All right, moving on to your favorite topic. I'm sure you've seen patients by now, even as a resident as well with upper GI bleeding. And so Dr. Shyam Thakkar is going to talk to us about that. Something that you're going to deal with as a gastroenterologist, no matter what kind of gastroenterologist, subspecialized, not subspecialized, this is what we do all the time. Thank you. Thank you. Thank you, Mayor, for that kind introduction. And thank you to you and Catherine for the opportunity to share the passion that we all have for upper GI bleeding at this fantastic first year fellows course. It's been great interacting with all of you and looking forward to sharing with you a little bit on upper GI bleeding. So in terms of my disclosures, I'm a consultant for Boston Scientific, Medtronic, Steris. We have a very parallel life to Neil Sherma, if you haven't guessed already. So the ASGE has put out clinical guidelines, ACGS as well, on upper GI bleeding and ulcer bleeding. And I encourage you all to review these guidelines. You'll find these very helpful as you continue to encounter patients with upper GI bleed. And so the way we're going to kind of walk through this is review the initial management of patients with upper GI bleed. We'll also look at how to manage medications in patients who present with upper GI bleed. We want to talk about the role of endoscopy, of course, and specifically illustrate specific hemostatic techniques in the management of upper GI bleeds. So to start with, upper GI bleeding is really defined as any bleeding source that's proximal to the ligament of trites. It's a significant medical problem. Over 250,000 hospital admissions occur per year from upper GI bleeding. There's 50% additional episodes of GI bleeding during hospitalizations for other reasons, such as a hip fracture, as an example. It has a fairly decent mortality rate associated of 2% to 10%. And it's three to four times higher if the reason for admission was not upper GI bleeding to begin with. 80% of upper GI bleeds do stop spontaneously, and endoscopic therapy is the mainstay of treatment. Mortality is increased if re-bleeding occurs. And so we'll start with a case, 86-year-old female, who presents seven days following a hip fracture. She has an episode of melana at 10 PM while she's been in the hospital for the past week. She feels lightheaded, but no syncope. Her blood pressure is 100 over 60, heart rate is 80, abdomen is soft, melana is found in the rectal vault. Her maticrit is 28%, and it was 33% the day before. EGD in the endoscopy unit is planned for the following morning. And so at the time of endoscopy, here's what's seen. There is an active GI bleed going from the stomach, it appears. So the initial assessment, she has a history of dysphagia, abdominal pain, vomiting, weight loss, altered stool color, abdominal aortic aneurysm, history of ulcer and liver disease, as well as varices. Her medications include anti-thrombotics, aspirin, SSRIs, and she has a social history of sniffing for alcohol. So when it comes to patients who present with upper GI bleeding, we often find certain signs. Hematemesis and melanoma are our most common findings. Both are present in about 50% of patients with upper GI bleeding. And then hematokesia can occur when patients have a brisk upper GI bleed, that is bright red blood per rectum. And so the volumes of blood that are required to generate these kinds of signs, about 50 to 100 cc's of blood is required for a patient to develop melanoma. A liter of blood developed hematokesia. And etiologies for the findings of upper GI bleeds include peptic ulcer disease as the most common, esophageal varices, AVMs, Malory-Weiss tear, tumor bleeding, and dulafoil lesions. And so starting with medications, let's talk about warfarin reversal. The goal when we're doing upper GI bleed management is to, of course, optimize our medications prior to the procedure as one part, and to control the bleeding, of course. Our target INR for anyone that's on warfarin is less than two and a half. The American College of Physicians suggests using Kcentra or vitamin K to help achieve that. The American Heart Association and American College of Cardiology suggest for valvular heart disease using four-factor PCC, so Kcentra, or FFP. They do not recommend vitamin K in those instances for those with valvular heart disease. And so I think it's very important that any time you encounter someone with an upper GI bleed that's on antithrombotic agents, that it's very important to communicate well with the primary service to determine what needs to be done to manage this anticoagulation. You know, whether it's okay to give FFP, or the Kcentra, or vitamin K, and, you know, that cardiologist needs to be involved in that conversation, or the primary service, whoever's really managing those anticoagulants. Also part of that initial management is risk stratifying our patients, okay? We want to stratify into a higher or lower risk for bleeding, and that helps us determine the timing of our endoscopy. There's several stratification scoring systems that are out there. The most common is the Glasgow Blatchford score, and it's best used in terms of helping us understand who's in need for an intervention, what their risk of death is from the upper GI bleed. The higher the score, obviously, the more at risk they are. And it's calculated, it goes up from anywhere from 0 to 23, but it is calculated based on the BUN, the hemoglobin, the systolic blood pressure, other markers such as the heart rate, findings of melanoma, syncope, cardiac or liver dysfunction. All these things are very helpful in terms of determining the GBS score, and that in turn helps us determine the risk that that patient has. What about other medications? So acid suppression is a big deal when it comes to managing an upper GI bleed, okay? And one of the things we do is we start these patients on PPI immediately, and this can be an IV bolus followed by an infusion, an intermittent IV bolus, or oral PPI. One of the things that PPIs can do is in patients with high-risk GI bleeding can reduce the findings of high-risk lesions at endoscopy. However, it does not decrease our risk of re-bleeding, mortality, or need for surgery. So that's just something to keep in mind that medical therapy alone for high-risk lesions isn't enough. Acid suppression after the treatment of peptic ulcer disease, post-EGD, for high-risk lesions that we have, we generally like to treat these individuals with at least 72 hours of high-dose therapy followed by oral twice-daily therapy for another two weeks and then daily. For low-risk lesions, we can probably get away with once-daily dosing of PPI, okay? And the reason why this is important is the high-risk lesions that we treat for 72 hours with an IV bolus twice-daily decreases re-bleeding and need for surgery. It's superior to H2 receptor antagonists, and it can also be done either through a continuous infusion or through oral dosing as well. Now, importantly, continuous versus intermittent PPI dosing has been looked at following the treatment of peptic ulcer disease post-endoscopy. And this was a meta-analysis done by Sacher and colleagues, and essentially, the reason why they looked at this study was in patients that were undergoing continuous infusion of PPI, you know, it's a little bit cumbersome. It's a higher dose of PPI that the patients are getting, and it's more costly. And does it have any benefit as compared to intermittent dosing, a high dosing of PPI? And what they were able to demonstrate was that actually the intermittent dosing was more favorable in terms of this meta-analysis when it came to patients that were treated for peptic ulcer disease bleeding with intermittent PPIs following the upper endoscopy. And so as such, it's very reasonable to do just 40 milligrams IV twice a day for the 72 hours, OK? What about the timing of endoscopy? So early endoscopy within 24 hours of presentation is recommended for most patients with acute upper GI bleed. Now in patients with acute upper GI bleeding who were at high risk for further bleeding Now in patients who were with acute upper GI bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after GI consultation was not associated with lower 30-day mortality than endoscopy performed 6 to 24 hours after consultation. So the bottom line is that we want to appropriately resuscitate these patients, stabilize these patients, and then perform our endoscopy, you know? We don't really want to delay, but getting to them in the first hour after consultation may not necessarily be of a significant advantage and may be detrimental if they're not appropriately resuscitated. That's the key, resuscitate, stabilize, scope, OK? What about urgent endoscopy like within 12 hours? So again, always after hemodynamic resuscitation and stabilization, and variceal bleeding is a good example of this, studies don't show decreased re-bleeding need for surgery or mortality with EGD less than 12 hours. So again, that concept again still holds that we want to appropriately resuscitate, stabilize that patient, and then when it's safe, we move forward with that endoscopy, ideally as early as possible. But it's not that if we don't get to them in the first 6 or 12 hours that we're increasing their mortality, OK? What about prophylactic endotracheal intubation? So this requires good communication with the critical care service that's involved, as well as the anesthesiology team that might be involved, OK? In patients who have massive hematemesis, altered mental status, you're concerned about their airway, it's a good idea to do prophylactic endotracheal tube intubation. I think you have to have an open conversation with those critical care docs about what you expect, what you think is going to happen, how they've presented, and then determine what makes the most sense for the patient. Some things to keep in mind is that any time we do endotracheal intubation, there's an increased risk for aspiration pneumonia, and there's an increase, may increase our cardiac adverse events. Patients may develop shock as an example. So just some things to keep in mind as well, because it is a little more stressful on the patient. But nonetheless, we want to weigh out those pros and cons when we're thinking about it. What about tips for visualization? So now we've talked a little bit about medications. We've talked a little bit about prepping and risk gratifying. One other medication to keep in mind is the motility agents, erythromycin or Reglan, OK? These medications can help evacuate a lot of the clot buildup that's occurred in the upper GI tract. So by giving that medication intravenously, we're promoting motility through the upper GI tract. So when trying to evacuate it, it can help us tremendously at the time of scope. Other things that can help us to evacuate that clot is to use a therapeutic large channel scope, power irrigation. External suction devices can also be very helpful as well. And then finally, changing the patient position. If you have a big clot sitting in the fundus of the stomach, you can turn that patient and then move that clot, and I'll show you some images of that. Here's just an example of a therapeutic scope. On the left-hand image, you see more of a clot buster-type scope. You can see how large that working channel is to allow us to evacuate and irrigate that area. And then at the same time, on the right-hand side, you can see a twin-channel scope where you have two channels for suctioning and things like that. So that can allow us better evacuation as well. And so here you can just see an example, a patient who's lying in the left lateral position, and you have this large clot built up in this area. And so when we turn the patient onto their back, suddenly that clot moves, and now we can expose that area of the cardiac fundus that we could then potentially see if anything needs to be treated. And so these are some examples of how you can use factors to help optimize our opportunities for visualization. So what about endoscopic stigmata and the risk of re-bleeding? So the force classification is what we use to help us determine the type of lesion. And it tells us the stigmata, essentially, that's present. We classify it as a force 1A, 1B, 2A, 2B, 2C, or a 3. And accordingly, these correspond to the type of stigmata that's present, whether there's active bleeding, non-bleeding visible vessel, adherent clot, pigmented spot, or a clean base. Now, each of these types of lesions has a different risk of re-bleeding, anywhere from 55% to 5%. And the mortality is appropriately associated with those findings, much higher for an active bleeding vessel as compared to a clean-based ulcer. And so here you can see a force type 1A lesion spurting actively bleeding vessel there. Here you can see the 1B type, where, again, we have active bleeding, but it's from a more of an oozing type. The next is the force type 2A visible vessel, which still also has a significant risk of re-bleeding. It's a vessel that we can see there, but there's no active bleeding at the time. And then here you can see the force type 2B adherent clot. And that adherent clot, there's, again, no active bleeding at the time, but there is a high risk of re-bleeding from these lesions as well. And then the pigmented spot. So this is more of a flat pigmented spot. The risk of re-bleeding is lower here, about 10%, and the mortality is lower as well. So these would not warrant, essentially, an endoscopic intervention. And then finally, the clean-based ulcer. So here we have our first question of the day. Which type of lesion has the strongest recommendation to be treated with endoscopic therapy? And also with a flat pigmented spot, and also with an adherent clot, and also with a non-bleeding visible vessel, or a clean-based ulcer? Go ahead and make your vote, please. So the response is, so good, looks like most everyone got that right, also with a non-bleeding visible vessel. So the type of lesion with the strongest recommendation to be treated in this example is also with a non-bleeding visible vessel. The endoscopic features, active bleeding or visible vessel, have the highest risk of re-bleeding and we promote endoscopic therapy in these instances. We also want to do high-dose medical therapy as well with high-dose PPI therapy. Adherent clot, it's controversial as to whether we should remove the clot at the time of endoscopy. However, if you do choose to do so, we do it with a cold guillotine snare to assess what's going on at the ulcer base and then potentially treat any lesion that is present there. Also, these we would treat with high-dose medical therapy. You don't necessarily have to remove it, but if you choose to remove it, then you should obviously be doing so to look and treat any visible lesion that you think is appropriate to treat. Flat pigmented spot, this is one where that risk of re-bleeding is a little bit less and standard PPI therapy is considered enough. These don't necessarily require any endoscopic therapy. And then a clean base ulcer, of course, also does not require endoscopic therapy. And this is best treated with just standard PPI therapy as well. So as I was saying, the adherent clot, this is a little bit more controversial. I always remove the clots any time I encounter a patient with upper GI bleed. I want to know what's underneath it and if there's something there that I can actively intervene on, such as this, an oozing vessel, then that's what I would do. And so the data, though, on this has had conflicting results regarding re-bleeding between medical therapy alone and medical and endoscopic therapy. No difference in need for surgery, mortality, transfusion, or length of stay. So just something to keep in mind when it comes to these. But if you're going to do it, do it with a cold guillotine snare. Remove the clot. Wash it. See what you got. And then go from there. What about aspirin? So this was a randomized controlled trial of aspirin versus placebo after peptic ulcer disease bleed. So in patients who underwent treatment for peptic ulcer disease, what they found was that in patients who resumed aspirin versus a placebo medication, they had a higher risk of 30-day bleeding, about 10.3% versus 5.9%, something like that. However, mortality, all-cause mortality, was significantly higher in the patients that received placebo. And so as such, as compared to those that were on aspirin, primarily from cardiovascular events. So as such, it's really recommended that if someone's on aspirin therapy, that we want to start it back up. If it's been held for the procedure, we want to start it within one to seven days after the bleeding stops for secondary prevention of any other cardiovascular-related pathology. What about warfarin? So resuming warfarin after GI bleeding, this was a study that essentially was published in Archives of Internal Medicine. What they showed was that 90-day recurrent GI bleeding, there was a trend towards increased risk of bleeding in those that resumed warfarin. However, those that didn't resume warfarin, there was a significant 90-day risk of thrombosis. And so as such, when anticoagulation has been reversed for an upper GI bleed, this is something that we want to restart within four to seven days after the therapeutic endoscopy. If it's a low-risk lesion, then we can resume it the same day. There are guidelines, again, also published on this as well in the Management of Anticoagulants and Antiplatelet-type Medications. This is just clinical guidelines from the ACG and Canadian Association of Gastroenterology clinical practice guidelines on the management of anticoagulants and antiplatelets for acute upper GI bleeding during the peri-endoscopic period. Again, nice article for you guys to look at and guidelines for you to look at and make sure you're familiar with, given all the different types of anticoagulants and antiplatelets that are out there as well. What about suspected variceal bleeding? So octreotide is something that we give for these patients in the peri-endoscopic period as well, 50-microgram bolus and 50 micrograms per hour. And we continue it for 72 hours in the setting of variceal hemorrhage. IV antibiotics have also been shown to reduce the risk of infection when it comes to patients with variceal bleeding, re-bleeding, and mortality as well. And so here's just another case for you. A 42-year-old female executive has 48 hours of dizziness and dark, tarry stools. She's taking Advil for her tennis elbow, and you suspect an NSAID ulcer. You send her to the ED and decide to perform an endoscopy that evening. There is no blood in the stomach, and a gastric ulcer is identified. And what do you see? So raise your hand if you see a clean-based ulcer. Raise your hand if you see a flat pigmented spot. Raise your hand if you see a visible vessel. And raise your hand if you see active bleeding. Okay, good. You guys didn't raise your hands very high. So remember, what we have there is what appeared to be a non-bleeding visible vessel, pigmented protuberance. You can also sometimes refer to it as, but it's essentially a non-bleeding visible vessel. And so when we look back at our endoscopic stigmata and re-bleeding risk, this is what we want to be thinking about, the type of lesion we're seeing, as to determine whether we should intervene endoscopically. And so if we see an active bleeding, obviously that risk, again, of re-bleeding is quite high. Mortality exists. Non-bleeding visible vessel, he has a 43% risk of re-bleeding and 11% mortality as well. Adherent clot, again, that has a 22% risk of re-bleeding. And then the pigmented spots and clean-based ulcers are, again, are lower risk of re-bleeding or mortality associated. And so when we look at this lesion again, this was not treated initially endoscopically. And three days later, this is what developed. So we certainly want to, whenever we find a lesion like this, this is someone that we would strongly think about intervening at the time and want to intervene on, unless there was really something that was precluding us with respect to INR and things like that. So which of the following would not be an appropriate endoscopic treatment for this ulceration? Injection of epinephrine and placement of hemoclips, injection of epinephrine and use of bipolar probe, injection of epinephrine alone, use of an over-the-scope clip, or use of a bipolar probe alone? OK, everyone voted, good. So what do we get? OK, great. So injection of epinephrine alone, that is correct. So injection of epinephrine alone is not an appropriate endoscopic therapy for this ulceration, OK? Epi alone, monotherapy is not considered adequate for the management of an upper GI bleeding lesion, OK? It's always best used in combination, either with thermal therapy, the bipolar probe, or with mechanical therapy as well. It can be used, the hemoclips. But monotherapy in and of itself, it's not enough. You saw some examples earlier from Dr. Sherma about using the BICAP as an example. But again, we don't want to use epinephrine alone as only therapy because it's a very temporary type treatment. And really, what we primarily use it for is to create some type of tamponade and some vasoconstriction so that we can then perform our thermal therapy or mechanical therapy in a more stable type fashion. So there you can see, we typically inject in four quadrants, 1 cc in each quadrant of 1 in 10,000 epinephrine. So it's diluted to 1 in 10,000, OK? It's a four-quadrant injection around the lesion, followed by the thermal therapy that you would apply at the lesion itself. Again, monotherapy not sufficient when it comes to epi. Coagulation probes, so we have heater probes, bipolar probes, bipolar in combination with injection and coagulation forceps. You'll see some of this over in the hands-on lab. Here, you can see the gold probe. The way I apply this, we apply heat, energy. As we do it, I do it for a good 10 seconds. I pause for a little bit, and then I gently pull the probe off while applying heat as well to try not to pull off that eschar and then wash that area as well, OK? Again, this in combination with epi works very well for treating bleeding lesions. And one thing to keep in mind, these come in different sizes, 7 French, 10 French, depending on the type of scope you're using. You know, you have a therapeutic scope, you can certainly use your 10 French gold probe as an example. But if you have a diagnostic endoscope, you're not going to be able to fit that 10 French probe through it. So things you want to keep in mind when you're looking at a lesion, how you're intervening on the lesion, what type of lesion you have, and what type of device or accessory you're going to use to treat it, OK? All things to be thinking about. Argon plasma, we saw a little example. We saw an example of this treatment process already from Dr. Sherma. But essentially, this is more of a superficial type treatment, and it's an arc that's being created to treat, in this case, more superficial type lesions, such as arteriovenous malformations. It can also be used to treat GAVE, as you can see in the upper left-hand image there. And in the bottom left-hand image, you see the effect that's been given. But here, steadily, just that APC is being applied. One thing to note about APC is that argon gas expands very rapidly. And so you just want to keep that in the back of your mind. As you're applying APC or doing the painting of the area, the stomach may get more and more distended, as an example in this case. And so you want to be cognizant about decompressing so you don't develop any respiratory compromise or all of a sudden vomit in the middle of the procedure that they aspirate. So keeping an eye on and suctioning through the procedure is important as well. Hemoclips. So this is mechanical therapy. Here, you can see a bleeding lesion in the esophagus. You guys are going to get some exposure to this on the hands-on as well. But in essence, what we're doing is trying to place a mechanical treatment to tamponade and stop that bleeding. And so in this case, one of the nice things about when you deploy a hemoclip is that if you have it open and then you close it on the lesion, that's actively bleeding. If all of a sudden you see that the bleeding has stopped or significantly slowed, you know you're in a good spot, and it's a good spot to deploy. If it hasn't slowed or stopped, then in that scenario, you could still deploy the clip. However, it may not do much for you for that lesion, and it might just be in your way. So just some things to keep in mind if you want to reposition, if you're not getting a good tamponade effect at the time of the attempt to use the clip. So again, combination therapy, you want to inject first with the dilute epinephrine. And hemoclips and thermotherapy, equally effective. And combining injection with thermotherapy or hemoclips is definitely the way to go if you're going to use the epinephrine. Combination therapy is safe and effective. Other therapies that are available, we're not going to get into this too much in this course, but you'll see this as your fellowship unfolds. The over-the-scope clip, chemo sprays, and Doppler probe guided therapies. The Doppler have really kind of gone a little bit out of the wayside, but it's a nice technology. In essence, you're putting an ultrasound Doppler probe to the lesion and seeing if there's flow to that. If there is, then you'd know that that's a good target lesion to treat. If not, then you can safely probably leave it alone. But more commonly used now as more advanced hemostasis techniques are the chemo sprays and the over-the-scope clips as well. Finally, a little bit about variceal bleeding. This is treated a little bit differently. You'll see this in the hands-on course. We use rubber bands to essentially ligate these varices. And in some other parts of the world, they actually use endo loops as well. But this involves a cap on the tip of the scope. And in essence, we're suctioning that varice right into the cap and deploying a rubber band on it in order to ligate that varice. And it's the same concept if you were using a loop. You would just suction it in and loop close on it. No one really does that much in this country, but I've seen it done in other parts of the world. What about the repeat endoscopy for re-bleeding? So whenever we get initial control, our chances of success for permanent control is pretty good, 80% to 90%. If the patient does re-bleed, our percent of endoscopic success for permanent hemostasis does go down to about 50% to 75%. If the patient re-bleeds again, it's probably time to start thinking about, do we really want to take this patient for another endoscopic procedure? Because our chances of success are reduced to achieve permanent hemostasis. And that might be someone to consider for a IR procedure or surgery. And so in conclusion, initial assessment concurrently with resuscitation is critically important. Anytime you're approaching a patient with upper GI bleed, you want to risk stratify them for their triage for the endoscopic procedure. Management of medications, management of the antithrombotics, the use of PPIs, the use of motility agents will all be beneficial to you. And you want to optimize your endoscopic visualization, again, either with those motility agents or with patient positioning and with removal of clot using larger caliber scopes. And then apply effective and durable endoscopic therapy. And so with that, thank you guys for your time, and you're welcome to rate the talk as well. Thank you. I'm happy to take any questions. I noticed that the ACG guidelines did not recommend for or against starting PPI prior to endoscopy. I know that's generally been practice patterns. But if it reduces risk of finding high-risk lesions, is that something that we want to still routinely do? We do, and I think it's important in the sense that a lot of things can come up in that peri-operative, peri-endoscopic period. And the last thing you want is things to get delayed and a potential opportunity for that patient to not be receiving their PPI in a timely fashion. So I tend to favor just giving it to them. If it reduces my high-risk lesion, great. It's still, I think, early enough that if I find it went from a bleeding lesion to just a visible vessel, it's still helpful to intervene on. Can you clarify when we should be giving the erythromycin or the promotility agents to clear the stomach? I don't know if I was doing it wrong, but as an internist resident, I was not giving that routinely for upper GI bleed. So I think that as an internist or a hospitalist, that should be left to when the GI is recommending for a scope. So once you've made the decision to scope this upper GI bleed, then I think giving it as early as possible is very beneficial because it can help evacuate that clot. But if you're, as an internist, you see the patient, you think they have an upper GI bleed, you will give them the Reglan. And then, of course, the GI fellow comes in and says, no, this patient doesn't need scope for another seven days, then that's a good joke, of course, but then you're just giving them the medication unnecessarily. You know what I mean? So I think it really, once, but as the fellow, once you've come in and made that decision, then giving the Reglan or erythromycin as early as possible is beneficial because you want to maximize the opportunity to move that clot out of the upper GI tract. Yeah. Good. Other questions? Hi. Is there a preference for you to use erythromycin versus Reglan? Yeah, there isn't really any data suggesting one beneficial over the other. As long as you can get the erythromycin mixed up from the pharmacy and up to infuse pretty quickly, then that's fine. If there's going to be a delay with it, then using the Reglan is probably more readily available. Yeah. Of course, it has some of those warnings associated with it, but just to keep in mind, yeah. Yeah. So I'm going to repeat your question because there was some interference there, but I believe your question was, if you have a patient with gastroparesis or is on GLP-1 receptor antagonist and presents with upper GI, do you just give one dose or do you continue to give dosing? We don't really have good data on that for patients with, that are on GLP-1 receptor antagonist if they need to be on continuous motility agents. One thing we would do, of course, is stop that medication during this entire hospitalization period. The need to intervene more urgently is probably going to require that we give them whatever dose we can give them, and then we get started on our procedure, though if it's going to be a day or two before we end up doing the procedure, then I would probably consider having a discussion with your attendings about whether we should continue them just on a motility agent or not in that setting. There are no guidelines on that for patients with gastroparesis, but I think we're talking about more of the urgent upper GI bleed, so generally speaking, we will get to these within the first 24 hours. The other thing I think to keep in mind is that, you know, for these types of patients, they're probably ones that you would want to consider endotracheal intubation on, because of the risk of aspiration, of course, if they have a lot of, if they have potential stomach contents. And, again, blood is a pretty good cathartic as well, so things would move, but, yeah. Go ahead. Other questions that you guys might have? Yeah. How often are you kind of on the fence about whether what you're seeing is a visible, non-bleeding visible vessel versus a pigmented spot? And if you're in that position, do you normally treat them as a higher risk lesion to kind of avoid any future re-bleeding episodes? Yeah, so good question. So the question is, how often are you on the fence? As you look at more and more of these lesions, it'll become more and more clear to you. You know, if it's flat and just pigmented, you're pretty convinced that it's not, okay? If it's obviously protuberant, then that's a vessel, you know? And sometimes if you're on the fence, you might, you know, have your probe with you and you just might touch a little bit and you see it starts oozing all of a sudden, that's kind of, you know, gives you a sense as to what's going on and you'd probably want to treat that, okay? So I think, you know, as you continue to look at these lesions, it'll become more and more obvious to you, but generally if it's protuberant in a fashion, then that's essentially a vessel. The other thing that can help kind of tell you, too, sometimes some of these vessels can actually be a little bit pulsatile, so, you know, and you can see that. And so that will clue you into yourself that say, hey, this really needs to be treated, you know? Good. Good question. Any other questions? Awesome. Thank you guys for your time.

upper GI bleeding

endoscopy

hemostatic techniques

risk stratification

antithrombotic medications

variceal bleeding

gastroenterology