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to read. I think we've gone life. Hi, everybody. I'm lifting for my Argentina years. And we also have male here to help moderate today. Welcome to the i r. Bite session on G I bleeding. Presented by Dr Linda Walk ins that Would you be able to share your slaves, please? Yep. Number alone. Right. If we got my sleep there. Just Yes. Yes. Okay. Can you see them Not flicking through? Yes, Linda, to try one more time to share. Still nothing. Stop sharing and see that makes it any easier. Cool. That's it. There. I was going to say that I've know. It tells me that issuing nice That's what you have. Me just so it's it's still on the window It can you It's not on the actual presentation itself, you know? Like it's not full of screen if that makes sense. Mm, No. Okay. We'll get there. We'll get there. Were almost We'll go back to Yeah, that's the full screen. Now you said that should Perfect. Right. Okay, so how everyone? Thanks for introduction. Let's see. So my name's under walk ins on Diamond ST five. Intervention, radiology training in the west of Scotland on tonight. We're here to talk about GI I bleeding. So the end of the session AM is partly essentially to cover every single aspect of diabetes. That's what it feels like, a least. So we're gonna look at the A clinical features of your bleeding. The different tapes and causes will discuss imaging and suspected am Joe bleeding and going into the management with a particular focus on I are procedures that can help. Okay, we're not lately to go through it in a nice, beautiful order like this, but we will attempt to cover all of these things. So Right, so Oh, you're there if I won, Okay. On your own for medicine surgery. You're in the d. You're on a care of the elderly words. You're just about anywhere in the hospital here. And this this situation could come up. Okay, so you get called and asked to see a patient nurse on the phone tells you they've got a 71 year old women who has been admitted with stomach pin on. They just form it'd what? Looks like blood. All right. No. One of my protests for being the foundation doctor. That is the first person who's called to come and see patients. You've been formed until the patient is vomiting blood. Okay on that. This is new. You're going to see them all right? Unless you've got several other on well, patients that you're about to see. You don't actually need any more information right now. Okay, You're going to go and see them. And actually, it could be really helpful to just say to the nurse, I'm coming in. You get ah, use it. Evolves, please. On the blood sugar. Okay, Because that covers you for every situation. It means that when you get there, you've saved him on the form. You save time when you get there, because there's a up to date set evolves on. Actually, you've increased your chances that the nurse looking after the patient is going to be around when you arrive to tell you where the notes are and give you any other information and stuff you need about the patient. So you get there. What you gonna do? You're probably all absolutely sick off a B c d e. But I don't care. It's really important him on even know, you know, like as in ST If I've like, I go back to this when I'm faced with I am Well, for example, a patient that's collapsed in the CT waiting room because those are the sorts of patients that I am I get called to see on. It just gets you out of trouble. It helps you think clearly, so I don't apologize for doing it again. Okay, so you asked me how she's feeling, says Obama. But I'm a bit rough, doctor. So here we fighting. Okay, she's talking to you. Nurse gives you the up to deorbit, and so they're spiritually is 22 or oxygen. SATs are 90% on room air. Blood pressure's a little on the low side at 110 over 75 hurries up a little bit. 105. She's a poetics. Heal on their BMD's. Fighting at 9.8 doesn't hurt. Chest, which is clear on capillary refill, is about two seconds. So remember to look at the trend. So okay, so these absurd, maybe a. You know, you may be a just a little bit concerned, you know, something's clearly quite not right. But if that heart rate has bean tracking up on that BP tracking down for the past four hours. You're more concerns. Okay? I'm one of the most important things in these patients is also exposure. Okay, You need to look at the moment. Is it fresh? Red blood doesn't look like coffee grains because coffee grande vomit actually does look like coffee grinds. That's why it's called coffee grande vomit as the patient just drank and entire bottle of red cooler unfortunate it back up. Okay, so these are old things that you need to You need to know about it. Okay, So look at whatever fluids the patient is producing, as well as exposing and looking at the patient. So with maybe you pulled by the covers and before you see anything, your head by a distinct smell on you realize that you recognize it anywhere because you smelt it before but six weeks ago on you're a on another rotation. But it's Melena, Okay? And you can see that there's Melena constraining the bed on things as well. So this sounds like an upper GI. I plead right, But what does that actually mean? So, on Upper Terribly, just where the source of bleeding is before you get to the ligament of treats, which is also called the Suspensory Ligament of the Duodenum. It's a road about the the DJ Flexeril, which is Mark. It's just on this diet. I'm over the right side of the screen there. That's the junction between the Judean, um, and the judge in, um, anything after that is kind of us a lordy. I bleed. So the lower GI bleed actually encompasses a lot more volume of the GI tract than an upper GI. I bleed us. Let's compare the two. So we've talked about some of the features of Upper GI Bleed already, so you can have fresh hematemesis call figure involvement, which is partly digested blood that's being brought back up. Um, on Molina, which is also partially digested. Blood bought a me is being passed your rectum. Patients can also have a hemoglobin drop hemodynamic instability on there. You know you can rice that's actually another product off digesting the blood, and that's what makes the makes the union rice and Lord I bleed. You could also still have the hemoglobin drop in the hemodynamic instability, but they tend to have a more fresh looking PR bloods that has a fancy name that I'm not really sure what you meant to produce. We're going with. I'm not sick. Easy up on. They can have blood taken passable it that looks quite fresh, but it's mixed in with stools and things as well. A caveats. All this. So is that a really big opera? Gee, I bleed calm present with fresh PR bloods. If they're basically, if there's enough bleeding, the to do have quite different causes. So for Upper GI Bleeds, we've got peptic ulcer disease, disease body sees mucosal information, inflammation, Maliti base tears, things like vascular abnormalities of malformations. And, like a deal, if I lesion vasculitis, your toujeo Fessler, which is a pretty catastrophic thing. We're quick. Let's really There is an abnormal connection between the Yorktown in the Judean, Um, and you can have tumors and things as well. Less for Lord I bleeds is a bit smaller. Diverticular disease, angiodysplasia, colorectal cancer and polyps, inflammatory bowel disease and hemorrhoids was the Lord I bleeds. Things are about more evenly split diverticular disease and angiodysplasia, potentially the most common that cause a really serious bleeds. But for Upper Gi bleeds, the horses are definitely peptic ulcer disease and body sees. And these a current for a huge portion off the upper GI bleeds the A you'll and cancer. So let's go back to be maybe. All right, so you've a sister. You think she's having a GI bleeds. Okay, so what do you want to do? So you need to think about the basics. First, make sure there's good venous access I doing to good cannulas. Take bloods. Consider. Well, immediate resuscitation is required. Okay. Do you want to get the fluid? Bullis, Actually, is the patient really a whale? And you need to put a period rest cold. Is the patient emergently needing blood? And you need to think about activating the major hemorrhage political when you take bloods. The important bloods are all of the ones around the hemoglobin, the clotting on getting the patient more blood if they need it. Okay, so you need to feel blood count calculation on at least a group conceive. But if you think a patient is actively bleeding, I would suggest getting across much before you need it. Rather than waiting until you could really be doing with the blood. Great. Now venous blood cast could be really helpful Naked setting as well. You'll get an instant AM estimate of the hemoglobin you get UTI on most blood gases. Most venous blood gases as well on get a better measure just of HOA. Um, well, the artist mail is there, like, two trees are the becoming acidotic. You need to check the patient's medications if they're bleeding. Are the old warfarin on their last eye on our was six? Okay, you want to correct any? Quite. You OPATHY speak to hematology. If you need to have on, then then we get to everything. Okay, So consider imaging a 99 times out of 100 is when you think of patient has a GI bleed, you're going to get a CT scan. Okay. What? It's fast. Most places have excellent over hours access to C T Night on from and I our perspective, it's actually really important because we can plan our intervention from as well. We can see any other sclerotic disease. We can see any and atomical video because I'm a basket on Tami comedians. A really quite common um, and it's also it's pretty sensitive as well. So ct will detect bleeding of a recruiter than 0.3 mils per minute. Suppressible. If you think they're bleeding, they need a triple fees scan. Okay, More about why and that in a minute. But it needs to be triple fees. That means it needs contrast. Okay, Many of these patients, the renal function will be off, but it will be really off if they start perfusing their kidney because their BP drops so low. Eso in an emergent situation where they're suspected bleeding, the imaging is only useful. With contrast, you still need to have discussion for sure is the pain Is the patient gonna be a candidate for renal replacement therapy? You need to discuss with the patient. That's what I'll make sure that we know the risks off a the CT scan with the With the renal function on, it's worth always discussing with a senior before you get imaging. Uh, in some cases, patients make the street to endoscopy, particularly if they've already had imaging or had a previous endoscopy. And, you know, they think they know what the what the issue is on. That could be particularly useful if a patient has, you know, severe renal impairment to tickle street to street treatment option. This is an example off triple fees imaging on why we get triple fees imaging. So, first off, what we mean by triple fees in this case is non contrast, which is what I've got in the skin there just night you want in our TV. Oh, phase on, then you want some sort of Venus fees or delayed phase on. That all depends a little bit, depending on where you work. Scan is done with three acquisitions, so the body has scanned three times once without any contrast on then. One contrast bolus is given on the patient's scanned again, while the contrast is in the arterial system. And then they just wait a little bit longer and scan again once that same bullets, with contrast, is in the venous system. So you end up with the acquisitions. But one contrast fullest to get your sea fees is so there's a little to see on this noncontrast fees. Okay, we can tell this is an R t e o fees, because the Orta in the middle of the screen there is great, but nothing else really is. Apart from these break spots over in some off the bell up. What is the rate state of the skin to look at it. But because it's a CT scan, it's the other we don't remember. So this is on the left side of the boat. So this is the R T e o fie. So we're seeing contracts going to the limit of the ball here on the arterial phase on on the Venus fees. We can still see this break, but it's changed sheep. Okay, so we call this venous Pilling. So this is really important separating the arterial venous fees out like this and seeing the change in the pool over that time. Let's us know that this isn't r t e o pleats and know a venous bleeds. Venous leads are much more likely to just stop by themselves. They don't require immunization isn't usually an option for them and in terms of ir, so it's quite important to make that distinction on the non contrast is essential, essentially, for so that you don't confuse things that aren't blood with being blood. If you just had this high density image, you wouldn't know that that wasn't something identity that the patient had eaten, but it wasn't on the non contrast, so it must be contrast. This must be extra physician on actively. Okay, so is there other imaging in the acute setting? The short answer is no. CT is really the only useful imaging modality in the acute setting. Rarely in your clear medicine a studies could be used. These are done known emergently, where there's going to be a slow gee, I bleed or an intermittent job. Lead is incredibly sensitive, so it candidates leading dug in to like 0.5 mils per minute. So really, really slow. Slow bleeds. And so these are the reading Isaiah talk usually technetium 99 m on the technician in today, and I am so for. Coolaid's scan is usually the one that is preferred, although they can also do read sale labeled red cell in scans as well. On After they do, it is it was injected and the were a certain amount of pain. The patient goes and lays on a gallon. Gamma camera on the gamma camera basically forms a picture, be some counting the number of signals that it receives him from the Gamma being given off by the radio is a tool. So let's go back to our patient again. So CT is diagnosed gi bleed because, ah, we've got the answer, right? So we'll discuss I our treatment and woman. But there's some other treatment points to consider first. Okay, So need to make sure that your patient is adequately resuscitated because the need to make it through endoscopy or procedure something potentially, so make sure that they're adequately resuscitated. I know. I said create coagulopathy What we're going to see again, Um, on a few photos were going to ask if they're Guadalupe a thick and if they are, what you've done advice that so make sense that just just fix that first. All right, um, on the other thing that's really important. Once the emergent management is done, is that you need to treat whatever the underlying condition is a swell. So if the patient has spectacles, your disease, you need to think about HPV already. Indication therapy. If the patient has bleeding viruses, you want to make sure that the liver disease is optimized. If they've got diverticulitis, give them antibiotics. Our surgery already involved in the patient's care do they need to be? So you need to think about all these things as well. And most cases, endoscopy will be the first line treatment, particularly for an upper GI. I bleed, but for Lourdes as well, usually these patients will have an adults could be on this localize and diagnose. The cause is of bleeding, but can also prevent treatment, too, so they can inject adrenaline. They can clip bleeding vessels. Uh, the combined fantasies, bond hemorrhoids and things like that. The there's nice guidelines for Upper GI Bleeding on. The British Society of Enterology gave things for Lordy I bleeding on. Both of these are really pretty strong on endoscopy being an important, important first line treatment. So what comes to I R? So when I can start doing a thought for this, it was like there's there's 30 mean treatment kind of patient groups When it comes to him, it comes to GI bleeding, and I are. So there's emergent amble ization were in dose endoscopic management is field, so these are patients that are sick. They are unstable. They usually need on rivers in the middle of the night. Whenever the present, um on Yeah, they have, they have to be done quickly. There's empirical embolization. So what we mean by that is the patient is either not thought or not proven to be actively bleeding right now on there, potentially currently stable, you may not be, but they're potentially stable. But in discovery, treatment has been tried. They don't think that it's been successful, or there would eat that. They've not managed to treat completely on the have a high suspicion that the patient is going to bleed again. So these can often wait till the daytime if the patient's stable. Sometimes it would be a case of off doing it. A street off when endoscopy maybe hasn't shown a bleeding point hasn't showing something to treat. But the patient is still is still, um, well on the third group are a cases where in discovery treatment has failed or is no enough by itself to reduce bleeding. Body sees. So these convenient marriage in because the patient is actively bleeding at the time, but they can also be done is planned cases where a patient has had recurrent bladder seal bleeds. Let's talk about embolization, so I find this definition okay, so embolize the poodle of em Bliss. Word that comes from the Greek embolus. Meaning, ah, wedge or pluck Embolus was derived from n, which means in pollen to through. So em by or something through an end. I quit like that because it's quite up description of what we actually do. An ambulance, A shin. Okay, so we usually we access the femoral artery in the growing usually can come from above as well. Places she's in the growing on the news videos, wires and casters to manipulate. Are we to whatever vessel it is that we're wanting to embolize We usually use a bigger catheter to anchored into the main basal. We call that the mother catheter usually. And then we put a maker catheter so smaller catheter sitter that to get into the smaller branches. So what do we threw it? Okay him In the case over cute GI bleeding where I work, the answer is coils feels more coils. Something's books occasionally glued all the liquid and bullocks, Um, on sometimes jail full. So gelfoam is a cane dove. I don't really know how to describe it if you've not seen it, to be honest, but it's a kind of weird textured material that you can call up into bets on mixed with ceiling to create kind of slutty that you can then inject on it, blocks off it, blocks off the arteries, so we've got a fair, fair amount of choice. The only other emboli we've not really mentioned is particles, and these aren't generally used in the GI bleeding a setting, and you'll probably hear about them in some of the other talks. I'm not really gonna talk about them. It's D. So what we use? So, yeah, I said What I work because which abolishes use depends on a mixture of factors, including what the operator prefers to use, what the operator is expedience than using. Well, it's available in the shelf. That's actually a particular thing right now, because there's bean VDs, stock problems and supply problems from videos suppliers for different things. So you're sometimes not always quite sure what's on the shelf and also what's required in the situation. So these embolic they work in different ways, so coils and plugs they work were the are deployed, so they slowly dying and cause thrombosis. But they rely on the patient's clotting to do some of the work, which is why I was hammering the point of correcting coagulation. There's no point in trying to do an embolism, a shin with something like coils. If the patient is a, it's a patient's anticoagulated or the coagulation is just not working properly. And so liquid and Bali's. They move away from the end of the catheter with floor, so they'll include a small level. But they can be a bit trickier if you're no experience with them, and you're not used to have fast the floor. How much to inject and things like that on these methods. So the part of the sort of the coils, the plugs on the liquid embolic sorrow old permanent. The gel foam is not so permanent. It dissolves over the course off a few weeks on. Doesn't leave, doesn't leave anything behind on. It is also possible to use a combination, so you may occasionally hear someone talk about a coil sandwich, so that's when they put in some coils and then they'll put in some gel form or another liquid embolic on. Then put in some more coils, um, or they'll put in coils and then inject gelfoam over the top of it. Um, and these are old, just just different techniques in order to gain. He was acid control. You're probably familiar with these canes of pictures of the blood supply to the GI tract. And he probably been told about how you've got the different arteries, the celiac superior mesenteric lymph video music tannic on the all supply these different regions on different parts and reality, the blood supply is about more like less okay, with absolutely tons of collateral supply. Despite all of the name branches, this means two important things. Firstly, it means that any bleeding point needs to be addressed, or both sides of that. Or you need to be super selective to reduce the chance of any collateral flu continuing to cause bleeding. I'll explain it, but more of a cold and a second. Secondly, it also means that just by everything that your common sense on your brain is telling you as long as you're not in a major branch, you're really going to cause any meaningful e any kind of clinically meaningful escape. Me, uh, by doing an ample is a shin. You feel like they should be really hard, high risk of causing bails. Give me Ah, stomach asking me, uh, you know, but they they just do it, and it just in some ways, it doesn't make sense. So this is what I mean by treating both sides of the bleeding points. So we call it closing the front door in the back door. So here we've got a Judean, um, carving room, the head of the pancreas with the gastrojejunal artery on. We have a bleeding point here. This is bleeding from branches off the GED. So we go in, we get caster to the celiac access and take a make a catheter into the gastrojejunal artery when we see the bleeding, so we deploy some coils, but we don't know that this isn't also bleeding from balloons, so we know you have to go. We have to go into the superior mesenteric artery on. Look at the collateral brunches here. So we inject more quinja contrast here to make sure that we don't see any bleeding enough where you could still see ongoing bleeding with them. Put coils here too. Ideally, what you want to do is you want to get across the bleeding points from the start uncoil from one say through to the other so that when you're going into the other artery, it's just it's just a little chick. And here's some pictures showing this from a case. So the catheter in the left actors through the celiac access so you can see the hepatic artery is going up to the top left of the picture, and you can see the the order June of the Gastrojejunal artery, which has been coiled. You could also see just to the left of the coils that there is ah, clipped there. So that's a clip that's been placed in the Judean, um, and Oscopy prior to this procedure on. That's really helpful because that helps you. That just increases your confidence that you're embolize in the right artery if you don't see any bleeding at the time off. The procedure on the rate the mother caster has no been taken into the superior amusing Take Our Tree on. There's another caster coming out of the tip of that. That's a major catheter, so you can see contrast going up towards more coils. But I suspect that what happened in this case because they've got the maker catheter in there was that they had to put some more coils in from a the bottom as well. So to be able to close the front and back door with toils at a plug, you need to be able to get there because the coils air plug are going to come out The tip of the catheter on that is just where they're going to be. That is where they're going to embolize. That's where they're going to cause cause the thrombosis. Sometimes this isn't possible. That could be for video seasons. Sometimes you go, Ah, a pseudo aneurysm and the wire just coils in it and won't go away the other site. Sometimes if you've got a like a Judean also, that's bleeding really briskly. You're wired, just actually goes through the hole and ends up in the Judean. Um, and you can't get it to follow. Follow the vessel runs. So in case is on some things that actually just too small a swell and you're not gonna be able to get into it. So if you're unable to get across to close the front or in the barn door, then you can use glue or gel form because the the fluid will take them forward. Um, a book A it obviously cardio the embolic to the other side off the vessel. I'm blocking up that way so the can be useful in different situations. So the other way that we can treat Joe bleeding is to get into a selective brunch. So these images, sure that can a lot of shape that gets form to give lords of Court in off collateral supply with the visa vector going right to the boat. I am doing the right here. We've got bleeding again. On this time, we've invalid used a single branch that is causing the bleeding. But again, that's no a problem, because what we can see here is that you've got these Taney branches of all these middle trunks that come in so first, so just don't seem to cause ischemia. However, if you were to embolize further back then you could potentially take a whole section or bowl because you wouldn't have you would have taken all of that supply. So these are looking a two ways that you can that you can do this. So you're some relief pictures again. So Here we go. Um, other caster in the superior music take artery on. Then we've got make faster out, and it is demonstrating the bet. That's bleeding. Okay, so I am simple. I like things to be very straightforward. Um, on essentially, when it comes to these undo grams where you're looking for bleeding tubes are good and gloves or buts. So in this case, you can see I wonder I don't know if you're gonna be able to see my my scar, sir, But here we've got nice party, little trip. That's feeling with contrast. Contrast is staying within those part of the lanes off the tube. But here, we've got a whole bunch of blood going on. Okay, so this is demonstrating some active bleeding. And in this picture, the selective brunch has them being coiled to embolize off. So that's unexamined of that one, Linda, Just to confirm, we can see your mouth. There is a how good's That's really helpful. Thank you. So what? What? When we get in there, we've got an idea where the bleeding may be coming from from the school. Pissed imaging the clinical history. But we can't see a bleeding point it's not bleeding at the time that were in there ready to embolize. Should we still embolize? The answer is yes. In most cases, you should part of something else that starts, you know, having to come back in two or three hours later when the patient is bleeding again. That's no, actually the reason for doing it. And so we do this most often in the Gastrojejunal artery. So in our center we've got lots of peptic ulcer disease, but we also cover the regional pancreatic center. Um, and the equate often have issues with the gushing Judean, Large E and post surgery or in pancreatitis, because the pancreatic juice is just they love blood vessels on blood vessels hate them, so it's quite common for us to do gastroduodenal immunization as a as an empirical thing. Um, embolize ing it has loads of ischemic complications on There are some studies that have shown that the outcomes are better if you embolize that if you don't even when you can't even when you can't see a bleeding point. If you think that the patient is or has been a or has been clinically bleeding, so we want a bit of a different thing. Nice. So variceal bleeding and is another, you know, really common cause off a GI bleed, but it is a bit different, so the portal hypertension in cirrhosis creates of back pressure that opens up lots of anastomosis, ease and collateral. Pathways that exist are usually very small. So these open and various locations so you can get gastric body, sees a sofa, do a body, sees petty petty splenic body, sees you can get paraesophageal viruses coming right up into into the throat. Acts and things, too. They're also responsible for some of the clinical findings that you may be heard about or being talked about, but never seen. So M Capital medicine is a collaterals opening up in the abdominal wall on hemorrhoids are actually collaterals. A At the canal is well on. Quite often, you know, these are opening up in order to reduce the portal hypertension, but usually they're just know enough to compensate on the virus is a runner. Pressure is well on the bleat, so there's a couple of ways that I archangelica this first off his tips, which does for trans ducal er intrahepatic portosystemic shunt. So here we have an ivc on deliver. All right, so we come in from the jugular vein, therefore trans drug dealer, and we use the special kits to tunnel through the liver. Intrahepatic on this creates a connection between the portal vein and one off the hepatic means. And that is what becomes the port. A systemic shut. A stent like this one that's gonna mostly covered, but no. Also, there's a there's a draft material on this top part of this thing here. Mm. But the bottom part is a is open. So we create the channel. The channel is going to be kind of really goes from kind of right atrium through they possibly in through the liver on into the portal vein. Um, on. Then we deploy a stent across that this thing has this all combatants on the portal sides. So this means that there's still blood full able to go from the force of being into the liver. But some of the blood is diverted up, so there's overall reduces the a portal hypertension. This is an angiographic picture of your in the channel that's been created. So this is the channel here that's been created so this end is in the systemic circulation at the AM That the kind of eat too ivc junction on then these are some of the body sees that we were talking about. So they they're still tribulus. But they're very, very tortuous on don't look, don't look like normal and the street things. And then this picture here shows you you can just make out the stent here on then. This ring is the transition between the injury protic portion, which is covered on the portion that's here in the portal vein, which is uncovered. So one of the things that can happen, though with this procedure, is that you can cause hepatic encephalopathy. Essentially, the liver is being bypassed by a lack of the blood supply you can see from this picture. The most of the blood supply is going up through the shot. There's not a huge amount going off to going off to the liver from this contrast injection. So that means that the liver isn't getting a chance to filter all the stuff that it that it normally would be. So one of the contraindications for tips is a patient that already has signs of a party and get full and careful opathy because you're more than likely going to make that I'm going to make that worse. If you if you do, attempts procedure on there have been cases that we have to go in and reduce the diameter of attempts or even block off attempts. Even a little. They've got to be about a seal bleeding. And But we have to block off this channel that we've created because in the patients develop hepatic encephalopathy and you know our no longer able to live independently and then it's really, really affected their quality of life. So there are other options. There's a these things bark to impart. Oh so Glynn occluded or plug assisted retrogrades transvenous obliteration. These both have similar principles, so the body sees a rack cess am by the venous system this time seem to remember that and put into the beginning of the artery on you. Take a catheter into the policies and then inflated balloon or deploy a plug along, say that catheter to include the virus you're shunt on. Then you can inject embolization material, lake glue or am quails a through the catheter on the rule of the blender plug is essentially to stop whatever you're injecting, stop the cause of the gel form moving with the floor into places that you don't want them to be in this like she block off and some of the virus seal a pathways. So and my really, uh we don't do a whole lot of lordy I embolization. Um I think Lord, I bleeds are well, significant. Lordy, I bleeds are less common than opportunity bleeds anyway. But also the more commonly respond to conservative a management on a stopping, stopping anticoagulants and bill is a shin for opportunity. It is much more common. I'm for the reasons that we talked about. We do quite a lot of guts to do denial artery embolization in particular. If body sees need treatment emergently, we will do, uh, tepes on. We mostly do tips for kind of elective cases where there's been recorded variceal bleeding too. And but we are increasingly doing some or in bark to impart know is well embarked on part o r the go to em in some a and some other countries. So what about our patient back to me? Maybe so we may have the CT scan that showed active bleeding at the duodenum on she was taking for endoscopy, which diagnosed and treated a peptic ulcer in D too. Everything was done, D But then two days later, she had another episode where she was vomiting blood again and was about tachycardia and drop your BP. She didn't have any further imaging. She went straight for a real school. But the school bus wasn't able to treat any more any further because the clot was sore here and stuck down into the ulcer that they couldn't get at it. There wasn't any active bleeding at the time of the school pinch it stabilized with them some resuscitation and things. So she was monitored or Renee on a ah, a relatively elective and critical gastroduodenal artery. Embolization was performed the next day on either some pictures. Eso all in the left ear has discussed. So we've got a big, bigger Muller catheter and celiac taxes here on a little a little maker caster coming out of the tip of it. This is the gastrojejunal artery. Here's an okay looking trip. Here is a blow. All right, Um, and then this image on the rate here shows you the coil and in there to treat her. What else has made anything? Okay, so she's got a peptic ulcer, so she needs to treat it with whatever your H. Pylori eradication is that if people to call is, um, your HB after the first bleeding and also could be dropped to 68. So she was transfused, So she'll be turkey McGugan to be continued to be monitored and may need some more blood. Ambien is a shin usually holds bleeding on the table. Okay, It's usually an instant instant gratification. Patient stabilizes. All is good with the world, but sometimes they can bleed again afterwards. Um, Andi. In those cases, you can go back on trying to a second attempt. Sometimes, though, a surgical intervention is is required, and there's not too is about that. So that was a very world winter off a G I hemorrhage. So let's just summarize, So J bleeding could be upper gi I so before the ligament of fits. Typically presents with hematemesis or melena on is most commonly caused by peptic ulcer disease on viruses. Lower GI bleed usually has fresh or looking blood that's being passed correct um on the causes include diverticulitis, hemorrhoids, counselor and angiodysplasia. Both of them are imaged with triple face CT and the acute setting both requires substitution connection of coagulopathy treatment of the underlying cause. Both of them have endoscopy, usually as the first line treatment. Iron treatment is probably more common, and upper GI bleeding on includes embolization and using videos methods. I'm provide a CEO bleeding tips on some more things that you are lost in a bit. Reader. I need to get a special show. It's one of my consultants who sent me his G A hemorrhage. Talk for me, Teo, to use, um, images and stuff from So, um yeah, thank you particular to Don't repeat your drug list for that. And that's me, guys. I will stop shaving. Thank you very much for your presentation. If anybody's got any questions, they can put him in the chats on to happen. We do. Do you also perform splenic artery embolization? Yes. Would you like for other information? I shouldn't be, but and yes, the splenic artery embolization is another weird voodoo one where you blow cough the main artery to an entire Organon. Somehow the organ constructs and goes here. Right? Um, in most cases, occasionally you can cause, um, some slight increase Kenya. And so it's Benicar Campbell ization. We more commonly due for a we would do for pseudoaneurysms. We sometimes do them in a young woman with splitting pseudoaneurysms who are wanting to get pregnant because they're known to grow. Um, we quite often will image them. CD Lee symbolized. Um, if the are getting bigger rather than anything else on, we do some splenic artery embolization in trauma. Thanks again London for that. And thanks for a great talk. I think there's like even some of the core things that you talked about in terms of like triple face scanning and and kind of breaking down tips at the tips procedure that obviously we all hear about a medical school on. But people don't really get a great grip of I found, like triple face scans chatting two people no one really knew actually what it meant. So I think even those bits were were really, really interesting. I have a quick question myself in terms of obviously you talked about the front door on the back door technique in terms of you know, cutting off the blood supply. You obviously I would imagine have to take some approaches to avoid distal immunization in our our embolize ing the wrong If you've got blood supply coming from both sides as well Is that something that you have is you have to consider during the procedure that you're embolic they're going to go in the wrong direction or implies Oh, I guess we use coils so much invite like almost exclusively. We use coils. So you you have quite a lot of control with the in, particularly if you and if you're worried about that, you use a detached a bulk oil. So one that you mg has a release mechanism, so you would put the oil out and then decide if you're happy with the position before you, you let it go. Um, I guess some of it comes with expedient, but Kyle's don't tend to go the wrong place If they are the correct size. Um, and if they're not the correct size, then you can sneak out. Sometimes something's it doesn't really cause that much of an issue. It just, you know, it may be ST about more than you would want it to rather than being a nice, satisfying coil shape. Um, but I think this is a lot of the reason why where I work uses coils. Um, unplugs because you just have a lot more, have a lot more control and over exactly where your implies ing it. And you don't have to embolize until you're completely happy with the position that you don't. Yeah, that's that's addressed in here, and this is this might be a little bit more of a difficult question, but in terms of you obviously said that in dusky be is usually first line, particularly for the lower GI I stuff. Do you then find out of the case in mind myself that I came across, that it was over a year ago now where the patients who aren't necessarily fit friend oscal here? Then they start to call the eye our team. And then, you know, they're not necessarily that's stable. They're all they're frail. They've got, you know, core mobilities is patient selection, something that obviously comes into consideration when doing these are is it when it's like acute bleeding? I guess it's kind of life and death, so you kinda have to just go with it. Yeah, on the and I have had situations where, you know, we've been maybe a boat to start, and I are embolization. And you realize that actually, what the patient needs is the major hemorrhage for school. Um, on hip. I am. Ah. And it is It's really important to have the patient resuscitated before, you know, before you do anything, um, years, Lee, you know, most patients are fat for upper endoscopy. You know, like the mm they get through, it's free and maybe about observational. It's not something that needs a G or anything like that. Eso I think it's not really an issue that I've come across in terms of. I don't think I've ever heard someone say to me, This patient's not fit for endoscopy. Therefore, they should get an eye our procedure because actually, I think that they probably have their probably just a taxing just in may be different ways. Um, in terms of on the patients themselves. I guess the only thing I could think of would be if there was a reason that the patient couldn't have endoscopy. I'm thinking of something like in order for you and your cancer or, you know, or something And, you know, or something like that that would that would really precludes endoscopy being and being possible. Ah, I guess in those in those situations we would probably just a go for immunization if we had a problem. Bleeding point. Let's go to this. There's any other questions moment, but thank you very much. I think we'll probably close it out there. I think, for next week, obviously. Thanks, Kevin. Who's joining us are watching it back after the fact we're back next Thursday evening with, um G a renal and genital urinary urinary intervention. So, uh, hopefully you'll join us for that Again are watch it again on demand on and feel free jobs to go back and watch the previous talks, which have been very well received a swell. So thank you for everyone. And thanks for joining us again. Thanks, Linda, for speaking