Video Endoscopy Conference 3/26/21 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 3/26/21 Overview Three cases presented here: 00:00 Gastrointestinal Stromal Tumor (GIST) 19:12 Delayed Gastric Conduit Emptying 32:45 Hemobilia Okay. All right so today I'm presenting a case involving a 74 year old male with a past medical history of diabetes hypertension. He's had a stroke in the past as well. The remote alcohol use history um was brought in by E. M. S. With ultra mental status as well as it one day of turkey, graham nemesis and melon. Oh according to his daughter he has never had an endoscopy. He's not really on anti tribulation or n says His initial labs were notable for a hemoglobin of 13-14 baseline. His last known values in 2012 to 9.3 on arrival Black pit with 98 near the very elevated the when to create name. Several hours after he arrived in the er he had two witnessed episodes of large volume Elena with associated hypertension. He received two units of blood for his hemoglobin of 9.3 which subsequently rose to 10.9 only to drop to 7.6 a few hours after. And as a result we decided to perform an emergent E. G. At the bedside in the ICU. So on his endoscopy, as you can see in the stomach body, there was a 4cm sub epithelial lesion along the last of furniture, with evidence of both mucosal and some mucosal destruction by tumor growth. There was an inherent cloth. I was easily washed off, but no active bleeding was seen and the stomach was full of a lot of old and clotted blood. That we irrigated instruction given that this large subject to feel a lesion was clearly the source of his bleeding. Surgery was contacted and he was actually taken for a weather section later that day. Here are some representative images of his lesion and you can see on the right there is evidence of ulceration And this is the path from his wedge resection. His tumor was found to be consistent with the gist of the spindle cell type measuring up to four cm and its greatest dimension. With a low my topic rate. The immune of historic chemical stains were positive for CD 1 17 and dog. one with the search over sexual origins being negative or tumor standing to touch briefly on jets. They are the most common mistakes Baltimore, accounting for 1-2 of tumors in the gi tract. They do have a variable aggressiveness and can be benign or indolent, too aggressive and metastatic And they're usually diagnosed in the 5th to 7th decade of life in terms of their distribution in the Gi tract, the most commonly found in the stomach, followed by the small intestine and colon, and less commonly in the esophagus. Most gastric just protruded aluminum and are actually identified incidentally on E. G. D. S. That are performed for other indications an endoscopy. They can appear as a smooth bold with a normal overlying mucosa that is often firm inconsistency with surface ulceration, patients can present symptomatically with acute or chronic bleeding, which was the case in our patient. And when you encounter these kinds of lesions on upper endoscopy is important to keep a broad differential of stuff at the piano lesions. These include like homa neuro endocrine tumor, leo, my oma, euro stromal tumors, pancreatic rest and extrinsic compression from alternative solution. The U. S. Can be helpful as it accurately, it helps to accurately depict the size of the tumor is type of characteristics and the wall layer of origin. The majority of these tumors are less than 3 to 5 centimetres in size. They usually HIPPA Covic homogeneous and solid, though they can also appear heterogeneous with cystic space with cystic spaces and most of these lesions arise from the musculature is appropriate. His ideologically most of these tumors are composed of spindle cells that can also be composed of epithelial cells or a mix of the two and and um you know, he's still chemical staining, 95 of these tumors will show positivity for CD 117. Dog. One is a recently discovered marker for just and it can be useful if the CD 1 17 stain is negative in our patient sample, his terror was positive from both With these. Just it's important to stratify them by their malignant potential. And this assessment is usually based off of a combination of tumor size, their location and my topic rate presently there is no true consensus on which us features best correlate with malignancy. Given conflicting results from prior retrospective studies though, some suggest that Larger tumor sizes of over three cm and irregular tumor margins more consistently are more consistently associated with a more aggressive genotype. whereas features like eca Jericho science, cystic spaces, heterogeneity and alteration or found to be less consistently associated with malignancy. Yeah, management is determined based off of size. The tumor size, location and symptoms and surgical referral seems to be the main state, which should be considered in patients when they are symptomatic and come in with symptoms of obstruction, pain or bleeding should be considered when lesions have surrounding linkedin apathy and lesions over two centimeters in size anywhere in the Gi tract. Just given that the larger tumor size, his thoughts will be associated with a more aggressive genotype and finally, any tumors originating from the small bowel because they appear to have a higher malignant potential or gastric gist that are less than two centimeters in size and do not carry high risk US features. There are some data to support the uh surveillance by the US at 6 to 12 month intervals rather than your section. Though the optimal interval has not been determined. The National Comprehensive Cancer Network Guidelines actually recommend that with just over two cm or small illusions that have high risk features on us that these lesions should undergo or section. So this is an algorithm regarding the management of sub epithelial lesions that was published by the A. S. G. E. In 2017 focusing on just Which primarily involved the fourth layer or the muscular is appropriate. There are recommendations to consider endoscopic management, especially if these tumors range to the four cm in size, although laproscopic reception remains the standard of care. Some of the endoscopic techniques that have been studied include E. S. D. Sub mucosal tunneling and discovered reception and endoscopic, full thickness reception. Um And here a few studies that look at each of these endoscopic techniques. Uh So for E. S. D. He and company utilized it in 145 gastric sub epithelial lesions arising from the muscular is appropriate. These tumors had an average size of 1.5 cm and complete resection was obtained in 92 of these lesions. There was a perforation rate of up to 14%,, but all were managed endoscopic lee And no local recurrence or district mess we're seeing during an average follow up of 19 months. The limitations with E. S. D. Is that it is technically challenging, time consuming and it may not be as useful for larger tumors over five centimeters because of a reported corporation rate of up to 20% with larger lesions. And additional risks include positive perception margins leading and tumorous village because of a disruptive capsule. Now, some proposal tunneling endoscopic perception is a technique that involves creating a postal incision at least five cm proximal tibia lesion. Through this incision, the scope is advancing to the sub mucosal space and some mucosal dissection is then performed until the lesion is seen in the tunnel. Once the tumor is completely respected, it is retrieved through this tunnel and the mucosal incision site is closed. So yeah. And company uh, utilize this technique in 85 upper gi sub episode allegiance arising from the muscular is appropriate. All of these cases were completely respected. Um with an overall rate of adverse events being about 10%, with the pneumothorax being the most common. Um and all adverse events were managed conservatively. The rate of complications, however, was significantly higher for lesions originating in the deeper muscular is appropriate. This is about 70 compared to the more superficial muscular appropriate, which is about 1.3%. And this was statistically significant with the highest complications occurring for just compared to other tumors in this study. Finally, uh, endoscopic full thickness reception. The potential advantages include that its applicability with larger tumors up to four cm if the ability to perform complete resection of lesions, horizon from the muscular is appropriate and its performance in difficult to access locations such as the fund this and approximate body. And Palin Company utilizes technique on 26 gas trips up out of the a lesions arriving for the muscular is appropriate. He's an average tumor size about 2.8 cm. Complete reception was obtained in 100 of cases. And there were no major adverse events recorded on all the decision to pursue endoscopic versus surgical reception is really case. Plantronics expertise dependent. Um But I'm curious to hear more advanced team what their experience has been in approaching these cases. Um So a couple of things. First of all that is a really good summary of just those first use. Lives is basically everything you ever really need to know. I do want to drive home the fact that the small biologists have a much higher malignant potential than this gastric ones. The gastric ones by there's a whole grid of my top grade and size that shows their malignant potential. Aghast regis can get up to 10 centimeters and still be pretty indolent actually. Whereas like a one or two centimeters duodenal gist can become pretty is fairly high risk for malignancy. So just know that gastric just can be enormous. We'll see these on C. T. Scans sometimes of a huge upper abdominal mass but at the end it might be a lower intermediate potential lesion. The other thing about this case that I really like is that the surgeons took the patient to the O. R. Without getting an E. U. S. And tissue. We get asked to buy after these things all the time to which we usually say they bled. I don't care what it is. Get rid of it. Um And it's a it's a it's a it's a wedge resection. It's a straight it's not a gastric cancer is clearly said the epithelial. So um I commend the surgeons for sort of just acting on this and not sort of diddling around for waiting for path and the U. S. And so on. So uh this is I think the right way they should be managed in terms of you know and I like this a S. G. Algorithm a little bit um you know myself. I was a skeptic about having um these just removed with E. S. D. Or E. F. T. R. I initially a handful of years ago thought this was just endoscopy is showing off these are low risk lesions. But now, you know having worked with McKeel and also seen the data evolve over the years. It's quite safe. They show a preparation right here but many times that perforations intentional, it's to get it off the muscle and it's not a complication like perforation of the colon from Apollo pick to me, which is a different issue. And so these are very controlled perforations. Even intra procedural bleeding is very controlled and readily managed. So some of these complications may be a little overstated in this grid format, but I've actually changed my approach to this. This is a really safe procedure. Inexperienced hands to kill has been stellar at this and many of the other experienced, I add that caveat the experienced people in New york city have been very good with this as well. The surveillance of these things is really annoying. If you think about a 50 year old coming in every two years for an E. G. Or the U. S. It's just not resource practical. And you can't underestimate that. This makes some people very anxious when you tell them we have a thing that's growing that's a tumor. Nobody likes that. And there's a real mental wear for many patients that I don't think we appreciate. So now that there is a safe, I mean it's a it's like an hour, hour and a half procedure which could be a big, just a tough colonoscopy. When you think about timing, um anything that's over 1.5 centimeters um I usually send over for an endoscopic resection because then it's gone. It's cured. There's nothing to do. You don't need to worry about it anymore. Um So I think that and and that encouragement most people anytime they get referred to me, I've been referring all of these on because we should get rid of this surveillance stuff for life on these young patients. Um Any other comments out there? Um If you could scroll back a couple of slides to the picture of the gist, I didn't want to point out one thing before we move on to the U. S. Case right there. So this is a pretty good appearance of it. You see how they're sort of sharp borders at the junction of the lesion on the stomach wall. I tend to find like Hamas have sort of softer edges that they're not as sharply demarcated. So one can risk stratify as an endoscopy ist is it firm? Um That might make you think of a muscle tumor. This is what I that's how I describe these two patients. And also um are those borders very sharply defined like they are sort of here and this I tend to see this more ingests. Um It's important to tell patients when you found something in the stomach that is not a cancer. About half the patients who come from the U. S. Are freaked out. They have a stomach cancer. Um And so I make it very clear this is a semi benign muscle tumor, is how I sell it. Um Any other comments Hi station kill here? Um So Christina smiling because I remember we did this case at like four in the morning. And uh and the patient had a pretty um pretty massive hemoglobin dropped. And as you alluded to, as soon as we saw this we knew it would suggest. And so I, you know, I think it's very certain specific to really get the correct treatment of churches, which which in this case was an easy enough wedge. Um and so I called the surgeon specifically to make sure that we could bypass, you know, getting a tissue diagnosis because this was not um concerning it all for a gastric adenocarcinoma. And so literally within a matter of a few hours that patient was in the O. R. And I think that also um you know, it was to, you know, communication directly with the surgeon so that you you don't delay patient care. Um and you know, one of the higher risk factors and indications for surgical reception are these bleeding ulcerated um gist. But um I would echo your comments that, you know, with respect to those guidelines, Particularly for the smaller, just the trend now is moving towards endoscopic resection because it is very safe. And actually, the reason why we don't go after lesions that are more than five cm, it's not that we can't uh physically cut them out is that we can't, it's very hard to physically remove them because remember, with just you need to keep the capsule intact and you don't want to fracture it. So, if you have a six or seven centimetre gastric gist, you're not, we're not gonna be able to pull it out through the g junction or through the upper, a soft shell splinter or out through the mouth. So oftentimes those end up going on to surgery. And even for the larger, just like the greater than 10 centimeters you talked about, the surgeons will oftentimes give the patient Gleevec or a magnet to try to shrink it and uh, and improve their surgical chances. The only caveat, um, is that we, some locations are harder in the stomach to do these types of reception. So, um, the fund is in particular because you've got to work in that you turn retro flux position that can sometimes be challenging. So if they're really small in that case, like, you know, a centimeter or less than those are the ones that will opt to survey. But if it's, you know, bigger than two guns that like 10, 15 mm, even if it's under the NCCN guidelines as Satish mentioned, patients will have a thorough discussion within the office, but more than likely they're going to opt to have that. Um, just respected so that they don't have to undergo, you know, long term surveillance and anxiety that you know, that may come with it. Um So I thought that was you know, a great presentation that you did remember this basement ability and um I think your slides were great and I would just you know, highlight that for our patients. Um You know, we can really offer a great endoscopic resection. They have outstanding um results. And I think the comments teach made was very pointed about those perforation. It's really aren't perforations. Um You know, you have to cut it off the muscle. So the reason that the tunneling technique is probably the preferred approach now is because you don't have one, you know, sort of full segment of stomach wall that's completely breached from the mucosa through to the cirrhosis to Um it's a tunneled approach. So you know approximately you have your coastal incision, then you're kind of tunneling through with 70 cosa. And then you know closer where the lesion is, where you're having your muscular is appropriate dissection or sometimes even a full thickness. Um dissection just distantly of them of the muscle. So it's sort of a controlled almost like that Z. Line technique that you use during you know like paris and pieces. So um it was a great presentation. Great case. Alright. Ji eun. Um Have you taken over here? Mhm. We do yeah. Mhm. Mhm. Good. Okay. Yeah. All right. Good morning everyone. Um I wanted to present a case that came across some consoles which is a little more surgical. Um This is a six year old lady with end stage renal disease on human dialysis history of an esophageal adenocarcinoma. Um Had an Ivor Lewis herself rejected me. The path showed she had T. Two N. Zero M. Zero disease with barrett's on a background barrett's esophagus. Um She is presenting with recurrent vomiting and coffee ground nemesis which is an ongoing for about a month after herself rejected me. Her operation was successful. She was discharged on day nine without any particular complications. Um She's now tolerating minimal oral intake without vomiting. Um But she is passing stool and gas and not complaining of any abdominal distention or abdominal pain. Um On the right here is her uh initially g showing an irregular lesion which turned out to be herself. She'll adenocarcinoma. So just to go over the anatomy of the Ivor Lewis subject to me. Um Initially a laparotomy is performed. That's to mobilize the stomach from the surrounding structures pile or a plastic is performed to prevent delayed gastric emptying. And then the surgeon also performed the lymph node dissection. The patient is then turned onto the left lateral and the right thoracotomy is performed. The stomach is mobilized into the thorax. The esophagus is mobilized with the reception of the tumor and then um the anastomosis is performed between the stomach and the esophagus. So back to our patient she underwent a C. T. Scan in the emergency room which uh this show so this is a representative image as you can see that is thoracic conduit with the air fluid level. It looks pretty dilated. Um And then we were asked to perform an E. G. D. On this patient firstly to evaluate the cause of the coffee graham, MSs possible bleeding and to look at any signs of look for any signs of obstruction in the contract. So these are the first images that we found on entry. Um This is her esophagus. She has a lot of esophagitis. Um She had a lot of fluid built up in there and then you can see the thickened area on the bottom around five o'clock. This is herself. Forget gastric anastomosis with surgical uh staples. Mm hmm. Um Next is the image of her um of her thoracic conduit. So you can see that it's extremely ulcerated. Um There's a lot of every thema bleeding without contact. Um And then here is a fold beyond which which is her diaphragmatic pinch. So her condo is very dilated. And then we can see a fold beyond which we proceeded. Um This is her distal. Uh This is our contract beyond the diaphragm. So everything looks pretty good. Normal mucosa. We passed through the fall pretty easily without any resistance. Um This image is of the pile or a plastic. It's wide open, no resistance to passing the scope. And then beyond that the duty and was entirely normal. Um So what I wanted to talk about today was delayed gastric emptying from a G. I perspective, I'm sure there are surgical colleagues that are qualified to talk about this. The surgical perspective of this. Um so occurs in about 15 to 40 patients after a Selfridge back to me. And the mechanism is thought to be because of the complete vehicle to me from mobilizing stomach, resulting in decreased contract, ill, itty and increased pile oric tone. Um There's a lot of literature about whether pile or a plasticky um uh procedures to reduce pilot turns or whether that be a finger disruption of the pilots during the surgery or pilot capacity during um their surgery as well. And it seems to be that um performing these procedures helps reduce the incidence of delayed gastric emptying after surgery. So um and then there's also decreased blood supply which reduces gastric motility. Um The symptoms are as you might expect early satiety nausea, vomiting. There's a lot of regurgitation and then the inability to meet caloric need by oral intake. The post op course of the selfish ectomy is fairly morbid. Um it's very common to lose about 15 of body weight from diagnosis to six months post op. Unfortunately it levels off thereafter. And then there are other disorders that affect post op quality of life in uh the gastric cancer patient reflux this feature and dumping syndrome. So usually these patients are obviously still seeing their thoracic surgeons. But if they happen to enter into our world throughout the E. D. Or via our clinic, I was thinking you know the simple and easy imaging technique without going through the full C. T. Might be a chest X ray is very suggestive. So this was her chest x ray. You can see that the gastric on the condo is taking up most of her right thorax. And then you can see an air fluid level and the air fluid level is very suggestive of delayed gastric emptying in these patients. Um So what do we do about these patients? Um There are no guidelines as you might expect. However there have been studies that demonstrate that motility agents are effective in these patients. Um Raglan has been tried. There are obviously a lot of problems with patients being on these agents for a long time especially with tired of dyskinesia. So the first line agent is um Aretha mason. And it has been shown to be effective salty immediately after surgery or several months after surgery. If this presents later. Um recommend high dose P. P. I. To treat reflux because there is a lot of stasis. Um And then N. J. Tube if the patient is unable to meet their calorie needs. And it seems like usually they're able to remove that once the motility returns somewhat. Sometimes the pilot capacity is not successful or it was not performed during the initial surgery and then we can help um relieving the obstruction. So um endoscopic options are an endoscopic pylori balloon dilation and entropy Lorik injection of botulinum toxin. Um And I I don't I'm not I think the pilot balloon dilation is slightly more preferred. Although I don't know the exact data behind that. Um There is a gradual recovery of the contract, a function of the contract over time so the patient is eventually um able to tolerate a little more um oral intake and maintain their weight hopefully without the feeds. I was wondering if anybody else had come across this and whether they had experience in managing this these kind of patients. So we'll say I've seen a lot of patients with this is a great presentation. This comes up fairly often. Um And I tell like fellows trainees residents all the time. Like of all the G. I. Surgeries that like we see the one that I would least prefer for myself is that a savage ectomy because the stomach doesn't belong in the chest. Um There is no room for expansion of the stomach there. You've got Jurassic pressures that ultra the the motility and function of the stomach in addition to the vigata. Me uh It's just not a great place for your stomach to sort of live. Um I've done both the Botox injection of the pile orris as well as the pilot balloon dilation. I don't really have a sense of one's better than the other, but I will say that a lot of times you have to do this early on post operatively and then I have seen many of these patients will get somewhat better over time, patients never really get normal right, like after a digital distracting patients kind of do okay, but after a self injecting me, their lives are very different. You don't have an L. E. S and all the other issue. Um, and then as well as all the other issues you we just talked about um it is important to try not to overstretch that conduit. It's a straight shot from the anastomosis down to the pilots essentially when this is done optimally. Is that in your x ray, which is really good. That conduit has sort of a J shape to it and that ends up behaving almost like that little, you know, J shaped pipe under your sink. And you know, there's a lot of stasis in that turn and if that becomes a permanent configuration, then you have an an atomic problem. You've got like a, like a, like a recessed area for food to sit. Um, so I try not to push these patients too hard and J tubes, Pedj tubes, all those gastric Teresa's diets, we put people on redland on paradigm. Um, you don't want them to end up with a big baggy conduit that will fail them uh in the years to come any other comments? Yeah, it's just a really bad problem and there's no great reason why I mean stretching the pile oris or injecting Botox, like it's hard to understand even why those are even gonna work. So, I mean, we do them, but um, you're right. It's not a good operation to begin with, from our point of view to the surgeons of any comments, as as Gm was asking may not be anyone a question. Um While I was looking into this, there were a lot of uh, there was a lot of literature that was debating whether the entire stomach should mobilize or whether a gastric tube should be made. Um This is obvious kind of out of our domain. But have you noticed any differences and Patient outcomes after those two. Normally, the stomach is tube their eyes. You know, they don't just lift it up. They sort of remold the stomach. That's why they call it kind of a gastric conduit. Usually it isn't just the native stomach just pulled up. They kind of slice it down around the cardiac. Um and then they kind of change it, so it's more to configuration. Um but I'm sure there's some variances there uh that are not obvious to me the other type of surgery. I don't think we do that that much here, but because our thoracic surgeons do a lot of the sa projective is here. But in some places they have gi surgeons to do it and they don't really like hanging out the chest. So they do their nasty moses up in the neck that's called a three hole. Asaf rejected me And they pull the whole thing off the anastomosis around 1817 cm. Um The advantage of it appears that there is a leak, it's in the neck and not in the chest. And then for a gi surgeon, they don't want to be in the chance anyway. Um But I I found I don't like that surgery very much that anastomosis is so high. So when there's problems up there, um it's very hard for us to do anything because it's just under the U. S. Any other comments. But the doctor rubinstein is raised. I was just going to ask what the surgical alternatives were since this is such an objectionable operation on many fronts. But it's a bad disease and a bad location. And the question is what what's better to get rid of the cancer? I don't know if any that surgeons are on. But I will say from my own experience and asking this question to surgeons and oncologists, there isn't anything else. You know I mean obviously you come back to sort of barrettes and screening and early cancer and endoscopic therapy. But here you got a T. Two tumor, you can give chemo radiation, but the recurrence rate is much higher. If you don't go follow within a subject to me. Um So it's just kind of a bad situation. Unfortunately. A lot to get your position sometimes sounds nice but it's far worse. Um and those patients end up doing uniformly not great 10, 15 years later. So this is an argument for keeping on top of barrettes screening and watching your barrett's patients. It's interesting because I think something like 70 or 80 of the esophagus adenocarcinoma are in patients who do not have a known history of barrettes. Um There is there it's microscopically it's just we didn't know and so all of this obsession we have over finding barrett surveilling their following very closely is unfortunately the wrong piece of the pie. Um But you're right for the paris various patients we do have. Um Next yes, I will show in your way. Thanks to you. Thanks. All right today I'm going to present yet another unusual gallbladder. Tried to go with our other unusual gallbladder triads of call Somalia Zimbabwe syndrome. Uh huh. So This is an 85 year old female. She has a straight coronary artery disease. And she had a stormy four months ago and had a stent placed. So she's on tight hey girl or an aspirin. And she presented with abdominal pain. She was human dynamically stable and she was initially had mildly elevated uh liver enzymes that within 24 hours rapidly became much worse. Her t billy jumped from 2 to 4. Her asd was 1000 lt 800. Her alphas jumped. So she had imaging and her gallbladder was found to be distended with sludge on the left. You can see an ultrasound. The gallbladder wall is thickened, there's a little sludge in the bottom and these little wispy pieces of sludge floating around on the right. You can see sludge towards the bottom of the gallbladder layering. And she also had billy ray dilation With the common bile duct measuring 1 7 year. So because of the jaundice and the biliary dilation and the sludge, um she was presumed to have Cholodenko with ISIS and went for ERcP. So when we went in there was actually blood spontaneously flowing from the major papillon here on the left most picture, that's the ambulatory on the rim of a diverticular, that's why it looks dark and that blood was before we did any procedural intervention. So this was just spontaneous after cancellation. And we opened up the orifice a little bit, there was even more blood flowing. And then we placed a biliary stent and blood was just flowing through the stent. Uh We obviously shot ACL angiogram as we do and there wasn't really a clear stone or filling defect. And sort of in retrospect because we weren't looking at the labs at this uh the hemoglobin that closely, we noted that she actually had had a two point hemoglobin dropped since her admission. Um Probably from this using she was human dynamically stable. But we sent her for a ct angiogram to see if there was any active extra visitation. And just to compare on the left was the cT the day before the procedure. And we saw again the gallbladder with some sludge on the right. You can notice a density change between this pre and post image on the right. This was after the procedure and now there's high density material filling the gallbladder which was presumed to be blood. So she we actually diagnosed her with hemorrhagic colitis cystitis. The reason probably she was jaundiced is that that blood from the gallbladder can flow into the duct and Klopp and then cause biliary obstruction. So her taika galore was held at this time because of the bleeding and the risk for further bleeding. With surgery. And the fact that she was improving clinically without with conservative management surgery was deferred at that time and then she was discharged a few days later. She has been subsequently seen in clinic doing totally fine with the biliary stent. And then yesterday we actually took out the biliary stent. Um There was no more bleeding swept some a little sludge from the duct and she's doing totally fine in the outpatient setting. So this is the rare triad of hemophilia which we don't really see and you may not even see the full triad. So in her case we didn't have each piece. But they can present with biliary colic, obstructive jaundice. Again that's from clotting in the duct leading to biliary obstruction. And then they could present with him a gemesis or Melania. If it's significant enough bleeding they can have over G. I. Bleeding as well. The most common causes hemophilia is usually going to be some sort of military intervention. Either a liver biopsy um per cutaneous ir intervention, a surgery E. R. C. P. Something that involves manipulating the bile ducts that's leading to bleeding. The other thing to think about in someone who hasn't had a procedure is always going to be cancer. So do they have a Colangelo carcinoma, a gallbladder cancer or a liver tumor that's bleeding invading into the ducks and then bleeding out into the ducks? Uh It can also be caused by more common just generic things like trauma or gall stones due to inflammation. Can cause bleeding or cola cystitis from the inflammation again can cause bleeding in this case hemorrhagic colitis. It is sort of like a subset of things that can cause hemophilia, but it's bleeding from the gallbladder itself and then the the blood from the gallbladder can go into the ball ducks. Um And it can cause cholangitis, it can mimic cola cystitis, similar risk factors to just overall hemophilia, usually trauma or malignancy. In this case, the patient was just on antique regulation. And so the theory was essentially, she had some sludge in the gallbladder is probably causing some inflammation. She was on a blood thinner and that caused bleeding. It was enough with the combination of inflammation in the blood thinner to cause bleeding in the gallbladder. And then that led to all our problems. So the ultimate solution would be surgery to take out the gallbladder if the patient's a good surgical candidate. Again, the surgery was deferred in this case. Just patient was older with a lot of comorbidities, um but she actually did well, luckily with conservative management. So that is it. Uh Great, thank you nick. Um It is a very surprising thing when you see it, because, I mean, I remember walking in the room when you guys do this case and there was just blood pouring out of the Angela. And I like how you first say it wasn't our fault bleeding before we got there, I swear. But it's just a good point because a lot of times a week after we got there, we do possible, but not in this case, most of the time we see hemophilia, it's using the context of some kind of horrible cancer um or against like usually known malignancy or new diagnosis Klan joke all butter CS. All the times I've seen it. Usually the patients are an extraordinary pain, largely because there is such an incredible expansion of the bile duct with blood and clots and then eventually when that duct expands so much their stasis and that's what makes them stop bleeding. But all the times I've seen this, they've been just really bad pain. Um and so sometimes you have to repeat that procedure fairly quickly because your stent gets clotted. Um and so after you reverse things, so, you know, sometimes you just go back in and repeat and cleared out again. So thankfully she did really well. We were pretty concerned about her when she was here. Um But yeah, looking for that obstructive, Jonah's drop in hemoglobin. Those are all uh sort of good tip offs that maybe uh memorabilia. Um Peter, what are you going to tell the cardiologist when they want to know if they can restart the anti coagulation? This was a big discussion. So after she stabilized uh we discussed with the cardiologist and given her recent stent, we actually restarted the anti coagulation. And we were confident at least with that. She did well with the biliary stent that she wasn't going to have um biliary obstruction but you know there was the risk of her current bleeding. But she she luckily did well that's a cardiologist, really loved their anti coagulation. I think we all have learned um other sort of comments before we move on towards grand rounds. I used to see this after liver biopsies once in a while. I haven't seen in a long time. I'm not sure if that's because of better ultrasound guided liver biopsy technique or just happenstance. Although I think that might have been I mean I don't know if people are doing that many blind liver biopsies anymore. Um Maybe even I did blind liver biopsies for goodness sake. Um but um it was great because it only took like two seconds but when they sat and pack you for four hours so because somehow thought that putting them right side down with Tampa, not all that bleeding that occurred in deliver Perrin comma. Which sure. Um All right. Um mm before we start, before we So um is there any argument for not putting in the stand and not draining the CBD if she is actively bleeding for a tampon artifact in the absence of cool injectors? Um You know, I think again, the issue usually is pain um because again that rapid obstruction and then that clot sort of propagates up into the liver so you end up with a rapidly progressive biliary obstruction sometimes. Um So usually the paradigm is clear out the duct and stop the bleeding. Um And so uh unfortunately yeah if you just let a clot then you're just gonna have just this ongoing biliary obstruction so there's really not a good way out. Um And the cases of cancer we often just send them down to I. R. And M. Belies the tumor. Most of the liver tumors are fed arterial early so you can knock out selective branches of the hepatic artery and that usually fixes the problem. Generally this is fixable. Get the gall bladder out or immobilize the tumor. It's rare that you're sort of left in a really bad scenario. Published April 22, 2021 Created by Featured Faculty Christina Wang, MD Icahn School of Medicine at Mount Sinai