Today, management of immediate bleeding after cold snaring on the ASGE SuTab tip of the week. Substantial immediate bleeding from cold snaring is extremely uncommon, but occasionally you'll see more bleeding than you want to. You feel like you have to do something about it. I've seen a couple of occasions where I had to place clips because patients were bleeding, usually from multiple sites, they have some sort of coagulopathy, but it's distinctly unusual. In the great majority of time, we can stop persistent bleeding from cold snaring with simple tools that don't involve clipping. So we'll review the use of the water jet, direct pressure with the tip of the scope, squeezing the area with the snare for a bit, and then releasing it without transection. And then finally, even if it's bothering you in many cases, if you just leave it alone for a couple of minutes and continue on with additional examination, when you go back and check it, it's stopped. The first tool to use in almost all cases, if you've got immediate bleeding that's more than you like, is the water jet. So you have a good strong water jet, blast the defect, it'll force fluid into the submucosa. You'll see it build up as a submucosal mound of fluid. Then just leave it alone for a minute, let it tamponade. Another measure you can take to stop immediate bleeding after cold snaring is to use tamponade with the tip of the scope. So here you can see we've pumped some fluid into the submucosa, and we've still got bleeding. So we're just going to take the tip of the scope and push it into the defect to tamponade the bleeding. I don't know how long to hold it. This is filmed in real time, it's unedited, so you can get a sense of how long it's held, perhaps 20 seconds or so. This reminds me of when we did sclerotherapy for esophageal varices years ago, and it was not uncommon when you pulled the needle out of the vein that there would be some hemorrhage, sometimes brisk, and we would simply hold the scope tip against it, put pressure on it, and it would typically stop it. So this very often is useful to stop immediate bleeding. It's more rapid than you'd like after cold snaring. There you can see this bleeding stop. A final approach or tool to use to stop immediate bleeding after cold snaring is to use the snare again and re-grasp the defect, squeeze it, put a tamponade on the mechanical constriction with the snare and hold it for a short time. So here you can see we've got some fairly brisk bleeding coming off the bottom edge or in the previous orientation sort of to the left side of it, and we've grabbed a hold of that part of it with the snare, sometimes grab the whole defect. We tried already filling up the defect with the water jet. I don't know how long to hold on to these. Usually I think probably if I do this, which is not often, it's held for about 30 seconds and then release it. Usually you'll see a little submucosal cord where you were squeezing it and good control of bleeding. This is a cirrhotic patient who bled briskly from every polyp that I removed, and there were multiple polyps. This is in the sigmoid. So get right down on top of it, blast away with the water jet until you see the submucosa start to swell a little bit, and then usually best to leave it alone, go do something else. I took off a couple more sigmoid polyps. They also bled briskly, gave them the water jet treatment. The patient had varices in the rectum and then drove back up here, which you'll see in a second, and the defect, which is at the top there, looked fine. Cessation of bleeding, nice swelling of the submucosa. Next week, cold clearing of FAP on the ASGE SuTab tip of the week.

bleeding management

cold snaring

ASGE SuTab tip

water jet

mechanical constriction