So this is a 55 year old woman, she came from an outside hospital where she'd been admitted for a while, history of hypertension, obesity, gastric bypass, alcohol abuse, reported ankle injury, taking a ton of ibuprofen, outside hospital EGD showed LA grade deesophagitis. I too would have assumed that there's going to be a marginal ulcer, so I would do a gastroscopy like they did. There was nothing there. Transferred to us because ongoing bleeding, melanoma, requiring several dozen blood transfusions. So ongoing extravasation. We did an endoscopy, they actually did three single balloon enteroscopies. Again, just keep in your mind that picture of the single balloon enteroscope with the big red X through it. Don't do that. She was transferred to our MICU, this was actually her third double balloon enteroscopy to try and get to the remnant stomach. They weren't able to find it, weren't able to get their way there, but they did see that there's blood, old blood and fresh blood throughout the small intestine. Ongoing more than 10 units of blood transfusion every day. I'm a blood donor, so it kind of kills me to know that all my blood is being used for something like this, but I guess that's why we do it. So she's getting her blood transfusion. I took over bleed team, so we have a bleed team service where for a week we're on for 24-7 for a week and you do nothing but emergency endoscopy. Chris Gostow invented this service. He was one of the founding guys who invented the overstitch device. So here we're going to, so again, you don't always have the expertise for EUS. That's why this patient underwent multiple single balloon scopes, but I said we need to get to the remnant stomach. It's very clear on bleeding studies that the blood is coming from the remnant or soon thereafter. So we go ahead and place our gait stent. I go ahead and dilate that tract every time. So here we're doing our dilation between the two. You could actually see blood in the stomach, and you saw that my stent hung up on a big blood clot and I was kind of trying to shake it off when we deployed the stent. Here because look, she's bleeding. If there was any time to go through your stent and do something, I'm actually going to use what I know is full thickness suturing. I do a lot of TORI for weight regain after a gastric bypass, so I'm going to use what I know is full thickness tissue at the gastrojejunostomy to take a really nice full thickness bite here. So I'm going to get a, this is not just a mucosal bite like we might do for esophageal stent fixation. This is going to be a really strong suture here through the gastrojejunostomy. Like Amy was saying, really important that you don't suture far away from the stent. That's a really great point. If you suture far away and then cinch, you're going to actually pull back tension on your stent, which when you're inserting your scope may be helpful as you're pulling out your scope. You have to remember also your scope's going to hang up on the stent as you pull back potentially. That may actually be some, you may have several vectors backwards that pull this stent back out. So here we went mucosa to stent to mucosa. I worry that if you suture through a stent first, one of those T-tags could wobble and actually come through the interstices of a stent. Probably won't happen with an Axios because the weave is so tight. But again, here we went mucosa, stent, mucosa. We're going back. We suture, we cinch that suture. I always do a contralateral side suture as well. So we had two sutures placed. Here we're going into the stomach. We wasted a bunch of time because there's all this blood in the body of the stomach looking for a source, looking, looking. And then eventually we made our way down to the second portion of the duodenum where we found potentially something a bit more active. Again, that slide actually was to remind me to tell you that I'm just watching fluoro constantly when I advance through the Axios. So I'm just keeping a really close eye. And here you can see there's a nice duodenal ulcer. Unfortunately, right, this is our worst spot. It's right at the sweep on the right lateral wall of the duodenum as we're making this sweep from the first to second portion. You can see here, I love a clear plastic cap. It's our friend for so many different uses. But here I'm able to pinch off the artery that's bleeding in the ulcer when I put pressure on it with the cap. And then as soon as I back off a little bit, it starts bleeding. Now here's, here's a conundrum and I, we face supply chain issues. I'm sure everyone else is too. I didn't have a 20 millimeter Axios, so I'd placed a 15. Even with the 20, I would be extremely cautious about, about going through it with a 12.6 over the scope clip. Yes, it's on your 12 millimeter scope or your 10 millimeter therapeutic scope, but the outer diameter of that little hook piece that the, that the clip is lodged against is, is quite wide. So it's more like 14 millimeters. So that I think you're very likely to dislodge the stent. So I had a 15 millimeter Axios, even with over dilation, I was a little nervous about pushing through an Ovesco, which is clearly what I would use in this situation with native anatomy. So I'm trying left and right. I like the seven French gold probe because it allows me to suction beside it. Some of my colleagues will say bigger is better, but I personally really liked the, the seven French gold probe and you can just stand there and cook these vessels. And I'm, I'm amazed often with a lot of persistence, you'll achieve hemostasis. Unfortunately, this one, as she expressed through her care, you know, I think she had amassed like 40 or 50 units of blood and I had to go to my least favorite device, which is the, which is hemo spray. I find it a cop-out for bleeding, but I have to admit when it's bleeding, especially ulcer related bleeding, where you expect that you just need to buy some time for the ulcer to heal it works really nicely. So this, this is, it was the perfect case for hemo spray. Alternatively now available soon to come for everyone from Olympus will be another kind of head of starch type material. So this doesn't have to be you know, one company to consider, but great, great, great device that worked well for this patient. So we left the edge stent in place. This is not someone where you would pull the stent or close anything, certainly acutely. We'd let that track stay. She had an endoscopy the next day because she had stopped bleeding. So it was her first day without a blood transfusion. She did really well, stayed for two more days in the hospital. She was discharged home with her edge stent in place. And then she came back a month later when she had had no further bleeding episodes. We did a quick endoscopy to pull out the stent and actually did closure as well, which we already showed today. So that's, that's that case. There's a question online. Why not Coag Grasper? Yeah. Coag Grasper is great. That would have absolutely been an alternative here, particularly I don't know if you could tell the bleeding was kind of at the right upper side of the screen. And in this position at the sweep, it's impossible to, I think it's impossible to rotate your scope around so that your working channel is up at that kind of two o'clock position. So I love the Coag Grasper. I use it a lot on bleed team, but I felt that I wasn't going to get it where I needed it to go. I mean, sometimes if the vessel is pretty big, then it can be a problem with the Coag Grasper because you want to get the whole entire width of the blood vessel in, into the force. You don't just want to grab one wall and then it shears off and the bleeding gets worse. Great point. Yeah. That's another underutilized tool in bleeding. The Coag Grasper is wonderful, but you really do need to see the vessel. All right. One question. Would it be an alternative to go ahead and have a surgeon do lab? Absolutely. Yeah. So this is something, right. This is a point where she had had dozens and dozens, yeah, dozens of blood transfusions. So there's a big cost to that too, right? Yes, absolutely. This is someone where I think at some point she would have gone for either probably X lap and maybe a, maybe a gastrectomy. All right. Well, for the sake of time, we're going to move on, but that was awesome. Thank you.

hypertension

gastric bypass

bleeding

gait stent

hemostasis