Welcome. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's webinar. My name is Lauren Loding, Manager of Evidence-Based Guidelines and Documents at ASGE, and I will be the staff facilitator for this presentation. Our program tonight is entitled GI Bleeding Toolkit. Please note that this presentation is being recorded and will be posted on GI Leap, ASGE's online learning platform. You will have access to this recording in GI Leap as part of your registration. Just go to learn.asge.org, and that is where this recording will be located in one to two days. At the conclusion of this presentation, you will receive an evaluation survey for tonight's webinar. We would appreciate you completing this, and it only takes a minute or two. Tonight's objectives include identifying and applying the appropriate therapy options for both upper and lower GI bleeding. There will be time to answer participant questions, so please submit your questions through the Q&A box. Our course directors this evening are Drs. Bashar Qumseh and Madhav Desai. Dr. Qumseh is an Associate Professor and Associate Chief of Endoscopy at the University of Florida and is the Chair of the Standards of Practice Committee for ASGE. Dr. Desai is an Assistant Professor of Medicine at the University of Minnesota and a member of the Standards of Practice Committee. Now it is my pleasure to hand it over to Dr. Qumseh. Thank you so much, Lauren, and good evening to everyone. Welcome to all of you who are watching us live and also if you are watching us later on, I'd like to welcome you as well. Today I'm happy to be joined by my good friend, Dr. Madhav Desai, who is also one of our very important members on the Standards of Practice Committee, where we discuss and produce guidelines for the ASGE. Today's topic is a bit different from guidelines, although we may be mentioning some of the guidelines, and we will be talking about the toolkits that we have for GI bleeding. These are not a conflict of interests or disclosures that we have. And we have already gone through the objectives today. We're going to try to give you our advice on how to proceed if you have somebody with a GI bleeder and what are the tools available to you and how to best utilize them. Without further ado, I introduce Dr. Desai. Thanks, Bashar, and thanks, Lauren, for a great introduction. I would like to thank ASGE as well for this opportunity. So gastrointestinal bleeding is a, you know, one of the most common and favorite things for all of us. It's a common GI condition leading to hospitalization, one of the common calls overnight during inpatient rotations and so forth. Bleeding could be from upper GI sores, including esophagus or stomach or small bowel, or it could be lower GI tract in the form of fresh blood per rectum. This could involve a large bowel or sometimes rarely a small, you know, bowel as well. Now, severity and acuity depends on, you know, how long it has been going on and how much blood loss has happened. And that's what kind of guides us in terms of how should we plan the management. Now, the initial management steps include, you know, proper history, you know, going through what led to current presentation involving their medical conditions, previous surgeries, any recent surgery, any prior history of GI bleeding, and then what medications they have been on. And that kind of helps you determine what are the most probable sources. That includes, you know, physical exam, including a rectal exam, and if they have fresh blood or active melanin, that kind of gives you a trigger of when you should be intervening. Now, their hemodynamic status is quintessential in terms of how much and when you should be giving what type of treatment, and resuscitation is a key. Severity needs to be determined early on, and some of the risk prediction tools like Glasgow Blatchford score for upper GI bleeding or Oakland score for lower GI bleeding is pretty helpful. And these are the scores that you can use in your toolkit for determining whether to safely discharge a patient or that if patient will have worse outcomes during the hospitalization. So, based on these factors, you should be making an overall assessment, including what is the most probable source, what's the prognosis, and what type of procedure you should be doing, and when you should be doing. For example, if you are suspecting upper GI bleeding, including variceal hemorrhage, you should be doing upper endoscopy within 12 hours per ASG guideline on the role of endoscopy in management of variceal bleeding. If you are suspecting upper GI bleeding, you should be intervening within 24 hours after resuscitation, because resuscitation is critical. It will impact your outcomes in terms of what endoscopic therapy you will be doing and how long it will last, especially the outcomes among elderly individuals and those with comorbid conditions. At the same time, you should be thinking about sedation and the airway protection strategies, especially for upper GI bleeding. Now, when you start thinking about the endoscopy and you have decided about, you know, endoscopy that you want to do, you should be thinking next about how will you achieve a clear field, because if you do not have a clear field, you will not be able to find lesion, you will not be able to apply appropriate therapy. Clots, food, stool, debris, all of this interfere with visualization. For upper GI source, using a pro-kinetic like erythromycin infusion could be a good strategy. Double-blind randomness control trials have shown that they have, you know, erythromycin has better visualization compared to placebo. Meta-analysis of eight trials have shown that it could reduce the need for a second look endoscopy and improve mucosal visualization. However, there are certain caveats to keep in mind. Erythromycin could be difficult to obtain at your institution, so please check that. Pharmacy may require separate approval. You should review prior electrocardiogram since it could prolong QDC interval, and drug monitoring is required. It has some drug interaction, so something to keep in mind. Alternative is metoplopramide, one-time use, 5 to 10 milligram IV. The robust data to support its use is lacking, but again, it's something that could be considered. For lower GI source, you know, you need to give a bowel prep. This could be done as a rapid or a purge prep. You could, you know, administer large quantities, a gallon or half a gallon over next two to four hours, as far as it's safe and tolerated by patient. In some cases, nasogastric tube or nasodural tube could be placed to rapidly administer such large quantities of volume. Now, once you have this plan in place, the next step would be to review the case with your endoscopy team, and you need to discuss what are the required tools for you, what accessories you need to have, check the, you know, on-call card, what are the things that are already available, what type of scopes you will be using during the case, one or two, and what tools you might be needing, including a backup strategy. Now, for routine upper GI cases, you know, diagnostic gastroscope could be used, but be mindful that if you have large quantities of material that needs to be suctioned, you could have a larger channel, you know, therapeutic scope handy, because you could remove large quantities of material using that. Similar principle applies for colonoscope, so be mindful of various, you know, specifications of this scopes that you have available. Sorry. So, now you are doing an endoscopy, and you have, you know, started the procedure, but you have the same issues that are interfering with the exam. So, besides using a larger suction channel scope, you could use a Rothnet to remove large quantities of clots from stomach. Unfortunately, you will have to come out every time using this, and then go back in, and if your airway is not protected, that could result into some issues. Using a BioVac, which is a separate suction accessory attached to your suction channel, with the help of the suction machine directly hooked to it, could be a useful strategy as well, if that's available. For colon, you could use, you know, water exchange to, you know, clear the contents, if it's possible, and if the stool is not solid, that works well, or in rare cases, you could administer go lightly using the scope. In some cases, if the hydrogen peroxide is handy, it could be used to kind of, you know, liquefy the clots in the stomach or other debris, and that's something that could be incorporated in your toolbox. A simple method could be also to use your routinely available suction catheter at the bedside, and you can, you know, kind of cut the front part, make it less blunt, sorry, less sharp, and attach it to a pediatric gastroscope or a ultra-thin gastroscope, you know, slightly with tapes, and then you can use this through the OR tube so that it doesn't cause any injury to the esophagus. A nice video and demonstration is available at this source by Sobani et al. in the American Journal of Gastroenterology. Now, after these steps, once you are inside and examining, you should be examining meticulously for, you know, the probable source, if it's not readily visible. Look behind the folds and examine fundus and proximal stomach. Sometimes these are the areas that are hidden and may not readily show you what might have caused the bleeding. Do your best to clear the fundus, as discussed. Now, in difficult access areas, if there is spasm going on, especially in small bowel or colon, or if things appear and disappear behind the folds, a good strategy would be to use water, and a small amount of bleeding could appear readily when you are using water exchange or suction method using underwater exam. Similarly, a clear cap mounted on your scope could be a good strategy for small bowel AVM localization. All right, so let's get into the meat of the talk, which is what type of modalities we should be using or should be aware of for endoscopic hemostasis. Most of the modalities ultimately focus on some sort of pressure tamponade, and mechanical tools are the most common modalities that we use. This includes through the scope clips, over the scope clips, band ligation, and in rare cases using a balloon tamponade method or a stand. The clips come in various designs and of various size through different companies, and be aware of what type of clips you have and what type of over-the-scope clips you have, because they do come in different forms. They work pretty well when you apply them over the focal bleeding spot, and, you know, they have a wide range of applications. Almost anything can be, any place clips can be used. Studies and meta-analysis have shown that over-the-scope clip works pretty well compared to through-the-scope clip, because they are more durable, they are associated with less re-bleeding. However, be mindful that this requires you to come back, come out with the scope, go back in. You have to load the, you know, extra accessory on your scope, so you may find it difficult to get through certain areas where there is looping or, for example, upper esophageal sphincter or pyloric channel. Now, application is straightforward. You will apply through-the-scope clip precisely over the bleeding vessel. Be patient, take your time, and then you may need to place two more clips parallel to it or maybe more, depending on endoscopic hemostasis, you know, required. For over-the-scope clips, as we discussed, there are various types of teeth that they have, depending on what your purpose is, so examine your tool before you use it. The blunted type or the type A is the most common one for compression effect for GI bleeding cases. There are sharp teeth and beveled sharp teeth available, which are more useful for leak closure, fistula closure, and so forth, so you do not want to use those. Also, depending on the type of the scope, the clip diameter is different. Now, this works pretty well for lesions that are on FAS, something that can be suctioned well inside the gap, because application is similar to using a banding kit. Here, you will be deploying a clip instead of a band, so anything that is less than a two centimeter and suctioned well is a good, you know, lesion for over-the-scope clip. Second, you know, approach is band ligation method, and the principle by which this works is to kind of suction the entire tissue inside the cap and then applying the band. Mainly works pretty well for submucosal varics or anything that is submucosal by creating tamponade initially and finally healing by scarring. So, it can be applied for esophageal varices, rectal varices, internal hemorrhoids. Some studies have shown that it works pretty well also for game lesions in stomach. Be mindful that this works well for anything that is slightly elevated or flat. It is not going to work for polypoid lesion because this works by the principle of creating an artificial polypoid lesion. And again, diuretical bleed also could be tackled by a band ligation method, and the cap may help you find the lesion also. For refractory cases of esophageal varices bleeding, you know, there are certain options that are available and worth mentioning. One of them is placement of a balloon, a tube with two balloons actually, in the esophagus and stomach. And this is kind of vanishing art these days. You may not have it readily available on cart or, you know, in your unit, but in rare circumstance, you may need to use this. So, be aware that this is out there. Most of the time, this is available in medical ICU units, and nurses are well versed with this. So, please ask them if you need to use this. This requires the tube to be placed endoscopically in the esophagus and secured, you know, with a special accessory and need to be in place for certain hours, like 12 to 24 hours with a plan to go back in because this is also a temporizing measure. So, if you do not have overnight interventional radiology or capabilities of, you know, doing it overnight through TIPS or BRTO, then this is something to be aware of. Nowadays, we have, you know, other options available, including hemostatic agent application and self-expanding metal stents. Small-scale randomness control trial, you know, showed that self-expanding metal stent compared to esophageal balloon tamponade achieved better hemostasis among 28 patients and had less number of adverse events as well as less transfusion requirement. There was no difference in short-term survival. Meta-analysis of cohort study also showed that stent works pretty well, but again, this requires special expertise, and sometimes you need, you know, stent available readily when you are doing a call case, and you might need a fluoro as well if you don't have through-the-scope type of stent, which is not that common. Now, while you are waiting for the instrument that your tech is finding or giving it to you, you can do certain things when you see a bleeding spot, and one of them is using your water jet. So, you should direct it to the bleeding spot. It may provide some submucosal water pressure and tamponade and reducing the amount of bleeding. At the same time, you know, with any sort of hemostasis, you want to slow down the bleeding fast. This works pretty well for your bleeding during resection and dissection. Submucosal vessels that open up during resection and dissection can be controlled with, you know, water jet pressure. You can use the same principle using a distal cap as well by directing your cap right above the lesion or a bleeding vessel. Changing gears to thermal type of therapies, and almost all of these therapies basically work by principle of creating coagulation in the vessel. So, it could be a bipolar or a monopolar circuit causing electrocoagulation, argon plasma coagulation, radiofrequency ablation, cryoablation, or using coag forceps. Bipolar probe or goal probe is one of the most common modalities among this, and these are readily available. This generally is used as a dual therapy in conjunction with injection of epinephrine, which will cause vasoconstriction and slowing down the bleeding, and then you apply the probe directly over the bleeding spot or visible vessel. You need to apply firm contact with the ulcer base or the visible vessel, and at a lower power settings of 15 watts, you need to apply energy for good 8 to 10 seconds, especially for stomach ulcers. Now, be aware that when this is used in other areas, it may cause some deeper injury with longer contact, and especially when you use this instead of other modalities like APC for treatment of AVMs in stomach or radiation proctopathy in rectum because you do not have other modalities on call card. Then, be mindful that settings could be used that could be lower to avoid deeper injury. So, this is like one demonstration where if you encounter an AVM in colon, you could first inject, create a blab using submucosal cushion, submucosal saline injection and cushion, and then apply the Google probe over it to minimize any injury. We were talking about APC earlier, so this is a non-contact, you know, coagulation compared to other types of thermal coagulation. You would want to limit the mucosal contact because the principle with which this works is different. And if you are touching mucosa a whole lot, that means that you need to change your strategy and probably get near the lesion. But you should stay away at least 2 millimeters and not more than 10 millimeters away. It could create submucosal gas entry if there is too much contact with the mucosa, and that could lead to perforation. Now, this is pretty good when you have multiple, you know, mucosal lesions like AVM or GAVE, because you can apply APC over multiple areas or a wider area like GAVE over a shorter time effectively. This works pretty well for smaller, non or minimal bleeding lesions. It generally does not work that well for arterial bleeding or breast bleeding. Radiofrequency ablation and cryoablation are other options for minimal bleeding lesions like AVM or GAVE. And here you could touch or contact the mucosa for application compared to Barrett's where, you know, you could apply the ablation in two applications, cleaning two applications or three applications and no cleaning type of protocol. Here, when you are treating in stomach, you may need to apply maybe four applications and make sure that the lesions have been completely removed and there is a white coagulant that has formed. Similarly, cryotherapy is another option. This comes in various types of catheter. You could have a balloon type of catheter method or a spray cryotherapy. Again, these are different from each other, but know how to use them. They could be used to treat, you know, GAVE or radiation proctopathy type of changes. Finally, hemostatic forceps, you know, contrary to what forceps are used for, this is a little bit different. Here, the soft coag current, you know, applied to the vessel, you know, for a brief duration of one to two seconds lead to coagulation and reduces, you know, chance of bleeding. This is very common during endoscopic submucosal dissection, ESD-POEM, for prophylactic coagulation, but could also be used for treatment of visible vessel in a forest class 2A peptic ulcer disease. Again, you need to grasp the vessel, bring, you know, in the, you know, your hemostatic forceps a little bit. Do not yank or cut the vessel, otherwise there will be more bleeding. So you need to be very precise and just brief one to two seconds of coag current. All right, so now epinephrine, a very common agent. We all are aware of epinephrine's use in various aspects of GI tract and, you know, mainly works by causing vasoconstriction. So it is helpful to slow down the bleeding so that it improves visualization of the field and you could apply definitive therapy. It's not a good option at all for standalone therapy. It should always be used with a second form of therapy, like a clip or thermal coagulation. Do not use anything less than 1 is to 10,000 because this could be absorbed in the systemic circulation and cause arrhythmia and other complications. And do not use more than 2 mL per site. It could lead to local tissue ischemia. All right, so now fibrosing agents, not so common, but they have typical use during management of gastric or the ectopic viruses elsewhere in the GI tract. They mainly work by the principle of causing tissue scarring and fibrosis and ultimate collapse of the varic sclerosants in the form of absolute alcohol in an aliquot of 1 to 2 mL max, less than that could be injected into the varics. Glue injection, now less favorable option because it is associated with several side effects, including arterial and venous embolism. EWAS guided coil placement is also very common nowadays because it is very precisely done under the guidance of ultrasound of your EWAS scope. Finally, the application of hemostatic agents. I have been seeing this for last probably four or five years now, and they have become very, very popular to the point that they are misused in some cases. And know that they are good for immediate hemostasis. These are chemicals that when come into contact with body fluids, including blood, will start coagulation cascade and form a local clot. But again, that can be washed off with body fluids, especially in esophagus, stomach, colon. So it's pretty good as a salvage or a rescue therapy, but it could be used in conjunction with primary therapy to provide additional hemostasis. The meta-analysis of 19 studies have shown that they work pretty well with high clinical efficacy and success, but know that re-bleeding occurs in almost 23%, 25% of the cases. All right, so now I will hand over to Bashar to discuss some clinical cases and polls, and then we can start our discussion. All right, thank you, Madhav, for an excellent presentation. I do want to remind our audience, if you have any questions, please feel free to use the Q&A, and we will try to answer those as much as possible. Madhav, this was a very good presentation about various aspects of how to manage bleeding. I'd like to, before we do cases, add a couple of comments. As we're discussing a lot about endoscopic management and what you can use. But of course, what we teach the fellows and residents, obviously, any time you have GI bleeders, always pay attention to the ABCs, the airway, breathing, circulation, make sure the patient is resuscitated, things like that. I always also like to point out to our trainees, fellows, residents, and students, the differences between managing a variceal bleed and a non-variceal upper GI bleed. Mainly, obviously, you said about the timing, Madhav, that for variceal bleeding, our guidelines would indicate that you should do endoscopy within 12 hours, but not for non-variceal pericardial ulcer kind of bleeding, where the patient can be resuscitated and this can be done the next day if the patient is stable. So that's one difference, is the timing. The other two things that are different about variceal bleeding, obviously, is octreotide and antibiotics that are in the guidelines as well. With regarding to clearing the field, one additional thought I had was about moving the patient to move the clots from, if the clot is covering the lesion, then sometimes, depending on where the lesion is, you might have to move the patient. We recently had a case like this where a patient had a large amount of clots in the fundus. And once a patient was done in the ICU and we moved the patient more to the left lateral position and semi-prone position, and we were able to uncover a very large ulcer in the fundus which is not a common place, and biopsies turned out to be mucormycosis. Oh, interesting. It was a very interesting case. So positioning can be very important for clearing the field. So think about that as well. Agreed. There are newer methods for hemostatic agents that are coming on. And we don't have to mention specific ones, but there is two or three more modalities that are currently available and they may be available in your endoscopy suite. So some of these agents, obviously once you start spraying them, you can't see anymore because of the snowstorm, but some of the newer ones don't have that limitation. So be on the lookout for some of these newer agents and some of them may be very helpful. We have a question. Let's see. What are your thoughts regarding the utility of using a Doppler endoscopic probe in GI bleeding? Madhav? Yes. No, that's a good question. And there is some data available. Some of the old studies showed that there is utility. It's just that it hasn't become that favorite in terms of widespread availability. But to my knowledge, I have never used it, but all the data that I write up on it sounds to be a good strategy in a way that you could localize active vessel and then direct your therapy accordingly. But again, now with over-the-scope clips and other options, you could argue that what will be the cost effectiveness and the competency expertise required in the interpretation of using a Doppler-based sound or some strategies. So something to kind of needs to be studied further. I agree with that. Thank you, Madhav. So thank you for the question. If you have any further questions, please go ahead and use the question and answer. So we'll present this case here. We'll go through a few cases and see if we can have some discussion with the audience here. So we have a seven-year-old male. He has a coronary artery disease, AFib, congestive heart failure, COPD, chronic kidney disease, GERD, and alcohol use, and apixaban, who presents with hematemesis for four hours. On admission, he was found to be hypertensive with a blood pressure of 90 over 60 and tachycardic heart rate of 115. What are your thoughts about this, Madhav? You know, your fellow on-call called you about this, and what would you tell them and what are the next steps? Yes. So, you know, first things first, right? So as you mentioned, the ABCs are very important and assessment, including, like, what medications they have been taking, when was the last dose of apixaban, what are their hemodynamic parameters, are they orthostatic, are they able to protect their airway right now, you know, things like that. So those are very important. In an individual, you know, of 70 years old, with, you know, using anticoagulation, presenting with brisk upper GI bleeding, I would be very concerned about airway, their hemodynamics appear worrisome to me, so definitely starting fluid resuscitation and thinking about what are the possible etiologies and the timing of the endoscopy. So first goal here would be to prevent hemorrhagic shock, you know, medical ICU admission for very close observation, considering starting proton pump inhibitor drip, if you are suspecting chronic liver disease in this individual, starting octreotide also would be a good idea initially. And then once patient has been, you know, resuscitated well enough, then the question is the timing and type of the procedure. Excellent, excellent. So as we said, you know, airway, breathing, circulation, transfusion, can you remind us what are the transfusion goals for especially a patient like this coronary artery disease? What do current evidence tell us about transfusion goals? Right, no, that's also a good point to highlight here that there is very robust data and well-supported by the ASG guidelines on upper GI bleeding management that, you know, packed red blood cell transfusion should be performed if the hemoglobin is less than seven to the goal of seven. But if somebody has coronary artery disease or recent, you know, intervention, then that criteria could be between seven to eight gram per DL. So it would be good to obtain precise history on, you know, if they had any interventions or they are having active angina consulting cardiology if they have different goals. But something to target for. Excessive transfusion in any setting, you know, might lead to more complications than any benefit. So there is no point of overshooting here. Excellent, excellent. So goal of transfusion seven to eight and seven for patients with no coronary artery disease. A common question we get about this is, you know, the patient recently had an epixy band. So, you know, it's contraindicated to do endoscopy. What do you say about that? Right, no, it's a great dilemma, but it's like, you know, that point where if they need to undergo endoscopy, they need to undergo endoscopy. So ideally, if you can hold the blood thinner, which obviously since they are presenting to a hospital, which will be held, but waiting too long may be perilous sometimes. Now, if they have stable condition and if you can achieve a complete reversal of the agent, that's ideal, because in that situation, you could apply endoscopic therapy better, or you may not see any lesion that requires endoscopic therapy, which means a good prognosis and a good outcome. So ideally determining whether what's the severity, acuity, but whether you need to do a reversal or not. Exactly, that's a good point, you know. So all this discussion about anticoagulation, if somebody is emergently bleeding, then you have to intervene. Clearly, if somebody is on anticoagulation, you can still apply CLIPS and they would work fine over the scope of CLIPS. You could argue that maybe bipolar may not work as well and APC and stuff like that, but localizing the bleeding and trying to treat it as soon as possible in somebody who's urgently bleeding is very important. So, all right, very good. Next. I would also like to emphasize that, you know, bleeding is unfortunately common in patients who had elevate therapy for heart as, you know, bridge or transient therapy, or sometimes after the recent coronary intervention, where they cannot stop, you know, the blood thinner. And in that case, delaying the management, you know, is not gonna help the patient. At least a diagnostic exam would be helpful to localize the lesion and grade the severity and management can be planned that way. So, this patient underwent upper endoscopy and, you know, the patient was noted to have significant inflammation in the form of esophagitis in the distal esophagus. Nothing actively bleeding. There was a large hernia. There was no blood in stomach or small bowel. But when, you know, further examination was performed, you know, there was this area where bleeding started in the form of oozing. So, at this point, should we be doing anything or should we be waiting, you know, maybe bleeding will stop on its own or should we be applying some form of therapy? So, that's the question. And, you know, after cleaning the area, actually a brisk bleeding started. And at that point, it was obvious that this was the culprit. So, the point that- What, Madhav, do you want to interrupt? If people can tell us what they would do in the Q&A, that'd be nice. You know, you go in, you find this lesion. It's obviously actively bleeding. What are your thoughts and how would you do it? And Madhav, you can go ahead and tell us what you did. Yeah, so the point that I was trying to emphasize before I jump onto the management is that many of these cases, by the time, you know, you actually do the procedure, they might have formed a fibrin plug because of resuscitation, timing, you know, body is, you know, working towards the clotting, but it can open up again. And it would be a good idea to remove any clots, remove any fibrin plugs, and do a thorough exam. And that will save another endoscopy, reduce the hospitalization, and reduce the transfusion requirement, because all of them are associated with more complications, as you know. So in this case, basically, you know, clips were placed with complete hemostasis. You know, I would like to know what audience think about, what are the alternatives? And I can talk about the alternatives in this. Madhav, we have Daniel saying he would consider banding. So that's one of the alternatives that somebody came up with. And we also have a question about this. It says, in which clinical scenario would you do a second look endoscopy for ongoing or recurrent GI bleeding versus consulting IR? Right. So let's say you want to end in this case, and the first endoscopy is like the first picture you showed, and you really didn't see any active bleeding. What one do you think a second look endoscopy is useful? So second look endoscopy is useful when either you are strongly suspecting a lesion that was just not seen, there was large amount of blood clot that you could not clear despite your best attempts, and or there is ongoing, you know, bleeding, overt bleeding, or that there is ongoing hemodynamic, collapse and patient is not recovering. So these are all good points to have a second look because you need to consider the benefit and risk ratio. So the benefit of doing endoscopy outweighs any possible risks involved in that case. Coming back to the first question from Daniel, that banding. So, you know, no obvious varices or varics was demonstrated here. There was visible inflammation and banding may work well, but it may backfire as well, meaning that the band may not stay in place in the setting of significant scarring from inflammation. It may dislodge, you know, within a few hours and may not provide sufficient hemostasis. But that's definitely a good thought. I had some other alternative considerations including over the scope flip. But again, you know, this area is inflamed, fibrotic, again, you need to have lesion better on FAS, which this may not be, it's at around three o'clock. So you may not be able to apply the clip. You have to get the clip down from UES for the esophagus. It can cause sufficient edema and blockage of the lumen and you may have dysphagia. So those are the considerations you should be running through your mind before deciding the therapy. So very good points that you make. You know, I think the banding is not a bad idea, although with the lack of varices, it may be difficult to suction that area and stop the bleeding. So Daniel was also thinking that this does have the look of a variceal bleed in the sense that it looked there was an active bleed that was brisk. Although based on that picture, obviously endoscopy is based on video, not based on pictures. This looks like an arterial bleeding source, which is not kind of what you expect from a variceal kind of venous bleeding source. I agree with you. Sometimes I'm reluctant to use over the scope because it is more permanent and whether it can cause dysphagia down the line is a question, although I have not seen that personally. And I do not shy away from using a vesicle because it's a much bigger clip and it can definitely control the bleeding if you cannot control it. I think the key when using clips is to sometimes, actually a lot of times the first clip does not get it. So it's okay to use several clips, but the point is you need to clip enough until there is no more oozing or bleeding, right? You have to convince yourself that this is not bleeding anymore, that you got it. And usually you can tell when you get it that it's no longer bleeding. So once you place, in this case, you placed three clips, I usually would watch for at least a few minutes, rinse it with some saline and just sit there and make sure that I am convinced. The other thing with the clips that they can, obviously everybody knows, that IR can then target the clips if free bleeding occurs and they kind of know where to go. The problem with consulting IR early, if somebody is having bleeding, you go and you don't find anything, the likelihood that they are going to find an active bleeder is low and they usually will end up, if you tell them there's an ulcer but it's not bleeding in the duodenum, they might call the GDA or something like that. We do have a question from Abu Zafar and he said, any role for epi injection before clip? Yes, so no good point. In certain cases, you could use it so that the bleeding slows down and then you can take your time, be patient, applying the therapy because first clip is the best clip. Other clips, you will be just placing alongside and that's how it should be. So if that's the modality you want to use, go for it. And again, this is one circumstance where using epi may help or make things worse because if you are using epi, especially the needle, if you are not precise and taking time, it could create more trauma and that may create more problems. Second thing is that sometimes if you are using too much of epinephrine or any fluid in a narrow space, it may create some tissue edema and then applying clips over that, at least within the next few minutes, might be a little bit tricky. I agree with you, Madhav. The third point I would say to Abu Zafar is epinephrine is less likely to be helpful in a brisk bleed or arterial source like this. And I think it may be less helpful in these cases. More and more data is suggesting that we're going away from injections because they are temporary, they can help temporarily, but they're not good for the long term. So we need to be thinking about something more permanent in this case, although I would say never use epi in this case, but I personally would not have used epi in this particular patient. The next question we have is from an anonymous attendee. Said, can you use bipolar or epinephrine in the esophagus? I think we kind of talked about the epinephrine. Yes, you can use it. We talked about when it may not be a great idea. What do you think about bipolar? Again, the same principle that the bleeding is so brisk and be mindful that esophagus has a narrower kind of wall. So there is no separate cirrhosis. There is only adventitia. And the muscle layer is much thinner than the stomach. So it may work in some rare case or here and there, but for this type of bleeding, I would go with clips, more durable as well, and more guaranteed that it's less likely to re-bleed. I would agree with you. I think theoretically, yes, you can use bipolar in the esophagus. Bipolar is really good if you find a bleeding source and you think there's a blood vessel underneath it and you wanna coagulate that blood vessel. And it works better, I think, in peptic ulcer kind of disease rather than in this setting. But yes, you can use bipolar. Anywhere in the GI tract. And another point I would like to emphasize is that majority of data for the bipolar probe is inclusive of patients for peptic ulcer bleeding, and especially that Forrest class 1B and 2A. It doesn't have a whole lot of data for other type of lesions, especially Forrest class 1A or like Malory-Weister where there is substantial inflammation in esophagus. So, yep. Very good point. Okay, keep going. Thank you for the questions. We hope we're answering your questions. So we talked about the alternatives here. Yes, so- Go ahead. The second alternative was using a hemostatic powder. Again, for a salvage, you can consider it if some oozing continues. But as a primary therapy, again, it's not gonna work that well. It's esophagus. There will be a lot of saliva going through mucus flow and it will wash off very easily. So have a second strategy ready if you are using hemostatic powder. I agree with you. A lot of time we're using hemostatic powder if it's a larger field that clips cannot cover it, like that mucor cases I was telling you about we ended up hemo-spraying because it's a large area. Or if you fail or you place clips, you think you're still maybe seeing some oozing, then maybe a good adjunct therapy. Okay. So the next case here, we have an 80-year-old patient with end-stage renal disease with AFib and Warfarin, coronary artery disease, self-postentive and aspirin presented with three days of melanoma. And, you know, we're going to skip the questions about, okay, ABCs and then transfusion and stuff. We kind of talk about that already. The question is, when would you do endoscopy and what are the options? All right. So, you know, after the initial management as discussed, you know, the question is, when should we be intervening? And this is a scenario where, you know, you know, past medical history itself is suggestive of possible upper GI sores. So once the patient is, you know, stable enough, then, you know, within 24 hours, you would want to take a look in the stomach and small bowel. Possible causes could be, you know, peptic ulcer disease, AVMs, and so forth, right? Again, melanized there, so less likely upper, sorry, esophageal sores, but again, that could happen as well. So ultimately upper endoscopy was done and it showed this finding in the second portion of the duodenum. And then, you know, one question is, what is this lesion? How do we classify and what can be done for that? All right, well, we'll open this up for discussion. If you want to tell us what you think about this, what does this look like? How do you classify this in the duodenum? And what would you do about it? We'll tell you what we did about it shortly here, but again, no wrong answers here. This is a learning session, so you can tell us, feel free to say whatever comes to mind and we'll discuss it. Go ahead, Manav. Yeah, so, you know, this is a, you know, duodenal ulcer. And since there is a red spot in the form of visible vessel, as per the forest classification, this is forest class 2A duodenal ulcer. So once you have determined that this is, you know, peptic ulcer with a visible vessel, you should be thinking about what type of therapy you will be performing here. All right, Manav, we have an answer from Farnaz Shariati in forest 2A, epi, bi-cap, and clip. And Jared says, looks too big for a vesco. Anonymous attendee saying epi and bipolar. Ahmed is saying epi and a gold probe, essentially bipolar. So a lot of people wants to inject it with epi and use bipolar. Right, and these are all good choices. And, you know, in this case, you know, after injecting epi, a clip was placed. There was no, you know, issue either with using a bipolar versus a clip, it's just that a clip was placed. And after placing the clip, there was still, you know, minute oozing, and this could happen very commonly. So don't be afraid, watch if it continues. A capillary leakage occurs very commonly after placing your first clip. But once you place, you know, the second clip, that generally stops after providing enough tamponade. Again, bipolar is a good strategy, and I will tell you the reasons why this was not attempted. You know, posterior wall of the duodenum and a very deep excavated large ulcer. If bipolar fails, then problem is that application of clips could be challenging. But again, that's a real life scenario. Second thing is that your scope channel and application of the bipolar to the lesion. So sometimes, you know, it is not in an area where you get the bipolar probe easily applied. And that was one of the reason that clips was chosen. Again, I'll say- If you go back, Madhav, this ulcer doesn't look very typical, if you will. It is a bit, as Jared said, bigger. Has a lot of fibrosis. What are your thoughts? Do you remember what was the etiology? Do you know what was the etiology of this ulcer? Was it related to aspirin or was it ischemic or what's going on? Do you remember? Right. So a lot of thoughts came through. I mean, malignancy was also a consideration, but it looked benign. Just a lot of fibrosis and large size. You know, patient with end-stage renal disease with, you know, hyperperfusion because of dialysis and et cetera. So ischemia also came as an option. It turned out that aspirin was likely the culprit because patient was using aspirin for his knee pain as well. And that could have caused it. And it did not occur, you know, afterwards. Sorry, recur. It didn't recur. So we did not know exactly. Stomach biopsies were negative for H. pylori as well. Okay. I have a couple more questions in the chat here. We'll address the issue of Ovesco. This being too big for Ovesco, I think we're going to talk about in the next slide. Wilfredo says 15 watts in bipolar for duodenum. What do you think about that? Yes. So for duodenum, I generally check. So basically for each type of thermal coagulation, make sure that you check the electrocautery settings before, you know, starting the therapy. And it's important, be it APC or GoPro or anything. So for small bowel, I lower the settings to eight or 10 watts and generally it serves the purpose well enough. Again, it depends on the lesion as well. Sometimes if the ulcer is very, you know, fibrotic and you do not have any significant bleeding occurring after you've started the therapy, you could use a higher settings as well. But generally I go with around 10 for small bowel and 15 for stomach. Yes, I agree with that. I agree with that setting. I have seen a patient who had perforation in the duodenum from bipolar. It wasn't a patient that I did, thankfully, but obviously it could happen to any of us. So this can happen. So you have to be mindful of that. And I think that's one of the beauties of using a clip. You don't have to worry about that as much. Anonymous attendee says, ACG guidelines give stronger recommendation to bipolar compared to clips. What are your thoughts? No, definitely. And this is one area where there is more data probably for bipolar because that was a time when only bipolar was available. And once clip came out, especially in last, you know, at least seven to 10 years when we have over the scope clips as well, and we have become more familiar, there is not a whole lot of data being reported. So a head-to-head, you know, comparison is always difficult and challenging. So the level of evidence and certainty is definitely strong for bipolar. But again, you should be thinking your options and what type of, you know, lesion you are tackling with. Again, using bipolar is not a problem. You could use it, but for the same reasons, what I wanted to emphasize is that be mindful of certain aspects where bipolar may cause problems. I think bipolar, clearly a lot of people are training on bipolar based on the answers. There's nothing wrong with that. I think more advanced endoscopists, and that's just, I don't have data for this, but that's just my feeling, tend to like to use more clips, maybe because they're more comfortable using clips. You can see the immediate effect of clips working, or you can place more clips, and less of an issue of possible perforation. Clearly the guidelines do recommend bipolar, nothing wrong with using that. Clearly here, you could have used bipolar, clips was done, and it seems to have worked. Another case from Kock, Poon Chen said, in cases where we suspect uremic placer dysfunction and see adrenal disease in this case, in addition to using anti, use of antithrombotics, would we consider DDADP or estrogen? What are your thoughts? Yeah, so that's a good thought. I mean, reversal of the endocogulation should be definitely part of your management algorithm, and definitely depending on the hemodynamic compromise, you should be considering. Now, speaking about estrogen, I have not personally used it, because it's more of a kind of a salvage option if everything has failed, because it's more of a medical option rather than endoscopic hemostasis option. DDADP has been utilized for certain cases where you feel strongly that there is widespread angio dysplasia or small bowel AVMs are the culprit. But again, that's something could be done in consultation with hematologist. I have not personally used or come across a strong literature favoring them for standard routine use. I think for DDADP, I have used it, mainly ICU attendings have also done it for end-stage renal disease with brisk bleeding. I think it's not an unreasonable idea. As Amadav said, I don't know about a lot of evidence, but it does make sense, and it is used usually for patients who have brisk bleeding upper or lower. So it's not a bad idea. Does the clip stay where when there is so much scarring and we are not able to get a healthy margins and can they have delayed bleeding since the clips are at risk of falling off? I'll just talk about the delayed bleeding here, if you will, Amadav. Normally we think of delayed bleeding mostly happens because of thermal injury. And so actually you're more likely to have delayed bleeding if you use the thermal modality like bipolar, because then you form a scab and then you do that can fall off and that's when the bleeding happens. So I personally don't think that is much of an issue. We don't know when the clips fall away because we don't really follow them to see when they go away. And having the scarring in there is an issue, but as long as it seems like in this case, you got the culprit blood vessel and that seemed to have worked. Would you agree Amadav? Yes, and see the basic tenet is that you want to convert a lesion from high category to the lower category. That's all we are doing. So endoscopy hemostasis is important, but it basically is one of the steps in your management. So let's say in this case, so patient will be needing some sort of medical management as well in addition to resuscitation, endoscopy, and then, you know, PPI or whether they have H. pylori, you know, stopping their aspirin, things like that. So that is very essential. So you are converting, let's say, forest two now to forest three eventually, and, you know, finally resolution of ulcer. So that's important. Another point I would like to highlight is in favor of clips, I guess, kind of to piggyback what Dr. Kamseya mentioned that ulcers can be formed later on from bipolar could happen. This in rare situations where I had difficult ulcer bleeds in, you know, posterior wall of the duodenum or in duodenal bulb where, you know, excess has been challenging for any sort of therapy. I have placed clips and then immediately called radiology to be on standby. Because if things are challenging for you or very difficult for you, your clips can provide a roadmap for the interventional radiologist if things open up. Second thing is that anywhere, even after your endoscopic mucosal resection or your ulcer, you need to apply clips so that you do not see, you know, more than one millimeter of tissue in the prong. So when you apply the clips, you should have the tissue or the vessel completely within it. So it should be deeply embedded in the tissue. Very good points, Madhav. And we'll move on. But we have a couple of questions about, can we use bipolar and anticoagulants? Yes, you can use them. As we said, if somebody is bleeding and you have to stop the bleeding, then, you know, you can try to anything at your disposal. And it's not contraindicated to use and it could save somebody's life. How soon after a doacroversal agent would you feel comfortable performing coagulation hemostasis? I would say you can perform coagulation hemostasis on anticoagulation if you have to do it, you know? So if somebody is bleeding, there is no problem with doing endoscopy and whatever you would do normally, injecting epinephrine in this case, placing clips, Ovesco, Hemophage, anything else you can do. And the goal is to stop the bleeding. So I don't let that stop you from providing a potentially life-saving treatment. Go ahead, Madhav, so we can get to that. Yeah, I think we kind of already discussed alternate options. So I'll move on to the third case. All right, excellent discussion. Thank you guys so much. Third case, a 70-year-old female, history of a simple vascular accident or plavix present with melanin for 12 hours. A history of two prior similar presentations with EGD and colonoscopy being unrevealing. Capsule endoscopy was done the first visit with non-bleeding ABMs, one of them, as seen in the duodenum and was treated. On presentation, she's hypotensive, tachycardic, hemoglobin down from 11 to eight. MBUN is not elevated. What are the next steps? What are your thoughts, Madhav, and what would you do? Right, so like this is kind of a challenging scenario that this is kind of in the category of, you know, overt but, you know, obscure source. So a small bowel source is suspected, or at least you should be thinking through that. At the same time, other lesions can happen, right, that there might have been proximal small bowel AVMs that might not have been seen on a capsule study. Be mindful that capsules do miss lesions, although they are pretty good, but 15% chance that proximal small bowel source could be missed as they pass very rapidly in this area. Her presentation is very unique in the sense that she is having repeated occurrences, so something is being missed, and one AVM by itself is not enough. She is hypotensive, tachycardic. That means she's having significant, you know, bleeding going on. So in this case, upper endoscopy was done first to look for any proximal source that could have contributed, but the endoscopy was unrevealing. That led to colonoscopy, and you can question why colonoscopy was done versus capsule endoscopy. During the upper scope, no, you know, significant pathology was seen in small bowel and colonoscopy, you know, could show you divertical bleed or any lesion that could happen in colon. That was the reason colonoscopy was pursued. There was evidence of hematin, like old blood and some fresh blood throughout the colon, some diverticulosis, but nothing actively was there that was seen. At this point, what would you like, what would you guys do? Would you guys do anything differently during the procedure, or you would just rather wait and watch? She had, this is her third episode. We'll see if people have comments, but one important thing you mentioned is that their BUN to creatinine ratio, you said maybe the BUN wasn't elevated, indicating maybe this is not an upper source of bleeding. And we'll see what you guys did, but I think it would be reasonable to, at least during this colonoscopy, to try to intubate the TI and push as deep as possible, if you can. Let's see what, there are some comments coming in. Bleeding scan, says one of them, is this, is the patient, was the TI intubated, which is what we talked about, push enthoroscopy, Ahmed said, not sure upper or lower, and could we have pursued a push in enthoroscopy to begin with? So a couple of questions here, maybe at the time of the EGD, maybe we should have just done a push enthoroscopy to see. So those are some of the comments. Thank you guys for the comments. Go ahead. No, all good options, and this is definitely something to kind of think through when you are actually doing the case and doing the colonoscopy. So since there was like evidence of fresh blood, kind of prompted to take a look in the terminal ilium as one of the participants mentioned, and TI was intubated, and initially there was nothing, but after like 20 centimeters deep inside, there was this lesion, you know, that is being highlighted on the video here, very brisk bleeding, almost kind of making the field murkier, more water is being pushed, and it shows like a brisk bleeding. This appears to be an arterial bleed. You can see the pulsating blood coming out of this. Very good case. So what will people do about this? You can let us know. Guess, I would kind of guess if Medav did this, what he would do, but what would people do about this? Clearly you can find the source here. I think personally, this would be a perfect case to try to clip it, right? Right. And, you know, this is like, you know, and doulafoil lesion. So they are not uncommon, especially nowadays when, you know, everybody's taking PPI, and H. pylori is like getting extinct, I guess. Anyway, but they do happen. And when somebody had a source that was never localized after two hospitalizations, this is something to think about, especially for overt substantial bleeding. So this was an ileal doulafoil, and, you know, three clips were placed. Point that I would like to highlight here is that do not give up. Take your time. If you see some fresh blood, going back and forth is worth your time and hospitalization. And, you know, bleeding scans are good, but many times they do not show any substantial, you know, finding. They will show you that there is a bleeding in right lower quadrant, which will again make you do either deep endoscopy or colonoscopy. Second thing is that, you know, tattooing the, you know, area proximal to the doulafoil lesions as a roadmap for endoscopist if they have to go back in. All right, very good. Excellent case. Next. So now I will hand it over to you. All right. Well, today we've tried to go through how you would decide about using the right tool. Sometimes it's only not one tool and need to do a combination of tools. And we said multiple options to consider, which is good news for us endoscopists. There's a lot of things that you could do. Always think about the durability of what you would do. Especially we talked about using epinephrine not being very durable. Also a lot of hemostatic agents are not very durable. Be aware of the anatomy, the location, and as we said, after you do an intervention, make sure you wait and confirm that you have achieved hemostasis because that's very important. Next. We said about electrocaloric settings and how to try to avoid harms. Talked a little bit about delayed complications. You do an intervention, somebody comes in later, they have new symptoms after recent endoscopy. This is very common, delayed bleeding, especially after colonoscopies, polypectomy. It's the most common cause of bleeding that we see after intervention is bleeding after polypectomy, especially hot. I'll throw in my one cent on this, that the more cold sneers, and I feel very strongly about this, and there's a lot of data about this now. A lot of guidelines are recommending cold sneers now. The more cold sneers that you use, the less likely you're going to encounter this delayed bleeding. You have these delayed bleedings come in, doing a colonoscopy or endoscopy as soon as possible is important because we know where we took the polyp out, we know where most likely the bleeding is, and we can intervene effectively and stop the bleeding. And we said, if you cannot achieve hemostasis, then what are your options? We talked about IR, obviously surgery is an option. Repeat endoscopy, colonoscopy is always an option, bleeding scans and things like that. Next. So the take-home points that we want to take from today, you know, know all the tools that you have available. We're having more and more tools available, seemingly all the time, which is good news. Think about the steps that you need for management, you know, the timing, the clearing of the field, and then the different options that you could use. Clearing the lumen of the patient using some of these agents, repositioning the patient, decide on the right therapy, use it effectively, confirm that it is effective, and keep backup ready. One modality may not work, always important if you're doing this on the go in the ICU, on the floor, you don't have all of this stuff available, make sure you let your technician and nurses who are on with you say, this was suspecting a peptic ulcer disease, please bring CRIBS, please bring a VESCO. They may not have that stuff available all the time. You know, if you want a therapeutic scope, if you want a banding kit, so make sure you have that discussion before they head over to the floor or the ICU so you have everything you need and you don't have to stop in the middle of the case and go back and get hemo spray or whatever. Thank you guys so much for being here tonight for all the questions. We hope this has been helpful for you. Thank you, Medha, for preparing these slides and these very interesting cases. Always GI bleeding is an important topic that all of us have dealt with and will continue to deal with and keep up the good work. If you have any questions, feel free to let us know and thank you guys so much. Thank you.

70-year-old female patient

stroke

Plavix use

melanoma

endoscopy

AVMs

bleeding

duodenal AVN

hemostasis

alternative therapies

gastrointestinal bleeding