Video Endoscopy Conference 11/6/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 11/6/20 Overview Three cases presented here: • 00:00 – Paresophageal Hernias • 13:30 – Upper GI Crohn's Disease • 25:20 – Giant Duodenal Polyp My name is Stephanie, readily from one of the second year Fellas, but I think you probably know that, um, this is a case of an 81 year old woman with a history of diastolic heart failure, a fit, morbid obesity, sleep apnea, spinal stenosis and she squealed Chair bands. You can probably get a sense of her final type in your mind. Hopefully, you can see her in your mind's eye. She has been having recurrent food inspection since 2000 and 18, with five GS on our system since then, and from one Friday evening at six o'clock, she came in with complaints of being unable to eat or take any of her meds since Tuesday. So she was a patient of Dr. She still is a patient of Dr Rubens and Dr Wine. Christina was on cold, so the two of them took her to the O. R. For an endoscopy on Friday night. But before I go to the endoscopy finding this is what her ex chest X ray shows you can see. I don't want to give it away, but there's something obscuring the retro cardiac shadow or but behind the heart, you don't seem to be able to see the nice diaphragmatic border very well. And there seems to be something large there. And then I won't say much about her. C t. But there seems to be something abnormal. I don't know if you can see my nice, but here and then this is what they found on endoscopy. This is actually an amalgamation of her endoscopy. Over the last few years, I just picked the best images because they all essentially show the same thing. But if you see you see the food here, it's been cleared on the top, right? But I think this is a really good photo. If you look here, you see something interesting. So you see the scope coming through the G junction were in retro flexion, and then you see something else here. So actually, before giving it away, I would love to know what people think. Especially about this middle finding, like, Why do we think she's having food imp actions? And what is this? I think it might be a Paris often Jill hernia. Since no one else's you're correct. That's exactly what it is. And for the fellows who may not be able to sort of recognize that. So remember, with a pair esophageal hernia is stomach kind of sliding up next to the G junction. So if you look on the retro flex view, you can see the scope coming through right in the middle. And there's something patching up on the left side of that scope so you can imagine the G junctions in the right place. And there's other tissue that is north or superior to the G. These are really hard to reckon. Yeah, I think this is an amazing shot. This was the only one over the five years that really shows it this well, which is great. And here's what, like, based on what the teachers saying, These are the two types of hernias, So there is the more common sliding Heidel hernia that we see very commonly. So the G junction has been displaced. Oh, Uh huh. And on the right side, you see the Paris Daffodil head a hernia. So the G junction is is in its usual place. But there's a defect lateral to it in the French philosophical membrane, and the funders has herniated up. And so that's a true hernia. Where There's an entire hernia sac that's displaced in a location where it's not usually, which is the definition of a hernia. Where's the Heidel? Hernia is more of a sliding upwards. You don't have that hernia sac. And then there are four different types of hernias. Just to sort of this is more out of interest, but the parapsychology hernias are typically not pure parasol Fujio. So usually you don't have your deduction in the perfect place and the parasol video Hernia hernia, an upright decided you usually have a little bit of a mixture, so a type three is like a little bit of a sliding hiatus. Hernias with a parasol video component. So here you see the G junction is displaced, and there's that herniation as well. So most hernias are most parapsychology. Hernias are type three and not a pure, pure parapsychology, a hernia, although her imaging, her endoscopy does look almost like a pure type two. But it's really hard to tell some of the complications of parapsychology. Hernias are you can get gastric fabulous so that that herniated stomach can become strangulated and called ischemia. You can get to Spiaggia when that huge hernia compresses on the lower esophagus or after you eat and drink, you can often get postprandial pain. I think it's because when when you eat or drink there, you usually have funding accommodation to allow for a diet for digestion in the stomach. But the funding is all up in the hernia, so you're essentially are having, like, almost like a functional dyspepsia. And then, as we spoke about last week, Cameron Lesions are where you get ulceration around the the hernia, where it's indented by the diaphragm from local musical mucosal tension and ischemia. And you can get respiratory complications from simple mechanical complication and the compression of the hernia on the lungs. And so the thinking about how we manage hernias of parasites Jill Hernias has changed a lot over the last 20 years. Most experts advocate against repairing them surgically prophylactically, and that's because the annual risk of developing acute symptoms that need emergency surgery are less than 2% and the mortality rate from an elective repairs about 1.51 point 4% and that risk of acute symptoms really decreases after you hit 65. So where did this new recommendation come from? Because prior to the 2000 and the days of Hill, who described some of these hernias. They described cohorts where nearly 50% of patients with these hernias were developing complications. So the authors of this paper did a very large mark of Monte Carlo decision analytic model, which I had never heard of. Essentially, you create a hypothetical cohort of patients based on these big studies that we already have done. So it's retrospective and sort of like a machine learning type algorithm where you divide patients into two strategies. The repair or the watchful waiting. And then you look at what happens to patients who undergo elective repair, and for that they use an analysis of 20 studies. And then you look at the watchful waiting and emergency surgery patients, and they used a payer database and surgical literature over the preceding 36 years, and they looked at patients outcomes in quality adjusted life years, and the way they did that was they put patients into a sort of an algorithm, and you can. They can either have an elected repair. They can die or survive, and if they survive, they can have an uneventful recovery and Basically, every month a patient has an option to either have a complication to just be watchful, waiting and doing fine or to go for the hernia repair. And based on the studies that have been done, they look at the probability of each of those things happening. And they run that cycle over and over again until they sort of figure out what what happens to that cohort of patients over years doing this. This, um, algorithm of options and basically what they found was watchful. Waiting was the optimal strategy. Over 80% of patients and elective repair in 17% meaning that if elective repair is recommended to patients who are asymptomatic or minimally symptomatic, less than one in five of patients age 65 will benefit. So that was a paradigm shift in the thinking about repairing these 10 years because it shows that you really your risk of surgery is outweighing. The benefits are the risk of elective repair, especially as you get older because here you see the probability of acute symptoms decreasing. Um, as a Jew increases, I don't know why that is. I didn't understand. Maybe over time your body has adapted to it. It sounds like a very layperson explanation, but I if anyone knows, I'd be interested because it seems like they just had a slower the lower chance of complications as they got older. Usually I feel like it's the opposite. So to conclude parasol vigil Hernias are rare. They're only 5% of hernias. Most of the sliding hate, all hernias that we see. The complications are fabulous. Cameron Lesions, respiratory compromise and food imp action is rarely reported as we saw, but what I think was happening was the food was going up. And I can show you where it was probably getting stuck and the risk of developing acute symptoms less than 2%. So, given this, most experts will recommend just watching in the absence of symptoms. Any patient with a parasol. Fujita hernia. It's stuffy. Yes, Dr. Rubin, this patient had obviously not read the literature because this has happened somewhere between four and six times. Uh, it seems to occur only on national and religious holidays. Uh, and and, um, she is, um uh this was the hardest dis imp action that we've had to do. A couple of hints. Endoscopic lee is that it wasn't a clear shot, uh, to get into the sea. The whole stomach from the, uh, from the esophagus, we could just push things through. Uh, it was very tricky to get through. There seemed to be an angular ation there. And I think what happens is as the esophagus gets more and more distended with the imp action, it becomes more the hernia. It becomes more challenging. And the other hint is the view, As you pointed out on on the retro flexed view where you see a lot of stomach up there more than you normally would want to see on a retro flexed view. I have advised her to have surgery because I'm sick of coming in, uh, in the middle of the night and doing this in the O. R. And she's got and she actually developed aspiration pneumonia after this. Uh, and I don't believe the literature because she's she's sitting around all the time. She never stands up, uh, and and she's had this happened now, 4 to 6 times in his head ammonia. And I don't believe that there's that much risk in a elective repair of this. I've tried to get her come in for an Asafa Graham in between attacks, uh, and and maybe even Manama tree studies, if necessary, as a prelude to surgery. And, uh, he's very uncooperative. She only likes to call when she's been impacted for four days and on a weekend. So I I sort of disagree in this particular case because of how recurrent it's been. Contrary to what your your chart show, I think she should have an elective repair. Oh, go ahead, Stephanie. You know, your conclusion was that if people have no symptoms, watchful waiting makes sense. Which you can say that about any hernia and in anywhere, any part of your body if if there's a hernia, but it's not causing symptoms, we don't operate. But if it is causing symptoms, you really have to think about operating. And I think Peter is right. Um and you know that that paper that you cited as interesting as it is, it's you know, it went back to the 19 sixties 19 seventies when we didn't have laproscopic approaches. Um, nobody really wanted to operate because it would mean open surgery. So I think you have to take that Those findings with a grain of salt. Um, so I agree with Peter. One other thing. I've actually I had a patient who developed atrial fibrillation related to Paris Esophageal hernia. So that's another interesting complication of this. Oh, yeah. I actually was arguing that she I mean, on behalf of all the fellows, I tried to convince her very hard to do the surgery, but she wanted to. She was not convinced. But I thought that actually, I would have argued that she does need the surgery because this isn't a symptomatic or minimally symptomatic. These are like life threatening symptoms, So I actually I agree with both of you. I would love if she would do surgery, but she disappeared off, and she hasn't come back. She'll be back Thanksgiving. Thank you. Friday night. Thanksgiving? Yeah, Probably looking forward. Biggest holiday. Any other comments on this is a great good case. It's good to sort of see the parasitical. Honey, it's hard to get good pictures of it. Um, excursions. You were on to sort of comment at all? Pretty picture. Um, thanks. Uh, Lauren, uh, present your case. Hey, guys. Good morning. Be sure my morning. Right. Okay, so This is my case. A 36 year old female with uncomplicated small bowel. Crohn's disease, diagnosed 25 years ago intermittently on the Salomon currently not on came into the hospital with one month of progressive dysplasia. I don't think you're not sharing your Oh, hang on. Oops. Uh, uh huh. Yeah. You guys see it now? Okay. Alright. Take two. So, 46 year old lady, she's got uncomplicated small balcones. Uh, if I can see diagnosed 25 years ago intimately, I'm a Salome. No treatment currently came in with a month of progressive dysplasia and Dina Facia to solids only, as well as some progressive shortness of breath. Her review of systems was only otherwise positive for intermittent diarrhea and Hamad occasion. Otherwise, she was feeling pretty well. Yeah, her data. She was a federal human dynamic table had done remarkable head and neck and abdominal. And then she had a normal white count. Her hemoglobin was about her baseline with enormous sick anemia, and she had elevated inflammatory markers. And then she did have an outside contrasted CT chest which showed mild diffuse fats training and the media Steinsson concerning for trivial and a soft deal inflammation also say here that she has not had an e g d s in the past. So we took her for E g B while she was impatient and these were our findings. So these pictures are the just till 1 30 esophagus, and you can see that she's got quite a bit of inflammation. She has these kind of cratered, um circumferential serrations. Um, that also looked a bit linear, but definitely a lot of, uh, inflammation and for liability when we were passing the scope. Um, and I will say also that she underwent a bronchoscopy. This admission with biopsy. We don't have any photos from that, but I'll talk about the path for both of those on the next slide. So we took biopsies of this. Her pathology from the esophagus came back with squamous oesophagus. Esophageal mucosa with chronic active esophagitis and GMs was negative for fungi. And then her trivial biopsies came back with chronic and eosinophilic inflammation with small granulomas. So overall, her kind of clinical picture was most consistent with Crohn's disease involving the esophagus and trachea. She was managed with a prednisone start on a prednisone taper inpatient, and then the tentative plan was for initiation of biologic therapy on an outpatient basis. So I'm just gonna take a minute to talk about Upper GI Crohn's disease. This may be a little basic given the audience, but I didn't know too much about it. So I looked at this paper from J. G. H on just a review article on Oral and Upper Gastrointestinal Crohn's. It's a little bit on the background, so the definition of upper GI crones based on this paper is diseased, proximal to the duodenum. But it looks like in the past it's actually been characterized as disease proximal to the terminal ilium. Um, Asafa Jail involvement of chronic disease is actually very rare. Only 0.3 to 10% of Crohn's patients have a soft shell involvement, and then usually this is diagnosed after the onset of intestinal disease in kind of the patient's thirties. So this is fairly close to the case that I presented, and then we often see findings in the distal one third of the esophagus and then upper esophageal uh, upper GI Crohn's predicts kind of a more severe Crohn's genotype overall, with increased surgical complications, increased need for biologic therapy and kind of extra intestinal manifestations as well. So the diagnostic criteria that this paper talked about, whereby Nugent and Roy so the kind of first criteria you can have non castrating granulomas, plus or minus crones elsewhere. So if you have that kind of histological confirmation, then you can make the diagnosis. On the flip side, you can have radiological endoscopic evidence of diffuse inflammation, kind of like what we saw on this patient's, um, endoscopy and on the CT scan, with the media style fat stranding, um, consistent with Crohn's and then, uh, Crohn's elsewhere. So if you don't have a histological diagnosis, you need to have kind of a a diagnosis of Koreans elsewhere in the body in order to make the diagnosis of Upper Gi Crohn's, um, without histology a note on pathologic findings. So I was surprised that we didn't see any kind of granulomas on our patients off jail biopsies and actually this paper talked about granulomas are actually only found in a minority of patients. So almost 60% of patients you won't. You won't find kind of character characteristic histological findings, Um, and then I did come across several case studies that showed patients even requiring to get a histological diagnosis. E M R large deep biopsies to really get a good diagnostic yield on the on the upper GI crones and then just a brief note on treatment really just kind of follows the patients. Regular cartoons treatment. There's really very little data regarding treatment of just isolated soft Jillian's or upper GI crones. But this paper did talk about half of patients improving on first line agents like five essays and steroids. They also included H two blockers and PPS there, which just to know don't really impact the underlying path of physiology of the disease but do provide patients with some symptoms symptomatic relief. Um, and I thought it was interesting that a Softail Crohn's responds faster and more completely to steroids and intestinal Crohn's does, and patients will often times have complete resolution just a few weeks, and this patient had significant improvement in dysplasia after starting steroids, and they talked about. Second line is I mean immuno modulators, and then third line is inflicts a mob. And of course, there's always a role for dilation or surgery. If there's any sort of complicated disease like visualization um, etcetera. So a couple takeaways. So Upper GI Series is rare, typically presents in the thirties and in the setting of established Crohn's disease. The diagnosis you can either make by histology or by inflammation in the setting of established Crohn's and then treatments include kind of all of our normal Crohn's treatments. And this pretends a more aggressive disease course than intestinal disease alone. And I will also just comment that the the other interesting part of this case is the trade deal involvement and the respiratory involvement of Crohn's disease. And I will probably talk about that next week. Um, any questions? What did the bronchoscopy show? Um, she had granulomas on her bronchoscopy. We don't have any images from that, unfortunately, and did those ulcers? I couldn't see it very well, But those ulcers really look like Crohn's. Typical Crohn's ulcers to you from from the case reports that I looked at and I could have included pictures of other patients. But it did. These kind of, uh, cratered alterations did look pretty consistent with the other case reports that came across, but I don't know if anyone else has any thoughts. You have seen this they don't. They don't. I thought this was me. Herpes. I thought it was going to be viral. I thought when I saw this When I see this, this is herpes, right? But, you know, chrome, chrome zone. The esophagus is so rare. I mean, I literally in my quarter century of doing IBD, I think I've seen less than five cases of really serious, not just a little bit of microscopic inflammation of the esophagus. And I've seen it looks like all different things. So this is not out of the range. It isn't not like Crohn's. It does look more like a viral her paddock. But, um but it really can look like anything the trickle involvement in combination with the soft shell that I have not seen. Although I've seen trickle involvement separately, and I even have had one case of the ring. Vokoun's and almost all these patients, as you pointed out, also have intestinal crones. You know, more distal, typical illegal disease would be very rare. Maybe I've seen one case of this where it was purely thought to be a soft shell Crohn's, and the last thing I'll say is five makes absolutely zero sense as a treatment for this because these drugs aren't even delivered until they make it to the distal bell. So there's absolutely no point in treating this with with five essay Steroids are great. They can also be done topically. Um, and that can be very effective. But probably the best treatment of all is going to be anti TNF. I would like to suggest that there's the possibility that this is a salvageable diverticular aosis um, notice the small little craters scattered all over the esophagus, and I doubt that this is going to be a viral illness. But this easily could be esophageal diverticular, aosis, which causes this pager, uh, multiple small debates like this all over the esophagus. And several of them are ulcerated, so a, um, an upper GI barium study may may readily show little pockets all along the esophagus, and that's a possibility. I think that needs to be considered. Is it? It's not the jail diverticular, Asus or particular Isis usually result of chronic inflammation. So couldn't it be secondary to esophageal perforations? Probably not. Yeah. Um, the, uh, there's a patient I think I share with Rob who I think we I think has a softball questions and has pretty significant dysplasia. It almost looks like the O. E. Um, and I think we've chosen it. There was a patient formerly of Tom Almonds. Um, and I think we've chosen to treat that patient like topical steroids almost like you. And he does actually reasonably well, is that sort of a? Does an anti TNF prevent you from having to use topical therapy? Or do you need to use something on top of a systemic drugs? If the anti TNF works for the primary bowel disease, that will likely also work for the esophageal disease. And, um, the the only think about the topical steroids is it might be a little bit faster than anything else it would not. Typically, I wouldn't do it long term, and I've never needed to for these patients. I would, uh, just I agree with Bruce that NF work. It's great, but my own experience with any four gut grown you know, again I agree with the esophageal is extremely rare. I c e o e. Far more commonly in the Crohn's patients, but any any Crohn's disease in the four gut I find particularly hard to manage. Even with the anti TNF, these can be pretty stubborn to treat. So either PPS of it's in the stomach or duodenum topical steroids. If it happens to be in the esophagus, I almost always have to rely upon Hey, Jerry, question. Um, you're mentioning esophageal Sciutto, diverticular, Asus. I mean, how commonly where you see that it's a very rare disease entity. I think that, you know, there's association with HIV in the past, but, um, I don't I can't really appreciate the sort of stippling that you would typically see in this in this particular case. Can you just talk a little bit more about that? You know, maybe lost. Hello? Mhm. Um, alright. Other comments or questions about this one. Mhm. All right. Um, I have a case to present. Thank you, Lauren. It's a great case. You don't see this very often. Um, uh, let's let me get my case up here, all right? I'm gonna share my screen. Nick is taking his boards. So we decided it was reasonable for her to take the day off. Although there was some debate on the validity of that. Thanks. So at that case before while you're getting this teed up status, there's a There's a case reports journal now. And so if you take a mixture of upper Gi Crohn's and trickle involvement, I mean, that's not going to have been reported a lot, if at all. So that would be a nice thing to add into the literature. Yes. I think we have a case that I think every fellow has been exposed to, who has quite a conglomeration of the sofa jail, a bit of gastric sump original and Kalanick ruins, Um, who has been through all of the biologics? Can't tolerate that night slippery. So we're always in a tizzy with how to manage her. I think she might also be like a the reason I will. Case report. Yeah, I was thinking about her as well. Actually, like a perfect fellows case. Let's talk. Unfortunately, maybe we can do a key series instead. Uh huh. Okay, So you were talking. Um, you guys can see my screen. Okay, um, this is a patient that went to Mount Sinai greens at 65 years old, has a history of hypertension hyperglycemia, and basically came with melon. A weakness, shortness of breath, had an emergent endoscopy performed there. No active bleeding scene, but down in the duodenum was this And, um, which is clearly abnormal. And, uh, they biopsy showed my old non specific inflammation of duodenal mucosa, which we decided was not very satisfying or helpful. Um, and so they were referred to us for an urgent inpatient, the U S. To which we said Thanks, but no thanks. Continue. We work up for bleeding. We're not going to do an impatient us. Um, weird Palepoi duodenal lesion that had a normal biopsy but said that maybe we need to see him as an outpatient to think about taking it out or figuring out what it is. Colin, as he was a small item known with the colon Normal terminal Ilium saw me the offense a month in the office a month later. No recurrent bleeding feels well, and so, you know, hasn't really had a small bowel evaluation at this point. Other than just a regular CT hasn't had an angiography or capsule. But given the lesion, um, you know, we said All right, well, let's at least um, investigate this a little bit further. Um, I'm gonna switch a screen here we see. All right. So be seeing my endoscopy video. So as you go in, uh, hi, Loris. In this graciously unedited video, I see a tough old Then you start to see, um, so you see long, uh, Palepoi lesion on a big stock here in the middle. And you can see this palette extends down to, uh, one time and actually the second portion of the duodenum. And there's a big broad stock that I think you guys just saw here, um, huge stock here in the duodenal bulb. Um, that that large polypropylene extends down to the second portion of the duodenum and you can actually see it sort of adjacent to and budding the ambulance. Um, and so we decided, uh, I didn't know what to expect when I saw the original endoscopic images. So it's hard for me to tell if this is a large societal lesion in the D two d three or if this is going to be some productive waited lesion over here. So, um, the question is, what do we do? Um, did you think this was origin in the stomach? I was I was trying to identify that and it looked like it was actually clearly coming from the duodenal bulb. I know sometimes you get these huge floppy polyps and along the pilot channel that elongate out into the duodenum. This is coming from the duodenal bulb. Okay, so a couple of still shots Here's another Hang on. Uh, teaches you in the U. S. Sorry I missed that part. Did not. Well, I was prepared to if needed. Um, but now that I had a good sense that this is a PowerPoint lesion coming from the duodenal bulb, I didn't really see merits of anti us here. And I think that's a question that comes up for us a lot. As you know, what's the value of the U. S. Or something like this and not really the idea of the US just to see something is behind the walls are within the wall of the duodenum. Um, but when something clearly is originating from the mucosa, the U. S. Doesn't really add to the value of the case. Um, at least in my mind here that, like, you know, if you because it does have, like, a long stalk and, um, you know, in the U S could potentially help differentiate. Like if this was a you know, like Prometheus lesion or, you know, the other things you would think about in this area. Be like a like a Brunner's gland hammer. Toma. Um, you know, because if it's if it's, you know, very bright hyper Coicou has, like, a pillow sign, you know, on seven dias Copy. And it's like, Palma, then you wouldn't need to necessarily respected unless the patient was symptomatic. But if it wasn't that, then you would have a You know, uh, I need to go in and try to remove it. Yeah, interestingly enough, I mean, even if it was a like Poma, you know, these things can sometimes also a twist and tours, tours or coercion on themselves, causing bleeding so that still, theoretically, one could consider respecting. Um, I agree with you. Just take the thing out. Uh, Jerry, what would you do? Um uh, so I think the options, you know, to me or us, as nickel said just to define the lesion, Um, you could e s d. Um, because why not, um, there's snare polyp activity or end a looper and a clip. The base followed by snare Paula Victory. Um, any thoughts from the audience about the last two auctions Near politic to me or some kind of treatment of the base Before you do a snare politics to me to teach? Doesn't the tip of the polyp look different from the stalk? Even on your pictures? It absolutely does. So the stock itself, this picture isn't great, But I think on the videos, I was pretty featureless, like normal mucosa. Yeah, but head of this almost looks like it could be an ominous Yeah, it looks like it looks like a podunk. Elated at an ominous power. No. So So teeth tell you what I would do so teach. I would call you, but don't keep us. So there's some value in putting something at the base because the base is really brought. If you think of this as a big podunk related pop was a big, large blood vessel in the middle of it, there's some data that would suggest that putting a loop or a clip or something around it first is going to decrease the risk of bleeding or injecting it with some, um, something like happy. So I agree. You know Dave on this is that I'll show some hold on before I show that there is some data. A couple of studies recently? Um, yes. Trying to get back to that. There's a randomized trial from South Korea couple of years ago. Calculated polyps over a centimeter, randomized to clipping of the stock prior to politic to me versus just Paula picked me alone and they did Particulate pops again over a centimeter in size and basically, you know, in the end, there was some 130 patients randomised and the big take home of this in terms of, um, you know, for the clip versus the no clip group in the no clip group, there was a much higher rate of severe bleeding. So this is ongoing using or spurting longer than 60 seconds requiring treatment. Um, And when they aggregate those numbers, you see about 20 patients in that no 20% of patients in that no clip group had bleeding that required treatment. Um, compared to the cliff group where there's only about 4.5% of patients delayed polyp ectomy bleeding was about the same in both groups. Um you know, the no clip group, you know, had a couple patients that needed to be, uh, endoscope and retreated. But, um, it wasn't statistically significant, but this is a fair number. Yeah, you might say. Well, 80% of patients didn't bleed, but the 20% that do you believe those are stressful. You're wherever you are. This study, I think, was in the colon, but it's really the best data you're gonna find. Um, when those things bleed, it's a little scary because, you know, when you think about it, the stock has a huge blood vessel right in the middle of it, and it could be sort of spurting blood and you lose visualization. And many times these are outpatients. And the last thing to do is be frantically clipping one of your outpatients, especially when you have the opportunity to preempt this. I'm pretty sure if we were all together in Jerry way conference room, Jerry would yell at me for clipping, but that's what I did. Um, and so I put two clips. There's one here. I know how a picture of the second clip it's a big stock. So I put two clips across the days here. Here's my post politics to me photo You can see clips kind of crossing the base. What's great is after you click this, you can actually see the head of the polyps. Start to engorged turn really purple And Adam Entous, um you know, as if you're inducing, uh, some loss of blood flow there, Um, I have a team. You also use glue Keegan in a case like this so that the specimen doesn't disappear downstream. I absolutely did that, Um, I because that is definitely one of the most annoying things is to lose a polyp and have it go flying out in the middle of nowhere. Uh, let me show you what that politics to me looks like. Um oh, I'm trying toggle back to that video. Here we go. So it's a little bit of a you know, it's tricky to get the snare around this. I mean, we're down in D two. It's quite mobile. Um, eventually, you kind of wrangle your snare around it, and then you almost have to sort of work the snare back. Um, what you eventually end up doing is you kind of move the snare back and forth a little bit to sort of shimmy it up the long stock of the palette. And you're sort of seeing maybe you have to trust me. That access. There you go. You can sort of see here eventually get around it. And then in order to move up that palette, I'm gonna move it kind of back and forth, and you eventually end up sliding up the entire shaft of that pile up here. You can see my clips over there, and eventually I get it to the point where I'm really around this base. And then I closed the snare and then right after the close, Uh, here we go. So we have just given a half milligram of glue gun right prior to, um, coming through with Kateri. There's a pretty big stock. It took a while to pop off. And then, of course, the next thing that happens is a couple of choice curse words for me as I go shooting down the duodenum and I can't even reach it with the upper scope. And so I actually have to go back and get a telescope to go and get the darn thing. Um, but eventually grab it and send it off to pathology. And there is the ever so exciting path finding of, as Nico called it, the calculated Bruner gland lesion. Dilated Bruner glands, smooth muscle bundles, adipose tissue, large vessel suggestive of bruner gland hammer Telma. Um, which, which I mean, we do see every so often, every every year or two we get one of these large, large vertical invasions. They can sometimes, um, cause bleeding. They can ulcer it, they can twist. Um, beyond that, they don't usually cause any other symptoms. Um, and, uh, and that was the patient is really? Well, no post polytechnic bleeding, no bleeding. During the case, you saw that that stock was really nice and dry, and I looked really good. Um, any questions? Yeah, I think in the duodenum. You know, it's it's pretty rare to get sporadic adenomas in the duodenum to begin with and in the bulb. That's exactly where Brunner's glands reside. Once you get past the bulb, you don't see many Brunner's glands. Um, you do. But I think the ball was really where you see the most. So, yeah, um, I was kind of guessing that there's even Bruner gland Adenomas. Oh, just ham or Thomas? Um, yeah, the, uh, glue guns helpful. I'm a big fan of clipping. I do this in the colon to any time. There's a big stock more than like 34 or five millimeters. That 20% lead rate. I clinically do see, um, And if you if you take a podunk related palette and take it to close and respect too close to the Kalanick wall, that vessel kind of drops into the wall, and it becomes very hard to clip it after the fact. So I always make sure to leave a little bit of stock out, so you have something to treat if you need to. Um, but I've seen some pretty awful bleeds from from these kinds of lesions. I don't like Kendall. Oops. I find them hard to use. It's very easy to tear through a polyp. I think you need someone who's really comfortable with Endo Loops. Um, so I just We're good at clipping. We all know how to clip, and so I just clip and there's data to support that now. Status. Did you think this was the cause of bleeding? First of all, And second of all, did you use pure coagulation current, or did you use a combination of co regulation cutting? You know, I in terms of the first question whether I thought this was the cause of bleeding, I think he still needs a small bowel evaluation. I think this is pretty likely to be the cause of bleeding. Um, but he's older. He's got some cardiovascular risk factors. He could have small valley VMS if the capital is normal. I feel pretty comfortable that this was the cause of bleeding. I know these lesions can can ulcerated and having a portion, Um, you know, my general preferences to I generally use co at current from most everything. What happened with this is this lesion is so thick it started to dedicate out. And once it dries out, the snare, the coed Kurt requires moisture. Just sort of, like, boil and burst to allow you to get through the tissue. Um, so midway through, I actually just switch to cut current because the snow was about to get stuck. Um, and so, yeah, I needed to go that direction. Would you have, um, Jerry gun right to cut current like um, or would you have done a similar thing with co ag? I would have pulled harder. Yeah, but you wouldn't have clipped. Oh, I would have. I would probably put a put a loop on it or clip, but I think I'm surprised that the ecliptic good, because with these very thick stalks, the clip barely rarely goes over the entire, um, circumference of the polyp. So, um, I would probably up for a loop rather than clips. Yeah, I ended up doing two clips. Um, you're right, though. It can be tricky to get all the way around. Um, any other comments? All right. Um Published December 7, 2020 Created by Featured Faculty Stephanie Rutledge GI Fellow, PGY5 Icahn School of Medicine at Mount Sinai
