Welcome to the ASGE Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I am very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Approach to Non-Variceal Upper GI Bleeding and Hemostasis. My name is Michael DeLutri, and I will be the facilitator for this presentation. But before we get started, just a few housekeeping notes. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&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 the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. It is now my pleasure to introduce our GI Fellow moderator, Fatima Khan, from Yale School of Medicine. I will now hand over this presentation to her. Thank you, Michael. Hello, everyone. My name is Fatima Khan, and I'm a third-year GI Fellow at Yale. Thank you to the ASGE for hosting this webinar tonight, and thank you to our wonderful discussants and to everyone joining us this evening. It's my pleasure to get to introduce our content expert and panelists for tonight. Dr. Lauren Lane is our content expert this evening. He's a professor of medicine and chief of the section of digestive diseases at the Yale School of Medicine, as well as medical chief of digestive health for the Yale New Haven Health System. Dr. Lane is a past president of the American Gastroenterological Association and has also been a member of the American Board of Internal Medicine and of the Gastrointestinal Drugs Advisory Committee for the Food and Drug Administration. He's previously served as an associate editor of gastroenterology and gastrointestinal endoscopy, and he currently is the chair of Digestive Disease Week. Our panelists for tonight will be Dr. Michelle Hughes and Dr. Kenneth Hung. Dr. Michelle Hughes is currently an assistant professor of medicine in the section of digestive disease at Yale School of Medicine in New Haven, Connecticut. Since 2019, she has been practicing as a GI hospitalist, specializing in the care of hospitalized patients with gastrointestinal disorders. She also serves as the digestive health medical chief of quality and safety for Yale New Haven Health. Her clinical and research interests are in the practice of gastroenterology in the inpatient setting, novel approaches to GI bleeding management, and care delivery improvements through system approaches. She's actively involved in medical education at all levels with special interest in quality and safety curriculum development for trainees and faculty. She is the co-founder of the ASGE GI Hospitalist Special Interest Group and their current chair. And then finally, Dr. Kenneth Hung is currently an assistant professor of medicine in the section of digestive diseases at Yale School of Medicine in New Haven, Connecticut. He is a gastroenterologist specializing in the management of inpatient gastrointestinal issues. He, along with Dr. Hughes, started the GI Hospitalist Program at Yale New Haven Hospital, where they care for a variety of patients with gastrointestinal issues, including GI bleeding. He has served on national committees as the general gastroenterology and colorectal cancer work group lead of the American Gastroenterological Association's Quality Committee, and currently serves as the gastroenterology medical student elective and associate program director of the Gastroenterology Fellowship Program at the Yale School of Medicine. He has interest in GI bleeding, peptic ulcer disease, and H. pylori. And with that, I will hand it over to Dr. Lane to start the presentation. Thank you very much, Fatima. And let me just share my screen. Then are we seeing the slides now? Okay. Okay, great. So it's really a great pleasure to be here and talk about my favorite subject, that is GI bleeding. And these are my disclosures. And tonight, really, we're gonna talk about GI bleeding, and I could talk about this for hours, but I won't. But because this is ASGE, I'm gonna really focus pretty much all on the endoscopic aspects of management of upper GI bleeding. And we can certainly talk about other non-endoscopic things during our question and answer period or after I'm done. So we'll talk about time of endoscopy briefly, then spend most of the time talking about management of bleeding ulcers with endoscopy and endoscopic therapy. And then if we have time, we can talk about non-ulcer, non-varicella upper GI bleeding as well. So let's start talking about timing of endoscopy. This is very important if you're a GI fellow, of course. So in a patient hospitalized with upper GI bleeding, when should they be hospitalized? Well, what does the evidence say? First, if we look at the overall population of people with upper GI bleeding, there are a number of observational studies that show that scoping within 24 hours as compared to not scoping within 24 hours, reduces the length of stay, the need for surgery, and possibly even mortality. A randomized controlled trial found no additional benefit of scoping them earlier within 12 hours as compared to later than 12 hours after presentation. Now, in the past, we've often been taught in some of the older guidelines suggested if you're higher risk, you should be scoped earlier. And actually the liver society guidelines still say that for cirrhosis. But I'll suggest to you, there really aren't good data to support those suggestions. And most of the guidelines now no longer have those kind of carve-outs, if you will. The best study was one in the New England Journal not that long ago that looked at people with high risk, a Glasgow Blatchford score of over 12 and showed no benefit of early versus later endoscopy. And actually importantly, there's some observational studies that suggest scoping within six hours may even increase mortality, not decrease mortality. And finally, there are a couple of randomized trials in low-risk patients, people with normal vital signs and no severe comorbidities that show that you can identify low-risk endoscopic findings in at least 40% of people, things such as clean-based ulcers and this allows early discharge of these patients. So they actually benefit not clinically, but economically. So when we did our guidelines a couple of years ago, taking all this together, very simply, we just said patients admitted to or under observation in the hospital should undergo endoscopy within 24 hours of presentation without really any other special circumstances discussed. Now, I think most important is you don't have to wait, obviously, till 24 hours to scope them. The key is don't just race them to endoscopy, don't have magical thinking about endoscopy, begin resuscitation, attend to their other comorbidities before you race them to endoscopy. That's really the key, I think. I also believe that, and we said that hemodynamically stable patients without severe comorbidities should have endoscopy as soon as possible, but within routine hours. You're not gonna come in in the middle of the night for them, but if you do them within routine hours, you will find low-risk findings in a good number of them and will allow early discharge, thereby saving society money and patients probably would rather be able to go home early as well. Now, I just wanted to share with you the European guidelines actually went even further. Not only did they recommend 24 hours as we did, but they specifically said, you don't have to do it within 12 hours because it doesn't really improve outcomes. And you shouldn't do it within six hours because it may worsen patient outcomes, as I mentioned earlier, based on observational studies. So again, when you have your ER doctor saying, you've got to come in and scope the patient right away, you can cite these kind of guidelines to help you out. But let's move on and talk about the management of bleeding ulcers. And I think endoscopy, one of my themes has always been endoscopy is really key in really how you manage patients. The endoscopic features that you find are key in assessing risk in guiding your subsequent management. And I'm sure everybody knows this, but I just want to go through the different stigmata. This is a clean-based ulcer of course here. Here we see a flat pigmented spot. Hopefully you can see those little flat spots down the bottom of the ulcer. This is what an adherent clot may look like. You see the ulcer here, but you see this raised kind of a regular eschar or blob of blood. And then of course, a visible vessel is a smooth surfaced, organized looking plug in an ulcer base. And of course the worst thing to see is blood spurting across the room. And as you know, active bleeding is separated into spurting and oozing. Oozing is far more common than spurting, but spurting has worse outcomes than does oozing. And one of the reasons we make such a big deal about that is shown in this slide. If we look at the pre-endoscopic therapy era and basically look at outcomes related to these different endoscopic stigmata, and we use the outcome of bleeding that is so severe that it requires surgery. We see that on the right, if you have a non-bleeding visceral vessel or active bleeding, about 35% of people would have such major bleeding they require surgery. This is a group of endoscopic therapy makes a very big difference obviously. On the left of the slide, clean-based ulcers almost never have really big time bleeding that would require surgery. So for years we recommended based on these data that those patients can be discharged home soon after their endoscopy. They don't need to stay in the hospital. And then clots are quite variable. We'll talk more about that. And flat spots are relatively low risk, but not as low risk as clean bases. Now, how well does endoscopic therapy work for these different stigmata? And if we look at randomized controlled trials, most of them done many years ago of endoscopic versus no endoscopic therapy, we see that there's really very dramatic risk reduction for both active bleeding and non-bleeding visual vessel with NNTs that are really quite small. You only have to treat two people with active bleeding to reduce further bleeding in one additional patient. Now, this is quite clear-cut. When we did this meta-analysis over a decade ago, we found that clots had a very broad and wide confidence interval. It was not a clear-cut benefit to providing endoscopic therapy in people with clots, but there was marked statistical heterogeneity, meaning there's marked variation in the different studies from study to study. Now, more recently, really just in the last month or two, there was a more recent meta-analysis with an excellent editorial by Dr. Hung here on this. And actually, there've been a couple of more recent studies that have been done in, frankly, very obscure journals, but they did also suggest possible benefit so that the odds ratio still was not significant, but it was getting closer to having both values below one. There was still pretty marked heterogeneity. The I-squared was 41, and the P-value for heterogeneity was 0.09, which does suggest fairly important heterogeneity. So basically, one point I want to make is why is there this dramatic heterogeneity? It's really hard to, when you look at these studies of clots, some studies show very high rates of re-bleeding without endoscopic therapy, and others show very low rates. So one of the differences, and I think this is really important when you're seeing patients with an ulcer that has a clot on it, is vigorous irrigation. We and others all suggest you want to vigorously irrigate because in almost half the patients, if you do this, you're going to remove the clot, and you'll expose a high-risk stigmata, and therefore you're going to remove many people who would have bled. You'll treat those people appropriately. So if you see this ulcer with this kind of clot overlying, and you wash it, and here we see that there's a non-bleeding visible vessel, this raised protuberance here, so you would go ahead and provide endoscopic therapy. But what we found, at least in our series in general, if it's adherent, despite that vigorous irrigation, they have a fairly low re-bleeding rate. But again, what's interesting, when you look at these individual studies, when the re-bleeding rate with clots is high, then endoscopic therapy is beneficial. When it's not, it's not beneficial. And for instance, there's two studies from Asia, one in the New England Journal and one in the Annual Journal of Medicine, both pretty high quality, which showed that zero of 24 and zero of 64 patients treated with just intensive PPI therapy alone had no re-bleeding. So again, quite variable. And so that led us, when we did our guidelines, and other international and European guidelines agree, patients who have upper jaw bleed with active spurting, active oozing, or non-bleeding of the vessel, those people should get endoscopic therapy. But we felt you couldn't really reach a recommendation for or against endoscopic therapy in people with adherent clots resistant to vigorous irrigation. And frankly, that means you can choose whichever you like, and both are okay. Now, before we start talking about the endoscopic therapies we use to treat bleeding ulcers, I think it's actually instructive. I like to show this picture. This is a photomicrograph of what a bleeding ulcer really looks like. And here on the left, we see the edge of the mucosa. Then we see the base of the ulcer. And when these have been looked at, bleeding ulcers, what it turns out is in almost all cases, there's an artery in the base of this ulcer. And here you see there's a hole in the base of this artery. And in this case, there's a thrombus filling this hole, if you will. This is what a visible vessel looks like histologically on a photomicrograph. So this is what we're trying to treat when we're actually going ahead and providing endoscopic therapy. So when we went through all the literature, all the randomized controlled trials available on all the different forms of endoscopic therapy, this is what we came up with as suggested recommended endoscopic therapies. On the left are those with strong recommendations, just meaning that the quality of evidences is better as higher quality. On the right were conditional recommendations. It's just the evidence may not have been quite as strong, but all of these were considered potential endoscopic forms of therapy. On the left, of course, bipolar and heater probe, absolute ethanol injection, which almost nobody uses, but it's very good based on randomized trials. And we'll talk more about epinephrine should not be used alone, but only in combination with another modality. On the right, we have CLIPS, we have APC, we have soft monopolar electrical halation, which is something that's used mostly for ESDs, but some have adapted for bleeding ulcers. And then finally, we'll talk more about hemispatic powder spray, but remember that you only use that for active bleeding. So very quickly, let's go through these different forms of therapy. This of course is how we do injection therapy. We basically place the needle into the base of the bleeding ulcer. Now, what are the data to inform us about how we should actually do endoscopic therapy? What should be the technique for endoscopic therapy first with epinephrine, usually in a one to 10,000 dilution? Well, it's interesting, there are a number of randomized trials, believe it or not, on epinephrine monotherapy, and they show you wanna have very large volumes, which again raises the question, is this working by a tamponade effect or by a pharmacologic effect or both? Unfortunately, as you heard, we recommend never to use epinephrine as monotherapy, and there's no studies in the optimal volume if followed by a second modality. So in general, we just recommend using anywhere from half to two cc aliquots around and in the bleeding site. If you have an actively bleeding lesion, you wanna treat it until the bleeding stops or at least until it slows to allow you to provide your second modality. In a non-bleeding lesion, you wanna do it at least in all four quadrants around the bleeding site to minimize bleeding when you apply your second modality. And absolute alcohol, like I said, isn't used that often, but it has very good, excellent results, even reducing mortality in randomized trials. If you ever use it, you use it in 0.1 to 0.2 ml aliquots using like a TB syringe with a limitation of one to two ml because of concern about tissue injury with higher volumes. Now next, let's talk about thermoprobe, most typically bipolar and heater probe. And I'm gonna get a little into the weeds because I'm not sure a lot of fellows may know this, but we don't really talk about this anymore. So I pulled out some old slides today. And first, remember that we wanna distinguish between monopolar and bipolar electrocoagulation. Remember when we do monopolar electrocoagulation, that's what we use for, let's say, when we do colon polypectomies, right? And we place this ground electrode on the patient. And basically what happens is there's one electrode on the monopolar probe or the monopolar sphincter tone or biopsy forces, whatever. And electrons complete a circuit from this electrode to the patient electrode. And that's a fairly large distance. And the farther the distance between the electrodes, the more tissue injury. Bipolar electrocoagulation meant that both electrodes were on the probe. So the circuit was completed between these two electrodes, a far shorter distance and therefore less tissue injury. And it turns out that was sufficient to provide good hemostasis. Now, again, let me just go back for a minute. If you think about it for a moment, when you treat bleeding ulcers, if you only had two electrodes, just like this, both of these electrodes have to touch the tissue so that the electrons can flow from one to the other and complete a circuit. So that wouldn't be very good. You wouldn't be able to apply this tangentially or on the side, right? So nobody ever used or developed something exactly like that. The first probes you may have heard about the so-called multipolar electrocoagulation when you read old literature, it was bipolar electrocoagulation, but what it was is it was alternating electrodes along the side, green, blue, green, blue. And that was much better clinically because as long as any two electrodes touched the tissue, the circuit could be completed and you could provide hemostasis. So again, you needed something like this because just having only two electrodes on the tip of the probe wouldn't be very useful. Now, basically other probes then came along, other companies wanted to get on the action. So they did things like the spiraling, right? Which are the more typical ones we're used to often where there's one electrode, then another, then back to the first, back to the second. And again, as long as any two are in contact with tissue, you'll complete the circuit. Now, remember when you're doing bipolar electrocoagulation, what's happening is electrons are flowing through the tissue. Now, what happens when you apply heat? You get evaporation of liquid, you get tissue desiccation, and after a while, electrons can't flow through desiccated tissue. This is from a study we did a number of years ago, but it looks at different watts. This is 10, 15, and 20 watts. And what happens is the higher the watt setting, the more rapidly the tissue gets desiccated, the impedance goes up really high. And that means that the electrons can't force their way through the tissue. So you're no longer delivering your electrocoagulation or your thermal, your heat and your hemostasis. And that's why, I don't know if you ever do that, but if you listen, when you put the probe down, you hear kind of a snap, crackle, pop for a little while. And then all of a sudden, you can keep your foot on the pedal forever, but you don't hear that any longer. So again, after a period of seconds, you can keep your foot on the pedal, but you're not providing any further hemostasis. So what do we recommend when we apply a bipolar or heater probe? We always recommend the largest probe possible with the least angulation as close as possible with firm maximal pressure. And one of the biggest mistakes I see people make is they're very ginger when they apply this probe because people think, oh my gosh, I'm gonna push right through the ulcer. That virtually never happens. We and others actually looked at this. And the amount of pressure you're applying is really quite minimal when you think this relatively floppy catheter through the entire length of the biopsy channel. So you really don't have to worry about applying firm pressure. And again, you ideally use a large channel scope for a GI bleeder, which takes the large probe. A regular endoscope does not take the large probe and will only take the 2.3 millimeter probe. And we suggest doing multiple applications in the ulcer base, both around and on the bleeding site until the bleeding stops, the vessel flattens and the base whitens. And I know later we have a picture of that as well that we can show. And for bipolar electropolation, we recommend maybe eight to 10 second applications, multiple ones at a setting of about 15 watts. And for the heater probe, you apply setting, you just put in a setting of 30 joules. Now, finally, CLPS, obviously very popular now. There is probably not a lot of good information about the best way to apply CLPS. So we basically say place a CLPS over the bleeding site and adjacent to the stigmata. And if you think back to that photomicrograph I showed you, what we're really trying to do is close that underlying artery and the hole in that artery that I showed you in that picture. Now, a brief word about dual versus monotherapy for endoscopic hemostasis. Epinephrine should not be used alone. If you look at randomized trials, it's less effective than other monotherapies. And there's a significant benefit when you add a second modality as compared to epinephrine alone. Now, our guidelines do suggest that thermosclerosin and CLPS can be used alone. They appear to do quite well alone. I will say that if you look at the CLPS literature carefully, it may be less effective for initial hemostasis and active bleeding, especially spurting bleeding. And frankly, I wouldn't use a sclerosin like ethanol for spurting bleeding either because of the limitation and the amount of volume you can eject. So certainly if you're gonna do CLPS, it makes sense if it's active bleeding to use epinephrine first, but actually there's no study done that actually assesses whether that's effective or not. Most of the studies have actually used epinephrine after the CLPS rather than before, interestingly, or kind of in combination. But that's all probably old hat. Most of you know that. What I'd like to spend a little bit of time talking about are some of the newer endoscopic hemostatic modalities. We'll talk about topical therapies and then over-the-scope CLPS. Now, there are a variety of endoscopic topical hemostatic therapies that have excited interest lately. I've listed four of them here, the four that are approved in the United States. I'm only gonna talk about the first and a little bit about the second because those are the only ones for which there's randomized controlled trial data available. But all four of these are topical hemostatic therapies that at least in case series have been used for upper GI bleeding. So this is, again, we're not supposed to talk about brand names, of course, in, I don't know if this is CMU or not, but I did put the brand names here for you since most of us wouldn't know what TC325 or UIEWD or TDM621 was. But for the first one, TC325, as you can see here, this uses a CO2 cartridge to basically spray out the powder and just to go through the steps for you. One, you activate the cartridge, CO2 cartridge by turning the red knob and then you flush the biopsy channel with air to make sure there's not moisture in the channel. You advance the catheter out through the scope one to two centimeters out of the scope and it said you want it to be close to the bleeding area as well. You turn the red valve up there to the open position and then you press that red button to deploy the powder and you apply in multiple one to two second bursts until the area is covered and hopefully there's no active bleeding. You can then close the valve and remove the catheter. So just to show you pictures, so here we have a more diffuse area of bleeding and you see multiple bursts being applied. You see down the bottom, sometimes you get this or you do get this periodic kind of whiteout. And then at the end on the lower right, you see the whole area covered with this powder and this will slough off within 24 hours. Now, what's interesting, if you look at the observational studies for this powder spray, the studies seem to indicate very high rates of initial hemostasis, but very high rates of re-bleeding in the next week or so, in the next few weeks. So this led all of the guideline panels to suggest that this should not be used, in general as a therapy, a monotherapy, but rather it could be used in a temporizing situation when you have persistent bleeding and you didn't have other conventional endoscopic therapies that were available that were gonna work. So again, it was really a temporizing therapy, not kind of a destination therapy, as we might say. But then last year in the ulcerative medicine from the very good group by James Lau and colleagues, it was a very good randomized trial in over 220 patients, over 225 patients, you could say, 224, I should say, patients, all people with actively bleeding non-variceal upper GI lesions. And this was a non-inferiority trial and they randomly assigned them to either the spray or the standard therapy. And we see here is not only was the spray non-inferior, it actually tended to be close to being better. It certainly wasn't worse, right? And this was with monotherapy only. It was true for ulcers. It was true for spurting and oozing. Again, no differences you'd expect in mortality. So based on this study, which we knew about when we did our guidelines, we did feel that that was sufficient to suggest an endoscopic hemostatic powder spray TC325 could be used for actively bleeding ulcers. Now, we did say a couple of things. It was a little confusing. Why did this do so well with monotherapy while those old case series and observational studies suggested a very high rate of further bleeding in the first few weeks? So we did think we'd like to see confirmatory information, especially in spurting bleeding. We also said, at least in the US where the cost of this was extremely high, we didn't think it would normally be the initial modality, not for efficacy, but because of cost. Now, the other one I was gonna talk about is this UIEWD. And just quickly to take you through this little brochure, there's this spray body, this big thing, and then the smaller catheter device that you basically plug into it. You make sure this red valve is closed, and then you take a vial that has the powder and you basically connect it into that catheter device, just like other things. You move that little protective film that separates the battery, and then you turn it on. And then you insert the catheter, same kind of thing. You put it one to two centimeters from the bleeding site, a little bit outside the scope, and that's when you push the red valve up and you can spray. Again, it doesn't come out in those bursts in the same way, but there's a little motor pushing it out, if you will. And then after you're done, again, you don't wanna have the catheter directly in contact with fluids. When you're done, you basically close the valve, turn off the spray body, and then remove the catheter. And again, what I did wanna... The reason I'm mentioning this, there was a really interesting and very large study presented this DDW using this. And again, this study was a little different. What they did is, these were people who came in with active bleeding or non-bleeding visceral vessels, 340 patients, so a very large study. And basically, everybody got conventional therapy, and then they were randomly assigned to either get no additional therapy or this hemostatic powder. And what we can see here, at both three days and 30 days, there was significantly less bleeding when they had the add-on powder. So very interesting. And again, more studies are needed to really identify the place of this in the hemostatic armamentarium, but this was certainly a very interesting and large study. Let's move on and talk about over-the-scope clips, something else that, again, not that new, but is something that's not one of the old standards. And as you guys probably know, similar to ligation, which you may be more familiar with, there's a cap that's over the tip of the endoscope. You place the cap over the target lesion. You apply suction, sucking the lesion up into the cap. You release the clip and then leave the clip in place as shown in this cartoon. And here in endoscopic photos, here on the left, we have this lesion that's bleeding. Then we see that we're over the bleeding lesion. We make sure that it's centered. We suction it, make sure it's centered. And then we release the clip, and here you see the clip overlying. Now, probably, maybe more than you want to know, but there's two types of over-the-scope clips that are available in the United States. One's called the OTSC clip and one, the padlock clip. Pretty much all the bleeding literature is done with the OTSC clip. But initially, there's all different variations, different sizes, cap depth, and three different configurations. So I've just mentioned, usually people use the 11 or 12 size, probably the smaller cap depth. And let me show you the three different configurations. There's atraumatic, there's traumatic, which has those little points in the middle, and then really big points on the right for the gastric closure one. And in general, a recent observational study said they thought atraumatic may be better, but if you look at the randomized trials, they've used both atraumatic and traumatic. So either one has been used. Now, again, one of the things about the over-the-scope clip, if you misplace it, it can be kind of a problem. It's not like misplacing one of those little regular through-the-scope clips. So it can really get in the way. Now, there is a device that the company also sells to remove these clips. And basically, it's a bipolar generator and a bipolar cutter. And basically, in these cartoons, it basically shows you go on one side of the clip and then you go on the other side of the clip to melt and cut it. Then they also sell a grasper and a cap for you to grab the fragments and pull it into the cap and remove them. So again, although I know we haven't been able to get this yet at our place, it actually is, I think, potentially useful because every so often, when you look at the literature, these are misplaced and they can be problematic to then treat the patient. Now, probably the first really good study for over-the-scope clips was done in patients who had re-bleeding after initial endoscopic hemostasis. And basically, what this showed is that they were markedly better than standard repeat endoscopic therapy at further bleeding. So this actually led us in our guidelines to suggest over-the-scope clips as a potential therapy for people who have recurrent bleeding after prior successful endoscopic hemostasis. Now, more recently, there have been actually, to my knowledge, published four randomized controlled trials looking at over-the-scope clips as initial therapy as compared to standard therapy. Three of them were positive and one of them was negative. I just quickly did this meta-analysis of the four just to kind of, for giving this talk and some others, just to kind of look and see. When you do a meta-analysis, it does look like the over-the-scope clips are more effective. And I won't disagree that over-the-scope clips certainly are effective. I do want to point out that there's some major methodological limitations in the three positive studies. So we shouldn't, you know, I like to really look at these studies carefully and there were more than the usual things to consider in these three positive studies. First, two of the studies changed their original sample size. You know, everybody has to register their trial on clinicaltrials.gov and they never mentioned it on clinicaltrials.gov or justified it in the article. So that's always concerning. Second, the positive studies had very high bleeding rates. Remember that we expect re-bleeding rates in the order of, let's say, around 10% nowadays, but their re-bleeding rates were 20 to 29%. And in some of these studies, if just one more patient in the standard arm had been successful or two more patients had been successful, the significant difference would have gone away. There were also some marked inequalities in important prognostic factors. And finally, the Lau study, which was really, you know, from a very good group published in the annals, actually 15 patients were either excluded or not included because there was unfavorable lesion position or they couldn't successfully place the over-the-scope clip. Now that, you know, generally would be considered a failure of therapy, but if you exclude those from analysis, it's going to really make your therapy look better. So there are a lot of issues here. I don't want to say that over-the-scope clips aren't good. I just think that we can't necessarily say that they absolutely are first-line therapy. But the European guidelines have suggested that you might consider them first-line in selective patients, people who have very large ulcers, you know, very fibrotic or excavated ulcers. And we all know that. If you try to apply clips or certain other things to these large, hard ulcers, they may bounce off. You may not get them very well. So certainly in that kind of patient, I think applying an over-the-scope clip is very reasonable. So I certainly think it's certainly reasonable a second line, and it certainly can be reasonable in some first line as well, depending on the patient. Now, before we finish, I just wanted to talk about some non-variceal, non-ulcer sources of upper GI bleeding. And basically there's almost all the evidence, I should say, in endoscopic therapy of non-variceal upper GI bleeding comes from ulcers. So there's very, very little high quality evidence for any of these other sources, but let me just take you through some of them. And then we'll have plenty of time, hopefully for questions and answers and discussion. And we can talk about things unrelated to endoscopy as well, which is what I can find myself to. Let's talk about Malloy-Weiss tears. I really like Malloy-Weiss tears. Now, again, almost all of them or most of them do stop bleeding spontaneously. If you look at lots and lots of older case series, re-bleeding is really uncommon, up to 10%, but most of them much lower than that, frankly, when you look. Only one study got up to 10%, most of them it's really in the low single digits. A very recent study that I was involved with, one of the more recent studies in the literature, we did a prospective study of a couple of thousand GI bleeding patients. Among the Malloy-Weiss tear patients, only one of 66 re-bled and that person didn't even need intervention. So again, once they stop, they rarely re-bleed. We and others recommend endoscopic therapy only if there's active bleeding, because again, if they stop bleeding, they do extremely well in most cases. And you can find at least case reports showing that almost everything works, as I've shown here. Now there's two randomized trials that compare endoscopic therapy to no endoscopic therapy. And they reveal that bipolar works and epinephrine polidocanol worked better than no endoscopic therapy. Now there's other randomized trials that compare epinephrine alone versus CLPS and or ligation or CLPS or ligation. And in one of the three, epinephrine was less effective and the other two wasn't. So again, you can probably use anything you want, but rarely do you need to do anything. So again, only if it's actively bleeding should you actually consider endoscopic therapy. Now upper GI tumors are really very interesting. Again, a variety of endoscopic therapies have been reported to work. I've listed most of them here, but there are probably others. Now this is a very varied literature. And obviously some of it relates to the tumors and how advanced they are. But if you look, initial hemostasis is seen with endoscopic therapy in most patients, anywhere from two thirds to a hundred percent, but delayed bleeding occurs also in most patients. We did one of the larger series. We did 106 consecutive patients some time ago, and we found very good hemostasis with endoscopic therapy. We also found even when we didn't do endoscopic therapy, they often stopped bleeding on their own. And the most important thing is that very frequently, in our case, half the patients were hospitalized for re-bleeding within a meeting of one month. So bottom line is, in my mind, yes, hemostasis is important, but the real key here is that these people are gonna keep bleeding unless you have some more definitive therapy. So if there are candidates for some more definitive therapy, you know, and this could be either, well, interventional radiology is one, but obviously things like actually oncologic therapies, such as surgery, radiation, et cetera, that's really the key to preventing further bleeding in most cases. Now, I do wanna talk about hemostatic powder spray because there's been a lot of interest in this and people have felt that there is promise. So let's go through what the trials show. It's interesting, this is the first, to my knowledge, one done just in upper GI bleeding, a study in almost 60 patients. And it's kind of funny because they took 28 of the patients in the powder spray arm, they all received powder spray and everybody had hemostasis. But in the control arm, only six of them received endoscopic therapy. So it seemed to be that the others weren't felt to need endoscopic therapy. And despite that, there was no benefit seen with the powder spray. So this actually says, hey, not very impressive. But there are subgroups in two randomized control trials of powder spray that did, on the other hand, suggest benefit. If you remember that study I talked about from the animal internal medicine and non-viroseal upper GI bleeding, they did have, as you can see here, over 40 patients with tumor bleeding, and there did appear to be better 30-day outcomes with the hemostatic powder spray than with standard therapy. Just published this month basically, or I should guess it was September last month, in Gash Neurology was a fairly good study, mostly from Thailand, a randomized trial of powder spray versus standard esophagic therapy for actively beating upper and lower GI tumors. And immediate hemostasis, if you look just at the upper GI tumors, was 100% versus 65%, so it worked better there. And also interestingly, 30-day re-bleeding was also markedly lower. So these two studies do suggest that you can get at least 30-day control with powder spray that may exceed that with endoscopic therapy. Although the prior study didn't suggest that. And again, I think there's also such heterogeneity among different tumors and how advanced they are and how often they'll re-bleed. I will say that this does not appear, endoscopic therapy doesn't appear to have any impact on survival. In this particular study, they looked at what the independent predictors of survival were at six months, and the endoscopic therapy was not, receiving the powder spray was not an independent predictor. It was really what their comorbidity index was, and if they got additional non-endoscopic or oncologic treatment. So really what I said, how far advanced they are, how sick they are based on a comorbidity index, and do they have other therapy that's going to be more definitive than the stopgap endoscopic therapy. And finally, just a brief word about Diliphoys lesions. As you know, most of them in the stomach, but they're reported all over the GI tract. Again, everything has been reported to work, except I will say, there are randomized control trials of epinephrine versus Klipser ligation. And in all cases, epinephrine had fairly poor results versus Klipser ligation. So I think you can use other things. I tend to really personally like thermal therapy because I like the idea of really burning that aberrant vessel and the feeding vessel. I like that, but everything has been shown to work well. I do think tattooing the lesion is useful because these do have some tendency to rebleed. So if you need to do repeat endoscopy or surgery, it may be difficult to see where it is. So it's nice to tattoo. And again, the idea of placing a Klip, not necessarily just for endoscopic therapy, but it's also helpful potentially if angiography, if you may want to look at it in any event. Well, I've actually tried to not take too much of our lengthy time up talking about endoscopic therapies. I wanted to leave plenty of time for interactions. So we can talk about lots of things that related to either endoscopy or non-endoscopic aspects of GI bleeding. We can talk about other aspects as well. And we also have, Dr. Kahn has developed some cases as well. We can show some pictures and discuss some cases as well. So I will stop sharing and we can move on to our interactive portion of the evening. Thank you for that talk, Dr. Lane. I have a couple of cases prepared that I think will touch on a lot of the topics that you brought up, and then maybe it can stimulate some discussion about everything we've talked about. So I'll just share my screen. And it looks like there's a question in the Q&A. It says, what do you reach for? One for large greater than five centimeter ulcers that clips cannot approximate. Is it okay to use a clip or over the scope clip inside the ulcer bed? Or do you try BICAP first? Okay, well, I really want to make sure that we include, as you heard, Ken Hung and Michelle Hughes are our GI hospitalist team. That means they basically every day are seeing patients. Our hospitals said to be the largest in the country. So we have bleeders every single day with perhaps a thousand bleeders upper and lower a year. So they have tremendous experience with this. So I'd like to get their input into this. So a very large ulcer, bigger than a clip could approximate, maybe bigger than an over the scope clip could approximate in some cases. So why don't we say, one where the over the scope clip can approximate, and it's okay to, the other interesting thing is it okay just to be clipping within the ulcer bed as long as you include the, as long as you include the bleeding site, or do you have to actually get the edge of the ulcer beyond the ulcer bed? So why don't you guys discuss that and I can jump in later. Yeah, so I generally like to use epinephrine first just to make sure that if I inadvertently cause some issues, at least there's something on board to help me. I think that depends on the size of the vessel, right? As Dr. Lang mentioned, you want to get the big 10 French probe in order to treat it. So if it's very fibrotic and you can't get the cap, you can't get the ulcer in, then I will usually use bipolar electrocoagulation with epinephrine as well. I don't know if anyone else- Jo, what do you think? I sort of echo Dr. Hung. I think that the real question is, it's not necessarily the size of the ulcer, but the size of the vessel and the location. My general approach is why I like to assess visibility. Is there active bleeding or no active bleeding? And sort of the acute versus chronic nature of the ulcer. Is it horribly fibrotic or is it a fresh ulcer? And then sort of what is the nature of the tissue around? So it's not a one size fits all answer, unfortunately. And so once I sort of assess, is that tissue viable? Can I grab it with a clip? Most likely the through the scope clips are just not strong enough to really pinch and get the vessel along with the fibrotic tissue. So as it kind of comes together, often the vessel will go underneath what you're trying to grab. And so I find that through the scope just isn't enough. One, because of the span of the clips, but two, because it won't necessarily get your vessel in there. The other question is sort of what I'm treating with modality-wise. I think that one, I share Ken's desire to always try to ward off the bad juju with Epi if I can. It just, whether or not it actually matters in the end, I'm not sure. But I think that even if there is bleeding that's provoked, it tends to be a bit slower and a bit more controlled. You may have that extra 30 seconds of visibility to prevent catastrophe. And then really when I'm picking between bipolar over the scope clip or sort of picking your battle and really erring on just placing a clip and asking IR to evaluate is, what vessel are you dealing with? Are you dealing with a gastrodugenal artery, potentially an aduodenal bulb that's a difficult visibility? Is it a straightforward gastric ulcer that you can get easily? And if there's bleeding, you can still kind of... And so I sort of use all of those factors to figure in what I'm gonna use to treat. I do favor when I'm using bipolar to use the bigger probe if I can, especially if it's a bigger vessel. And then when I'm picking potentially or thinking about it over the scope clip, I have used it in an ulcer bed. It doesn't always have to get all of the healthy tissue around an ulcer. You really just need to compress a mechanical compression with the vessel that's running through the ulcer. Whether or not your institution uses Doppler or not, often in a really large ulcer, you can see multiple spots of like pigmented material along with a visible vessel. And so you can kind of understand where that vessel is coursing through the ulcer and try to grab with your over the scope clip that vessel in the center and compress what's coming up to the surface. And so I guess the short answer to summarize is that over the scope clips do not always have to grasp the healthy edges of an ulcer. You really just wanna mechanically compress the vessel and they tend to be a little bit more durable, get a little bit more grasp on the vessel than a through the scope clip. And if you're worried that a bipolar may not be big enough or you may only get part of a vessel or that 10 French even isn't big enough, the over the scope clip can be a nice solution for that. One thing I should add just about size of vessel. Luckily, it turns out that the average size of vessels is 0.7 millimeters and very, very few are larger than one or larger than two millimeters, which is good because experimental models suggest that that means almost all are gonna be able to be treated by the therapies we use. Now, obviously a bigger vessel, not that you always know that is gonna be better treated by something like an over the scope clip. That's gonna do much better than let's say a bipolar will do well for maybe a one millimeter, one and a half millimeter. But if it's larger than that, probably an over the scope clip is really... The only problem with that though is, I will push back a little is we really can't tell by looking above for sure what size vessel is underneath because really when we're seeing a visible vessel, that's mostly a clot we're seeing. It just looks like a visible vessel. So we probably shouldn't, I think we shouldn't be fooled by thinking, oh, that's a big or that's a little vessel. We can't be that certain, I think, just by looking at how big the underlying vessel is. I would say actually, in the chat, not the Q&A, there's a question which goes right into our first case. So maybe we could show that first case and we'll answer the question, which includes suction and biovac, Dr. Hung and Hughes. Perfect. And while I'm opening up my slide, there was another question about tumor bleeding. Do you believe in APC for treatment of tumor bleeding? Okay, Drs. Hung and Hughes. Michelle, you can go first since Ken went first last time. Okay. I do have to say it depends on, Dr. Lane-Earmuffs, I go back and forth on this. I think there are situations where APC for tumor can work, although I do think it, you get into a bit of a vicious cycle where you APC and then it forms ulceration and it further breaks down non-viable or sort of malignant tissue. And so you kind of get into a vicious cycle where you're really, you may be temporizing, but in a few days you end up provoking more bleeding, more ulcer and further tissue damage. So I have used it in select situations. It is not my favorite. Often I will counsel patients ahead of time if I suspect tumor bleeding that there's really, there are not great modalities for tumor bleeding. There are hemostatic sprays tend to have actually a bit of an evolving evidence pool to treat and potentially a bit longer than our studies for APC. So I will often talk to them about that. But then I also have a chat with the oncologist, with our radiation oncology group and our IR group as well with a multidisciplinary discussion, knowing that endoscopic therapy is often not a durable option for patients. Yeah, I completely agree. I think that, you know, the evidence base is just not as strong as what we have with other modalities to sprays. So I think Dr. Hughes captured it very well. You know, these are really friable things and, you know, burning things will lead to more ulceration, lead to more injury. For me, what I do is I will also make sure if it's like a gastric ulcerated mass, you know, PPI therapy may be helpful. You know, there are some data that, you know, lowering the, sorry, increasing the pH, lowering the acidity of the stomach in basic science models can help improve platelet aggregation and presumably might help decrease the risk of bleeding. Not the best studies out there, but that's something that I consider as well as kind of a non-endoscopic kind of adjunct to try to help. But I wholeheartedly kind of echo Dr. Hughes' sentiment that this is all a multimodal approach, you know? So what I will usually do is spray and say, hey, oncology, hey, radiation, hey, IR, can you help us out? That's interesting. And in terms of your point about PPIs, again, old case series from way back when actually indicated that PPIs can actually lead to re-epithelialization of malignant ulcers. Again, not giant masses, but malignant ulcers actually can sometimes cure, which is actually one of the issues people were concerned about that, you know, that people were getting treated with PPIs and the ulcers were going away, but they really, the cancer was still there. So again, not, I don't think that's really a great long-term solution. And I agree with what Michelle said, you know, long-term endoscopy is not the answer. So I think this will answer the question that's in the chat. So we have an 88-year-old female who presented with melanin hemodynamic instability. She's admitted to the ICU and appropriately resuscitated. Before we go to the endoscopy, I just wanted to ask the panelists, this is a question that we get very frequently from the ICU. So in what cases are you intubating this patient before you go up with your cart and do the case? I guess we'll bounce back and forth. I'll answer this one first. So in general, you have to consider, you know, the patient's situation as in, are they actively vomiting up blood, right? Are they, because whenever you want to make sure that they have a controlled airway, you cannot be scoping someone without actively vomiting up blood. That's a dangerous situation. And also what's their mental status, right? So if you have someone who's abundant and you stick a scope down there and they're not going to be able to protect their airway just because they're so somber and so out of it. So those are my primary situations in which I'm really concerned about a stomach full of blood. They're actively vomiting up blood. They're really unstable. Or if they have like zero reserve, like they're on high flow nasal cannula. And if I go down, they're going to be in trouble if I don't intubate them. Those are my primary folks that I will try to intubate preemptively. I share, Ken and I have a lot of similar practice patterns, but I think evidence suggests that, you know, I think it's institution dependent a little bit, a little bit of a culture, a little bit of a multidisciplinary conversation between ICU and you and your team. But, you know, they've sort of looked at intubation, no intubation for upper GI bleeding. And, you know, what are the predictive factors for poor outcomes? And it really, things like mental status tends to be the biggest one. Hemodynamic instability are sort of my two barriers. And then also just sort of how safely can I sedate the patient and control the situation? And if I have concerns about the patient's respiratory status, I'll be at, you know, is it oxygen saturation, needing supplemental oxygen, high flow, that sort of thing will certainly shift me more towards intubating versus not. Okay, so just real quickly to you guys. So this person just had melanin. They were 88, but they were with it. And so you didn't intubate them and you went in. So before we talk about how you deal with the blood in there, are you gonna, what are you gonna do? Are you gonna yank out the scope and intubate them right away? Depends on what kind of toys we have. Again, I would say that the bedside cases, the ICU cases are not a one size fits all recommendation. And again, if they're hemodynamically stable and I have control of the situation and I am able to sort of visualize what I need to see and then I will, and I think I don't need to be re-intubating the patient with the endoscope multiple times. I will often try to use what is available to me, taking off the suction button to improve our suction, potentially using BioVac to sort of avoid intubation. Certainly intubation alone does not protect against other outcomes such as aspiration pneumonia, prolonged ICU stays, that sort of thing. So intubating this poor 88 year old just because I saw a blood clot doesn't necessarily, I think change her outcome or yeah, her outcome. But again, if I think I'm gonna need to be pulling out large amounts of clots with a Rothnet, putting in an NG tube alongside my endoscope to try to suction and pull clots out, that becomes pulling foreign bodies out of the patient multiple times. And that I might be a little bit more nervous about proceeding if I really can't get visualization. And so those are the times I might stop, have a discussion with my ICU colleagues and decide whether intubation at that point makes the most sense. And Ken, what are some of the other things you do? Again, disregarding a worry about if it's not quite this much liquid there, but just in terms of trying to visualize when you can't, the person who asked the question in the chat was raising just trying to visualize as much of the upper jaw tract as you can to find lesion. What are some of the tricks you use? Yeah, so I'm gonna rewind a little bit and like erythromycin has data that can help clear out the stomach. So if you're concerned, not everyone needs erythromycin, right? If they have stable melanoma five hemoglobin drop or something like that, and they're not tachycardic, not hypotensive, so I pre-test probability is fairly low if something's significant, then I might not give erythromycin. But if someone's having significant bleed, vomiting up a lot of blood, tachycardic, then those are the folks that I would give erythromycin before the procedure, because erythromycin can clear out the stomach now sometimes you don't have erythromycin and people will say, hey, why don't we try a metoclopramide? The data would not suggest that metoclopramide is effective. I think there's a Cochrane meta-analysis that looks at that and says that metoclopramide has not been associated with decreased need for a second look endoscopy in folks who were not able to have adequate visualization. So I would try erythromycin in someone who's unstable, such as our 88-year-old lady in this case vignette. And then what I would do is I would try to find the scope that would have the biggest suction channel. So that's your therapeutic scope, you know, because if you remember, your therapeutic channel or your working channel of your scope is also meets up with their suction channel. So bigger working channel means bigger suction channel. And so I believe as Dr. Hughes mentioned, you know, she does several things just taking a suction button off, you know, and directly occluding things. I sometimes will actually take the cap off the working channel and kind of just stick with suction tubing onto it to help suction things up because the clots will get stuck at in the button, the button that I use to suction. So if you can kind of bypass that and just directly suction onto the working channel, that can be helpful. Other things you can do are remember that the things will generally pool in the fundus. So what you can do is you can reposition the patient, right, assuming she's stable enough to reposition, right? Like don't reposition her and then she like her pressure tanks, like that's the situation. And so you can always like have her sit upright, you can always roll her on the other side, you know, those are things you could do. One of our colleagues who I'm going to give a shout out to, Jane Sabani, published something out of in the Red Journal, a video, which I recommend that folks watch. It's where they stuck an overtube down and they stuck a suction tubing next to a really ultra thin scope and they put both of them together. So it's like you're directly vacuuming under visualization and those suction tubes can be pretty big, you know, bigger than the sucking channel that you have on the scope. And I can try to look up the reference and put it in the chat function, because it's a pretty cool video that one of our colleagues did, which I've done it several times for food, for food impactions, but it can be really effective if you need to, obviously, you know, assess the situation. If she's unstable, you may have to think of several other modalities. And just in follow up to the metoclopramide, interestingly, frankly, the largest and probably first decent study, you know, larger metoclopramide randomized trial was presented at DDW, again, from the same Thailand group, and they actually did not find a significant benefit of metoclopramide. So it's kind of hard to understand why it doesn't work, but at least at this point, there's scant evidence that really isn't evidence to support metoclopramide. The only other option that didn't get thrown out, I'll put it out there, is, so this is actually Dr. Hungism, but, you know, using your Rothnet to scoop out a bunch of, you know, clot or drag and drop into the duodenum once you've cleared the duodenum is another favorite of ours. And then the last, if you do have it available, is if you have a dual channel endoscope, it allows you to have a kind of a therapeutic working channel, so a 3.2 millimeter working channel, as well as a channel that you can kind of still either suction or put a therapeutic instrument through. So that's another option. They used to have a super sucker, very large channel endoscope, but I don't think that that's in production anymore, which is unfortunate. So if you have one in your institution, protect it with your life, because they don't exist anymore. But the dual channel is also another option that you can use for suctioning, usually helpful for active bleeding, putting a therapeutic instrument down, you know, injecting epi at the same time as maintaining visualization. That can be another useful piece of equipment in your arsenal. Perfect, thank you. So I think this case has multiple interesting talking points. It's a 73 year old male with AFib on apixaban and coronary artery disease, had a stent placed for ACS, acute coronary syndrome, three months prior and is now on Plavix and aspirin as well. He has a known duodenal bulb ulcer that was treated endoscopically once with bipolar and is now presenting with melana. So I guess my first question is, in what cases are you considering reversal agents for patients on anticoagulation? So it's, it's not very straightforward, like the evidence is not that great. So, in general, folks have to be really hemodampic significantly, like unstable, because the half-life of these drugs really, especially for the anticoagulants, is fairly short, you know, so we generally don't prescribe those like kind of monoclonal antibodies against these sort of antibodies to these, these direct oral anticoagulants, because number one, they're super expensive. And then if you wait long enough, the anticoagulant effect will go away. So in general, we don't do that. Unless someone is extraordinary, an extremist, and you need to rapidly reverse them to save their lives. Let me just add, say two things for myself. So, you know, one, there's a great quote from Ian Groundlake, who wrote the European guidelines that the time, as Ken said, time is the best antidote for the DOACs. This is said just, you know, the half-life, you know, being in the order of, well, anyway, six to 14 hours or whatever, depending on the DOACs, you know, basically the effect will go away. And again, all of the guidelines, the ones that I did with the ACG and other ones, you know, everybody basically says it should only be for, you know, really like catastrophic, life-threatening bleeding, whatever the term used. So we really rarely use it. And again, there are one of the other concerns is nobody knows for sure, but there has been the question of whether there are thrombotic episodes that are increased with the use of these agents. Again, there are no studies, you know, all these studies are really not very good. They basically just show that they can reverse the, you know, the pharmacologic effects, but in terms of really good studies for showing a change in bleeding outcomes, their studies aren't very good. Sorry, go ahead, Michelle. No, I'm glad to have the reinforcement on that one. Yes, so I think this unfortunate patient is on the trifecta, aspirin platelets and a PIXIVAN, which, you know, you always want to have a nice chat after a bleeding episode and things settle out about whether or not that's the best option for patients going forward. But in the moment, that's not necessarily something you want to have a leisurely chat about. And aspirin, I think, you know, evidence supports we don't stop, at least in the world of GI hospitalists, unless you can't get the aspirin in the patient, we don't stop it. Plavix, in a perfect world, we would hold it. If you're doing a high risk procedure, it's considered, you know, you would hold it if you're on dual antiplatelet, but in a bleeding situation, I might just shift my decision about what I'm using to treat. And then a PIXIVAN, yeah, I think if the patient has a relatively, you know, otherwise functioning organ systems, I wouldn't force the patient to get reversal for fear of having an undue complication if they're not in hemorrhagic shock. I think hemorrhagic shock, if you're playing at the massive transfusion protocol, if you're, you know, adding presser after presser, that's a different story. But this patient is pretty stable. And so I wouldn't reach for a reversal agent. I would just have a conversation with a patient and or the patient's family, whoever's consenting, that it is a slightly higher risk of procedural bleeding. It may affect our ability to treat a little bit endoscopically what we'd like to do in terms of our modalities, but that it shouldn't stop us from trying to control the case and delay endoscopic therapy more than 24 hours. As Dr. Lane is well published on, you know, that sweet spot is really between 6 and 24 hours. If you're waiting for a PIXABAN and following the ASGE guidelines for an elective outpatient sort of high risk, high risk procedure, which is hemostasis, then you would wait more than 24 hours. But obviously that guideline or practice guideline is not written for acute sort of GI bleeding situations. And so you have to put everything in context and have a well-documented conversation. And so for these patients, I generally document quite well about this and then proceed with endoscopic therapy. I may, depending on what I'm seeing, I may favor more mechanical compression options if I have to start them immediately back on anticoagulation and I'm not sure my hemostasis is going to be durable. But it, again, is a bit of a case-by-case scenario. For this, looking at this ulcer, I feel like it's cheating because I know this one. But I think that, you know, this patient has already, looking at the context clues, right, he's already been endoscopically treated once and he's coming back with bleeding. And so he's already sort of failed endoscopic therapy once. And so my algorithm is changing a little bit as to how I'm approaching this, right? So we've already treated this once. I go back. I compare with the prior endoscopic pictures. It looks the exact same. I trust the endoscopist who did the therapy and know that this vessel is pretty refractory. And so I'm probably not going to reach for bipolar again in this scenario. I might reach for more of a salvage type of therapy. Perhaps like an over-the-scope clip, knowing that the patient has to go back on triple therapy and has failed bipolar. Let me just make a few comments about the anti-thrombotic stuff because I think this is fascinating. First, right, you know, the cardiology guidelines suggest people should not be on triple anti-thrombotic therapy. So it should be rare and very short-lived if it is. And obviously, this is one reason why. So it is recommended that actually the default should be the DOAC, apixaban, and the clopidogrel, the P2Y12 inhibitor. And so they shouldn't be on three drugs. They should be on two. So that's the first thing. And so going forward, this patient, you know, that would be the call for this patient. Now, you know, as Michelle said, we always keep aspirin going no matter what, basically not based on any good data, but the recommendations are that you stop one of the dual antiplatelet therapies in the acute setting. And then if it's necessary, you start it back. But maybe some, you know, some people stay right after hemostasis. Other people say, you know, up to five days after hemostasis. One point I want to make, though, is the current cardiology guidelines have stated, you know, after drug-eluting standard, actually anybody with acute coronary syndrome should be on a dual antiplatelet therapy for 12 months. Although they say if you have high risk, you can be for just six months. But those guidelines are a little bit out of date, I would say, because there are now several randomized controlled trials, quite a few in meta-analyses randomized trials that clearly show if you do dual antiplatelet therapy for just one to three months and then you switch to monotherapy with just a P2Y12 inhibitor, that your bleeding risk is significantly lower, but your cardiology risk, your risk of cardiac advance is no higher. So honestly, in a patient like this who three months ago had their stent for ACS, this patient, basically, if they, forgetting the apixaban for a minute, I would put them on just the P2Y12 inhibitor and stop the aspirin. You could do the other way around, but all the literature is largely with the P2Y12 inhibitors. And honestly, if the afib were high risk, then I would put them on apixaban and the Plavix, let's say, and I would not put them back on the aspirin. So I honestly don't think they probably should have been on this to begin with, perhaps. But again, maybe for the first month or two after the incurable syndrome, it was reasonable to do all of this. But again, it is concerning. And this person obviously is tremendous risk. But again, I always try to make the point, also, the heart is more important than the stomach. And that pains me to say as a gastroenterologist, but in a patient who's on antithrombotics for good cardiovascular indications, the message is you've got to get them back on their antithrombotics as quickly as possible. Now, admittedly, the literature does not tell us, really guide us very well. Is it one day? Is it three days? Five days? Seven days? 14? But the key is get them back on it and get them back on it fairly quickly. For antiplatelet therapy, it's quite clear that if you don't get that, you need to get them back on it quickly. The period of time for getting back on an anticoagulant is less clear. And I can show you anywhere from some people say as little as three days. Some people say as much as three months. So most of the GI guidelines are more in the 7 to 14 day range. But it's very variable and honestly not based on very good information at all. Perfect. Thanks for that discussion. And like Dr. Hughes predicted, the patient was treated with an over-the-scope clip. I have a few more cases. But just for the sake of time, I just wanted to see if there were any questions from the audience. This actually, it's funny because when we had the question earlier about using over-the-scope clip for modalities when the ulcers are large, this is actually a really good question or case that exemplifies that where the over-the-scope clip can still be very, very effective when it doesn't encompass the normal surrounding tissue of an ulcer. So you can see in this post-deployment picture, the vessel is actually, the patient is actually at least the picture on the left, perhaps a bit more on the right, just with the angle. You can see the vessel already looks a little bit decompressed. There's really excellent sort of positioning of the clip around the vessel. And you can kind of imagine that that vessel has been sucked up and compressed with the clip. So even though you didn't get the ulcer tissue around it, you've really gotten good mechanical compression and treatment of that vessel. So this is actually, it's almost like that question was a feed into this case. But this is sort of what you would like to see after an over-the-scope clip deployment for something that you maybe can't capture the full ulcer, even though we would love in our heart of hearts to be able to get all of that ulcer in there. It's not always possible. And this is actually a really nice example of using the over-the-scope clip for something That's an important point. Because if you're closing a perforation or a potential perforation, then obviously you do want to approximate the edges. But that's not what you're doing here. You're just trying to grab that feeding artery and the hole in the artery, if you will. So as long as you can grasp that nicely as seen here, there's no reason to worry about that. Maybe it's getting a little late. I mean, if you want to do one more case, and then we can turn it back to Michael, maybe. I think we can just end on this one. We kind of touched on this earlier during your discussion, Dr. Lane, and with the question in the chat. But this was an 80-year-old male who came in with coffee-grown emesis and melanin. His EGD showed a large friable cardiomass oozing and overlying clot. And just for the sake of showing a picture of topical hemostatic powder, this is the patient after we used hemostatic powder, which obviously is a temporizing measure. But does anyone have anything to add for that? I think we kind of covered it. Perfect. OK. I know Mike has some. I did want to thank Dr. Kahn for the introduction and for putting together those great cases. And I also want to thank Drs. Hung and Hughes, who have just tremendous experience day-to-day in treating GI bleeding. And I appreciate their practical comments, as well as their review of the literature, Dr. Hung. OK. And thank you to everyone for participating. I want to thank all of our attendees tonight for coming on. And I want to thank all of our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure to check out our upcoming ASGE educational events. Registration is open. And you can visit the ASGE website for the complete lineup of the 2023 and going into the 2024 events. And you can register. Our next Endo Hangout session will be on November 9. And it will be on feeding tubes. Again, it'll be at the same time, 7 to 8.30 central time. So registration is open. 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 want to make sure we are offering interactive sessions that fit your educational needs. As a final reminder, ASGE 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, I want to thank Dr. Lane and to thank our panelists and our moderators for this excellent presentation. Thank you again to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. So have a good night.

ASGE Endo Hangouts

GI Fellows

Approach to Non-Variceal Upper GI Bleeding and Hemostasis

endoscopic therapy

non-ulcer

non-variceal upper GI bleeding

over-the-scope clips

gastrointestinal bleeding

hemostasis

individualized treatment plans

Dr. Loren Laine