Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY

Size: px
Start display at page:

Download "Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY"

Transcription

1 Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY 15 FEB 2018

2 Sources

3 Sources

4 Sources

5 Initial evaluation History Physical examination Laboratory evaluation Obtained at the time of patient presentation assess the severity of bleeding possible location and etiology

6 Risk assessment and stratification Should be performed distinguish patients at high- and low-risk of adverse outcomes assist in patient triage timing of colonoscopy level of care

7 Fluid resuscitation Hemodynamic instability and/or Suspected ongoing bleeding should receive intravenous fluid normalization of blood pressure and heart rate before endoscopic evaluation/intervention

8 Packed red blood cells (RBCs) Maintain the hemoglobin above 7 g/dl 9 g/dl massive bleeding significant comorbid illness (especially cardiovascular ischemia) possible delay in receiving therapeutic interventions

9 Endoscopic hemostasis in patient with prolonged PT INR of Colonoscopy may be considered before or concomitant with the administration of reversal agents INR >2.5 Reversal agents before endoscopy

10 Platelet transfusion Maintain a platelet count of / ml in patients with severe bleeding those requiring endoscopic hemostasis

11 Prevention of recurrent bleeding NSAID Should be avoided in patients with a history of acute LGIB particularly if secondary to diverticulosis or angiectasia

12 ASA and risk of recurrent LGIB A retrospective cohort study involving patients with LGIB those who continued aspirin after the bleeding event significantly higher rates of recurrent LGIB over the ensuing 5 years of aspirin (18.9% vs. 6.9%) significantly lower rates of serious cardiovascular events and death Gastroenterology 2016; 151: 271-7

13 ASA, secondary prophylaxis Patients with established cardiovascular disease who require aspirin (secondary prophylaxis) should generally resume aspirin as soon as possible after bleeding ceases and at least within 7 days The exact timing depends on the severity of bleeding perceived adequacy of hemostasis risk of a thromboembolic event

14 Aspirin for primary prevention of cardiovascular events Should be avoided in most patients with LGIB

15 Dual antiplatelet therapy Data are lacking to guide the care of patients who have LGIB The patient who have undergone stenting in the previous 30 days acute coronary syndrome in the previous 90 days High risk for myocardial infarction and death after discontinuation of dual antiplatelet therapy generally advised to continue taking both medications

16 Dual antiplatelet therapy Should not be discontinued in patients with an acute coronary syndrome within the past 90 days coronary stenting within the past 30 days

17 Dual antiplatelet therapy In patients on dual antiplatelet therapy Monotherapy with non-aspirin antiplatelet agents (thienopyridine) non-aspirin antiplatelet therapy should be resumed as soon as possible and at least within 7 days based on multidisciplinary assessment of cardiovascular and GI risk and the adequacy of endoscopic therapy aspirin use should not be discontinued or

18 Dual antiplatelet therapy In patients who underwent coronary stenting coronary syndrome Less recently discontinuation of the second antiplatelet agent is recommended for 1 to 7 days Circulation 2009; 119:

19 Multidisciplinary approach In patients on anticoagulant agents Hematology Cardiology Neurology Gastroenterology deciding whether to discontinue medications use reversal agents to balance the risk of ongoing bleeding with the risk of thromboembolic events

20 Randomized trials Lacking to assess the effects of endoscopic hemostasis for acute LGIB The choice of hemostasis method is generally guided cause and location of bleeding ability to access the site operator experience

21 Efficacy and safety of endoscopic hemostasis in LGIB Observational studies and case series of diverticular hemorrhage A comprehensive review showed successful endoscopic hemostasis in 92% of patients early rebleeding in 8% late rebleeding in 12% Clin Gastroenterol Hepatol 2010; 8:

22 Endoscopic hemostasis methods for acute LGIB Injection (usually diluted epinephrine) Contact and noncontact thermal devices bipolar electrocoagulation heater probe argon plasma coagulation Mechanical therapies endoscopic clips band ligation

23 Epinephrine injection therapy 1:10,000 or 1:20,000 dilution with saline initial control of an active bleeding lesion improve visualization In combination with a second hemostasis modality mechanical contact thermal therapy To achieve definitive hemostasis

24 Metallic injection sclerotherapy needle

25 Injection treatment

26 Diverticular hemorrhage Is arterial Painless hematochezia Occurs from either the neck or the dome of the diverticulum

27 Diverticular hemorrhage Candidates for endoscopic treatment active bleeding (spurting or oozing) non-bleeding visible vessel an adherent clot (that cannot be removed with vigorous washing and suctioning) Found at the time of colonoscopy

28 Diverticular hemorrhage Mechanical therapy endoscopic clips reduce the theoretical risk of transmural colonic injury associated with contact thermal therapy Kaltenbach T, Watson R, Shah J, et al. Clin Gastroenterol Hepatol 2012;10: 131-7

29 Diverticular bleeding Through-the-scope endoscopic clips may be safer in the colon than contact thermal therapy easier to perform than band ligation particularly for right-sided colon lesions

30 Different types of hemoclip

31 Diverticular Hemorrhage postendoscopic clip placement

32 Heat probe Irrigation ports are locate 1cm proximal to the Teflon-coated tip, allowing targeted irrigation of an ulcer bed

33 Principle of coaptive thermocoagulation. The artery is compresse firmly, reducing the heat-sink effect. The two walls of the artery are then sealed using thermal energy

34 Angiectasia bleeding Colonic angioectasias including radiation proctopathy common in the elderly Usually manifest as mild overt rectal bleeding Severe hematochezia in patients who are taking antithrombotic agents

35 An oozing angiodysplastic lesion in the ascending colon.

36 Angiectasia bleeding APC treatment of choice ease of use safety profile observations of increased Hb levels reduced blood-transfusion requirements

37 Argon plasma coagulation probes

38 A 7-Fr lateral-firing APC probe

39 Lesion after APC directed around and then to the center in precise mode

40 Area after APC in pulsed mode

41 Pneumatosis intestinalis of the transverse colon, 3months after APC treatment for polyps

42 Post-polypectomy bleeding Mechanical (clip) Contact thermal endotherapy with or without the combined use of dilute epinephrine injection

43 Postpolypectomy bleeding in the sigmoid colon

44 Bleeding polypectomy site after an initial APC treatment that only coagulated the surface blood, but not the underlying bleeding source

45 Clips for post-polypectomy bleeding Preferred limit tissue injury tattoo or clip (if not already used for hemostasis) Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111:

46 Clips on polypectomy site

47 Detachable snare at the base of a pedunculated polyp

48 Roles of surgery For the prevention of recurrent LGIB individualized source of bleeding should be carefully localized before resection

49 Surgical consultation In patients with High-risk clinical features Ongoing bleeding After other therapeutic options have failed Should take into consideration extent and success of prior bleeding control measures severity and source of bleeding level of comorbid disease

50 Radiographic interventions In patients high-risk clinical features ongoing bleeding Who have negative upper endoscopy do not respond adequately to hemodynamic resuscitation efforts unlikely to tolerate bowel preparation and urgent colonoscopy

51 Radiographic interventions Successful embolization (no further contrast extravasation) 73 to 100% Rates of clinical success (cessation of bleeding) 63 to 96% Rebleeding rates 11 to 50% American College of Radiology (ACR) Appropriateness Criteria: radiologic management of lower gastrointestinal tract bleeding (updated 2014) ( / acsearch.acr.org/ docs/ 69457/ Narrative/ )

52 Angiographic Diagnosis and Therapy of Acute Colonic Bleeding.

53 Other causes of LGIB Ischemic colitis Inflammatory ulcerative colitis Colorectal neoplasms not amenable to durable endoscopic hemostasis usually treated with supportive medical care, surgical care, or both

54 Procedures for the Evaluation and Treatment of Acute LGIB

55

56 Adverse events in interventions Perforation Worsened bleeding Congestive heart failure 0.3 to 1.3% Bowel ischemia, in radiologic intervention 1 to 4% Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010

57 Areas of Uncertainty RCT needed better delineate the most effective timing of colonoscopy the role of colonoscopy versus radiography as the initial diagnostic method the choice among radiographic imaging studies the efficacy and safety of endoscopic hemostasis treatments (including topical powders, band ligation, over-the scope clips, and Doppler ultrasonography as an adjunct to endoscopic hemostasis)

58 Areas of Uncertainty The efficacy of conebeam CT technology as an adjunctive diagnostic method in selective angiography Embolic agent of choice in endovascular therapy better risk-stratification tools are needed to improve the triage of patients

59 Thanks for your attention

ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding

ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding Lisa L. Strate, MD, MPH, FACG 1 and Ian M. Gralnek, MD, MSHS 2 1 Division of Gastroenterology, University of Washington

More information

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA When to Scope in Lower GI Bleeding: It Must Be Done Now Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA Outline Epidemiology Overview of available tests Urgent

More information

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding PRACTICE GUIDELINES nature publishing group 459 CME ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding Lisa L. Strate, MD, MPH, FACG1 and Ian M. Gralnek, MD, MSHS2

More information

ACG Clinical Guideline: Management of Patients with Ulcer Bleeding

ACG Clinical Guideline: Management of Patients with Ulcer Bleeding ACG Clinical Guideline: Management of Patients with Ulcer Bleeding Loren Laine, MD 1,2 and Dennis M. Jensen, MD 3 5 1 Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut,

More information

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami 1 Approach to the patient with gross gastrointestinal bleeding Grace H. Elta, Mimi Takami Gastrointestinal (GI) bleeding is a common clinical problem that requires more than 300 000 hospitalizations annually

More information

On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding

On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding On-Call Upper GI Bleeding John R Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Associate Professor of Medicine Harvard Medical School Upper Gastrointestinal Bleeding 300,000000 hospitalizations/year

More information

Sangrado Gastrointestinal Alto Upper GI Bleeding

Sangrado Gastrointestinal Alto Upper GI Bleeding Sangrado Gastrointestinal Alto Upper GI Bleeding Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion Colombiana de Gastroenterologia 31 de Agosto, 2012 Pereira, Risaralda

More information

Kathy P. Bull-Henry, MD, FACG Dr. Bull-Henry has indicated no relevant financial relationships. Don t Waste Time With No Chance to See

Kathy P. Bull-Henry, MD, FACG Dr. Bull-Henry has indicated no relevant financial relationships. Don t Waste Time With No Chance to See Don t Waste Time with No Chance to See Kathy P. Bull-Henry, MD, FACG Dr. Bull-Henry has indicated no relevant financial relationships. Don t Waste Time With No Chance to See Kathy Bull-Henry, MD, FACG

More information

GASTROINESTINAL BLEEDING. Dr.Ammar I. Abdul-Latif

GASTROINESTINAL BLEEDING. Dr.Ammar I. Abdul-Latif GASTROINESTINAL BLEEDING Dr.Ammar I. Abdul-Latif CLASSIFICATION OF G.I.BLEEDING GIB Appearance Acuity Site Apparent Acute Upper Obscure Chronic Lower UPPER&LOWER G.I.BLEEDING CAUSES OF UPPER G.I. BLEEDING

More information

Upper gastrointestinal bleeding in children. Nguyễn Diệu Vinh, MD Department of Gastroenterology

Upper gastrointestinal bleeding in children. Nguyễn Diệu Vinh, MD Department of Gastroenterology Upper gastrointestinal bleeding in children Nguyễn Diệu Vinh, MD Department of Gastroenterology INTRODUCTION Upper gastrointestinal (UGI) bleeding : arising proximal to the ligament of Treitz in the distal

More information

Endoscopic Doppler in the Management of Upper and Lower GI Bleeding: Case Studies & Atlas

Endoscopic Doppler in the Management of Upper and Lower GI Bleeding: Case Studies & Atlas Endoscopic Doppler in the Management of Upper and Lower GI Bleeding: Case Studies & Atlas Presented By: Dennis M. Jensen, MD Professor of Medicine David Geffen School of Medicine at UCLA Associate Director,

More information

Shou Jiang Tang, MD, FASGE. Director of Endoscopic Research Professor in Medicine

Shou Jiang Tang, MD, FASGE. Director of Endoscopic Research Professor in Medicine Shou Jiang Tang, MD, FASGE Director of Endoscopic Research Professor in Medicine Through-the-scope clipping devices Over-the-scope clipping devices First reported clipping device Hayshi T, Yonezawa M,

More information

Supplementary appendix

Supplementary appendix Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Oakland K, Jairath V, Uberoi R, et al. Derivation

More information

Before Endoscopy? Indications Thermal Coagulation Injection Therapy Combination Therapy Fibrin Sealant Endoclips Argon Plasma Coagulation Lysine -

Before Endoscopy? Indications Thermal Coagulation Injection Therapy Combination Therapy Fibrin Sealant Endoclips Argon Plasma Coagulation Lysine - Dr Simon Smale Before Endoscopy? Indications Thermal Coagulation Injection Therapy Combination Therapy Fibrin Sealant Endoclips Argon Plasma Coagulation Lysine - Haemmostop Variceal Banding Histoacryl

More information

Long-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy

Long-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:151 158 Long-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy SATOSHI SHINOZAKI, HIRONORI YAMAMOTO,

More information

Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization

Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization E233 Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization Authors Institution Yuto Shimamura, Naoki Ishii, Fumio Omata, Noriatsu Imamura, Takeshi Okamoto, Mai Ego,

More information

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding Lauren B. Gerson, MD, MSc, FACG 1, Jeff L. Fidler 2, MD, David R. Cave, MD, PhD, FACG 3, Jonathan A. Leighton, MD, FACG 4 1 Division

More information

Clinical Management of Obscure- Overt Gastrointestinal Bleeding. Presented by Dr. 張瀚文

Clinical Management of Obscure- Overt Gastrointestinal Bleeding. Presented by Dr. 張瀚文 Clinical Management of Obscure- Overt Gastrointestinal Bleeding Presented by Dr. 張瀚文 Definition Obscure: : hard to understand; not clear. Overt: : public; not secret. Occult: : hidden from the knowledge

More information

Endoscopic Treatment of Luminal Perforations and Leaks

Endoscopic Treatment of Luminal Perforations and Leaks Endoscopic Treatment of Luminal Perforations and Leaks Ali A. Siddiqui, MD Professor of Medicine Director of Interventional Endoscopy Jefferson Medical College Philadelphia, PA When Do You Suspect a Luminal

More information

Management of Lower Gastrointestinal Bleeding. Patrick Lau Department of Surgery Kwong Wah Hospital

Management of Lower Gastrointestinal Bleeding. Patrick Lau Department of Surgery Kwong Wah Hospital Management of Lower Gastrointestinal Bleeding Patrick Lau Department of Surgery Kwong Wah Hospital Lower Gastrointestinal bleeding The challenge Account for 20% of gastrointestinal bleeding 80% stopped

More information

Historical perspective

Historical perspective Raj Santharam, MD GI Associates, LLC Clinical Assistant Professor of Medicine Medical College of Wisconsin Historical perspective FFS first widespread use in the early 1970 s Expansion of therapeutic techniques

More information

Lower GI bleeding. Aliu Sanni, MD Long Island College Hospital 17 th June, 2010

Lower GI bleeding. Aliu Sanni, MD Long Island College Hospital 17 th June, 2010 Lower GI bleeding Aliu Sanni, MD Long Island College Hospital 17 th June, 2010 Case Presentation CC: Hematochezia HPI: 28yr old male presents with 1 day episode of bloody stools. Denies any abdominal pain.

More information

on Anti-coagulants -- Is It Safe? And When to Stop?

on Anti-coagulants -- Is It Safe? And When to Stop? Endoscopy for Your Patient on Anti-coagulants -- Is It Safe? And When to Stop? John R. Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Associate Professor of Medicine Harvard Medical

More information

Antiplatelets in cardiac patients with suspected GI bleeding

Antiplatelets in cardiac patients with suspected GI bleeding Antiplatelets in cardiac patients with suspected GI bleeding Acute GI bleeding is a common major medical emergency. In the 2007 UK-wide audit, overall mortality of patients admitted with acute GI bleeding

More information

Role of radiology in colo-rectal bleedings. Alban DENYS MD FCIRSE EBIR CHUV LAUSANNE

Role of radiology in colo-rectal bleedings. Alban DENYS MD FCIRSE EBIR CHUV LAUSANNE Role of radiology in colo-rectal bleedings Alban DENYS MD FCIRSE EBIR CHUV LAUSANNE Epidemiology Lower GI bleeding accounts for 20-25% of all GI bleeding Annual incidence in USA :21-27/100000 Longstreth

More information

Management of acute upper gastrointestinal bleeding

Management of acute upper gastrointestinal bleeding 1 Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK 2 Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut,

More information

In the United States, gastrointestinal bleeding is the most common. Acute Lower Gastrointestinal Bleeding. Clinical Practice. The Clinical Problem

In the United States, gastrointestinal bleeding is the most common. Acute Lower Gastrointestinal Bleeding. Clinical Practice. The Clinical Problem The new england journal of medicine Clinical Practice Caren G. Solomon, M.D., M.P.H., Editor Acute Lower Gastrointestinal Bleeding Ian M. Gralnek, M.D., M.S.H.S., Ziv Neeman, M.D., and Lisa L. Strate,

More information

Colonoscopy and Management of patients under anti-thombotic therapy. Christian BOUSTIERE St Joseph Hospital Marseille, France

Colonoscopy and Management of patients under anti-thombotic therapy. Christian BOUSTIERE St Joseph Hospital Marseille, France Colonoscopy and Management of patients under anti-thombotic therapy Christian BOUSTIERE St Joseph Hospital Marseille, France INTRODUCTION The use of antithrombotic agents (aspirin, thienopyridines, warfarin,

More information

Antithrombotics and the Gut

Antithrombotics and the Gut Antithrombotics and the Gut Panelists: AR Tagahvi MD, N Nozari MD Moderator: S Nasseri-Moghaddam MD, MPH IAGH monthly meeting Shahrivar 1395 (September 2016 ) IAGH Conference Hall Antithrombotic agents

More information

James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015

James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015 The Management of Acute Upper Gastrointestinal Bleeding James Irwin Gastroenterology Department Palmerston North Hospital Acute Medicine Meeting Hutt Hospital June 21, 2015 Outline Common Definitions and

More information

Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital

Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding; Survey results from internists Optimal resuscitation

More information

Epidemiology and Treatment of Colonic Angiodysplasia; a Population-Based Study. Naomi G. Diggs, MD Lisa L. Strate, MD MPH March 2, 2010

Epidemiology and Treatment of Colonic Angiodysplasia; a Population-Based Study. Naomi G. Diggs, MD Lisa L. Strate, MD MPH March 2, 2010 Epidemiology and Treatment of Colonic Angiodysplasia; a Population-Based Study. Naomi G. Diggs, MD Lisa L. Strate, MD MPH March 2, 2010 Background Angiodysplasia is an important cause of occult and acute

More information

The New England Journal of Medicine URGENT COLONOSCOPY FOR THE DIAGNOSIS AND TREATMENT OF SEVERE DIVERTICULAR HEMORRHAGE

The New England Journal of Medicine URGENT COLONOSCOPY FOR THE DIAGNOSIS AND TREATMENT OF SEVERE DIVERTICULAR HEMORRHAGE URGENT COLONOSCOPY FOR THE DIAGNOSIS AND OF SEVERE DIVERTICULAR HEMORRHAGE DENNIS M. JENSEN, M.D., GUSTAVO A. MACHICADO, M.D., ROME JUTABHA, M.D., AND THOMAS O.G. KOVACS, M.D. ABSTRACT Background Although

More information

The Role of Colonoscopy and Radiological Procedures in the Management of Acute Lower Intestinal Bleeding

The Role of Colonoscopy and Radiological Procedures in the Management of Acute Lower Intestinal Bleeding CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:333 343 STATE OF THE ART The Role of Colonoscopy and Radiological Procedures in the Management of Acute Lower Intestinal Bleeding LISA L. STRATE and CHRISTOPHER

More information

Occult and Overt GI Bleeding: Small Bowel Imaging. Outline of Talk

Occult and Overt GI Bleeding: Small Bowel Imaging. Outline of Talk Occult and Overt GI Bleeding: Small Bowel Imaging Lauren B. Gerson MD, MSc Director of Clinical Research, GI Fellowship Program California Pacific Medical Center San Francisco, CA Outline of Talk Definition

More information

Colon ischemia. Bible class 12 September Stefan Christen. ACG Clinical Guideline: Am J Gastroenterol 2015

Colon ischemia. Bible class 12 September Stefan Christen. ACG Clinical Guideline: Am J Gastroenterol 2015 Colon ischemia Bible class 12 September 2018 Stefan Christen ACG Clinical Guideline: Am J Gastroenterol 2015 Definition Definition Imbalance between blood supply and metabolic demands of the colonocytes

More information

Tools of the Gastroenterologist: Introduction to GI Endoscopy

Tools of the Gastroenterologist: Introduction to GI Endoscopy Tools of the Gastroenterologist: Introduction to GI Endoscopy Objectives Endoscopy Upper endoscopy Colonoscopy Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic ultrasound (EUS) Endoscopic

More information

Therapeutic Endoscopy for Nonvariceal Gastrointestinal Bleeding

Therapeutic Endoscopy for Nonvariceal Gastrointestinal Bleeding Journal of Pediatric Gastroenterology and Nutrition 45:157 171 # 2007 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

More information

Oral anti-thrombotic therapy-management in patients requiring endoscopy

Oral anti-thrombotic therapy-management in patients requiring endoscopy Oral anti-thrombotic therapy-management in patients requiring endoscopy Management of anti-thrombotic therapy in patients requiring endoscopy This guideline suggests appropriate management of patients

More information

Advanced techniques for resection of large polyps. John G. Lee, MD February 2, 2018

Advanced techniques for resection of large polyps. John G. Lee, MD February 2, 2018 Advanced techniques for resection of large polyps John G. Lee, MD February 2, 2018 Background 1cm - large polyp on screening 2cm - large for polypectomy 3cm giant polyp 10-15% of polyps can t be removed

More information

Colon Cancer Detection by Rendezvous Colonoscopy : Successful Removal of Stuck Colon Capsule by Conventional Colonoscopy

Colon Cancer Detection by Rendezvous Colonoscopy : Successful Removal of Stuck Colon Capsule by Conventional Colonoscopy 19 Colon Cancer Detection by Rendezvous Colonoscopy : Successful Removal of Stuck Colon Capsule by Conventional Colonoscopy István Rácz Márta Jánoki Hussam Saleh Department of Gastroenterology, Petz Aladár

More information

UGI BLEED. Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore

UGI BLEED. Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore UGI BLEED Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore Outline UGI bleed: etiology and presentation Management: Non variceal / variceal bleed

More information

True obscure causes hemobilia, hemosuccus pancreaticus, vasculitis

True obscure causes hemobilia, hemosuccus pancreaticus, vasculitis Endoscopic Techniques for Small Bowel Imaging Going Where No Man Has Gone Before! Jonathan A. Leighton, MD, FACG, FASGE Mayo Clinic in Arizona 2014 ACG Governors/ASGE Best Practices Course January 2014

More information

Improved risk assessment in upper GI bleeding

Improved risk assessment in upper GI bleeding EDITORIAL Improved risk assessment in upper GI bleeding Acute upper GI bleeding is the most common GI emergency, with a reported incidence in various epidemiological studies ranging from 50 to over 100

More information

Definitive Surgical Treatment When Endoscopy Fails. Erik Peltz D.O. Resident Debate February 26 th 2007 University of Colorado Dept.

Definitive Surgical Treatment When Endoscopy Fails. Erik Peltz D.O. Resident Debate February 26 th 2007 University of Colorado Dept. Nonvariceal Gastrointestinal Hemorrhage: Definitive Surgical Treatment When Endoscopy Fails Erik Peltz D.O. Resident Debate February 26 th 2007 University of Colorado Dept. Surgery Non-Variceal Upper GI

More information

Therapeutic water soluble contrast-thrombin enema use in bleeding colonic diverticula: A case report

Therapeutic water soluble contrast-thrombin enema use in bleeding colonic diverticula: A case report www.edoriumjournals.com CASE REPORT PEER REVIEWED OPEN ACCESS Therapeutic water soluble contrast-thrombin enema use in bleeding colonic diverticula: A case report Edward Fogarty, Justin Mauch, Dakota Orvedal

More information

Update on the Management of Anticoagulants and Endoscopy. ACG Eastern Postgraduate Course, Washington, DC June 25, 2016

Update on the Management of Anticoagulants and Endoscopy. ACG Eastern Postgraduate Course, Washington, DC June 25, 2016 Update on the Management of Anticoagulants and Endoscopy ACG Eastern Postgraduate Course, Washington, DC June 25, 2016 Vivek Kaul, MD, FACG Segal-Watson Professor of Medicine Chief of Gastroenterology

More information

Colon ischemia. ACG Clinical Guideline; Am J Gastroenterol 2015

Colon ischemia. ACG Clinical Guideline; Am J Gastroenterol 2015 Colon ischemia ACG Clinical Guideline; Am J Gastroenterol 2015 Manifestations Acute, reversible Irreversible : gangrene, fulminant colitis/stricture formation, chronic ischemic colitis Recurrent sepsis

More information

Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient

Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient John Greenaway 1 Turning off the tap: Endoscopy Answer the questions Benefits and risks of endoscopy Urgency

More information

Multiple Polypoid Angiodysplasia with Obscure Overt Bleeding : A Case report. Jong Pil Im 1, Joo Sung Kim 1. Seoul, Republic of Korea

Multiple Polypoid Angiodysplasia with Obscure Overt Bleeding : A Case report. Jong Pil Im 1, Joo Sung Kim 1. Seoul, Republic of Korea Multiple Polypoid Angiodysplasia with Obscure Overt Bleeding : A Case report Jooyoung Lee 1, Sung Wook Hwang 1,2, Jihye Kim 1, Jinwoo Kang 1, Gyeong Hoon Kang 3, Kyu Joo Park 4, Jong Pil Im 1, Joo Sung

More information

Bleeding in the Digestive Tract

Bleeding in the Digestive Tract Bleeding in the Digestive Tract National Digestive Diseases Information Clearinghouse National Institute of Diabetes and Digestive and Kidney Diseases NATIONAL INSTITUTES OF HEALTH U.S. Department of Health

More information

Upper GI Bleeding. HH Tsai MD FRCP FECG Consultant Gastroenterologist

Upper GI Bleeding. HH Tsai MD FRCP FECG Consultant Gastroenterologist Upper GI Bleeding HH Tsai MD FRCP FECG Consultant Gastroenterologist Financial Disclosures I have no financial relationship with any manufacturer or supplier of any product mentioned in this talk. GI Audits:

More information

MANAGING GI BLEEDING IN A COMMUNITY HOSPITAL SETTING DR M. F. M. BRULE

MANAGING GI BLEEDING IN A COMMUNITY HOSPITAL SETTING DR M. F. M. BRULE MANAGING GI BLEEDING IN A COMMUNITY HOSPITAL SETTING DR M. F. M. BRULE DISCLOSURES Presenter: Dr Michele Brule Relationships with commercial interests: None OBJECTIVES Assess the severity of GI bleeding

More information

Laboratory Technique ROLE OF CAPSULE ENDOSCOPY IN OBSCURE GASTROINTESTINAL BLEEDING

Laboratory Technique ROLE OF CAPSULE ENDOSCOPY IN OBSCURE GASTROINTESTINAL BLEEDING Laboratory Technique ROLE OF CAPSULE ENDOSCOPY IN OBSCURE GASTROINTESTINAL BLEEDING J. JAIN* ABSTRACT Capsule endoscopy (CE) is a safe, non invasive technique for evaluation of small bowel (SB) lesions.

More information

EndoClot PHS A medical application on 74 patients march 2013

EndoClot PHS A medical application on 74 patients march 2013 EndoClot PHS A medical application on 74 patients march 2013 EndoClot PHS as a new method to achieve hemostasis of gastrointestinal bleeding Evaluation of a medical application involving 74 patients. Introduction

More information

Original Article INTRODUCTION

Original Article INTRODUCTION Original Article Endoscopic treatment for high risk bleeding peptic ulcers: A randomized, controlled trial of epinephrine alone with epinephrine plus fresh Mahsa Khodadoostan, Mohammad Karami Horestani,

More information

Endoscopy and the Anticoagulated Patient

Endoscopy and the Anticoagulated Patient Endoscopy and the Anticoagulated Patient John R. Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Professor of Medicine Harvard Medical School Objectives To accurately assess the risk

More information

Peptic ulcers remain the most common cause of upper

Peptic ulcers remain the most common cause of upper CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:33 47 STATE OF THE ART Endoscopic Therapy for Bleeding Ulcers: An Evidence-Based Approach Based on Meta-Analyses of Randomized Controlled Trials LOREN LAINE*

More information

Review article: the management of lower gastrointestinal bleeding

Review article: the management of lower gastrointestinal bleeding Aliment Pharmacol Ther 2005; 21: 1281 1298. doi: 10.1111/j.1365-2036.2005.02485.x Review article: the management of lower gastrointestinal bleeding J. J. FARRELL* & L. S. FRIEDMAN à *Division of Digestive

More information

Case 37 Clinical Presentation

Case 37 Clinical Presentation Case 37 73 Clinical Presentation The patient is a 62-year-old woman with gastrointestinal (GI) bleeding. 74 RadCases Interventional Radiology Imaging Findings () Image from a selective digital subtraction

More information

Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy

Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy Original article Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy Authors Yeong Jin Kim, Jun Chul Park, Eun Hye Kim, Sung Kwan Shin,

More information

Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions

Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions Showa Univ J Med Sci 12(3), 253-258, September 2000 Original Incidence and Management of Hemorrhage after Endoscopic Removal of Colorectal Lesions Masaaki MATSUKAWA, Mototsugu FUJIMORI, Takahiko KOUDA,

More information

Imaging abdominal vascular emergencies. V.Stoynova

Imaging abdominal vascular emergencies. V.Stoynova Imaging abdominal vascular emergencies V.Stoynova Abdominal vessels V. Stoynova 2 Acute liver bleeding trauma anticoagulant therapy liver disease : HCC, adenoma, meta, FNH, Hemangioma Diagnosis :CT angiography

More information

ICU Volume 14 - Issue 2 - Summer Matrix

ICU Volume 14 - Issue 2 - Summer Matrix ICU Volume 14 - Issue 2 - Summer 2014 - Matrix Upper Gastrointestinal Bleeding Authors David Osman, MD Medical Intensive Care Unit Paris-South University Hospitals Assistance Publique-Hôpitaux de Paris

More information

Research Article Super-Selective Mesenteric Embolization Provides Effective Control of Lower GI Bleeding

Research Article Super-Selective Mesenteric Embolization Provides Effective Control of Lower GI Bleeding Hindawi Radiology Research and Practice Volume 2017, Article ID 1074804, 5 pages https://doi.org/10.1155/2017/1074804 Research Article Super-Selective Mesenteric Embolization Provides Effective Control

More information

SAGES 2019 Flexible Endoscopy Course for Fellows

SAGES 2019 Flexible Endoscopy Course for Fellows Goals and Objectives: At the end of the course, the MIS fellow will be familiar with GI endoscopes, towers, and the instruments used for endoscopy and endoscopic surgery. The fellow will also be able to

More information

Therapeutic barium enema for bleeding colonic diverticula: Four case series and review of the literature

Therapeutic barium enema for bleeding colonic diverticula: Four case series and review of the literature Online Submissions: wjg.wjgnet.com World J Gastroenterol 2008 November 7; 14(41): 6413-6417 wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327 doi:10.3748/wjg.14.6413 2008 The WJG Press. All

More information

Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal Upper Gastrointestinal Bleeding Nonvariceal Upper Gastrointestinal Bleeding Stephen R. Rotman and John R. Saltzman 2 Introduction Upper gastrointestinal bleeding (UGIB) is defined as bleeding in the gastrointestinal tract originating

More information

ENDOVASCULAR THERAPIES FOR ACUTE STROKE

ENDOVASCULAR THERAPIES FOR ACUTE STROKE ENDOVASCULAR THERAPIES FOR ACUTE STROKE Cerebral Arteriogram Cerebral Anatomy Cerebral Anatomy Brain Imaging Acute Ischemic Stroke (AIS) Therapy Main goal is to restore blood flow and improve perfusion

More information

Lower gastrointestinal bleeding (LGIB) is a common

Lower gastrointestinal bleeding (LGIB) is a common CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2004;2:485 490 Early Predictors of Severe Lower Gastrointestinal Bleeding and Adverse Outcomes: A Prospective Study FERNANDO S. VELAYOS,* ANN WILLIAMSON, KAREN

More information

Roles of Capsule Endoscopy and Single-Balloon Enteroscopy in Diagnosing Unexplained Gastrointestinal Bleeding

Roles of Capsule Endoscopy and Single-Balloon Enteroscopy in Diagnosing Unexplained Gastrointestinal Bleeding ORIGINAL ARTICLE Clin Endosc 2016;49:56-60 http://dx.doi.org/10.5946/ce.2016.49.1.56 Print ISSN 2234-2400 On-line ISSN 2234-2443 Open Access Roles of Capsule Endoscopy and Single-Balloon Enteroscopy in

More information

High Value Care of GI Bleeding

High Value Care of GI Bleeding High Value Care of GI Bleeding Bennie R. Upchurch MD, FACP, FASGE, AGAF, FACG Medical Director, GI Bleeding Program, Division of Gastroenterology, Nutrition, and Hepatology Ohio State University Wexner

More information

Supplementary Online Content

Supplementary Online Content Supplementary Online Content Tran AH, Ngor EWM, Wu BU. Surveillance colonoscopy in elderly patients: a retrospective cohort study. JAMA Intern Med. Published online August 11, 2014. doi:10.1001/jamainternmed.2014.3746

More information

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy. a prospective, randomized, multicenter study

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy. a prospective, randomized, multicenter study 598 Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study Authors Jeong-Seon

More information

Scottish Medicines Consortium

Scottish Medicines Consortium Scottish Medicines Consortium esomeprazole, 40mg vial of powder for solution for intravenous injection or infusion (Nexium I.V. ) No. (578/09) AstraZeneca 09 October 2009 The Scottish Medicines Consortium

More information

Correspondence should be addressed to Justin Cochrane;

Correspondence should be addressed to Justin Cochrane; Case Reports in Gastrointestinal Medicine Volume 2015, Article ID 794282, 4 pages http://dx.doi.org/10.1155/2015/794282 Case Report Acute on Chronic Pancreatitis Causing a Highway to the Colon with Subsequent

More information

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit Authors Shahrad Hakimian 1, Salmaan Jawaid 2, Yurima Guilarte-Walker 3, Jomol Mathew

More information

Clinical Outcomes of Endoscopic Hemostasis for Bleeding in Patients with Unresectable Advanced Gastric Cancer

Clinical Outcomes of Endoscopic Hemostasis for Bleeding in Patients with Unresectable Advanced Gastric Cancer J Gastric Cancer. 2017 Dec;17(4):374-383 pissn 2093-582X eissn 2093-5641 Original Article Clinical Outcomes of Endoscopic Hemostasis for Bleeding in Patients with Unresectable Advanced Gastric Cancer 2,*

More information

Urgent Computed Tomography for Determining the Optimal Timing of Colonoscopy in Patients with Acute Lower Gastrointestinal Bleeding

Urgent Computed Tomography for Determining the Optimal Timing of Colonoscopy in Patients with Acute Lower Gastrointestinal Bleeding ORIGINAL ARTICLE Urgent Computed Tomography for Determining the Optimal Timing of Colonoscopy in Patients with Acute Lower Gastrointestinal Bleeding Satoko Nakatsu, Hiroshi Yasuda, Tadateru Maehata, Masahito

More information

Peri-Endoscopic Period. Neena S. Abraham MD, MSCE, FACG

Peri-Endoscopic Period. Neena S. Abraham MD, MSCE, FACG How to Manage Antiplatelet Therapy in the Peri-Endoscopic Period Neena S. Abraham MD, MSCE, FACG Michael E. DeBakey Veterans Affairs Medical Center Sections of Gastroenterology & Health Services Research

More information

The focus of Chapter 9 is on anoscopy, proctosigmoidoscopy, flexible sigmoidoscopy, and colonoscopy procedures and all

The focus of Chapter 9 is on anoscopy, proctosigmoidoscopy, flexible sigmoidoscopy, and colonoscopy procedures and all 9 Anoscopy, 45380 45380 45385 Proctosigmoidoscopy, Flexible Sigmoidoscopy, and Colonoscopy 45378 The focus of Chapter 9 is on anoscopy, proctosigmoidoscopy, flexible sigmoidoscopy, and colonoscopy procedures

More information

Evaluation and Management of Gastrointestinal Bleeding Part 2: Lower and Obscure Gastrointestinal Bleeding

Evaluation and Management of Gastrointestinal Bleeding Part 2: Lower and Obscure Gastrointestinal Bleeding Evaluation and Management of Gastrointestinal Bleeding Part 2: Lower and Obscure Gastrointestinal Bleeding Edward Lung, MD, MPH ABSTRACT This article, the second in a 2-part series, provides information

More information

Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review

Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review bs_bs_banner doi:10.1111/jgh.14114 REVIEW Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review Fadi H Mourad and Rupert W Leong * Gastroenterology and Liver Services,

More information

INVESTIGATIONS OF GASTROINTESTINAL DISEAS

INVESTIGATIONS OF GASTROINTESTINAL DISEAS INVESTIGATIONS OF GASTROINTESTINAL DISEAS Lecture 1 and 2 دز اسماعيل داود فرع الطب كلية طب الموصل Radiological tests of structure (imaging) Plain X-ray: May shows soft tissue outlines like liver, spleen,

More information

Deep Enteroscopy Methods to Diagnose Small Bowel IBD

Deep Enteroscopy Methods to Diagnose Small Bowel IBD Deep Enteroscopy Methods to Diagnose Small Bowel IBD Name: Institution: Peter Draganov University of Florida, Gainesville, FL Overview Types of enteroscopy Enteroscopy equipment Enetoscopy do and don'ts

More information

Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline Guidelines 445 Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline Authors C. Boustière 1, A. Veitch 2, G. Vanbiervliet 3, P. Bulois 4, P. Deprez 5, A. Laquiere

More information

Quality Measures In Colonoscopy: Why Should I Care?

Quality Measures In Colonoscopy: Why Should I Care? Quality Measures In Colonoscopy: Why Should I Care? David Greenwald, MD, FASGE Professor of Clinical Medicine Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York ACG/ASGE Best

More information

Esophageal Varices Beta-Blockers or Band Ligation. Cesar Yaghi MD Hotel-Dieu de France University Hospital Universite Saint Joseph

Esophageal Varices Beta-Blockers or Band Ligation. Cesar Yaghi MD Hotel-Dieu de France University Hospital Universite Saint Joseph Esophageal Varices Beta-Blockers or Band Ligation Cesar Yaghi MD Hotel-Dieu de France University Hospital Universite Saint Joseph Esophageal Varices Beta-Blockers or Band Ligation? Risk of esophageal variceal

More information

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic. bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published.

More information

INTRODUCTION TO DIAGNOSTIC ENDOSCOPY

INTRODUCTION TO DIAGNOSTIC ENDOSCOPY INTRODUCTION TO DIAGNOSTIC ENDOSCOPY EGD & Colonoscopy Procedure Kolegium Ilmu Bedah Indonesia B. Parish Budiono Sub Bagian Bedah Digestif FK UNDIP/RSUP Dr. Kariadi Semarang GI Endoscopy GI Endoscopy is

More information

A bleeding ulcer: What can the GP do? Gastrointestinal bleeding is a relatively common. How is UGI bleeding manifested? Who is at risk?

A bleeding ulcer: What can the GP do? Gastrointestinal bleeding is a relatively common. How is UGI bleeding manifested? Who is at risk? Focus on CME at the University of British Columbia A bleeding ulcer: What can the GP do? By Robert Enns, MD, FRCP Gastrointestinal bleeding is a relatively common disorder affecting thousands of Canadians

More information

Billing Guideline. Subject: Colorectal Cancer Screening Exams (Invasive Procedures) Effective Date: 1/1/14 Last revision effective 4/16

Billing Guideline. Subject: Colorectal Cancer Screening Exams (Invasive Procedures) Effective Date: 1/1/14 Last revision effective 4/16 Billing Guideline Subject: Colorectal Cancer Screening Exams (Invasive Procedures) Effective Date: 1/1/14 Last revision effective 4/16 Florida Hospital Care Advantage plans include full coverage of in-network

More information

Occult GI Bleed. July 2015

Occult GI Bleed. July 2015 Occult GI Bleed July 2015 Occult GI Bleed Occult vs Obscure Occult positive FOB and/or IDA, but no evidence of visible blood loss to pt or physician Obscure GI bleed that persist/ recurs without obvious

More information

UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital ABSTRACT

UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital ABSTRACT Original Article Jewsuebpong T THAI J GASTROENTEROL 2008 Vol. 9 No. 2 May - Aug. 2008 67 UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital Jewsuebpong T ABSTRACT Background:

More information

Atlas of Colonoscopy

Atlas of Colonoscopy Atlas of Colonoscopy Techniques - Diagnosis - Interventional Procedures Bearbeitet von Maximilian Bittinger, Helmut Messmann 1. Auflage 2005. Buch. 248 S. Hardcover ISBN 978 3 13 140571 5 Format (B x L):

More information

Emergency Surgery Board Department of General Surgery Rambam Health Care Campus

Emergency Surgery Board Department of General Surgery Rambam Health Care Campus Emergency Surgery Board Department of General Surgery Rambam Health Care Campus Surgical Complications of Peptic Ulcer Disease Bleeding Case Presentation and Review of the Literature Case Presentation

More information

Peri-endoscopic Management of Antithrombotics & Anticoagulants

Peri-endoscopic Management of Antithrombotics & Anticoagulants Peri-endoscopic Management of Antithrombotics & Anticoagulants ACG Postgraduate Course, Nashville, TN Dec 5, 2015 Vivek Kaul, MD, FACG Segal-Watson Professor of Medicine Chief of Gastroenterology & Hepatology

More information

Approximately 5% of patients presenting with gastrointestinal

Approximately 5% of patients presenting with gastrointestinal CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:664 669 Long-Term Outcomes After Double-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding LAUREN B. GERSON,* MELISSA A. BATENIC, SHARESE L. NEWSOM,

More information

REFERRAL GUIDELINES: ENDOSCOPY

REFERRAL GUIDELINES: ENDOSCOPY Outpatient Referral Guidelines Page 1 REFERRAL GUIDELINES: Referrals for endoscopy must be made using the Essential Referral Content Gastrointestinal Endoscopy Referral Form Please fax the completed referral

More information