Welcome back, everyone. Thanks to you all who are sticking it out for the end of today's seminar. What we were going to do this afternoon was some case-based discussions. And we have several cases, but given time limitations, we will try to get through, let's say, two cases. And we'd like them to be interactive as well. So case number one is 58-year-old male, has been vomiting red blood for 12 hours, no abdominal pain, two episodes of black stool. Past medical history is osteoarthritis and coronary artery disease. Medications, metoprolol, aspirin, ibuprofen, acetaminophen, as needed. Blood pressure, excuse me, physical exam. Blood pressure is 92 over 54, so that's a little low. Heart rate is 120, which is elevated, otherwise normal. And labs show a hemoglobin of 9.3, so that's low. Other labs are normal. So let's open it to the panel. What does everyone think? Ayo, you want to start us? What are you thinking right now? It might not be on. Sorry. In this gentleman presenting with hematemesis, the first thing that comes to mind is that this is acute gastrointestinal bleeding. He's got a history of coronary artery disease. He's on aspirin, ibuprofen. The combination of both medications could predispose him to gastric ulcer, particularly an NSAID-induced gastric ulcer. His hemodynamics are also quite tenuous. His blood pressure is 92 over 54. My suspicion that that's relative hypotension and that his true blood pressure is typically a little higher than that. And this is reflected in his heart rate of 120 beats per minute, which means that his cardiovascular system is trying to compensate for the blood loss. And his hemoglobin is 9.3, suggests that he's anemic. Because of his hemodynamics, I'll be very concerned about this gentleman. I would want him admitted in a high-dependency unit like the ICU. The first thing we'll want to do is resuscitate him. So we'll need two IVs, large-bore IVs, in his arms. And we'll first try to resuscitate with crystalloid solution, normal saline, or lactated ringers. And we'll ask them to group and save blood for transfusion. I agree. Let's see what... Okay. So we actually have some questions for you. Which of the following are important next steps in this patient's management? Oh, that's a lot, the questions. Let's say... We'll give you a hint. It's not A. B, begin IV fluids. C, begin IV proton pump inhibitors. D, all of the above. Okay, all of the above, which is correct. So as I pointed out, we would want to start resuscitating. We want to get good vascular access, begin resuscitation with crystalloids, get a type and cross off to the blood bank to get blood ready, and begin IV proton pump inhibitors. So discussion. The patient's tachycardic and hypotensive. As we discussed, his heart rate is elevated, tachycardia, and hypotension is reflected by the low blood pressure, which means he's volume depleted. He needs blood. That takes time. Essential steps for all acute GI bleeds include IV access and fluids. And then proton pump inhibitors are typically started to increase gastric pH, which allows blood to clot better, regardless of the underlying cause. What's the most common cause of upper GI bleeding in the United States? Question. A, cancer. B, variceal. C, peptic ulcer disease. D, Mallory Weiss tears. Mallory Weiss means with very significant retching and vomiting, you get a mucosal tear by the esophagogastric junction. And very good. The majority chose peptic ulcer disease. That's correct. So peptic ulcers can occur in the duodenum, or the stomach, and account for about 50% of all cases of upper GI bleed. And the majority of ulcers are related to non-steroidal anti-inflammatory drugs, ibuprofen and aspirin, which we saw in this patient, and the bacteria Helicobacter pylori. What's the best initial test for evaluating and treating patients with upper GI bleed? Angiography by the interventional radiology team. Upper endoscopy, EGD, by GI. A CT bleeding scan, which would be a CT angiogram, to look for radiologic evaluation. Or surgery. Remember you're at an endoscopic society. It could be a trick question. Wow. Nobody got tricked on this one. So in the setting of an acute upper GI bleed, once the patient is stabilized, we don't want to intervene on a patient who's hemodynamically unstable. So we do want the patient to get resuscitated somewhat before we intervene. But then we would go forward with an upper endoscopy for further assessment and management. EGD is almost always the best first test, because it allows for precise localization and treatment over 90% of the time. If a patient's too unstable to undergo EGD, which requires sedation, the patient should be resuscitated. And in the situation where they remain too unstable, just bleeding too much, and we're not able to stabilize them, then consider usually IR. Angiography would be the next step. And as a fallback, if things are really, really going down, then you would consider surgery. But that would be a very unusual setting. Bill? So Arti, I think it's important for the audience to understand this is a very common situation that we take care of as gastroenterologists. And invariably, these patients show up at 1 o'clock in the morning. And then the thing that I've learned to do and what I'll try to teach our trainees to do is that when you get called on these patients, don't rush in right away to do endoscopy. The most important thing, as Dr. Abagunde mentioned, is to assess this patient. This patient's really quite ill and has got dramatic decrease in their intravascular volume. And so you have to resuscitate the patient first. And if you don't do an adequate job resuscitating the patient, their outcome is going to be worse. So don't rush in and do an endoscopy right away. You've got to take the time to resuscitate the patient. In fact, there's studies now that show if you do an endoscopy too early, within a couple hours of GI bleeding, their outcomes are worse than if the endoscopy is done somewhere in the 12 to 18 hour after they present range. Now there are patients that will present that are exsanguinating, and they can't wait. You try your best to resuscitate them, and they can't wait. And you've got to do something. And you can certainly try to do endoscopy, but if they're bleeding so briskly that you can't visualize, then our colleagues in interventional radiology and surgery can certainly help manage these patients. And it is a multidisciplinary approach to managing these patients between the critical care physicians, the gastroenterologists, the interventional radiologists, and occasionally the surgeons. And those surgeons aren't as necessary as they were 30, 40 years ago for managing GI bleeding patients. Questions you guys have? But they do invariably show up at 1 o'clock in the morning. I'm not sure why. Yeah. I'll just add that sometimes if you do, depending on the underlying cause, if you do it too soon, sometimes you go down and the stomach's just full of blood and clot, and you just can't see anything. You can't see the underlying cause. You can try to suction out some blood, but invariably there's clot and everything gets clogged up. You can try positioning the patient to different positions to allow gravity to help pull the blood in different orientations to try to better visualize certain areas. But invariably, it can become a limited exam and sometimes require the need for a repeat exam the following day, like continue to stabilize them. Sometimes we give them a promotility agent to try to help empty their stomach of blood and clots. They might get a little Reglan. Sometimes they might get that before you even come in as part of the management before the GI team comes in to scope. Yeah. There are some products, like sprays, that can go down to scope. Does anyone have any experience using those in this type of situation? Sure. Brooke? Sure. So you're absolutely correct. There are a few sprays that are available right now that can be a temporizing measure for a lot of GI bleeds. I have used it a few times, and it's a really good mechanism for very specific situations. But what I'd say is that it's not the preferred gold standard of treatment for treatment of bleeding in general. Do you have anything else to add? Yeah. So you have that patient we talked about where they're coming in, they're just exsanguinating, and you want to try to reset the clock, so to speak. Let's get this patient stopped, stabilized, and then control them later. Hemospray can be an effective tool to really kind of create a global coagulation status in the field. However, as Brooke mentioned, that's not a definitive therapy. You'll have to go back within 24 hours after all of the hemospray. Once you use this, once you deploy the hemospray, it basically, this powder disperses everywhere and it completely obliterates your visualization. But it can control active bleeding. For those of you that aren't aware of the product, it's a compound that has history in the military for wound hemostasis on open wounds in the field. It does basically absorb moisture and creates a barrier to form a physical barrier over the bleeding site, but it does require blood for it to be activated. And so that's why it really should only be used in active bleeding situations. But it is very good at temporizing the situation, bring them back when the light of day is open, re-scope them, got your whole team and all your resources available to more definitively identify and treat the bleeding source with whatever tools we need for that. Yeah, we have the same experience. It might help in the acute setting. We usually try our other primary tools first, injection, corduroy, CLIP. But it's sort of a fallback, but our feeling is that it's only a temporizing measure. It's not really a good, you know, people just re-bleed. And as mentioned, when you go to use it, it's almost like a blizzard whiteout. You know, it's just, you start spraying it and everything just starts turning white, you know, from powder to, you know, diffusely, you know, covering everything. But it, you know, as Bill was mentioning, it could help, you know, stem the tide at that moment, allow you to further resuscitate, stabilize, and then come back another day to better assess the underlying cause and do something more definitive. Okay, continuing on with this case, you perform an upper endoscopy, EGD. You find a deeply cradled, actively bleeding ulcer in the stomach. What are your treatment options? And if you can see this image, there's actually a stream of blood going up. So this is an active bleeder spurting. So your options are inject epinephrine, place a clip, corduroy, or all of the above. I think I have to go to the next slide for the... Okay. Very good. The injection therapy, clipping, corduroy are all options for treating an active bleeder. Aya? The first thing to do would be to inject epinephrine. That will cause local visconstriction, improve your field of vision. And if I see a distinct vessel, then I have two options. I could place a clip directly on that vessel, and that will close the vessel and secure hemostasis. If I don't really see a definite vessel, I could use just cauterized area. When you inject the epinephrine, how deep are you injecting it? It's into the submucosal. It's into the submucosal. Yeah, and you just want to do that in like four quadrants to make sure you approximate the lesion that you're aiming to treat. I would say most times that we're treating an ulcer such as this, we're at least using two of our three options. And a lot of times, we're using all three. So a lot of times, we're using epinephrine to control the bleeding, increase visibility, cauterizing the vessel, especially in this case where you can see it. And then for good measure, putting a clip or so on it afterwards to ensure that you maintain hemostasis. Great. Thank you. Sometimes we'll actually, even if we got control, if it's our second time treating the patient, we usually will treat this endoscopically, get control, and if they re-bleed, try it again. And then the third time, if they're bleeding again, we'll usually call on our interventional radiology colleagues. And the clips will actually serve as a radiologic marker, too. So our radiology colleagues can see where the bleeding site was. When they inject a blood vessel, they can see it leading to where the bleeding site was to help coil or embolize that particular blood vessel. Interesting. Thank you. That's very good. And that's our experience as well. And if you're having difficulty controlling a spot where you think you're going to be going urgently onto interventional radiology, you may leave a clip before you back out, just as Bill was saying, as a radiologic marker for IR. And they can target that. Great. OK. Treatment options include injecting epinephrine, placing a clip, and cauterizing the bleeding vessel. Epinephrine alone does not last long. Clipping or cautery are best and can be performed with or without epinephrine. By the way, we also keep in mind if the person has underlying significant coronary artery disease in our mind, or arrhythmia, tachyarrhythmia for injecting epinephrine. OK. This is, it looks like an example of placing a clip, I think. It looks like they might have already epied, because there's a lot of blanching. Yeah. That's a good point. The pale, relatively lighter mucosa is probably, as Brooke mentioned, from epinephrine injection. It gets pale from the vasoconstriction. Sometimes if I have a patient that has an oozing lesion, so it's not necessarily a pulsatile spraying lesion, and the patient's completely stable, I might opt to either burn or clip before I do epinephrine. Because then if it stops, I feel satisfied that I've actually, in fact, treated the vessel appropriately. Versus if you use epinephrine, and it vasoconstricts, and it stops bleeding, and you put your clip on, even if you think it's perfectly placed, it may not be. But in a case where the patient is unstable, you don't want to continue. Or if you can't see, if you have no visual field. So you can't see. OK, good. This actually looks like an anastomotic ulcer, I think. Yeah. It really altered the anatomy. It looks like a cheek. Extra points if anybody noticed that. What medication most likely caused the ulcer? Acetaminophen, ibuprofen, metoprolol, aspirin, or the combination of ibuprofen and aspirin? Acetaminophen is Tylenol, of course. Very good. So both aspirin as well as ibuprofen, these are non-steroidal anti-inflammatory drugs. Either of them could cause ulceration on their own, but they're probably some synergy of having kind of dual aspirin and NSAID therapy. Plus, this patient was taking 800 three times a day, which is a lot. I guess they wanted to make this person into a case study for us. Yes? What about naproxen? Naproxen is the same thing, yeah. Any of the ibuprofens? Or even Excedrin. A lot of patients might take that, but that actually has high dose aspirin in it. That's Tylenol. But anything, Nuprin, naproxen, ibuprofen, Motrin, Excedrin, any aspirin or other NSAID. Non-steroidal anti-inflammatory drugs and aspirin are the most common cause of bleeding ulcers in the US. And Helicobacter pylori is a bacteria that can colonize the lining of the stomach and is the other common cause, but is becoming less common in the US. So treating H. pylori, if it's detected. So we should point out that if somebody has a bleeding ulcer, we check for H. pylori. Either a biopsy could potentially be done, but sometimes in the setting of an acute ulcer, people might be more leery about taking a biopsy so as not to confuse matter. If you don't biopsy, then you could do a non-invasive test like a breath test, Deris, thank you, or we were just talking about this earlier. That's why I'm joking. But all kidding aside, a breath test is a possibility or a stool test for an H. pylori antigen. And if positive, you treat, which helps reduce the risk of a recurrent ulcer going into the future. I just want to say one real quick. The treatment for H. pylori is generally a pretty involved treatment course for a couple of weeks. And it's very common. And the medications used sometimes have a lot of side effects. And so it's not uncommon for patients to kind of not complete the therapy. And so it's important that after you complete treatment to really prove eradication by either a breath test or a repeat endoscopy, which you might be doing anyway to follow up an ulcer. Or another stool antigen. Or another stool antigen, any other test.

vomiting red blood

58-year-old male

osteaoarthritis

coronary artery disease

NSAID-induced gastric ulcer

acute gastrointestinal bleeding