GIT j club endohemostasis new

Kurdistan Board GEH/GIT Surgery J ClubKurdistan Board GEH/GIT Surgery J ClubSupervisor:Supervisor:

Professor Dr.Mohamed AlshekhaniProfessor Dr.Mohamed AlshekhaniMBChB-CABM-FRCP-EBGH.MBChB-CABM-FRCP-EBGH.

Introduction:Introduction: EndO intervention reduces high mortality of acute EndO intervention reduces high mortality of acute

NVGIBNVGIB Inj +second endoscopic modality reduce re-bleeding, Inj +second endoscopic modality reduce re-bleeding,

need for surgery& mortality.need for surgery& mortality. Mechanical hemostasis with hemoclips & thermo-Mechanical hemostasis with hemoclips & thermo-

coagulation are equivalent &used interchangeably by coagulation are equivalent &used interchangeably by therapeutic endoscopists, depending on individual therapeutic endoscopists, depending on individual preference. preference.

For variceal bleeding, endoscopic therapy has emerged For variceal bleeding, endoscopic therapy has emerged as 1st-line treatment;includes endoscopic variceal as 1st-line treatment;includes endoscopic variceal ligation EV &cyanoacrylate (CYA) glue injection for ligation EV &cyanoacrylate (CYA) glue injection for gastric varices GV. gastric varices GV.

Despite successful primary endoscopic hemostasis of Despite successful primary endoscopic hemostasis of NVUGIB nearly 100%, recurrent in-hospital bleeding NVUGIB nearly 100%, recurrent in-hospital bleeding occur in 8.2%, with overall mortality of 5%.occur in 8.2%, with overall mortality of 5%.

Introduction:Introduction:

The results of traditional endoscopic therapies are far The results of traditional endoscopic therapies are far from perfect:from perfect:

Large ulcer defect >2cm Large ulcer defect >2cm Visible vessel >2 mmVisible vessel >2 mm Inaccessible lesions Inaccessible lesions Challenging positions ( posterior wall stomach ,lesser Challenging positions ( posterior wall stomach ,lesser

curve , posterior bulbar wall)curve , posterior bulbar wall) Fibrotic base for hemoclip. Fibrotic base for hemoclip.

Introduction:Introduction: Failure to control bleeding from EV bleeding, is 17% , Failure to control bleeding from EV bleeding, is 17% ,

for GV, recurrent bleeding occurs in 37– 53% with for GV, recurrent bleeding occurs in 37– 53% with sclerosant injs &40% after standard endoscopic CYA sclerosant injs &40% after standard endoscopic CYA therapy.therapy.

New endoscopic technologies & procedural techniques New endoscopic technologies & procedural techniques are needed, especially in patients failing to respond to are needed, especially in patients failing to respond to initial endoscopic therapy:initial endoscopic therapy:

New technologies:New technologies:Cap-mounted Cap-mounted ClipsClips

Over-the-scope Clip System:Over-the-scope Clip System: Allow suction of tissue before release of the clip by using a Allow suction of tissue before release of the clip by using a

hand wheel, similar to band ligation. hand wheel, similar to band ligation. OTSC used for endoscopic closure of perforations& fistulas.OTSC used for endoscopic closure of perforations& fistulas. Endoscopic hemostasis with OTSC promising with 90% successEndoscopic hemostasis with OTSC promising with 90% success Lesions managed:bleeding PUD,MW tears, anastomotic Lesions managed:bleeding PUD,MW tears, anastomotic

bleeding, post EMR or bleeding, post EMR or ESD, or ESD, or diverticular bleeding. diverticular bleeding. OTCS particularly advantageous along the posterior wall of OTCS particularly advantageous along the posterior wall of

the duodenal bulb, where standard therapy is prone to failure.the duodenal bulb, where standard therapy is prone to failure. Excellent results with LGIB failed conventional therapies Excellent results with LGIB failed conventional therapies

&recurrent bleeding occurred in only 2 patients. &recurrent bleeding occurred in only 2 patients. OTSC is cleared by FDA for:OTSC is cleared by FDA for: (1) bleeding ulcers (2) arteries < 2 mm (3) colon diverticula (1) bleeding ulcers (2) arteries < 2 mm (3) colon diverticula

(4) polyps< 1.5 cm diam.(5) mucosal/submuco defects<3 cm(4) polyps< 1.5 cm diam.(5) mucosal/submuco defects<3 cm

New technologies:New technologies:Cap-mounted Cap-mounted ClipsClips

Padlock ClipPadlock Clip:: FDA-cleared FDA-cleared Consists of a nitinol ring with 6 inner needles Consists of a nitinol ring with 6 inner needles

preassembled on an applicator cap (for 9.5–11 mm scope preassembled on an applicator cap (for 9.5–11 mm scope tips). tips).

The trigger wire is located alongside the shaft of the The trigger wire is located alongside the shaft of the endoscope, thus freeing up the working channel for endoscope, thus freeing up the working channel for continuous suction of blood/secretions. continuous suction of blood/secretions.

This design may allow for more efficient suction of tissue This design may allow for more efficient suction of tissue into the cap, thereby not requiring other instruments for into the cap, thereby not requiring other instruments for tissue retraction. tissue retraction.

Used to treat 5 patients with Used to treat 5 patients with GIB with recurrent bleeding GIB with recurrent bleeding from a bleeding rectal ulcer&delayed post-polypectomy from a bleeding rectal ulcer&delayed post-polypectomy bleeding, &duodenal bleeding, &duodenal Dieulafoy lesion bleed.Dieulafoy lesion bleed.

Padlock clip:Padlock clip:

New technologies:New technologies:Thermocoag or Ablative Thermocoag or Ablative TherapyTherapy

Radiofrequency Ablation:Radiofrequency Ablation: FDA cleared it for the treatment of GAVE & radiation FDA cleared it for the treatment of GAVE & radiation

colitis failed previous APC with 87% GAVE treated with colitis failed previous APC with 87% GAVE treated with RFA did not require further transfusion.RFA did not require further transfusion.

There are endoscopic differences between classic There are endoscopic differences between classic watermelon-striped type & punctate type of GAVE, watermelon-striped type & punctate type of GAVE, latter consists of sharply demarcated red punctate latter consists of sharply demarcated red punctate lesions of nearly even size diffusely scattered over a lesions of nearly even size diffusely scattered over a large area in the antrum &associated with large area in the antrum &associated with cirrhosis.cirrhosis.

New technologies:New technologies:Topical Hemostatic AgentsTopical Hemostatic Agents

New tools used in endoscopic hemostasis. New tools used in endoscopic hemostasis. Three different powders available: Hemospray, Three different powders available: Hemospray,

Ankaferd Blood Stopper, EndoClot& CYA topical spray.Ankaferd Blood Stopper, EndoClot& CYA topical spray.


Hemospray:Hemospray: 11stst used to control external bleeding in battlefield. used to control external bleeding in battlefield. Mechanisms of action:Mechanisms of action: A a mechanical barrier over bleeding site. A a mechanical barrier over bleeding site. Absorbent & serum separator, increase the conc of clotting Absorbent & serum separator, increase the conc of clotting

Fs.Fs. Electrostatic because of its negative charge. Electrostatic because of its negative charge. Activates the intrinsic clotting cascade. Activates the intrinsic clotting cascade. In Forrest I bleeding peptic ulcers it achieved good In Forrest I bleeding peptic ulcers it achieved good

hemostasis >90% with a low recurrent bleeding.hemostasis >90% with a low recurrent bleeding. Alone or in combination with other modalities showed Alone or in combination with other modalities showed

successful hemostasis of 92%.successful hemostasis of 92%. Bleeding sources treated include:Bleeding sources treated include:portal hypertension, portal hypertension,

varices,tumors,iatrogenic varices,tumors,iatrogenic (post-sphincterotomy), post-ESD. (post-sphincterotomy), post-ESD.


LGIB from diffuse ulceration, post-polypectomy LGIB from diffuse ulceration, post-polypectomy bleeding, radiation proctitis, AVM with increased risk of bleeding, radiation proctitis, AVM with increased risk of delayed bleeding because of impaired hemostasis delayed bleeding because of impaired hemostasis caused by antithrombotic agents, anticoagulation, or caused by antithrombotic agents, anticoagulation, or thrombocytopenia.thrombocytopenia.

Advantages:Advantages: ease of use, act as an “extinguisher” even in difficult ease of use, act as an “extinguisher” even in difficult

locations&potential efficacy for different bleeding locations&potential efficacy for different bleeding lesions. lesions.

DisadvantageDisadvantage: : Inability to use another modality if hemostasis should Inability to use another modality if hemostasis should

fail, because the powder obscures the target site.fail, because the powder obscures the target site. Only works when there is active bleeding or oozing Only works when there is active bleeding or oozing

from the vessel or lesionfrom the vessel or lesion..


AnkaferdAnkaferd Ankaferd Blood Stopper (ABS) (Ankaferd Blood Stopper (ABS) (Turkey) is a traditional Turkey) is a traditional

Turkish herbal mixture(Thymus vulgaris Turkish herbal mixture(Thymus vulgaris Glycyrrhiza Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, Urtica dioica)glabra, Vitis vinifera, Alpinia officinarum, Urtica dioica)

ABS is delivered through the scope with a spray ABS is delivered through the scope with a spray catheter. catheter.

Exact mechanism of action remains incompletely Exact mechanism of action remains incompletely understood. understood.

Hemostatic efficiency of ABS for UGIH of various origins: Hemostatic efficiency of ABS for UGIH of various origins: ulcers, tumors, variceal bleeding.ulcers, tumors, variceal bleeding.

Ankaferd is not FDA cleared.Ankaferd is not FDA cleared.


Endoclot:Endoclot: Endo Clot Polysaccharide Hemostatic System used as an Endo Clot Polysaccharide Hemostatic System used as an

adjunct hemostat to control bleeding from capillary, adjunct hemostat to control bleeding from capillary, venous, or arteriolar vessels in the GI tract. venous, or arteriolar vessels in the GI tract.

It consists of starch, which explains its relatively low cost. It consists of starch, which explains its relatively low cost. The applicator comprises a powder/gas mixing chamber, a The applicator comprises a powder/gas mixing chamber, a

delivery catheter (7F width, 1800 or 2300 mm length), delivery catheter (7F width, 1800 or 2300 mm length), connecting tube between a gas filter & external gas connecting tube between a gas filter & external gas source. source.

A large study described its usefulness for controlling& A large study described its usefulness for controlling& preventing bleeding related to preventing bleeding related to

Immediate hemostasis in UGIH, although not as mono or Immediate hemostasis in UGIH, although not as mono or primary therapy.primary therapy.

Demonstrate its ease of use. Demonstrate its ease of use. Not FDA cleared. Not FDA cleared.


Cyanoacrylate Spray:Cyanoacrylate Spray: CYA used off label for the endoscopic treatment of CYA used off label for the endoscopic treatment of

recalcitrant NVUGIB&bleeding with malignant tumors. recalcitrant NVUGIB&bleeding with malignant tumors. Despite its ease of application & availability, there are Despite its ease of application & availability, there are

no large scale trials. no large scale trials. It can destroy eye/endoscopic equipments &appropriate It can destroy eye/endoscopic equipments &appropriate

precautions are neededprecautions are needed..

New technologies:FCSEMSsNew technologies:FCSEMSs

Persistent immediate post-sphincterotomy bleeding Persistent immediate post-sphincterotomy bleeding requires endoscopic intervention. requires endoscopic intervention.

When conventional hemostatic modalities fail, When conventional hemostatic modalities fail, placement of FCSEMS achieve durable uncontrolled placement of FCSEMS achieve durable uncontrolled bleeding after balloon sphincteroplasty,post-transplant bleeding after balloon sphincteroplasty,post-transplant anastomotic stricture dilatation& intraductal anastomotic stricture dilatation& intraductal biopsy,esophageal variceal bleeding refractory to biopsy,esophageal variceal bleeding refractory to conventional therapy such as band ligation.conventional therapy such as band ligation.

Success of therapy was more frequent in the Success of therapy was more frequent in the esophageal stent than in the balloon tamponade esophageal stent than in the balloon tamponade &considered as an alternative &considered as an alternative to balloon tamponadeto balloon tamponade with less aspiration pneumonia in VUGIBwith less aspiration pneumonia in VUGIB..

New technologies:New technologies:Endoscopic SuturingEndoscopic Suturing

Requires a double-channel endoscope & consists of a Requires a double-channel endoscope & consists of a suture anchor with a detachable needle tip carrying suture anchor with a detachable needle tip carrying absorbable or non-absorbable sutures ,mounted on the absorbable or non-absorbable sutures ,mounted on the scope tip &attached by a wire that runs alongside the scope tip &attached by a wire that runs alongside the scope shaft to the handle portion of the system to the scope shaft to the handle portion of the system to the ports of the working channel. ports of the working channel.

The main application; closure of perforations&post-The main application; closure of perforations&post-bariatric, large bleeding gastric ulcers achieving bariatric, large bleeding gastric ulcers achieving durable hemostasis by using a figure-of-eight suture to durable hemostasis by using a figure-of-eight suture to mimic surgical ulcer exclusionmimic surgical ulcer exclusion

To prevent GI bleeding after ESD.To prevent GI bleeding after ESD.

New technologies:New technologies:Doppler Probe UltrasoundDoppler Probe Ultrasound

A feeding artery may be “invisible” beneath the A feeding artery may be “invisible” beneath the endoscopically visualized lesion&require DOP-US. endoscopically visualized lesion&require DOP-US.

Two DOP-US systems are available for use in Two DOP-US systems are available for use in endoscopy.endoscopy.

Adverse events associated with the through-the-scope Adverse events associated with the through-the-scope probes rare (< 2%); bleeding (oozing or spurting) by probes rare (< 2%); bleeding (oozing or spurting) by probe contact. probe contact.

A negative DOP-US signal reduces or eliminates the A negative DOP-US signal reduces or eliminates the need for routine second-look endoscopy&persistently need for routine second-look endoscopy&persistently positive DOP-US signal found immediately after primary positive DOP-US signal found immediately after primary endoscopic therapy may be a marker for recurrent endoscopic therapy may be a marker for recurrent bleeding. bleeding.

RCTs are needed to determine whether DOP-US has RCTs are needed to determine whether DOP-US has beneficial impact on the management beneficial impact on the management of GI bleeding.of GI bleeding.

New technologies:New technologies:EUS –guided TherapyEUS –guided Therapy

In recent years, vascular access & therapy are emerging In recent years, vascular access & therapy are emerging as new targets for endoscopic ultrasound (EUS)–guided as new targets for endoscopic ultrasound (EUS)–guided interventions.interventions.

New technologies:New technologies:EUS–guided TherapyEUS–guided Therapy

Non-variceal Gastrointestinal BleedingNon-variceal Gastrointestinal Bleeding In refractory bleeding from In refractory bleeding from hemosuccus pancreaticus, a hemosuccus pancreaticus, a

Dieulafoy lesion, duodenal Dieulafoy lesion, duodenal ulceration&GIST with at least ulceration&GIST with at least 3 bleeding episodes & required multiple units of packed 3 bleeding episodes & required multiple units of packed RBCs & repeated ineffective endoscopic / vascular RBCs & repeated ineffective endoscopic / vascular therapies.therapies.

EUS-guided inj therapy of absolute alcohol&/or CYA was EUS-guided inj therapy of absolute alcohol&/or CYA was delivered directly into the bleeding vessels. delivered directly into the bleeding vessels.

Control of the bleeding source was achieved in all of Control of the bleeding source was achieved in all of these refractory cases without any complications.these refractory cases without any complications.


Variceal Gastrointestinal Bleeding:EVVariceal Gastrointestinal Bleeding:EV Recurrent bleeding seen in 15–65% result of failure to Recurrent bleeding seen in 15–65% result of failure to

treat the feeder vessels (perforating veins / collateral treat the feeder vessels (perforating veins / collateral vessels).vessels).

EUS enables the visualization/targeting of perforating EUS enables the visualization/targeting of perforating veins /collaterals for sclerotherapy.veins /collaterals for sclerotherapy.

The sclerosant was injected into the esophageal varices The sclerosant was injected into the esophageal varices directed at the perforating vessels until flow was directed at the perforating vessels until flow was completely impeded. completely impeded.

New technologies:New technologies:EUS–guided TherapyEUS–guided Therapy GV bleeding: less common but present in up to 20% with GV bleeding: less common but present in up to 20% with

PHT. PHT. 65% of GV present with bleeding over 2 years. 65% of GV present with bleeding over 2 years. Direct endoscopic CYA inj of bleeding GV, widely considered Direct endoscopic CYA inj of bleeding GV, widely considered

first-line therapy with hemostasis 58–100%& recurrent first-line therapy with hemostasis 58–100%& recurrent bleeding 0%–40%.bleeding 0%–40%.

The most serious adverse event is systemic embolization,PE The most serious adverse event is systemic embolization,PE in 58% ,Sepsis, Embolization into the artery (via PFO or AV in 58% ,Sepsis, Embolization into the artery (via PFO or AV pulmonary shunt) result in stroke&multiorgan infarction.pulmonary shunt) result in stroke&multiorgan infarction.

Factors increase the embolization: overdilution with lipiodol, Factors increase the embolization: overdilution with lipiodol, excessively rapid inj, inj of too large a volume in a single inj& excessively rapid inj, inj of too large a volume in a single inj& isolated GV type 1 that have high blood-flow rates.isolated GV type 1 that have high blood-flow rates.

Rectal variceal bleeding 38-94%&Clin significant bleeding is Rectal variceal bleeding 38-94%&Clin significant bleeding is uncommon (0.5 – 5%). uncommon (0.5 – 5%).

EUS-guided CYA inj or +coil used for effective hemostasis.EUS-guided CYA inj or +coil used for effective hemostasis.


Delivery of CYA under EUS guide has advantage of enabling Delivery of CYA under EUS guide has advantage of enabling precise delivery of glue into varix lumen&enables precise delivery of glue into varix lumen&enables assessment with Doppler to confirm vessel obliteration after assessment with Doppler to confirm vessel obliteration after trt with prognostic significance, as recurrent bleeding risk trt with prognostic significance, as recurrent bleeding risk linked to residual patency of treated varices.linked to residual patency of treated varices.

Treatment can be performed without dependency on direct Treatment can be performed without dependency on direct varix visualization; even in the presence of retained food or varix visualization; even in the presence of retained food or blood that may obstruct the endoscopic view&varix lumen blood that may obstruct the endoscopic view&varix lumen can be accurately targeted for glue injection.can be accurately targeted for glue injection.

Targeting the perforating “feeder vessel,” rather than the Targeting the perforating “feeder vessel,” rather than the varix lumen proper, under EUS to achieve obliteration of GV varix lumen proper, under EUS to achieve obliteration of GV to reduce the risk of embolization. to reduce the risk of embolization.

Glue + lipiodol enabled fluoroscopic visualization of the Glue + lipiodol enabled fluoroscopic visualization of the injected vessel&confirmation feeder vessel accurately injected vessel&confirmation feeder vessel accurately targeted. targeted.

No recurrent bleeding or complications were observed. No recurrent bleeding or complications were observed.


Limitations: identification of the perforating vessel with Limitations: identification of the perforating vessel with EUS can be difficult &time-consuming.EUS can be difficult &time-consuming.

Because the perforating vessel may be afferent or Because the perforating vessel may be afferent or efferent, contrast medium must be injected before efferent, contrast medium must be injected before treatment to determine directional flow relative to the treatment to determine directional flow relative to the varix.varix.

EUA–guided coiling:EUA–guided coiling: Vascular coils under EUS guidance via standard fine-Vascular coils under EUS guidance via standard fine-

needle aspiration needles. needle aspiration needles. The overall obliteration was 97%.The overall obliteration was 97%. Higher number of sessions were required to achieve Higher number of sessions were required to achieve

complete obliteration in the CYA versus coil group.complete obliteration in the CYA versus coil group. Adverse events were significantly higher in the CYA.Adverse events were significantly higher in the CYA.


The deployment of a coil before CYA injection should The deployment of a coil before CYA injection should serve several functions:serve several functions:

1. The coil itself contributes to varix 1. The coil itself contributes to varix obliteration/hemostasisobliteration/hemostasis

2. The coil concentrates the glue at the site of coil 2. The coil concentrates the glue at the site of coil deployment.deployment.

3. The coil may prevent glue embolization.3. The coil may prevent glue embolization.


Prophylactic treatment of gastric varices. Prophylactic treatment of gastric varices. Isolated GV have the highest flow rates, are larger in size, Isolated GV have the highest flow rates, are larger in size,

have deeper feeding vessels, resulting in more severe have deeper feeding vessels, resulting in more severe bleeding.bleeding.

The mortality from the first variceal bleeding event has The mortality from the first variceal bleeding event has remained high at 20% within 6 weeks of the index event.remained high at 20% within 6 weeks of the index event.

Used for primary prophylaxis, CYA injn shown to reduce the Used for primary prophylaxis, CYA injn shown to reduce the risk of bleeding & mortality from type 2 GV or type 1 isolated risk of bleeding & mortality from type 2 GV or type 1 isolated GV >10-mm diameter as compared with propranolol alone.GV >10-mm diameter as compared with propranolol alone.

Effectiveness showed of undiluted CYA/ Effectiveness showed of undiluted CYA/ methacryloxysulfolane inj in achieving obliteration of GV.methacryloxysulfolane inj in achieving obliteration of GV.

Combined coil/ glue therapy experienced minor bleeding >1 Combined coil/ glue therapy experienced minor bleeding >1 year after & high obliteration (96%)& acceptable risk profile year after & high obliteration (96%)& acceptable risk profile support strong consideration of this type of therapy as support strong consideration of this type of therapy as prophylaxis in this group of patients.prophylaxis in this group of patients.

Forrest grade Ia Forrest grade Ib

Forrest classification

Forrest grade IIa

Forrest grade IIc Forrest grade III

Forrest classification

Forrest grade IIb

High risk lesionsHigh risk lesions

Adherent clotAdherent clot

Endoscopic therapy Endoscopic therapy injectioninjection

Reduce blood flow by temporary local Reduce blood flow by temporary local tamponade tamponade

Vasoconstricting agents reduce blood flowVasoconstricting agents reduce blood flow--Adrenaline 1:10,000 -1:100,000Adrenaline 1:10,000 -1:100,000 Sclerosants Sclerosants

Ethanolamine Ethanolamine PolidocanolPolidocanol

EthanolEthanol Tissue adhesive Tissue adhesive

HistoacrylHistoacryl Fibirin glueFibirin glue

Endoscopic therapy Endoscopic therapy ablative ablative

Contact ablative Contact ablative therapy by therapy by

1.1. Thermo coagulation Thermo coagulation heat probe heat probe

2.2. Electro coagulation Electro coagulation BICAP, Gold probe BICAP, Gold probe

Non contact ablative Non contact ablative argon plasma argon plasma cougulation cougulation

Endoscopic therapy Endoscopic therapy ablative ablative

Coaptive coagulationCoaptive coagulation compress vessel & compress vessel &

cougulate 15-20 watts cougulate 15-20 watts for 8-12 seconds for for 8-12 seconds for 4-6 pulses4-6 pulses

Larger 10 French Larger 10 French more effective than 7 more effective than 7 French probes French probes

Endoscopic therapyEndoscopic therapymechanical hemoclipsmechanical hemoclips

Application of a clip in upper GI bleeding

Iv erythromycinIv erythromycin Consider giving a

single 250-mg IV dose of erythromycin 30 to 60 minutes before endoscopy– promote gastric motility and

substantially improve visualization of the gastric mucosa on initial endoscopy.

– not improve the diagnostic yield of endoscopy substantially or to improve the outcome

We can only treat what we can see

Hemospray Hemospray

Hemospray Hemospray

95% acute hemostasis

Sung JJ Endoscopy. 2011 Apr;43(4):291-5. Epub 2011 Mar 31.

http://www.ncbi.nlm.nih.gov/pubmed?term=Sung%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=21455870

http://www.ncbi.nlm.nih.gov/pubmed/21455870/

Abstract:Abstract: Endoscopic interventions are first-line therapy for U&L GIB. Endoscopic interventions are first-line therapy for U&L GIB. Injection therapy + second endoscopic modality has reduced re-Injection therapy + second endoscopic modality has reduced re-

bleeding, need for surgery&mortality in NVGIBbleeding, need for surgery&mortality in NVGIB. . For variceal bleeding endoscopic banding For variceal bleeding endoscopic banding or cyanoacrylate or cyanoacrylate

injection techniques are recommended interventions. injection techniques are recommended interventions. Despite ease of application&general acceptance of these Despite ease of application&general acceptance of these

techniques, there is an ongoing re-bleeding rate associated techniques, there is an ongoing re-bleeding rate associated with significant in-hospital mortality. with significant in-hospital mortality.

So new advances in endoscopic technologies&procedural So new advances in endoscopic technologies&procedural techniques emerged to improve patient outcomestechniques emerged to improve patient outcomes..

New endoscopic technologies & procedural advances shown New endoscopic technologies & procedural advances shown promise in improving outcomes in failed conventional modes. promise in improving outcomes in failed conventional modes.

The incorporation of EUS to guide therapy is expanding, The incorporation of EUS to guide therapy is expanding, specially EUS-guided CYA glue&/or coils for bleeding GV .specially EUS-guided CYA glue&/or coils for bleeding GV .

GIT j club endohemostasis new

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