Video Endoscopy Conference 12/4/20 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 12/4/20 Overview Three cases presented here: • 00:00 – Gastric Ischemia • 16:32 – Post-Polypectomy Bleeding • 31:58 – Dieulafoy Lesion I'm young. I'm because I'm sure he said I had on service about a month ago. Um, so her case begins with a 63 year old female. She has a history of hypertension. Hyperloop anemia. CDSs post pc About five years ago, she initially presented with exertion all dystonia and was found to have three vessels C A. D. And underwent a cabbage on the same admission. Um, she had a post op course that was complicated by air Diaz requiring ECMO for a few weeks. And your renal failure secondary to a t n. She was on T v V H and developed also hit. So she was on by Vala Rudin. And at the time of my consult, she was still on to pressers. Um, we were consulted for ongoing coffee ground emphasis over the weekend. So this was a Monday. I see you case at the time of the scope, she had a white count into twenties which had been elevated for quite a while. Her hemoglobin, um, we're still in the tons, but had ongoing through transfusion requirements. And her lactate was 1.4. Um and so we performed a bedside e g d right, Um, so these are the images, and I'll show a video on the next slide. So here you can see sort of the few mucosal changes in the stomach. This is sort of in the, um, and from the body. It's hard to tell because there's such a few severe mucosal changes throughout, Um, it appeared, uh, congested. There was discoloration with ischemic appearing mucosa and also rations found in the entire stomach, along with a large amount of blood which are treated like hemorrhagic necrosis. So here's a video, Um, so you can just see that there's a lot of blood as well as the congested discoloration Did, um and also in the mucosa in the stomach concerning for ischemia. Um, and the blood we thought was the result of this, like hemorrhagic necrosis in this patient's clinical setting. We thought this was compatible with a low flow state versus thrombosis from her hit Oh, I'm going to get to the next long, um, so this patient was maintained on TPN, um was remained MPO and um had an n g place on suction, and she remained on brass country broad spectrum antibiotics. And then when Dave and I were on consult again. Sort of. 10 days later, we were re consulted on her form Elena and Coffee Ground Nemesis. Initially, they had asked us if there was any utility in doing a second look Endoscopy prior to re initiation of p o. Um, And we had, you know, there's not very much a lot of guidance about gastric ischemia, which will be the topic of my discussion. Um, but, you know, we did look through the literature and you know, we to suggest that there would be some utility in doing a second look, because in these patients they often have a poor prognosis, and many of them can develop deep, deep ulceration. Um, and this is what we saw on our second look endoscopy for sort of repeat coffee ground MSs. And you can really see that, Um, the ulceration is now more pronounced again with some old blood in the stomach as well. Um, so the topic of my talk today will be gastric ischemia. This is a relatively uncommon entity because there's such a rich blood supply to the stomach as a review. The main blood supply from the stomach comes from branches of the celiac artery, which provides the main vascular supply to the stomach. The celiac artery is the first major branch of the abdominal aorta and branches into the left gastric, splenic and common hepatic artery, which then divides into the proper hepatic and gastro duodenal artery. On occasion, the first branch of the superior Mesen Terek artery, which is inferior pancreatic duodenal artery, also provides collateral blood supply. So it's very rare entity. But in terms of what are the most common ideologies of gastric Sena really has to do with sort of systemic hyper profusion in the setting of shock substance. In our lady's case, she was on chemo for several weeks, Um, and gas with fabulous, um, less commonly vasculitis, embolism, endoscopic therapies. Um, so I'm going to briefly review and, um, Kay series that was published in C G H back in 2013 of six cases of gastric ischemia. Um, the first table just shows sort of the common findings endoscopic Lee on end histology of these cases, we didn't take biopsies in our patients case. So in animal studies, um, in terms of the lesions that can appear in the stomach, it can actually happen in 3 to 8 hours in the studying of systemic hyper profusion or shock and also racial may take 1 to 2 days. Histological e early gastric ischemic changes include, um, mucosal edema, vascular congestion and superficial necrosis, which we're seeing in our patients case. These changes then can progress to mucosal coagulation necrosis with surface erosions and fibre, and pure exit dates which happened on our second look endoscopy. These ongoing ischemic, um, sort of factors can result in full thickness hemorrhagic necrosis with deep ulceration of the gastric wall. In almost all six of these K series, they saw gastric ulceration. And this is because gastric acid exacerbates and fosters ulceration. Um, a large acid pocket forms around the funded and posterior gastric wall as a result of ischemic gastro Parisse is and the superposition of these patients. So this massive pocket actually facilitates the formation of very large ulcers. On our second look endoscopy, our patients ulcer was actually greater than 10 centimeters. Um, in all these cases to they noted a lot of gastric distension which happens in the setting of ischemic gastric purposes. Gastric distension can both induce and exacerbate gastric ischemia. Um, very interestingly, all six of these cases. None of these patients have Mesoamerica, ischemia or ischemic colitis. Um, so they had relative sparing of the superior and inferior military arterial supply during the initial insult. Um, but we can talk about that in the discussion, which, you know, this is something that I found kind of interesting. So there are no guidelines in, um, in terms of management. So they have a lot of suggestions on, um, what can be done in these patients because of the poor prognosis. Early diagnosis is is advice when possible. The authors believe that it is safe to perform endoscopy in the study of gastric Sena, much like an ischemic colitis. Um, it is safe to perform. And, um, the gastric wall is much thicker than the colon. So the risk of perforation is much smaller than those of colonoscopy. Imaging studies may detect um, gastric air and help out while other inter abdominal causes for the clinical presentation. Um, so if there's any suspicion for gastric mitosis, they suggest getting patients on broad spectrum antibiotics. Um, and as we discuss about gastric distension with food or food accumulation, it can be observed as either a primary or secondary event and because that gastric ischemia can be exacerbated by gastric distension in the setting of impaired motility and ischemic gastric paralysis, Um, the authors recommended intermittent energy suction with five pp therapy, Um, in a rat model, they actually found some evidence that getting patients on I v p p I therapy can reduce the overall surface story of observation as long as you get them on it within 72 hours. Um and they just created this, uh, table of severity of at dusk endoscopic findings of gastric ischemia based on I guess, the six K series. Um and I would say that, you know, in our patients case, she had severe gastric ischemia, especially on our second look. And Oscar, um, so just my take home points that gastric Yesenia is associated with a poor prognosis or early diagnosis with endoscopy can be crucial. There is utility to doing a second look. Endoscopy. If anyone ever want to have a case of this account in terms of management and the principles are sort of n g placement for suction to relieve gastric distension, maintaining an i V p p i selective use of broad spectrum antibiotics. If you save this patient, um, is at risk for gastric mitosis or if there's substance involved in a surgical consultation, just because ultimately a lot of these patients fail conservative management. Thank you. Okay, thank you very much. I would be curious to pull the surgeons. I know there's a couple of surgeons listening, Um, how often they've seen this and or have had to take a patient to the O. R. For management. Very, very rare To take the patient to the O. R. For this, uh, situation almost always gets better on its own. Mhm. Can you comment on you know, whether it's gastric, ischemia or necrosis Or, you know, sometimes we get for colonic ischemia, those kinds of things. There's always a debate around the safety and utility of doing endoscopy, and I think in general we tend to be a little more cautious because we don't want to create a perforation in a compromised wall or exacerbate what's already there. You have any thoughts or comments on that mark? This is mostly a mucosa related injury, and the strength of the wall really is in the sub mucosa muscularity. So very rarely will we see perforations, Endoscopic Lee. I have no problems with the scoping the patient because I'd like to know exactly what's going on so that we don't have to necessarily do anything for that patient. And we didn't have any didn't have any problems. And we thought about it, um, and came to the same conclusion and decided to be good to see whether it progressed or not. The problem after that, we weren't or what we would do next and whether this was going to hell at all, you know, any chance of it healing? I don't know how she did you young after that, but she's still in the ICU on TPN with the stomach with the stomach. Yes. Okay, good. I have a question. For the first time you went in, obviously, that was a very frightening looking stomach, and I'm sure because she was bleeding and because she was so sick, the thought was like, Let's not take biopsies and rock the boat, but because she was such a sick person, the differential is not just limited to ischemia. Obviously, there's, like a lot of things that could have been. Was there any consideration of taking biopsies either time. Um, so the first time? Definitely not. There was, like, a lot of blood in the stomach. The second time around, there was less blood, but it appeared very, I guess, based on her clinical story and just, um, just how, like, necrotic that area looked with observations. We didn't end up biopsy just because we didn't know it was, like, more of a full sickness involvement at the stomach, and we didn't want to risk. Um, any preparation I wouldn't shy away from doing. The biopsy is either time. I mean, you could have done the first time. You certainly could have. We didn't do it the second time, but the first time. Particularly like, um, like you're saying so if there was concern about ideology, what was going on? This very little risk in taking a couple of mucosal biopsy is really I would agree with that. I mean, we had a case not too long ago of a young woman with a post transplant who had a horrific looking esophagus with very deep created ulcers and biopsies were obtained and non diagnostic and was referred to us for further evaluation. And, you know, we went down and he said, Well, there's no real indication for an endoscopic ultrasound. Let's just take more biopsies And, you know, we went into the ulcer bed and took a bunch of biopsies and half came back positive. I remember talking to the folks who sent the patient like, What did you do differently? I mean, like, we just took biopsies where we thought it was going to be diagnostic and really had very little concern about causing a perforation. Everything with that, obviously esophagus, not the stomach. Well, esophagus, even thinner. Right? That's what I'm saying. You were in the in the esophagus that's even thinner. You still felt comfortable taking those five. I mean, I'm sure the IBD folks can relate if they have a severe someone with Crohn's disease, Crohn's colitis with severe alterations. I would I would, you know, be shocked if there was more than one biopsy, uh, biopsy induced perforation or something. I think it's pretty safe to do these things, something I would just point out. You know, this GI tract has two layers of muscular is appropriate, the inner circular and the outer longitudinal, but the stomach has a third layer the stomach has an oblique layer of muscles because it has to churn and mix the food. So it's an even thicker wall, so you shouldn't be as timid as you might be in other parts of the GI tract. I would agree the notion that these are pretty safe, they are really mucosal. Only where I get more worried is the distension and traction and tension against the working instead. So if you saw a stomach like that, you over inflated it and then said, Oh, let me go into the duodenum or approximately June, um, that distention from the scope we know that can perforated colon in a normal situation. And I know that's where it gets nerve wracking in these really bad severe. You see cases, you limit the extent of your exam because you don't want to have that shaft injury to the Yeah, and we actually talked about that during the second procedure. Yeah, we actually didn't just pop into the ball, but then it was like, come back. I would offer one other ideology to add to the list of, uh, causes of this. There was there was a report two years ago of a patient with, I believe pancreatic cancer, who under was undergoing multiple rounds of US guided celiac plexus in our life where we typically inject a combination of you pivot cocaine and alcohol in in or near the celiac plexus to manage, help manage cancer related pain. And there's one case report of some of a patient who developed gastric necrosis. I believe actually, there was aortic necrosis associated with it, and they obviously didn't survive this complication. But it was it was noted, and you know, so rarely, uh, things we do can also induce this. I I I don't think any of us had ever come across that. Um All right. Great. Thank you very much. Young. I was a great case in great discussion. Um, believe is who's our next speaker? Is it Steph? No. June. June. Sorry. Okay. June on. Yeah. Mhm. No, Sorry, I'm just trying to figure out how to get seemed mhm. Did you have to offer? Mhm. I'm glad everything is okay. What else? The sound. Your ultrasound is okay. Are trying to go to Mute. Okay, I will. Thank you. Okay. Is that working for everybody? Yep. Hi. Hi. I'm G and I'm one of the p d Y four fellows, Um, my case is much more basic than you, yang. Much more. But, um, but to, um So this I came across, um, during one of my coals 32 year old gentleman with hypertension, diabetes, and steamy PC in 2014 had a screening colonoscopy in a few days ago and then had four polyps removed of various sizes between 10 and five millimeters presents three days later with many episodes of Marine stool. His medications include prodigal listener probe foreman and then all of his diabetic medications. Um, he is Hamedani stable, but his hemoglobin has dropped from 13 to 16 grounds with us later about a month ago. Mhm. Um, so we do a colonoscopy? Actually, this was during the weekends. I was in the O. R. Um, fairly poorly prepped, but we did find some sites, including a visible vessel. Um, we identified all the polyp ectomy sites in the ascending colon. We had a site with active bleeding, descending colon with visible vessel under Unitarian cloth. Um, and we clip the sites to achieve human Stasis, and the patient was safely discharged. So the topic I want to just talk about was postponed. Picked me bleeding. Um, I guess it's more for the first year fellows, but it occurs in about one and 100 patients who undergo colonoscopy and politics to me. Um, compared to 1000.6 and 1000 patients who do not undergo polytech to me. Um, during the colonoscopy, it can be divided into two categories as immediate bleeding, which occurs during the procedure before the patient leaves the endoscopy unit. And this is usually not a problem because it's identified during the procedure and human synthesis is achieved. Um, delayed bleeding is the more problematic aspect. It's thought to be caused by sloughing of the air shower that covered the blood vessel, um, and increasing necrosis after quarterly. So the spread of the damage um, the risk factors for delayed, postponed but bleeding include um, the polyp size so estimated for about 1% of polyps less than 10 millimeters but 6.5% for polyps wage than 20 millimeters. And this is a significant risk considering that you know, your patients with who undergo polyp economies do not necessarily just have the one polyp site that is treated um, a location of the right colon or seek? Um um, politics on the site is also a higher risk. Um, and then needing to resume anti coagulation after the polyp ectomy, um, usually presents 5 to 7 days after the procedure. Magic easy, um, are in stroll, but it can be hours two weeks later. Um, the prevention of post politics of inbreeding was something I thought was interesting. Um, obviously, we do management of anti coagulation and completely agents according to the issue guidelines that everyone is familiar with, Um, there does not appear to be official recommendations. Um, regarding, um, you know what technique to use in terms of politics to me at least from what I what I found. Um, but polyps less than one centimeter. It is suggested that cold forceps or snap Olympic to me, um, may have a lower risk of delayed bleeding, whereas in polyps, great. In the one centimeter, you should consider use of prophylactic huma static clips. Especially if the patient has, um, polyps greater than two centimeters. Quite telepathy or the need to resume anti coagulation after the procedure. Yeah, um, I thought we would look at a couple of, um, just a couple of studies on which this is founded. Um, so this was, I think, published in 2018. It's a randomized controlled multi center, not inferiority trial. The outcome, actually, is rate of complete resection between cold snap pull it back to me and hot snare polytech to me and was found to be non inferior despite having, um, 538 patients, you know, the risk. The rate of bleeding was actually very, very low. I think they're only like four, um, patients who had delayed bleeding afterwards. Um, but this day only occurred in the hot step hop ectomy group. Um, the data for, um with the outcome specifically for delayed bleeding, um is much less good quality than looking at reception rates. Um, so this is a retrospective cohort propensity match analysis of 530 patients with various ranges of polyps size but not the big ones. Um, with DeLay bleeding, um, here occurring and for patients in the hot snack politics to me and not on the CSP group. So similar results, um, to the prior study, um, with reduced rate of bleeding in the cold snap parliamentary group, so a couple of take home points. Um, bleeding can be immediate or delayed. It usually occurs 5 to 7 days after Paul OPEC to me. Um, and the risk factors include 10 millimeter sized poke poling or greater right colon resumption of, um, anti calculation. Um, the cold snap all effectively appears to have a lower delay. Bleeding rate. Um, and this was specifically studied in the in the 5 to 10 millimeter, um, group. And then, um, consideration of perfect humans started clips for large polyps with risk factors, including antique allegation grading 20 millimeter. Um, I've seen various things being done. I've seen larger polyps being taken out without, um, consideration of him ascetics clip. So it would be really useful to have, um, someone comment on what your considerations are when you do these to prevent bleeding down the line. Thank you very much to you. And I think one point I would hammer home, uh is that while do you mentioned that you delayed bleeding Usually occurs 5 to 7 days after a polyp ectomy. It is well known that it can occur up to two weeks after polytech to me. Um, so you know, especially if your patients are having larger polyps removed or piecemeal EMR that sort of thing. We always counsel our patients that they need to be aware of, uh, bleeding risk. Um, that can occur up to 10 to 14 days out. Um, so if you are planning on performing something like that on a patient, you may want to counsel them pre procedure that they should not be doing this. You know, two days, it should not be having their call and ask me in politics to me two days before a trip to the Amazon or, you know, before a family wedding or something important, because bad things can happen. Unfortunately, um, we see the same. We see the same thing in general surgery. Uh, it's not uncommon. They can have an acute bleed within 24 hours after a bowel resection, and then they'll be perfectly fine. And on the seventh to 10th day, they'll bleed for me, the sloughing of the super liner or a scab coming off. So we see the exact same thing. Surgical and timing is the same June. Did you come across any data on the role or utility of of follow up colonoscopy in patients who present with post polyp ectomy bleeding. In other words, someone comes to the E D. Three or four days out, and there he mo dynamically stable. Should we be doing colonoscopies on all these patients? Or is it is there a role for just I'm not sure. I'm not sure about the data behind that. I'll be really interesting to look at. I think I think some of the big societies have put out recommendations on the day of you can comment that if the patients clinically stable, um, and the bleeding spontaneously resolves that you can just safely monitor them, uh, conservatively and not have to repeat a colonoscopy as as is not uncommon a case. By the time the patient gets prepped and a colonoscopy is performed and you get in there and find the site, it's probably already not bleeding anymore. Um, and you can always do you know Kateri or clips to profile act against re bleeding. But, um, there are good studies and data out there that show that stable patients can be monitored without need for re intervention. But I think the important thing to stress to patients is that it's impossible to predict which patient will fall in that category, and it's always in. Your patients should always be encouraged to come seek medical attention, an emergency room or an urgent care for vital signs and monitoring of their hemoglobin, etcetera. Um, and I think patients get frustrated with that because they're like, Well, you know, I bled and it stopped and I feel fine now, and it's like, Wow, could have been a sentinel bleed. You're right. Maybe it did stop. We have no way of really knowing. So Okay, key, discriminate, the key discriminator and the stuff that's been published recently This seems so obvious, but is whether they're having rectal bleeding at the time that you're seeing them. So if they're having rectal bleeding, obviously something still bleeding. But more important is the converse, which is that if they are not having rectal bleeding there bleeding and there came a dynamically stable, they're bleeding, has stopped, and the utility of then going in and trying to look for an intervention goes down traumatically. You don't need to do it. So, um, you know, you need to either act quickly, but if they stop on their own you can feel pretty comfortable that they've stopped. That's the crux of the guidelines and the data. Now, for patients who are on anti coagulation, they don't have a risk of re bleeding if they've stopped on their own. We always have a risk of re bleeding again kind of thing. But typically, you know they're going. Once they've stopped, they've stopped. The management of anti coagulation anti platelet agents in this setting is really complicated, and it's a a risk benefit thing. I mean, sometimes you do need to interrupt any coagulation again, Um, let things settle down. But again, it has to do the indications for why. And it needs to be individualized, and everybody needs to be a good clinician. At that point. I think the last point we'll sort of talk about which which you mentioned, uh, June is about the role of clipping um, for anyone who's ever heard Jerry talk about this or on Friday morning conference. Anytime Jerry took out a big pile up, we would always ask him, Did you clip it? And he always give one of his trademark don't need to do that, and for 50 years he was right Um, But now there's this whole plethora of prospective data showing, uh, again, G. You mentioned this that patients who have large polyps removed particularly greater than two centimeters and particularly in the right side, uh, so seek him ascending colon and proximal transverse colon. There seems to be a significant statistic, statistically significant benefit to decrease bleeding rates. Um, when you do prophylactic clipping, Um, so I think that is becoming the standard of care. The challenge is that if it's a very large site, you often cannot close the entire defect. And there's one study that shows that partial closure is just the same as doing no closure. Um, and that full closure is really where the benefit comes. So you know when when we do these big, piecemeal polyp economies and the seek them in descending colon, you know, sometimes the defect is five or six centimeters, and you know there's no utility in trying to close that because you're just not going to be able to do it. It's usually too big to oppose the edges or, and you end up placing like five or seven clips, and it's like, Well, I guess we got a third of it close, but we really probably clinically didn't really do anything significant. But But that is really where the main crux of clipping comes in is large polyps right side, and I and I think, as mentioned patients who are at high risk for bleeding because of anti coagulation, we should be considering clipping those patients clipping the reception site any other thoughts or comments, very common and important topic. Well, um, comment that the data for prophylactic clipping is kind of all over the place, you know, it's like every six months or a year. I mean, the data is getting more rigorous. That used to be K series, and now we're moving towards R C. T s. I think the most recent RCT should have no benefit to clipping with the one in the same issue of gastroenterology the one prior. So there was a benefit. Um, you know, some of it comes down to how you clip, and I agree these big defects like I think you end up creating more trouble than you do help the patient when you start to try to close these huge areas. But we've all scoped post politics. Maybe patients and seen the visible vessel between two clips. You know you got clip clip and the vessel in the middle. Um, and and And that speaks to the technique of clipping, which, if you were just taking that clip and just dragging the mucosa overtop the defect, you haven't done anything. You literally have to sort of Evert the sub mucosal tissue and kind of like getting kind of close up like this. Um, and what that does is it actually closes the stuffy coastal vessels, and that's harder to do. And the other thing is that that's important is how close your clips are to each other. I think Doug Rex or somebody from a couple of years ago at G. D. W. Talked about this. If your if your clips are further apart, you're less likely to actually achieve a benefit in preventing bleeding. And you know that starts to get to be an insanely expensive and complicated thing to do clips really close together to make like the great wall of clips in the ascending colon. Um, so there's a lot more to come, I think, in terms of techniques and how to do it, I think that's where the data is all over the place. But if you're going to try to do it, you don't want to just literally, like, just pull the mucosa over top, just like you're taking a bed sheet covering like a big mess on your couch. Um, you really want to try to get in there and get deep into the sub mucosa and close in some of the small vessels underneath? Just just follow up comment on that. I agree completely with ulcer bleeding. You know, we're always focused on the visible vessel that's there, but that's technically not where we want to be clipping. We want to clip on either side of the visible vessel because that's what's feeding bleeding through the pseudo aneurysm and the vessel. So I think it's something that we probably don't talk about as much or enough. And, uh, I agree. I think there's an art to place in clips, and if you don't do it right, he end up causing more damage than good. What's up? Cool. All right, Well, uh, great case. Thank you, G. And great conversation and discussion. Um, I believe Nick is still on Nick, Do you have a case to present today. I do. And here it is, uh, endoscopic wack. A mole. This is actually in keeping with the theme of the other cases is actually a bleed case, which I rarely present. But this one was particularly interesting. So the case is actually a pediatric case, and I don't know if any of our pediatric colleagues around here, but thank you to them for allowing me to share this. The patient was 16 year old female. She presented with an initial presentation of diabetes with diabetic ketoacidosis. And she just had a very dramatic course. Unfortunately, she was in the ICU. She had renal failure. I think she had, uh, v fib. Pancreatitis. Rhabdomyolysis. Basically very sick in the ICU. And in this setting, she had human nemesis. And that was the original reason for the consult. It was a little unusual. It was sort of a dramatic hemodialysis, blood with clots. And then it would just stop. Uh, and she required transfusions intermittently, and they were sort of watching to try to see how this was going to play out. Ultimately, they made the decision to proceed with endoscopy and what we encountered was a lot of blood, uh, and fresh blood. And there was basically no visibility. We didn't see any lesions. All we could see was blood. So the first step was we actually took the patient and rotated her from left lateral to right lateral. Uh, and this moved the blood within the stomach to allow visualization under that pool. Um, at this point, we're scoping across the bed, and then we were able to clean up, and we saw this. So she has a spurting vessel. In the absence of any lesion, there's really no ulcer. And just with minimal trauma, just the lavage, it basically just starts hemorrhaging. And so the decision at this point was made to attempt to close it with clips. This was very challenging. That's the title, but basically we're in retro flexion. The patient is right, lateral or across the bed. The visualization is poor because there's no lesion, just the vessel and blood. So the technique is sort of to try to tamp in on the vessel with the clip before you deploy it and see if you're in the right spot and see if it's still bleeding or if it stops uh, and then ultimately try to basically catch it in one of these clips. And as you can see here, it's very challenging. Uh, the second you get close enough to put the clip on your sort of in the puddle of blood. Ultimately, this clip was placed in the place where we thought the vessel was. You can see where agitating the area, there's no more bleeding, and this clip is deployed. But unfortunately, that's actually not where the vessel was at all. And it's actually over here this ongoing bleeding, uh, which is very frustrating. So further clips are deployed, Another one sort of closer. But right on the edge. Uh, this next one, I think, actually, you can still see the spurting there. This one is right on the vessel, and ultimately you can see again with irritation, Agitation. The bleeding has stopped with this clip. Anything connecting epinephrine at this point to get control. Then we I think that's a valid thought and we'll talk about treatment of dueling boys in general, which is what this is, um, similar to also believes combination therapy is better than single model therapy. In this case, I think that you could take it. Either way, that might help. You might hurt you. Uh, you want visualization, But if you inject epi and it stops bleeding, then you don't know where the vessel is. So I think it could be a double edged sword. Probably happy wouldn't be enough to stop it bleeding completely. So it might work out to just slow it down, and you would still be able to locate it. But that was one of the concerns with injecting epi is that we would just lose it completely and not be able to get a really definitive treatment. And the patient did great after this. She just stopped leading. Um, she was still going to ask you for a little while, but she stabilized, and then she went to a cute Yeah, So we can talk about do voice, uh, the path of physiology of the Duke boys. It's basically an apparent sub mucosal vessel that perforated through the mucosa in the absence of any clear mucosal defect like an ulcer. And the vessels are huge. It says 123 diameters, Which doesn't sound that, but these new coastal vessels should be capillaries at this point. they should have branched off into something an order of magnitude. Smaller than that, These do not, for whatever reason. And so they are very large vessels that get to the mucosal layer and then bleed very dramatically. The presentation is actually not our typical, not our patient. The typical patient is usually an older male with multiple comorbidities, uh, and said use has been associated with bleeding. They are found in often in the location that we saw this lesion in the proximal stomach. About 74% of them are in the stomach. They can be seen in the duodenum, and they can really be seen anywhere in the GI tract. But it's very rare to see them elsewhere. They present with upper GI Bleed and classically human nemesis, similar to the way this patient presented with a sort of stuttering bleed, they might start and stop as the vestal bleeds and then to stop spontaneously. In the study, I saw it said it comes for 1 to 5.8% of Upper GI bleeds in my experience that I've barely seen a single digit number of these, So I don't know if that's, uh that seems like an overestimate to me. But, um, treatment is with endoscopy. It can be very tricky because there's no lesion. And so if you don't catch it while it's bleeding, then you might not see the lesion at all, and it may require multiple sessions. So the key is that you have to scope them quickly while they're bleeding so that you don't miss it. And this topic therapy, as we discuss, is similar to ulcer disease. You can use any of the typical methods that we use Endoscopic lee and combined therapy is more durable than just solo therapy. With injection, uh, us can actually be used in these cases to locate the lesion on the right. This is all black and white, kind of hard to see. But there is basically vessel at that big arrow that is penetrating through the muscle layer and into the Symbicort Slayer and the other utility of the U. S. And specifically Doppler in this case would be that you could Doppler the vessel to see that it's bleeding and locate it. And then after treatment, you could Doppler it to confirm that there is no longer blood flow and that you've successfully treated it. And endoscopy is unsuccessful as usual. Angiography or surgery similar to also pleads could be used. That's it. It was foolish. Boy, do a FOI was not the first guy to discover this lesion. It was some other doctor who only reported one and then do a lot for a reported three or four, and he got his name on it. So I guess that's the trick. I think he was. He was like a French surgeon in the late, uh, century. Um, and I think this big claim to fame was like appendicitis or something like that. Yes. You saw? Yes. There are two aspects of the case that I thought were useful and to discuss. And I talked about this with the fellows. Anytime I'm on service, I'm a big fan of the rotisserie approach positioning. Um, when a patient is left lateral, the dependent part of the stomach is that fungus. Um, and if you just imagine a little like netters diagram and turn it left lateral. So, um, and that's what you see. Any time you throw water in the stomach, everything pulls towards the funding. And if there's a large volume, it's fun this all the way up to the cardiac, and we tried to suction the side. I mean, it was clot. I mean, this thing was bleeding and clotting, like the whole time. And so when you turn the patient right side down and distended stomach, the dependent portion actually becomes the Antrim. And so we literally would inflate the stomach. And this big massive clot went plump and like just dropped into the Antrim. And we had an incredible view of the entire funding. So I don't spend a lot of times I'm doing meat cases. If there's a big clot to fund us, I just turned the patient. Um, it's an annoying position to scope, but I've saved hours, even on call, even in the ICU, wherever it just makes your life better. Um, it is trickier to scope, but you can do it. Uh, this was one of the best doula. For example, I have ever seen we actually clean. The fund is completely and there was nothing there. There was no blood. And we're like, how is that physically possible? And then we're just spraying with water, and we hit one spot and just just old faithful went off. Um, and it was really impressive. I mean, so epi in this sense would have been really tough because there was literally nothing. We're staring at a clean fun this and then it just blew up out of the mucosa. Um, and so, uh, we had talked about it. I was a little worried. And the position, It was really pretty bad. Um, but really take advantage of the endoscopic rotisserie, um, and, uh, fellows trying to convince your attendings to do this. Um, and, uh, it really can save you quite a bit of time, So just to jump off of that, I I agree. But even easier technique is just to sit the patient vertically. 45 degree angle or higher. Well, obviously, what's that? We tried that first. Yeah. So, obviously, these patients should be intubated. A patient like this. That way you can take your own pulse. The situation is controlled, and the patient has, uh, their airway protected because not just blood. But you see all the fluid being, um, instill. So there's a high risk of aspiration, but but yes, the other cheap way and easier way without having to rotate the patient is just to lift the head of the bed. I scoped somebody with the virus will bleed sitting up. They were intubated, but it was the only way to maintain visualization and just have blood go into the stomach and not cool in the esophagus. So it could be a similar approach here, but very nice. Very good. Thought for sure. Very nice. Another quick thing, Chris, while we have it. I mean, I agree with the the turning stuff that you guys are talking about. Therapy for this. Um, I think there's recent stuff that would suggest that large things like over the scope clips or band ligation, is actually potentially more effective than superficial techniques. And it sort of makes sense. You think back to Nick's histology picture that he showed, Um, what do you guys think? I have to imagine over the scope clip would have been impossible in this position. Correct? Correct. If you can, you know, in other areas, if you can see it, if you could get to the area, certainly you can do it. But the nature of these things is they're just hard to visualize right there, briskly bleeding or there's nothing there at all. It's sort of an annoying dichotomy, and usually Nick, maybe you. Maybe you mentioned this or came across it. Like you said, it's These are typically like the person walking on the street doesn't get these. It's usually somebody who's really sick. Yeah, it's 100%. It's usually a sacred person, sick or older person. You know, it's interesting. The old literature talks about Cushing's ulcers and curling ulcers, and, you know, curling is ulcers were supposed to be with burns and Cushing's ulcers with head trauma. This patient had cerebral oedema, and so I thought you were going to get it like, you know, Ah, you know, an ulcer. But I wonder whether the old literature was really dealing with dual avoids altogether. Yeah, who knows? You may be right. All right, Fantastic. Thanks so much, Nick. Thanks everybody for the lively conversation Published December 8, 2020 Created by Featured Faculty Yuying Luo PGY4 Icahn School of Medicine at Mount Sinai Ji Yoon Yoon, MD PGY4 Mount Sinai Hospital Nicholas Hoerter, MD Advanced Endoscopy Fellow Icahn School of Medicine at Mount Sinai
