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Create a Free AccountProcedures - Hemostasis of GI bleeding
Modification of the endoscopic hemostatic powder application technique
EndoClot Polysaccharide Hemostatic System (EndoClot PHS; Micro-Tech Europe, Dusseldorf, Germany) is a starch-derived compound that consists of biocompatible absorbable hemostatic polysaccharides that absorb water when in contact with blood or liquids, creating a gelled matrix over the bleeding lesion. It also accelerates the in situ coagulation process through hyperconcentration of platelets and coagulation factors.1 Hemostatic powders are considered an endoscopic hemostatic option for upper and lower nonvariceal bleeding, which are easy to use and have a good safety profile.Novel simulator of endoscopic hemostasis with actual endoscope and devices
Endoscopic hemostasis is an essential skill for endoscopists and has been the first-line treatment.1 For example, we reported that 70% of bleeding ulcers were treated with endoscopic hemostasis.2 Endoscopic hemostasis, similar to most techniques, is currently acquired through on-the-job training with real patients. However, such high-risk situations are not preferable for trainees. To perform a hemostatic procedure safely, the operator needs skills such as maintaining an appropriate view, stabilizing the scope, and controlling hemostatic devices precisely.Use of helical tack system for management of a high-risk fibrotic peptic ulcer
GI bleeding because of peptic ulcer disease is a well-described entity in its diagnosis and management. Although hemostatic clips and thermal therapy have been the primary tools in bleeding from peptic ulcer disease, some bleeds remain refractory. New data have shown that obliteration of the underlying arterial blood flow is needed to control refractory peptic ulcer bleeding. Although this has been shown with over-the-scope clips, we present a case where GI bleeding is controlled via a helical tack system.Endoscopic ultrasound–guided embolization of refractory splenic pseudoaneurysm
Visceral arterial pseudoaneurysms are common sequelae of chronic pancreatitis, occurring in 10% of patients, and carry a non-negligible 50% risk of rupture and 14% to 50% mortality with rupture.1-4 Transcatheter arterial embolization (TAE) is an effective modality for treatment of visceral arterial pseudoaneurysms with high technical and clinical success rates (97%-100% and 94%-100%, respectively) but a variable adverse event rate of splenic infarction of 6% to 24%.1-4 However, in cases refractory to TAE, EUS embolization approaches have demonstrated clinical efficacy, with studies demonstrating up to 100% technical and clinical success in this setting when using thrombin or cyanoacrylate glue.The use of water immersion technique during device-assisted (single-balloon) enteroscopy to treat actively bleeding jejunal Dieulafoy's lesion
Dieulafoy’s lesion (DL) is an uncommon but potentially life-threatening condition, which can result in sudden, massive gastrointestinal bleeding. The water immersion technique can be helpful in localizing the source of active bleeding during an endoscopy. Herein, we present a case of gastrointestinal bleeding due to jejunal DL found on a video capsule endoscopy (VCE). We describe the use of the water immersion technique in localization and treatment of actively bleeding DL during single-balloon enteroscopy.Utility of red dichromatic imaging for identifying the bleeding point in endoscopic hemostasis of colonic diverticular bleeding
An 82-year-old woman was admitted to our hospital because of hematochezia without pain. She had been admitted to our hospital several times in the previous year for colonic diverticular bleeding (CDB) and had already undergone multiple hemostatic treatments for the CDB. A previous plain computed tomography scan had showed multiple colonic diverticula in the ascending colon and sigmoid colon (Fig. 1), so recurrent colonic diverticular hemorrhage was the primary differential diagnosis.Cholangioscopic diagnosis of hemobilia: an unusual case of left hepatic portal hypertension by plasma cell tumor
Hemobilia refers to potentially life-threatening bleeding, of diverse causes, into the biliary tree. Digital direct cholangioscopy could be a useful tool to identify the source of biliary bleeding in cases in which it cannot be clarified by imaging modalities.Direct clipping using underwater inversion method for colonic diverticular bleeding
Colonic diverticular bleeding is the most common cause of acute lower GI bleeding, sometimes requiring hemostatic interventions, such as endoscopic hemostasis, transcatheter arterial embolization, and surgery. Recently, various methods have been developed to achieve endoscopic hemostasis for colonic diverticular bleeding.1 Endoscopic clipping is widely used because of its rare association with tissue damage and is classified as direct or indirect types. Direct clipping is performed on the exposed vessel in the diverticulum, whereas indirect clipping is performed to close the responsible diverticulum in a zipper fashion.Balloon tamponade for control of myotomy bleeding during peroral endoscopic myotomy
Peroral endoscopic myotomy has revolutionized the management of achalasia. Although capnoperitoneum or capnomediastinum are not uncommonly seen in the immediate postprocedure setting, severe adverse events such as perforation and bleeding requiring cessation of the procedure are rare. Individuals with a sigmoid-shaped esophagus are known to be at increased risk for adverse events. Minor bleeding is relatively common during submucosal tunneling and is treated easily using coagulation from the dissecting needle itself, cap tamponade, or coagulation forceps for larger vessels.Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices
Endoscopic injection sclerotherapy (EIS) is an effective therapeutic option for esophageal varices (EVs). However, the outflow of sclerosant impairs its effectiveness and increases the incidence of adverse events. Hence, we developed a novel EIS technique with compression by an inflated balloon. The present study reports a case of EVs treated with balloon-compression EIS (bc-EIS).The use of the cap and underwater technique as an aid in endoscopic diagnosis and treatment of upper gastrointestinal bleeding: case series
Upper GI bleeding (UGIB) is a medical emergency associated with elevated mortality and significant costs to the health care system. EGD is currently the method of choice for the diagnosis and management of these conditions. However, the location of bleeding lesions and technical difficulties in achieving endoscope stability may challenge even the most experienced endoscopists. Herein, we demonstrate the use of the cap and underwater technique as a helpful aid in these situations.A case of improved visibility with gel immersion in the presence of ongoing bleeding during colorectal endoscopic submucosal dissection
During endoscopic submucosal dissection (ESD), it is often difficult to secure a visual field in the presence of ongoing massive bleeding because water, which is injected through the accessory channel to wash out debris and blood clots, rapidly mixes with fresh blood in the lumen. Gel immersion is safe and effective for securing the visual field, creating a space for endoscopic visualization and treatment in patients with ongoing bleeding.1EUS-guided blood patch delivery during liver biopsy: nature’s gel foam
EUS-guided liver biopsy is emerging as an alternative form of tissue acquisition to percutaneous or interventional radiology–guided liver biopsy. Recent studies have shown adequate specimen acquisition and an enhanced safety profile. EUS-guided liver biopsy has been found to be extremely safe. The most common adverse events are mainly due to bleeding events. Unfortunately, there are limited endoscopic interventions available to prevent bleeding during liver biopsy.Bone wax-tipped catheter and 3-way stopcock to optimize hemostatic powder deployment
TC-325 Hemospray (Cook Medical, Winston-Salem, NC, USA) is a highly absorptive mineral powder used for endoscopic hemostasis in the setting of nonvariceal upper GI bleeding. The hemostatic powder is propelled by compressed CO2 through either a 7F or 10F catheter inserted through the working channel of the endoscope.Endoscopic hemostatic spray for uncontrolled bleeding after complicated endoscopic mucosal resection or endoscopic submucosal dissection: a report of 2 cases
There is a significant bleeding risk after gastric endoscopic submucosal dissection (ESD) and EMR cases. This case series describes the use of an endoscopic hemostasis spray, which is not typically used to treat this type of bleeding, after multiple attempts with other modalities failed.Successful hemostasis for refractory colonic diverticulum bleeding by clipping with polyglycolic acid sheets
There are various methods of achieving endoscopic hemostasis for diverticular hemorrhage, such as endoscopic clipping1-3 and band ligation.3-6 Endoscopic clipping is the most commonly used method. However, direct placement of the hemoclips on the bleeding site is often challenging, and inadequate clipping may lead to early recurrent bleeding. Generally, it is easy to directly place the hemoclips on the exposed vessel when it is visible at the neck of the diverticulum (Fig. 1A). However, it is difficult to directly place the hemoclips on the exposed vessel when it is located at the dome and the diverticular orifice is small (Fig. 1B).Endoscopic resection of large Paris 0-Ip pedunculated polyps: video demonstration of recent U.S. Multi-Society Task Force recommendations on resection and removal for general endoscopists
Large pedunculated polyps have several unique features that contribute to the complexity of their removal. Pedunculated polyps typically have larger feeding blood vessels in their stalk, which increases the risk of immediate and delayed postpolypectomy bleeding. In addition, maneuvering instruments around the head of very large polyps can be difficult within the confined space of the colon lumen. The 2020 U.S. Multi-Society Task Force Recommendations on the Endoscopic Removal of Colorectal Lesions have offered best practice recommendations on the resection and removal of pedunculated lesions.Novel approaches to minimize intraoperative bleeding during endoscopic submucosal dissection of a large rectal lateral spreading tumor extended to the dentate line with internal hemorrhoids
Endoscopic treatment of rectal lateral spreading tumors (LSTs) extending to the dentate line with hemorrhoids is a challenging procedure because of the risk of bleeding and the reduced visual field caused by the dilated venous packages and the narrow anal lumen. Although a few Japanese reports have described the safety and efficacy of endoscopic submucosal dissection (ESD) for these tumors,1,2 technical approaches to reduce intraoperative bleeding are not fully described. We present a successful ESD of a large rectal LST that extended to the dentate line with large internal hemorrhoids and describe novel approaches to minimize intraoperative bleeding.Active bleeding from downhill varices: case report and management
Proximal esophageal varices, or downhill varices, develop in the setting of venous hypertension of the superior systemic circulation, commonly because of superior vena cava (SVC) obstruction. They are named based on their cephalad-to-caudal direction of blood flow. The incidence of downhill varices is low (0.5%), and they account for 0.4% to 10% of all acute esophageal variceal bleeding.Hemostasis of an actively bleeding lesion at the ileocecal valve by low-pressure endoscopy using the gel immersion technique
In emergency endoscopy for GI bleeding or colonoscopy without preparation, the visual field can become obscured. The water immersion method is often used, but it is difficult to secure the visual field because the injected water rapidly mixes with blood or stool. Excessive insufflation, especially in the large intestine, may make insertion of the endoscope difficult. In such a situation, gel immersion endoscopy is very effective (Video 1, available online at www.VideoGIE.org ).1Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique
A 40-year-old man presented with a 1-year history of difficulty in swallowing liquids and solids. His Eckhart’s score was 6 of 12. EGD showed dilated esophagus with liquid stasis and mild resistance noted across the gastroesophageal junction. Esophageal manometry showed elevated integrated relaxation pressure with panesophageal pressurization (achalasia cardia type II). Peroral endoscopic myotomy (POEM) was planned and was performed using the novel Evis X1 endoscopy (Olympus Corporation, Tokyo, Japan) system.EUS-guided coiling and cyanoacrylate injection of ectopic duodenal varices
Duodenal varices due to significant portal hypertension are considered ectopic and are less common than esophageal or gastric varices. Duodenal variceal bleeding is a rare cause of upper GI bleeding and carries a mortality rate of up to 40%.1,2 Current treatment methods include transjugular intrahepatic portosystemic shunt (TIPS) placement, balloon-occluded retrograde transvenous obliteration, and endoscopic interventions including band ligation or sclerotherapy. Coil embolization and cyanoacrylate injection via EUS have been previously reported for the treatment of ectopic varices.Endoscopic tamponade using a fully covered self-expandable metallic stent for massive biliary bleeding from a pseudoaneurysm rupture during metallic stent removal
Hemobilia is a rare but life-threatening adverse event related to pancreatobiliary diseases, transhepatic percutaneous intervention, or endoscopic procedures including ERCP and interventional EUS.1,2 The rupture of the pseudoaneurysm after plastic stent or self-expandable metallic stent (SEMS) insertion has been reported to induce massive hemobilia, which requires prompt transcatheter arterial embolization (TAE) for hemostasis.2,3 In addition, hemobilia has occurred after plastic stent removal, according to several previous reports.Hemostatic forceps used as a scissor-type knife in combination with the transanal-traction method for assisted endoscopic submucosal dissection in the area of the dentate line
Endoscopic submucosal dissection (ESD) of rectal lesions extending to the dentate line is technically challenging. Eastern experts have demonstrated the feasibility of polyp resection in this region using a traditional ESD technique that makes use of the tip-cutting knife.1 The scissor-type knife has also been demonstrated as an effective instrument to perform ESD on lesions in the anal region.2 ESD by hydrodissection is an effective treatment for colorectal polyps.3,4 The water-jet hydrodissection technique also has been shown to be effective in overcoming various difficult situations.A spiraling journey into the small bowel: a case series of novel motorized power spiral enteroscopies
The small bowel has, to date, remained a difficult area to access via endoscopy. The novel motorized power spiral enteroscopy, recently introduced, has more depth of insertion and is of shorter duration. Presented here is a case series of motorized spiral enteroscopies.Loop combined endoscopic clip and cyanoacrylate injection to treat severe gastric varices with spleno-renal shunt
Endoscopic cyanoacrylate injection has been successfully applied in the management of gastric variceal bleeding and is recommended as the first line of treatment in China.1 Systemic embolism is one of the most severe and fatal adverse events associated with cyanoacrylate injection when used to treat severe gastric varices with a spleno-renal or gastric-renal shunt.2 Here, we report a case in which we used a new method to obstruct severely isolated gastric varices with a massive spleno-renal shunt and reduce embolic risk.Detachable snare to prevent postpolypectomy bleeding
Pedunculated polyps with a thick stalk (>5 mm) have an increased risk of bleeding with resection.1 Bleeding risk can be reduced by placing a detachable snare around the stalk of the polyp before resection.2-5 In this video (Video 1, available online at www.VideoGIE.org ), we demonstrate step-by-step use of a detachable snare for resection of a large pedunculated gastric polyp. The indications for use of a detachable snare include prevention or treatment of postpolypectomy bleeding, particularly of pedunculated polyps with a thick stalk or gastric polyps.Complete anterograde small-bowel exploration with the novel motorized spiral enteroscope
The advent of deep enteroscopy with the support of capsule endoscopy has given impetus to the diagnosis and therapy of small-bowel diseases, especially in relation to GI bleeding and Crohn’s disease.1 However, deep enteroscopy still has a few limitations, such as the difficulty of fully exploring the small bowel and inaccurate measure of the enteroscope insertion depth.2Targeting the perforator vein: EUS-guided coil embolization for the treatment of bleeding rectal varices
A 71-year-old man with alcohol-induced cirrhosis, complicated by portal hypertension, esophageal and rectal varices, and chronic portal vein thrombosis, presented to the hospital with rectal bleeding. This was his fourth presentation over the past year, with multiple diagnostic colonoscopies revealing rectal varices as the source of the bleeding and no therapeutic interventions performed. He was hemodynamically stable with unremarkable physical examination findings. Laboratory results revealed hemoglobin of 9.6 g/dL, platelet count of 103 × 109/L, and international normalized ratio of 1.4.Every trick in the book: EUS angiotherapy for management of refractory bleeding secondary to a complicated duodenal ulcer in a patient with Roux-en-Y gastric bypass
A 76-year-old man with a history of Roux-en-Y gastric bypass (RYGB) and a prior perforated duodenal ulcer presented to our emergency department with melena. An urgent EGD did not identify a source of bleeding in the esophagus, gastric pouch, gastrojejunostomy, or examined portion of the Roux limb.Endoscopic therapy for bleeding small-bowel venous malformations
An 84-year-old man was admitted to our inpatient ward with melena. He had a history of coronary artery disease treated with aspirin and clopidogrel and atrial fibrillation treated with apixaban. Initial laboratory analysis showed a hemoglobin level of 7.7 g/dL; hemoglobin level was normal 1 month before admission.Blue rubber bleb nevus syndrome in a 10-year-old child treated with loop ligation facilitated by double-balloon enteroscopy
Blue rubber bleb nevus syndrome is an extremely rare systemic vascular disorder (with only 200 cases published to date), characterized by multiple cutaneous and GI venous malformations.1 Patients present with fatigue, iron-deficiency anemia, and occult or overt obscure GI bleeding. Patients are usually managed conservatively with iron supplementation and/or blood transfusions. However, endoscopic (argon plasma coagulation, sclerotherapy, polypectomy, and ligation), radiologic, and surgical approaches are preferred for severe cases.Endoscopic rectal variceal ligation
A 62-year-old woman with hepatitis C cirrhosis (Model for End-Stage Liver Disease Na 11) and a history of esophageal variceal bleeding after endoscopic variceal ligation (EVL) presented with a 2-day history of hematochezia, lightheadedness, and palpitations. The initial Hb on presentation was 12 mg/dL. Her presenting heart rate was 106 beats per minute, and her systolic blood pressure was 112 mm Hg. She received intravenous fluid resuscitation with resultant resolution of tachycardia. Repeat Hb testing approximately 5 hours later was 9.1 mg/dL.Diffuse cavernous hemangiolymphangioma of the rectosigmoid, diagnosed by contrast-enhanced EUS
Diffuse cavernous hemangioma (DCH) of the rectosigmoid is a rare congenital venous malformation resulting in hematochezia.1-5 We report a rare case of DCH associated with lymphangioma, successfully diagnosed by contrast-enhanced EUS.Usefulness of a thin-endoscope endoscopic submucosal dissection using the traction device for early gastric cancer in a patient with esophageal stricture
Use of endoscopic submucosal dissection (ESD) for early gastric cancer has become widespread. However, the conventional endoscope sometimes cannot be used for reasons such as the presence of a stricture. Previously, endoscopic resection could be performed only after dilatation (eg, balloon) to treat the stricture, but this has the risk of adverse events (eg, perforation and bleeding).1 We report successful ESD for early gastric cancer using a thin endoscope.Endoscopic submucosal tunneling dissection: use of a novel bipolar radiofrequency and microwave-powered device for colorectal endoscopic submucosal dissection
A 57-year-old man with no significant medical history was referred for colonoscopy after positive multitarget stool DNA testing (FIT-DNA testing) as part of routine screening for colorectal cancer. The patient was asymptomatic with no family history of colorectal cancer. An initial colonoscopy revealed a large, 60-mm, laterally spreading tumor granular-type lesion in the rectum, approximately 3 cm from the anal verge (Fig. 1A). Examination of the lesion via image-enhanced endoscopy with narrow-band imaging revealed a type 2 noninvasive pattern per the narrow-band imaging international colorectal endoscopic classification (Fig. 1B).Effectiveness of endoscopic Doppler probe ultrasonography for identifying the source of colonic diverticular bleeding
Colonic diverticular bleeding (CDB) is the most common cause of acute lower GI bleeding. The diagnosis of CDB is made through detection of the stigmata of recent hemorrhage (SRH).1,2 To increase the rate of SRH identification, bowel preparation, water-jet endoscope, and transparent hood have been recommended.3 Despite the use of these methods, the rate of SRH identification is only 15% to 40%.1 Even if blood or blood clots are present in the diverticulum, these areas are not always the source of bleeding; in some cases, blood from the bleeding diverticulum flows into other areas.Endoscopic resection of large pedunculated colon polyps using only a scissor-type knife: a case series
All pedunculated colon polyps (PCPs) should ideally be resected en bloc for accurate histopathological evaluation. However, maneuvering a snare around the large head of a pedunculated polyp with a long, wide stalk can be technically challenging. In addition, clinically significant bleeding after snare polypectomy remains a legitimate concern. Small case series from Asia have supported the feasibility of endoscopic submucosal dissection (ESD) for the removal of these challenging large PCPs. However, ESD is not widely performed in the West because of its technical complexity, steep learning curve, and higher risk of adverse events when compared with conventional endoscopic mucosal resection.Preventing clogging of hemostatic powder during control of bleeding
Hemostatic powders are topical agents used in therapeutic and potentially prophylactic control of GI bleeding.1 When effectively applied to the site of bleeding, the powder allows for better visualization of the area and subsequent definitive therapy. These powders are generally composed of small mineral granules that stimulate hemostasis. In the United States, the inorganic powder TC-325 (Hemospray; Cook Medical, Bloomington, Ind, USA) was the first to be brought onto the market.2 It was approved by the United States Food and Drug Administration in May 2018 for treatment of nonvariceal bleeding.Endoscopic treatment of colonic diverticular bleeding with an over-the-scope clip after failure of endoscopic band ligation
An 86-year-old woman with a history of hypertension and colonic diverticular bleeding (CDB) presented with severe hematochezia to a nearby medical institution. Contrast-enhanced CT identified extravasation in the sigmoid colon (Fig. 1). Emergency colonoscopy revealed an active diverticular hemorrhage in the sigmoid colon. Although an endoclip was placed on the responsible diverticulum, active bleeding persisted. She was then referred to the emergency department of our hospital.Endoscopic submucosal dissection for Barrett’s-associated adenocarcinoma in a patient with decompensated cirrhosis and esophageal varices
Presently, endoscopic resection is the preferred treatment of choice for patients with Barrett’s dysplasia, especially high-grade dysplasia and even early esophageal adenocarcinoma.1 However, among the various endoscopic resection techniques, endoscopic submucosal dissection (ESD) may carry a higher risk of adverse events in patients with cirrhosis because of the low platelet count, coagulopathy, and presence of esophageal varices.2,3 To date, only small case series of esophageal ESDs, especially for squamous cell carcinoma, have been reported from Asia in patients with cirrhosis, but the included patients were well compensated, with platelet counts >50 k/μL.Endoscopic submucosal dissection for a laterally spreading tumor involving the colon diverticulum using a knife with water supply function
The development of colonic endoscopic submucosal dissection (ESD) expanded the use of endoscopic therapy regardless of the tumor’s size, location, or degree of fibrosis. However, lesions involving diverticula in the colon are considered a contraindication for endoscopic treatment because of the absence of muscle layers.Making the transition from endoscopic submucosal dissection fellowship to independent practice: successful ESD of a large near-circumferential rectal lesion
Widespread adoption of endoscopic submucosal dissection (ESD) in the United States has been challenging, partly because of the limited availability of training opportunities.1 Recently, a junior faculty member based in the United States completed a novel 1-year ESD training program within a traditional American Society for Gastrointestinal Endoscopy fourth-year advanced endoscopy fellowship.2 During the course of the training program, the trainee had assisted with or observed 19 cases, partially performed 18 cases, and fully or mainly performed 26 cases, in which the mean lesion diameter was 44.5 mm and in which 79.2% of lesions were colorectal.Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter
GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported.Advanced resection and closure techniques for endoscopic full-thickness resection in the gastric fundus
Most gastric subepithelial tumors (SETs) are gastroxintestinal stromal tumors (GISTs).1 The National Comprehensive Cancer Network guidelines recommend resection of GISTs with symptoms, high-risk EUS features, or size ≥2 cm.2 Endoscopic full-thickness resection (EFTR) provides incisionless, organ-sparing, en bloc resection of SETs <5 cm.3 The gastric fundus is a challenging location for endoscopic resection and closure4 because it requires extreme retroflexion. In Asia, a “double-bending” endoscope facilitates resection in the fundus,5 but it is not available in the United States.Efficacy of rapid bowel preparation with new 1 L polyethylene glycol ascorbate solution in severe acute lower GI bleeding
Ileocolonoscopy (IC) is the usual procedure in cases of acute lower GI bleeding (LGIB). It should be performed within 8 to 24 hours of a patient’s presentation after adequate colon cleansing to improve its diagnostic and therapeutic yield, which can range from 48% to 90%.1Novel use of endoscopic morcellator to clear large obscuring clot in patient with upper-GI bleed
Significant clot burden limits visibility and prevents finding intervenable lesions for hemostasis. Endoscopic tools such as BioVac (US Endoscopy, Mentor, Ohio, USA)1 and distal caps with suction2 and promotility3 agents are available, with varying degrees of success. Here, we present a challenging case in which standard endoscopic techniques failed to clear a large obscuring gastric clot, and the novel application of an endoscopic morcellator (EndoRotor; Interscope, Whitinsville, Mass, USA) allowed successful localization of the culprit lesion.Endoscopic hemostasis with hemoclips for post-variceal ligation bleeding ulcer
The development of portal hypertension in cirrhosis is associated with a multitude of diagnoses, most commonly ascites, gastroesophageal varices (GEV), and hepatic encephalopathy. Nearly half of the patients with cirrhosis have GEV at the time of diagnosis, and 5% to 15% of the patients experience esophageal varices each year.1 Guidelines recommend noncardioselective β-blockers or endoscopic variceal ligation (EVL).2 Recurrent bleeding after initially successful EVL occurs in 20% to 60% of patients, most commonly from the ulcers, and is associated with 20% to 50% mortality.Luminal and extraluminal bleeding during EUS-guided double-balloon–occluded gastrojejunostomy bypass in benign gastric outlet obstruction with portal hypertension
A 45-year-old man with longstanding idiopathic chronic pancreatitis and splenic venous thrombosis presented with postprandial vomiting and abdominal fullness 10 months earlier. He received a diagnosis of duodenal narrowing (D1-D2 junction) (Fig. 1) and underwent several sessions of endoscopic balloon dilation, with an ill-sustained response. Surgery was attempted elsewhere; however, gastrojejunostomy was not done because of extensive perigastric collaterals. His laboratory evaluation showed moderate anemia (hemoglobin 10 gm/dL), platelets 1.2 lakhs/mm3, prothrombin time 17 seconds (international normalized ratio 1.28) and normal liver function test results, serum amylase levels, and lipase levels.Submucosal tunneling endoscopic resection of a subepithelial lesion assisted by EUS miniprobe
A 68-year-old asymptomatic woman was involved in an ongoing research study evaluating the performance of a circulating tumor DNA-based blood test for early cancer identification (DETECT study). An abnormal result led to positron emission tomography–CT, which showed focal radiotracer uptake at the gastroesophageal junction (Fig. 1). This was followed by upper endoscopy, which revealed a small subepithelial lesion (SEL) at the esophagogastric junction/gastric cardia (Fig. 2). EUS showed a well-defined 22-mm × 14-mm hypoechoic lesion arising from the muscularis propria layer of the esophagus (Fig. 3).Cyanoacrylate injection of an ectopic variceal bleed at a choledochojejunal anastomotic site in a patient with post-Whipple anatomy
Ectopic varices account for up to 5% of all variceal bleeding; the mortality from untreated or misdiagnosed variceal bleeding has been reported to be as high as 40%.1-3 Variceal bleeds originating from the choledochojejunostomy (CDJ) site are a rare adverse effect of pancreaticoduodenectomy (PD), with few cases reported in the literature.Failure of over-the-scope clip to control duodenal ulcer bleeding despite successful application
The over-the-scope clip (Ovesco; Ovesco Endoscopy AG, Tuebingen, Germany) has been designed for apposition of larger mucosal surfaces for GI perforations and for bleeding. The clip has some evidence of success in the treatment of GI bleeding, particularly for large vessels for which standard hemostatic clips were not designed. A major limitation is that once the clip is deployed, the size and location of the clip make further endoscopic therapy more challenging.Clinical efficacy of partial endoscopic band ligation for treatment of large-orifice colonic diverticular bleeding
Endoscopic band ligation (EBL) is one of the major endoscopic treatments for colonic diverticular bleeding, along with clipping and coagulation methods1; however, EBL is not indicated for all cases of colonic diverticular bleeding. In particular, it remains unclear whether EBL can be applied to cases involving bleeding from a large-orifice diverticulum. Although the EBL procedure commonly includes suction of the entire diverticulum into the suction cup to ligate the neck of the inverted diverticulum, partial ligation inside the diverticulum has not yet been reported as a treatment option.Successful closure with endoscopic suturing of a recalcitrant marginal ulcer despite Roux-en-Y gastric bypass reversion
One serious adverse event of Roux-en-Y gastric bypass (RYGBP) is bleeding. Early bleeding can occur in up to 5% of patients, with predominant early postoperative bleeding (<30 days) and bleeding from extraluminal causes. Most late RYGBP bleeding is caused by marginal ulcers, with rates reported as 0.6% to 16%. Intraluminal causes of bleeding are endoscopically diagnosed and treated. Endoscopic suturing is in the new arsenal of tools to treat bleeding marginal ulcers that are refractory to medical prophylaxis.Hemostatic powder for the intraductal treatment of biliary cancer bleeding
Biliary tract bleedings are rare cases of upper-GI bleeding1 that are usually self-limited; otherwise, viable treatment options are represented by transarterial embolization, balloon tamponade, biliary stent placement,2 and argon plasma coagulation.3Endoscopic submucosal dissection of esophageal metastatic melanoma
A 65-year-old man underwent surgical excision with lymph node dissection for a scalp melanoma in 2011. In 2018, he presented to his melanoma oncologist for routine follow-up and subsequently underwent an upper endoscopy for reflux symptoms. His upper endoscopy revealed a pigmented lesion in the esophagus, biopsy specimens that showed malignant melanoma. Positron emission tomography/CT and magnetic resonance imaging of the brain revealed no evidence of distant metastases. He was referred for further endoscopic evaluation and treatment.Management of arterial bleeding after endoscopic resection of a neuroendocrine gastric tumor
We report a case focusing on the management of arterial bleeding after endoscopic resection of a neuroendocrine gastric tumor (NET) (Video 1, available online at www.VideoGIE.org ).Gastric and duodenal pseudomelanosis: a new insight into its pathogenesis
Very infrequently, gastric melanosis and pseudomelanosis have been described.1-6 Melanosis refers to melanin deposition, and pseudomelanosis is due to hemosiderin deposition. The etiology of these entities is poorly understood, and endoscopically, it is generally very difficult to differentiate between melanosis and pseudomelanosis. They are, likely, incidental endoscopic findings with minimal clinical significance. Gastric and duodenal pseudomelanosis manifests as speckled black pigmentation or black spots in the mucosa.Endoscopic resection of a giant fibrovascular esophageal polyp by use of a scissor-type knife
A 73-year-old woman presented to the emergency department because of loss of consciousness; she recovered within a few minutes. Chest CT revealed a large intraluminal tumor arising from the proximal esophagus (Fig. 1). Accordingly, she was referred to our department. Barium esophagography revealed an approximately 10-cm-long intraluminal esophageal mass arising from the cervical esophagus (Fig. 2).Endoscopic submucosal dissection with a grasping-type scissors for early colorectal epithelial neoplasms: a large single-center experience
The Clutch Cutter (CC) can grasp, pull, coagulate, and incise targeted tissue with the use of electrosurgical current. It was developed as a biopsy technique to reduce the technical difficulty of endoscopic submucosal dissection (ESD) with knives. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early colorectal epithelial neoplasms (ECENs).Alternative approach to hemostatic particle spraying for treatment of GI bleeding by the use of cross-platform devices
GI bleeding is a leading cause of morbidity and mortality in the United States, with an estimated 20,000 deaths per year. Some subgroups of patients show refractory recurrent bleeding despite standard endoscopic therapy. The U.S. Food and Drug Administration has recently approved a hemostatic spray for clinical use in nonvariceal bleeding. Despite its efficacy, not all endoscopy units have access to this spray, at times because of cost. Our aim was to determine the safety and efficacy of a plant-based hemostatic particle spray in nonvariceal GI bleeding by use of a cross-platform setup.Lumen-apposing metal stent for the management of intramural hematoma of the GI tract
GI intramural hematomas are uncommon and usually occur in the esophagus or the duodenum, and in rare cases they occur in the stomach.1 The most common cause is blunt abdominal trauma; other causes include endoscopic interventions, peptic ulcer disease, and pancreatitis; in very rare cases they can occur spontaneously in patients receiving oral anticoagulants.2,3 We present the management of 2 cases of gastric and duodenal intramural hematomas by the use of lumen-apposing metal stents (LAMSs).Endoscopic resection of a gigantic gastric polyp causing symptomatic iron-deficiency anemia
A 69-year-old man with a history of carotid artery stenosis who was taking clopidogrel presented with dyspnea secondary to acute iron-deficiency anemia. His hemoglobin level was 6 g/dL. He underwent EGD at an outside center, which revealed a large bleeding gastric polypoid lesion. Histopathologic examination of a biopsy specimen revealed a hyperplastic polyp with superficial erosions but no dysplasia. He underwent 3 attempts at endoscopic resection over the next several months at the outside center, which were all unsuccessful.Assisted line to visualize endoscopic screen for endoscopic submucosal dissection
Endoscopic submucosal dissection (ESD) has been established as the general treatment for early GI cancer in Japan; however, ESD is considered a very difficult procedure to perform by those who are inexperienced with endoscopy.1-3 The direction of the accessory channel differs according to the type of upper and lower endoscope used. For ESD that requires an accurate tip for endoscopic manipulation, imaging in the direction in which the attached channel emerges is important. We previously discovered an approach to train individuals in the performance of ESD by attaching a transparent sheet to the endoscope4 and devised an approach for an assistance line to appear on the actual endoscope screen.Endoscopic resection of an unusual ampullary adenoma
A 40-year-old woman with no comorbidities presented with episodic postprandial bilious vomiting of 6 months’ duration and mild abdominal discomfort. Her liver function tests showed normal bilirubin with raised alkaline phosphatase and γ-glutamyltransferase. Abdominal US had shown dilatation of the common bile duct (CBD) and pancreatic duct (PD). She had previously undergone MRCP, which showed diffuse dilatation of the CBD, common hepatic duct, and intrahepatic biliary radicles with smooth tapering at the region of the ampulla, diffuse prominence of the main PD, and ectopic ampulla of Vater.Lumen-apposing metal stent–related splenic artery erosion: diagnosis and management
Lumen-apposing metal stents (LAMSs) have been shown to be easily placed during endoscopy and appear effective in draining symptomatic peripancreatic fluid collections. Several series have reported late adverse events, especially bleeding, which can be severe and can occur in up to 25% of patients. We report a particularly well-documented bleeding adverse event (Video 1, available online at www.VideoGIE.org ).Endoscopic management of gastroesophageal reflux disease after sleeve gastrectomy by use of the antireflux mucosectomy procedure
Sleeve gastrectomy is the most common bariatric surgery in the United States.1 However, studies have reported an increased rate of de novo GERD after surgery and high rates of new-onset cases of Barrett's esophagus.2-5Endoclip line-assisted traction to control cardial postpolypectomy bleeding
Bleeding is the most common adverse event associated with gastric endoscopic resection.1A novel diathermy knife with suction function capable of keeping clear visibility while controlling bleeding
Innovative endoscopic devices have been developed and are now commercially available, which have contributed to the spread of the endoscopic submucosal dissection (ESD) technique for superficial neoplastic lesions.1 In particular, needle-type diathermy knives with a waterjet function enable injection into the submucosal area from the tip of the knife immediately after the cutting maneuver.2,3 This may reduce the number of times the knife is moved through the working channel, leading to a shorter procedure time.Hemostatic powder facts
We read with interest the VideoGIE article by Storm et al1 from Mayo Clinic Rochester. The case shows the unique benefits of Hemospray in offering durable hemostasis for bleeding that is resistant to conventional treatments, even in the setting of dual antiplatelet therapy. We commend the authors for their persistence in providing a positive outcome for this patient. However, we noted several errors that should be corrected because they do not accurately reflect the potential adverse events that may result from Hemospray treatment.Early experience with use of an endoscopic “hot” scissor-type knife for myotomy during per-oral endoscopic myotomy procedure
Current devices used for per-oral endoscopic myotomy (POEM) function predominantly to either cut tissue or coagulate vessels. When bleeding vessels are encountered within the submucosa or muscle, dedicated coagulation grasping devices are often necessary. An endoscopic “hot” scissor-type knife is available that combines coagulation and cutting functions. Scissor-type knives may therefore be helpful during the POEM procedure.EUS-guided thrombin injection of cystic artery pseudoaneurysm leading to Mirizzi’s syndrome and hemobilia
A 52-year-old man presented with a history of right upper-abdominal pain for 7 days and melena for 3 days. General examination revealed tachycardia, pallor, and icterus. Abdominal examination showed normal results. Laboratory investigations revealed hemoglobin, 7.2 gm (reference, 13-15); alanine aminotransferase, 314 U/L (reference, 0-30); aspartate aminotransferase, 140 U/L (reference, 0-30); serum alkaline phosphatase, 470 U/L (reference, 30-120); and serum bilirubin, 4.6 mg/dL (reference, 0.2-1.2).Hemospray hemostasis in bleeding diffusely ulcerated esophagus
Bleeding from diffuse esophageal ulcerations can be difficult to treat. Hemospray is a hemostatic powder, and its mechanism of hemostasis is thought to be through concentrating clotting factors and forming mechanical plugs on bleeding vessels.Creation of a gastrogastric conduit by use of a lumen-apposing metal stent in a patient who had extensive small-bowel surgery secondary to a Peterson hernia
A 48-year-old woman underwent gastric-bypass surgery for obesity management. This was followed by the adverse event of a Peterson’s hernia. Attempts to repair the hernia failed and were complicated by extensive postoperative small-bowel ischemia. The patient underwent multiple laparotomies, right hemicolectomy, small-bowel resection with end jejunosotomy, a blind-ending esophagus into the gastric pouch, and rectal stump with mucous fistula.Step-by-step use of hemostatic powder: treatment of a bleeding GI stromal tumor
Hemostatic powder (Hemospray; Cook Medical, Winston-Salem, NC, USA) was recently granted clearance for clinical use by the U.S. Food and Drug Administration for endoscopic therapy of nonvariceal GI hemorrhage (Fig. 1). This device has been in use internationally for more than 5 years, since it became available in 2011, and has been used in more than 70,000 procedures.1 The powder is an inert, nontoxic material called bentonite, and it is aerosolized with the use of a carbon dioxide canister to deliver the powder through a 7F or 10F delivery catheter.EUS-guided portal pressure gradient measurement with a simple novel device: a human pilot study
Portal hypertension is a serious adverse event of liver cirrhosis. Recently, we developed a simple novel technique for EUS-guided portal pressure gradient (PPG) measurement (PPGM). Our animal studies showed excellent correlation between EUS-PPGM and interventional radiology-acquired PPGM. In this video we demonstrate the results of the first human pilot study of EUS-PPGM in patients with liver disease.EUS-guided placement of coils and glue for the management of large bleeding fundic varices
We present the case of a 58-year-old woman in whom challenging gastric fundic varices were managed successfully with endoscopic variceal obturation by the use of EUS-guided coil placement with subsequent glue injection (Video 1, available online at www.VideoGIE.org ).A case of hemobilia secondary to cancer of the gallbladder confirmed by cholangioscopy and treated with a fully covered self-expanding metal stent
Hemobilia is a rare cause of upper-GI bleeding that may be secondary to iatrogenic biliary injury, malignancy, or vascular malformations.1,2 ERCP has an established role in both the diagnosis of and the therapy for hemobilia. This recently has been augmented by the introduction of cholangioscopy.Successful EUS-guided treatment of gastric varices with coil embolization and injection of absorbable gelatin sponge
Gastric varices occur in 15% to 20% of patients with portal hypertension and are associated with significant GI bleeding and high mortality. Here, we report our experience with EUS-guided coil embolization and injection of absorbable gelatin sponge for the treatment of gastric varices (Video 1, available online at www.VideoGIE.org ).Endoscopic resection of a giant solitary fibrous tumor of the esophagus
A 63-year-old woman with a medical history of hypertension, hypothyroidism, and GERD presented to our clinic with worsening dysphagia to solids. EGD performed by a local gastroenterologist showed a large esophageal mass. CT of the chest with contrast material revealed a high-density, nearly occlusive, esophageal mass, beginning at the thoracic inlet, measuring 3.8 cm × 2.1 cm × 10.4 cm (transverse, anteroposterior, craniocaudal), and demonstrating well-delineated smooth margins without esophageal disruption (Fig. 1).Maintaining hemostasis during third-space endoscopy
Third-space endoscopy is technically challenging and time consuming. Third-space procedures are associated with a significant risk of bleeding, both during and after the procedure (Fig. 1A). There are limited data and guidelines available on how to manage bleeding during per-oral endoscopic myotomy (POEM) and other forms of third-space endoscopy. The aim of this video is to demonstrate options for bleeding prophylaxis and hemostasis during third-space endoscopy and to educate readers on how to use these techniques in daily practice (Video 1, available online at www.VideoGIE.org ).Endoscopic removal of migrated endovascular coils from the duodenum
Upper-GI bleeding (UGIB) is a common problem and is defined as hemorrhage originating proximal to the ligament of Treitz. The disease is divided into nonvariceal and variceal subtypes. Common causes of nonvariceal UGIB include ulcers of the esophagus, stomach, or duodenum; mucosal erosions; Mallory-Weiss tears; and malignancy.1 Unusual causes such as Cameron lesions, Dieulafoy lesions, subepithelial lesions, gastric antral vascular ectasia, hemobilia, and vascular-enteric fistulas are less frequently encountered.Hemobilia: a rare cause of intermittent biliary obstruction
A 48-year-old man with a medical history of metastatic small-bowel neuroendocrine tumor, who was using chemotherapy, presented with nausea, vomiting, and right upper-quadrant abdominal pain. His laboratory tests demonstrated abnormal liver enzymes (bilirubin 2.7 mg/dL, alkaline phosphatase 187 mg/dL, aspartate aminotransferase 174 mg/dL, and alanine aminotransferase 89 mg/dL). He had a low hemoglobin of 10.6 mg/dL. His liver enzymes and hemoglobin were normal 1 week before the presentation.Double-lumen duodenum with obscure overt GI bleeding
Intraluminal duodenal diverticula are rare congenital malformations that may present with vague abdominal symptoms such as pain or bloating; however, patients may also present with pancreatitis, biliary obstruction, duodenal obstruction, or GI bleeding. We report a case of intraluminal duodenal diverticulum causing recurrent overt GI bleeding and exhibiting a unique endoscopic appearance of a double lumen (Video 1, available online at www.VideoGIE.org ). A 67-year-old woman was admitted with melena and an acute drop in hemoglobin.Over-the-scope clip to close bleeding pancreaticoduodenal fistula
A 39-year-old woman with chronic pancreatitis presented with necrotizing pancreatitis and 2 days of hematochezia. CT of the abdomen revealed severe acute pancreatitis with several gas-containing fluid collections that suggested fistula (Fig. 1A). The results of initial EGD and colonoscopy were unremarkable, and no bleeding source was identified (Figs. 1B and C).Incomplete hemostasis of high-risk adverse outcome bleeding lesions after placement of the over-the-scope clip: causes and solutions
High-risk adverse outcome (HR-AO) bleeding lesions—large-caliber (2 mm) vessel or high-risk stigmata within deep penetrating and fibrotic ulcers located in the distribution of major arteries where endoscopic therapy can cause adverse events—are at significant risk of treatment failure. Although over-the-scope clips (OTSCs) are effective in such lesions, they can sometimes fail to achieve hemostasis. We describe the causes of incomplete hemostasis and provide solutions to mitigate such OTSC failures.A novel, duodenoscope-friendly endoscopic clip for treating massive upper-GI bleeding secondary to a Dieulafoy lesion
A Dieulafoy lesion is a rare vascular anomaly in the GI tract at risk for clinically significant bleeding. Here we present a case of clinically significant upper-GI bleeding secondary to a Dieulafoy lesion that was successfully treated with the help of a novel duodenoscope-friendly endoscopic clip.Adverse events of pancreatic fluid collections
In this video (Video 1, available online at www.VideoGIE.org ), we present 3 similar cases in patients who presented to our hospital over 3 consecutive weeks.Massive bleeding after EUS-guided walled-off necrosis drainage
A 58-year-old man with a history of necrotizing pancreatitis of biliary causes 8 weeks previously presented with a 20-pound weight loss and daily epigastric pain. Abdominal magnetic resonance imaging (MRI) demonstrated a 12.3-cm collection surrounding the pancreatic body with a large amount of debris, consistent with walled-off necrosis (WON) (Fig. 1A). Given the collection size and the patient’s symptoms, we proceeded with EUS-guided drainage using a lumen-apposing metal stent (LAMS).A bleeding vallecular varix, visualized by GI endoscopy, confirmed with CT angiography, and treated with sclerotherapy and cyanoacrylate
Upper-GI bleeding is most commonly secondary to peptic ulcer disease, Mallory-Weiss tear, esophagitis, or variceal hemorrhage.1,2 Significant hemorrhage from an oropharyngeal source such as vallecular varices is rare, with only a few case reports available in the literature.Successful obliteration of bleeding duodenal varices by EUS-guided injection of N-butyl-2-cyanoacrylate
Duodenal varix rupture is a life-threating condition that calls for immediate hemostasis. EUS-guided glue injection and coil deployment have been reported as effective means for obliterating gastric varices, but the therapy has been limited to a few case reports of duodenal varices.Use of hemostatic powder in bleeding portal hypertensive gastropathy
A 55-year-old woman with Child-Pugh B alcoholic cirrhosis and ongoing excessive use of alcohol (50 units/week) presented with hematemesis and melena, hemodynamic instability, acute anemia (hemoglobin 98 g/L), stable hyperbilirubinemia, coagulopathy (international normalized ratio [INR] 1.9), Model for End-stage Liver Disease (MELD) score 22, and Blatchford score of 16. After resuscitation, reversal of coagulopathy, and empirical variceal measures with intravenous terlipressin and gram-negative antibiotics, urgent endoscopy was undertaken (Video 1, available online at www.VideoGIE.org ).Endoscopic treatment of internal hemorrhoids by use of a bipolar system
Hemorrhoids occur in 4% of the population and are identified in 39% to 45% of colonoscopies.1 Internal hemorrhoids have been categorized further according to the Banov classification, which has grades I to IV. Although grades III and IV have typically been managed surgically, grades I and II can be treated by endoscopic means.1-3Hemostatic powder: a new ally in the management of postsphincterotomy bleeding
ERCP with sphincterotomy is the criterion standard treatment for the management of choledocholithiasis because it has low morbidity and mortality rates and excellent outcomes; however, adverse events are not uncommon.EUS-guided coiling of hepatic artery pseudoaneurysm in 2 stages
Hepatic artery pseudoaneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudoaneurysms constitute 20% of all visceral artery aneurysms. They carry a very high risk of rupture with severe bleeding into the peritoneal cavity, bile duct, or portal vein. Essentially all pseudoaneurysms, whether symptomatic or not, require early treatment to prevent lethal adverse events. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity in comparison with endovascular treatment.EUS imaging of splenic artery pseudoaneurysm
A 32-year-old man was admitted with massive hematemesis of approximately 700 mL of blood associated with melena. His hemoglobin was 6 g/dL, and he was hemodynamically unstable. He had experienced an episode of alcoholic acute pancreatitis 2 weeks earlier. After hemodynamic resuscitation and blood transfusion, upper-GI endoscopy in a search for the cause of the GI bleeding showed normal results. CT of the abdomen with angiography revealed features of acute pancreatitis and no source of upper-GI bleeding.Massive small-bowel bleeding treated with hemostatic powder
In patients who present with GI bleeding, the underlying cause may not be evident on initial evaluation in 10% to 20% of cases. Recurrent or persistent bleeding occurs in approximately half of these patients (5%) and can pose a significant challenge to both diagnosis and management.Endoscopic use of oxidized regenerated cellulose and topical thrombin: a novel approach for control of bleeding pancreatic pseudocyst wall after endoscopic cystgastrostomy
A 37-year-old man with alcoholic pancreatitis complicated by pancreatic pseudocyst underwent endoscopic cystgastrostomy with an AXIOS 15-mm lumen-apposing metal stent (Boston Scientific, Marlborough, Mass) (Fig. 1A and B). Seven weeks later the patient was hospitalized because of hematemesis and melena. The patient had a baseline hemoglobin of 11.1 g/dL, which acutely declined to 9.1 g/dL. CT angiography did not show a bleeding source but did reveal complete cyst resolution. An EGD revealed a blood clot in the cystgastrostomy stent with active blood oozing through the stent (Video 1, available online at www.VideoGIE.org ).Management of a Dieulafoy ulcer bleed with an over-the-scope clip
A 50-year-old man presented with massive hematemesis. Upper-GI endoscopy revealed a visible vessel in the center of a small ulcer over a small submucosal bulge in the anterior wall of the first part of duodenum (Fig. 1A). The differential diagnosis of submucosal mass with an eroding vessel, Forrest IIa peptic ulcer, and Dieulafoy ulcer was considered. A small ulcer with massive bleeding suggested the possibility of a Dieulafoy lesion EUS color Doppler showed a vessel entering the submucosa with arterial signals and confirmed the diagnosis of Dieulafoy ulcer (Figs. 1B and C; Video 1, available online at www.VideoGIE.org ).EUS-guided arterial embolization with cyanoacrylate glue of a pancreatic neuroendocrine tumor infiltrating the gastric wall causing upper GI bleeding
A 53-year-old man with a history of pancreatic tail neuroendocrine tumor (PNET) with liver metastasis, since 2014, presented with sudden onset large-volume hematemesis, hypotension, and an acute drop in hemoglobin from 8.7 g to 5.1 g. The patient was transferred to the intensive care unit and received 4 units of blood, 1 unit of platelets, and 1 unit of fresh frozen plasma. Pantoprazole 40 mg intravenously (IV) was given twice daily (BID) IV. A first EGD showed blood clots that precluded adequate visualization of the gastric body (Fig.
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