See if I can present the case to the panel and then, so I need your guys' help, okay. So this is my patient, so basically I want to keep it simple because we are the endoscopist, the people now are on IBD and the transfusion, this is at the time of first surgery, had the bowel inflammation in the terminal ileus, so that's why I could get a surgery, resected at the bowel. Then after the bowel and the resection and the transfusion required, hemoglobin 6 and 7. Now, come to my service, I feel like this, this is the area where I had a friable anastomosis, this is around one month after surgery, one month after surgery. So as a routine, the tricks, I sprayed some sugar, put a lot of the clips there, and then so I did it again, so one month later, continued bleeding, but looking at the area, slightly better, but they keep coming back. So one month, two months, and then hemoglobin dropped down, required a blood transfusion. Now, so multiple attempts, I did it three or four times, and at this time, the family is fed up, said, you know what, I go for surgery. Another surgery, same area, within a year, same area, resection, redo anastomosis, and you know what, after two weeks, three weeks after surgery, bleeding again. Now this is the bleeding, you can see the new anastomosis, like here, the oozing blood. Now he required a blood transfusion still, between every two to four weeks. Now medical therapy, I believe that he is on Stirela or Remicade, but no bowel inflammation. Now what's the treatment? Any treatment, some people giving me idea about APC, some people giving me an idea about, you know, the epinephrine, I don't know, and some people even mentioned about redo anastomosis, but this, the previous surgeon here is actually a pretty experienced one. What's the trick? Is anyone here? Dr. Raj, you can go first, and then we'll go along. So one thing is, I don't know the answer, but I'll share with you some of the stuff that we're doing in the setting of stem cell transplant, when they have ongoing gastric vascular bleeding, capillary bleeding. This looks like a capillary wooze, right? It's not like a vessel, major vessel bleed. It's not like an artery or an aberrant varic. This is not, this is a capillary wooze. And when I think about capillary wooze, you know, traditionally we have used APC setting at a higher setting, a higher setting, right, you know, try to burn it to a brown. But what I have tried to do in the stem cell transplant setting is to use a very low setting, you know, like a 15 watt and just have treated so that it is just a little bit of whitening rather than brown, right? If you create a brown effect, you're going to create a deep thermal injury, and you will probably end up with more bleed if you have a vessel close by. If you just have just a little bit of whitening effect, that's what I've tried for some other patients because I found that even for radiation telangiectasia related to prostate cancer radiotherapy, I don't use high settings, very low settings, just a little bit of whitening. And you can apply that principle and see whether it helps, right, you know. Thank you. Last, actually, surgical resection specimen, the specific mentioned about ischemia changes. Uh-huh. Okay. I wonder, is anybody have tried to use a heparin or Lavanox? Because can you imagine if your ischemia caused the bleeding, right? It's like in the heart, right? You give it a heparin or you give it aspirin. No, it's a capillary bleed, Arishan. It's a capillary bleed. Probably, I think, I don't think it'd be helpful much for this bleeding. Uh-huh. I have two suggestions. I mean, what is the role of cryoablation? Because cryo doesn't cause ulcerations, heat, and I've done it in refractory case of GAVE, at least in the upper GI tract, where the rastorectasia, cryoablation works really well. Cryoablation, uh-huh. And the second option is really bad ischemia, what is the role of hyperbaric oxygen treatment, hyperbarics? So we work on that. We work on that, actually. We work on that. And actually, this last session, I even did a hemo spray. But that doesn't work for bleeding. Yeah. Like it's only for temporizing measure, like patient may be bleeding. It does like for 48 hours and then it may bleed again. It's more like a temporizing measure rather than actually controlling that like process which is causing this bleeding. So we have a cryo as an option. Yeah. But I know, but I don't know any ischemic area, but I have done it in the upper GI tract where it worked really well. Yeah. I think if you're planning to use cryo, it's probably use, probably better to use a balloon-based cryo. Balloon-based cryo. Right? Otherwise, you'll be putting in a lot of air into that small bowel. Yeah. C2, balloon. C2. I think Pentax has bought that balloon recently. Okay. Pentax C2 balloon. You can just put the balloon right on top of this area and they can spray that area. Yeah. No gas exposure, nothing. Very safe. Yeah. That's just a really, I was run out of options because these are from our local, yeah. Right. The other thing is I would always get a hematologist involved to check if the patient has any type of platelet dysfunction. We did that. We did that. Actually, at one point, he has a temporary elevation of the liver enzyme. We are working very hard for rule out a PSC, right? The people with the IBD, primary sclerosing cholangitis, but then they even did a twice liver biopsy. Twice liver biopsy, no PSC. So that's a, yeah, that would be a good start, yeah. Maybe I missed the presentation, but what kind of bleeding, what type of bleeding he had? It's intermittent, like dark maroon stool with a drop of the hemoglobin required blood transfusion every two to four weeks. Okay. Then if that is the case, if that is an episodic bleeding episode, then we scope when he bleeds and the bleeding point could be the vessel or artery at the site of the ulceration. Targeting clip placement could work if that is episodic bleeding. What do you say, what do you, since you apply, I forgot, I may, yeah, I missed the one. Clip placement, the point is the timing of the examination. Yeah. Exactly, we should find the bleeding point if that is the vessel in the ulcer. And then as long as we can find the bleeding point, then we can use hemoclip or the hemostatic forceps, anything. But if we don't treat the vessel bleed, then it doesn't work. That's my opinion. So, yes, Dr. Yamamoto, these things, like I can see the edge. When you go there, I wash it, and you should see the oozing, all the oozing like this. So that's why I put a clip there. If the oozing is the real problem, then he should have a chronic type of the bleeding and it's not the episodic type, I guess. Yeah, it's just oozing intermittently at a dark stool, you know. We try to upgrade the escalator, the medical therapy, and try a lot of the tricks. Okay, another thing is, which side is this anastomosis, is this close to the anus? Yes, about 25 centimeters now, because two resections, is the iliocycloid anastomosis. Okay, so the enema, the Kapentaza enema, or some kind of enema? You want an enema, okay, the Louisa enema, yeah. We give it a try. Even we tried some, what is called, the enema we tried, used for the stomach. We tried a lot of things too, you know. So this is a very hard case, and thank you, I got some idea, and then I presented it to other patient family. The other thing, Bo, is you could, I don't know whether you have this set up. You know, Dr. Jensen talks about using the Doppler to figure out, this is all white, and you don't know whether there's a vessel somewhere, because of the intermittent bleeding, and whether you can take time to Doppler that whole area, and see where you have a signal, and wherever you have a signal, put a bunch of clips. In the past, I did use the probe-based Doppler, just the sound, yeah. Right, that's what I'm, I'm just thinking about, you know, it's a difficult problem that you have here. Yeah, it's like, now the no surgery, no, of course, so another thing is the one surgeon offer for stoma, for stoma, so convert it into a stoma. So, but I don't think the idea, it's not a great, great idea, 20, only 28 years old, you know, and otherwise the bowel is a pretty well, you know, well, well, well maintained. Now, try just cauterizing that entire ulcer bow, because that's what we would normally do in the operating room, what we would do is just use cautery to burn that, it doesn't look ischemic at least, you know, on endoscopy exams. So in our IBD, I always reluctant to cause a cauterization, maybe this time, as Uday and Raju suggested that we use the, some of the cryo or the low setting APC, I would try probably low setting APC rather than use the clip as a mechanical force in that setting. So I think it is like, probably, there may be the, Uday, we can wrap things up.

intermittent bleeding

gastrointestinal tract

treatment options

inflammatory bowel disease

difficult case