All right, so we're circling back, remember everything we talked about in terms of physiology and where we are. So small intestines, main things we're talking about today, it likely mostly are bleeding, but we'll go into that. So just a reminder about your anatomy, as you know, with your small intestines being this kind of highlighted section right here. Okay, so we're going to cover a couple of things here. The first one is celiac sprue. The second is obscure GI bleeding. Small bowel obstruction, thirdly, and then lastly, mesenteric ischemia, and we'll try to move as expeditiously as possible. So first off is celiac sprue, and I'm sure everyone has seen a ton of stuff on the internet about people saying that they are gluten allergic. These are the people who are actually gluten allergic, who have celiac sprue themselves. They're people who may have intolerances to wheat or other things that are in bread, maybe an intolerance even to gluten, but not necessarily allergic. So these people actually have an immune reaction to gluten itself of unknown etiology, usually with a genetic predisposition, so it runs in families, and also is linked to other autoimmune diseases. And so what is gluten? It's a protein found in wheat, barley, and rye. It gives dough its doughy texture, and that's why all of the alternatives for these foods taste like trash. So people who choose to have them, so be it. Also found, however, in cosmetics, hair products, skin, and other things like that. So when I do actually diagnose patients who have that, I have them make sure that they're going through a list, and there's lots of great websites and resources that allow them to make sure that they're not getting cross-contamination from simple household things. So what are the symptoms? It's a whole spectrum. So there's some people who are asymptomatic. Personally, in my clinic, a lot of times I'll end up meeting people who are having fertility or new anemia workups that they're unclear about, where their OB has seen them, and that's kind of part of the workup, so they may be asymptomatic. Other people may just have the fatigue, like I said, with this anemia, so that's part of the workup there as like an upper GI potential source. And then for others who have more significant symptoms or they've had more progressed disease, you may see cramping or a diarrhea of some sort, and that's generally because of that intestinal lining destruction that we talked about that we see. And then, of course, that can lead to malabsorption, which can give you vitamin deficiencies, which can lead to osteoporosis, growth failure. Obviously, we see that more in the pediatric population, and weight loss, which we can sometimes see in adults as well. So how do we diagnose it? So of course, the clinical history and being in clinic is the most important because you want to get a good story from people. Generally, they'll say, oh, I just feel achy or something's just not right when I eat certain things, and a lot of people aren't very specific about their diet. I don't know about you, but I can't remember what I ate yesterday. So getting an idea of what exactly they're taking on a daily basis, and then we test. We want to make sure that they're not one of those people who just decided to avoid gluten altogether because this can skew our results. But with serologies, we can find antibodies in the blood to endometrial things, antibodies, the tissue transglutamase antibody, or the amygdala peptide. And something to keep in mind also is that there's an overlap as well with IGA, which is one of the immunoglobulins that kind of feeds into all of this. So if people are low, sometimes it makes it even harder to detect celiac because they don't set off these test antibodies the way that they should. The next thing, which is more of a definitive diagnosis, is endoscopic biopsies of the small bowel. And that would be the small intestines, after the stomach, past the pylorus, through that little channel. So what do we see? So a spectrum of things we can see based on how long the inflammation's been going on, how severe the disease may be. So you can see things as simple as mild reduced folds. Remember how it was so furry before? So we start to lose some of that architecture. So the next thing we'll see is scalloping, which you can kind of see along this border here very well. And then you can see even nodular mucosa, where you can't even tell at this point that this is small intestinal mucosa, right? You don't see any of that little hairy furriness that we previously had seen in healthy places. So the treatment for that is simple. It's my favorite one, because there's nothing I have to do but say, don't eat gluten. That's it. Just don't eat gluten, which is actually much, much, much, much easier said than done. And so most of the people who truly do have that, there are resources. And like I said, you want to make sure that they have their own set in the refrigerator in terms of where they store their food, cutting boards, things like that, utensils, eating out. Even though it says gluten-free, that doesn't guarantee it's being prepared in a kitchen that is gluten-free. So they may have little hiccups here and there. It takes a lot of planning to actually truly live a gluten-free lifestyle. So the next thing, we're kind of switching shifts here. We're going to talk a little bit about obscure GI bleeding. And so basically what that is is that after looking for obvious, we don't see it initially with an upper or lower endoscopy. But it's either occult, where we don't actually see blood, but they've tested positive in their stool or they're anemic, or it's overt, where we're seeing blood, but we're just not sure really where it's coming from. Approximately 10% of GI bleeding is this. Generally it's in the small bowel, not to bury the lead. So causes. So Crohn's disease is one of them, and that is another autoimmune chronic inflammatory condition and it waxes and wanes. And so unlike ulcerative colitis, which is just in the colon, Crohn's can be anywhere. It does tend to sometimes pop up in the small intestines and can cause, as you can see here, ulcers that can cause a person to be anemic or have bleeding. There can be ulcers just like we've seen in the stomach. Then, of course, there's those same little kind of like weird blood vessel abnormalities, which could be a dullifoid lesion. And this one's like pretty impressive. When you catch them when they're bleeding, it can be really scary to see and impressive, but they sometimes just stop and you don't see anything at all. But like massive hemorrhage can happen from these. Angioctasias, which we see quite a bit in people who are older with chronic conditions, generally with kidney or heart disease, where there's kind of popping these up and they can cause a fair amount of blood. Meckles, which is a congenital condition that we sometimes see that presents oftentimes with bleeding, painless, and it's coming from the small bowel. And then pain can be a part of it too. And then lastly, small bowel tumors. And that's where we talked about the upper endoscopy. We can only reach so far. So that's where using some of those additional modalities like pill camera, things like that, allow us to kind of get a little bit more insight into what could be happening more distally. So how do we evaluate that? And that's kind of leading into this part. I'm going through a series of slides about the ways that we can look at some of this small bowel bleeding. Because once you've kind of done the upper and lower GI, you don't see anything, or you might see blood and you do a colonoscopy coming from the terminal ileum, then you know it's probably more proximal, but maybe somewhere that I can't reach. So we usually repeat the upper and lower endoscopy first. Generally, anything that's in the upper GI tract is reachable with a standard upper GI scope. But occasionally, there's more going on. Then the next step would be that capsule endoscopy. So that's a very cool device where you swallow a camera, and it goes down and clicks thousands of pictures. And then we're able to compress it, take a look at it, and it has like sentinel places where we can look for things and give you a report. So this is actually a video of a capsule. So this is the person right here swallowing the capsule. It's a little bit bigger than your average multivitamin, like it's got some size on it, but it goes down just fine. And we have a timer so we can kind of see where there's an image where we know that it's hit the stomach based on what we can see and based on how the lining looks. We can tell that it's in the small intestines. We can see that it's passing into further portions of the small intestines, and then we can oftentimes signify that we've reached the end by how it's changed in lining perspective in terms of hitting the cecum. So we get that, and then we download it. And so things that we can see on a capsule. So there's obviously active bleeding. And so based on like the length of time between like when we saw those kind of like landmark spots, we can kind of help to localize better where the bleeding may be coming from. We may see a small bowel tumor. We may see these little angioctasias, which these actually, I don't know about my colleagues, I would say, but taking care of patients with advanced heart disease, they get a device that helps to pump things along and it puts them at a very high prevalence for creating these little things. They trickle blood. So sometimes we see them, sometimes we don't, but they're definitely there. If there's one, there's 10. If there's 10, there's 100. And it causes ongoing bleeding, a revolving door of anemia and bleeding that we can never quite catch. So this is usually the culprit somewhere in here. And then occasionally small bowel ulcers, which we see because of IBD occasionally, but sometimes because of insets, they can create ulcers anywhere, not just the stomach. We see in the colon. We see it all kinds of places. So the disadvantages of a capsule. So it only examines the small intestines. Obviously, you can't really do a therapeutic maneuver. You're just kind of seeing what's going on. The reading times can be quite intense. Like we usually try to run it at certain rates that we can see multiple images at once, like maybe on that 46 screens at a time. And then there's the risk of a retention capsule. And I've actually diagnosed a small bowel tumor that way, or one of my partners that I had a guy, we're working him up for anemia. He was supposed to have an upper and lower. He had it in the hospital because he came in. They dropped a pill can. Pill can gets stuck. Got a CT. CT shows a tumor. He goes to surgery to get the camera out, but also it ended up being a therapeutic maneuver as well for the tumor. So that can happen. And we often want to know if someone has a medical history that puts them at risk for retaining it. So abdominal surgeries or strict shrink Crohn's disease, things like that, we would hesitate to give it. There were, at some point, we did have patency capsules where you kind of test and see first. But those have fallen out of favor, at least in our office, just because we don't have them as often. Then, of course, the evaluation of obscure GI bleeding. So you want to repeat the upper and lower. You do the capsule endoscopy. And then we can use some of these devices if we happen to see something on that capsule that helps us get that scope a little bit further down. How do you do that? Well, there's a couple of things. So there's balloon-assisted and tube-assisted enteroscopy. So that just means small bowel scoping, basically. And it can be a single or double balloon. And so basically, what it's doing, because like we said before, the intestines kind of flops around. It's one of the very few things that kind of traverse your entire body. That's several feet that just kind of move around with the peristalsis and things like that. So this device actually helps to kind of pin it in place a little bit and does this thing called more or less like a pleating or push-pull technique, where it's almost like folding, like your curtains have those folds, pulls it towards you by kind of holding it and pulling and holding and pulling. So the endoscope advances through the small intestines by inflating, deflating these balloons at different times. And then it pulls kind of the intestines closer to you. And that allows you to evaluate the entire length of the small intestines if done well and if you're patient. And you're able to see all the way down to where it reaches the colon. And so you can actually do that either anterograde, which is through the mouth, or retrograde, which is through the colon. So basically doing a colonoscopy first and then pulling. Or you're going down into the small intestines and then pushing through. And so here's a couple of schematic images of kind of what that looks like. So you can see the balloon here. And that's your scope coming down through the stomach into the small intestines. And so you kind of watch it progress through. And so you see that's kind of holding its place, that blue balloon. Then you use the green one there. And that kind of gives you another placeholder. And then you kind of advance and keep on moving. So that's space. And you just continue that along the way. And so you're able to traverse more or less the length of that very, very small intestine to a very, very, very long portion of floppy intestines with a single device. The nice thing about that, and so you can kind of see here, this is like a fluoroscopy image where you can see how much scope is in there. But you can still, just like before, introduce tools through the biopsy or through the therapeutic channel and either do things like APC for burning for some of the angiotasias. Or you may even be able to find like a tumor, for example. So another evaluation of obscure GI bleeding. Sometimes we also use radiologic approaches. And so I think that's one of my favorite things about practicing gastroenterology is the opportunity for multidisciplinary care. At any given moment, you can be working with a surgeon or a radiologist to stabilize and provide best practice management for a patient. And when things go right and you're working down like a schematic for bleeding or something, and the patient is satisfied and everyone comes away with a nice, happy ending, it's really awesome. So this is actually a nuclear study right in that unclear medicine box called a tagged red blood cell scan. So that's when we see if there's just enough bleeding to help us identify where we could localize it to. We sometimes use this one, for example, for like the small bowel bleeds that we can't see. Sometimes also used in like diverticular lower colon bleeding sources that are not quite clear and someone has like a colon full of diverticulum. We can't tell which one. The next thing where the patient is slightly more unstable, because this previous one, it just kind of helps you see. It's like a pill camera. You can't necessarily do anything. But with angiography, they can sometimes look with CT scan modalities and occasionally inject or do something to clip a bleeding source. So recently, for example, I had a patient who had a PEG tube that was placed. It was an LVAD, and it had somehow corroded itself back through and was feeding one of those arteries, kind of was tamponizing. So he was bleeding and then not bleeding, bleeding and then not bleeding, and they couldn't quite find the source. But when we sent him to CT, sure enough, he blushed right in that area where that little PEG was kind of doing its thing. It was placed by IR, not by GI, which is a different thing. And so they were able to tamponade and clear that space and embolize the bleed, which was great for the patient. He did well after. So you can kind of see that here. Okay, so treatment obviously depends in terms of bleeding based on the etiology and the severity of bleeding. So sometimes bleeding, like they call us when someone's super duper anemic, but they're not actively bleeding. That gives us time to kind of take our time and maybe prep the patient for both an upper and lower at the same time. They may call us and the patient is like actively vomiting blood, like a variceal hemorrhage, for example, where we have to act right away. And then there's a whole bunch of gray area in between. So depending on what the patient looks like, whether they present in clinic or in the hospital, we'll make decisions about blood transfusions, obviously volume resuscitation, iron supplementation in response, some of that extra testing for like celiac and H. pylori and looking for IBD. And then, you know, at the more severe side of things, radiologic and surgical solutions. So the next piece we're gonna talk about quickly is small bowel obstructions. And so those can be either mechanical where it's overtly obstructed by something anatomic, or it's just a functional obstruction where things just aren't moving well and it seems that way. It's just prevention of normal transient of digestion, and it can be a medical emergency in some cases for sure. So symptoms that patients generally present with are abdominal pain first, then a distention we'll see, and then it progresses oftentimes to nausea and vomiting. And just like with that gastric outlet obstruction kind of profile patient, they look very similar. Occasionally they'll have constipation as well. So there's lots of different causes for a small bowel obstruction. So we talked a little bit about constipation before. Here's an example where adhesive disease kind of plays into that. So adhesions of the small intestines where two pieces are kind of unnaturally being tethered together can keep things from moving through. And that, of course, can cause some issues and certainly for some people cause overt obstruction. The next one is hernias. Most commonly we see them as umbilical hernias right at the belly button. A lot of times they just contain fat. No big deal. We're usually not worried about that. When they start getting bigger, they change color, they become painful, or people have obstructive type symptoms, that's when we're more concerned. So here you can see where there's some intestines that's herniated through the bowel wall sac and now is potentially can get strangulated or caught. That's definitely an emergency. The next one is small bowel tumors. So you can see obviously that can cause an obstruction. So things are moving through and there's an overt blockage that may be malignant or even benign that can be problematic. There's intussusception. And so, you know, with normal peristalsis, things are kind of moving that nice wave-like kind of configuration, but occasionally they can telescope bowel onto itself and almost get caught. And so that can become an emergency of a bowel obstruction type. Then there's strictures, which just like before, like insets usually are one of the main causes, but also IBD, other surgeries, radiation can cause strictures. There's lots of different things and having that good history, I always say that's your very best friend, is getting a good thorough history from the patient allows you to cut out a lot of the extra work in terms of working things up and going after the high yield. And then lastly, there's a besor. So that is not supposed to be there. And it can be made of lots of things, but generally what we see mostly is some type of like consolidated food, especially in patients who have poor motility like gastroparesis, for example, or they, you know, people who eat things that are not edible and they don't digest well and then they pass down further and then get stuck. Those are all things that can happen, do happen, and we've seen them. And so when you're diagnosing an obstruction, the first thing, the easiest thing to do is to get an x-ray because we obviously do not want to see like big dilated, small bowel here, like the black is air. So, you know, that's definitely not something that we're looking for. And then you'll kind of see areas where it's decompressed distally. That means like nothing's passing through. So that's a concern. And air fluid levels are also a sign that things aren't moving. The next thing would be like a CT scan. So that will ask our radiologist to look for like transition points, for example. And so that helps us to identify the etiology, like maybe something's pressing or, you know, there's a new tumor or what have you. And then the management, of course, is about the same as a gastric outlet obstruction. So we want to make sure that the patient is not getting dehydrated, conducting their electrolytes and decompressing them. Because like we said before, whether you're eating or drinking, you're still making that bile and all those things that are meant for digestion. So those have to come out because we don't want them to aspirate those or get them into their lungs. And then, of course, there's a surgical technique. If there's something that they find overtly that needs to be removed, they just kind of remove that, you know, path and mouth piece and they put it back together. And that's called a small bowel enterotomy, so piece to piece small bowel. The last one, I think, is mesenteric ischemia. And that we basically see inflammation of the small intestines due to inadequate blood supply. And so here's just your general kind of like blood vessel layout for your intestines is generally driven from your aorta, which is the big one right here. And you've got your SMA and IMA that all kind of feeds your intestines and celiac artery comes off and feeds your stomach. So that's what we're looking for, especially with those angiography type things. So they can be either acute or chronic. Acute is obviously more of an emergency. And so that can be from like a blood clot. People usually present in shock and have horrible abdominal pain. The physical exam, they're usually way, way, way tender more than you expect them to be based on what you're kind of seeing. Then chronic are people who generally have like bad heart disease and have plaque that just kind of depositing places. So they usually have like peripheral vascular disease or they were like previous smokers or something like that. And so just that mismatch of a supply demand, like when they eat and they need all that blood and everything to kind of feed those intestines, they don't have enough to carry around because they've diseased their vessels. They'll have a lot of postpandial abdominal pain. That's almost classic weight loss or even a fear of eating because they know it's going to be painful. It's like work. Their intestines are not built to do that lifting at that point. And so a blockage of SMA by blood clot, you can see here ends up with like dusky or ischemic appearing bowel beyond the lesion. And so that's obviously a medical emergency. There's like blood work and CTs and vitals and things that help us along in our surgeons certainly help us manage that. And so that's where you can kind of see here where this is obviously diseased intestines versus healthy where there was likely a clot. And then there's chronic mesenteric ischemia here where you just have some angiography. We're kind of just looking to see, you know, all of these little offshoots and things. Abdominal pain is up, as I said before, due to poor blood supply. And then imaging, as you can see, there's angiography, there's CT. If you're worried about contrast, there's MRI, which has a similar thing as angiography from a CT perspective. And Doppler ultrasounds, which I actually like quite a bit in the elderly population, especially in the hospital, because it doesn't hurt and it doesn't bother them. And so the treatment, as you can see, would be angiography to help open those vessels back up versus surgical. And that is it. Questions for me? Oh, yes. I think you call it the b-zor as far as like the popcorn, things like that. You think of like a diverticulitis or... So that's in the colon. Popcorn's pretty small. Usually, like things that we see, it'll be like food. Generally, a lot of the meats, for example, that don't break down very well, then they have other things build up on top of them. Pills can do it. So if you're not digesting medications well, they'll just sit there in the stomach and create a b-zor. And then like, you know, we've had people who eat things like, you know, paper towel holders and tissue paper and things like that that just kind of turn into concrete and sit. Yeah, you can think of it almost like if you had to build like a dam. One more question. So thank you all so much for doing this. When you have to go back in and learn some of these new techniques, I have to ask, do you go back to the lab, the pig lab, or are we all your guinea pigs? Right. Now, there's usually a very nice symposium that allow us to practice on that. Okay. Yeah, that's a great question. No, yeah. Dr. Callaway hit it on. This building here does a lot of that education when new products come out and stuff like that. We do refresher courses for stuff. We also do advanced courses. So a lot of it is sort of retaught with either different curriculums or programs. Sometimes it's hybrid. So like people are sitting here, they're sitting there, they're sitting there, they're Sometimes it's hybrid. So like people are sitting here, sometimes they're at home doing virtual and come in for a skills assessment. Oh, yeah. You would not be. Good question. Was there one more? I thought I saw a hand. Am I totally making it up? By the way, that's so scary to have a bleed with a peg tube like that. I would have just. Yeah, are you sure? I'm like, I'll come in and write the note. It'll get radiology to come in. And they did. My gosh. Then there was one other question that came up in the break that I had that I thought was a really good one. For those of you who are not of age, 45 or older, and for those of you who haven't had a colonoscopy yet, the question is, and this is a good one. Do you use x-rays? We showed x-rays with ERCP and stuff. Do you use x-rays with colonoscopy? And the answer for that is no. It's just video camera work. The only time somebody after a colonoscopy would need an x-ray is if something sort of went wrong. They woke up in pain afterwards or they had a distended abdomen. And in that case, we would get an x-ray to make sure that they don't have a hole or a perforation. So that was a great question. Thanks for asking it, whoever that was.

small intestines

celiac sprue

obscure GI bleeding

small bowel obstruction

mesenteric ischemia

gluten-free diet