Alright guys, I think we'll get going just because we want to get as much of this done. So this is the case-based portion of the day. Now you're all, you've done the studying, you, you know, you've learned every part of the GI tract and every disease that could be thought of. You then, you know, mastered endoscopy so now you're in clinic. So we're going to do a couple of cases and again, we can reach out into the audience and see and ask questions. So this is a 58-year-old male who's been vomiting bright red blood, so we call that hematomasis, for 12 hours. He isn't complaining of any abdominal pain and then he's had two episodes of black stool. And just really quick, does anybody know what black stool is called? Melanot, right. And if you're a resident presenting to an attending, it is not melanotic stool. So that's a really big point, right? Every attending will, like, it's like a fun way for attendings to get on residents. It's melanic stool, right? Because melanotic stool is like a melanoma of the stool and I don't even know how that would happen. I would hope it wasn't possible. But this patient has had two episodes of black stool, which we call melana. And then he has osteoarthritis and coronary artery disease. And that becomes important because when you ask about medications, the individual's been taking ibuprofen, which is an NSAID three times per day, some aspirin as well, just to give it a little bit of an extra boost, some Tylenol, and then his metoprol. So his blood pressure's low, his heart rate is high, a number of things you want to see. And his hemoglobin is on the lower end, so he's anemic. So which of the following, so now you're seeing him in the hospital, you're called in as the first-year fellow, and what's the most important next step in the patient's management? A? I got one for A. What do you think? D? B? Anybody for C? All right, it's all of the above. So we're going to go through this. Okay. So number one, he's tachycardic and he's hypotensive because he's having an upper GI bleed. So one clue to an upper GI bleed is that they become decompensated really quickly. Sometimes you'll see patients with melanic stool, or they'll tell you they have melanic stool, but their blood pressure's completely fine. That can sometimes be a clue that they're not having some sort of an abrisk upper GI bleed in that moment. But when they're tachycardic and hypotensive, you very quickly want to get two large IVs in place, and you want two of them because you want to be able to do multiple things with those IVs. And then, of course, one of those IVs should be getting fluid because they're tachycardic and hypotensive, which means that they're volume depleted. You also know that they're volume depleted because they're anemic. And blood doesn't come right away. You need to get labs, which is another reason that you want to have IVs in place in case you need to do some of these things. But for the blood to come, you need to be able to get a type and cross. And so there's initial steps for that now. There is a massive transfusion protocol, but he's not necessarily meeting that. And the PPI, there's many different reasons that I could give to do it, and none, really, not to do it. The reason that you want to get a PPI on board is that even if it isn't what you need in that moment, there's not a big downside to giving it. So there's a much higher upside, right? So it's risk-benefit anytime we're doing this stuff. And as you guys have asked questions today, which are really so great, like, are we doing screening for things like pancreatic cancer? Are we doing screening for liver? Everything we do is based on cost-effective analyses, right? So if some benefit outweighs the downside, then we're going to promote it. PPIs and giving PPIs in a patient with an upper GI bleed, even if that's not the reason they're having an upper GI bleed, like let's say the guy had cirrhosis and we just didn't know it and this was an esophageal bleed. There's still not a big downside to giving those PPIs. So what is the most common cause of upper GI bleeding? Is it cancer? Is it variceal bleeding, which you're going to get from cirrhosis, most likely? Is it peptic ulcer disease, which you can get either from a bacteria called telicobacter, or you can get it from the largest secondary reason is going to be NSAID use. Or is it a Mallory Weiss tear? Mallory Weiss tear is when people vomit so much that they like irritate and they tear their esophagus. Right. So cancer is never going to be the most common cause. It's actually rare and that's a good thing, relatively speaking. Variceal bleeding is going to be specific to a population that either has some underlying condition that can lead to a varix or cirrhosis. And Mallory Weiss tears, just because you're vomiting, you're not going to get a Mallory Weiss tear. They're much less common. But peptic ulcer disease is something that we see very often. They can occur in both the duodenum, duodenum, however you want to call it, or the stomach. And they account for about 50% of causes of upper GI bleeding. And that's because when these ulcerations erode, they can a lot of times erode into vessels. So a lot of the things that we were talking to you about on instances where we might burn, like you just learned, or instances where we might use a clip, like you just learned about, are because of these types of ulcerations. And it's very important for us to understand what the ulcer looks like. The other thing is that if you go down there and you just see this ulcer, even in this gentleman who's got a history of ibuprofen use, you don't want to automatically assume it's peptic ulcer disease. Right. So everything you want to prove. You need to make sure that this isn't a cancer. Right. So even though cancer is not the higher likelihood, you're going to want to make sure that. So you do that by either taking a biopsy in that moment, which you may not want to do in a patient that's bleeding, or you go back at some time in the future. So the two most common causes you heard me talk about is NSAIDs. NSAIDs are ibuprofen, aspirin. Every GI doctor, APP, healthcare provider in this country needs to understand that NSAIDs means nothing to the average patient. So if you ask your patient if they take NSAIDs and they say no, and then you come back and you present to me and you say there's no history of NSAID use, and then I walk up to them and I ask them if they were taking goody powder, and they tell me yes, it's because they didn't understand what an NSAID was. So you just have to understand, they only know drugs by their term. A lot of patients do not know the difference between acetaminophen and NSAIDs. A lot of patients don't know the difference between acetaminophen and Tylenol. And they may think of those as two different things. A lot of patients don't realize that aspirin and ibuprofen come from the same category of medications. So this is where it becomes on us. So those absolutely are the most common. And then the secondary thing is Helicobacter pylori, which is a bacteria that we can get from ingestion, from contact, grocery carts, bathrooms, touching dirty stuff, toilets. And we ingest it. And it's a urease-positive bacteria, a little nasty bugger, but you can cure it. But it can lead to ulcerations. So next question. What's the best initial treatment for patients with an upper GI bleed? Angiography, which helps us to identify where that bleed could be coming from and then potentially intervene if it was possible. An EGD, where again, that would allow us to see it and then intervene if possible. A CT bleeding scan, or just take them to surgery. So all of these can become a part of our treatment paradigm. And I think that you just have to take it into consideration, not necessarily what's best in all patients, but you take each scenario. And so in the majority of patients with upper GI bleeding, EGD is what we want. Sometimes we'll get called in the middle of the night, and then we will say, well, maybe you should send them to angio, or for a bleeding scan, or surgery. And then they'll ask, well, have you done an EGD yet? And so you have to have a good reason not to do that EGD first. And if the patient is unstable and an EGD does not fit with what you're doing at that time, you want to resuscitate the patient. If there's nothing else that you can do, like an unresponsive patient or a non-resuscitated patient is also not a very good candidate for surgery, and sometimes may or may not be a suitable candidate even for something like angio, although angio is going to be a little bit more of a stable situation to use if you have no other options. And you perform the EGD, and there is a deeply cratered ulcer, and it is spurting. So that's a nice spurt of blood. So I know my group was hearing me talk about this, I'm sure the other groups were, that sometimes you go down there and it is just a bloody mess, and it is exceedingly difficult. And I will also tell you that you see all this bright red blood right here? It coagulates really quickly into a nice big blood clot that you then have difficulty suctioning back up into your scope. But here we have this nice little area right there that is gushing for us. So what would you guys do first? Would you inject epi, which was that little injector that you had? Would you place a clip on there? Would you cauterize it? Or would you do all of it? I would do the spray. Oh, the spray. All right. All right. I got it. We really have to get this back out to the ARIA people. All of the above, including spray. So again, one thing to know about epi is it's a great way to slow a bleed down and give you some visualization, but it doesn't tend to last. So it isn't always definitive treatment, but it will buy you time. So epi is a good start when you've got a really big bloody situation going on. Placing a clip and cautery is really entirely up to the endoscopist in that moment. You may find that a clip is all you need. You may find that that cautery and then a clip is really good. Sometimes it's difficult to do one before the other. And so you may want to think about that side of things and what you would want to do first or second. But certainly you can do all of the above as options here, but maybe not all of them together. Yeah. So that's what we were talking about. Those are also really good options. And one of the things that we were talking about before is where our guidelines are changing. And the guidelines constantly change. And so we've got these new modalities to help that are there. And this is just not an all-encompassing answer. But I think that if that is something at your institution that you have access to or if it's something that you feel comfortable with, then absolutely, that can be another way to treat this. The one thing about certain sprays, not all of them, but certain ones, right, again, you need to have, you need to be able to have somewhat of a dry environment. And if it's very, very bloody and it's wet, the sprays can sometimes be a little bit difficult. But now we've gotten better sprays and we've got gels. We've got so many different things now in our repertoire. And so this is just a little bit into like different things that we can do. And the message here is that you can do clipping or cautery without the epinephrine. And honestly, you're trying to get in and get out of there, but it's also your environment. So that's where that comes in. So now we're just going to see it. And it's it's pretty cool in the sense that like the bleeding will really stop as soon as you get the right vessel So in this situation, we're putting on a second a second clip not a second vessel And then there you go you can wash that area to make sure that the bleeding has ceased So of all of his medications, which one do you think was most likely to have caused the ulcer after what we talked about? Yeah, yeah, it's both The what Well, yeah, but ibuprofen also is gonna cause a big bleed risk Yeah, yep And you know and and aspirin is something like again you there's all new Recommendations in regards to where we should be using aspirin in terms of primary prevention, which is never right versus secondary prevention, so our bleeding guidelines in in regards to the the coronary The coronary heart association are changing But non-steroidal anti-inflammatories and aspirin are the most common cause of bleeding ulcers and H pylori is the most common cause of Bacteria and I think we have enough time to do a second case here So this is a 54 year old woman who's had six hours of epigastric pain that goes to her back along with some nausea and vomiting She's got diabetes high blood pressure and hyperthyroidism and she's had a tubal ligation and a cholecystectomy In the past just for you guys if you just don't know cholecystectomy means she's had her gallbladder taken out She's on metformin, which is her medication for diabetes hydrochlorothiazide, which is likely in part for the Diabetes and probably also for the hypertension and then levothyroxine for the hypothyroidism She hasn't smoked and she rarely drinks any alcohol And she's got pain in the mid epigastric region and she doesn't have any rebound Rebound if you guys don't know what that is is that if you push your hand on the belly and then you release really quickly It's that pain that happens after you rebound off of them. So that's that's usually a worrisome feature So that's good that she doesn't have rebound So at this point you're considering you're considering office This is any this is an except exception questions are always they make you they mess with the mind So you it could be everything on here except which one it could it not be Good job All right, it can't be because she doesn't have a gallbladder like it So she already had her gallbladder out. So but it's it's really great Did you guys realize that you can still have choledocholithiasis? So a lot of times your patient may come in and you're like, well, you know It could be it could be stones and then they'll say but I had my gallbladder taken out But you still have a duct in those ducts. Those stones can still be stuck in that duct and Then pancreatitis typically presents with epigastric pain that radiates into the back and then we already talked about some of the things for peptic ulcer disease So the other things can cause abdominal pain and nausea and vomiting and so now what would be your next step? so would you get a CT scan an ultrasound a lab and Pancreatic enzymes would you be like an amylase and a lipase or would you go straight to an upper endoscopy here? So The labs are helpful for us to be a be better able to elucidate which which organ we think that this could be right so Amylase and lipase being elevated is helpful. If we're thinking that there's something in the pancreas Choledocholithiasis is going to be helpful for us if we're looking for signs Of abnormalities within the liver function test, which is where you're getting the liver enzyme panel And then the CBC because we had peptic ulcer disease on here again, right? Is there some bleeding that we're missing or something that we should be looking for? and So here's you did that and this is what it came back with the lipase is elevated at 6,500 and I'll give you a clue that that's really elevated and the liver function tests are perfectly fine The white blood cell count though is is is elevated. The hemoglobin is normal and the platelet count is normal So you've confirmed that the diagnosis is acute pancreatitis and that's based on the fact that you've got Right now two out of three findings, which is abdominal pain and an elevated lipase. The only thing you don't have is a CT scan fine So she's got characteristic pain she's got elevated Pancreatic enzymes and then the third thing right here as you're seeing it is typical CT finds TT CT scan findings of pancreatitis So in the US and I think you guys may I'm gonna give you a little bit of a hint here because it's not on Here, it's not scorpion bites. All right. I know we talked about that. What are the two most common causes of acute pancreatitis in the US? No So hypertriglyceridemia can cause elevated can cause pancreatitis But it's very high triglycerides. Like typically we're looking at triglycerides in the thousand range or 800 to thousand range Most Americans who have hypertriglyceridemia do not have it that high So it would be worrisome to have it high enough to cause pancreatitis But I understand where you guys are thinking that hypertriglyceridemia in the US is a common disease state It's just not always high enough that we're gonna get in there Gallstones you're right on so a hundred percent gallstones So then let's think about this between hypertriglyceridemia and alcohol triglyceridemia now that you guys know It's got to be super high like in the thousand Versus alcohol that many many people do and we don't oftentimes don't express how much we're drinking of said alcohol So alcohol is gonna be a much more common type and an alcohol In and of itself can be such an addicting habit that once you start to develop some of these things whether or not Cirrhosis or liver issues or pancreatitis it can lead to long-term consequences And then every time you drink it's like poison to said organ And so here's sort of the breakdown of those two 45 percent and 35 percent All right patient already told you they rarely drink and you believe them and they've got normal liver tests So what would you recommend to look for a possible etiology of the of the pancreatitis? Would you look for the Tylenol level the triglyceride and calcium levels or the hemoglobin a1c? see It's B you guys got it right the first time it struggles right right because I could triglyceride levels So so diabetes can be a risk factor for certain things But just having an elevated hemoglobin a1c is not gonna make me think okay. That's a cause for pancreatitis Tylenol levels can lead to acute hepatic failure and and liver toxicity But pancreatitis is not one of the things that we typically think about when we look at Tylenol levels, but triglyceride and calcium are they're uncommon and We talked about this the scorpion bites again Never gonna go away. Autoimmune pancreatitis is a really important one for young patients where you don't have another expressed Etiologic factor and they're not living in the state of Arizona or the Scorpion Island that we talked about previously ERCP right you're gonna know if they had a recent ERCP or not and then of course trauma But these are some of the uncommon causes that we typically see The calcium level was normal at 8.5 and the triglyceride level is 1573 So remember like I told you greater than 1,000 is what we're looking for. So what are the treatment goals for this patient? Lower the hemoglobin lower the BUN lower the triglyceride level or do it all Do it all, do it all, good job. Okay, so why do we do it all? Triglycerides were the obvious answer there. You wanna lower the triglyceride levels to less than 1,000 as quickly as possible. You can do this with medications, and medications will work, but sometimes they can take a little bit of time. So if you need to, you can do plasmapheresis. And then the other thing when you have acute pancreatitis is that you wanna get them under control as quickly as you can. So that's usually staying hydrated, making sure that you're managing pain, and that you're getting their hemoglobin and BUN to decrease. So which of the following will lower the triglycerides the most? Is it simvastatin, phenolphybrate, niacin, or fish oil? I hear A and C. I heard B, it's B, it's fibrate. So A is great for lipids. Simvastatin is gonna be your choice if this was hypercholesterolemia with elevated LDL. Fish oil, good. I like fish oil. It should be a part of it, but it's not gonna be the most prominent here, but you should do fish oil. I'm a big fan of omega-3s. And then niacin is for your HDL, if you remember. So niacin's gonna fit a little bit there. Yes, niacin can help with triglycerides, but out of these choices, phenolphybrate's gonna be your number one. And we're running sort of low on time, but really quickly, we've got a large polyp, and they want a second opinion about the need to have it removed via surgery, or if we can do a big EMR. And look at the, there's that polyp. So that's a nasty bugger. Yeah, that's not, as the IBD doctor here, I'm not taking that thing out. I'm sending that to my colleagues. So right there, what they're doing is they're injecting it with some methylene blue. I don't know how many of you injected. We injected with some water in our group on the pig. I know somebody tried to perforate their pig and succeeded. And so when you make it, when you lift it up like that, you're better able to get the snare around a chunk of that. And one of the things that you wanna be aware of is whether or not you're taking out a polyp piecemeal, which means in pieces, or if you're taking it out whole. So here, what do you guys think? Are they doing this piecemeal or whole? Piecemeal. Piecemeal, right? They got good margins. They got good margins, they do. This is a qualified endoscopist. ACG would give us no less. And I think my colleagues who do this, and we have colleagues here who do this, this is absolutely incredible. And I think that endoscopy has come so far and our ability to do this and this patient not have to go to surgery. Yeah, and our next session is talk to us again. So if you guys have questions while we're watching this, please feel free to ask all of us, especially those of us that do this a little bit more often. So you can see how gorgeous that looks at the end there, you know. So now they're taking a cautery around there because you see that it was bleeding a little bit and then they're going to cauterize some of those edges there. I heard somebody mention good margins which is really great and something that we obviously want. But I think at the same time one of the things that we have to wonder is whether or not, you know, those margins are good under the microscope too. But certainly this is something that you can do, you can cause a defect like this without perforating an individual, without taking them to the operating room. And I just sort of opened it up, does anybody have any questions about this to anybody that's here? I've got a couple questions. Yeah. Case number two.

gastroenterology

upper gastrointestinal bleeding

peptic ulcer disease

acute pancreatitis

gallstones

endoscopic mucosal resection