So, basically, for this section, we have several different kind of multiple-choice questions that we can go over, go through as a group. So, if anyone knows the answer, feel free to shout out, and then we can ask our extra faculty for any input as well, too. So, the first case, we have a 58-year-old male who's been vomiting red blood for 12 hours. He's not having any abdominal pain and has passed two episodes of Black Stool. He does have a past medical history, that's what that shorthand means, of osteoarthritis and coronary artery disease. In terms of medications, patients taking metoprolol, 50 milligrams daily, aspirin, 81 milligrams, ibuprofen, 800 milligrams three times per day, and acetaminophen as needed. His physical exam demonstrates a blood pressure of 92 over 54, which is normal, heart rate of 120 per minute, which is high, but otherwise normal, hemoglobin 9.3, which is lower than normal, particularly for a male, and all this other blood work is normal. So, the first question here is, which of the following are important next steps in the patient's management? So, options being, A, place two large-bore IVs, we get an IV fluid, we get an IV proton pump inhibitors, and all of the above. If anyone has any thoughts, feel free to shout it out. Any other thoughts? Thoughts from the group? So, A is right, however, actually all of the answers are right, it's one of those. And the reason why is, so when a patient comes in with brisk GI bleeding, we're concerned that basically the patient has a tachycardia, meaning his heart rate is fast, and he's a little bit hypotensive, which means that he's lost a lot of blood volume. So, he needs a blood transfusion, but practically that takes time. So, you need to check the patient's blood type by matching blood for the patient. So, in the meantime, you want to kind of just replace the blood volume that's been lost with some fluids. And so, yes, you need to place some large-bore IVs, but you also want to make sure they're getting fluids started as well, too. Then you also want to start a proton pump inhibitor through the IV that increases gastric pH to counteract acidity. That allows blood to clot better, regardless of the cause, and if the cause is related to any sort of increased acidity and heptic ulcer disease, it also does that, too. Okay, so question 1B, what is the most common cause of upper GI bleeding in the United States? Yes, absolutely. So, as we were, I think we talked about that earlier, peptic ulcer disease. So, peptic ulcers, they can commonly occur in the duodenum or in the stomach, and they do account for about 50% of cases of all upper GI bleeding. The vast majority of ulcers are due to either NSAIDs, such as ibuprofen, aspirin, also naproxen, and the bacteria H. pylori, as you heard about earlier from Dr. Chang. So, what is the best initial test for evaluating and treating patients with upper GI bleeding? Angiography, EGD, CT bleeding scan, or surgery? Yes. Well done. The answer is EGD. So, EGD is almost always the best test, because it allows for precise localization and treatment over 90% of the time. If the patient is too unstable, then they should be resuscitated, meaning giving them blood products and IV fluids to allow them to be stabilized. However, if they are still too unstable, then you can think about surgery or, more likely, angiography that may be necessary. I'm sorry. I should pause. Any that go along with all of your kind of thought process? You guys with us? Okay, great. Mostly, yeah. Mostly? What's the not mostly? Not mostly, because everyone has different practice styles, too. Only in certain rare cases, like you have to go to intervention radiology. Right, right. Or an NGO. Yeah, exactly. Okay. So, you perform an EGD, and you find a deeply cratered, actively bleeding ulcer in the stomach. What are your treatment options? So, you can inject with epinephrine, place a clip, cautery, or all of the above. All of the above. Great. Well done. And, like I think Dr. Chang was talking about previously, so epinephrine, you can definitely use that to treat ulcers, but we can't use it on its own. It basically slows down the bleeding, but if you just inject with epinephrine, that's not going to be enough to prevent the bleeding from starting up again. So, if you want to do epinephrine, you need to do that plus one other thing. And the other option that we choose is kind of dependent on what the bleeding lesion looks like, the location, and lots of other factors. Okay. Yes, and this is just what I just said. So, this is a video kind of showing an actively bleeding ulcer, and so you can see there's just a lot of blood in the area. I think this is in the stomach, but honestly, it's even hard to kind of make out where it is exactly. So, right now, we're using a hemo clip to kind of clip off a visible vessel, which is kind of that red dot where the bleeding is coming from. And now we're putting on another clip. And those clips that we were talking about earlier, once they're in place, they usually stay on. It kind of depends on the exact location how long they stay on. So, and this looks like it's small actually. So, you know, it may last, you know, a few weeks to a month or something like that. In the stomach, they can honestly be there for years. So, next question, which medication most likely caused the ulcer? Acetaminophen, ibuprofen, metoprolol, aspirin, or the ibuprofen and aspirin? Yes, exactly. That's because they're both non-steroidal anti-inflammatory drugs. Now, while NSAIDs do have anti-inflammatory in the name, unfortunately, within the GI tract, they're actually pro-inflammatory. They cause mucosal erosions and ulcers. And it's the most common cause of peptic ulcers in the United States. H. pylori also causes ulcers, as we've discussed, but it's less common in the United States. Okay, so second case, this is a 54-year-old woman with six hours of severe epigastric pain radiating to her back, nausea, and vomiting. She has a past medical history of diabetes, hypertension, and hypothyroidism. She has a past surgical history of a tubal ligation and a cholecystectomy, or gallbladder removal. Her medications include metformin, hydrochlorothiazide, which is a diuretic, and levothyroxine, thyroid medicine. She is a nonsmoker, and she rarely drinks alcohol. Her physical exam is normal, except she's tender to palpations with TTPs in the mid-epigastrium, so kind of in the upper middle part of her abdomen, and without rebound. And that essentially is suggestive that the peritoneum, or the lining of the abdomen, is not inflamed. They're not inflamed severely. So first question about this case, at this point, you would be considering all of the following diagnoses except. So choledocholithiasis, which is stones caught in the common bowel duct, acute cholecystitis, or inflamed gallbladder, acute pancreatitis, or peptic ulcer disease. B. Right, yes. I had to think about that for a second. Yes. A nice pickup. So yes, she already has had her gallbladder removed, but all of those other complications are still possible. So they all can cause abdominal pain with nausea and vomiting. So it can be difficult to distinguish these without imaging. So what is the next best step in your evaluation? An abdominal CT scan, a right upper quadrant ultrasound, labs to include a liver panel, pancreatic enzymes, and a CBC, or an upper endoscopy? Actually, what does our panel think? Yes. Yes, I think the next step, practically, would be to get blood work, and that would be including the liver panel, pancreatic enzyme, and CBC. And so the reason why we go over this now is that the liver panel basically gives us several different blood work values that kind of give you a hint of, first of all, is the liver inflamed? There are a couple of numbers that tell us that. There's also a number called the bilirubin, which can be high if there's a blockage in the bile ducts. Also, there's an alkaline phosphatase. So it's a whole panel that's very helpful. There's pancreatic enzymes that will be high if you have pancreatitis, and your hemoglobin may be low if you have teptic ulcer disease. So blood work can be done pretty quickly, doesn't require radiation, and that can kind of give us a hint of what the next step would be. So in this patient, her liver function tests are normal. Her lipase is elevated at 6,500, which, to give you an idea, kind of depends on the exact lab, but normal is usually something like 30 to 50. White blood cell count is 15,000. Normally, it's less than 10,000. Hemoglobin of 14, which is about normal. And platelet count is 360,000, which can be normal. So you have confirmed the diagnosis of acute pancreatitis, which requires two of the following three. So characteristic pain, elevated pancreatic enzymes, and typical CT scan findings. So what are the two most common causes of acute pancreatitis in the United States? So medications and trauma, alcohol and gallstones, gallstones and hypertriglyceridemia, and alcohol and hypercalcemia. Yes. Nicely done. That was from Dr. Chua's talk. So alcohol and gallstones are the most common. Gallstones account for about 45%. Alcohol accounts for about 35%. And the rest are much rarer. So since the patient rarely drinks and has normal liver function tests, you recommend the following to look for a possible etiology. So telomole level, triglyceride and calcium levels, or a hemoglobin A1c. This one's a little tricky. A little tricky. Yes, exactly. So here, yeah, so high levels of triglycerides and calcium can cause acute pancreatitis, rarer but definitely not unheard of. Other uncommon causes are certain medications, trauma, like blunt trauma to the abdomen, post ERCP, as you heard earlier today, autoimmune pancreatitis, and scorpion bites is another kind of trivia question answer. So your calcium level is normal at 8.5. Triglyceride level is very high at 1,500. And in this picture here, you can basically see this is like a tube of blood in someone who you draw their blood, and basically the fat starts to separate out from the rest of the blood because it's so high. So treatment goals for this patient would include lowering the triglyceride level, lowering the hemoglobin, lowering the BUN, and all of the above. So actually, so what does the panel think? I don't think we really discussed this portion. Yeah, we didn't. That's just fair. I know. For them to answer this question. Urea and nitrogen. Yeah, blood, urea, and nitrogen. So A is correct in this scenario. The more correct is all of the above. Because we use, more often they'll say using hematocrit or hemoglobin and BUN. So you mentioned that supportive care including IV fluids. Oh, I'm sorry, the microphone. Are they off or are they on? Or do I have to push? I think you have to press the answer. It would be closer to the mic. Well, anyway, supportive care including IV fluids and appropriate fluid resuscitation is the important backbone of treating acute pancreatitis. As we mentioned before, once it's happened, we don't have many tools. We know that within 6 to 12 hours of symptom onset that we have a small window for expanding the blood volume, reducing local ischemia or lack of blood flow to the organ can help improve outcomes. So we use, if you've diluted the blood enough for the BUN and the hemoglobin to go down, then that means you've reached your goal in giving them enough fluid. In practice, we don't always meet this window. People don't know what's happening to them and they stay at home for a couple days in pain. But ideally, we want to be able to give them enough IV fluid to lower these blood markers. Yeah, exactly. So where you're kind of thinking an ideal scenario, you basically want to be lowering the triglyceride level and also hydrating them to the point where the other numbers come down. So you want to lower it to less than 1,000 as quickly as possible. We often do it with medications, but sometimes a procedure called plasmapheresis, which is similar to dialysis. Basically, it's a machine that filters out the blood. And all patients should be aggressively hydrated. So next question. So which of the following medications lower triglycerides the most? And I know we didn't go over this either, so no problem. Best guess is just fine. Simvastatin, phenofibrate, niacin, or fish oil. Phenofibrate. Yeah. I feel like my husband being a cardiologist, I should really answer this question right as it's a force. But yeah, all of them will reduce. Phenofibrate. Yeah. Yeah. Phenofibrate definitely will work the best in the acute setting. And phenofibrate works the fastest. OK. So the next case is a 67-year-old female who's found to have a large polyp in the cecum. And the previous endoscopist referred the patient to a surgeon. The patient is seeking a second opinion about the need for surgery versus removal with colonoscopy. So this is the video here. It's a nice-looking polyp here. So basically, the endoscopist is doing right now. What they're doing is kind of marking the margins of where they'd like to cut. And you'll notice that when he was marking the margins, he was marking it around the polyp because he wanted to get some normal tissue around the polyp, as Dr. Guha mentioned in his presentation. And he's basically doing an EMR where you kind of lift up the polyp from the mucosa and then burning off the polyp. Now, in an ideal world, ideally, you want to be able to try and cut off the polyp all in one go. This is what we call the piecemeal, which is not ideal. Our guys will do ESP here. Oh, yeah. It is ESP. Yeah, sorry. I'm making a funny face because we try not to inject through the polyp. Yeah. This looks benign to me, just like a tupular adenoma, but just in case. So I should have let you guys narrate this one. But if something is benign and it's in a thinner portion of the colon, and we think the risk of it harboring some kind of cancer is perfectly appropriate to EMR in pieces. Mm-hmm. Yeah, it's scary to watch as a general gastronomist, but very impressive. And now the endoscopist is basically using that APC, which probably a lot of you used before, to kind of burn the edges at the end. So which of the following should be done for this lesion? So perform a four-step biopsy of the lesion, inject a dye-based solution prior to the endoscopic resection, refer to surgery, riblate the lesion with argon plasma coagulation. I think the slides were kind of mixed up, so you kind of already know the answer. But the answer here is basically to do, to inject the dye-based solution. So endoscopic mucosal resection can be used for a large Cecil or flap hollow. So you're basically injecting a dye into the submucosa. So it lifts the lesion, which prevents thermal injury. The contrast allows for better visualization. And also you're staining the submucosal layer just above the muscle to confirm that you didn't perforate the patient. And endoscopic removal of large benign polyps we found to be safe. There is a risk of bleeding that's higher in certain parts of the colon, like the right colon. And if you're using blood thinners for larger polyps, we'll also use, we'll often use hemoclips to prevent risk, prevent bleeding. And there's always a risk of perforation. However, endoscopic removal of polyps is associated with a rapid, more rapid recovery and fewer complications compared with surgery. So the next case is a 54 year old man presenting with abdominal pain. This has slowly worsened over the past several months. He has no appetite. He's lost more than 20 pounds and he has not been having any nausea or vomiting. He has an abdominal ultrasound. The bile duct is mildly dilated. There are no obvious stones. A mass is seen in the head of the pancreas and the pancreatic, pancreas duct is also dilated. It's a double duct sign. So the next question is, what procedure would you recommend to obtain a tissue diagnosis of the pancreatic mass? So an EGD, colonoscopy, endoscopic ultrasound, or an ERCP? Yeah. Yeah, that's right. So I think Dr. Iguoda talked about basically using an EUS. With a linear probe, if you're trying to sample the lesion. So the endoscopic ultrasound allows you to look at the pancreas and then you can do what's called a fine needle aspiration. So just using a needle to take small amounts of tissue that can be sent to a pathologist. So the EUS guided biopsy does confirm pancreatic cancer, unfortunately. Over the next few days, the patient becomes jaundiced. He develops itching all over his body and a CT scan shows the pancreas is causing a blockage of the bile duct. So what procedure would you recommend to relieve the obstruction? So an EGD, a colonoscopy, an EUS, or an ERCP? Yes, exactly. And that's what Dr. Chua was talking about in her talk. We often will do ERCPs to relieve the bile duct obstruction. You can leave a biliary stent in place into the bile duct to allow drainage and improve the patient's jaundice as well, too. So the patient, as we know, has pancreatic cancer. He gets chemotherapy, but despite this, the pancreatic mass is continuing to grow in size. And after three months, a repeat ERCP is recommended to replace the biliary stent. So which type of biliary stent would you recommend in this patient? And this I'm actually not sure if we went over, but we'll talk about it. I don't think the audience can answer this. Yeah, this is a little tough. So the answer is basically a metal stent. And the reason why, so there's plastic stents that are basically placed more temporarily. They don't last as long. They start to close off or occlude. Metal stents will stay open for longer. However, metal stents can also not be removed. So we only use them really in patients with cancer patients who are not expecting for them to ever need the stent removed. And it also allows someone to most likely towards the end of their life to not have to come in for repeat procedures. Okay, so this is the last case. So we've got a 29-year-old female who is diagnosed with Crohn's ileitis, meaning Crohn's disease that's involving the terminal ileum in the small intestine in 2010. In 2010, she had a colonoscopy that showed ileitis and a deformed ileocecal valve. Previously, she's been on Pentassa, which is a 5-amino salicylic, 5-ASA, and Bdecinib, which is a steroid. And she has not had significant relief despite being on this treatment for five years. So she's referred to an IBD specialty center with abdominal pain, diarrhea, anemia, bloody stools, malaise, and fatigue. The colonoscopy gets repeated. Again, she has an inflammatory structure in the ileum, exudates, deep ulcerations, luminal narrowing, severe ileitis, so just picture the photos that Dr. Mishra was showing in her talk. So clinically, the disease is mild to moderate. Endoscopically, she's moderate to severe ileitis. She has not been responsive to standard therapy, although I would maybe question whether what she had was standard therapy. I know what you think, casually. You agree? Yeah, I think these questions are a little bit outdated, but that's okay. So the risks and benefits of biologic anti-TNF therapy are considered. So historically, the biologics that we had available were anti-TNF, such as infliximab, Remicade, and Humira. She gets appropriate pretreatment workup with tuberculosis screening, hepatitis B screening, and a chest X-ray. And the patient opts for treatment with adalimumab, which is Humira. So the patient's luminal symptoms resolve after two injections of adalimumab, so that basically means her bowel symptoms have improved. Her malaise and fatigue are significantly reduced at four weeks, so she's starting to feel better. Now, we checked some blood work. She has a C-reactive protein, which is an inflammatory marker in the blood. Before treatment, it was 15, which the normal value is definitely very based on the lab. But after treatment, it's basically undetectable, and the patient's doing well. So which of the following is typically not used for initial management of mild to moderate Crohn's iliitis? Misalamine, cyclosporine, budesonide, or eosinoprine? And this, again, is a more advanced question, so that's okay. I know, Kajla, you wanna comment? Yeah, there's actually, it's not just one right answer, but I think what they're trying to ask is one, which is absolutely never used in Crohn's is cyclosporine. It has some role in UC, but not in Crohn's, but nowadays, misalamine has also fallen out of the guidelines for use in Crohn's, whether it's mild or not. Exactly. So cyclosporine, because we definitely don't use it in ulcerative colitis, but I do believe most inflammatory bowel disease specialists would kind of balk at using the misalamine as well, too, for Crohn's. So cyclosporine, the only time that we really use it these days is in patients coming in with severe ulcerative colitis who you're trying to save their colon, quote-unquote. So someone who, if you don't do anything, they're gonna go get a colectomy. That's when you use it. So next question, which of the following test investigations is not typically done prior to starting biologic therapy, an IBD, chest X-ray, a TB skin test, 2D cardiac echo, or hepatitis B serology? Yeah, exactly. So the echo is not typically done. The rest are, chest X-ray's kind of dependent on the center and the IBD-ologist. So a cardiac echo is usually not needed. The other tests are required. However, I would edit that by saying that if you do another blood test called a TB quantifier on gold, that screens for tuberculosis exposure, that can absolve your need of a chest X-ray. All right, and we're all done.

gastrointestinal bleeding

peptic ulcer disease

pancreatitis

endoscopic evaluation

H. pylori infection

hypertriglyceridemia