All right, thank you. We'll continue our case discussions, and I have a few cases lined up. We'll try to keep it rapid fire and see what somebody would do in the middle of the night. The two topics I've been given are esophageal varices and esophageal emergencies that wake you up in the middle of the night. So you don't have much time to think. These are 2 a.m. questions, your fellows, or as a fellow, you're asking, you're attending. The first case, I have black stools. I would like to thank Dr. Pankaj Desai for sharing this case with me from India. So this is a 46-year-old male with decompensated cirrhosis, had prior variceal bleed, was banded, and presents with melanoma. Patient on the presentation has a hemoglobin of 8, and of course, I think everybody decides that they want to do an EGD. I think that question is answered. And this is, anybody feel this is a high-risk stigmata? Yeah? The white nipple sign, everybody wants to band it? Yes. Okay. All right. So banding is attempted. You can see there is some scar tissue around. It nicely comes in as soon as you suction, there is bleeding. The key at this point is you don't let go, and you put that band around it. And if you lose suction at this point, it's catastrophic. But you get the band around, you're happy, and the band falls off right in front of your eyes. And the varice starts to bleed. So options at this point that you're starting to think? I mean, you can try to place another one. Yeah. So the first one slid right in front of your eyes. So of course- We're assuming it slid because you had scar tissue from the prior banding incident. So repeat attempt was made, and there was no success. And it continues to actively bleed. What do we want to do? What do you think they're injecting here? Oh, sclerosant, phenolamine, sclerosant agent. Yeah. So they decided to go with glue. And with the hope that, you know, here you have the bleed has slowed down, 0.5 ml of glue was injected with the hope and prayer that it works. And it didn't. Hemospray. So then a second attempt is made- It's only approved for non-variceal bleeds. Yep. The second attempt is made, and you can actually see the glue fly out of the opening. Wow. That's cool. So at this point, you're pretty convinced. You're in the varics. You got the glue right in the hole. And as nature has it, the patient continues to bleed. Yeah. So at this point, what are we starting to think? Now, now we are thinking, right? Two modalities failed. No, I agree with the suggestion from the audience. Potentially a covered esophageal stent and coli-R. Right. So at this point, right, you're starting to think tips. Somebody's making a phone call. Somebody's making sure the blood is hanging. Patient is intubated. Airway is protected. Because at this point, you know, the situation is kind of slipping out of the endoscopist's hand. And that's essentially what we spoke about yesterday is, you know, you want to have that mental clock going in terms of the multidisciplinary care. Your ABCs are in check. And after that glue extruding out of the varics, that were prior bands, the bleeding still continued from underneath that glue. But I guess bringing up sclerosants, we don't use them that much anymore. That could be a potential option. Right, right. So I mean, I personally... Sclerosing agent. So I personally have used sclerosants, ethanolamine, which is on our travel cart in these situations. And then one final last injection of another 0.5 ml of glue is what controlled this bleed. But the key is, if you... I'll get to the end. The good thing is, after the last injection, they went back a few minutes later to make sure hemostasis was achieved. So it slowed down. And that's what I said yesterday in my talk is, you want to make sure that, you know, this is your window. If, of course, the bleeding didn't stop, here you can see nice hemostasis, if the bleeding didn't stop at all, you're calling IR at that point or putting a fully covered stent if you have that access. Now, many a times, these patients are not on a fluorotable. You're doing it as a travel in the ED trauma bay. You don't have the access to put an esophageal stent. So you could, with a T1 scope, you could do a fully covered stent under direct vision without fluoro. Right. Right. So through the scope stents, you can use that if you have that available. And you have a trained tech who knows where they are and where the stents are, bring them down and put this in. So... Let me go to the take-home points. You know, you're in Rochester, New York. I assume you don't have glue access there, do you? You do? So we... I use it quite a bit for the gastric varices. For esophageal, I primarily have used sclerosants for post-banding ulcers or when the band slips off. So in this situation, you'd go to traditional sclerotherapy for that? Yeah. Yeah. And we've had success with that. I mean, there are some gastric varices where the bleeding just doesn't stop with the glue and then patients have gone to IR. So we've had some cases of that happen. Yeah, we don't have glue with us on our travel cart. Yeah, it's not on our travel cart. We don't have access at all. So it probably wouldn't have been an option for us emergently. Yeah. We don't have glue on our travel cart. I have a question just for the interventionalists in the room because I don't do variceal management and I don't do stenting, but the stenting sounds interesting, but it does sound fraught with concerns. I mean, I've seen what happens when they take the stent out and you've got an esophagus full of varices. Is that just a temporizing thing to get them to tips or is that considered a therapy that you're going to use? No, it's temporizing. Just to get them to something definitive. And again, off-label use, like Uzma said, hemospray has been used in salvage situations. It's not a lefty approved for that. Yeah, again, just trying to get them to IR. Hemospray is approved now for variceal bleed. Variceal bleed. Yes. I want to ask if you can use it in a vesicle. So white nipple signs should be considered high risk and, you know, if you're dealing with a massive bleed, make sure you protect that airway and if banding fails, rescue glue or sclerotherapy. Again, we have sclerosants on our travel cards with ethanolamine can be considered. And refractory bleeding may need IR, so start thinking and mobilizing in that. It is okay to back off. You know, sending patient to IR is not a sign of defeat. You have to do what's right for the patient. So now you get another wake-up call. So just done with this and the patient comes in with frank hematemesis. There's no melanoma. This is a 92-year-old female and this was a phone call I got a few weeks ago, so it was perfect for this session. Patient has a history of achalasia, dysphagia, TIA, macular degeneration. She comes in with hematemesis. EMS, as per the report, found her lying in a pool of blood and she had about 100 cc's in the toilet bowl, 50 cc's in the trash can. Overall, hemodynamically stable when she hit the ED, a little tachycardic. Hemoglobin was 10. Her baseline in our system was at 12 and a slight white count. And they do a chest x-ray because everybody in the ED gets a chest x-ray. And anybody think the chest x-ray is abnormal? What? Very nice. So it was a widened mediastinum and the ED went for an emergent CT thinking, you know, whether there is an orthoesophageal fistula, she had an aneurysm. So even before GI, she gets a CT. So here you can see the CT images and the arrows pointing at her esophagus. The overall impression was that the esophagus was distended, thickened, and there was concern for a wall injury, development of a large intramural hematoma. And this could be from retching, prior vomiting, they didn't know. She didn't know whether the vomiting came first or the hematomas. And thoughts at this point, if you're the fellow. Well, it's also, it's a big esophagus. You're able to tell that by the chest x-ray. You know, it's a big, you know, she's an older woman, her esophagus is really quite markedly dilated. There also looks like there's a conserved amount of debris in there, whether that's blood or food or both. I can't tell by that. Well, I guess if you're giving this retching history, could she have a Borhaus and a potential perforation? Anybody would scope her the same night? But she didn't have, there's no, there's not a lot of air, it's just mainly this collection next to the esophageal wall. Show of hands. Yeah. So, I did recommend call surgery and surgery said we're not doing anything. There's no pneumo-bediastinum, you know, back in your court. So the ball came right back in my court. which is intraluminal, or if anything, maybe a diagnostic EGD, just to find out what's going on. And when do you want to do the EGD? Do you want to come in at 2 in the morning to do it, or what's your timing for doing it? So, the heart rate's 110, she's lost some 15-20% blood, as soon as they resuscitate, and I feel it's adequate, then yes. I wouldn't rush to the EGD, per se, until she's resuscitated, but... She's resuscitated, it's 2 in the morning. As a fellow, I think I would... No, no, no, that's not an excuse. You know, again, I tell all our fellows, put your nickel down. I would. Put your nickel down. I would. It's a dollar now, Gary. I'm leading now. I mean, she is 92, and she's having red blood from below, with an upper GI, I presume, source. Yeah. It's pretty bad. So, she's not hypotensive yet, but she's probably intending hypotension, so I think you have to come in to do this. It's not... So, they thought it was a hematoma, not a mass. I mean, she's achalasia, long-standing. We don't know whether she's at risk for neoplasia, too. Pale esophagitis on top of achalasia would be another thought, with ulceration, and you mentioned Mallory Weiss with the intramural tracking of the blood would be a huge hematoma. And the other thing, too, if you're going to do an EGD, this is someone with the way this is... She needs to be done intubated. This is the general anesthesia case. Absolutely. She's got esophagus full of fluid and blood. She's very high risk, in terms of complications, just by age alone, but with that esophagus, this is not a conscious sedation case. This is not a propofol in the ICU case. This is an intubated case, so everything has got to be totally teed up and lined up for you. Yep. So, we tried to activate the OR, same thinking. She is limited reserve. She's 92. Surgery is not touching her, and at this point, we have to intervene, and as we go in, this is what you see. What are we looking at? Clots. A whole lot of clots and a very distended esophagus, all the way from the UES to the LAS. This is what we saw. So, the question is, do we suction these? We don't know if she has a microperf at some point, based on the test. I was wondering if she had a microperf, the clots are covering everything, so you're not seeing as much air. Am I... Do I rip the Band-Aid or no? I know. I was thinking you should try to, because you're there now, so your hope is to provide some sort of intervention. She's not acting like she's infected. She's not septic or anything. There was no air extravasation outside of the esophageal wall, so I think it's just a huge intramural, or maybe intramural hematoma, but if there's no... Is this because I don't see any red blood? It looks like it's all clotted. I don't know if I would pull this off. And you know, you activated the, you did your activation, you came in. What's happened in the ensuing time since you came to the emergency room? Is there ongoing bleeding, hemodynamic instability, blood transfusion requirement, what's going on? So she didn't require any blood, but she had another episode of hematomasis while our team was coming in. She never became hypotensive. They had preemptively given her crystalloids, and she was running fluids. As I said, her hemoglobin stayed in the 10 to 9 range. It wasn't like she was profusely dropping. So you got all the way past this? Yes, yes. So I... So we got past this, got into the stomach, and it was just a huge clot burden in this half, I guess. So then you cleared the clots? So then I did try to rip the Band-Aid. So slowly and steadily we, using Rothnet suction, we start to clean the clots and either push them down, bring them up. It took a while, and made a whole bunch of progress after 30 minutes. And after an hour, the esophagus was completely cleaned. Yeah, I had the same reaction. And my nurses are looking at me. And the cardia was normal, too, just below the G-junction? The cardia was normal, and my nurses are looking at me like, you woke us up, but show me the bleeding. Is it like a... And nothing up higher. Interesting. It could still have been a Mallory Weiss or something, but just the intramural tracking instead of the luminal tracking of blood. I mean, dual of four, dual of four, it's usually in the cardia, but it can be more proximal, and you don't see a lesion, could have bled, then it stopped. So the surprising part was her stomach and her duodenum were completely clean. So that's what had me kind of scratching my head when I went initially, you have the esophagus filled with blood, but your stomach and duodenum have almost no blood, there was bile in the duodenum, and the clot burden was so impressive that I did expect a huge linear tear or something in the esophagus. And that's why I kept the GE Junction picture, there was no obvious Mallory Weiss, we went up and down three times, because I literally have my nurses staring at me that, what are we doing here at 2 a.m.? But both at 9 o'clock on the left image and at 3 o'clock on the right image, there's a hint that that washed off? Yeah, that did get washed off. Did she bleed from her nose or something? Has excretion... She had some nose bronchus something, and then she swallowed it, but it was such a heavy clot burn. She has accumulation, it must have said that. But I agree with you, again, in pulling the clots off, because you are there now, so now is your chance to intervene, and it's better to know now what the etiology is. Yep, so actually, we pulled out, we got ENT involved, and the thing was that she did have a nose bleed, but she kept swallowing it. With her history of acclasia, the blood never made it to the stomach, and the clot just collected in her esophagus, and that's the hematomas that she came with. So I think, I just wanted to put the algorithm for risk stratification for upper GI bleeds, and the key is, you know, you look at the patient as a whole. Not all the blood in the esophagus is GI in origin, is the take-home point from this case. And, of course, your ABCs come first, multidisciplinary care. The moment we were concerned about a borehouse, we got our surgical colleagues involved. They had my back when I went in, that, you know, if something opens up, we are here, but you go in and there's no obvious part. We did what we think was the right thing for the patient. She was having hematomas, is 92 years old, not much reserve. And I think we solved the mystery. I think you've started a new specialty in GI, is a complicationologist. I know, I think that's the theme for me in this course. But had you not gone in, everyone would have still been saying GI hasn't scoped the patient. They have hematomasis, and so you did help the patient move along the algorithm for treatment. So I don't know if we have time for more, but I can stop. I think we should move to the next case. We have a chance to do this later, too. Yeah. That's true.

esophageal emergencies

variceal bleed

esophageal stent

TIPS procedure

achalasia