamped. If they are, they're having active bleeding oftentimes because they're having a big adrenergic surge. Then I put them head down in a Trendelenburg position, and I check their blood pressure. If their blood pressure goes up with the Trendelenburg position, then I know that their volume depleted. And so I bolus them lactated ringers until the red blood cells are ready. I also look at their IVs. I need two large IVs at least, but there's no limit. You can have as many IVs as you want. There's a saying, I think I mentioned earlier when I played football, before the quarterback snaps the ball, he says, green 18, blue 22. Those tell you the gauge of the needles. The smaller the gauge, the bigger the diameter. Green is 18, blue is 22. You want green 18 if you can. Blue 22 sucks. Green 18, or even if you find a green 14, that's incredible. The guidelines here in Europe both recommend a restrictive red blood cell transfusion strategy between around seven to eight. Sometimes you can go a little higher if they have cardiovascular comorbidities. I always ask for the BUN creatinine ratio, and it means even more in some ways than the hemoglobin. Their BUN creatinine ratio rises for two reasons in upper GI bleeds. One, when you're having a bleed, your volume depleted, so you get pre-renal azotemia. That makes your BUN creatinine ratio go up. Also, you're digesting your own blood, which is a large protein meal, and that causes your BUN creatinine to go up. Interestingly, the vast majority of protein absorption happens proximal to the ligament of trites. So if someone's having melanoma and you're suspecting a small bowel bleed, but their BUN creatinine ratio is not high, it's very likely beyond the ligament of trites. That may or may not be useful to you at the moment of contact. It might be useful in terms of which scope you use, push enteroscopy or just a standard upper endoscopy. In terms of scoring systems for bleeders, they're not very useful. The Glasgow Blaster score has largely been relegated to the world of research. It's very good for research because you can classify the patients before they get endoscopy. But in terms of actual determining whether they need endoscopy or the timing of endoscopy, it's not very useful. Because almost every patient that you get called on has a higher score than zero or one. And so essentially they all need some type of admission or endoscopy. AIM-65 is a score that Dr. Saltzman developed in Brigham. It's a little bit more useful. It only requires five parameters. There's a calculator for it. It can predict mortality fairly decently. Still not incredibly useful. You still have to take out your phone and look at it. If you really want to know the truth, the only score that I use is one that you've probably never heard about. It's called the Harbinger score. It was finally published this year. It's basically three components. Whether or not the patient has been taking PPI or not, which is quite protective, as Dr. Abraham can attest. The second is the shock index. We don't hear about it a lot, but trauma people do. Shock index is a very clever ratio between the heart rate and the systolic blood pressure. And if it's greater than one, then you get one point. The shock index is actually used quite a bit in trauma. In fact, when someone gets on a medevac helicopter, I know this from a personal friend of mine in a war zone. When the moment they get on the medevac helicopter to the moment they get off, they have to report the shock index to the field hospital because it tells you how badly the person's bleeding. Lastly, of course, is the BUN creatinine ratio. If it's over 30, you get one point. If you have two or more, you get scoped. If you have just one, you can be observed in the hospital. If you have zero, you can be discharged. The Harbinger score has been compared to AIM-65 as well as the Glasgow score, and it predicts high-risk stigmata better than any of the others. That's area under the curve type analysis. So this is the one I use. It's very easy. You almost viscerally know this as a GI fellow. The third year fellows, you haven't heard of this, but you kind of know that these are three important things. This is the one I use after I eat lunch. What I mean is the afternoon consult. Afternoon consult comes, you get a bleeder, and you know every one of you fellows knows this. Then you start to think, are we going to have to keep the endoscopy staff late or my own attending late? Do we have to add this one on today or not? The Harbinger score is your friend. Use it. If it's positive, 2+, you probably do need to stay. And you're probably going to do an endoscopy and find high-risk stigmata. In terms of the timing, the guidelines say less than 24 hours, potentially less than 12 if they're not responding to resuscitation, or if they have frank hematemesis or they have a contraindication to the interruption of anticoagulation. There are a few cases of that, as Dr. Abraham can explain later. Type 1 is worse classification. The fellows, it's good to know the classifications. 1, active bleeding. Type 2 classification, some stigmata. Type 3 is clean-based ulcer. Between 1 and 2, they're separate categories, spurting versus oozing. And then 2A is visible vessel. 2B, adherent clot. 2C, flat clot. The adherent clot is highlighted because in the European and the American guidelines, they're ambivalent about what you should do. Mama always said, don't pick your scabs. But in this field, we often have to. The people that benefit the most from picking the scab, from removing the adherent clot and performing endoscopic therapy are the people who can least afford to rebleed. And those people are people who have comorbid conditions, who have concomitant antithrombotic therapy because they're going to bleed more, or older, so on and so forth. Because extra transfusions and their cardiovascular ability to tolerate shock is a lot worse in those elderly comorbid patients. That just makes sense. So for those people, you probably don't want to run the risk of them rebleeding. You're going to run that risk right there when you remove the clot. And of course, you've got to be ready, you've got to be brave, and hopefully with the tools I'm going to give you here, you will be. Everyone is familiar with the endoscopic therapeutic options. Epi and bipolar is the mainstay of therapy. You're trying to burn, you push hard, you want to see an eschar. Through the scope clips, good for non-fibrotic ulcers, dulafoil lesions, usually soft things. Fibrotic ulcers are tough. Over the scope clip, a rescue device for very big vessels, greater than the diameter of a 10 French bipolar probe, basically 3.33 millimeters, pardon. Cratered fibrotic ulcers that are tough to grab. Hemostatic forceps and hemostatic powders can be used. Alcoa is never used epi alone. Any questions? We're about to start the cases. I have a quick question for you, Andy. So talking about the timing of, I mean, before we get into the cases, but specifically, I mean, sort of more generally about the timing, there's always this sort of saying, like, too unstable or not stable enough, right? So, you know, I think this is, especially you highlighted something, which is that this gets viewed through the lens of what time of day it is, but really probably shouldn't be. So what do you think is, what do you think, you know, I mean, that's my opinion, but what do you think is the sweet spot for these upper GI bleeds in terms, I mean, you know, you could say, you know, if they go to the ICU and they're getting actively resuscitated, they're never going to achieve stability, right? That's an unreasonable goal. But what are you looking for as a GI hospitalist when these patients come in who are very sick that you know are not going to achieve, they're not going to be a heart rate of 70 and a blood pressure of 120 over 80. What are you looking for in that situation? What I'm basically looking for is I'm trying to at least normalize one of their vital signs and to get the number of units of blood in them and the hemoglobin to about seven. If, for example, someone comes in with active GI bleeding, the hemoglobin is five, you get a pressure bag, you get two large oval IVs, you give two units of blood, an hour later, it's five still. Well, you're not going to be catching up. You know, you can say two unstable, you're going to just transfuse for 13, 12 hours until the morning? No. In that case, you've had your time to resuscitate, they're not being resuscitated. Order two more units of blood, push a lot of fluid and begin the case because there is a point where you realize that they're refractory to your resuscitative efforts. Now, I don't recommend not resuscitating at all if they're actively bleeding and their parameters are going down and just jumping right in. I don't think that's the right move either. I usually give them, this is not applicable to every single case, but I give them two hours to resuscitate the patient, give the number of units of blood that's needed that's short of seven. And if I'm not there yet, if I'm not catching up, then I think I probably just have to go in a suboptimal resuscitative effort. That's usually how I do it, two hours usually. I like that. Dr. Abraham, any thoughts on that? And any thoughts on the concept of picking the scab more often in the setting of anti-thrombotic therapy? Oh, yes, definitely. I'm going to start with the latter as opposed to the former. In patients who are on any anti-thrombotic therapy, which is anticoagulants or any platelets, I think it's really important to know what the stigmata is underneath the eschar. So, yes, use guillotine, a cold guillotine to remove it. Or if you can, a forcep. I prefer a cold guillotine, shaving it off layer by layer because you want to know what's under it and treat what's under it. Because remember, with a cardiac patient on those kinds of drugs, the key is to get them back on their drugs as soon as possible. So you need to lock it down, as I like to say to the fellows with the GI bleeds. And you can't do that if you don't know what's underneath the adherent clot. So, yes, I do believe in picking the scab, as Andy said. Secondly, in terms of timing, I would agree with everything that Dr. Tao has said. And keep your eyes on parameters other than the hemodynamics. What you want to also ensure is that they're not having secondary issues such as renal failure. If they're going into a heart failure or they're getting demand ischemia, those are all bad signs. You can't twiddle your thumbs and look for a number to appear on a blood draw. You need to take action. And the only thing I would add is to say that I think the critical care specialists are a great resource, too, in that situation. We need to trust them. I think one of the really important metrics is when the critical care specialist says to me, when the intensivist says, look, they're ready, this is when we need to go, then I think you really have to take that seriously because this is what they do day in, day out. And that's very important. It might not be a specific number, but their gestalt is important in that setting, too. All right, should we move on? We have a couple of relevant questions from the audience. So one is, is there a hemoglobin that is low enough where you're afraid of fluid resuscitation before blood transfusions are given? No, I essentially try to replete with crystalloid because it's immediately available. And then I give the blood as soon as it arrives. There's not really any level that I'm afraid to do in that sequence. I use that for every single patient. They get crystalloid until their blood is ready. The other question we had is, how are you planning the size of your scopes and clips or bipolar set up? Oh, I don't. I usually always use a therapeutic upper gastroscope as my main scope and my backup scope. I use a large channel therapeutic six millimeter, we call it the clot buster scope as a backup. And then I also, for reasons that I'll explain later, bring one additional scope, which is the duodenoscope, which is a side view scope in case we get into duodenal posterior areas and I can't see very well. Those are the three scopes that I bring. In terms of the devices, I essentially bring them all. My favorite over the scope clip is the OTSC 11 slash 6T. That is good for any spot in the body. I'd like to reiterate the importance of bringing big is better when it comes to therapeutic endoscopy and you're doing a GI bleed. Nothing makes me more mental than seeing a diagnostic scope being used for a GI bleeding case because they're going to get just jammed up with clot. You're not going to be able to get things done and you're going to end up changing up your scope. Go big or go home. That's a real Baylor College of Medicine approach, but it works really well. Thank you, Nina. That advice is especially poignant as you're petting your dog. My puppy's decided to get in on the conversation. You guys ready to start these cases? Let's do it. These three bleeding cases I'm going to go through, they're probably going to run through all of the devices that are in our armamentarium in various scenarios. The first one is a dual FOI vessel. This is a 55-year-old person on ECMO COVID on heparin. They develop massive hematemesis. This is no surprise for anyone who works at a tertiary high-level cardiac center. There's massive clots in the stomach. They look just like this. There's fresh blood pooling in the dependent area. You know there's active bleeding beneath. You've brought a diagnostic scope. It's not suctioning. What do you do next? This is a video of this. All the fellows have been here before. You're suctioning and then you want to flush, but then you're just flushing it back out. You're getting nowhere fast. You look at the clot, it goes all the way down to the duodenum. The very first thing I do in this situation is I try to localize the bleeding even though there's a clot. I go down to the duodenum. I try to clear it if possible. If it's in the proximal stomach, then I refocus my efforts on suction, on augmenting suction. This is Poucille's Law. This is the reason that you took physics to get into medical school. It says that to maximize flow, an ideal rapid infusion or suction system in this case, consists of a largest diameter and shortest length of tubing with minimal viscosity under maximum pressure. You can actually control every one of these constants in terms of pressure, radius, fluid viscosity, and the length of tubing to maximize your suction. I'm going to quickly tell you how to do this. This is maybe the most important lesson I can teach tonight. The first thing you want to do is get rid of the diagnostic scope and grab the 1T scope or the therapeutic channel scope. It has a 3.7 millimeter channel as you can see on the left. It can accommodate 10 French devices as well as 7 French devices. In our unit, we print out a badge that includes every scope that we have. This has the inner diameter and the outer diameter. There's one called the Clot Buster. It has a 6 millimeter channel scope. It's my favorite scope in terms of clearing the stomach in rapid fashion. If you also notice, the Duodenoscope has a 4.2 millimeter inner diameter. It is the second best scope at clearing clots. It also has an elevator that helps you cut clots. This is the Clot Buster. It's a GIF XTQ160 from Olympus. It has been discontinued. However, it can be purchased in the aftermarket markets. Boston Scientific, for example, has an aftermarket scope market. They do sell this scope. 6 millimeters is really, really big. It's 18 French. Think about what an NG tube looks like. If you take this scope and you augment the suction in the ways that I'm about to tell you, you can clear almost every stomach and every clot. This is the Duodenoscope. It has an elevator that can actually suction clots. When you get it stuck, for example, the elevator, you can move up and down. It can cut the clot away. It's a clever move. You can use it in a pinch. It also happens to face directly into the fundus when you pass it down and you make a slight left turn for the advanced endoscopist. It's pretty good at clearing as well if you don't have the Clot Buster. The second way that you can influence... The first way that I influenced that we were discussing was by increasing R. If you look at R, the flow is to the fourth power of the radius. It's the most bang for your buck in terms of increasing flow. The second way is to reduce L. By reducing L, or the length of the scope, you basically take the suction channel off the back of your umbilicus and you directly plug it in to your biopsy port. How does that reduce the L? It basically bypasses the entire umbilicus. If you look at a gastroscope that hangs in the clean closet, your umbilicus is actually half your length. If you can reduce the length by half, then you've essentially doubled your flow. If you do this with the Clot Buster, you will get tremendous suction. There's also a device called the Neptune that can increase the power, but we can talk about that later. There's a suction system called the BioVac that's sold by Steris. It essentially does exactly what I just told you, except it has a little button that you can control, but it has the exact same mechanism. You can also actually increase the power slightly. I don't think it's actually doubling the flow, but you can increase the power. If you put two vacutainers in series to one another, it slightly increases the power. I don't think it's entirely by two. It is also helpful because if you overflow one canister, you don't have to wait. It starts automatically flowing into the next one, allowing you to reload the other one with a new canister. If none of that works, then I would recommend passing a gastric overtube and then taking the raw suction tubing and just passing it down into the patient blind. This sounds terrible to some of you guys, but for those who can remember, evacuator tubes and Ewald tubes, or anyone who works in the emergency room who has to detox patients who have overdosed on certain things, there are really big channel oral gastric tubes that you can use. If you have a gastric overtube, that's just an easy conduit to just basically plunge these huge clots out. One problem is that the overtube, if you guys are familiar with it, it has a little diaphragm at the end that holds suction. That's not good. It prevents venting. You oftentimes just collapse the entire stomach and nothing comes out. Well, if you move the suction tubing around or you pinch the diaphragm or even cut the diaphragm a little bit with a pair of scissors, you can make venting air around it. You can break the seal, and that can help allow more suction to come out. In the Red Journal, Dr. Rustagi and some of his fellows invented a way to kind of attach raw suction tubing onto an ultrasound scope, pass it down the overtube, and apparently that works pretty well too. It takes a lot of arts and crafts, so it takes a minute to get working. I've never done it in vivo. You can also reduce the viscosity by flushing with water, but also by actually cutting the clots using a cold snare. You grab the clots, and you just constantly pull back and forth on the snare, cold guillotining all the clots. You're basically just chopping them, if you will, like rough chopping a whole bunch of clots. If you do that for a minute, which in the active Blié, seems like an eternity, you will have the clots that are smaller and you should be able to suction the majority of them away. The other ones that are really huge, like the ones that are the entire cast of the lumen, I recommend getting a very large snare and snaring around the clot but not cutting the clot. Do not cut the clot. Just, you see, snare it. Get it firm around it but don't cold guillotine it, okay? Get it firm and then pull the whole scope out of the patient like you're doing a PEG tube. You hold the snare and you pull the whole thing out. You'll be able to dislodge a huge clot. Now remember, you got to make sure where the bleeding is. I already told you that earlier. If the bleeding is in the duodenum, then pull the clot into the stomach. If the bleeding is in the stomach, then push that baby back down into the duodenum, right? Get it out of the way. You can keep working on this clot that comes out. See, this clot is certainly from the duodenum. I knew that because I first went into the duodenum. I saw flashes of fresh red blood and also I was able to clear the fundus earlier relatively well. Finally, you can move the patient into the right lateral position which essentially moves all the gastric contents distally and away from the fundus. Ergonomically, it's not very friendly to scope in a right lateral position. It's a little bit difficult but in a pinch you can do it. Here's an example of rotating patients or moving them in different positions. It's not exactly a suction mechanism but it shows how when bleeding develops in an area that's actually in a dependent space. If you rotate the patient, then you can actually get an undisrupted, unpooling view of the actual bleeding source. The patient's being rotated right now. Being rotated right now, the blood falls away and then suddenly you can see the active source without any pooling. The guys who do ESD are quite familiar with this method. Back to the case. After you clear the clots and you change the position, you see this arterial bleeding. You try to take a bipolar probe but you can't get it past the scope. You can't get it through. It's not going through. Of course, some of you guys know the trick which is to push it out and then retroflex but now you've lost 15-20 degrees of retroflexion and blood is accumulating rapidly, your visual field is about to deteriorate again. What do you do? What do you do next? So one of the things that I often start with, I just automatically put it onto the scope, is a clear cap. So one of the important things about the clear cap is it can help with crowd control. It can actually provide temporary tamponade. So suction is diminished or lost when you decide to pass the instrument down. Everyone knows that. Except for the dual-channel scope. So the moment you start passing an instrument, your suction is essentially almost gone. If you have a therapeutic scope, you still have a little bit left. So the clear cap can actually help maintain a clear field while you pass the instrument. It can actually tamponade, for example, this bleeding vessel here. I pull it back, oh, there's the blood. You can actually tamponade it while you get your instrument ready. You guys are actually familiar with this method because the over-the-scope clip or the bandliners, more familiarly, have this built in. They all have a clear cap built in. And it allows you to tamponade that barracks, right? And you can still suction, obviously. This is a very dramatic case of a rectal artery bleed. I was able to tamponade it at the level of the anal rectal area. You can see it pulsing right there. As soon as you see the blood, push the scope back, cover it up, tamponade it, and then get your hemostatic forceps, this is what I'm using in this case, out. And then you can apply it without ruining your visual field. The clear cap is wonderful. Now, if you have the clear cap, you'll notice that it has a little hole in the side. If you're doing a food bolus and you wanna get really, really good suction and hold something in your clear cap, flip it around so that you cover the hole. That way, you don't get any loss of suction. You maximize the suction in that little cap. It becomes like a little tentacle plunger that the octopus has, full suction in the leak. But for bleeders, actually, you want the hole open. This is a subtle point, but I actually called Olympus. The Japanese guy on the other line told me how it works. When you isolate a bleed, you can irrigate and suction, or even just irrigate, for example, continuously, and the irrigation will fall out the hole. And so you can constantly build or create an underwater isolated environment that's very, very clear, and it helps you isolate the bleeding source. You can just sit on the water, guys, and it'll clear everything for you. You don't have to suction, no blood will pool. You'll just create this underwater environment, and then you'll see this one wisp of blood going through the relatively more viscous water relative to air. Then you can help localize the source. Once you localize it, move the cap to tampon on it, get your device down the scope. It also sieves liquid and separates water. So if there's a bunch of food or blood clots that might fall in the way, when you have the clear cap making this little underwater terrarium, if you will, isolating everything, nothing is gonna get into that space. Back to the case, the bipolar probe can't reach, you ditch it, okay? What's next? Clips, they come in different shapes and sizes. There's three main leaders of clips in the market. One is the ConMed DuraClip, Boston Scientific has a resolution 360, and the Instinct CookClip. Each three of these clips have in development now a larger big brother, but these are the main ones that you guys have. The ConMed DuraClip comes in 11 and 16, and it's the only clip, the only clip that can pass in full retroflexion. And when I mean full retroflexion, I mean, you don't have to un-retroflex the scope, you just pass the thing through, it will go all the way through. No other clip on the market can perform that maneuver. It has a one action pop, it's very loud, you have to use a lot of strength, which is okay. And it has the shortest stem. The Boston Scientific Resolution 360 has the amazing ability for the endoscopist to precisely control the rotation. So you don't have to wait for the tech to keep helicoptering around until they get it right. Unfortunately, it has the longest stem. The Instinct Cook Clip, and this is evidence-based, is freakishly strong. It has incredibly durable holding strength and closing strength. So each of these clips has their unique benefit. And I'm lucky because in private practice, I can order whatever I want. So I have a little bit of each of these in the unit. If you don't believe me, look at this. This is me messing around with some samples. This is the Cook Instinct Clip, it doesn't pass. This is the Boston Resolution Clip, it doesn't pass. And then finally, the blue one, this is the ConMed DuraClip, it does go through. And you can see right there. So if you don't believe me, I've tested it myself. Look, I'm double retroflexed, right? Small wheel, big wheel, all the way back. And it passes through, right? Okay. So you clear everything up. Maybe you inject some epi. You get it to kind of slow down. There's a little fibrin clock. Here it is, the DuraClip in retroflexion. You notice it's a little curved. That's because the nitinol actually gets bent a little bit, but it gets bent in a favorable direction. It gets bent in that curvature that actually makes it a little bit more favorable. So there it is, you deploy it and you got it closed. How many clips do you place? Some people use dopplers. I find that a little bit cumbersome. I always try to place two clips, okay? And I try to place them in a different axis because in Euclidean geometry, if one line is perpendicular to another line, it's also perpendicular to any line that's parallel to the second line. So basically what I'm saying is if you place a clip perfectly wrong, like you directly place a clip parallel to the blood vessel, right? And you totally miss it. Well, if you place a perpendicular clip or one that's even just slightly off angle, you will be able to intersect that blood vessel, okay? So I always try to put two at angles to one another. Here's three in that case with the duophoid. I feel pretty confident that I got it, whichever direction the blood vessel is running. I don't know which direction it is. I didn't use the doppler, but I figure I gotta have transected it with these three different vectors. Questions? We have several. I'll go ahead and do one. So you touched on this a little bit, but one question is when and which locations is the cap helpful? Yeah, the cap is particularly useful in two locations. In the esophagus, as we all know, because we've done variceal bleeding, and it's also very useful in the duodenum. The duodenum has two posterior areas that are hard to see. One is in the bulb. As soon as you get in, looking posteriorly is a little difficult, but really the hardest part, the great black hole of the foregut is the posterior sweep of the duodenum, okay? It's where, you know, when you make that right-hand turn, fellows, right? And you're pulling back, you're pulling back. It's that three o'clock position that you can never see. And when you're just about to see what you wanna see, you fall back into the distal stomach, right? That area is very good for a clear cap. It can hold the folds back, and it also stabilizes your position because it gives you a little bit more bulk, okay? It lets you sit there for a second, nudge a little bit, wiggle up and down, wiggle left and right, and then you can finally kind of see the ulcer. In addition, if you have the clear cap and you're doing this maneuver and it's still difficult, take out all the air. Take out all the air and just swim underwater, totally in the duodenum, just totally swim. As many of you guys have seen before, there's an underwater EMR technique. Why is it beneficial? It's because the mucosa can float. Everything is soft. So if you use this underwater technique, you might be able to actually see more of the mucosa as it free floats towards you using the clear cap to hold it back. The other place a clear cap is really important in GI bleeding is anywhere beyond the duodenum in the proximal small intestine. When you're looking for obscure occult GI bleeds, if you're going down with a pediatric colonoscope as a push enteroscopy, you'll double your yield if you put in terms of finding and making the diagnosis for treatment if you put on a clear cap because you can just flatten out those folds and just very systematically check, Dr. Abraham, you have another tip for the suite? Yeah, I was just trying to think about how to describe this. You have to realize I trained and spent most of my career doing GI bleed work before the clear cap came around. So there are other techniques that are endoscopic. There's one called the duodenal break, which is better shown than described. But essentially what you're doing is instead of doing, you're doing the reverse of the Nike swoop that would ordinarily take you into the second part of the duodenum, requires you to keep tension on the shaft of the scope at 180 degrees from the trajectory of the scope as you withdraw it. And by doing that, you can actually control the removal of the scope through the sweep. And you can actually see all areas of the sweep. Alon's a believer in this technique, taught it to him as a first year. Now he tells everybody about it, but it really does work. If that is hard for you to visualize, a cap is the next best thing, but you don't always have what you need at the moment. So learn these sort of strategies too. You can put it in your fanny pack if you have one by the way. Yeah. One more question pertaining to the cap. Is there a specific orientation that the hole on the cap has to be placed in? If you're doing upper GI bleeding, I think the cap should be at least around the six o'clock position. The purists who do ESD keep it at the four o'clock position. I think it's best just to keep it in that position because that's the natural way that water will typically drain, not always, but typically drain in the upper GI bleed. Yeah. So just keep it near the bottom. Yes. Also don't put it in an area that is of interest. For example, if the bleeding is at the bottom, don't put the hole to overlap the bleeding site. That's obvious. This is more of a comment, but Dr. Tower, Dr. Abraham, if you have anything to add, this was saying there was recent data to suggest that large visible vessels in a duodenal ulcer with hemodynamic instability is likely to fail endoscopic therapy. So GI bleeding is a multidisciplinary event and IR needs to be called too. I don't entirely agree with that. It depends on what that vessel is. You may not know what it is. For example, I do agree with that statement. If, for example, you're going after a GDA pseudoaneurysm, yes, you will fail. You will fail because like Dr. Abraham said very elegantly, you need to know what's underneath that beast, what you're dealing with. And sometimes you just never know. So if you take an OTSC to a large GDA pseudoaneurysm, you will lose. They will still bleed because the pseudoaneurysm is very weak. They will re-bleed. It is good at that time to get IR involved, maybe get a CTA, for example, if you suspect it. It's hard to know. But having IR contacted as your backup is never the wrong thing. It's never the wrong thing. A question that you answered in some aspects before, Dr. Tao, besides pre-endoscopy prokinetics, what are methods used to clear the large clot burden in the stomach? And maybe you could also talk about prokinetics. Right. There is actually a lot of data that shows that erythromycin is very useful. It's evidence-based, randomized, good stuff. So it should be used if it's available to you, if you can get it in time. Sometimes you don't have it or you give it too late or whatever. You could, for example, pass orogastric tubes early on and try to clear the stomach. I don't see too many people doing that. Now, I'm going to say something to you that is a little embarrassing. But I do ask this of my patients. Before we intubate them, I hand them a bag. And I tell them, if you don't mind, would you vomit for me into this bag to clear your stomach? I know you look nauseated. It looks like you want to vomit. Will you just vomit for me once? They look at me funny, but they're protecting their airway when I ask this of them. And they sometimes will upchuck their whole stomach. They don't want to do it then because they're scared. They're embarrassed. They don't know what to do. They feel terrible. They're clammy. They're nauseated. But when I hand them that bag, and I look them in the eye, and I ask them to do that for me, they give it a good damn try. And sometimes, they empty the whole stomach at once. And it makes the job a lot easier. That is not what anyone does that much. One thing I would add is if you have hemodynamic indications of a significant GI bleed, those bleeds that are not responding to aggressive resuscitation, intubate the patient. Because you need to be able to control the airway. And then you have just a lot more leeway to throw the kitchen sink at the bleed if you're not worrying about aspiration. So that's an important basic. And before I start thinking about clot, sometimes you go down with a scope, your therapeutic scope. You see a whole bunch of clot. I recommend pulling the scope out, intubating, then going back in. The other thing, if I were to carry a fanny pack, which I don't, but if I were, what I would put in my fanny pack first off for any GI bleed is a BioVac device. That's something we used all the time at my second institution. They didn't have it at Mayo, Arizona. We got it. And it just, it's like night and day. Once you learn how to use it, there's a reason why they call it the super sucker. I have never had a clot not be able to be evacuated with a BioVac. So if you could have one thing to put in your fanny pack or on your cart, get comfortable with a BioVac. It just makes your life so much easier. And again, the BioVac is utilizing the biopsy port to bypass your umbilicus to double your suction power. Yeah. And it's just, it's really like taking a Dyson Hoover out and just getting rid of everything. Yeah. All right, great tips. Let's move on to the next case. All right. Right, so here's a classic peptic ulcer, case two. So this is a 68 year old male. He's coming with hematemesis and he's found to have an actively bleeding enteral ulcer. You attempt standard dual therapy and this is what we see. So it's bleeding. This is a forest 1B. It has a little bit of a clot on there but it's actively oozing. You inject epi, then you cold guillotine it. You gotta be brave, but you gotta do it. There you see, there is a vessel that's oozing. It's not pumping. You take, I think this is a seven French bipolar probe. You cauterize, you put a little water on it. It still bleeds. Okay, that was a one session of eight seconds. This is a second session. It's still bleeding. You're not that uncomfortable yet. This is a third. Okay, now you've burned for over 30 seconds and it's still bleeding. Okay, you try for some clips, you try to use the clips but because you've burned so much, the clips won't close. It's too fibrotic. This happens in a variety of situations. Sometimes it's made worse actually by bipolar and you actually make it even more fibrotic and difficult to close. So imagine you're dealing with this. You've burned for 30 seconds. You're in the stomach, so you're probably okay. Many layers of muscle but now you're thinking about next steps. Okay, so. Dr. Tal, why did you start with a seven French instead of a 10 French gold probe? Ideally, I should have used a 10. I don't know why. I think this one's a seven. I actually can't tell, I forget. But usually I use a 10. I'm not sure why this one was a seven. It may have been an error in terms of which scope was brought, for example. And then we're relegated to using a seven. But ideally a 10 would have been better. And I'm using 30 Watts on an Irby. So a decent amount of wattage there. So in terms of, this is getting close to being kind of refractory. Okay, so in terms of the two rescue options, you have the over the scope clip and you have hemo spray. If the bleeding is torrential, this is a tip. Have your tech load the second device or the rescue device onto your backup scope, onto one of your backup scopes. Sometimes I even bring two therapeutic scopes or one diagnostic, one therapeutic scope if I'm really thinking it's gonna be a tough case. And I have them pre-loaded for me so that I don't waste a lot of time taking it out, loading it, for example. That's true for hemo spray, which you need to keep dry. It's also true for loading banners and OTFTs. So that way you can just take the scope out quickly, right? The tech is already switching out that your umbilical situation. You're already passing, shoot, you might just pass the scope. Blind, you guys know how to do that at this point. And you're going down there and oh, the flash is open. You can see the video. Now you're ready to go. You lost what, eight seconds, 10 seconds? Very little time, right? There's three over-the-scope clips I use. 11 slash 60, that's universal. 12 slash 60 is a little bit bigger. The 12 is the outer diameter. The six is the depth of the cap, okay? There's also a 12 slash six GC. GC stands for gastric closure. That's for closing fistulas in the stomach. Okay, so you're uncomfortable. So you use the over-the-scope clip. It's coming up nicely. It's bleeding. That's okay, don't be scared of that. You turn the wheel and it deploys the over-the-scope clip, a nice puckering and the bleeding is stopped. So that's nice. Okay. Fellas definitely need to become comfortable with the over-the-scope clip. It's such an important advance for acute GI bleeding endoscopic management. If you don't have much opportunity to use them at your current training institution, I'm gonna make a plug for the ASGE onsite training labs that they have at all the national meetings. They do a great job of teaching you how to use these clips. The over-the-scope clips come in two brands. One is the Ovesco system, which is sometimes people call the bear claw or the bear trap, okay? There's another one called the padlock, which is a ring of knives, if you will. The Ovesco OTSC has a directionality to it. That's important to know. When it's deployed, these four pillars kind of pop up and they can sometimes obstruct the lumen partially. This is true of the duodenal sweep and it's true of the esophagus. So it's important to line up the axis of the teeth with the axis of the lumen so that the lumen is passing through ideally that direction of the jaws. It's also important when you're trying to close, we're not talking about this, but if you're trying to close some type of a fistula and the fistula, let's say it's a slit like my lips, well, you don't, if you guys can see my face, you don't want to close your lips using jaws that close left and right. You want to close them going up and down. That's more morphologically favorable for getting a good seal. This is a subtle point, but it's important. If you look at my example here, I dropped one of the pillars right in the lumen, the sweep of the duodenum. That's not that good. Sometimes people will feel that and it can sometimes give them a bit of nausea obstruction. In the second case here, I do a better job of dropping the clip in the axis of the lumen so that food and material can pass a little bit better. This point is not that important with the padlock, which tends to lay flat after you deploy it. It doesn't have pillars that stick out. If you notice here, the fluid can go or the food can go down the lumen. There's no obstruction there. Subtle point, once you start using the clip, it sometimes becomes more important. Believe it or not, the over-the-scope clip can fail. There's a theory behind it. Here's an example. So this is a large duodenal ulcer, a visible vessel. It's not a big ulcer, actually just a big visible vessel. When I took the 10 French probe and I put it next to it, it was very close to being the same size. It was almost 3.33 millimeters or maybe even slightly bigger. So I got concerned about using just a bipolar probe for that. So I pulled it out and I decided to use an over-the-scope clip. That earlier comment about how duodenal torrential bleeding is a multidisciplinary system. It is, it is. I would call for backup, for example, if this doesn't go very well, which it's about to not go very well. So here's a duodenal ulcer. I suction it up, there's bleeding, that's fine. I deploy the clip and everything looks good, right? Bleeding seems to have stopped, but then the patient re-bleeds like within a couple minutes. Now it's oozing, it's better. In this situation, the pseudopolyp is still being fed. It's not completely clamped off. You can use a bipolar probe and you can really go to town on that because you have the backup of the clip behind you. You will not perforate the patient. The hypothesis is that there's gaps in between the over-the-scope clip that can still allow perfusion of blood through these little gaps in the four pillars. I actually proved this to be true this evening, actually. That case that I just got back from, I had an over-the-scope clip that failed and I proved this thing that I'm telling you. So here is the case I did tonight. Here's, there's ongoing bleeding through a strip of tissue, the pseudopolyp that's been pulled up. You see, it's still being fed blood. And if you look, there's a little blood vessel there. And it's being fed from the cross, that X-shaped tissue that's being allowed to exist between the gaps of the OTSC. I burned the bejesus out of it there and I got it to stop. And so I think I proved that hypothesis that blood flow can get between those gaps tonight. This is kind of what delayed me, by the way. And don't forget, when you are in a situation where you've put a mechanical clip on of any kind and you still have bleeding, instead of just blindly burning, ask for some epinephrine. Epinephrine will blanch your field and give you a good 20 to 30 minutes to work with. And so you can really examine what's left and look for that visible vessel that you missed because you deployed in the wrong place. Or as Dr. Tao mentioned, you didn't really bisect the vessel when you put your TTS on. So don't forget, epinephrine really doesn't have a lot of place in GI bleeding as a monotherapy, but it can be used adjunctively even just to clear and cause vasoconstriction and let you really inspect well. Then you can burn the crap out of it. Dr. Tao said. Right, exactly. Use that epi, it buys you that time to call IR, for example. Same with hemo spray, which we'll get to. It buys you time, clears the field, lets you examine. Thank you so much for that comment. That's very, very insightful. Lastly, here's another example of an OTSC and an incisora ulcer. These are tough because you have to get these in retroflexion. Whenever you're in retroflexion, like the angularis or the cardia, like we showed earlier, it's harder to treat and everything works backwards. You got to pull to get closer, isn't that right? And so here I deployed it over the clip and I just transected the blood vessel. I just like knocked its hair off and it kept bleeding. This one was really tough to stop. I thought about just ripping the clip off, which can you imagine? So instead what I did was I used hemo spray and I called my IR friends to help me. Eventually the patient did rebleed and was embolized. Remember hemo spray is a bridge to a definitive therapy. It's not one and done. I hear about that and shudder when I see that because within 12 hours, the fiber integrates and you've got a big mess on your hands. Absolutely agree. So moving on to hemo spray, the second of the rescue devices the indications are, in my opinion, the five can'ts. Can't stop, can't reach, can't finish, can't touch and can't sir, is the last one, right? So can't stop is the rescue we talked about. Can't reach- That should go on GI Twitter. That's a very- Yeah, Twitter is just fantastic. And please tag Alan Barkin on that. He's gonna love that. You got it, you got it. The cardio, the sweep, the posterior bulbos are can't reach areas, tough to reach. Can't finish, like diffuse bleeding, like ischemic ulcers. Can't touch, thin walled ulcers, duodenal ulcers that are on the verge of perforating. Diverticula, for example, right? Cancer, everyone knows that this is perhaps the finest indication for hemo spray. And one that is, relative to the rest, more durable. Hemo spray has limitations. You can't use suction, blood is pooling actively if it's a refractory bleed. There's a delay in trying to dry the scope as you're trying to get it through the channel. And also you can't get the catheter tip once you actually get it down the channel. But if anyone follows my Twitter, you can overcome this with a little piece of stuff called bone wax which the US fiducial guys used to use. You basically take a three-way stopcock and a little bit of sterile bone wax which you can borrow from the orthopedic OR. And you basically tip the catheter with bone wax. This method basically prevents you from having to flush. It allows suctioning and it prevents the tip from ever getting wet, at least before you deploy the initial shot. Do you find it impedes your ability to fire out the hemo spray? Oh, no, because you actually blow the bone wax off with an air flush just before. Okay, that's important. Yeah, that enhanced the three-way stopcock because as you can see here, I'll show you the setup. It just takes a second. Also don't use very much bone wax. Just use the tiniest little bit and use it like a little cookie cutter. Get the rest off of the outside. You put the three-way stopcock on and you hook that up to the gun just like that. And then the three-way stopcock makes things faster so that you can blow the bone wax off quickly and then just turn the stopcock and you're ready to fire. Isn't that right? Yeah. So that's the setup. This is the ex vivo method here. You start off like this, right? Notice the syringe is ready to blow the bone wax off, right? You can dip the catheter tip, which has a bone wax protective thing on it. Okay, blow it off, turn the stopcock and fire. That's it. You don't need to flush the catheter. You don't need to flush the channel. Just pass the catheter and you're ready to go. The setup takes 20 seconds. It's not very long. Here's an in vivo method of it. There's bone wax on the tip. Look, you can suction. Normally this is totally, utterly not allowed. Look at how dirty I'm getting the catheter tip. It's not infiltrated with water at all. There, I blow the bone wax off, turn the stopcock and blast away at this bleeding gastric cancer. You can also use a different method. It's called the CO2 borrow method. I just made that up. You basically borrow the CO2 from the back of your scope, okay? And you connect it in lieu of the syringe, the air flush syringe, right? And you basically now get a continuous stream of CO2 that protects the catheter. Now this is quite gassy for the patient and you're already gonna blow CO2, which is what projects the powder. But a good tech can swivel between ammunitions, between powder and CO2, powder and CO2. This method actually can allow you to protect the catheter at all times. And not just after the bone wax is blown off. No, not just before the bone wax is blown off. You can continuously fire this. It will never, if the technician is very smooth about it, they'll protect you the whole time with the CO2 stream. You can still use the air from your scope. You'll be using room air, which is not wonderful. This reminds me of my friend, my good friend who was a medic. he says, oh, this reminds me of switching between ammunitions on a rifle or methods of firing. So this is how it works. You take a four-way or a three-way stopcock. It looks like this. You hook it on just like this. You attach your CO2 to the side. That's a four-way stopcock there. You borrow the CO2. If you have a four-way stopcock, which basically allows you to turn the stopcock in a direction that faces nothing, essentially everything is open, you can actually blow CO2 and hemo spray at the same time. You can actually, so here it is. I'm getting it wet. There's bubbles coming out of the catheter. You can fire it. You can get it wet again. You can still fire. It never gets clogged. And of course, you still need to use air to clean your lens, so you can switch to room air. That's the second method. It's gassy, but it's OK. It's pretty good. Here's an in vivo method. There's a bleeding gist that I couldn't stop. See, I'm putting it under the water, and it's just blowing CO2, just like the ex vivo model. You can suction, because I'm using a 1T scope, guys. That's a 7 French catheter in a 1T scope. So I have some diameter around the catheter, so I can still suction. Nothing's getting clogged here. You don't even have to turn the stopcock if you have a four-way stopcock. And you can fire powder and CO2 all at once. And I'm using CO. Why do you need the air? Because you need to clean your lens. And if you guys don't know, the lens cleaner is powered by air or CO2. You can also air exchange, which means you can suction the powder out of the air. It will clog your channel. So if you do that, just keep in mind that this is your last maneuver. You're going to have to use a different scope after that. Usually, hemo spray is the last maneuver. Here's another example. This is the esophagus, a terrible bleeding tumor in the esophagus. Within seconds, the esophagus fills with blood. I first tried the manufactured method, because the rep is sitting in the room. So I do it the proper way. And quickly, it clogs. And look, you can't. Where can you put the catheter to not get it wet? So I do it the manufactured way. It clogs within seconds. After this one little burst, it clogs. So then I use my method with the bone wax. I blow it off. You can barely suction first, which is so useful to be able to suction. Then I blow the bone wax off. You can't see it that well. And then I fire through. One last comment. Hemo spray shooting and retroflexion, hitting that cardia, one of the hard to reach spots, it can sometimes lead to your scope getting stuck or you feel like it's getting stuck. Don't panic. Just advance the scope into the duodenum or wherever in the distal stomach and spread out some of that powder. Spread it out over the rest of your scope and then withdraw in a torque-like fashion. Eventually, you'll be able to get out. Don't freak out. It should be fine. Here's just an example of that type of situation. That's it. Questions? We have a question. How can one be sure of not overusing the goal probe, asking in terms of perforation? There's no real good way. The stomach is very, very forgiving. If you perforate the stomach, you win like a prize because it's really tough. The duodenum is a different animal. And a very deep crater duodenal ulcer, I would be careful about applying more than the sum of, I don't know, 20 seconds in a deep crater duodenal bulb at 30 watts. I would probably start at 20 watts. And after 15 seconds, I would think about using it over the scope clip. I have a few cases, not here, but in which I used a bipolar probe. I cauterized the vessel. And I noticed that I was like three fibers away from perforating. I put an over the scope clip on. I closed the defect. One thing, if I could just add to those comments, is your technique really matters when it comes to a goal probe. I want you to remember this. You all know I like to teach in idioms. If you've heard some of my other lectures, I want you to remember to do less, better, all right? So in other words, when you're using a goal probe, you have to co-act or crush the vessel, which means don't dab it as you're firing. like you would dab your mouth with a napkin. Instead, you've got to put some pressure on it, hold it, one Mississippi, two Mississippi, three Mississippi, and then go to your next spot. So you're doing less in terms of touching the lesion, but you're doing it better. And if you do that, you won't need to touch your lesion multiple times to get it to stop. When that happens, it's because people are just not co-acting the vessel. Dr. Abraham, can I ask you one more question? So along the lines of, you know, one of the areas that you specialize in, you know, any of these cases that Dr. Tao is talking about, especially these really refractory tough cases where you finally achieve success, right? So, you know, he was just saying in his hospital, these patients are all on complex antithrombotic therapy, right? So, you know, the basic principle is once you achieve hemostasis, that's the time to get back on your therapy. Would you have hesitance in these kinds of cases? What would your approach be in terms of getting patients back on their important antithrombotic therapy, especially in cases like this, where it's taken you a lot of effort to get to that point? Yeah, that's an incredibly important question. So I want you to remember two things when it comes to these cardiac patients who are on complex antithrombotics. First, you have to understand what their thrombotic risk is. So what is the risk that the patient's gonna have a major cardiac event or embolic event by temporary interruption of your antithrombotic after your case, right? And you should know that, and there's multiple tables and existing guidelines, and the new one that is just about to be published that has that all lined up, okay? So the higher the risk of the patient to have a secondary cardiac or embolic event, the shorter your period of temporary interruption should be after you do your hemostatic therapy. So that's number one, because the heart always wins over the GI tract. There's no tug of war, the heart always wins. Number two, then you need to look and see what your hemostatic picture is immediately at the end of the case. So if you are like Dr. Tao, and he makes sure it's really locked down, that's why I love that expression, lock it down, right? Don't leave a little dribbling blood, get it locked down. If you know and you're confident that it stopped bleeding because of your technique, then I would restart any patient at high thromboembolic risk the next day, all right? Now, if you're doing a case where there is just a lot of difficulty in getting hemostasis assured, you could, when it comes to anticoagulants, wait no more than 72 hours to restart. But again, you wanna keep the window as short as possible, the higher the risk of the patient's thrombotic sequelae. When it comes to antiplatelets, you've got seven days of dead platelets anyways, so that's less of a concern, right? You've pickled them, just the use of antiplatelets. But I think the real question comes with the direct moral anticoagulants where the time to onset and the time out of the system, it's much shorter. I'd like to piggyback off of that. If you cannot lock it down with thermo methods or mechanical methods, and you rely on hemo spray, and the patient is on antithrombotic, whether it be antiplatelet or coagulant, I wanna tell you that hemo spray is not gonna be working because hemo spray's mechanism of action is desiccation and aggregation of platelets and coagulation factors, instantaneous aggregation, okay? I don't even think it's activation, it's aggregation because it basically dehydrates the blood and allows those two clotting systems to come together, to get closer together. Yeah, you're potentiating the fibrin clot. Right, right. You're making it happen faster. But if the platelets don't work or the clotting cascade is neutered, then the hemo spray is not going to work, okay? Even if they're not on them, if you use it on let's say a forest one type ulcer, actively bleeding, all you're doing is shifting the force classification from a one to a 2B, 2B is adherent clot. And if you're the type of person that doesn't pluck off adherent clots for whatever reason, then fine, you may be justified in not re-scoping that patient. I don't agree with you, but if you're not a clot picker, then okay, you may not re-scope, but I don't recommend that. If I pick clots, I dig 2Bs and I treat them. I guillotine them just like Nina does. And so I recommend that if you take a forest one to a forest 2B using hemo spray, you re-scope them in 24 hours, hard stuff. And if you can't get it under control, call in the multidisciplinary team. That's when you call IR. Sometimes you need to call a good old general surgeon to do an over so that there's less of that going on now, but there are some places in the foregut which are just difficult even for IR to embolize and coil. Love it. Also, you know, the hemo spray is not FDA approved for variceal bleeding. I have a hypothesis why that might be. One, it's because variceal bleeds are all serotics and they all have low platelets. And many of them are coagulopathic. I know that the INR doesn't necessarily represent that very well, but they're bleeding. Let's just be real. And so I actually don't think that their clotting cascade and their platelets, well, they don't have many platelets, work that well. And that's why it probably failed and didn't get that approval. That's just a hypothesis, but it's- No, I think you're right. I think they're in a constant dynamic balance and it's shifting around. So you can't apply it to the whole population, right? Some of them, it might work. Some of them, it wouldn't. And I think you're totally right. Yeah, any given patient- And we talked about antibiotics and impairing platelet function, but don't forget your CKD grade threes, right? People with severe renal dysfunction, they have very impaired platelet function. So if you've got a patient with third degree chronic kidney disease and you're, you know, bone waxing and puffing in a whole bunch of hemo spray and you don't know why you're not getting a response, it's because those platelets, they're not up to the, they're just not up to the task. Yeah. We have a bunch of questions from the audience. Thanks everyone for your participation. One question before maybe we can move on to the next case is can you comment on when you would like to use the Coag Grasper? Yes, so the Coag Grasper is very, very good for people who do ESD, wide field EMRs because the Coag Grasper is actually not that big. It has a relatively small diameter and it's good for targeting small blood vessels. It cannot, I really don't recommend you try to take a Coag Grasper to a large, you know, posterior bulb vessel, for example. You are gonna lose, essentially what you're doing is biopsying the head of the blood vessel and exposing it. Okay. It's good for small, small, tiny arterioles, if you will. It's good for little targeted treatments. Okay. Now, actually, the Coag Grasper costs a lot of money. It's a $200 device. The hemostatic forceps, the biopsy forceps, or we call them hot forceps, they fell out of favor many years ago because they were not for, we won't get into it, but they weren't good for taking off polyps. It was bad. It destroyed the specimens and so on. But they're very cheap. They're only $25. They have a cup in the middle, so it doesn't burn the middle of it, whereas the Coag Grasper is a flat plate. But you can grab quite a bit of tissue. And so, for example, for big stalks that re-bleed, for example, post-polypectomy, big stalks, you can actually grab the stalk in a hot biopsy forceps and use soft Coag, 80 watts, soft Coag setting, and get a really nice shallow burn, okay? And so, in certain situations like that, where you need to kind of grab something, okay, not push something, but maybe grab something, collapse it, it's a nice device. If you ever show a surgeon how we treat ulcers by using push and coaptation, they're blown away how dumb we are in gastroenterology. It feels, yeah, to them, it's a Cro-Magnon. It is a terrible mechanism. I showed that to the surgeon and they thought we were Neanderthals. And then I showed them the hot biopsy forceps and he was like, yeah, that's the good stuff. You know, you grab it- And if you're gonna use a hot biopsy forceps, don't have your tech close it all the way. So it's sort of like when you're bringing the snare onto a pollet, you don't guillotine it and then put on your heat. You just want to snug it up against the tissue and then put the heat. Give it a hug, yeah, for most people. Give it a hug. And to Andy's point, I would point out that the one study that does support using the coag grasper for ulcer bleeding, actually their protocol was to inject epi in four quadrants and then burn in the middle with a closed coag grasper tip. They didn't even have you open it in that study. So I think if you're gonna use it in that setting, you don't expect to be able to grab a visible vessel with your coag grasper. Don't grab a big vessel. Please don't do that. Now, a side point, very fascinating, something I've been waiting for a long time. There is something called a Hemostat Y that is produced by Pentax. It's their ESD department in Japan. It's a bipolar coag grasper, a bipolar coag grasper. And it allows you to open and close and do coag grasping. When you close it though, it becomes a bipolar probe. So in one device, you have a bipolar probe and a coag grasper. I think it will be the revolution of GI bleeding once it comes to the United States. It'll be here in a year or so, yeah. I think we have a few more minutes if you wanna just touch on this last case. Oh, sure, sure. So many great tips. This one's a bit faster. So 52-year-old guy with alcoholic cirrhosis, he presents with bleeding melanoma and an isolated episode of hematemesis two days prior to admission. You do an EGD, you see this, this is the white nipple sign that is very high-risk stigmata. You put the banding kit on and the technician hands you the scope. What would you guys do next, right? Look at how many juicy red whales that are more distal. Would you go after those or would you go after the white nipple? I used to be kind of greedy and I would go after everything. And now I have to be a little bit more careful because in this case here, I accidentally banded too close below the white nipple and I didn't leave myself enough space to get it. And unfortunately there was not a lot of space to try it. And so as I tried to suction the fibrin clot, I couldn't get enough tissue around it to pull in. I deployed it suboptimally. It kind of really was not in the center of the band, it was really on the band itself, but there was no bleeding. So I thought, oh God, thank God. And so I learned right then, prioritize the stigmata of recent hemorrhage above all else. Not everyone will agree with me. Nina, I'm eager to hear how you feel about it. I would say if you go distally and you get those non, not the white nipple, but you try to get the other ones first below it, make very sure you leave yourself enough room for the real main course. And I think that what you just said at the end is the key, because that's the best of both worlds is a strategic approach. Because the reason you start at the bottom and you spiral up is you're essentially turning off the tap at the source in terms of the source of the blood that's under high pressure in a large vessel. But you do need to leave yourself some room because you do want to take that stigmata and make sure it's in the middle of your cap. And that should be your last one. Right, exactly. That's your last band that you placed. So you have to be, you know, when it comes to any GI bleeding case, I always tell the fellows, take a deep breath, calm yourself down. What's your strategy? Because if you just go in there and you're panicked and you're trying to do a whole bunch of stuff and you don't have a plan of attack, you're going to back yourself into a corner that becomes a rescue situation. So in this case, if you see where the red whale signs and you know where the white nipple is, you can plot your approach to the spiral approach. You would probably only need to put four bands in a spiral configuration below that white nipple. And you could put your fifth band right on top of that with that nipple in the middle, and you would be done. And that patient, as long as you started a PPI, would not re-bleed. Yeah, exactly. So I made that mistake. And then, and so something bad happened later. But one of the key lessons also is that desufflating the lumen is important to maximizing tissue acquisition when it comes to banding. Oh, very important point. Right? Yeah. The banding and clipping, and of course, over the scope clipping, right? So you want to deflate the lumen a little bit to get it softer, right? You can also augment your suction in the ways that I taught you before. Also, when you band a varix, Dr. Abraham, you know, when I was at Baylor, they said something to me that was actually really wrong. And I don't know if you teach it the same way, but they said that when you band a varix, suction it, and then push in to get more varix in. It's totally wrong. Totally wrong. I think you should suction, and then you should loosen your big wheel up, straighten, and actually wiggle back a little bit to allow more of the tissue, more of the mucosa to come into your cap to get the proper red out. What do you think? Yeah, the key is to get the maximum amount of tissue into your cap. So I think the reason why you may have been taught to push in is because they were not deflating the lumen before placing the cap. So if you've got a big distended lumen, you have to put a fair bit of force in so that you can do suction. Yeah. So the secret is to just take a little of the air out so things are softer. And then I like to just put a little gentle pressure on the lesion within the cap. Suction, deploy at the same time. Right. I think the other reason too is because, you know, there's this thing about the positioning of it, of course, but the second thing is people letting go, right? So you never want to let go of the suction and then you want to maneuver. But I think as supervising attendings, maybe sometimes what they were afraid of is that if you pulled back, you would let go of the varix, right? So there's this fear of letting go. I think that's where it comes from, but I agree with you. There's this sort of, you never let go of the suction, but then there's this sort of wiggling experience that I think helps to bring in more tissue into the cap that we're all talking about. Right, yeah. None of that will work if your lumen's super distended, right? Exactly, exactly. You can't overcome the air tension that's being put on the walls. Here's an example. I'm suctioning and pushing. That didn't pull up that much. I'm suctioning here and I wiggle back, ah, and you can get a lot more. Yeah, and it's that side to side too, right? It's not, that's what I'm talking about. It's not just pull back, but it's kind of that side to side. Right, exactly. Right, so here I keep it relatively soft, right? You saw how easily the wall came on under there and you can get a pretty nice band on that with the stigmata in the middle. That's the ideal. Bands pop off if your band is placed too shallow and that's because you've not followed these strategies. Exactly. All right, so I placed a suboptimal band. Three days later, or that evening, the patient begins to have re-bleeding. I look, oh gosh, my band is gone. It's fallen off, right? Just like Dr. Abraham said. So then I find it, I target it, I reposition, I re-band and everything looks better. This patient is particularly at high risk and three days yet again, he bleeds again, right? This time I try to suction, oh, the fibrotic reaction has taken and now the mucosa is gone. The base is too fibrotic. I inject ethanolamine. I forgot what I used, but that didn't work. It actually bled more. Hemospray is not even FDA approved. I threw it down there. It didn't work. So what do you do next, right? You could, the ICU is fresh out of football helmets and Blake Morton. What do you do next? I know where you're headed. Yeah, so I think every GI fellow, non-advanced GI fellow, should be able to deploy a through the scope, fully covered, self-expanding metal stent, okay? Here, I have a couple of videos and we're not gonna look at it. It takes too much time, but this technology, I know you guys, a lot of that out there are not advanced fellows. For a very long time, we could not find a way or the companies could not find a way to squeeze an esophageal stent into a gastroscope. It just couldn't, it wasn't possible, okay? The colonic, yes, right? But finally in 2019 or 2020, I believe, finally three companies, all three companies came out with through the scope, fully covered esophageal metal stents. Boston, Cook, Olympus, they all have them. If I believe, I thoroughly believe that if you can do through the scope balloon dilation, which is standard for every non-advanced GI fellow, you should be able to deploy a through the scope, fully covered metal stent. And research has shown, a very nice article has shown, I think it was in GIA, that this is better than the tamponading balloons, the Blake-Mores and the Sengstack and- This is the evolution of the Blake-More concept. Right, exactly. My generation put down Blake-Mores, your generation probably doesn't even know what a Blake-More looks like. I hope not, I hope that this was what made it extinct, but this has not caught on yet. And that's why I'm so- Yeah, they're still looking up Blake-Mores in the middle of the night on YouTube. I know. This is the evolution. It shouldn't be. These can last a lot longer in there. You can buy you a lot more time to talk about tips or BRTO or whatever you need. And that was the most important thing that needs to, this is not a one and done. No, no. You do this in the middle of the night, you don't go home to bed without setting up the BRTO. You need to communicate that, because otherwise you leave your patient in the lurch. This is a temporizing measure. So I can summarize quickly. We're taking too much time, I'm sorry, but here are the pearls. Augment your suction by using a therapeutic 1T gastroscope by connecting the suction directly to the instrument port or using the BioVac system, which is the same thing. You can cold snare clots and you can link two suction canisters in series to further boost your flow. Carry a badge with all the scopes and the channel diameters and lengths once you finally get to your job like me. Use a clear cap to tampon on active bleeding and preserve the visual field while you pass the instruments. The DuraClip can pass in full retroflexion. The ResolutionClip allows the doctor to rotate it and the Cook InstinctClip is freakishly strong. Place two clips perpendicular to one another to ligate an unseen vessel. Align the access over the overscope clip jaws with the luminal direction to reduce obstruction. Bone wax tip catheter and a three-way stopcock can optimize hemo spray deployment. The CO2 borrow method is for more extreme circumstances but it can also be used. Soften the walls when deploying bands and over the scope clips and even through the scope clips by desufflating before suction and wiggling side to side while you suction. I prefer to prioritize the stigmata of recent hemorrhage above all else. Leave yourself some room to bandit. Lastly, through the scope, fully covered self-expanding metal stents for refractory esophageal bleeding deployed through a 1T gastroscope, in my opinion, should be standard practice and should be within the realm of the capabilities of a non-advanced gastroenterology fellow. That's it, guys. Jamie and Jasper, is there any question that comes up repeatedly that you think we should handle before we say goodnight? There are definitely a couple of questions, not a lot of repeats, but if there was time for one or two, we would have those. Yeah, let's just handle a couple of last questions. Sure. Okay. I see one there. What about firing twice on the varix? No, do less, better. Get it right the first time, make sure you've got enough tissue in it and your band is not shallow. If you do have the band in the air, if you do have the band pop off, or if the band just doesn't look like it's deep, you're better off going slightly above it and then placing a band correctly. By slightly above it, do you mean, well, you put your cap over it, or do you mean actually, yeah, put your cap over it, right? Not moving more proximal, yeah. Correct. Yeah, right, right, okay. I thought this one was good too. When do you remove a stent placed for varices? Does rebound bleeding happen while removing? Oh yeah, so you'd make sure you have, that's when the patient's ready for their BRTO. They're in the IR suite. Usually you go down with the patient and you take out the stent and let the radiologist- Sometimes you can take it out the next day, it's okay. Yeah, let the radiologist save the day, but make sure you do that before you're futzing with your tamponade. All right, well, I think, is there any other pressing questions from our fellow moderators? I think we're already over time, so I just wanna make sure we are respectful. All right, well, I just wanna thank everyone, the participants, thank you so much for everyone who showed up and sent us great questions. Especially thank you to our fellow moderators and to our fantastic faculty panel who just gave us so many wonderful tips. This is gonna be recorded and put on GI Leap shortly by the staff. And so you'll be able to rewatch it and share all these pearls with some of your co-fellows and friends. So thanks again to Dr. Tao and Dr. Abraham for joining us and giving us tips tonight. And thanks to the organizers again. Thank you so much. Thank you again to all the panelists and moderators for tonight's presentation. Before we close up, I just wanna let the audience know to check out our upcoming ASG educational events. Visit the ASG website for a complete listing of 2022 activities. The next ASG Endo Hangout session will take place on Thursday, February 10th, 7 p.m. Central Time on esophageal motility. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we wanna make sure we are offering interactive sessions that fit your educational needs. As a final reminder, ASG membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website and make sure to sign up. In closing, thank you again to our panelists and moderators for this excellent presentation. And thank you to our audience for making this session as interactive. We hope this information has been useful to you. Thank you and have a good night.

acute management

gastrointestinal bleeding

panel discussion

endoscopy techniques

Clear Cap device

hemostasis clips

prokinetics

intubation

maximizing suction

bipolar probes

through-the-scope stents

practical insights