All right, guys, our next speaker will be Dr. Adler, Advanced Endoscopist at Sensura Health, and he'll be talking to you guys about upper GI bleeding. Thanks, Dr. Adler. Appreciate it. Whew. All right. You guys good? So this is half the group, and the other half is in there. So I get to make the same jokes twice, is basically what you're saying. So just a couple of broad intro comments. So some of you guys at the Tools of the Trade yesterday, I know you guys are really focused on these super tiny concrete things now, like getting to the cecum, deploying a clip. You're going to figure all this out really quick. It's actually kind of the dirty little secret is it's actually not that hard. I would encourage you, right, you guys are at ground zero. I said to my group yesterday, I wish I could go back in time, like get into the TARDIS and come out and be a first-year fellow again, because it's really exciting when you're at the beginning. Think big about your career, right? If you think small, you will achieve small. If you think big, you may achieve small, but you'll never achieve big unless you guys think big, right? Don't think about just like this year. Think about make a five-year plan, make a 10-year plan, make a bigger plan than that. That's how you'll get there. Like all of us, we were just fellows here just like you guys were, right? So it is my hope that the 2032 ASGE first-year fellows course directors are in this room right now listening to my voice, right? That's thinking big. Okay. There's my disclosure. So my first-year fellows course was in 1999. I will not ask where you guys were in 1999 because it will only depress me, right? It was at the Intercontinental Hotel in downtown Chicago. This building didn't exist. This is actually the second IT&T Center. Remember, the other one was in Oak Brook, right? And then that was the one that they had before this, but before then, they would just get a hotel downtown. And actually last night when you guys were at the reception, I actually went into the ASGE archives and I dug around and I found a photo of me at the first-year fellows course, right? There's the Intercontinental. And that's it. That's exactly what I look like. That's me. It's hard to see because I'm the one who's hunched over there, but man, it was state of the art. It was really impressive. Okay. So we're going to be talking about GI bleeding, right? And this slide is just sort of showing that there's a lot of guidelines that are very, very helpful. And these guidelines are very frequently updated. I actually wrote the upper GI, I wrote the variceal and the non-variceal guidelines for the ASGE way back and I think like, oh, five or something like that. So it's been superseded a couple of times, but this is a, it's a document that will always be relevant, right? So here's what we'll do. We'll go over management, meds, endoscopy, and to your great interest, hemostatic techniques, right? So upper GI bleeds proximal to ligament of trites. And it's amazing that in 2022, right, where everybody is on a PPI, I mean every single person is on a PPI. Like we're still seeing so much GI bleeding. I'm in a big hospital and I'm part of a big hospital system and it's just, it's all day every day. We're always getting these calls. And what's also really amazing is that there's still a lot of mortality from this. You would think with all this knowledge, all these meds, all these scopes, right? That dying from a GI bleed would be a thing of the past, but you will see plenty of people die of their GI bleeds, especially in the setting of cirrhosis, like you're just going to see it. Therapy has really, really emerged over the last couple of decades as the mainstay of therapy. That's not going to change, right? And basically everybody else in the hospital knows if they call somebody besides GI first, surgery or IR, they're just going to say, well, did you call GI? So this really, this is something that will definitely fall on your shoulders starting now until about the year, you know, 2062 when you guys retire, right? So just recognize you're going to be doing a lot of GI bleeds for the next couple of decades. So first case, 86-year-old woman, had a hip fracture a week ago, had some melana, right? Feels lightheaded, but didn't pass out. Pressure is a little saggy, pulse is okay for 86, belly looks good. She's got some melana in the vault, meaning in the rectal vault, right? Some dark stool, crits down a little bit, right? Get scoped in the following AM, and we'll talk a little bit about, should you go in at night, should you go in the morning, right? And then this is what you see, right? This sort of spurting, visible arterial vessel, right? So maybe the kind of the point of that case is she shouldn't have waited until the morning, right? Right. And you'll see like, you're, and I think we talked about this somewhere else in the talk, but like your assessment of should you go in is affected by a lot of things, right? What else is going on, right? The patient's vitals, the patient's overall history. Is it 2 p.m.? Is it 2 a.m.? Is it cold out? No, I'm serious, like you're lying in bed and it's 1 a.m. in the middle of winter in Rochester, Minnesota, anybody here from Mayo? You know, you're like, oh man, maybe I could just sit on this thing till the morning, right? So these things all do, for better or for worse, kind of come into play. I always try to think, and again, you can't always be your best self, but I always try to think like, man, if my mom was on that table, would I want the doc to go in? Not my mother-in-law. That's a totally different calculation and I understand that, but like if my mom was up there, maybe we should go in, you know? Okay, so initial assessment, and some of this is like telephone thoughts, like when you're taking the call from the ER doc or the ICU attending, do they have dysphagia? Is there abdominal pain? Are they vomiting? Is there signs of active bleeding? Are they throwing up blood? Are they throwing up clots? Do they have a history of an abdominal aortic aneurysm? Because once in a great long while, you will see somebody that has an aneurysm that has eroded into the bowel, and people kind of talk about that and it's like on the boards, but if you hang out in the lab long enough, you will see somebody's aorta in the third slash fourth duodenum. You'll just see it with your own eyes, right? What meds are they on? It always amazes me how many people are on blood thinners in the modern era. Like the threshold for primary care and family practice to put people on blood thinners is basically non-existent, so everybody is taking some form of blood thinner it seems like. Do they take NSAIDs, right? People often will underestimate how much NSAIDs they take. I had a musculoskeletal injury earlier this year and I felt like I was taking a lot of NSAIDs and I started writing it down every time I took an NSAID and at the end of the month I was like, wow, I was taking a lot of NSAIDs, like much, much more than I perceived, you know, just sort of opening the bottle and popping a pill once in a while, right? Do they drink, right? Everybody underestimates how much they drink, right? Anybody who drinks more than you is an alcoholic, right, kind of a good rule of thumb, right? But you're going to be asking, right, these are the questions you're going to ask, right, when you're talking to the ICU or the ED, right? Doesn't take that much blood to produce melanoma. That was actually a study done on medical students where they had medical students drink their own blood to see how much blood, they would draw blood off and they would have med students drink their own blood, god med students. Looking for that honors, you know? And they would just see how much blood it actually took for them to drink before they actually saw melanoma in their stool, right? It's melanic, stools are melanic, your GI fellows do not say melanotic, do not. It looks really bad. It's like a rookie error. And the other rookie error is don't correct people if they say melanotic because then they'll hate you. So just sort of like wink and let your attending and know like we know they don't, right? That's kind of a better way to do it. Etiologies, what this slide doesn't really show is that actually, I guess they're lumping in with peptic ulcer as esophagitis. I'm always amazed at how many people that come in with pretty good hematemesis will actually have fairly unimpressive esophagitis, right? So I guess they're lumping that in with peptic ulcer because it's an acid mediated phenomenon. Basically peptic ulcer and varices is the overwhelming lion's share of bleeds that you are going to see, especially in the acute setting. Mallory Weiss tears can sometimes bleed very, very profusely, but they don't always. Tumors rarely bleed significantly. Tumors tend to ooze, right? And people with tumors, especially gastric cancer, tend to be anemic, but they very, very rarely will have a significant bleed. And then there's the oft discussed but rarely seen doula foie. What's a doula foie? Is that true? Is a doula foie lesion a visible vessel in any part of the GI tract? You can do like millionaire and phone a friend. Like what does this guy think? You could phone him. Is that the definition of a doula foie? He doesn't agree. So you know, in a millionaire, the phone and friend is usually right. So what do you think? Yeah, it's usually in the stomach. But what makes it different than other visible vessels? There's no surrounding ulcer, typically, right? It's a naked visible vessel. It's a submucosal vessel that has dived towards the surface, right? And often is not surrounded by a visible ulcer. And if you look, you will see these. And a lot of times you'll, the patient will have a story of brisk bleeding, and you'll look and there's nothing there. And you'll be like, I don't see anything. And maybe that's because they had a doula foie that stopped. But you will, if you look long enough, you will catch one. Life and reversal, right? If you can, right, we'd like a goal of less than two and a half. Sometimes you can't. Sometimes they're getting FFP, and they're human amically unstable, they're dying right in front of you, and you've got to go in and do it. So if you can, right, give them FFP or vitamin K or a combination thereof, but sometimes you don't have time, right? You just have to go in and do the procedure, while they are essentially therapeutic or super therapeutic on their INR. And that's okay. I would say that as time has gone on, I'd be curious what the other faculty think. My comfort level with doing procedures for hemostasis on people with high INRs has, it's really gone up. Like, I'm pretty comfortable. Like, if I kind of feel like I got to go, I got to go. And I used to worry about it a lot more early in my career, and now I don't. So again, this is kind of what I was talking about, mother slash mother-in-law, like, what's the risk stratification here? Like, how likely is this person to die or have a serious event if you don't go in right away, right? So triage is kind of an art, right? And some of that, too, is laying eyes on the patient. And sometimes, like, I was fellowship director in Utah for seven years, and sometimes I would get very angry calls from the ICU, and they would be like, you know, the fellow said no without coming by. And like, it's, you know, like, that's a fair complaint. Like, maybe it's, scoping isn't the right thing, but if you, if the team feels like you brushed them off or you blew them off, right? So like, even if it's 2 a.m. in Rochester, Minnesota, and it's minus 30 out, it really gets to be minus 30 out in Rochester, like, maybe a good idea to go in and eyeball the patient, right? And that way, the team will at least feel like, well, they took this seriously, right? So that's really, really important. There are these pre-endoscopy scoring systems, right, Rockall, Glasgow, Blatchford, AIM-65, and they're very, very good for studies. They're not really used clinically in practice. I mean, maybe you guys use them. I typically don't. Like, I don't be like, oh my God, they're Glasgow, Blatchford, AIM-64.2. Like, nah, you don't really do that. Like, you kind of like, you look at the labs, you look at the patient, you make an assessment, and you decide on whether you're going to go or not. But they're, they're very, very useful in studies. And you guys should have at least some familiarity with these scores, because every once in a while the ICU will calculate them, and you don't want to look silly if they call you and they tell you the score of the patient. So acid suppression pre-EGD, super important. Whether you think the patient has variceal or non-variceal bleeding, because you don't know, and people with ulcers, sorry, people with cirrhosis can take NSAIDs and get ulcers too, right? So you can have more than one thing going on at a time. We give these almost universally, right? And a lot of times if we, in the same way that if we're not sure if it's peptic ulcer or variceal bleeding, we'll start octreotide at the same time too. Like until you look, you really don't know. And some people who don't have a habitus suggestive of cirrhosis actually have cirrhosis and bleeding varices. So it's pretty, it's pretty low-lying fruit to go ahead and start an IV PPI and IV octreotide. You can always adjust or stop those medicines after the scope. After the scope, for example, like if they are found to have peptic ulcer disease, right, we generally want to continue PPIs for 72 hours, right? So that decreases re-bleeding risk, decreases risk for surgery. We really don't give H2RAs in the modern era unless somebody has a real reason they can't take a PPI, which is basically almost nobody. And there is an extensive literature about should that PPI be bolus or continuous infusion. The data is kind of a wash. And this is, for example, a meta-analysis showing a small advantage to bolus therapy versus continuous infusion. You're usually not the person managing that, like that's the ICU attending doing that at that point. So, you know, you could say continue PPI, time 72 hours in your note, and be completely within the letter of the law and the standard of care, and then let them worry about that. So again, timing of endoscopy, right? As a general rule, sooner is better than later. And I have always kind of erred on the side of let's go sooner, right? It makes, I think it's better for the patient, you get more information, maybe you could stop something earlier in this course, makes the ICU or the ER feel like you're more responsive, right? All these things kind of matter. And the docs will kind of figure out what kind of doctor you are, right? Like, you know, like, oh man, who's on, who's on call? Oh, it's John Morris. John Morris is on. Well, you know, John comes in most of the time. All right, let's call John. You know what I'm saying? As opposed to like, ooh, that guy is on, he drags his feet. Like you don't necessarily want that reputation in the hospital, right? So you want to be responsive. You do somebody who, when they call with a problem, right, you're there to help them, right? I always used to remind the fellows, like, you guys didn't just volunteer for these jobs. You competed for these jobs. So if they call you for a consult, you don't really have a big reason to drag your feet. Like you guys said how much you wanted to be here. Urgent endoscopy, right, typically in less than 12 hours, right, after hemodynamic resuscitation and stabilization, right? The patient has to be able to tolerate endoscopy, right? And most of the time, the patient can tolerate endoscopy, right? I mentioned to one of my groups yesterday, right, Adler's kitten test. Who was at my table when we talked about this, anybody? Right, so I'm going to tell you Adler's kitten test. You can use this. You should feel free to use it. But you must reference me, right? You must refer to this as Adler's kitten test, right? Like when you go to the ICU, if you look at the patient and in your assessment, a kitten could wrestle the patient to the ground, probably shouldn't scope, right? But in a tie, like if you're like, I don't know, that's a tough call between him and that little kitten, you push to endoscopy, right? So like, or another way to say it is if you think the patient wouldn't tolerate a haircut, don't scope them, right? And sometimes this can get uncomfortable, right? Like I've had experiences in the ICU where like I've had to say to the ICU attending, you know what? He's really not ready. I'm very hesitant to scope him. And then you usually get some response along the line of like, well, he's unstable because he's bleeding. And if you scoped him, he'll be stable. And we're like, well, but he's unstable now. And if you say to him, he will die, right? So like you'll sometimes get into this like chasing your tail conversation with the ICU attending. And it's often a bit of a negotiation, right? In general, right, outcomes are better if you go sooner, but outcomes are also worse if you go before the patient is hemodynamically stable and resuscitated and ready to go. So again, it sort of bespeaks that there is a fine point there. Low threshold for intubation, right? And in the modern era, you shouldn't get pushback on this, right? In the old days, I think we used to get more pushback. I think now there's more of a global awareness of the benefits of general endotracheal intubation, right, for significant bleeders, especially if they're drunk, right? At some point, you will have the experience of the drunk variceal bleeder. Like that's a tough one. Like that guy needs a tube in his airway, right? It'll make your scope easier, it'll protect them, it'll lower their risk, but it won't take away their risk of aspiration, but it will lower their risk of aspiration. It's actually astonishing to learn that you can aspirate with a tube in your lung and an inflated balloon cuff. You could still aspirate, especially blood. And if you aspirate blood, they get a significant pneumonitis. So again, when you're in there, right, you want to, right, endoscopy is all about visualization and seeing. And it's often shocking the first time you go down there and, you know, the stomach is full of 500 cc's of dark clotted blood and you can't see anything, right? And you can't suction that blood, right, right? You just realize like, oh, after all this like history, physical, I wrote a note, the attending drove in, right, and we put the scope down and we can't see anything and we're not going to accomplish anything, right? So you should have a low threshold to give a prokinetic prior to the procedure. Typically, I think most of us are using erythromycin, right, typically 250 milligrams. Give it as soon as you kind of think like the scope is within an hour or two, like that's kind of when you want to give the erythromycin. It actually has quite an impressive effect and it will produce significant gastric contractility and promote a lot of movement of non-adherent clot out of the stomach and down into the small bowel. So this slide actually is sort of like talking about like there's a large channel scope and I think it's the next slide or when there's a slide in here somewhere. I actually like to do GI bleeders with the regular scope. I almost never start with the T1, the so-called therapeutic channel, like a 3.7 channel versus a 2.8 channel because I feel like in a lot of bleeders, the regular scope is a little more flexible and lets me sort of maneuver a little bit better, especially if maybe I have to do some therapy retroflex. So I always start with a regular scope. There are external sort of like modified suction devices that you may or may not have in your lab. We have these in our lab. It looks like kind of like a droid from Star Wars. It sort of stands next to you and it's loud, but it gives you just incredible suction. So it's very, very helpful. They make the point here, oh, that's the therapeutic versus the regular scope. So really everything is the same except for the size of the channel itself, right? The bigger channel lets you suction clots. There's actually a six millimeter channel scope that's referred to as the clot buster, but there's very, very few of those in North America today. And I don't even know if they're still manufactured by the big endoscope vendors. I haven't seen them in their catalogs in a long time, but they're floating around and sometimes you can ask the vendor to loan you one. So this says, tips for getting clot out of the way, and what they're talking about here is rolling the patient. And then when you roll this patient, you see this. This isn't really an ulcer. I mean, this just looks like a giant perforation. I wouldn't really call that an ulcer per se. It's sort of an odd finding to see in the cardiac of the stomach. So you'll talk a lot about stigmata, right? You'll sort of hear these terms again and again and again and again and again, right? An actively bleeding visible vessel, a non-bleeding visible vessel, an adherent clot, a flat pigmented spot or a raised pigmented spot or a so-called clean-based ulcers. So these are important because it really has to do with the risk of re-bleeding, right? So for example, this is really referring to if you didn't do any treatment, right? Like what would be the risk that this lesion would re-bleed, right? And obviously if you have active bleeding and you do nothing, the potential risk of that re-bleeding is up to 100%. But for example, like you're going to see a lot of clean-based ulcers, right? They usually don't require endoscopic therapy because there's nothing really to treat. Whereas if you see a non-bleeding visible vessel, even if it's not bleeding at the time of the scope, right? You should treat it because if you don't, there's a very high risk that that lesion will re-bleed and you'll be right back in this situation in six or 12 or 24 hours, right? So this is a subtle lesion. If you look really carefully and squint, you might be able to see the source of bleeding, right? But you're going to see stuff like this. And it's actually, I always love seeing this. Like sometimes people freak out, right? Like when they see something like this, but I actually love seeing something like this because I know I'm going to fix this person, right? Like it's not a diagnostic dilemma. I know exactly where to go. I have great tools to solve this problem, right? The ICU team's going to love you, right? So this is actually a really, really good thing to see because you know you're going to turn this case around, right? So that's, you know, a bleeding visible vessel and you will see this all the time. It's important to remember when you see this, that the image in the endoscope is greatly magnified, right? This is not the hose connected to the faucet in your backyard, right? This is a vessel that's a millimeter wide. So it looks really, really dramatic. But like the actual volume of blood coming out is manageable in the ICU if they're giving blood and fluids like, so like, you know, as they say, have you guys read the house of God? It's probably pretty old. These guys may not know what the house of God is. But there's one of the rules in the house of God is in a code, the first pulse you check is your own, right? So when you see this, like, just stay calm, like it's all going to be fine, right? This is a oozing, right? That's a visible vessel in an ulcer crater that's oozing, right? That's a non-bleeding visible vessel. And you could see if you blew past that quick, you might miss it, right, right? That's an adherent clot, and we'll talk about that in a little bit, right? That's a flat pigmented spot, which may be a collapsed visible vessel, right? So, you know, maybe there's something there, like I would probably treat that. I don't know if you guys would, I'd probably treat that if I saw it, right? Again, my threshold to treat is pretty low, right? And this is what you're going to see more than anything else, the clean base. You're always a little disappointed when you see the clean base because you're like, hmm, nothing to do, you know, check H. pylori, treat if positive, right? So people have really strong feelings about adherent clots, right? And I trained in the era where this was changing, and a lot of my older attendings when I was a fellow would just kind of leave the clot alone, whereas some of the attendings would start to snare these off or suction them off and be like, well, look, the lesion is under there. We can't see it. So we can see. Now, my older attendings would be like, are you crazy? You're going to trigger a bleed. They're not bleeding, right? But again, you're there to make a difference. You're there to help people. And I was more influenced by the camp that said, let's go ahead and take that clot off. And sometimes you can dislodge it with a scope. Sometimes you can snare it off. And you may in fact trigger an episode of bleeding, right? So just be prepared. In taking off that clot, you may trigger an episode of bleeding. But what are the tools to treat the bleeding? The scope in your hand, right? And all the tools on the cart right behind you, right? So it's sort of like if you're banding somebody and you trigger a bleed, like somebody comes in for an elective outpatient banding, you may trigger a bleed when you suction that varix into the cap. But what's the treatment for that bleeding? A bander. That's on the tip of the scope right now. So it's OK. Just stay calm. Do you guys, for the faculty, do you guys take the clot off? Pretty aggressive bunch, wouldn't you say, right? Take the clot off. Fear not to do good, right? So you'll often get asked by the ICU, well, what about their aspirin, right? Should we restart their aspirin? And the answer is, yeah, you can pretty safely start their aspirin in a fairly short time frame after the procedure, right? Because the danger is that they have a cardiovascular event, right? So you may stop their aspirin because you're worried about re-bleeding, and then they have a heart attack or they throw up, you know, right, embolize or something, right? The stent in their left main, right? So this says start aspirin one to seven days after bleeding stops for secondary prevention. I would agree with that. And I would definitely err on the side of starting the aspirin sooner, because these people are going to be on high-dose PPIs anyway, right? So again, it's much easier for us to treat a bleeding vessel in the stomach than it is for cardiology to treat, you know, 100% thrombosis in their previously placed, right, heart stent. Similarly, right, if you, if the patient's on Coumadin, right, there's a fairly low threshold to go ahead and resume the warfarin in short order, right, so that they don't have a stroke. And I've had the experience once or twice where I've held a patient's Coumadin and they had a stroke, and that is a terrible, terrible feeling, right? And like, just like, wow, like, huh, I thought I was helping them and I really wasn't. And like, and it's not a GI bleed case, but I once stopped a patient's Coumadin after an FNA that was very tricky, and he bled a little bit from the FNA, and I stopped his Coumadin, and two days later, his wife called me and said he's in the ICU and he had a huge stroke, right? And I was like, oh my God, that was maybe from me. This is, so the management of anticoagulation and antiplate drugs is a whole talk in and of itself that's really beyond the scope of this lecture, but just recognize that this is always going to be a big area of interest. These are guidelines that are frequently updated, right? For the faculty, right, we've seen NOACs and DOACs and all these new antithrombotics come in during the course of our career, and you guys are going to see this as well, and as new drugs come, the guidelines do adjust. So if you think you're having variceal bleeding, and again, very low threshold to start IV actreotide, it's really easy to remember, it's 50-50, it's a 50 bolus, right, then 50 mics an hour, right, 72 hours after your scope if you treat bleeding, right? If you go down there and there's no variceal bleeding, right, like maybe it's a cirrhotic, right, and he was taking aspirin and didn't realize it, right? Anybody here from the South, right? What's BC powder? What's BC powder? It's aspirin, right? And people get it in gas stations, and like, oh, I wasn't feeling so good, so I took a BC powder at the gas station, and it's like 4-aspirin, essentially, is what a BC powder is. And I remember when I was in Texas, I had never heard of it, but it was all these people taking NSAIDs that they didn't realize, right? So if you go down there and the cirrhotic has a peptic ulcer, but their varices aren't the issue, or they don't even have varices, you can stop the actreotide. Do give antibiotics for variceal bleeds, right? They're high-risk for SBP, they're high-risk for aspiration pneumonia, so we typically treat these people, right, with antibiotics. Here's another case, right, 48 female executive, I'm not quite sure why they said she's an executive, but that's interesting, right, 48 hours of dizziness and dark, tarry stools, taking Advil for her tennis elbow, I guess tennis is like a game that executives play, I guess maybe that's why they put that there, right? You suspect an NSAID ulcer, send her to the ED, right? And you scope her, and you see an ulcer, right? So what do you think? What do you think? How about you right there? What did it look like to you? Yeah, this is the incisor. So you think that's him? Raise your hand if you think that's a visible vessel. And raise your hand if you think it's a pigmented spot. Raise your hand if you didn't raise your hand. There you go. So I would call that a non-bleeding visible vessel for sure. I mean, that's about as clear a visible vessel as you are going to get. That is the vessel just waiting to go. So again, this is why, for example, if you see that, I would 100% treat that. Absolutely, without a second thought, I would go ahead and treat that. Because if you don't, the risk of re-bleeding is very high. And this is what they're trying to show. Like, if you didn't do something, here's this patient three days later. Now it's 2 AM. You could have done it at 9 AM, and you were rested and ready. Now it's 2 AM. So when I was a fellow, we published a study that analyzed outcomes of GI bleeding as a function of time of day. And there's a time window between 1 and 5 AM where the worst outcomes occur, the most adverse events in these bleeders. Because then, you've now selected for the most sick patients who couldn't make it to the morning and the most tired physicians. So you're at your worst. The patient's at their worst. So just recognize there's danger in that 1 to 5 AM window. So here's the part that you guys really all want to know about, like the toys, all the cool stuff we get to use to treat these bleeders. So injection therapy, a mainstay of treatment for many years. The main action is tamponade. You probably have heard this by now. You would think that injecting epi would cause the vessel to constrict. Not really. What you're really doing is you're creating a semicostal cushion that tamponades the vessel locally. In Europe, for many, many years, to save money, they would just inject saline. We use epi in America because we spend money on everything. But in Europe, they would just inject saline. And they had basically equal outcomes. Here it says four quadrant injection around vessel. I don't typically do that. I'll just do one big injection close to the vessel. And if it stops it, that's great. But the whole point of the injection is not to really stop the bleed. It's just to buy you a few minutes where you can work in a non-bleeding site. Maybe you'll have a better field of view. Monotherapy is insufficient. I just recertified on my boards in May. The exam was notable for two things. One is there was a question about, was monotherapy with injection sufficient? And the answer was, no, it's not. The other thing that was notable about my board recertification is I got COVID at the test. I'm 100% sure I got COVID taking that test because I was locked in a room with all those people for 12 hours. So coagulation plosives, you guys will mostly probably be using the so-called gold probe. The Boston Scientific Gold Probe. That's kind of taken over the modern world in terms of coagulation probes. Some of the older faculty, and I'm sort of dismayed as I look out to realize that I might be the oldest person in this room. But the older faculty might remember heater probes. And heater probes actually worked incredibly well, but they've kind of gone out of fashion. They've kind of been replaced by bipolar probes, like the gold probe. This list, for example, a hot biopsy forcep, which you guys probably will not get experience with. But recognize that these are extremely helpful to use. You do have to apply pressure, right? Like you're aiming for what's called coaptation. You want to compress the vessel shut and then cauterize it in the closed position. And sometimes like rookie fellows, like they're so nervous about like applying pressure. Like they're afraid they're going to go through the wall or perforate, but you actually have to apply pressure with these probes for them to work properly, right? Have you guys seen Bring It On? Who's raised your hand if you've seen Bring It On? Now raise your hand if you're embarrassed to admit that you've seen Bring It On, but you've actually seen Bring It On, right? It's like they say in Bring It On, be aggressive. Be aggressive, right? That's how you got to be in these bleeder cases, right? APC, not typically used in the setting of a bleeder. We talked yesterday about gastroenteral vascular atasia. One little trick, sometimes if you clip a vessel and it's still oozing a little bit at the ulcer base, you can APC the clip. That's something a lot of people don't think about anymore. You can just APC the clip and transmit sort of thermal energy down through the clip and it'll kind of bake the base and sort of way to combine mechanical therapy and thermal therapy in one. But you're not going to be using a lot of APC in the setting of an acute bleed. Hemoclips, right? Hemoclips have really gone from zero to hero, right? In the past 20 years. And the clips that you guys have now are, depending on how you calculate them, they are fifth or sixth generation clips. They are incredibly reliable, right? The old clips used to be deeply unreliable and they had a very high failure rate. And the clips failed so often, we didn't even get upset. Like it was just factored into your thinking. Like, you know, there was like a one, you know, like 1.6 clips per lesion, right? Because it was always like the clip that failed or fell off. Now you guys are dealing with clips that are much larger, much stronger, bigger jaws, stronger materials, right? Rotatable. These were things that like we could only dream of back in the day. And these clips work incredibly well. And hemoclips actually work very well as monotherapy. Like if you get a good clip on the vessel, right? And the bleeding stops, like you can be pretty, pretty sure that that bleeding is not going to come back. And you're going to see, like you're going to get so facile with these clips. Like it's just, it's incredible how much use you're going to find for these. It's funny because you'll see like, you're going to do so many bleeds over the course of your career, that like you're going to be doing this stuff on autopilot. The pediatric GI, I forget his name, yesterday he made that comment that you're going to be doing all this stuff on autopilot. And it's really true. I was in last week, I got called to the ICU. And this, this lady was just, she had the visible vessel, like the gigantic like gout of blood. And you know, like, this is what, this was the, like, if you could have recorded the audio, this is what it would have sounded like. You know, the ICU attending is in the back of the room, and they're very nervous and the respiratory person is very nervous. I'm like, this was the audio in the room. Like, yeah, so last night I was watching Star Trek and there was this great episode where, could you open the clip please? Where Spock said to Kirk that, da, da, da, open the clip please. And then Kirk beamed down to the planet. It was incredible. Close the clip. All right, we're done. Like that was the audio of the actual procedure. Like you're going to get so good at these clips. Like you're going to get so facile. You're going to do without even realizing that you're doing, you're going to walk out of the room and all you're going to remember is that you had a conversation about Star Trek. You're not even paying attention to the clip, right? So get very, very good with these clips. And they can literally turn, right, a catastrophic bleed into complete hemostasis in seconds. You have to push too a little bit too, right? It's not this, it's this. You have to apply pressure on a clip, right? You want it, it's designed to grab tissue, but it's got to have the tissue to grab. Right, this looks a pretty good looking bleeder wouldn't you say? Remember too, you can close the clip without firing it. We talked about this yesterday in tools of the trade. Like if you're not sure that you stopped the bleeding, you can just close the clip and then just stand there for a minute and don't have the tech deploy it, right? And wash and if the blood stops, you're like, oh, okay, now I can deploy the clip. Combination therapy refers to injection plus another modality, either thermal therapy or mechanical therapy in the form of clips, right? So just recognize you'll be doing that quite a lot. And don't be passive in bleeder cases. I know I'm running a little bit over, but we started a little bit late. Don't be passive in these cases. Like, don't just kind of like, you remember when you were like three and you were like, look at your mom, like, what do I do? Like, don't be that person, right? Like when you're in the bleeder case, like say to the attending, I would like to inject and then place a clip, right? Your attending is gonna love that sort of initiative, right? So like get used to trying different approaches or if you think, you know, I can get this with just a clip, say to the attending, I think I can skip the injection and go straight to a clip and get it, right? Think what you want to do, because very, very quickly in just 35 months, you guys are gonna be out on your own. Other things to think about over the scope clips, right? Not designed for hemostasis, but now widely used for hemostasis in certain contexts. Hemospray, right? Hemostatic powders. There's one available in the US, a so-called hemospray. In Europe, they have endoclot and hemospray and there's others coming to the US. Hemospray giveth and hemospray taketh away, right? Hemospray can stop a bleed when nothing else will work. Two weeks ago, I saw a patient who had a bleeding gastric varix, but it was very scarred and it was a broad ulcer on the surface of a varix and we had very, very few options and I stopped it with hemospray, right? So it bought me enough time to get the patient to IR for a TIPS procedure, right? But when you, so this is like a beautiful kind of cartoon view of hemospray, but in real life, it's like a snow globe that you can buy at O'Hare. Like once you deploy that hemospray, your visualization might be gone for the rest of the case. Like it's gonna, it's very non-selective. It just coats everything. Even if you point it right at the target, it kind of goes everywhere. It often gets on the lens, can be hard to clean off. So like if you're gonna use hemospray, that might be the last thing that you use at the end of the case. Variceal banding real quick, right? Again, variceal banding I would say is like the one thing in all of endoscopy that is easier than it looks. Most stuff looks easy and then you try it and you're like, wow, that was tough, right? Banding, super easy. A chimpanzee could band. It's really, really easy. Like, so you guys will get good at banding very, very soon, especially in outpatient follow-ups. Like someone got bled, came back a month later and they're doing their follow-up. You're gonna band so often. So I'm not gonna belabor that a ton. So we're pretty much on time. So again, remember your initial assessment, right? Think about, right? What's the cause? What do I need to do now? Do I need to go in to assess the patient? Or sometimes it's just obvious and I need to go in and do hemostasis, right? And the attending is gonna follow your lead. Like if you say to the attending, I think we should go in. They're very rarely gonna argue with you. So just recognize like a lot of this is on you. You have a real responsibility here and people are gonna take you at your word. So do a good assessment, right? Risk stratifies what we're talking about. Triage for endoscopy, start PPIs. If you have any thought, right? That there could be a variceal bleed, go ahead and start Octreotide. Have you guys ever seen Ronin? Ronin, Robert De Niro, it's a John Frankenheimer movie. There's a great line in Ronin where Robert De Niro says, if there's any doubt, then there's no doubt, right? What that means is if you think maybe there's a 1% chance it's a variceal bleeder, start the Octreotide. If you're not sure, just go ahead and do it, right? Manage the antithrombotics as necessary. Remember Adler's kitten test, right? Optimize visualization and apply effective and durable therapy and follow me on Twitter. Thanks guys. And give me a four, give me a four. Thank you. So first of all, thank you for that outstanding talk. That was wonderful. A couple of just quick comments. The other culprit powder is Goody's powder that has a lot of aspirin, but the term melanotic is incorrect for GI bleeding, but it's actually not a completely incorrect term. So a common place for melanoma to metastasize is the small bowel. And some melanomas elaborate melanin that ends up in the stool creating black stools. So that is melanotic stool, and that's accurate. It just happens to be inaccurate in 99.9% of the cases that we see. But so it's a thing, but yeah, I totally agree. Melanotic is a pet peeve, but even as an attending, it's sort of, it makes you feel bad inside to correct people. Questions? So for endoscopic therapy, for let's say a low-risk ulcer, let's say a flat pigmented spot, if the patient is, let's say, on a DOAC and Pralenta, let's say he had a PCI and he has AFib, is the chance of you offering endoscopic therapy becomes like a lower threshold? Well, I will tell you, I would probably treat a flat pigmented spot in most cases, right? Because that makes you wonder, is there a decompressed vessel underneath it? Like if I see an ulcer that has a flat pigmented spot, like I'm leaning towards treating it anyway, right? And if they're on, for example, Eliquis, right? That might be a perfect indication for a clip, right? Because remember, when you cauterize something, you're not seeing it at 48 or 72 hours, and that cautery will produce injury that will evolve and can ulcerate, right? Like if you watch a sphincterotomy, it looks so clean, but if you go back and you look at a sphincterotomy site, 48 hours later, it doesn't look so pretty, right? So like if in those settings, maybe your best bet is to put a clip on it, right? Because then it's not gonna cause any cautery injury. You'll have a mechanical object in place that will stay while the PPI is working. Then maybe you could start their anticoagulation quicker. Other questions? So talking about the pigmented spot and the possible compressible vessel, I saw a few slides back about using a Doppler. Is that where- Yeah, and I purposely kind of ignored that. So there is a device that you can buy. I don't remember who makes it, where you can like put like a little probe on and like, you know, like there's no visualization, but you'll hear like, you'll hear like this little like, ah, there's the, but you're like, but there's the site, like there's the ulcer. So I don't know, like it came out and there were some papers about it, and there was some fanfare. Do any of you guys use it? Yeah, so oddly enough, during my fellowship, I got to present this probe in front of all the faculty at Michigan, and the papers on it are actually pretty very, I'd say reliable science until the fact you actually get in a case and attempt to use it. And the Doppler probe could be going off when the blood just sits in the clot and moves, or, you know, so I think there's some people, a very select faculty around the world that love it. I think for the vast- One person in California in particular. Yes, yes, I'll exclude the names you guys can read. But I think the vast majority, it's very difficult to use. And by the time you use it and figure out what you're going after, it's probably gonna be easier to visualize it, so. John Saltzman, who made the AIM-65 score, he always talks about it, because he likes it, he uses it. Yeah, I mean, we got pretty hot on it in Michigan, not us personally, but I mean, it got to the point where actually, you know, Grace Elta had it put on all the travel cards. So it was sort of a thing, I agree. All the randomized control trials were basically single operator type of thing, which of course has a lot of bias associated with it. But I totally agree, it's like, it's hard to know if you're listening to the vessel or just to the probe rubbing up against the mucosa. And so, I don't know, in my experience, I don't feel like it's made a meaningful difference. And especially since in most scenarios, to your point, Doug, is that the risk-benefit ratio of deploying a clip is limited. The worst thing that can happen is that you induce a bleed, which then proves that it actually was an underlying visible vessel, right? So, you know, and rarely with a clip are you gonna create a perforation or something like that. So if you're gonna reach for the Doppler probe, then you might as well reach for the vessel. Right. Yeah, reach for the clip. Reach for the clip. Right, then go to the vessel. Yeah, but you caught me, you caught me like stealth, ignoring that. Anything else? Other questions? All right, thanks guys. Thank you.

upper gastrointestinal bleeding

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hemostatic techniques

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