This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. Hello and welcome to this video presentation showcasing the practical use of the endoscopic Doppler probe, EDP, in guiding treatment decisions and effective hemostasis. We will explore how the EDP can help us in three challenging scenarios, assessing ambiguous lesions for high-risk stigmata, targeting treatment in large ulcers, and guiding therapeutic decision-making when the clinical scenario and endoscopic stigmata are discordant. Our first case involves a 67-year-old man with a complex medical history, including paroxysmal atrial fibrillation on apixaban. He presented with coffee-ground emesis, melanin, and presyncope. The patient's acute blood loss anemia and hemodynamic instability necessitated ICU admission and multiple blood transfusions. During the emergent EGD, a gastric ulcer with indeterminate features was identified. Distinguishing between a flat pigmented spot and a visible vessel can often be challenging with visual assessment alone. This is an important distinction to make, as this has implications not only on treatment but also on re-bleeding. In this patient, the EDP showed that there was arterial blood flow underlying this indeterminate lesion. This information helped guide decision-making on whether to endoscopically treat this lesion. The ulcer was successfully treated using an over-the-scope clip, OTSC, and epinephrine. Following treatment of this lesion, the patient achieved hemostasis. This case demonstrates the role of the EDP in cases where visual assessment alone was inadequate in assessing for high-risk lesions. Moving on to our second case, we have a 37-year-old man with a history of asthma. He presented with hematemesis and melanin, associated with NSAID use for lower back pain. During the initial EGD, a large antero-ulcer measuring 20 millimeters by 10 millimeters with a visible vessel was discovered. The ulcer was treated with epinephrine and bipolar cautery, but due to incomplete hemostasis, an additional through-the-scope clip was deployed with successful hemostasis. The patient was monitored and discharged on a proton pump inhibitor. Unfortunately, the patient experienced recurrent melanin and acute anemia after discharge. A repeat EGD revealed a missing clip. Use of the EDP here enabled precise targeting of the optimal treatment area in this large and difficult-to-treat ulcer. An over-the-scope clip was placed over the area of maximal arterial blood flow, as guided by the EDP. EDP was used to confirm that there was no residual arterial blood flow. The patient was discharged without further bleeding. Our final case involves a previously healthy 46-year-old man. He arrived at the emergency department with three days of melanin associated with an acute hemoglobin drop from 11 to 7 grams per deciliter. He developed hemodynamic instability and demonstrated an inappropriate response to blood transfusions requiring an ICU admission. An urgent EGD showed a clean-based gastric ulcer and a clean-based duodenal ulcer. Given discordance between the clinical presentation and endoscopic findings, the EDP was deployed, which revealed a positive arterial doppler signal within the base of the duodenal ulcer. To address this high-risk stigmata, the ulcer was treated with clips, which initially provoked oozing. Following clip placement, there was no further arterial signal. EDP provides us with an easy-to-use, objective tool that goes beyond visual assessment to help us in optimizing hemostasis in patient outcomes. We hope this presentation encourages incorporation of the EDP into routine practice and further exploration of its impact on endoscopic hemostasis. Thank you for watching our presentation.

endoscopic Doppler probe

hemostasis

high-risk lesions

patient outcomes

therapeutic decisions