I'd like to introduce our esteemed faculty for the first session. We have Dr. Kaushik Das from Washington University in St. Louis, Missouri. We have Dr. Andy Tao from Austin Gastroenterology in Austin, Texas. We have Madam President Jennifer Christie from Emory Clinic and Alan Barkin from McGill University in Montreal General Hospital, Montreal, Canada. What we thought we were going to start off with is some interactive videos as we have them loaded up. The emphasis of this year's postgraduate course is on real-time decision-making and video analysis. We thought it would be really critical to go through some videos, break it down, figure out what people are thinking at that time and that moment when they're seeing this. So if we can get some of the videos up here ... All right, who's going to lead off with this one? Okay. Fine. All right. Should I just do you? Yeah. Yeah. So nice. Thanks Vinay and Uzma and everybody for the invitation. So just to start it off with a relatively basic case, we're going to talk about a 60-year-old gentleman with recurrent melanohemorrhagic shock who had multiple duodenal ulcers previously treated with through the scope endoscopic clip placement earlier this hospital admission, but presenting again with hemorrhagic shock and melanoma. So he did a repeat EGD. He had a clean base force three ulcer in the duodenal bulb and a one and a half centimeter force 1A, 1B ulcer in the second portion of the duodenum across from the ampulla. Dilute epinephrine was injected with slowing of the bleeding and blanching. Just to quickly review the force classification, 1A, 1B with spurting or oozing hemorrhage, 2A, 2B, 2C with non-bleeding visible vessel adherent clot and flat pigmented spot and three with clean based ulcers. We take this for granted, but it's a lot of work over the course of two or three decades, helping us understand which lesions need to be treated and which lesions don't based on re-bleed risk. So after injection of epinephrine... Give a mouse. We have to play that video. You can skip ahead to about 30 seconds, please. So here we're using a seven French bipolar cautery probe to attempt hemostasis. You can see it's a little bit challenging to get that vessel in direct view of the endoscope given its location. We're trying to have co-optive coagulation with this device, applying cautery to tangential aspect towards the vessel, applying cautery and then utilizing the water jet to try to relatively dramatically lift the device off of the treated surface while getting off the coagulant. Can we pause the video right here for a second? I would like to pause the video right here and ask the panel, so is what's being demonstrated right now your go-to for an oozing vessel like that? Is bipolar coag your go-to modality? What are you thinking about? He's talking about the technical aspects. What makes you say, I'd like to use this device rather than something else? Well, I'll jump in. Thank you, Dan. So, well, my question would be, why'd you choose a seven and not a 10? Yeah, that's a GIF scope, so it can only accommodate a seven French device, but good question. Okay. You want to go ahead and take that? And then I would also probably inject it first. It was injected. Okay. All right. I missed that piece. Yeah. So that's good. So this is the whole point. So, you know, if you didn't hear, injection first and then go to bipolar coag. Another thought process, some people would think if they have active bleeding to maybe use a therapeutic gastroscope so you can accommodate with a 10 French probe is another thought that you just need to think about cognizant when you're approaching these cases. We also know that it's a duodenal ulcer, right? Because this is a rebleed. And so I would have probably started with a clear cap, kept the walls very de-cephalated. That way, when I pivot against that rightward wall, the vessel would become on FOS and you would be able to direct the probe, maybe not so much tangentially, but on FOS and you could get a little bit more coaptation. Once your ability to produce coaptation is limited by the fact that your scope is running into the sidewall itself. And so once it meets that resistance, that's as much as you're going to be able to get, but there is no resistance with a forward punch. I mean, you could just really drive that thing in there, but you need an on FOS view. And just to highlight that the effectiveness of the thermal component relates to how much you can put coaptive electrocoagulation. So the force has to be there for up to 10 seconds. This is why the randomized trials had a 1% perforation rate. So it's very important. The other thing you can do is use a side-viewing scope, for those of you who are familiar with those, if it is D1 to D2 superior to the ulcer. Great tips. All right, we're going to run the video now. Dr. Das, we'll continue to narrate. I think it started back at the beginning, unfortunately. Maybe go up to 25 seconds. Can you go back? No, can you go back? Can you go to three quarters of the way? We're playing the video. There you go. And what we'll do is we'll advance the video for about 45 seconds now. Can you advance the video to three quarters of the way through, please? Keep going. Perfect. Keep going further. Keep going. Keep going. I think the point will be made. So I noticed you were applying some water or saline as well. Correct. So do you do that right at the end, or what's your approach for that? As I said, the point will be made. All right, so go to the next slide. So what now? As Jennifer said, 10 French versus 7 French, do you go up the wattage? The great idea of using a clear cap. We did have a duodenoscope, but given its location, it didn't feel like it would be a great place, and the elevator may have been more trouble than it's worth with some of these devices. Do you try a coag grasper, though there's not a clear actual specific raised vessel to grab there? Is the location one where a TTS or OTSC clip would be useful? Would you bail and use hemostatic powder at this point, or bail and call for vascular intervention? This is the table from Lauren Lane's ACG guidelines on upper GI bleeding, just to show that there isn't actually that much comparator effectiveness data in moving from one modality to another when one has failed. The third line up shows clips after thermotherapy, there's not actually that much data to show that actually helps all that much. For the sake of time, I would just keep going. Can you click this video? Clips after thermal therapy is tough, because once you've burned it, the area has become fibrotic. Likewise, if you inject epinephrine, you make, through the scope clips, that much more difficult as well, just a technical nature. We did what Greg Ginsberg would tell me in training, is to use superior endoscopic skill, and essentially, exactly as Andy said, try to get a little bit more of a direct on false view, and you can see we got hemostasis there. Then the question is, is that enough? Do you leave well enough alone? Do you want a detective clip? That was kind of a gnarly forest 1A, kind of bleed in the middle of there. Before you show this video, poll the panel, what would you do next? I would have put in a ligation device. You could have come out and used the over-the-scope clip with your data, however, then you're going to lose two, three minutes of an active spurter. In volumes, it's minimal, but in personal pressure, it's huge. I would go through the scope clip, and I would perform. I'm not too worried, because it wasn't a fibrotic ulcer bed. I realize you did thermal points well taken. I would still go like that. Even tangentially, if you get enough healthy tissue to really apply compression across it, it's doable. Here, seen from 40,000 feet, it seems doable. That's what I would have done. I agree. I always feel like dual modality is not epi and bipolar epi, but clip, but rather mechanical plus cautery, or cautery plus mechanical. To me, those are the more durable ones. For a 4S1A, I try to apply maybe what you would call triple therapy, epi, cautery, and why not a clip if it can. This tissue looks pliable. I think the tissue looks pliable, but I think in real time, when you're in there, you're just happy that it stopped. Yes, I agree with that, but in real time, after seeing that spurt, I probably would just ... Play the video. All right. We'll play the video. See what happens. Some nice photo documentation, I see. Thank you. Oh, uh-oh. Let's go to the next slide. Was that a trickle? Was that a bleed? Does this change your calculus? It looks like everybody was excited about putting a clip on anyway. Everyone has had- Here it is. Dual modality. Nice try. I was just trying to ... I was baiting you, basically. Yeah, I know. I got it. Hit the video, please. This is a rotatable cook instinct clip. As you guys said, it's not a fibrotic ulcer bed, but its location is somewhat challenging. You'll see, to actually successfully get across the area that we want to get, we essentially have to lose the entire view, suction down the lumen, turn our shoulders to try and really get there. Again, I think to Andy's point, a clear cap could also help preserve some of that view as well. If it's on, but it wasn't in it. It wasn't on to begin with. Here we are. Pretty good result at the end of that. Remember finishing off with a through the scope clip is a nice radiological target if this thing re-bleeds and you want to send it up to arterial embolization with IR. The other questions I had at the end of the case were PPIs, duration, route frequency, anticoagulation resumption, when, how much, how. If he has to be on aspirin again or NSAIDs, would you put him on PPI prophylaxis? I guess Andy already addressed if there was bleeding again, having a metal object there will be helpful for IR. I guess one of the pearls with this is with duodenal ulcers, if someone's not on NSAIDs, you have to really think about H. pylori as well, H. pylori eradication, high association with duodenal ulcers, especially duodenal bulb ulcers. Quick poll. How long do you keep people on PPI after this? What are your recommendations? What do you, what do you, Alan? So high dose for three days, we can go high dose, it'll take an hour. And then for the duodenal ulcers, usually a week, sorry, a month, and for gastric ulcers, two months. For the, if you know your Rockwell score is six or more, the high risk patient he would qualify, the first two weeks is double oral PPI dose. I agree with all that. I also remind you to train your technicians. Every time you see an ulcer, remind Dr. Tao to take a biopsy for H. pylori. If I ever forget, you need to tell me because sometimes emotions are running high. I want to get out of there. And you should do it if you feel comfortable at the time. There's good data suggesting it gets lost in the wilderness afterwards, but not everybody wants to. The, the bleeding from spontaneous ulcers, even patients who are going back on anticoagulants from just doing biopsies is minimal. I would urge you to consider that possibility. So again, just to recap, take biopsies from the gastric, from the, from the body for H. pylori. If you run into a duodenal ulcer, it's totally safe. If you can recall, please make that part of your practice. All right. We'll go to the next case. So these are some variceal bleeding cases. How do I advance this? Yeah. Okay. Right. Disclosures. So this is an alcoholic cirrhosis, presents with melanohematemesis two days ago, and it shows these varices. You install the banding kit, the technician hands you the scope. Please note, there are very large varices below this stigmata, this white nipple, as we call it, which of, what do you, what do you ban first? Dr. Barkow? Thank you. If there's not a drop of blood, you want to go, you're almost at the G-junction and we agree. So you're going to aim for G-junction, not cheating very much. I am, and you want to go low. If there was a big distance to the G-junction, I would still take my chances, go down. You do, and then come up to this. If they're close together, and that's almost the G-junction, you may want to start with that right away, and then we'll deal with the others. In this case here, probably I would take my chances and go down. It takes literally a few seconds. If the actual nipple starts bleeding, you just come up, you compress it. I wonder if that's going to happen. Oh yeah, I wonder. You then compress it. But it does. And, but you need to know, plan. You compress it with the cap. You can see it. You slide up a little bit, suction it, and you capture it. So I feel comfortable enough in my practice to do, to start with the others first, because the reverse is going to be harder. Right. Yeah, I was going to say, I think that, go ahead and play the video. I think the important thing to notice is that there was stigmata of recent bleeding. Right. So that was, that was something that we just need to emphasize. Right. So this is that case. There's that white nipple, very large. And I did what Alan said. I got, I want, I want to get it all really. But immediately it started bleeding as soon as I brushed past it. And just like you said, this is where you want to use the clear cap to tampon out the vessel to maintain your visual field. You know where it was because you just passed it. It's right there at 11 o'clock. It's very subtle. You just slide back, you target it, and you suction them in. Now there's a slight art to targeting something within a cap. When you suction it, your target will move. Even though it seems like it's in the center of the screen, when you suction it, it'll move. And it'll move in a way where it sucks towards the pivot point of your clear cap. So here in this situation, the clear cap was kind of at the 11, 10 o'clock position. You want the center of your target to be actually away from that pivot point. Because when you suction, your target will migrate centrally towards that position. It's a little bit of a subtle point. But if you do enough banding, I think you'll know what I mean by that. So can I pause right there? So if you see stigmata of bleeding, do you treat that area or just distal to that area? Right. So I don't know. Even though there's hundreds of people here, I still don't really know what the right answer is. But that's why I kind of posted it out there. No one. So to be fair, no one knows. I just know what your practice is. What do I do? I've been burned enough times that I take that vessel first, the high risk stigmata first. And as you guys know, you can, that band is pretty durable. Okay. And you can go around that band. And I try to get underneath that band, put another one at the G junction and move up from that position because I feel relatively secure that I'm not going to cause a visualization disaster. You know, as I, as I went through and thought about this exercise, and that's exactly what I would do too. And that's what I think most people would do. If it's a little bit higher up, maybe one, one can say, well, we'll band the vessel a little bit distally. So you decompress the, uh, the, the blood flow to that area. Then target that. Secondly. Yes. No, I would go straight for the vessel. I go, I go straight for the vessel. Yeah. You just don't realize how terrible things can get and you just, there's just a little bit of greed I'd say. Yeah. All right. Keep, sorry. Keep going. Let's wait. We've got four more minutes to go. So what if you deploy a different case here, but you deploy the band. You got a little too excited. You didn't wait for a red out and you got a really shallow capture. Okay. Okay. You see here, it's not getting read out or maybe your suction was poor and, and you just deploy that. That's okay. But remember the most fearsome complication of this is a post banding ulcer, right? Where we have few modalities to treat. If you're in this scenario, let's pause it right here, Jennifer, what would you do next year? It's a pretty shallow deployment. You're like, look at that. I mean, you just barely got mucosa, right? You're exposing a little bit of that submucosa, right? And you were right on it. Yeah. So I probably try to maybe go below it. Right. Yeah. Right. Yeah. Go below. It is a great answer. In this scenario. Yeah. Go ahead. Step back. These patients suspected variceal bleeding. They should be general anesthesia. Right. Right. So that that's first and foremost, because you see the amount of fluid that's exchange being exchanged here. The amount of bleeding, if you didn't anticipate it and you're in, in a Mac case or a conscious sedation, you kind of want to quickly convert that to a general scenario. So that's just something that just needs to be pointed out. Right. Just want to demonstrate here that it is actually okay to reband a previously banded position. Okay. Just to get a better suction, your initial band actually oftentimes will migrate slightly, but you can get called out the snowman band. You can get two at once. Did you make that up? It's patent pending. So this is what I'm talking about leading the target. The pivot point is on the left. The pivot is where your cap actually touches the mucosa. You don't actually want to bend it right there. You want to shift slightly back. I know this seems like a minor point, but if you want to really want to get it right in the center without any slipping, Oh, can you go back? Anyways, you want to try to get it, play that video again for me. You want to get it at least slightly to the right of center. This is probably too subtle of a point to waste too much time on, but when you're using there's actually more volumetric suction. So you want to actually position that target slightly to the right of center. With advanced endoscopes, I know you'll appreciate this minutia. You actually want it slightly right to the right of the center so that it won't move the target. I call that kind of leading the target, if you will, because you know, when you suction, it's actually going to center itself. Three days later, it bleeds again. Sclerotherapy, not too commonly used, but something, this is for you guys on edification. You can refer to this later. There are aliquots that you should recognize because these have significant tissue injury problems. And so if you need it, you can use it. But in reality, actually there's better modalities. So the patient bleeds again, these are post bending ulcers. This is not good. Okay. Again, you can use clear cap tamponade. It's now at the kind of four o'clock position. And here you are suctioning. There's active bleeding, but it won't come into the cap. This is a very feared problem. It won't red out. And your initial thought is that it's become fibrotic and that's probably right. In this case, to be actually honest with you, what really happened was that the nurse was standing on the suction. Okay. And the suction, it's an ICU travel case, the ventilator, it's just everything's so loud. You can't hear anything. Couldn't recognize that the suction wasn't on. Band after band, I think I used all six of the sites. I couldn't figure it out. And then the nurse, I told her, go get my, you'll see what I do next, a stent. And sure enough, as soon as she came off of the suction, I realized my problem. I was going to ask at what point would you sort of reach for a TTS stent, a Blakemore or get a TIPS? Right. Right. TIPS. If you're going for number four, number five endoscopy on the same hospital admission. Prevention is the best medicine. So when I'm in the ICU and things are loud and crazy, I always suction my glove. Using the glove after you install the clip to make sure that you're getting maximum suction, your glove should be able to be pulled all the way to the end of the cap, complete blue out, if you will. Right. And so I was, you can, here's an example of bleeding below the varix. But in this situation, I needed to get to TIPS. These cases that bleed at post banding ulcers, you can guarantee their HVPG is going to be very, very high. Right. And so I know there's a lot of advanced endoscopies out of here, but I will just stake this claim right now. Every general GI can and should learn to deploy the new technology of through the scope fully covered self-expanding metal stents, because you can directly see the stent. If your colleagues are calling you at three in the morning, it's an opportunity to teach them how to deploy the stent, because if they can leave a savory guidewire behind, they can leave a stent behind. You open the flange, which is oftentimes very large, 28. You leave it at the G junction and you simply pull the scope back. Just simply pull the scope back while they deploy the stent. Do you need fluoro for this? You don't need fluoro. Exactly. Right. And I think a lot of people don't appreciate that about four or five years ago, the industry hadn't figured out this technology. They couldn't get a fully covered stent through a gastroscope, it was a little too big. Finally, they figured it out. All companies now provide this. So you just deploy the flange, you see it, they pull back the scope, deploy, deploy, deploy, keep pulling back. It's hard for that thing to get migrated up because the flange is significant. It's 28 millimeters sometimes. All right. We're going to cut it off here with your take-home points right here. Take a look at these take-home points. I was going to let that take-home point sit on the screen. I just want to make one important point. This patient needs the tips. There's good data for randomization of sending the tips before, even in doing endoscopy, if they meet the severity of liver disease. This patient needs a tip, multidisciplinary approach, and that's the long-term response. It's a very important point. You mentioned it. I want to emphasize it. That if tips takes a couple days to get, you're not worried about Blakemore tube hurting their esophagus. You have time with that thing. By God, we leave it in there for four to six weeks sometimes, right? Yeah, you're absolutely right. It's a temporizing measure until they can get more definitive therapy, right?

postgraduate course

real-time decision-making

video analysis

endoscopic clip placement

variceal bleeding

multidisciplinary approach