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🚨Be sure to check out February 2025 issue‼️ ✅Dive deep into the latest research🔥 📢onlinelibrary.wiley.com/toc/13652982/c… maura corsetti Daniel Keszthelyi MD PhD RFF #FrankZerbib #KirsteenBrowning Chris Black Andrea Shin Michael Jones Mohsin Butt Pierfrancesco Visaggi, MD Rajan Singh ANMS ESNM.eu

“DU Your Best: Duodenal Ulcer Hemostasis Tutorial” I will go step by step through my thoughts [#] and struggle. This pt was transferred for IR embolization after re-bleeding after initial EGD (epi+clip) [#1 - Guidelines recommend repeat EGD after 1st rebleed, not IR]

[#3 I start with clear cap on therapeutic gastroscope bc I know it’s a DU bleed and the space is tight and clear cap tamponade may be needed. I don’t always start with it on for all UGIBs] Note: clip placed @ 1st EGD had fallen off as ulcers are often too fibrotic.

[#4 Turn up the volume. Listen. When I ask for 10Fr Bipolar probe, the technician answers “A Who?” RN repeats. I have been assigned an inexperienced on-call OR team, a struggle with a longer discussion outside the scope of this tutorial, but I should have prepared better.]

[#5 When the artery erupts and my tech is green, I keep my voice steady but firm. The Yerkes-Dodson law states that performance improves with stress up to a point, and then decreases as arousal increases too much. Freaking out won’t help @ this point; it will put us in the red.

The clear cap is used to tamponade the vessel during the time the technician is finding the 10Fr bipolar probe. Epinephrine injection is prepared but not used unless visualization cannot be achieved.

[#6 I prefer to attempt hemostasis without epi injection bc if it halts bleeding, I am never certain my next modality is effective. Epi+bipolar has never shown to be better than bipolar alone, only better than epi alone. To me epi is for optimizing visualization, not hemostasis]

With the team ready, I immerse duodenum in water, and pull back the probe, only to reveal immediate arterial bleeding. More cautery is applied.

[#8 I have IR’s extension memorized and my RN calls to soft block the next IR case in case we fail. IR 💯 answers as they know it’s serious when we call. This relationship/ sophistication is unique to GI hospitalist and would be atypical for on-call outpatient doctor or locums.]

With the bleeding controlled, I am concerned this may rebleed or I have created microperforation. I quickly exchange scopes with a backup scope preloaded with 12/6T Ovesco OTSC. Ovesco is deployed (note: bleeding erupts during suction) but shallow bc the ulcer is fibrotic.

The decision to OTSC was a hard one. I was worried for delayed perforation and bleeding as the patient had to be back on anticoagulation. [#9 Determining if an ulcer is too fibrotic for an OTSC is an art I have yet to master. Epi injection will certainly make it more rigid.]

Never one to waste, I used the Epi previously prepared to inject as the finale, for whatever it’s worth. If Epi does provide additive hemostasis beyond optimizing visualization, why not if it’s already drawn up?

Conclusion: The patient did not rebleed and AC was restarted in 24-48h. This is just how I managed this case. I wanted to give one a window to see the thoughts in my head in such a cases Certainly, I am open to and hope to spurn discussion from others.

📢 Join us next Tuesday, March 11 for another session of SCOPE Rounds with Dr. Evan Dellon on the topic of "Eosinophilic Esophagitis: How to Manage in 2025" 🔗Don't miss out - register now! us02web.zoom.us/webinar/regist… #SCOPERounds #EoE Dr Mark Silverberg Vipul Jairath MBChB DPhil John K. Marshall MD

Hear from returning MC IBD speaker, Dr. Parul Tandon Parul Tandon DO PhD FRCPC, as he dives into which IBD treatments are safe during pregnancy. Stay tuned for more updates!🚀 scopecanada.org/mc-ibd-2025 MCIBD Vivian Huang, MD #Gastroenterologists #MCIBD #IBDManagement

🚨Be sure to check out March 2025 issue‼️ ✅Dive deep into the latest research🆕🔥 📢onlinelibrary.wiley.com/toc/13652982/c… maura corsetti Daniel Keszthelyi MD PhD RFF #FrankZerbib #KBrowning Chris Black Andrea Shin Michael Jones nicolasc Mohsin Butt Pierfrancesco Visaggi, MD Rajan Singh ANMS ESNM.eu👏

🆕🔥#GutDirectedHypnotherapy for #IrritableBowelSyndrome: A Systematic Review and Meta-Analysis‼️ ✅GDH improves #global symptoms of #IBS ☑️GDH improved #pain symptoms compared to other standard IBS interventions👏 👉onlinelibrary.wiley.com/doi/full/10.11… ANMS ESNM.eu

maura corsetti Daniel Keszthelyi MD PhD RFF Chris Black Andrea Shin Michael Jones nicolasc Mohsin Butt Pierfrancesco Visaggi, MD Rajan Singh ANMS ESNM.eu Lin Chang Baha Moshiree MD, MSci, FACG, AGAF Purna Kashyap M.B.B.S., AGAF kara gross margolis Linda Ánh Vân Nguyễn MD Shanthi Srinivasan, MD Madhusudan (Madhu) Grover M.D., AGAF BeyderLab Jeffrey Roberts, MS BSc #TuesdayNightIBS Heidi Staudacher PhD AdvAPD Dr Hannah Mayr APD PhD Jahnvi Dhar Elyse R. Thakur Enrique de-Madaria Yuying Luo Steven Bollipo Rachel Sarnoff, MD Olafur Palsson UCLA Gastroenterology and Hepatology Alexander Ford Neha Santucci MD Shima Ghavimi Magnus Simren Keith Siau Kewin Siah Swapna Mahurkar-Joshi, PhD Emeran Mayer, MD Jasmohan Bajaj Lumír Kunovský Jordan Shapiro, MD, MS Stephanie J. Sohl Suzanne C. Danhauer, Ph.D. Miranda van Tilburg Emad El-Omar Melchior Chloé Sarah Kinsinger 🔥#Pain is a cardinal symptom cutting across #Rome IV anatomical categories in #DGBIs: A network-based approach👏 ✅#AbdominalPain symptoms are most strongly connect to all other symptoms, & pain symptoms grouped together‼️ 👉onlinelibrary.wiley.com/doi/epdf/10.11… ANMS ESNM.eu

Join us for another SCOPE Rounds webinar next Tuesday, April 22 with Dr. Miguel Regueiro! 🤩 🚨You don't want to miss this talk - register now! us02web.zoom.us/webinar/regist… #SCOPERounds Dr Mark Silverberg Vipul Jairath MBChB DPhil John K. Marshall MD

If we are reaching for coffee and vitamin E to “treat” our patients, we really have reached a limit of reality, and went beyond into the realm of “I’ve got nothin left to offer”