Welcome to our newly created webinar series called ASGE Global Spotlight. This new series was created with our global audience in mind and at a different time from our usual offerings to make sure that you all have a chance to join live. These webinars will feature global experts in their fields and I am very excited for today's presentation. We have attendees joining us from all over the world and the American Society for Gastrointestinal Endoscopy appreciates your participation. Today's event is entitled Urgent versus Early Endoscopy for Acute Upper GI Bleeding. The discussion of this webinar will focus on the most common causes of GI bleeding and the priorities that need to take place dealing with them. My name is Reddy Akova and I will be the moderator for this presentation. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box in the GoToWebinar panel on the right-hand side of your screen. If you do not see the GoToWebinar panel, please click the white arrow in the orange box located on the right-hand side of your screen. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASGE's online learning platform. You will have ongoing access to this recording in GILeap as part of your registration. Now it is my pleasure to introduce our presenter for today, Dr. Mostafa Ibrahim. Dr. Ibrahim is a therapeutic endoscopist at Theodore Bilhar's Research Institute in Egypt and also the chair of the ASGE International Committee. We are very fortunate and honored to have him present today's webinar. I will now hand the presentation over to Dr. Ibrahim. OK, thank you very much, Redi, for really such a great introduction. I'm proud and honored to be presenting in the first series of events that we have really created together. So as Redi said, this series of webinars are really targeting the global physicians all over the world. And this is why we have adjusted a little bit the timing and even you will see this every month. So we'll have faculty from all over the world. And really, I'm honored to start the first one. So for better quality, I will now turn off my camera and we start the presentation. So the outline of the presentation of today, I'm going to try to answer this question. Really, we should go very urgent to the hospital to treat the bleeding patient or we should really wait a little bit to do it in a proper way, I would say. So this is a very big question. I will try my best within the next couple of minutes to answer this question regarding variceal bleeding and non-variceal bleeding with a little bit of introduction about what we should do to treat this patient. And really, finally, do we have a gap in our management or not? And this is what I'm going to try to cover. So the definition of upper GI bleeding is very clear, which is hemorrhage from any part from the mouth till the ligament of the triads. So the cause of upper GI bleeding, either a peptic ulcer, which is very common worldwide, and then the nephrogytis, gastritis and variceal bleeding. So as you know, I'm from Egypt and we have, I would say, a lot, a lot of variceal bleeding here and then cancer and less common causes. So I have this, I think this is the most important slide in all my presentation. It's not about we as endoscopists, all we think, especially our junior fellows and colleagues, think, OK, bleeding means, OK, go for the endoscopy. It's no, the answer is no. So the answer is when you manage a bleeding patient, either variceal or non-variceal, we should think about everything, starting from resuscitating this patient, going through really stratifying this patient. Is it urgent to do it now? Should, what we should do in this special patient and then what we should do before the endoscopy, following up after that, the endoscopy. And then the most important box is this one. So what we do after endoscopy, should we have a second look endoscopy? Should we do a follow up? When to do the follow up? So if I, if just I'll give you only one message from this slide, all we think about bleeding patient as this train, it's not only one station, it's everything. So are we good? The answer, really, I'm not very happy to say this, we are not good. So even in 2021 now, with all the advances we have, with all the technology, with all the really skilled physicians all over the globe, still we have a lot of patients who died from bleeding. So you can see up to 14 percent from upper GI bleeding and even up to 20 percent of people, patients with acute variceal bleeding will die due to this bleeding attack. So this is another important slide. We need to think why we are not that good till date. So for variceal bleeding, we all know that this is it's the newly formed esophageal and gastric viruses from the patient in portal hypertension, and this is the most common complication and the most serious complication from portal hypertension. We have the esophageal viruses, the gastric viruses, as well as the ectopic viruses. So what we do, and during my presentation, I will try to always have screenshots from ASGE, from other guidelines, from European guidelines, from the British guidelines, from the Babino guidelines, it depends. So fluid resuscitation. So number one, when we have this patient arrive to our hospital, this patient with bleeding, acute upper GI bleeding, we should think about resuscitating him, treating the coagulopathy, and then blood transfusion or RBC transfusion. Previously, we were thinking, OK, we should just give the patient blood as much as we can. And this is totally changed after this really very good piece of work when they compared the restrictive versus deliberate transfusion in acute upper GI bleeding. And it was very clear and significantly clear that restrictive transfusion, which means we always keep the hemoglobin of the patient between seven and eight, this lower the risk and decrease the mortality in this very difficult to treat group of patient. So classification, here I'm speaking about variceal bleeding, trial classification, and we have also the multi classification. They are the most common two classification we are using them to assess this cirrhotic patient when he arrives at the hospital. We know that child C, the higher risk patient, we should do the endoscopy within the first 24 hours. But we also know that this patient is the most likely will have a very higher mortality rate than others. So antibiotics before, so as I said, first step, resuscitate the patient, give the patient fluids, give the patient RBC transfusion, but keep it around seven or eight. Don't really overload the patient with blood. And then we should start antibiotic as soon as possible when the patient is in even in the emergency room or in the ICU. And this is a very good meta-analysis showing that when we start antibiotic in this cirrhotic patient, it will reduce the mortality, decrease the risk of bacterial infection and even the re-bleeding rate. Because again, re-bleeding in patient, in cirrhotic patient is a very big question. It's not only the virus itself. It's about the general condition of this cirrhotic patient. The guidelines, they are all the same. We either start by kinolones or third generation kefalosporins. Another very important question, the vasoactive drug. So I remember the story when I was young and I was a fellow in Egypt, even before I traveled to Belgium. At that time, I said, OK, we know that if the patient is bleeding not that much, we should give him octereotide or somatostatin. If he's really breathing a lot, we should give him telepressin. But this was not true anymore. So this is another very good study, which compared all the different types of vasoactive drugs and we showed there is no difference. So you just simply use what you have in your hospital. So the ASG is very clear. We should start one of them right away and should be continued after the endoscopy for five days. The British guidelines is the same. We should start on admission and continue for five days. But again, this is a very good question. So which five days? This is another gap in the literature. So five days of successful endoscopic treatment or five days of admission. So because sometimes the patient will be admitted after 12 hours, he's successfully treated by vandalization or cyanoacrylate injection or whatsoever. And then should really we follow if we give this patient this vasoactive drug for five days or less? So this is a very big other question for future work. Regarding non-variceal bleeding. So, as I said, ulcers, erosions, Maryweird syndrome, other causes like cancer, post radiation, post chemotherapy, deliphoid lesion, we have a lot of bleeding causes in non-variceal group. So, again, same, ASG is very clear. Hemodynamic instability, we should replace, we should give fluid replacement. And we follow the same with this restrictive transfusion strategy. And then I have put just here the nasogastric tube. So this is another very big gap in the literature. So especially maybe even more in the variceal group. Should we put a nasogastric tube on admission? So if you go, if you dig in the guidelines, it's not that clear. Should we really put it if there is any added value? Personally, what I do, I put always a nasogastric tube in the emergency room for two reasons. Number one, this will make me, will give my fellows more taste of really the blood coming from the stomach. It's a fresh bleeding or not. This is number one. Second thing, which is more important, that this will allow us to clean the stomach, to do the gastric lavage and the gastric wash. So I remember a discussion. There is very few literature saying, OK, maybe this nasogastric tube will affect the varices and will hurt the varices themselves and maybe another re-bleeding attack. I have never personally, I have never seen this in my life. So I recommend personally to do, to put the nasogastric tube and maybe even we should all do more and more research work on this, the effect of this doing a proper gastric lavage before endoscopy. So American Society, as well as the ESG, we have the very common, the GPS scoring, and we sometimes we say, OK, this patient is a very low risk, we can just, you can go home and come back tomorrow morning to do the endoscopy in an elective way. So again, and as we said, this webinar is really targeting the global audience. I know from my, from my friends everywhere that not every doctor, not every young physician is doing this, the scoring system to all the patient on admission. So another very important piece of information, we should all do this because this will decrease, will save our resources as well as we really say, OK, this patient is urgent now, we need an endoscopist now for this or this patient is less urgent, I would say, and could wait for tomorrow morning. So intravenous proton pump inhibitors is the gold standard in all non-variceal bleeding, all guidelines is recommending to start as soon as possible, which will reduce the risk of, the higher risk of re-bleeding as well as also will make the endoscopist's life easier when he will do the endoscopy. So regarding endoscopic management, so for esophageal viruses, it's clear, we should do band ligation. So this is on the left side, you can see video, what I do for band ligation, I always start, I put, this is a six-shooter band, I will go to the stomach, I will come back a little bit, I will start my band ligation at the gastroesophageal junction, I will start putting bands in a zigzag manner, not to put two bands in front of each other to avoid discussing ulcers. And then another, another very important question, when to stop? So if we go to the literature here, there's some people saying, OK, we should put only the six bands and that's it. Other, we will say they will support, no, we should put bands as much as we can to really to obliterate as much as we can from the, from the, from the viruses. Other will say, OK, we should stop about 25 centimeters from the dental arch. So personally, what I will do, I will, I will, on the right side, you also, you see another patient with the same scenario. So I will start doing the band ligation same. From down, I will go with the band set downwards and start from the cardia, pulling the, putting one by one and pulling my scope one centimeter each time to put it in this zigzag manner. And as I said, what I do with my personal, on my daily life, if I see patients like this, I will put as much as I can from the bands to obliterate as much as I can from the viruses. And I stop always at around 20 centimeters from the dental arch. But sometimes it's not always easier. So sometimes this is an old video from where I was still a young fellow. When you, when you go inside the esophagus and you just see this, you see this really spurting bleeding from the, from the, from an esophageal virus. It's very small viruses, however, a lot of high pressure. So this is why this is an off-label use of cyanoacrylate injection in this bleeding viruses. So what we do, we inject one milliliter of a mixture of lipidone and cyanoacrylate just below the spurter. And as you can see, you can stop it immediately. And in this condition, you should not do anything. You should not do another band ligation for the other veins on the same setting. I will just leave this patient for one week, one week to 10 days, and then I will ask him to come back to do the band ligation for the other viruses. So for gastric viruses, I know that I'm speaking here today on behalf of the ASGE until date, we know that cyanoacrylate is not due to the high risk of complication in the States. It's not the, I would say the standard of care. However, a part of the US and globally, we are all using cyanoacrylate as the gold standard of treating of gastric viruses in primary as well as in secondary bleeding management of bleeding of gastric viruses. So how to do it? It's another, this is on the left side, you can see. So this is a video. You have the viruses and this is my scope is in the retroflexion now. Normally, I will put my needle. I will probe first the vein to make sure that it's really where I would like to inject. And I'm using here, this is a 21 gold needle. It's a special caliber for our Egyptian patients where we have, especially for gastric injection. And then we will prime the needle with lipidol and then we will push very fast the mixture of cyanoacrylate to lipidol and then we flush it back. After that, you can see now I'm flushing my needle with distilled water. And then the very good technical tip here to stop, to wait. So we should not be really, we wait, we wait for a couple of minutes till coagulation happens and then we probe the vein again to make sure it's solid. If it's not solid, what I will do, I will re-inject it again with another shot, which means another mixture of one to one mixture from lipidol and cyanoacrylate. In this part, we have a lot, a lot of unanswered questions. How many milliliters we should inject? Should we really inject only the bleeding one or we should inject all of them? Should we do the mixture of one to one or 0.7 milliliter of lipidol to one milliliter of cyanoacrylate? Should we use the 21 gold needle or should we use the 23 gold needle? This is a lot of open questions in this part. However, what what I'm doing on my daily practice, I always inject a one to one mixture and I always inject till the obliteration of the viruses and and then I will follow up this patient after two weeks. On the right side, sometimes you have a very small gastric extension, which you cannot really see it when within the retroflexion. What I do here, I inject what I call it the forward injection. So same mixture, same needle, but we do it from the cardiac. But the most important thing that you should pierce this extension below the gastroesophageal junction, not above, not in the esophagus. Regarding ulcer bleeding, again, we all know that we should do a combined technique with a thermal part or a clipping, not only one technique. So this is a video of one of the two techniques to put a clip. So this is a bleeding ulcer in the first part of the duodenum and you can see the vessel here. And my target, what I have done in this patient, I have I have injected norepinephrine around the bleeding vessel. And the idea is not to to do anything or just only to give my this tamponade for a couple of minutes to have a clearer vision, to be able to place my clip. So this is a technique of placing the clip when you when you place forward view. So you have the ulcer in front of you and you just put the clip. And then I would just forward a little bit. So this is the first clip and then you can see still there is a vessel on the left side. So I will put a second clip just here by the same technique. And then another question, when we should stop, I always in ulcer bleeding, I always stop when I have complete stoppage of the of the bleeding. So this is the second clip you can adjust it and all the new clips, you can really adjust them, you can open them, close them again. So this is nowadays with the with the new technology, it's easier than before. Another scenario is that putting a clip, putting a clip, yes, put this another bleeding ulcer when you when when you cannot really put a clip, you cannot put your clip in a forward direction. So this is another type of of applying a clip from a lateral wall legion. It's more technically challenging, but again, sometimes you have no option only to do this. You cannot really have the forward view as on the left side. So you can see here on the right side, I have put the clip when with this lateral technique. So, again, in taptic ulcer bleeding or acute non-vericeal bleeding, this is a very recent study comparing coagulation with hemoclips. You can see that the initial hemostasis is 98 percent in the coagulation part versus 80 percent in the clips only part. However, it's not very it's not in this study, it was not very clear, should we really do it only one technique or a combination of both techniques? However, this is my this is the very difficult question, when to do all of these things, when to put the clip, when to do the band ligation, when to do the cyanide creatine injection, when to do the coagulation. So, for variceal bleeding, ASG and Bavinu recommends very clearly that we should do the endoscopy within 12 hours of presentation of the patient. For the non-variceal bleeding, also the American Society, as well as the ESG, are very clear stating that after hemodynamic stabilization, upper GI bleeding, upper GI endoscopy should be done within 24 hours. And if the patient will persist to be instable, we should do it as urgent as 12 hours. However, the $1 million question, is it possible? Globally, the answer is no. So, you cannot have a therapeutic endoscopist everywhere, 24 hours basis. Number one, due to the lack of experience endoscopists worldwide, not only the endoscopists, the nurses, the staff, to have an endoscopy unit, which is able to manage bleeding 24-7, it's really not easy. So, this is why doing this every day, anytime, is not easy, is not easy worldwide. So, still the debate is going. Should we do it as early as possible? Or we should wait till tomorrow morning after 24 hours? Or within 24 hours? So, this is a very good piece of information. When they compared band ligation, for example, between within four hours, more than four hours, less than eight hours, more than eight hours, and then 12 hours, they showed that there's significantly more band ligation had been used in the group of patients less than four hours. And the only explanation for this, that at that time, you don't see really you put more bands, because you really cannot see a very well or a very clear vision. So, you simply put more bands to be safe. Another recent randomized control trial compared urgent, which the mean of 10 hours versus early, with the mean of 24 hours, and you can see there was no difference in mortality between the two groups. And this was a very specific group of patients, of higher risk patients with upper GI bleeding. Another retrospective study on 250 patients, again, comparing urgent within 12 hours versus early from 12 to 24 versus late, more than 24. And in this study, they showed that urgent endoscopy, they have 23%, they have active bleeding during the endoscopy, which limit the visualization of the bleeding site and how to control it. And in this group of patients, they have to repeat the endoscopy in a second look endoscopy. Another retrospective work on 300 patients, showing that delayed endoscopy more than 50 hours, it's another independent risk factor of increasing mortality. So, you can see, literature is really controversy. So, you can see people supporting that we should go early, as early as possible to do it. But sometimes you don't see, you cannot really identify where is the bleeding site. And if you leave the patient too much, the patient have a higher risk of mortality. For variceal bleeding, again, as I said, it's clear that we should go within the 12 hours, which I know that it's not always possible. This is another recent study on 274 patients when they compared urgent endoscopy less than 12 hours versus non-urgent or early after 12 hours. And we have no difference in mortality between the two groups. So, it's clear that there is a debate. There is a gap of the literature in this part. But the only thing which I know and which I believe that resuscitation and having the patient stable while you are doing for him the endoscopy is one of the milestones of treating this patient correctly. So, how to fill the gap? I think we should think about a very simple endoscopic technique that could be done anytime with basic experience. So, the young fellow can do it alone that allows early stabilization. And this is the very crucial point. Allow the hemostasis very easy and very early to avoid complication and to give the chance for this patient to be stabilized, to have a permanent treatment or a permanent endoscopic treatment in a clean, proper condition. So, I think for this, one of the future gap fillers are the hemostatic powders. So, we have different type of them, the endoclot, the hemostat, and the purestat. And the idea, all of them are very easy to use. It's simply you just see the bleeding site, you either spray or put the gel or whatsoever on this, diffused on this bleeding area, where you stop the bleeding temporary, you have very good initial hemostasis, and then you should come back to treat this patient in a cleaner condition, as I said. So, this is the endoclot. It's a starch-based single-use powder for hemostasis. Most of the studies on the endoclot was done post-EMR and post-polypectomy. The other one, which is the hemo spray, and it had been used mainly in ulcer bleeding and in other study in variceal bleeding. And the idea, when you spray this powder over a bleeding site, it will absorb water, and it will change to a foam-like structure, where this foam-like structure will initiate initial hemostasis, immediate hemostasis, which lasts, this powder will stay in position for up to 12-24 hours, and then it will be eliminated from the GI tract. So, this is one of the studies that have been used testing the hemostatic powder in variceal bleeding, and it had been tested in RCT, compared in 86 patients, where we have significant difference in mortality in the group of the hemostatic powder. An idea of the study that we put the hemostatic powder on admission, and then we will do the definite treatment after 12 hours from the hemostatic powder application. This is an example of a duodenal varices. So, this is exactly what I was saying. So, duodenal varices, ectopic varices, something which we don't see every day and really difficult to treat. So, ideally, I should inject cyanocrylate somewhere here. So, this one was one of the patients within the study of the hemo spray, and the decision was to apply, as you can see, we will apply the hemostatic powder just diffusely all over the area here, and then the idea is just to stop the bleeding immediately, and then you will come back, you can see this is the picture, this is the picture of the powder, the grayish material of the powder covering everywhere, and then I will come after 24 hours, the varice is there, it will never vanish, but in a very clean condition where I can inject this and treat it in a very proper way. For the ulcer bleeding, it had been used a lot in the literature. This is one of the recent studies in 200 patients where you have 88% immediate hemostasis, and then there is a re-bleeding, there is a 70% re-bleeding, and this is why personally I always think, and I have seen a lot of patients using this hemostatic powder, we should do a second look endoscopy in all of these patients after 24 hours. So, I think this is a technique which will fill the gap, but it will never replace the other techniques. It's part of our having this in your, you know, in your different weapons. So, we have the clips, we have the band ligation, we have the heat probe, we have the coagulator, we have everything, and then part of it, it's a new tool, a new weapon in our weapons, which is something easy to be done, which shows a very good initial hemostasis. It's not competing with others, it's a complementary technique to other techniques. So, this is another video for a very difficult condition of post-band ligation ulcer. So, you can see this is a patient, we have done band ligation for him, and then there is a diffuse bleeding from the post-band part, the post-band area. So, again, application of the hemo spray, as I said, I started the cordium, and then I will pull back my scope, applying this powder everywhere, diffusely all over the esophagus, and then I have done a follow-up for this patient after 24 hours. You can see this after 24 hours. So, we have a cleaner ulcer base, and for example, in such condition, you don't need to do anything, just give this patient proton pump inhibitor for a couple of weeks, you don't need to do it, but in other conditions, maybe you will come back to put a clip, or you can come back to do a band ligation in a proper way. So, to finalize my talk today, as I said, it's everything. It's not the endoscopy only. It's the resuscitation, the stratification, the risk stratification, endoscopic treatment, and the medical treatment, and then the post-endoscopic management. Pharmacological treatment should be started in variceal bleeding as soon as possible, as well as PPI should be started in non-variceal bleeding as soon as possible. Early endoscopy is the gold standard. However, it's not always possible, technical part, and but the cornerstone or the milestone is that we should have our patients stable before we do the endoscopy, and this is why I think newer technique could really fill the gap. Thank you very much. Thank you, Dr. Ibrahim, for that excellent presentation. The audience is ready with a question for you, but first, as a reminder, questions can be submitted online by using the question box in the GoToWebinar panel on the right-hand side of your screen, and if you do not see the GoToWebinar panel, please click on the white arrow on the orange box located on the right-hand side of your screen. Here's our first question, Dr. Ibrahim. In an emergency GI bleeding case, how important is the supporting staff when you make the decision of when to do the endoscopy? Okay, I think this is a very important question. So, I will give you a real-time, a real-life example. So, in Belgium, when we have a bleeding, when I was in Belgium, we have a bleeding patient come to the hospital. So, the hospital will call me. So, the fellow will call me. We have a patient, a bleeding patient. The first thing I will do, I will not say, okay, I'm coming in two hours or anything. I will call the endoscopy nurse, the charge endoscopy nurse of that day. I will call her to make sure when it's possible for her to come and when she will be ready. And then after that, I will call the hospital, okay, we will be ready at that time. So, this is the answer. So, endoscopy staff and nurses, even some anesthesiologists, all the team, this is maybe more important than the endoscopy himself. So, this is why, as I said in my lecture, it's not easy to find this setup everywhere. Thank you. That's a great answer. And not an easy one. On your talk, you mentioned GBS, the Glasgow Blatford score. How does, in your experience, how does that compare to the Rockhall score? Do you use that at all? No, no. Well, yes. Personally, I use more the GBS score. However, no, there is a lot of scoring systems in the literature. And I would say it depends on your local guidelines, on the national society, if you are using more, which one more. My only message here, that you should use something. Because I have seen a lot of countries, a lot of hospitals, they are just not using anything. So, okay, for them, upper GI bleeding is an upper GI bleeding. So, no, I encourage my friends and younger fellows to use one of them. It depends on, really, on which one your fellows really know better. Second thing, the national society recommendation, which one to use. But for me, you should use one of the scoring systems. Thank you. Yeah, it's important to back up your decision by data. So, I appreciate that. Do you use tips for recurrent gastric variceal bleeding, or do you attempt to repeat sinoacraliate injection? Okay. So, again, this is another important question. So, we know from 2010, after the New England Journal of Medicine, big RCT, that they showed that early tips is better than doing a second endoscopy in this difficult to treat patients. However, availability of tips everywhere, it's not like, okay, in Europe, it's easy to do tips in 2 a.m. But I would say in Middle East, Asia Pacific, a lot of other countries, I don't know, maybe same in the U.S., it's not easy to do tips. Personally, in Egypt, we have tips, yes, but we have more endoscopies, I would say, than radiologists. We tend to do more second endoscopy and to have another chance for doing another shot of sinoacraliate or another attempt of band ligation before sending the patient to tips. Thank you. Thank you. That's a good comparison. I appreciate that. For hemospray, how important is it to correct coagulate before endoscopy? No, for hemospray, okay, this is them. So, theoretically, when the hemospray started, they have a few of us trying to say, okay, that there is effect of the powder itself about the initiation of the coagulation cascade. And this was a personal challenge to me personally, because I have used it a lot in cirrhotic patients, where they have coagulopathy and where they have improper coagulation factors. And we don't have any problem in this patient. So, I have used it in more than 200 patients, in cirrhotic patients, actively bleeding patients, and we don't have problem in this. So, my own opinion that the hemostatic powder is more about doing a very superficial vasoconstriction to the vessels and doing this foam-like structure, which is just compressed on the bleeding site, which will stay there for 12 hours. It's more than activation of a coagulation factor or coagulation cascade. However, to prove this, it's really a very difficult study to be done, really, to compare which is which. In my studies, I have, I have, I didn't test the theory of the coagulation cascade or coagulation factor are started when I put the powder or not. However, what I have seen clinically on the patient, and when you put the hemospray on this bleeding site, you have it very clean after 12 hours. This is number one, mainly due to the vasoconstriction on the capillary vascular bed, number one. Number two, the compression itself on the spurted, on the spurted bleeding by this mechanical bag. Thank you. For, the question is, we're talking about hemospray method. In your experience, is that, how available is that around the world? So, for my knowledge, it's available everywhere. So, it's available everywhere. In the US, it's available. It's still, I think, again, one a year, half hour, it's an FDA approved. Before, when I use it, it was a CA mark only. Now, it's FDA approved. Globally, it's approved for non-vericeal bleeding. In Canada, it's approved for also for lower GI bleeding. I know that people are using it in vericeal bleeding as an off-label, but I think, from my knowledge, it's available everywhere. Okay. Thank you. We mentioned the GBS score. Besides that score, any other criteria that you use to send patients for stabilization before endoscopy and proper post-endoscopy management? Okay. So, the only benefit of the score is, from my point of view, is when you have a very low risk patient that you can say, okay, this patient can do an elective endoscopy tomorrow morning. However, in moderate risk and higher risk, we should always do the pre-endoscopy work. Resuscitation, blood transfusion, coagulation treatment of the coagulopathy or correction of the coagulation problem, intravenous, either octereotype or basoactive drug or PPI. This should all be done before the endoscopy, in both, in moderate risk and in higher risk. It's not only for the higher risk patient. I see it the other way around. I see the scoring system more to understand, to exclude, which is not important or which is not urgent, to be done in an elective way. But other than that, we should follow the same in every patient. Thank you, Dr. Ibrahim. Any final concluding statements for the audience today? Okay. First of all, thank you again, ASGE, for giving really, this is, I'm really happy to do this from Egypt and looking forward for a lot, a lot of more and more webinars from that direction. And for today, the only thing I will just conclude, always please think about the bleeding patient as everything, not only the endoscopy. Think about medical management. Think about resuscitation. Think about post-endoscopy management. And the final rule, think about your colleagues, which means if we fail, we still have the radiology colleagues, the radiologists ready to support us. We still have the surgeons ready to support us. So we should not, sometimes we think, okay, this is, we have done everything. Yeah, we have done everything as endoscopy, but still the surgeons and the radiologists can do a lot more. And that's it. Thank you very much. Thank you so much, Dr. Ibrahim, for that excellent presentation. And as a final reminder, please do check ASGE's calendar of events as we'll continue to feature relevant session to our global spotlight series. The next webinar, save the date for our next webinar will be on, for this particular series, will be on Thursday, February 25th at 8 a.m. Central Standard Time, same time as today. It will be presented by Dr. Alberto Murino on adverse events in luminal endoscopy prevention and management. Be on the lookout for registration to open for that event soon. In closing, Dr. Ibrahim, thank you so much again for this excellent presentation. And thank you to our attendees for making this session interactive and for all your questions. We hope this information has been useful to you on your practice. This concludes our presentation for today. Thank you. Thank you.

webinar

ASGE Global Spotlight

Dr. Mostafa Ibrahim

GI bleeding

endoscopy

hemostatic powders

scoring systems

holistic approach