Before I get started, I just want to congratulate all of you. I remember being in your shoes, and it's a very exciting time, and we all want to welcome you into sort of the community of GIs that we have. It's a really special community, and we're glad that you guys are all a part of it. Upper GI bleeding is one of my favorite topics. Very exciting cases. It might be a little bit scary as a first-year fellow, but if you like doing therapeutics, it's really very exciting. Here are my disclosures. At this point in your career, kind of at the start of fellowship, you probably don't have a lot of time to do a lot of reading. You're getting ready, most of you probably, to take your medicine boards. You've moved and adjusting to a new city, a new hospital, and you're now kind of going to be switching mentally from being really outstanding medicine doctors and then putting on your consultant hat and focusing on GI. What I typically recommend, especially as a first-year fellow, is you want to sort of get the high-level recommendations from our societies. The best way to do that is looking at the guidelines. There's a number of national society guidelines. Probably the two that are really helpful from a clinical standpoint are ones that come from the ASGE, where we are right now, as well as from the ACG. I put some of the guidelines here from the Standards of Practice Committee. In the middle, you have the most recent ACG clinical guideline that was published a couple years ago. So as you're seeing patients, use that as an opportunity to look at the guidelines, see what the recommendations are. It's really hard, I think, as a first-year fellow to look down in the weeds sort of at primary literature, so try to get sort of a very high-level summary by looking at guidelines. So with that, we'll dive into upper GI bleeding. We'll cover initial management, understand what medications we need to maybe hold or adjust or manage, the role and timing specifically of endoscopy, and then we'll talk a little bit about some specific hemostatic techniques. So upper GI bleeding, it's defined as any bleeding source that's proximal to the ligament of trites. And in the United States, it's a pretty significant medical problem. There's a number of ER visits as well as hospital admissions for upper GI bleeding. There is some associated mortality. Thankfully, it's generally pretty low these days. And the majority of bleeding does stop spontaneously. But as GI doctors, we're kind of the front line, as endoscopic therapy is really the main treatment for bleeding. With your initial assessment, you want to make sure that you take a really good history with your patients. So you want to find out what signs or symptoms do they have, what medications are they on. This will clue you in as you formulate your differential diagnoses. And early on, you want to have really broad differentials for your patients. So if you have an older patient that's coming in with dysphagia and weight loss, progressive dysphagia, weight loss, you want to be thinking more about potential malignancy. If you have someone who was out drinking the night before and then came in retching and vomiting, you want to think potentially about Mallory Weiss tears. A patient that had a AAA and a repair comes in with bleeding, think about aortic tachyfistulas. So use that history to try to help guide you with your differential diagnoses. Antithrombotics, I was joking around in the morning session. It seems like everyone in the hospital, they're really old and on antithrombotics. So you absolutely have to understand those medications, what you can hold, what you can continue. And then in terms of the presenting signs for upper GI bleeding, you can see the ones that we normally think of, hematemesis and melanoma, or both. But remember that there is a subset of patients that may come in with what you think is lower GI bleeding, when in reality, it may actually be a brisk upper GI bleed. So keep that in the back of your mind with patients with lower GI bleeding. You may have to, in some cases, do an upper endoscopy and rule out a brisk upper. It doesn't take a lot of volume to have melanoma, about 50 cc's, which is really not much. And you can see the various etiologies for upper GI bleeding, majority of the time it's peptic ulcer disease. So we'll spend a good amount of time on that today. And then sometimes you'll have varices, and you can see the other etiologies, AVMs, malary weiss tears, tumors, and dulafoil. Specifically regarding warfarin, so there has been a change in our society guidelines with respect to warfarin and reversal. So previously, we were giving vitamin K, we were giving FFP. But last year, there was a publication by Nina Abraham. And she led the combined ACG and the Canadian Association of GI Guidelines. And specifically with respect to warfarin, you only want to reverse in life-threatening situations. And for that, the recommended agent is four-factor prothrombin complex concentrate, or PCC. And you want to generally avoid vitamin K and FFP. So you're only going to really reverse warfarin if it's a life-threatening situation. Once you've done your initial assessment of the patient, you've looked at their medications, you've determined whether if they're in a life-threatening situation and need a reversal or not, you then want to stratify those patients into high-risk or low-risk. So this will help you with thinking about triaging and timing of endoscopy. So obviously, someone that's higher risk, you may have to put them in the ICU. They may need to be intubated. If it's a low-risk patient, sometimes they can go home. So we have various scores that can be utilized. Probably the most best and validated one is the Glasgow Blatchford score, or GBS. All of you should be familiar with that, even in first month of fellowship. But it's a good tool that we can use that's validated to predict the need for intervention and for death. And if someone is low-risk, they can potentially go home from the ER. So that's usually a GBS score that's 1 or 0. This is that score, if you're not familiar with it. But it incorporates lab values, your BUN, hemoglobin. There's hemodynamic parameters that are incorporated, systolic blood pressure and heart rate, and then some additional signs, whether they have melanin or syncope, and then any cardiac or liver history. With medications prior to endoscopy, specifically acid suppression medications, it does decrease the finding for high-risk lesions on endoscopy. But if something is actively bleeding, acid suppression pre-endoscopy will not decrease your re-bleeding, mortality, or the need for surgery. But we typically do give this up front in a suspected patient with upper GI bleeding. There's various different ways that it's administered. It can be given with a bolus and then an infusion, an intermittent IV bolus, or oral PPI. If you have a peptic ulcer that you're treating, post-endoscopy acid suppression is very, very effective. For high-risk lesions, that's where it will decrease your re-bleeding rate and the need for surgery. You want to use PPIs in the setting of high-risk lesions. It's superior to H2 blockers. And typically, we'll administer it as an IV bolus or oral PPI. For low-risk lesions that are found post-EG, you can just put them on an oral PPI daily. This is a systematic review that looked at continuous versus intermittent PPIs post-endoscopy for high-risk lesions at 72 hours. You can see on the forest plot that it favored bolus. So you do not have to keep these patients on for an infusion the whole time with PPIs. Timing of endoscopy as first-year fellows, I think that's kind of one of the things that you learn as a skill set of when do I need to scope this patient. And for the majority of patients with upper GI bleeding, typically, we want to scope them within 24 hours. In most cases, doing an early endoscopy within, say, six hours has not been shown to be associated with lower 30-day mortality than when a scope is done between 6 and 24 hours. And if you think about patients that are having bleeding in the acute setting, you want to make sure that you resuscitate them. You don't want to put them under anesthesia and sedate them when they're maybe a little bit more hypovolemic. An urgent endoscopy is defined as an endoscopy within 12 hours. And the caveat here is that's when you're having a higher suspicion for variceal bleeding. So in general, most upper GI bleeds, you can scope within 24 hours. If it's a suspected variceal bleed, you generally want to scope them within 12. And again, this is always after hemodynamic resuscitation and stabilization. Remember, these days, we're doing restricted transfusion thresholds. So make sure that if you get a call from the ED or from the ICU and they're telling you, we're giving all this blood, unless it's clinically indicated, we're using now restricted transfusion thresholds and use it as an opportunity to educate. With respect to timing of endoscopy, for urgent endoscopy, the studies do not show a decreased risk of re-bleeding, need for surgery, or mortality when it's done in less than 12 hours. So you have a little bit of a window there to get the patient stabilized and then on the schedule for endoscopy. Lionel mentioned it yesterday, and it's really important to think about the totality of the patient, someone that may be higher risk for, say, aspiration in an upper GI bleeding case as someone that has massive hematemesis. If they have altered mental status and they're not protecting their airway, you need to make sure that that patient gets intubated. This can be done either by the ER, by the ICU teams, or by anesthesia. But you really don't want to have a scope down in a patient and then all of a sudden they start retching or vomiting, and you've got an unsecured airway, and then you're dealing with an aspiration event on top of GI bleeding. With upper GI bleeds, sometimes we may not have great visibility. So here are some tips that you can use to help increase your visibility. You can think about giving prokinetic agents, typically erythromycin or metoclopramide are the two most common ones that we use to try to mobilize some of the blood or the clot out of the stomach. Use larger channel scopes. So we have therapeutic scopes. There's single channel therapeutics, double channel therapeutics. There's one that I'll show you in the next picture that we affectionately call the clot buster that has a really big suction channel. Most of the scopes that you will use these days will have a power irrigation, so you'll step on the water pedal. You'll be able to lavage and suction to clean and improve your visibility. There are external suction devices that some endoscopy units will carry that you can use to suction up clot. And then think about if you need to change the patient position. So let's say, for example, you have a bleeding lesion that's in the fundus. Most of our standard endoscopies are done in the left lateral decubitus position. But if you think about the endoscopies you've done already, that's going to be the gravity dependent portion. So if you have a bleeding lesion in the fundus, the patient's left lateral, you're going to see a lot of blood there, a lot of clot. You're not going to be able to clear things maybe necessarily to get good visibility and treat your target lesion. So sometimes you may have to rotate that patient, put them supine or even sometimes right lateral decubitus, and have everything move away from your target lesion. So you want to try to keep the target lesion for a bleed in the anti-gravity dependent position. Does that make sense? Here's some therapeutic channel scopes. On the right, we have the double channel scope. So there's two suction ports that you can see. And then on the left, there's a big 6 millimeter suction channel. This is the one that we affectionately refer to as the clot buster. So if you're anticipating that you're going to be running into a lot of active bleeding or clot, these are great scopes to bring with you for the case. Some tips for getting clot out of the way. You can utilize your scope itself. You can try suctioning, pulling it off. Or you can use ancillary devices like snares or a Rothnet to take it out. It's a little bit of a controversy in terms of removing adherent clot. I'll show you the data in a little bit. But you'll probably see over the course of your fellowship, you'll have some attendings that will just say, let it be, and others that will say, take it off, and let's see what's hiding underneath. This is probably the most important slide with respect to upper GI bleeding. So this is the forest classification. You guys have all heard of it? Yes? Perfect. So this is really important, because as you saw in terms of the percentage, PUD, peptic ulcer disease, is one of the most common etiologies for upper GI bleeding. What we have learned from this data is that based on the type of stigmata that you can see endoscopically, you can predict what the re-bleeding rate will be if there's no endoscopic therapy. And without any endoscopy there, you can see also what the mortality rates are. This is a little bit of older data. So I would argue in 2023, surgery is not really being done even for refractory bleeding. But you can almost sort of imagine that column would be IR if need be, if there was no endoscopic intervention. The forest classification delineates ulcers based on their stigmata of bleeding. So a forest 1 is active bleeding. This can be active spurting, which is a 1A, or oozing, which is a 1B. And you can see really high re-bleeding rates there. So you want to make sure that if you see this actively bleeding ulcer, you're going to treat it endoscopically. For a non-bleeding visible vessel, that also has really high rates of re-bleeding. So for those, which is a 2A, you want to make sure that you're doing endoscopic therapy. The area of sort of contention now in our field is adherent clots. We have conflicting data even with meta-analyses of whether to unroof or let a clot be. But you can see it's sort of moderate 20% to 25% risk of re-bleeding. And then the low-risk lesions, which do not require any endoscopic therapy, are pigmented spot, which usually represents just hematin, or a clean-based ulcer, which is a forest 3. So let's take a look at what these look like in pictures. If you can imagine if this was a video, and it's just pulsating to the rhythm of the patient's heart rate, this is going to get your heart rate up as a fellow. But this is where you have an opportunity to intervene and help that patient have a good outcome. So this is a spurting, actively bleeding vessel. It's a 1A. A 1B is where you have a visible vessel, and there's oozing. Sometimes these are a little bit tricky. You may just see a pool of blood, and you're not exactly sure where it is in terms of localization. So that's where you can use irrigation and suction to your advantage. Get your scope close to the lesion. You can use your water lavage or your power irrigation to clear out some of the blood, and then watch closely to see exactly where the blood is oozing from. And that will then help you determine exactly where you need to perform your endoscopic therapy for hemostasis. In the top portion of this ulcer where the arrow is, you can see a non-bleeding visible vessel. So remember, if you see this, even though it's not actively bleeding, it's still considered a high-risk lesion. So you want to perform endoscopic therapy here. And then this is an old video. You can tell because it's not high definition, but you can see an ulcer at the incisora, and there you have adherent clot that's stuck to the ulcer site. This is a 2B. And then we move to the lower-risk ones. Here's a pigmented spot, which is a 2C. And then the ones that's most commonly you'll see on endoscopy would be a clean-based ulcer, and that's a Forrest type 3. So let's go to a question. Which type of lesion has the strongest recommendation to be treated with endoscopic therapy? An ulcer with a flat pigmented spot, one with an adherent clot, an ulcer with a non-bleeding visible vessel, and a clean-based ulceration. In the morning session, they were 100%. So let's keep it going. All right, perfect. So exactly, a non-bleeding visible vessel. So like we talked about when we looked at that table of the Forrest classification, that's a high-risk, considered a high-risk lesion. We want to make sure we do endoscopic therapy. So this comes from the ACG guidelines that was published a couple of years ago. On one end of the spectrum, which is kind of easy if you see active bleeding or visible vessel, you're going to perform endoscopic therapy, and you're going to put them on high-dose PPI. At the other end of the spectrum, low-risk lesions, flat pigmented spots, or clean-based ulcers, no endoscopic therapy is indicated, and you can put them on standard-dose PPI therapy. The point of debate now is adherent clots. Even with grade methodology done for this guideline, they cannot make any recommendation for or against endoscopic therapy with adherent clots. So like I said, it will probably be a tending dependent at your institution whether you're going to unroof it or not, but those patients should still be on high-dose PPI therapy. If you are going to take clots off, as mentioned, you can use snares. You can use Rothnets to pull it off. There is conflicting results regarding re-bleeding between medical and endoscopic therapy. There is no difference, though, in the need for surgery, mortality, transfusions, or length of stay when you're pulling off a clot. If you are going to pull the clot off, be prepared to look for and be prepared to treat any high-risk stigmata that you may see. And then you can think about individualizing it for the patient. So for example, if you have a patient that's higher risk for re-bleeding, say someone that's on anticoagulation or needs to go back on their antithrombotics, that's someone that you might consider unroofing the clot and determining if there's any high-risk stigmata that need to be endoscopically treated so they can potentially go back earlier on their medical therapy. Speaking of resuming medications or continuing medications, this was an RCT that looked at aspirin versus placebo after a peptic ulcer bleed. And you can see there's not a huge difference between 30-day bleed rates on patients that are on aspirin versus placebo. But from a mortality standpoint, especially when patients are on aspirin for secondary cardiovascular prevention, really make sure that this gets continued. Historically, we would hold these, but that has now represented a change in the guidelines. So previously, and I think this still happens to this day, you get called by the ER, by the medicine teams, hey, I held the antiplatelet agents, including the aspirin. If they're on aspirin for secondary cardiovascular prevention, we can actually continue that and we can scope them and perform endoscopic therapy. So this is updated in the new ACG and Canadian Association guidelines that you can continue the aspirin for secondary cardiovascular prevention. If it had been held by the prior teams or the ER, you want to get it back on board as soon as possible. This is the guidelines that I mentioned. Nina Abraham, who's like the cardio GI queen, was the lead author. I would definitely, especially with the number of patients now that we see on anticoagulation, make sure you take the time and kind of go through this and understand it. We also want to resume warfarin after a GI bleeding. On the left, you can see the 90-day recurrent GI bleeding rates in patients who warfarin was stopped versus resumed. It was not statistically significant. But what was is the thrombotic rates in 90 days in patients that did not go back on warfarin. So we want to get the anticoagulation back on board as soon as possible. As I've heard Nina say in her talks, the heart always wins. So get the blood thinners back on board. Even if they rebleed, you can always transfuse them. You can perform repeat endoscopic therapy. But if they end up having a cardiovascular event from thrombosis, that could be much more catastrophic. So typically, if there's higher risk stigmata with warfarin, you want to restart it within four to seven days. If it's low risk, you can actually just start the same day and just monitor those patients. We'll shift gears now to talk about suspected variceal bleeding. So those patients are going to be getting octreotide as a bolus and then 50 mics per hour rate. You want to continue it for 72 hours in the setting of variceal hemorrhage. And remember, these patients, you want to give IV antibiotics, usually ciprofloxacin, to help reduce infection, rebleeding, and mortality rates. Let's do another case. We have a 42-year-old female executive who has 48 hours of dizziness and dark, tarry stools. She takes Advil for her tennis elbow. And you suspect she has an NSAID ulcer. You send her to the ED, and then you decide to perform an EGD that evening. There's no blood in the stomach, and a gastric ulcer is identified. So this is what you see. We don't have a poll, but you can shout out, what do you guys see? An ulcer with a visible vessel, yeah. So there's a non-bleeding visible vessel there. So by a show of hands, who's going to treat this? Yeah. For whatever reason, I'll show you in a minute, they did not, and then I'll show you what happened. So this is what we talked about earlier, but the FARS classification is a non-bleeding visible vessel. We don't do any therapy. This has a very high rate of rebleeding. And so sure enough, this was not treated. And then three days later, this happens. So now you're re-scoping this patient. Let's just say it was, I don't know, your co-fellow that didn't scope the patient or didn't treat it. And now you're on call on the weekend, and you come in and you do this scope. Which of the following would not be an appropriate endoscopic treatment for this ulceration? I saw a lot of you look at your co-fellows next to you when I said that. Which would not be an appropriate endoscopic treatment for this ulceration? Injection of epi plus hemoclips, injection of epi plus bipolar probe, injection of epi alone, use of an over-the-scope clip or OTSC, or use of bipolar probe alone? Which of these would not be an appropriate endoscopic treatment? Let's vote now. All right, so the majority are saying injection of epi alone, which is correct. We do not want to use epi monotherapy alone. So that segues us into endoscopic treatment options for upper GI bleeding. So broad-based categories, we have injection. We have thermal therapies, which Shyam did a great job of going over during the electrosurgery talk, which is probably the hardest talk, I think, to give for the course this weekend. And then we have mechanical therapies, which includes hemoclips, over-the-scope clips, or OTSCs, and banding. And then there's combination therapy. So we'll break down each of these individually. So you can see there, a nice spurting lesion. In terms of injection, there's multiple agents that are available for injection. But when we're typically referring to upper GI bleeding, the majority of the time we'll be injecting epinephrine, which is usually a 1 to 10,000 dilution. But you can adjust that if needed. The main effect with epi injection in a four-quadrant fashion is tamponade. But you can also have a secondary localized vasoconstriction effect. But remember, this is very transient. So that's why we don't do epi alone, because it's going to be very short-lived. So you need to do some combination, either mechanical or thermal therapy, to treat a bleed. With coagulation probes, there's a few that are available. One of the more old-school ones on the bottom left is a heater probe. I would say more commonly, we use a bipolar probe, which you can see in the video in the middle of the picture on the left. And then there are some devices that come built in for combination therapy. So in the right side, on the left picture, you can see a bipolar probe that has a injector needle incorporated into it. So this makes it easy. You can utilize that needle to inject epi, withdraw the needle, and then without having to exchange your device, immediately start your thermal therapy with the bipolar probe. Remember, for the bipolar probe, you don't have to pad the patient. But in the middle, on the bottom, you see a coagulation forceps. This is a monopolar device. So that you would have to pad the patient for. When you're doing thermal therapy, particularly with bipolar, you want to make sure, as you can see in the bottom right picture, that you're applying good outward pressure. A lot of times I see that the first year fellows are really timid about putting pressure against that site. But remember, the area of ulceration is going to have a lot of edema, a lot of inflammation. It's going to be really hard for you to perforate through like a gastric ulcer with the bipolar probes. You want to make sure you have good, nice contact against there. And then when you're stepping on the blue pedal, the coagulation pedal, you want to hold it down for much longer than you think. Like usually people just sort of tap, tap, tap, but you actually want to really hold it down and let the duty cycles go through. Usually 5, 7, sometimes even 10 seconds, which as a first year fellow, it's going to feel like an eternity. But you need to let the electrosurgical generator do its job and conduct current through for coagulation. And then APC, which is, I think, always very fun to do. I think you guys had a good time in the lab as well. So in the upper GI tract, the majority of time we'll be using it for gave or gastric anterovascular atasia, which is also known as watermelon stomach. You can also use it sometimes in the small bowel for AVMs or for even colonic bleeding. And then in lower GI bleeding, we'll use it for radiation proctopathy, so a patient that may have had prostate cancer radiation treatment and then developed rectal bleeding. And argon plasma, I think Cheyenne had mentioned earlier, it's non-contact and it's ionized argon gas. But you do need to keep the probe generally close to the area of treatment and the depth of penetration is about 2 to 3 millimeters. But it is helpful for those indications that I mentioned. Hemoclips, these are always very fun to use. I think you saw it in the tools of the trade yesterday. Was there a clip station in the morning? There was, right? OK. So you know that there is a lot of different clips that are available on the market. They have various jaw openings. When the wings are open, there is one-to-one rotatability for control. Some of them are also physician control, one-to-one. And when you're performing a therapeutic maneuver like here, you want to make sure to orient the target lesion to your scope channel. So as you saw in the video, they kept the lesion oriented towards 7 o'clock, which is where the scope channel is. So that made it easier for them to deploy the clip. And the same holds true for when you're doing, say, colonoscopy. If a polyp is at a sign in the colon, you want to reorient it to where your scope channel is, which is 5 o'clock on a colonoscope. Combination therapy. So we briefly touched on this. This is where you inject dilute epinephrine first. Remember, we do not use epi as monotherapy. And then hemoclips or thermotherapy are equally effective. And you generally want to combine the injection with one or the other. Think about your patient population again. If someone needs to go back on antithrombotics, then you want to potentially do epi and lean maybe more towards mechanical hemostasis as opposed to thermotherapy so that they can get back on their antithrombotics sooner. Then we'll finally touch on some other therapies which are not used as widely, but you should be aware of them and potentially how to use them. So we'll start with over-the-scope clips, which you can see in the top right. So these are nitinol clips. They are loaded very much in the same way as a variceal bander that you guys did in the lab this morning. So they're mounted on the outside of a transparent cap, which is affixed to the tip of your endoscope. So like you did in the lab, you would advance your scope with the cap up to the target lesion that's bleeding, use suction or grasping forceps to get the lesion within your cap, and then turn a knob that's at the scope handle to basically release this clip. It pulls on a pull string to deploy the clip. This is FD-approved for non-variceal bleeding. And this is the clip type that has a rounded tooth. So this is what's known as the A-type. In advanced endoscopy, we also have a couple of different types of clips where instead of a rounded edge, we have more longer teeth that we can use to close perforations or fistulas. But this has a very high mechanical compressive force, higher than hemostatic clips. So there is a role where you can use this for non-variceal upper GI bleeding. The caveat is that it generally needs to be a smaller lesion, like 2 centimeters or less, because remember, it has to fit into the cap. So there's only a certain amount of volume that you can get into the cap before you deploy the clip. Other therapies include hemostatic powders. So there's a few that are on the market, but the one that probably most people are familiar with is hemospray. I saw Cook had a booth back there. This is a proprietary nanopowder that gets dispersed through a catheter via the use of carbon dioxide. So you use CO2 to push out this nanopowder. It very rapidly activates the clotting cascade in the body, but it needs to be deployed in a setting where there's active bleeding or oozing. It needs that hydrophilic environment to activate the cascade. This is great for really significant bleeds that you may not be able to otherwise control, bleeds that are in difficult locations because it doesn't require you to be right up against the lesion. You can spray from a little bit further back. And there's a potential role for malignant bleeding, which historically we didn't have great endoscopic therapies for. The way that you deploy it, it's similar to when you do your fire safety training, pass, pull, aim, squeeze, spray. So that's literally all it is. You kind of push your catheter out. You pull a lever that opens up where the nanopowder comes from. Your tech will squeeze this red button that pushes the CO2 out and sends the nanopowder out. I typically will bring a separate scope, like a dry scope, because you don't want this powder to activate within a scope that you've used to suction blood or irrigate. But this can be very, very helpful. Very, very high primary hemostasis rates, even in really bad bleeds, 90% to 95%. But you have to be very careful because there is a re-bleeding rate after about 48 to 72 hours of 20% to 25%. So when you use this, they may do fine the very next day, but you have to continue to monitor them closely because there is a risk of re-bleeding. And then, yeah? You mentioned malignant bleeding that this is better. Does that mean a lot of the other methods you talked about are not recommended? Correct, yeah. For endoscopic therapy for malignant bleeding, this can be helpful. A lot of other endoscopic therapies are usually not going to be beneficial. Oftentimes these tumors, with neovascularization, they have pretty significant blood supplies. And so sometimes we can use that as a salvage therapy for significant malignant bleeding, or you can talk to other services in the hospital, like radiation oncology in some cases, to see if they can help with those types of bleeds. Yep? So if you use these powders, it won't be beneficial? Correct. Yeah, you typically need a hydrophilic bleeding environment, so it needs to be like active bleeding for it to be activated. Is there communication to repeat the EGDF alerts? So there's not a hard and fast necessity to do a second look exam. But because of the re-bleeding rates being in that 20% to 25% range, you and your team have to be prepared to potentially do a second look examination on these patients. And once you spray it, you kind of spray it and you leave it. You don't try to clean up and do water lavage. You just spray it, and then you essentially take the scope out and let it do its job. Finally, this is a little bit more like the research side. It's not, I would say, fully in terms of prime time. But the UCLA bleed team, among others, will sometimes do Doppler probe guided therapy. So if you find, say, a potential bleeding source at an ulcer, you treat it. You can actually put a Doppler probe up against there and make sure that there's no additional blood supplies. And if there still is, then you can do additional endoscopic therapy. So something to consider. I have a question. Yeah. So for hemostatic spray, since it activates innate coagulation cascade, would that still be effective in patients who have thorotax and have non-varicellal bleed or have coagulation cascade deficiency? Yes, it does work. I don't know the degree of effectiveness. But I personally have used it in those patient populations when there's been non-varicellal bleeding that has not been amenable to other endoscopic therapies. Varicellal banding. So you guys all loaded or saw bands and deployed bands this morning. So remember, endoscopic signs for recent hemorrhage that you can look for in someone that has poor hypertension include the red whale sign and the white nipple sign, which represents sort of a fibrin plug at the site of the bleed. When you're deploying the bands, you want to make sure that you're holding your suction down. Try to get as much of that varix into the cap. You really want to pink out. And then while you continue to hold the suction, rotate the knob away from you to deploy that band. And when you are doing the banding, you want to make sure that you start as distal as possible, so close to the GE junction. And then rotate the axis that you're deploying the bands on as you come back more proximally so that you're hitting different columns of varices. So it'll almost look like a spiral staircase as you're working your way back to decompress these varices. And then last slide, the re-bleeding that can sometimes occur and when you do repeat endoscopy. So thankfully, with initial endoscopic therapy, we're pretty good at permanently controlling bleeds. There is a small subset of patients that will re-bleed, and you may have to do a second scope. And in the majority of those cases, we are able to get it under control. But there are some patients that continue to bleed in spite of our endoscopic therapy. And that's when we then turn to our colleagues. Much more commonly now is the use of angiography and then interventional radiology doing an embolization as opposed to surgery, which is really more of a last resort at this point and thankfully is very rare in 2023. One thing that I will mention, when you're doing endoscopic therapy and the patient may need to go to IR, it can be helpful for them if you use an endoscopic clip, which can act as a fluoroscopic marker for them that they can see on their angiogram to help do a more targeted or selective angiogram and then embolization. So keep that in mind if you have a pretty persistent or refractory bleed. So conclusions, remember to do your initial assessment. Make sure that that patient is getting resuscitated. Think about having a good differential diagnosis based on how the patient is presenting. We want to risk stratify patients for triage and endoscopy. So remember to use the GBS, the Glasgow Blatchford score. If they're low risk, 0 or 1, they can go home with appropriate outpatient GI follow-up. Otherwise, admit them. If they're really high risk, consider putting them in an ICU. Remember, if they need to be intubated, patients that have massive hematemesis for airway protection or altered mental status. Medication-wise, we're going to start PPIs. We talked about management of antithrombotics. Only reverse the warfarin if it's in a life-threatening situation. You can continue aspirin for patients that are on it for secondary cardiovascular prevention. Ways to optimize your endoscopic visualization. So you can give prokinetic agents, erythromycin or metoclopramide. Make sure you bring a larger channel therapeutic scope with you. Use your water lavage. Sometimes there are suction devices. And then once you're able to identify the bleeding source and determine that if therapy is needed, perform your endoscopic therapy. And remember, epi is not okay as a monotherapy. It has to be done in combination with either thermal therapy or mechanical. Thank you. Applause.

upper gastrointestinal bleeding

management

guidelines

assessment

endoscopic therapy

resuscitation

re-bleeding