Good afternoon, hope everybody's awake. I was seeing some of them while both our speakers were talking and it's quite obvious. After a nice lunch, it's a little bit of closing of the eyes is very natural, to be honest even I was a little bit, but again, we have to go through this day and you have to bear me for the next 40 minutes before your break. So we'll talk about therapeutic colonoscopy. Just to make it more lively, how many people in this room have seen a lower GI bleed till now in four weeks? Just raise your hands, that's perfect. The rest are not working, what's going on? So basically today's talk, I have no disclosures, we'll be talking about four important points and I'll be hitting just on the take home points to be honest with you, not giving you, there are many information has been thrown at you since morning, but the goal for this talk is to make sure that you take some points which can stay with you for the rest of your life and the correct points. So today we'll talk about the lower GI bleed, how we control it, how we take care of it, when we happen to do a polypectomy, what tools do we use and what are the complications that can occur and how to control those complications. If we have a colonic obstruction, how to decompress the colon, whether it's a pseudo obstruction versus a tumor and the post polypectomy complications and how to deal with those. The acute lower GI bleed, the definition of a lower GI bleed is anything below the ligament of traits, but now with the small bowel, video capsule and everything coming into play, now the definition has changed that any lower GI bleed is considered anything after the IC valve. Acute means anything less than three days and it should be associated with any hemodynamic instability, anemia or need for any blood transfusion. The various causes of lower GI bleed of the top contender is diverticulitis, diverticular bleed, sorry, and it accounts for 20 to 65% of lower GI bleed. In that you can also include the ischemic colitis, hemorrhoids, it could be either external or internal hemorrhoids, post polypectomy bleed and IBD. Let's check your knowledge a little bit, four weeks of GI knowledge, 75-year-old female presents to the ED with five hours of painless bright red blood per rectum, filling the toilet bowl with blood every one hour. No prior history of GI bleed, no NSAIDs, aspirin or anticoagulation. Blood pressure stable, no orthostasis, hemoglobin stable, INR stable. Best step in management. We have an interventional radiology in the room, I think. All right, in the morning we had 100% answer for this but I can understand, that's okay. So the answer is bowel prep and then a colonoscopy. This brings us to this management of lower GI bleed and let's focus on the four symptoms which we are going to come across or the signs we talk about is the occult bleed. If that happens, then a colonoscopy is the first thing to be performed. If that's negative, then you go for upper endoscopy. Going on to melanoma, that is dark stool or tarry stools, you first perform upper endoscopy. If that's negative, then you go for the colonoscopy. Coming on to scant intermittent hematochezia, if it's a young healthy male or female and no red flags, no family history, the ideal thing would be to go for a flexic. But if it's a patient above 50 years of age with any family history, it would be ideal to go for a complete colonoscopy. Management of severe hematochezia can also be a patient comes to you and you have been called by the intern that hey, we need a consult for a patient with severe massive hematochezia. Can you just come and scope the patient? Your first answer would be sit tight, resuscitate the patient, make sure you have all the coags, everything checked, the INR is okay. And then the first thing you would ask them is to place a NG tube. The NG tube, if the aspirate is positive for any blood or any sort of lesions, you would technically want to do a first upper endoscopy. But if there's no aspirate from the NG tube, then you would go directly to the colonoscopy rather than going for the endoscopy. If the aspirate is positive, EGD is done, and you find some lesion or some dilaphoid, then you go by the upper GI algorithm. Now again, if the guy is constantly bleeding and your endoscopy and colonoscopy is, it's, you don't have any results from it, then the next step would be to go for, have surgery on board, but the first thing would be to go through the angiography, the RBC tagged red blood cell scans and all that stuff. And again, if the angiography is positive, it will be an embolization procedure by IR. If they do not find anything, then surgery is the next option. Timings of colonoscopy and acute lower GI bleed, which you will get this question very often during this year, is that we need the colonoscopy now. So your answer at that time would be less than 24 hours is a good option. We will do it within 24 hours. There is no 12-hour business, which used to be before. Now the guidelines have a suggestive of urgent colonoscopy within 24 hours. You do the prep with a rapid purge if the patient is able to do it within 24 hours. Take the prep, that's great, by mouth, or you can place an NG tube and finish the prep as soon as possible. Avoiding that you are not, if a patient is gulping down, go lightly or mirror legs, just make sure that you are not making the patient prone for any aspiration. Make sure that the bed is at least at a 45 degree angle. And in order to just augment or help the gastric motility, you can give some prokinetics like erythromycin or metoclopramide. So again, what is the advantage and disadvantage of a colonoscopy during the lower GI bleed? If a colonoscopy is done, the precise location is found, then you can treat it right away. There's a diagnostic yield of 45% to 90%. And if you find a mass, you can do the biopsy right away, saving time for future diagnostic procedures. Again, the disadvantage would be the patient who is actually massively bleeding will need a prep. Whether the patient is in a condition to take the prep, we are not sure. Even if you have a poor prep, and there'll be active bleeding, you can't see those active bleeding because the prep is poor. And if a patient is in sepsis, hypotension, and sedation becomes an issue. So I see a couple of yawning faces, so I'm switching on to a question again. It's a 55-year-old male on Warfarin due to AFib. He underwent a screening colonoscopy five days ago with removal of a secal polyp. Presence with painless prior to blood per rectum and basically repeated episodes. Blood pressure was stable, but the INR was 2.0. He underwent a colonoscopy revealing a 15-millimeter ulceration at the polypectomy site with a non-bleeding visible vessel. Next step in management. Perfect. Excellent. So mechanical hemoclip placement across the vessel is the correct answer. So that brings us to the modality that how to deal with this bleeding. So there are three modalities for bleeding would be injection, thermal therapy, and mechanical therapy. Injection would be injecting epinephrine, which would be 1 in 1,000 epinephrine mixed with normal saline. Thermal therapy would include APC or bipolar cautery, and your mechanical therapy would include endoclips, which Dr. Kumta talked about in detail. So I would skip through a couple of slides because we have to cover other videos in future slides. So let's move on to the non-endoscopic management of acute lower GI bleed. So if you happen to find a bleed, then you take care of it epinephrine or mechanical therapy, that is clips or thermal therapy. But if you don't see anything, what's the next thing now? Your EGDN colon has been done. You don't find a source of bleeding. The next step would be you go for either a tagged red blood cell scan, that is a tagged RBC scan. The problem with that is that it requires a bleeding rate, which is 0.1 to 0.5 cc per minute, and the yield is very low. It takes hours. Then the next step would be you go for an angiography, that is a helical CT angiography, which requires a bleeding rate from 0.3 to 0.5 cc per minute. Now, when you go for, normally we said that, OK, the patient needs to go for CT angio. So when they do an angio, they find a source of bleeding, and the next step would be to do an embolization by the interventional radiologist, because that, they would need a precise location where there's a flush of contrast, and that's where they will do the embolization, especially gastrointestinal arteries, the main culprit, most of the time in the upper GI bleed. So that brings on to diverticular bleeding. Diverticular bleeding, the definition is painless, often stops spontaneously. So by the time you prep the patient, the patient comes early morning, you prep the patient and bring the patient down in the afternoon for scoping, and the bleeding has stopped. So you are just looking at a clean colon at that point. But the good part is that you will see some ticks, some diverticular stigmata over there of epithelium bridge. It recurs in 35% to 40% within four years. Treatment includes thermal contact, endoscopic clipping, and endoscopic band ligation. There are a couple of videos which will be slowly just going through that in order to save time. Available data suggests that endoscopic intervention for diverticular hemorrhage is safe and efficacious in certain cases. Injection therapy shown here to treat bleeding at the neck of a diverticulum has been reported with limited success. Due to the lack of muscularis propria at the dome of the diverticulum, therapy at this site using injection or thermal coagulation must be carefully considered. When surveying the colon for the source of the diverticular bleed, it is often difficult to relocate the bleeding site following initial identification. We recommend using an endoscopic clip for marking in order to ensure future endoscopic identification as well as localization for future radiologic or surgical interventions if necessary. Direct clip application should be applied if a clear bleeding site is visualized. In this case, an actively bleeding large vessel is clearly identified at the neck of the diverticulum. After initially marking the location, direct clip therapy is applied. The clip is carefully positioned near the base of the artery in order to entrap the immediately surrounding tissue. The usefulness of the water jet is emphasized for precise clip application. Slight downward pressure is applied, the lumen is collapsed with minimal suction, and the clip is deployed. Although a single clip may be sufficient, we typically place two additional clips in order to ligate the feeding vessel proximally and distally to the bleeding point. This case demonstrates direct clip application to the dome of the diverticulum. An adherent clot is directly visualized in the diverticular dome. Bringing the clip close to the endoscope provides the most controlled technique. The clip is carefully positioned close to the vessel in order to entrap the immediately surrounding tissue, being cognizant of the thin diverticular wall. A second clip is placed at the opposite side of the defect in order to ensure hemostasis. So this was injection and clips. Again, the role of bipolar, that is the thermal aspect, is that if there is a bleeding going on at the neck of the diverticulum, and if it's visible to you, you can apply the bicap over there as well. The next bleeding lesion is the vascular lesions, the AVMs or the angioectasia, commonly found in elderly population with renal failure or aortic stenosis, and it's mostly found in the right side of the colon. Again, the same non-contact or contact thermal therapy can be used. There's a video that we're going to look at it. This case of AVM bleeding shows initially that our gut is not able to absorb the blood shows initially that argon plasma therapy was used. Bleeding nonetheless continued, and endoscopic clipping was necessary. Multiple clips were required to achieve primary hemostasis. On follow-up, the patient had no report of re-bleeding. So let's switch gears and go to polypectomy. When you see a polyp, the first thing that should come to your mind is the game plan. What exactly you want to do with the polyp? So there are two aspects. One is what equipment you should have in the room. The second thing is what type of polyp is this? So the first thing you want to look at is, okay, look at the polyp, look at the shape, the size, the nature of the polyp. Will you be able to take this out or not today? That's more important. If you think that you won't be able to take it out, then don't bother. Just take biopsy and send it to somebody who can take it out. And we'll talk about that, why am I saying this statement? But at the same time, when you select the polyp to be removed, you want all the accessories in the room so that if, God forbid, and that happens a bleeding, a spurter, which Dr. Kumta showed you, then you might not want to just keep running for instruments outside. You want everything in the room where you can utilize it. And that will save a lot of time and panic in the room. So let's talk about the polypectomies, the steps. Going to have an optimal view, entire 360 view of the polyp should be right in front of it. It should be a forward view so that you can visualize the polyp, go under white light, NBI light as well. The position of the colonoscope should be at 6 o'clock position because all the accessories in the colon scope is going to come from the 5 o'clock compared to an endoscope, which comes at 7 o'clock. So you want to make sure that whatever accessories are coming, you position your scope accordingly so that you can do the polypectomy in a 6 o'clock position. And communication with your tech or nurse who is handling the snares is very, very important or the clip is important. You might want to even shout just to make sure that if there's too many people in the room and you're not heard, but that should not be the reason for a miscommunication where the nurse is deploying a clip without your knowledge. So it's better to be firm in your commands than being sorry. This is the Paris classification for mucosal neoplasia. I always tell my fellows to print this in your mind and just keep it next to your table, wherever is your computer station, because every time you do a polypectomy, you might want to refer to this. An astute thing would be to actually refer to this and write it in your colonoscopy report. And that will be a very nice thing because every time you look at it, you're just going to learn and learn and gain knowledge from this chart. So there's multiple choices of polypectomy techniques. One is a cold biopsy where tiny polyps are removed. And there's a cold snare where any size polyp within 10 to 20 millimeters can also be removed. There was a time when it was recommended that anything less than 10 millimeters should be removed with a cold snare. But with studies in last five to seven years, things have changed. The paradigm has shifted completely. So you can actually inject, lift the polyp, and take it out in a piecemeal. Or if it's a larger polyp, take it out in a piecemeal with a cold snare. Then we have the conventional hot snare polypectomy technique. Hot biopsy is normally used when we resect a polyp and there's a residual edge of the polyp left. We can do it with a hot biopsy that is also called the aversion technique. And then the standard EMR where we inject the polyp with a saline or pre-mixed solution with methylene blue and then resect the polyp. Here we see an indigo carmine stain colon in which we're using a large capacity needle forceps to engulf small polyps and simply pull them off. The advantages of the cold forceps technique include that it's devoid of complications because we're producing only a mucosal injury. And also it's very efficient because it's easier to place forceps on small lesions than it is to place snares on them. And also you'll notice that these lesions are so flat that they would be very difficult to snare. In addition, this technique can be performed in patients who are therapeutically anti-coagulated and the risk of bleeding is extremely minimal to none. Very important point, the last statement. Patients sometimes when they come for a routine colonoscopy also the cardiologists do not want to take them off Plavix and anti-coagulation. At that point you're in a fix. You're like, what if I find a polyp? But if it's a tiny polyp, less than a five millimeter, it's a good idea that you can take it out with a cold biopsy forceps. The preparation we talked about, the equipment, the patient should be well-sitted. Depends on what type of colon polyp it is. If it's a large polyp, definitely general anesthesia, deep sedation is a good option rather than a moderate sedation. And most important is that you have to make sure that if the patient is on anti-coagulation, even if you took the patient off anti-coagulation three days or seven days prior based on what drug he or she is taking, always check the INR because you do not want to do a polypectomy in a patient with INR greater than 1.5. So the snare polypectomy technique, the concept is that rotate the lesion at the six o'clock position. As we talked about, the accessory channel is at five. Advance the snare into the lumen until the plastic sheet, that is a white sheet, is seen. And then you open the snare and then you have it a big wheel away from you. Try to seat the snare on the top of the polyp and then slowly, in communication with your assistant, try to close the snare. Once you close the snare, you apply the coagulation current and normally I use the cut current, that is the yellow pedal, which is the standard right now. Cold snaring has been shown to be effective in polyp removal. I usually try to remove a thin strip of normal mucosa around the polyp, a technique that is not recommended with electrocautery use. Cold snaring is devoid of bleeding complications in patients with normal clotting. Immediate bleeding is typical with cold snaring, but is of no clinical significance. The technique is to grasp the tissue around the polyp, including a bit of normal tissue, and then mechanically transect it. Tenting is not necessary with cold snaring, since there is no risk of injury to the deep layers of the colon wall. I currently use this technique for about eighty percent of the polyps that I remove during colonoscopy. Here you see the removal of a sessile polyp. We can grasp some normal tissue at the base and cut it off. It will stay in place as long as we don't tent. And after removal, we move the biopsy channel up to the site and suck the polyp back into a trap. So, if you remember, tenting came a couple of times, the word tenting. And for people who have gone through polypectomy at the Bioskill station this morning, when you do a hot snare polypectomy, you must have known that people told you that, okay, big will towards you. You're trying to stay away. You're trying to tent it a little bit so that the deeper layers are not involved, which is not the case in cold snare, because you're not using any hot polypectomy technique. So, tenting is required in the hot snare polypectomy because you do not want thermal current to go down and cause a transmural injury causing a post polypectomy coagulation syndrome. Here we see a pedunculated polyp that we're going to grasp by the stalk of the polyp and then lift or tent into the lumen. Please notice that we see a white cautery burn on the polyp before we begin the actual mechanical transection. Thus, we instruct the assistant to hold off on transecting the polyp until we see that white coagulum. Now we've got a sessile polyp about a centimeter in size. Notice that we're grasping right at the edges of the polyp, which is different from what we discussed with cold snaring. Again, before we begin the mechanical transection, we want to see a little bit of coagulum near the snare. That's the whitish color. And then we'll begin the mechanical transection and then we're going to inspect the polypectomy site. Some people prefer to photograph the polypectomy site, but I don't think the standard of care requires that. This is the final slide of post polypectomy and then you see that there's a complete resection. It's under NBI. So the tips for large polyp removal, reduce the loop, try to make it straight, whether it's the right side of the colon or the left side or the transverse colon. That way you can maneuver the scope as you want. Because if you're not reduced, then it's unable to have the scope in a very standard position. The polyp should be at six o'clock. Deflate the lumen to reduce the diameter. That will keep your scope steady. Consider using a clear plastic cap when you're trying to do a polypectomy because that will provide a little bit of two to three millimeter distance from the vision of the camera of the scope to the polyp site. Recognize any non-lifting sign as a sign of invasion. What does that mean? When you inject the base of the polyp and try to lift the polyp, if the polyp is not lifting, that's a sign saying that this polyp has gone down deeper in the deeper levels of the tissue, either to the submucosal or the muscularis. That could be a sign of malignancy as well. So you might want to back off at that point, just take biopsies and come out and maybe refer to a surgeon based on the biopsy. Again, once you remove a polyp, the goal would be to close the polypectomy site with the help of clips because that will act as a profile axis for delayed bleeding. The submucosal injections are the same concept that when you do an injection to lift the polyp, you use a car lock needle, which we went through in yesterday's session for the... What was the session? I forgot the session's name also. Tools of the trade, sorry. And then it has to be a dynamic injection. When we say a dynamic injection, when you're injecting at the base of the polyp, you can see in front of your eyes that the polyp is lifting. And it's not just that the nurse is injecting the solution and it's going deep down in the submucosa without you even knowing it. So there are various pre-mixed solutions in the market which can be used. Colloid plasma volume is one of the things that can be mixed with even indigo carbon or methylene blue. So that gives you a good idea that when you do a polypectomy, you want to see the base of the polyp as blue. That's the goal because that's a distinguishing factor that you are not gone deep down in the submucosal level as well. And again, what I said was don't start if you can't finish because when you start and you do a half polypectomy or incomplete polypectomy and that person comes to your friend who's going to remove the polyp next time, that area is going to fibrose and that will make and cause a scar tissue for the area that you have removed. So that's going to make his life difficult. So try to avoid that. If you cannot finish, then do not start. So this is a injection technique that we are going to talk about. The polyp found in the colon, it's a large sessile polyp. We are going to inject first the proximal end towards the cecum side and try to inject with a solution of normal saline and methylene blue and try to be generous in your injections. It's okay, there is no downside to that. And once we inject with a car lock needle or any injection needle, you will see a good lift of the polyp and that polyp on the proximal side is going to give you a good platform. And now you see that only the lower part is left, so which is the distal end of the polyp which is towards the rectum. So now we are going to inject the distal part of the polyp as well and have a nice lift. And this gives you a good cushion between the mucosa and the submucosal layer, so when you are making a polypectomy cut, it prevents any risk of perforation. Moving on to polyps that are too large to suction through the scope, if a large polyp is removed in one piece, we pick up the resected polyp with the snare and drag it behind us. If we have one large piece and multiple small pieces, we suck the small pieces through the channel and then pick up the large one with the snare and drag it a few centimeters behind so we can continue examining. So again, know your limits. Sample the lesion if you think that this is not possible today. And then tattoo the spot, so if the next guy is going to go for it, then he knows where exactly to target because if sometimes the polyps are flat lesion, you might not be able to see properly. So it's better to tattoo the area and then refer to your colleague. So coming on to the tattoo part, again, I'll quickly go through this. You have to place the tattoo, mostly it's recommended to place it proximal to the lesion so that at least when the person goes in, they can have a look and make sure that the polyp is noted. The take-home point is either you do proximal because sometimes if it's in the rectum, you might have to do it a little bit distal also. The take-home point here is that do wherever you want to, proximal or distal, but do not do beneath the polyp. That's a no-no. If you start doing a tattoo beneath the polyp, it's going to cause a scar tissue and fibrosis. And now again, you are dealing with the same concept that fibrosis is caused and the person cannot remove the polyp who is going to be the next guy to remove it. So here is a video for tattooing. The needle tangential to the mucosa. Then we need to get the needle tip through the mucosa into the submucosa. And a good way to check that is to see that we have just a couple of millimeters of needle in the tissue. Then if we lift the needle toward the lumen, you actually see the impression of the needle in the submucosa right there. And that's a good indication that we're in the submucosa and we can start the injection. We must immediately see fluid starting to collect in the submucosa or we stop. We're going to inject one to several cc's into each site. If we have a mound of saline already in the submucosa, then it's easy for us to reinsert the needle into that same mound and inject ink. Here you see in this next injection that we'll poke right into the submucosal cushion and inject again. So the last part of our talk, the postpolypectomy complications. Whenever that's your common spiel that you have to give to the patient when you do a screening colonoscopy, the risk of bleeding, perforation, infection. Those are the three major points that you need to just say without even thinking. But there's a rhyme and reason for that because the bleeding rate is approximately 6%. Perforation is approximately 3% and followed by retroperitoneal abscess and emphysema. So what are the postpolypectomy? Now we've done a polyp removal. Now what are the other things that can come across and that might wake you up in the night because you did a polypectomy in the afternoon is a postpolypectomy hemorrhage. The definition is a lower GI bleed which will require transfusion, hospitalization, intervention, and maybe even surgery. And the timing is either you did a polypectomy and it could start during the procedure or in the recovery or once the patient goes home or maybe even till one month later. The treatment could be the same what we talked about, the endoscopic thermotherapy injections. And if that's not possible to control it, then the goal is angiography and surgery. So if you remember, I spoke about postpolypectomy coagulation syndrome. That is the tenting part that I was talking in hot snare polypectomy. If there happens to be a transmural thermal injury while doing a polypectomy, the patient is going to present within five days after colonoscopy with fever, abdominal pain, white count, and some peritoneal signs. You would do an x-ray or a CAT scan. You won't find any free air or perforation. The treatment protocol would be to keep the patient NPO on antibiotics and do a serial exam with physical examination as well. And usually it spontaneously resolves in three to four days. Take it easy on the air during insertion. Enough air should be insufflated so that the lumen can be clearly identified. But additional air insufflation will lengthen the colon and make insertion more difficult as well as increasing some risk and discomfort for the patient. Be particularly careful about air insufflation after passing a tight stricture or angulation in a patient with severe diverticular disease. In such a patient, air may not be able to escape around the colonoscope in order to exit through the anus. If the ileocecal valve is competent to air, a closed system can develop. So when it comes to barotrauma, there are two places where you would find perforations the most. One is sigmoid and one is cecum. OK, so if there's a tight stricture before the sigmoid has arrived, sigmoid is the place where you would find perforation because of not just a barotrauma but also because of mechanical complications over there because of the scope not being reduced and all that stuff. But again, cecum is the main site where you're going to see this barotrauma a lot. So when you go in, you will see blisters or maybe even red signs that there's lots of biopsies being done. If you can imagine that picture in the cecum, that's what is called as barotrauma. There are two basic mechanisms of perforation during insertion. The first of these is mechanical rupture by the colonoscope, which usually occurs when the side of the colonoscope ruptures the colon in the vicinity of the rectosigmoid junction. The most important step in avoiding this type of perforation is to not continue to push the instrument when fixed resistance is palpated by the hand on the insertion tube. Fixed resistance is the sensation that the colon will not stretch further as pressure is applied. No matter whether the lumen is in view or not, you must stop when you feel fixed resistance. Mechanical perforations may also occur when the colonoscope tip is forcefully pushed against the diverticulum. Remember that not all diverticula are small and occasionally diverticula will mimic the lumen even for an experienced examiner. Mechanical perforations occur more rarely when the colonoscope tip is pushed against a stricture that is too tight to allow passage of the scope. Continued pushing can cause the tip to forcefully slip off the side of the stricture and dissect the normal colonic wall. This type of perforation can be avoided by either first balloon dilating the stricture or by passing a guide wire through the stricture before attempting passage, as shown in the animation. The guide wire will prevent the scope tip from slipping off the side of the stricture The moral of the story of that last two videos was that do not do anything forcefully. You have to see the lumen and the opening and then go. If somebody's saying just push, you've got to think twice. You have to see and then only you move forward. Otherwise, you're going to land yourself in trouble. The next one is the colonic decompression. The next one is the colonic decompression. There are various indications where colon is distended. It could be because of tumor, volvulus, or something called as post-op ileus, that is pseudo-obstruction. In that scenario with a patient with ileus, you want to first move the patient from a regular floor to a telemetry. Or maybe the patient is already in the ICU. That's the best thing because when you are trying to say that, OK, fine, this looks like a post-op ileus, you might want to give neostigmin, which is two milligrams IV every three to five minutes, over three to five minutes first. And then if it doesn't improve, you can give the second dose. But in order to monitor his heart rate, you need to have a patient in telemetry. So that's the number one take home point. Move the patient to telemetry, neostigmin, give a dose over three to five minutes under supervision with a nurse who is a cardiac nurse. And then you can repeat the dose. So the techniques, definitely it's an unprepped colon because there is no option over there. There is some obstruction going on. So there is no point of giving any prep. I technically turn off the air button for my fellows. There is no air in such scenario. You can use CO2 to some extent that to just a tap. Most of the procedure is done underwater because that's safe. When you try to advance your scope and you see an obstruction, you first and now it's time to pass your decompression tube. But before that, you flush the syringe, the accessory channel with a 60 cc syringe, which is mixed with lube and normal saline or water and flush it through the channel. Because that will help your wire, the decompression wire go through very smoothly. You advance your decompression tube wire and then over the wire, you can pass the wire, you can pass your decompression tube. Once you reach, once your pigtails, they come out, you can slowly pull back your scope while your technician is pushing your decompression tube, leading to a successful decompression tube placement. So in conclusion, colonoscopy is a test of choice. I would say less than 24 hours is a good timing for lower GI bleed colonoscopy. Do not rush in when somebody pressurizes you that internal medicine resident wants you to get a colon done today. You're like, OK, sit tight, resuscitate the patient. There is no hurry. But again, you might want to make sure what's going on. Awareness for all the options for endoscopic treatment. Polypectomy, the mantra is that if you can't finish, don't start. Don't take it to your heart. There's nothing about you are a lesser endoscopist. But there should be an insight. If you can finish it, definitely go for it. And the complications, complications happens to everybody. But the main thing is the differentiation between a good doctor and ordinary doctor is that you recognize the complications, take steps towards managing the complications in the correct way. Thank you. So what was the size of the polyp where you have to place a clip after the polypectomy? So any polyps, I would say greater than 10 millimeters, a centimeter. And depending on the right side also, it's the location of the colon and the size of the polyp. Those are the two things that matter after a polypectomy. For patients with diverticulitis, I kind of thought that we were moving away from just trying to scope all of them, especially if you know that they have diverticulosis. Because sometimes when you go in, you don't see anything. And it's hard to tell which one is, which one bled or which one is bleeding. Right. So the question is that what's the correct timing for diverticular bleeds patient to be scoped for colonoscopy? Is that correct? Yeah. Or like, do you always have to scope them? Can you just like? Yeah. So the, so the thing is that you, if a patient comes to you in the night and you look at the patient's vitals in the morning and the hemoglobin is still dropping, then definitely you prep the patient in the night. But if the hemoglobin is still dropping, then you might want to scope that patient. If the hemoglobin is stable, then you might want to just monitor and see what's going on with the patient rather than going in and scoping the patient. Thank you guys.

therapeutic colonoscopy

lower gastrointestinal bleeding

polypectomy

colonic obstruction

post-polypectomy complications

bleeding control techniques

injection therapy

mechanical therapy