Alan, there's a question directed to you regarding the use of prokinetics to help clear blood before performing endoscopy. So there are five or six studies, randomized trials in literature that have looked at this, mainly erythromycin, although a couple have looked at metoclopramide, but the best data is for erythromycin, and it shows that using erythromycin in select patients, and those are the ones with active bleeding in whom you think you'll see blood when you scope the patient with early endoscopy, defined usually in most studies by spontaneous hemostasis or red blood in the NG tube, that erythromycin is useful, you have to follow, I'm going to say unfortunately, in diminishing the need for repeat endoscopy. So it significantly decreases the incidence where you'll go in, there's too much blood, you've got to clean the patient out better, and then come back again. So because of that, it is indicated to use it in the selected group of patients, and it's also been shown in the subgroup of patients who subsequently had variceal bleeding to decrease length of stay. Thank you. Is there utility of endoscopic scoring documentation clinically, or is that really a research tool? Yeah, so no, in fact I didn't show it because I was told to stick to my time and only talk about hemostasis, thanks a lot Greg. But basically, yes, the Glasgow score, it has been shown to decrease the need for admission in very low risk patients. So the consensus group actually is recommending to use the Blatchford scale, and if it's under one or less, then those patients can be sent home. The problem is that it's a smaller number of patients that have a score of one, unfortunately. Some groups have looked at two as a score, but the data aren't quite as good. But we are recommending that, and there are now two studies that have looked at that. It significantly decreases the proportion of patients requiring admission overall. Thank you. Pratik, after we've achieved successful endoscopic eradication therapy for patients with dysplastic Barrett's, how frequently and how long should we undertake endoscopic surveillance? So there's some recent AGA clinical practice update coming out with about four or five experts who have looked into this field. And for low grade dysplasia, the recommendation we are making is that you repeat the endoscopy in six months with biopsies. If that's negative, then you repeat it at year one, and then at year three. That's for a baseline diagnosis of low grade dysplasia that you may have decided to have undergone endoscopic therapy. For high grade dysplasia, it's at three months, six months, 12 months, and then annually. And for high grade dysplasia patients or T1A cancer patients, we are not recommending that surveillance be stopped even after that time period. Good. Thank you. So let's move to a couple of cases that we've prepared. So this first case was an anterogastric polyp. It's a 49-year-old Caucasian man, has hypertension, hyperlipidemia, reactive airway disease, has a factor V Leiden mutation, but not on anticoagulation therapy. Upper endoscopy is done for occurred symptoms. And you see this raised, prominent pre-pyloric gastric fold. So we'll just bat that around. It seems mobile. It sort of has a sheen to the surface, doesn't it? So the pathology from this showed high grade dysplasia in the anteromucosa with acute and chronic inflammation and intestinal metoplasia. Stage pylori was negative. So this will be our first audience response question. So to the audience, what is your recommended management? Endoscopic ultrasound staging, B, piecemeal, snare resection, C, saline lift and on block mucosal resection, D, endoscopic submucosal dissection, or E, refer for operative resection. You're a brilliant audience. Gary, what do you think? Well, I think, again, just looking at that very carefully, despite the high grade pathology, you see it looks centrally depressed. We don't get a really good look, but I'm actually concerned that that's a very early cancer. It still may be amenable to endoscopic removal. Does EUS help? I probably would do it, but I suspect it's a mobile lesion. It's probably not going to help. And I think the most important thing is that this is removed on block. Whether you can, if you can do that with a lift and snare technique, but I think it's probably, if you have ESD available, it would be best removed with ESD because it's most reliably removed on block because it's the post-operative, the post-resection pathology is going to be vital to tell you whether you can cure this patient or not. Uzma, anybody else like to comment? No, I agree with those comments. I am concerned that this could be an early malignancy, so I probably would do the EUS just to document. If there were no local lymph nodes, the T-staging might be a little more difficult in this location near the pylorus and it's small size, and then resect it, probably ESD again for specimen protection. So I think Greg, in this you do, I mean, and you haven't shown us all the different images, but you'd really like to demarcate this lesion very carefully. I mean, you want to just, as you mentioned, as one of the options is removing it on block is the key. The issue is whether without ESD, can you actually remove it on block? It sounds like maybe you have, but I'd like to, you know, do magnification or NBI and make sure that you've demarcated this really well because the lesion, I suspect, is much larger than what we think it is. Well, as you can see from the video that just concluded there, what I opted to do was to assess whether this lesion would lift, and with methylene bluetid and normal saline injected around the base of the lesion, it lifted very nicely, and that afforded an on-block snare resection. I think all the panel agreed that no matter which technique, you want to resect this lesion on block with a collar of normal surrounding tissue and with a gentle tug. Again, we're using, it's a lot of tissue there, and as I said previously, I like to use a coagulation current in the stomach because of the high risk of bleeding, and you can see that there's a nice pale blue to the muscular isopropia there, and the histopathology from this confirmed an on-block removal of a intestinal aplasia adenomatous polyp. There was no carcinoma, and the deep and lateral margins were free of involvement. So I would agree, if this lesion was larger than two centimeters, ESD would be the preferred approach. Greg, do you ever like to use CAP or band EMR in the stomach? So you know, of course, Professor Inouye introduced the original CAP as part of a technique for endoscopic resection of early gastric cancer in the stomach before really applying it in the esophagus. However, I have gotten away from using CAPs in the stomach because of the increased likelihood that they can draw in muscular isopropia. What are your thoughts? Oftentimes, especially, we get a lot of referrals for carcinoid lesions, and it's nice if you can place a band to just kind of create that pseudopolyp and make the EMR, in my mind, a little bit easier. This lesion, once you did the submucosal injection, I think it did lift up very nicely, but if you had a lesion that perhaps was a little more flat or difficult to lift up, the band might help you. Gary, your thoughts on that? Yeah, I think if you've got a small lesion, we use a band ligation EMR. The ones that are a little bit larger, a CAP, I think still, despite the data, I think a CAP probably gets a little bit larger specimen, so you have both of those as options. But again, I think it's really, you have to be comfortable when we're dealing with mucosal lesions. Carcinoids, I think, are a little bit different, and I agree that you just, if you go after with EMR, that you're comfortable, you can do it in one bite and get an on-block removal. Thank you. Let me move on to the second case. This was a 42-year-old woman who we were asked to see approximately two days after undergoing a laparoscopic helomyotomy for type 2 achalasia. I will tell you, this case occurred just as we were introducing the POM procedure at Penn, and it was instrumental in winning over the enthusiasm of our surgeons. Intraoperatively, during the lapellar, they suspected an esophageal mucosal injury, and they placed an external drainage catheter. When there was persistent output, that prompted the consultation for endoscopy. Let me just go back and show the video clip here. This is in the bottom part of the esophagus. You can see they did an effective myotomy. There's a little bit of reflux, and you can see the JP drain that's there. We pulled some gentle traction to remove that from the defect, and it looks to be maybe a 15-millimeter-long perforation of the esophagus. It's sort of a tweener. It's two days after surgery. It's acute. It's not entirely fresh. All right. To the audience, what's your best option for management? A fully covered metal mesh stent, A. Endoscopic suturing, B. C. Through the scope clips, D. Over the scope clip. OK. Sort of even and out. Well, while the audience is coming to their conclusion, who would like to take this? I just want to make one point. There are other experts, more experts than me on this. I think it's an unusual case because it's drained. This makes, I think, a huge difference in your approach as opposed to many of the other perforations that we see. That's the main point I would like to make here. Really important takeaway. Absolutely. I think it opens up a variety of options that will probably work equally well. Yeah. Uzma? I was going to say it would have been nice if your surgeons had called you that day of the surgery when they suspected the injury because, again, time is always of the essence. But even at two days, you can see that the surrounding mucosa looks fairly normal still at this point. So for me, I'm thinking primary closure using some type of clip would be the ideal solution. And given the size, I would probably opt for the over the scope clip. Yeah. Well, you know, and I think that's all correct because, you know, any of these are good options. Any of the primary closure techniques. You know, this patient had an achalasia and had a myotomy, so the likelihood of a stent sealing this reliably anterograde and or retrograde is dimmed. And so we opted for an endoscopic closure. And I felt like this was a good opportunity for the OTSC because there was the prospect that we would be able to grasp the entire defect and close it in one fell swoop. And I'll just show the start of this so people can appreciate the technical challenge in introducing the OTSC into the esophagus. You want to hyperextend the neck. Once we get down there, and I had bloodied this up a little bit. I will tell you, I tried to use the twin arm grasper that comes with it. And I find that the twin arm grasper is very effective for causing bleeding in the lesion and rarely is effective in actually helping you oppose the tissue edges. So ultimately, we just aspirated the tissue into the chamber and we deployed the clip. You'll see in the last segment here that we come down and, yes, we got most of the defect, but inferiorly there's some persistent separation of the mucosa. And we put suspenders on as well as the belt by using two through-the-scope clips here to seal that up. So Greg, nice job. I mean, I think the key here is, you know, the extent, right? I mean, I think you were right at borderline of the extent of the perforation. I mean, I think anything longer than this, you probably would have hesitated in going directly for the OTSC, correct? Yeah. And, you know, and there's no question where... It's right there close. It's almost close to two centimeters here. We're, we've, you know, certainly people who are doing POM on a routine basis have become very facile in using multiple clips to close large defects in the esophageal wall or using sutures depending on your, whether you're a clipper or a sewer primarily. Any other comments? I was going to say, I mean, one of the issues, anytime you have a G-junction distal perforation, it is hard to get a complete sealing with a stent. So you could do multiple modality therapy, but clipping first. Yeah. How about, you know, what's the management hereafter? When do you get a contrast radiograph? What contrast radiography do you order? How long do you keep the patient NPO, empiric antimicrobials? Any comments? I would keep them NPO, and then we typically get an esophagram early on after the procedure. When you're worried about perforations, we usually request gastrographin because if you have a perforation and it leaks out with barium, you can get peritonitis or mediastinitis. So I'd get it with gastrographin. And if it's sealed, we always debate when to start the clear liquids. The surgeons will usually make the call, but probably within a day or so of that. Any other comments? No, I think so. We'll keep the patient in the house for 48 hours on IV antibiotics or do a X-ray at 48 hours. And if everything looks good, then the patient can be discharged. Very good. All right. Thank you. Here's our third case. This was a case I encountered last time I was on service. It was a 36-year-old Vietnamese-American man. He presented with dizziness, nausea, vomiting, and diarrhea for three days, had coffee-ground emesis and dark blood in the stool for one day. And we performed an endoscopy that revealed this lesion in the duodenal bulb. So the question to the audience and to the panel is, what should you do? Obtain biopsies for H. pylori and empirically treat with the PPI alone? Injection therapy with 1 to 10,000 diluted epinephrine? Contact thermal therapy with a 10 French multipolar electrocautery device? Cut through the scope clips or apply hemo spray? What may not be so apparent on this still image, but you'll see in a video in a few moments if I can get control of the mouse again. Oh, there we are. If I can just comment, based on this, I'm not sure I would do anything right now. I don't see any high-risk lesion, but that will evolve as the video goes. Yeah, so we'll go back to video, and that might help to discern a little bit better. The still image may not have shown it very well, but we felt there was very clearly a pigmented protuberance right there. And so I opted to inject diluted epinephrine. And you can see a nice little bit of blanching, and you get a nice swell there, just what you hope to see, right? Oh, jeez. So great, Greg. I wish I could say it was the fellow who was doing this, but it wasn't. So from doing nothing, you've created the bleeding now, right? Great. Thank you for those congratulatory remarks, Prajeet. At least it's real life. So it's still bleeding, so I'm going to keep at it. You can readily see the pigmented protuberance that we've angered at this point. Good job exposing it. It's no longer pigmented protuberance, it's actively losing. So OK, so I did some additional injection therapy there, and it didn't seem to be effective. What next? Alan? So, OK, just a couple of things, I think. So we weren't sure whether there was a high-risk, low-risk lesion. You didn't show the pigmented protuberance. I think absolutely it should be treated. If you're going to go to a combination of clips and injection, just so you know, I think five or six randomized trials in literature, two on secondary analysis suggested that if you inject first and then put clips, you have increased risk of delayed re-bleeding subsequently. So we actually recommend doing clips first, followed by injection usually. That doesn't mean it was the wrong thing to do here, I'm just sharing the data with you. So now your comment is that you've gone ahead and you've done clipping, sorry, you've done injection, caused more bleeding, then did clipping, and you're still getting oozing. Is that the situation? No. All I've done now is inject. OK. So at this point, I think... Your scold is premature, although not necessarily unvalid. So you can do two things, you can clip or you can do thermal. If you look at the data, and my personal preference is actually to do thermal. As I mentioned before, I was joking, a few people got the joke perhaps, but it was a joke, but it's true. James Lau from Hong Kong says that he prefers doing the classical injection and thermal therapy with compression in the two areas where you have arteries that have names in anatomy textbooks. And that's the pancreatic oedema, that's in the D2 posteriorly, and the left gastric higher up in the curvature of the stomach. So I still try and go with that, with the classical. You know, I'm an evidence-based guy, and so that's what I opted to do. You can see this is just in the bulb, just beyond the pylorus. So I'm using a 10 French multipolar electrocardiogram device, and you can see I'm compressing that, getting good coaptation. And I'm applying 25 watts for a 10-second, cold 10-second count. And then I'll... So note the prolonged compression, this is the way it's supposed to be done. And do you go ahead and actually inject it when you release it to try and... I do. So that's... I don't know if that's... No, right, right. If I'm helping myself feel better or the patient, but we'll generally step on the power flush as we back off. It's thought that that helps to reduce the sticking. You know, sometimes these... In this location, I'm really trying to compress the lesion against that medial wall. And it's starting to look good. Maybe I can go home. I wouldn't. Not quite. Okay. Yeah. Not yet. Can't go home yet? It's very ominous. So how long should I stare at that? No, you can't just stare at it. You've got to go monkey around with it some more. Right. Yeah. The other thing, Greg and Alan, I mean, the location also plays a role. I mean, here the pylorus is quite wide open and you can open the clips, but in the bulb, sometimes it's tricky to open the clips and get them right on... Fair enough. Particularly a shallow bulb. Yeah. Exactly. Agreed. So I did thermal therapy that this... I could not eliminate that little bit of active oozing. And so I opted then to place clips on this as well. That clips away from the bleeding there, Greg. Well, are you saying it's not like horseshoes and hand grenades that I actually have to... You need a couple more. Yeah. That's the placebo effect. Sometimes it's helpful also in bleeders to put a cap on the scope, just to help kind of stabilize your view when you're employing your different devices. That looks better. So to Pratik's point, that was close. And so we went back and placed some additional clips to ensure that we opposed those edges. If I can just make a comment. It's my personal, it's very personal, there's no data, but past three clips, you started running into a lot of trouble. You start opening preexisting clips and so on with a very punctate area. And when you think about it, the clips are not great because they don't always approximate and sometimes they're not as precise as you'd like them to be. But that looks so far good. Can you run it again or did it stop? I think that's my last slide. So that means we achieved durable hemostasis. I mean, let's ask, I mean, Alan, if we can ask you this, I think I would have probably done the same thing is like we are sort of impatient, right? Saying, okay, this thermal coagulation is not working. Do you think in this situation you would have persisted with thermal coagulation more before going to clips? Or do you think, I mean, I would have done the same thing as Greg. I think you don't wait usually. The end point that's been used in studies, certainly what I do is with the thermal, you want to see that you've had a blood duration. If it's all flat and it's still oozing because the tissue is basically not a good tissue, it's just oozing. Then I think you got to move on to something else because often what will happen is as you're doing more thermal, you just get more bleeding, right? And this looked like it. I would agree with the sequence of events. The only thing I would say is that occasionally you still have oozing after that. The hemo spray is actually not a bad thing to use if you're still have some oozing just to stop it. This is a patient then who we do a second look endoscopy for. I would do a second look regardless because this is a high-risk lesion. It was very touchy, you know, easy to start bleeding and so on. I guess the only other question is the over-the-scope clip. Should you use the over-the-scope clip as an initial treatment? I want to mention that I have limited experience because it's so expensive where I work. We do not have easy access to over-the-scope clips. But they've been used for refractory re-bleeding as such. So I don't think anyone would recommend based on the available data, unless other people feel differently, that we would use the over-the-scope clip as primary method for this when you came down and looked at it. So I would agree completely with the management you did. Very good. Well, I want to thank all the speakers in this session. We're going to take a 15-minute break. In addition to thanking the speakers, I want to thank...

endoscopic procedures

erythromycin

variceal bleeding

endoscopic scoring documentation

Barrett's dysplasia

achalasia