So, do you guys enjoy the lab? Yeah? You guys expert endoscopists now and can take things out and go, no, okay. We'll see. We'll see how you do in the post-test, and then there'll be an endoscopy testing later, okay? All right. Good, good. So, we'll go through a few cases. I'm going to alternate some cases. We'll start with case one, and then we'll kind of go, I'll kind of skip an IBD case because, I mean, unless we have time in the end, because I feel like you're more in the industry of, you know, endoscopy rather than, like, immunology, so we'll talk about medications for that. So, all right. So, we have a 58-year-old male, been vomiting red blood for 12 hours, but no pain, and has had two episodes of black stool or melanoma, has a history of osteoarthritis and coronary artery disease as well. And you happen to be the, you know, let's say you were the GI fellow on call for that night when you get this page, and you have to go and assess this patient. So, you get a little bit more history. Patient's on a beta blocker, metoprolol, aspirin, ibuprofen, 800 milligrams three times a day, and acetaminophen is needed. Blood pressure, 92 over 54, and heart rate 120. Everything else is normal, no pain on your abdominal exam, and hemoglobin comes back as nine, and that's the normal, so a bit anemic, and other labs are normal. So, just to get an idea, what do you think about this patient? He has an ulcer, okay. There you go. Oh, there you go. On it. On it. Yeah, there you go. Yeah. Lots of NSAIDs. Any other, some other thoughts? What do you think about this blood pressure and heart rate? Low. Really high. Heart rate is really high. Heart rate is really high, and heart rate's not good at all. Yeah, so are you, so this is when you're, if you're a fellow, you're like, ooh, I don't know, I might have to call my attending and have to set up endoscopy, I don't know, or, you know, we may do something else, but here. So, what do you think is the next step in the patient's management? So, place two large-bore IV intravenous lines, begin IV fluids, begin IV proton pump inhibitors, or all of the above. Probably all of them? Any takers on something else? No? Okay. Yeah, you're right. Standard protocol. We want to get large IVs because we need to pump more blood, and this patient, if he continues to bleed, and get more fluids in, get other medications, so you want to make sure the IVs are not teeny-tiny, get as large as possible. Start fluids to get their blood pressure up and their heart rate down, and kind of resuscitate them hemodynamically, and start, if we're suspecting, you know, our highest on the differential diagnosis, right, is the ulcer, then you want to start him on an acid-blocking agent, like a proton pump inhibitor here. So, our expert panel, do you agree with the audience, or would you do something differently? I agree. Perfect. Good. So, you're right. You get that one. Okay. $10? We'll start with $10? For sure? No, you have to get all of them right, because if you get something wrong, you'd have to subtract whatever. All right. So, patient's tachycardic, hypotensive, volume depleted, needs blood, but that might take some time, right? You have to type and cross, and get it from the, so you can't wait for blood to arrive. Get them started with some IV fluids right away, and start that PPI right away, and it'll help start the healing process of a presumed ulcer. We don't know that for sure yet, and also help the blood clot as well. Okay. So, another question for you. What is the most common cause of upper GI bleed in the U.S.? Cancer, variceal bleeding, peptic ulcer disease, or Malory-Weiss tears in the esophagus from vomiting. Yes. Peptic ulcer. Look at that. See? Okay. We have the expert audience here. Look at that. Yep. You're right. Okay. So, peptic ulcers can occur in the duodenum or stomach, counts about half the cases of upper GI bleeding. And of course, you got it right, got the nail on the head, NSAID use, ibuprofen, aspirin, and we talked about H. pylori earlier as well. And you end up scoping this patient, and, you know, maybe it was 3 a.m., who knows, but finally got it done. And to get this, what you see, an ulcer there. And what do you think about this spot there? Since you learned how to do some treatment, what would you choose? Oh, I'm sorry, let me go back to this one here. What would you choose to treat this patient, besides putting on the medication? Do you want to APC this, do you want to leave it alone, do you want to do that goal probe? We were having too much fun. Everyone was trying to put their initials. I think we were almost at 80%, right? Yeah, 90%? Okay, we'll give you 90% credit. Well, it depends on if you see it, obviously, if it's actively bleeding, you want to go ahead and cauterize it, but if it's not actively bleeding, or if there's not a stigmata of actively bleeding, then you may leave it alone. But let's, okay, let me hear from you. What would you want to do for this? And then I'll see what the expert panel wants to do. Leave it alone, put some goal probe, APC it, clip it. Leave it alone? Okay. Anyone else wants to? Clip it. Okay. Well, you're seeing this. It's not bleeding while you're looking at it endoscopy But if it was bleeding you could consider clipping, okay. Oh A needle for what? Inject Okay, what do you want to inject it with? He really wants that. Yeah, somebody said it, I think. Yeah. Epinephrine. Epinephrine, OK. Yeah, not a bad idea, if it was bleeding, yeah. All right, so expert panel, what do you think, what would you do in this case? So if you look at the, there are some, those black, you know, you can see some black spots. There is one area, could be what sometimes we call it a deodorant clot, so we don't know. So some, we do vigorous irrigation, meaning washing to see if there is anything, that clot, if it is a true clot, and if it comes out or not. But sometimes I, you know, depending on the case, I tend to be a little more aggressive, so I do dual therapy, so basically I inject epinephrine, one in 10,000, just around it, and then cold probe. So basically the goal is to see that color from black going to more brownish. The other thing to remember, I think Dr. Guha's slides mentioned, is to not just use epinephrine by itself, so dual modality with epinephrine, because it's too short acting. And then you also want to do like cold probe with epi or a clip with epi. So yeah, I mean, depending on how wide it is, you could potentially put a clip, but a cold probe with epi would be also a good idea. There was a question from the audience, yeah. Yeah, so would there be any value to biopsying it, or would that kind of be out of the scope considering it's an ulcer? Yeah, so that's a very good question, because sometimes if you see a big ulcer, and it's like, let's say they've been on NSAIDs, and we know the reason, and they're actively bleeding, and you know, their blood pressure was so weak, leave it alone. We don't want to end up causing more damage and cause a potential future bleeding. So in severe cases, we will just treat, and often what happens is we bring them back later for repeat endoscopy to confirm healing. But in some cases, let's say there's not been any NSAID use, and we just don't know why this patient's developed ulcer, I often just go ahead and take biopsies to rule out H. pylori. And you honestly have to take biopsies from the ulcer. You can take it from a normal-looking mucosa, because H. pylori is living in that stomach, and you can biopsy a separate area from that. Other times, when sometimes it looks a little bit odd, does this look like a clean-based ulcer? There's something irregular to it. This looks like there could be cancer here. If it just doesn't seem right, the patient's been losing a lot of weight, and there's some other history that doesn't seem right, then yes, I will opt in biopsy to make sure that this is not a cancer that needs other treatment. Because if it's something like cancer, this is not gonna end up healing up, and so it could potentially get worse, and they'll need additional therapy. So it really depends on the case. Obviously, the severity of bleeding, if they're more moderate, and we don't think they're gonna cause more damage, if there's a suspicion for adenocarcinoma, or lymphoma, or something else, then yes, we'll definitely biopsy it. Or if we think that we need to biopsy, but it's not safe, we'll bring them back later, put them on PPI for a couple of months, eight weeks typically, bring them back for reassessment of healing. Great question. Okay, I'm gonna move on. So what's the best initial test for evaluating and treating patients' upper GI bleeding? Let's say you haven't scoped them, you were just a fellow coming in, you saw the blood pressure was low, and they were having active bleeding, what would you do? Would you do an angiography first, an endoscopy, CT, bleeding scan, or send them to surgery? Okay, well, all right. Yeah. So yes, EGD, I'm sorry? Okay, so EGD, yes, because you can assess and treat at the same time. We talked about all the different modalities earlier. You could do an angiography, but really you can precisely locate it and treat it almost all the time. But if they're too unstable, then typically want to get them resuscitated so they can actually undergo a safe EGD. But if there's no way, they're just massively bleeding out, then angiography is typically our go-to to see if we can localize where the bleeding is. And I think Dr. Mathur was saying that you can also have the radiologist find that bleeding vessel and go ahead and coagulate it radiologically as well with their interventional radiologist. But in some cases, if it's rare that our patients go directly to surgery, but especially if a patient is, we tried an angiogram and they couldn't fix it radiologically, or they're too massively bleeding, what we can try to do an EGD, but if we're seeing blood everywhere, we can resuscitate them enough to calm it down, then it's gonna be a futile effort too. I mean, often we try our best to do the endoscopy because we can visually see and fix it, but there have been times where we went in, there's just clots everywhere, we can't see where the bleeding is coming from, and we have to abort the procedure and move on to something else. Yeah, all right. Okay, so let's say you find, you do the EGD and it's a different patient. They came at the same time, so you had to do double duty that night, which was really good. You don't have to wake up again and come back. You do another EGD and find a deeply cratered, actively bleeding ulcer in the stomach. What are your treatment options? You go in and you see this blood vessel shooting out at you, and your heart is beating as fast as this guy's heart was when you see this. So what would you wanna do here? Inject epi, place a clip, cautery, or all of the above? Okay, all of the above, our experts agree. You are right. Yeah, we talked about that. So yeah, I think we're ahead of the game here. So we could inject epinephrine to calm down, hopefully stop the bleeding vessel so we can actually see what's going on. It doesn't last that long, and also sometimes we see when we inject the epi, their heart rate goes up too, and the anesthesiologist is like, what are you doing to the patient? I'm like, I'm trying to stop the bleeding. Give us a few minutes while we're taking care of this. And then once the epi, hopefully it will work, you can see, you can clear out your view and get your better visualization of what's going on, and then you can go ahead and find exactly that blood vessel and clip it or cauterize it or both in some cases. So, okay, perfect. And this is you scoping in the middle of the night, you see this bleeding, you see this huge ulceration. Let's see here. You see that this is oozing out from here. You've epied it, it's calmed down a bit. Trying to put this clip right on that juicy vessel there. And you hopefully will deploy it nicely. There you go. And then one didn't work, so it's still oozing a little bit more from the other side to get the second clip in. Okay, we're hoping for the best here. And I think it worked, okay. For our sake, it worked, yeah. And which medication most likely caused the ulcer? You already answered this. Ibuprofen. And in this patient, it was on combination, so aspirin as well. Aspirin by itself, you know, used very often for as cardioprotective. You know, by itself it may not be the main culprit, but this person was taking too much, tons of NSAIDs, right? So they're the most common cause. And the second most common we saw was H. pylori. Okay, so I'm going to skip to case three real quickly. Then we'll come back to two if we have time, but I want to make sure we... Yeah, okay. So this is a 67-year-old female found to have a large polyp in the cecum of the colon, and the previous endoscopist referred the patient to a surgeon. And the patient's like, I don't want to go through surgery. I want to get a second opinion to see if I can, you know, get this removed endoscopically, because I heard you have great therapeutic endoscopists here and do tons of great work and prevent patients from going for surgery. So I want to come for a second opinion. So maybe we could ask both of our therapeutic endoscopists here, Dr. Kumar and Dr. Guha, what do you think about this polyp? It's a... So this is what we call a... This is what we call a, you know, it's a sessile. So you see it's not a polypoid structure, and it has this kind of a granular pattern. You know, it's pretty large. So this is what you see. I will inject and do an EMR, or endoscopic mucosal resection. Sometimes we don't get it in one shot, so we do it in piecemeal, we call it. We try to get it in one, and then after doing the EMR, as you see, and you're using a little bit of methylene blue, so that's what you see, the blue tinge in that injection. So now this piecemeal is going on. Once we do the piecemeal, I use the, you know, the tip of the snare, we call it, and coagulate the edges. We call it soft tip snare coagulation. So that there's a... You prevent the recurrence. Dr. Kumar, would you approach this any differently or any other comments on this one? No, I think in any polyp that is large, you always want to make sure there is no cancer in the polyp. So a good thorough endoscopic assessment of the polyp, just to make sure this is all benign, that we are removing it. And this one seems like, even though it's a large-sized polyp, there are no features of cancer in it. It's a laterally spreading tumor. It's very homogenous. It's a granular tumor. An EMR approach is very reasonable for this. You will be doing a piecemeal resection, just like is being done. And the snare tip soft coagulation will help with reducing the recurrence from a piecemeal resection. So they are noticing some bleeding at the EMR site. I was getting tachycardic looking at that there. That's okay. So methodically, you know, it's being approached. You go from one edge to the other edge, trying to make sure you don't leave any tissue in between your resection spaces. And it's very nicely done. And they cauterized the bleeding site as well there. So here we talked about, you know, two different techniques of applying cautery to the edges, whether you use APC sometimes to do that, or you could use the tip of the snare, as Dr. Guha mentioned, about using the tip of the snare to do soft coagulation. What did you say again, sir? Like it was going to be cancer? It did not look like a cancerous, look like a precancerous benign polyp. So if it was the same size and you maybe thought it looked cancerous, would you rather? So there are three, you know, thoughts. One, it's a benign polyp without any cancer. Two, it is benign with possibility of a superficial cancer. And three, it's a deeply invasive cancer. So the approaches will be different. If it is a benign with no chance of or less chance of having a cancer, then you would do a piecemeal resection with EMR. If there is a superficial invasion, then you would do an ESD. Try to remove the ESD technique, which is endoscopic submucosal dissection, allows you to remove the polyp all in one piece. That way you get better assessment of pathology and make sure that you have gotten all the cancer back, all the cancer out. And if it is cancer, is it superficially invasive? How deep invasion it is? We get all of that information with the ESD. If it's deeply invasive, then you're doing a disservice by trying to resect it because even if you do get the polyp out, if it is deeply invasive, that patient will need surgery because the cancer can spread to lymph nodes outside the colon, which you're not removing by this endoscopic resection. Another way that we can figure out if there is a deeply invasive cancer, as Dr. Kumar was mentioning, you saw initially how we were injecting that lesion, right? So we get that lift. So if there is a depressed section and it's not lifting well, then you're worried. Then you know there is a deep invasion. In that case, you have to think twice whether you want to go through the whole motion of piecemeal EMR. But in this case, it was nicely lifting. We could do piecemeal. We get the whole thing out, cauterize all these edges, as we mentioned, to prevent recurrence, and you can cauterize those bleeders, no problem. Do you bring these patients back at a certain interval after this is done? Sure, yes. Within 6 months, they come back for a repeat. So just a curiosity, if you are using a submucosal lifting agent and it's not lifting, then it's most likely cancer? Does that make sense? We actually use that, yes. We use that kind of sign, the non-lifting sign, as a kind of indicator. Not always true. Not always true, but sometimes. The problem is a lot of times we get referrals from patients where they have done some biopsies and then they develop some fibrosis post-biopsy, but they haven't removed this kind of sisal polyp, this lateral spreading. Then when we try to do the injection, it won't lift. That doesn't mean that it has cancer, but yes, if it is, mostly yes. It's not just one factor, it's a combination of factors, how the polyp looks, what has been done before, what the biopsies show before, and the lifting, as well as how the surface of the polyp looks, as well as the edges. Thank you. I think we've addressed all of these, what should be done for this lesion. We don't want to just do a simple biopsy, but really resect it, lift it, put the dye in, so we can get that. The patient came to you for a second opinion, so obviously you're going to get the advanced endoscopist to attempt to remove it before you send them to surgery and ablate it with APC like you saw, actually. So, colon polyp EMR, typically we do this for these large sessile polyps that you saw the picture for, but also flat polyps. I see a lot more flat polyps in inflammatory bowel disease because our patient's cancer sequence is not the typical bigger polyps that grow into bigger sizes. They can tend to have flat lesions, and that's what we are worried about. And I also feel very comfortable removing them if I can inject it and resect. But if I can, then I'm typically, instead of sending the patient to surgery right away, I'll actually have our advanced endoscopist take another look, see if they can do further lifting and resection. Again, avoid surgery in a patient if we can remove a polyp altogether, because who wants to get their entire... And for IBD patients, it's not resecting one section, they're getting their entire colon out because they have such a high risk of more polyps and cancer that we don't do partial resections for ulcerative colitis patients. So, yeah, lifting the lesion. I think Dr. Gohad walked us through this. It limits the thermal injury, and then the contrast helps visualize the border and stains that area. So you can see, you're not getting deeper into the muscle. We stop right there to avoid perforation risk and avoid complications as well. Endoscopic removal is actually pretty safe. Bleeding risk is based on the size, obviously, but you saw this one actually bleeding in the video. But it's like I was getting nervous, but our advanced endoscopist was like, oh, you see this little bleeding here? We just fixed it with some cautery, and it's all good. And, of course, there's a potential risk for perforation, especially the larger the polyp and, you know, how big it is. But it's really about 1% or less, and just as long as you do it safely. And pretty quick recovery. You leave endoscopy that same day and go home compared to, obviously, having major surgery and resection. So always attempt to, you know, do this by EMR and then send it to the surgery unless it's, you know, deemed unsafe to do so. Okay, we'll move on to Case 4. This is a 54-year-old male. Presents with abdominal pain. Worsened over the past several months. No appetite, but lost a lot of weight, over 20 pounds. But no nausea or vomiting, just has no appetite. So an abdominal ultrasound was done, and we find this bile duct is mildly dilated, but there's no stones in there. And we see this mass in the head of the pancreas, and the pancreas duct is also dilated, or the double duct sign. So what would you do next to get a diagnosis of this pancreatic mass that we're worried about? EGD, a colonoscopy, EUS with FNA, or ERCP? EUS? Okay, anyone? ERCP. ERCP. Ooh, the house is divided. EUS, the ERCP on the other side. Okay, let's ask our experts here. What do you guys want to do? So EUS will give you a better chance of getting a diagnosis than an ERCP. With the ERCP, you're doing intraductal brushings and biopsies of the bile duct. You typically don't enter the pancreatic duct to get a tissue diagnosis, because you have a much higher risk of causing pancreatitis by doing that. So with the EUS, FNA, you have over 90% chance of getting a diagnosis by doing that instead of doing an ERCP. And what typically we end up doing in these cases is a combined EUS and ERCP, because this patient also, was he jaundiced also you said? Not that we know about. We don't have any lab information. So if his LFTs, his or her LFTs were high, suggesting that the obstruction was clinically significant, you would combine an ERCP along with EUS. If the LFTs are normal, then you just proceed with the EUS and get a tissue diagnosis with FNA. With the bile duct being mildly dilated, would that change anything or not necessarily? So not necessarily. Again, the less is more is how we look at it in this particular situation. Sometimes the bile duct remains dilated and you don't necessarily get jaundiced in those folks. We do discuss with them at the time of the presentation, make sure the oncologists are also on board with the plan of just doing an EUS. But some people would prophylactically do an ERCP and place a stent. It's not unreasonable. So you're right. We'd start with EUS, and of course, I think we've seen many of our advanced endoscopists schedule for both, depending on what they see on the EUS exactly. All right. So endoscopic ultrasound used to evaluate the pancreas, but a lot of other things, too. But in this case, for the pancreas, FNA can be performed to get the diagnosis of these lesions. And so this patient undergoes EUS and the biopsy reveals pancreatic cancer, unfortunately. Now, over the next few days, he wasn't jaundiced, but now he actually becomes jaundiced, and he's now developing itching all over his body. A CT scan is done and shows his pancreatic mass is now causing blockage of the bile duct. Okay. So what would you do now to relieve the biliary obstruction? EGD colon, EUS, or ERCP? Okay. Oh, these are easy answers. You guys, we should get some harder questions. Okay. All right. We don't think we should give them more options. Well, has he had colon cancer screening yet? I don't know. Okay. Yes, you're right. Okay. And that's why I think most often, our advanced endoscopists will go ahead and get both of it done, especially if we think they're going to be a high risk for obstruction in the future, especially if it's not dilated. In this case, maybe there were some signs. The bile duct was mildly dilated in the ultrasound, but we didn't have evidence of any jaundice at the time, but now he's jaundiced. So this has progressed pretty rapidly for this patient. So, yeah, ERCP performed to relieve bile duct obstruction, and a biliary stent can be placed. So I guess I'll ask the advanced endoscopist here, do you typically put a stent in all the time when you do, you know, in these type of cases, or what are some indications for you to put a stent in? I mean, if there is biliary obstruction from cancer, they are getting a stent. And in majority of the cases, we would be placing metal stents, in almost all cases we're placing metal stents for relief of obstruction. Then they get evaluated by surgery, and then look at the options. So, actually, one more thing in this question. We throw in, like, cross-sectional imaging. So when we are doing, you know, these kind of procedures, we also have the luxury of looking at a good MRI with a pancreas protocol to see whether this mass in the head is resectable or not. When we are doing endoscopic ultrasound to get the tissue sample, we also can figure that out. What I mean by that is, in that case, if it is a resectable, you know that we can prophylactically put the stent, but it's usually we kind of sometimes avoid until the surgeon evaluates. If it is not a resectable, we most of the time, at least in my practice, we just go ahead and put a metal stent to avoid this obstructive jaundice with ERCP. So patient officially gets diagnosed with pancreatic cancer, starts chemotherapy, but the pancreatic mass continues to grow in size. And after three months, a repeat ERCP is recommended to replace this biliary stent. So what type of biliary stent would you recommend in this patient? They're giving away all these answers here. Okay, so yes, metal. So, yeah, metal biliary stents will have longer patency than the plastic ones, so they don't really need to be replaced or removed and really meant for palliative for these patients so they don't have to go through, I mean, imagine someone with pancreatic cancer is undergoing chemotherapy and having to come back and every three months getting a stent replaced just to get them to feel better. Why put them through that? Okay, so I think we can stop here. We're exactly on time right now for this. So do you have any questions regarding any of those cases? No? All right. So we'll finish up with life, a day in the life of the gastroenterologist. So now that you've seen all this, you can maybe come up with any more questions that you may have for us, right?

gastrointestinal issues

vomiting

peptic ulcer disease

endoscopic mucosal resection

pancreatic mass

bile duct obstruction