Where it gets tricky is the anchor point. Your Prague measurement is only as good as your GE junction identification. And the landmark most of us default to, the top of the gastric folds, has a couple of failure modes worth knowing about.

When gastric folds mislead you

Barrett’s patients can develop pseudo-folds in the columnar-lined esophagus that look like true gastric folds. If you anchor to a pseudo-fold, the entire measurement shifts.

There’s also the insufflation problem. A little too much air and the gastric folds flatten out. What looked like a clear GE junction becomes ambiguous, and a small tongue of columnar epithelium gets dismissed as “irregular Z-line” rather than measured and reported.

The palisade veins as a more reliable anchor

The submucosal venous plexus of the esophagus, the palisade veins, is visible on endoscopy and exists only in the esophagus. Not in the stomach. If you see palisade veins with columnar epithelium sitting on top instead of squamous epithelium, you’re looking at Barrett’s. No ambiguity about whether a fold is gastric or pseudo-gastric.

The Kyoto Classification and Consensus formally proposed the palisade veins as an endoscopic landmark for defining the GE junction. If you do variceal banding or POEM, you’ve already seen these veins. They’re the same vessels that give rise to esophageal varices in portal hypertension, and they’re clearly visible in the submucosal tunnel during POEM. You just may not have been using them as a Barrett’s landmark.

One more thing worth noting. The Z-line is inherently irregular. The name comes from the German “Zickzack” (zigzag). So “irregular Z-line” as a standalone finding shouldn’t trigger alarm or unnecessary biopsies. What matters is whether true tongues of columnar epithelium extend above the point where esophagus transitions to stomach. And to make that call, you need a reliable GE junction landmark.

Above is a 5-minute video lesson walking through the full Prague measurement with real endoscopic footage, followed by a written step-by-step guide with key frames from the video.

This lesson is from the Barrett’s Esophagus course on EndoCollab. Future lessons cover dysplasia detection with NBI and acetic acid, resection decision-making, surveillance intervals, and ablation techniques. Members get each lesson as it drops.

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The Prague Measurement: Step by Step

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You’re staring at a bulging, floppy papilla dangling out of a periampullary diverticulum. The orifice points distally, blood is oozing from the base, and your standard sphincterotome just isn’t going to cooperate with this anatomy. What do you reach for — and more importantly, do you know the hidden cannulation trick built into that instrument that even many experienced endoscopists miss?

The case begins with a Type 3 (protruding) papilla — markedly bulging and physically hanging out of a diverticulum. Blood at the base suggested a stone had recently passed. Endoscopic ultrasound (EUS) confirmed additional stones in the bile duct.

A papilla morphology classification table showing four types: Type 1 (Regular, 56% prevalence, 2% cannulation failure), Type 2 (Small, 13% prevalence, 12% cannulation failure with OR 7.9*), Type 3 (Protruding, 23% prevalence, 11% cannulation failure with OR 7.3*), and Type 4 (Creased/Ridged, 8% prevalence, 6% cannulation failure with OR 3.9). Difficult cannulation rates are 36%, 52%, 48%, and 43% respectively. Pancreatitis rates: 7%, 20%*, 2%, 6%. Below the table, an endoscopic image shows a papilla “hanging out” of a diverticulum.

Because of the floppy consistency, the hanging orientation, and the distally pointing orifice, starting with a standard sphincterotome was not a viable first approach. The decision was made to use the Huibregtse needle knife.

Why This Instrument: The Huibregtse Needle Knife

This knife is special because it is very useful both for cutting and for cannulation — a dual purpose that sets it apart from conventional needle knives.

Close-up photographs of the Huibregtse Needle Knife on a blue sterile drape. Four progressive views show the full pre-curved biliary catheter, the catheter body, the tiny needle tip highlighted within a yellow circle, and a magnified distal view. Key features: “It is a precurved biliary catheter!” / “A wire with thin end (’needle’) runs through the catheter” / “The needle can be moved in and out” / “Pearl: the ENTIRE needle can be removed.”

As the speaker explains, inside the catheter runs a wire whose distal portion is a very small-diameter segment — the “needle.” Crucially, this entire needle-wire assembly can be completely removed after the cutting phase is finished, converting the device into a standard cannulation catheter.

To access the full step-by-step technique, the advanced “hanging papilla” approach, and a downloadable quick-reference guide based on this video, consider becoming a paid subscriber.

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Techniques Overview

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In my experience one can close almost any large defect with any types of clips, as long as one utilizes logical closing method, starting from the edges and not in the center of the defect.

Here is our technique:

• The first clip is not intended to close the defect

• Place first clip on the edge of the defect, creating a little bump

• The second clip is placed next to the bump - the closure begins

• Have the clips approach the wound „parallel“ and on an inverted „T“ in relation to previous clip

• With open clip arms press against the wound borders

• Push clip out, open and pull back towards scope tip

• Scope tip needs to be close to working area

• Take your time before releasing clips

Imagine you’re mid-procedure, staring at a suspicious colorectal polyp. You know a biopsy means days of waiting—and a second procedure if the result demands resection. What if your endoscope could function as a microscope, delivering a histologic-grade diagnosis in real time? That is the central question driving decades of innovation in endoscopic imaging.

In this lecture, Dr. Klaus Mönkemüller traces the evolution of endoscopic visualization—from early fiber-optic magnification and dye-based chromoendoscopy to modern mega-magnification technologies like confocal laser endomicroscopy and endocytoscopy—and asks whether we have finally arrived at true “virtual histology.”

The Three Objectives of Endoscopy

Before exploring advanced imaging, Dr. Mönkemüller grounds the discussion in the foundational goals of the discipline. The objectives of endoscopy are threefold:

1. “Reach a visual diagnosis.”

2. “Assist in obtaining a histopathologic diagnosis”—generally by obtaining biopsies and sending them for analysis.

3. “Provide therapy (and palliation).”

The quest for improved endoscopic visualization has been ongoing since the origins of camera and fiber-optic endoscopy. Dr. Mönkemüller references elegant studies from Japan, dating back more than thirty years, that already demonstrated magnification endoscopy combined with dye application to characterize the mucosa.

Decoding the Mucosa: Patterns and Capillaries

To achieve a visual diagnosis, endoscopists must focus on two primary mucosal features: mucosal surface patterns and capillary patterns. These are the key elements for recognizing abnormal pathology.

Pit patterns become distorted in cases of neoplasia. And since the classic article by Volkmann in the New England Journal of Medicine in 1974, angiogenesis has been recognized as a hallmark of neoplasia—meaning neovascularization is a critical finding.

Narrow-band imaging (NBI) permits detailed visualization of submucosal vessels and the capillary architecture—the foundation of pattern-based diagnosis.

First Take-Home Message:

“Visualization can be improved by changing or adjusting essential photographic principles such as: light, focus, shadows, contrast and size (magnification).”

Endoscopic Microanatomy: Where Patterns Meet Histology

By examining the subepithelial capillary network, endoscopists can observe specific microanatomic patterns. Dr. Mönkemüller highlights a review by Uchima and Yao demonstrating that the microvascular architecture of the stomach resembles honeycombs, with oval crypt openings and marginal crypt epithelium.

These endoscopic patterns correlate perfectly with true histological findings. In Dr. Mönkemüller’s own PhD research on non-erosive reflux disease, red streaks visualized via magnification endoscopy directly corresponded to histological elongation of the papillae—establishing clear endoscopic-histologic correlates.

Practical Application: The JNET Classification

Pattern recognition directly drives therapeutic decisions. If an endoscopist identifies a JNET Type 3 pattern on a colorectal polyp, it indicates invasion and neoplasia—and standard endoscopic surgery will not be helpful for that patient.

Second Take-Home Message:

“There are clear histopathologic correlates of endoscopic imaging (the concept of ‘endoscopic microanatomy’), which assist in diagnosis and therapeutic decision-making.”

To see advanced comparisons between endomicroscopy and endocytoscopy, the role of AI, and a downloadable quick-reference guide based on this video, consider becoming a paid subscriber.

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Can Mega-Magnification Replace Biopsies?

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Basket impaction is one of the most feared complications in ERCP (endoscopic retrograde cholangiopancreatography). But according to Dr. Mönkemüller, it is also largely preventable—and when it does occur, entirely salvageable—if you’ve prepared in advance. This presentation covers two critical skill sets: anticipating mechanical problems before they happen, and executing a systematic rescue when they do.

Anticipating Mechanical Problems Before You Begin

The foundation of safe biliary stone management is pre-procedural cholangiogram analysis.

Dr. Mönkemüller instructs endoscopists to evaluate the following parameters on every cholangiogram prior to instrument deployment: the shape and degree of sclerosis of the bile ducts, whether problems are intrahepatic, extrahepatic, or bilateral, the degree of ductal dilation, the presence of any distal stenosis, and the size, shape, number, and consistency of the stones.

The key clinical inference: If a stone appears large, dense, and dark on fluoroscopy—with no yellow gravel emerging—a hard stone should be anticipated.

In that scenario, the speaker recommends proceeding directly with a large sphincterotomy or sphincteroplasty and a lithotripter basket from the outset, rather than attempting standard retrieval first and losing time.

Clinical Pearl: “If you have a stone that is large and looks dark and there is no yellow gravel coming out and you are anticipating a very hard stone, then it’s better to already know that you need to have a big sphincterotomy or sphincteroplasty and go with the lithotripter basket and crush that stone from the beginning. Otherwise, you will be stuck during the procedure for hours and hours.”

Understanding Mechanical Lithotripters: Three Types You Must Know

Dr. Mönkemüller identifies three categories of mechanical lithotripter, each suited to a different clinical scenario.

The three lithotripter types:

1. Strong plastic-sheathed lithotripter — Standard device for planned, through-the-scope lithotripsy.

2. Metal-sheathed lithotripter — A more robust option for larger stones or tighter ducts.

3. Emergency (Soehendra) lithotripter — Used when a basket becomes impacted and the endoscope must be removed; does not pass through the scope.

The security tip: Dr. Mönkemüller highlights a critical safety design feature: the distal pin holding the basket wires should be engineered to break off if crushing forces exceed a safe threshold. If the stone cannot be destroyed and this pin does not release, the basket and stone remain permanently impacted—and the patient will require surgical intervention. Selecting a device with this safety mechanism is therefore a patient safety consideration, not merely a technical preference.

Basket Impaction: Who Is at Risk and the Cardinal Rule

Conditions predisposing to basket impaction

• Large stones

• Square-shaped stones

• Small sphincterotomy (small papilla)

• Inadequate sphincterotomy that cannot be enlarged

The speaker reinforces a cardinal technical rule: always attempt to crush the stone in the middle of the CBD (common bile duct), never distally. The distal duct is narrower and is the most likely location for the basket-stone complex to become trapped. Moving the stone proximally before crushing it is a prophylactic maneuver.

⚠️ Warning: “Always crush the stone on the middle of the CBD, not distally, to avoid initial or further impaction.”

To see advanced troubleshooting tips, case variations, and a downloadable quick-reference guide based on this video, consider becoming a paid subscriber.

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Emergency Rescue: Step-by-Step Soehendra Lithotripsy

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Endoscopists have been injecting polyps since Professor Deyhle first introduced the technique in 1973. Yet, over 50 years later, many operators still rely on rigid, textbook rules—like mandatory four-quadrant injections—that can actually complicate resections. In this masterclass, Dr. Klaus Mönkemüller demonstrates why “dynamic injection” and “interventional chromoendoscopy” are the true keys to achieving a flawless submucosal cushion and an R0 resection.

The Challenge

First impressions in endoscopy can be deceiving. Often, polyps are bigger and nastier than they appear. A small-looking flat lesion (such as a 0-IIc) can hide elusive borders. Without an optimal submucosal cushion, it is difficult to fully expose all neoplastic tissue, leading to incomplete piecemeal resections or, worse, an increased risk of perforation.

Why This Matters

The submucosal cushion is not just a fluid bump; it is an active anatomical tool. It has great value for endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and third-space endoscopy.

As demonstrated in the video, a perfect cushion serves four vital functions:

1. It defines and physically raises the lesion.

2. The fluid performs some dissection of the submucosal space before you even start your incision.

3. It separates the lesion from the deeper layers below.

4. It provides a safety base against perforation.

Clinical Pearl: “Injection of a substance with blue color mixture—either indigo carmine, methylene blue, or toluidine blue—to improve the definition of the lesion’s borders and surface and submucosal space anatomy, thus improving interventional capabilities.” — Dr. Klaus Mönkemüller, defining the concept of interventional chromoendoscopy, a term his group introduced approximately 10–20 years ago. This applies to POEM and third-space endoscopy as well.

The full article includes:

• The 7-step protocol for dynamic injection

• Detailed visual analysis of scope torque and snare maneuvers

• Pro tips for avoiding the “groove” effect during fluid delivery

• The “Y-Trick” for capturing elusive polyps

• Snare-tip knife-assisted resection (KAR) technique

• Downloadable quick-reference card

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The Step-by-Step Approach: The 7 Rules of Injection

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A case of multiple gastric polyps with one confirmed as a Grade 1 NET prompted an excellent discussion on the classification, workup, and surveillance of gastric NETs.

Key Teaching Points

▸ Gastric NETs are classified into three types: Type 1 (80% of cases, associated with autoimmune atrophic gastritis, pernicious anemia, B12 deficiency), Type 2 (associated with Zollinger-Ellison syndrome/hypergastrinemia), and Type 3 (neuroendocrine carcinoma, usually solitary and >1 cm — the most dangerous).

▸ Both Type 1 and Type 2 are associated with hypergastrinemia but via different mechanisms. Type 1 and 2 are usually well-differentiated with low Ki-67 index, multiple, and <1 cm.

▸ A solitary gastric NET is more concerning (Type 3), while multiple lesions suggest Type 1 or 2.

▸ NBI/I-scan/FICE cannot differentiate between Type 1 and Type 2, but advanced imaging endoscopy is useful for identifying additional small NETs that may have been missed on white light.

▸ Differentiation between Type 1 and 2 relies on clinical features, endoscopic appearance, and laboratory tests (gastrin levels, anti-parietal cell antibodies, etc.).

▸ If resected with clear surgical margins and no other NET seen on PET, surveillance endoscopy alone may suffice for Grade 1 NETs.

▸ Other polyps should be biopsied and histopathology reviewed. Colonoscopy should be considered to evaluate for polyposis syndromes.

▸ EUS and DONET assessment should be considered for lymph node staging.

CASE 2: Difficult ERCP Cannulation — The Submucosal Injection Technique

A case of failed biliary cannulation in a patient with choledocholithiasis and a small papillary orifice generated valuable advice on advanced cannulation strategies.

Key Teaching Points

▸ Use a tapered-tip sphincterotome (e.g., Boston Scientific) with a 0.025-inch guidewire for difficult cannulations.

▸ If the guidewire enters the pancreatic duct, consider placing a 5 Fr protective plastic stent (single pigtail, 4–6 cm) and then reattempt biliary cannulation.

▸ The submucosal injection technique (described in a GIE video) can aid cannulation by elevating the papillary tissue. When using this technique, have a fully covered metal stent available in case of perforation — the stent seals the defect.

▸ Needle knife precut sphincterotomy remains an option if the papilla is visible intraduodenally.

▸ Careful assessment of papillary anatomy is critical — the orifice may be located higher than expected.

CASE 3: Botox Injection Technique for Achalasia

A practical discussion on the technical aspects of endoscopic Botox injection for achalasia, particularly useful for endoscopists starting this procedure.

Key Teaching Points

▸ Injection site: 1–1.5 cm above the Z-line, in 4 quadrants.

▸ Dose: 25 units per quadrant, for a total of 100 units.

▸ Calculate and account for the dead space of the injection needle before starting — there will be residual Botox that needs to be flushed out.

▸ Use 1.2 mL of saline to flush the last portion of Botox through the needle catheter.

▸ Prepare a pre-measured syringe of saline flush to ensure dosing accuracy.

▸ There is no reliable endoscopic method to confirm muscularis propria injection depth — clinical response serves as the primary endpoint.

▸ Consistent symptomatic improvement is expected in experienced hands, particularly in elderly patients who are not candidates for more definitive therapy.

CASE 4: Hemorrhagic Ascending Colon — Ischemic Colitis on Anticoagulation

A 68-year-old female post aortic valve replacement on DOACs presented with per-rectal bleeding and anemia with INR >7. Colonoscopy revealed hemorrhagic ascending colon mucosa.

Key Teaching Points

▸ Endoscopic appearance is consistent with ischemic colitis or intramural hematoma in the setting of supratherapeutic anticoagulation.

▸ CT angiography is recommended to assess for vascular compromise, especially given the risk of transmural necrosis and perforation in subsequent days.

▸ Antibiotics are reasonable given the risk of bacterial translocation in ischemic colitis — necrosis can be transmural.

▸ In the absence of active bleeding with stabilized hemoglobin, expectant management with repeat colonoscopy after INR normalization is acceptable.

▸ Restarting DOACs requires careful multidisciplinary consideration — balance the risk of recurrent ischemia versus thromboembolic events.

▸ Emergency right hemicolectomy carries high morbidity in elderly patients and should be a last resort.

▸ CT angiography should be the first step to guide the urgency of any intervention.

You have seen 3 cases. There are 21 more — and they are the ones your colleagues are bookmarking.

What is behind the paywall:

• The exact gold probe settings and coaptive technique that prevent rebleeding (and the duodenal mistake that taught one colleague the hard way)

• The stenting protocol after sphincteroplasty that protects against perforation

• Duodenal lesions in cirrhosis that look like adenomas but could bleed catastrophically if biopsied

• A named syndrome that explains elevated lipase with no pancreatitis — and four other diagnoses most of us overlook

• The fish bone rule that prevents fatal complications in delayed presentations

• Mid-esophageal varices too wide for EVL: the full management algorithm from an active case discussion

• Plus cases on EoE step-down therapy, ERCP in tracheostomy patients, juvenile polyp technique, scope trauma recognition, and more

Every case distilled into clear teaching points with image references. Real discussions. Real expertise. Real cases.

Upgrade now and read the full issue.

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Standard endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) handle most colonic lesions, but real-world endoscopy presents cases that don’t fit the textbook. From my toolbox today: six alternative techniques that transform “difficult” referrals into manageable outpatient procedures.

The Challenge: When Standard Techniques Fall Short

While snare polypectomy, EMR, and ESD cover the majority of colonic lesions, we frequently encounter scenarios where these methods struggle:

• Flat lesions that vanish after cleaning or insufflation

• Fibrotic polyps that resist simple snaring

• Pedunculated lesions requiring prophylactic hemostasis

• Large sessile lesions with central non-lifting areas

Each scenario demands a tailored approach.

Why Mastering Alternatives Matters

Clinical Impact: Knowing how to suction-mark a disappearing flat lesion or perform underwater resection expands your capability to handle complex anatomy safely. It minimizes surgical referrals and converts “impossible” cases into successful endoscopic resections.

Equipment Reality: Lesions vary in size and shape. As I tell my fellows: “One snare does not fit all.” Every endoscopist should master at least two to three different snare types—hexagonal, oval, double-buckle—to adapt to specific polyp geometry.

Clinical Pearl: I prefer snares with excellent expansile memory. Hexagonal or oval snares with double buckles tend to remain nicely expanded after several uses, maintaining their grasping capability throughout the procedure.

Technique #1: Polyp Reshaping (Suction Marking)

The Problem

Flat lesions often become nearly invisible after washing and cleaning. Relocating them wastes time and risks missing the target entirely.

The Solution

Use direct suction to transform a flat lesion into a pseudo-sessile polyp.

What happens: The endoscope tip applies direct suction over flat colonic mucosa. Tissue drawn into the channel creates localized erythema and edema—the “hickey effect.” This creates a visible, raised pseudo-sessile polyp that’s significantly easier to identify and snare.

Step-by-Step Technique

1. Locate: Find the subtle flat lesion initially

2. Suction: Draw tissue into the endoscope channel briefly

3. Release: Tissue remains raised and hyperemic (natural chromoendoscopy)

4. Resect: The flat lesion is now a “sessile” mound, much easier to capture with your snare

When to Apply

Ideal for: Flat lesions (Paris 0-IIa) that disappear with insufflation or after cleaning

Key advantage: This technique accomplishes two objectives simultaneously—it creates a sessile polyp from a flat lesion AND marks it with submucosal bleeding sites for easy relocation.

Pro Tip: This technique will save you in patients with mobile colons where tiny polyps become challenging to relocate. The submucosal bleeding acts as a natural marker.

Technique #2: The Combo Needle-Snare (2-in-1 Device)

The Innovation

This device integrates an injection needle within the snare catheter, eliminating device exchanges between injection and resection.

How it works: With a large pedunculated polyp in view, the needle extends from the device tip, allowing epinephrine injection directly into the stalk. The needle then retracts, and the snare deploys from the same device—zero device exchanges required. This allows prophylactic injection immediately prior to resection, reducing post-polypectomy bleeding risk.

The device was originally introduced in 2007 with a larger diameter that limited compatibility. Modern versions have reduced diameters and work well with standard scopes.

Key Features

The “Snowman” Snare Shape:

• Functions as a three-in-one device: injection needle + two snare sizes

• Small shape for initial grasping

• Large “figure-of-8” shape for capturing large tissue pieces

• Can grasp substantial polyp volumes in a single pass

Clinical Advantages

• Speed: No device exchange wastes time or loses position

• Precision: Inject exactly where and when needed

• Efficiency: Particularly valuable during both EGD and colonoscopy

The full article includes four additional advanced techniques:

• Underwater EMR: Why water flotation changes everything for large villous lesions

• Knife-Assisted Resection (KAR): Using your snare tip as a cutting instrument—no expensive ESD knife required

• Loop-and-Let-Go: The elegant solution for large lipomas with perforation risk

• Cap-Assisted Resection: How to suction fibrotic polyps into submission

• Complete step-by-step procedures with visual analysis

• Pro tips for underwater hemostasis and cushion creation

• When NOT to use each technique

• Downloadable quick-reference guide

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In this guide, Dr. Klaus Mönkemüller breaks down the anatomy and deployment mechanics of through-the-scope (TTS) clips to ensure your next application is precise and effective.

To see advanced troubleshooting tips, case variations, and a downloadable quick-reference guide based on this video, consider becoming a paid subscriber.

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1. Know Your Tools: The Variety of Hemoclips

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You are performing a colonoscopy, and you identify a lesion in the rectum. You snap a photo. But when you look at the image later—or worse, when you write the referral letter for the surgeon—you hesitate.

Is that polyp on the left lateral wall? Or is it anterior?

The flexible nature of the endoscope often disorients our sense of direction, particularly in the large, vault-like space of the anorectum. Yet, accurate localization is critical, especially when guiding future therapy for anal fissures or fistulas.

In this basic endoscopy review, Prof. Klaus Mönkemüller demonstrates a fundamental law of physics that can solve this problem instantly: Water seeks the dependent side.

The Clinical Problem: “Where are we?”

At the start of the procedure, you may encounter multiple polyps.

On Screen: Four distinct endoscopic images are displayed simultaneously. They show various rectal polyps of different morphologies (sessile, pedunculated). The camera angle varies in each, making it difficult to intuitively know which wall of the rectum is being viewed based solely on the image.

Prof. Mönkemüller asks the essential question: “Where are these polyps located?”. Without a reference point, it is nearly impossible to tell.

The Technique: The Water Trick

The solution relies on the patient’s position and gravity.

Step 1: Confirm Patient Position Most standard colonoscopies are performed with the patient in the Left Lateral Decubitus position.

Step 2: Instill Water Flush a small amount of water into the rectal vault.

Step 3: Observe the Pooling Because the patient is lying on their left side, gravity will pull the water to the patient’s left. Therefore, wherever the water accumulates on your screen defines the Left side of the patient.

On Screen: A large polyp is visualized. The endoscopist has used chromoendoscopy with blue dye (Indigo Carmine). The blue liquid clearly pools on one side of the lumen. Significance: The dye acts as a high-contrast fluid level. Because the blue fluid pools at the bottom of the gravity well, and the patient is on their left side, the pool of blue dye confirms that wall is the Left wall.

Prof. Mönkemüller notes: “You can see that the water accumulates on the left side. Therefore, the polyp is located on the left.”

Subscribe to EndoCollab to access the complete quadrant mapping guide, including how to identify Anterior vs. Posterior walls using this technique, and to download the Quick Reference Card.

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Mapping the Anorectal Quadrants

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Case 1: The Appendiceal Orifice Polyp - A Technical Challenge

Case Summary: A 44-year-old male was found to have a 10-12mm polyp at the appendiceal orifice, sparking a lively debate on the best resection technique.

Key Teaching Points:

•The Challenge of Location: Polyps at the appendiceal orifice present a unique technical challenge due to the difficult angle and the risk of involving the appendix itself.

•EMR with a Cap: Several members recommended EMR with a distal cap to stabilize the position and ensure a controlled and complete resection.

•EFTR - A Double-Edged Sword: Endoscopic Full-Thickness Resection (EFTR) was discussed as an option, but with the significant caveat that it carries a risk of iatrogenic appendicitis.

•Surgical Option: A laparoscopic appendiceal wedge resection was also proposed as a legitimate and safe option, offering a clear histological statement on margins.

•Underwater EMR: The discussion also highlighted underwater EMR as a viable technique.

•Favorable Morphology: The lesion was a Granular LST 0IIa, which carries a very low risk of submucosal invasion (around 0.9%), making less invasive approaches more favorable.

Case 2: A Large LST in the Right Colon - ESD vs. UEMR

Case Summary: A 40mm Laterally Spreading Tumor (LST) of mixed type (IIa+IIs) with a JNET 2B classification in the right colon of a multimorbid patient led to a discussion on the optimal resection strategy.

Key Teaching Points:

•ESD as the Gold Standard: For a lesion with these characteristics (large size, JNET 2B), ESD is generally the recommended technique to achieve an en bloc resection.

•FTRD as an Alternative: Full-Thickness Resection Device (FTRD) was also mentioned as a potential alternative.

•Pragmatic Approach: In this case, due to the patient’s comorbidities and the lesion’s position, the endoscopist opted for underwater EMR, which was successful in achieving a complete resection. This highlights the importance of tailoring the approach to the individual patient and clinical context.

You’re Reading the Recap. But the Real Learning Happened Live.

These eight cases sparked 425 messages in our WhatsApp group during December alone. While you’re reading the summary now, EndoCollab members were in the discussion as it happened—asking questions, sharing their approaches, and debating techniques in real-time.

The difference? Members learn by participating, not just reading. When one of our members faced a similar appendiceal polyp two days after this discussion, they knew exactly what to do because they’d been part of the conversation.

→ Join the Discussion as a Founding Member - Get immediate access to our expert WhatsApp group where cases like these unfold live, plus unlock all premium courses and case libraries.

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Case 3: A Rare Finding - Blue Rubber Bleb Nevus Syndrome

Case Summary: A series of images showcased the characteristic lesions of Blue Rubber Bleb Nevus Syndrome, a rare vascular disorder.

Key Teaching Points:

•Recognizing the Syndrome: This case served as a great reminder of the endoscopic appearance of this rare syndrome, which is characterized by multiple blue or purple vascular nevi throughout the GI tract and skin.

•Clinical Significance: These lesions can be a source of chronic gastrointestinal bleeding and anemia.

Case 4: The Incidental Esophageal Submucosal Lesion

Case Summary: A small (<1cm) submucosal lesion in the esophagus of a patient with long-term reflux symptoms prompted a discussion on the appropriate workup.

Key Teaching Points:

•EUS for Characterization: The consensus was that EUS is the next best step to characterize the lesion, which was suspected to be a benign leiomyoma.

•No Link to Reflux: The group agreed that the lesion was unlikely to be related to the patient’s reflux symptoms.

•Comprehensive Reflux Workup: For the reflux symptoms, a more comprehensive workup, including pH metry with impedance and motility studies, was recommended.

⚡ Quick Question: How many of these cases have you encountered in your own practice?

If you’re nodding along, thinking “I had a case like this last week,” imagine being able to ask our 1,600+ member community for real-time input. In December alone, members posted 8 challenging cases and received expert feedback within minutes—not days.

Upgrade to Founding Member and join today’s discussion. The last case was posted 3 hours ago.

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Case 5: A Puzzling Duodenum - Ischemia vs. Inflammation

Case Summary: Images of a duodenum with white-topped folds sparked a differential diagnosis discussion.

Key Teaching Points:

•Ischemia as a Possibility: The white tops of the folds raised suspicion for ischemia, a less common but important consideration.

•Inflammatory Differentials: Other possibilities discussed included chronic duodenitis with atrophic tissue or lymphangiectasia.

•Biopsy is Key: The discussion underscored that biopsy is essential to differentiate between these possibilities and make a definitive diagnosis.

Case 6: Severe Esophagitis - A Broad Differential

Case Summary: An 82-year-old diabetic and hypertensive woman presented with odynophagia and was found to have severe esophagitis, leading to a wide-ranging differential diagnosis discussion.

Key Teaching Points:

• Comprehensive Differential: The group considered a broad differential, including:

• Boerhaave syndrome

• Severe GERD (Grade D)

• Drug-induced esophagitis (bisphosphonates, doxycycline, KCL)

• Infectious causes (CMV, HSV, Candida)

• Ischemia (Acute Esophageal Necrosis)

• Eosinophilic Esophagitis

• Vasculitis (Pemphigus, IgA)

• Acute Esophageal Necrosis: This rare entity, also known as “black esophagus,” was discussed as a possibility, especially in elderly patients with comorbidities. It typically affects the distal third of the esophagus.

• Diagnostic Workup: The recommended workup included a CT chest to rule out perforation, a thorough review of the patient’s drug history, and biopsies to rule out infectious or inflammatory causes.

• Initial Management: High-dose PPI (40mg BD) with a plan for a repeat EGD after healing was the recommended initial management.

Case 7: Pancreatic Rest or Gastric Diverticulum?

Case Summary: An image from a 10-year-old with persistent indigestion showed a lesion that sparked a debate: was it a pancreatic rest or a small gastric diverticulum?

Key Teaching Points:

•A Common Dilemma: This case highlighted a common diagnostic challenge, with opinions in the group split between the two possibilities.

•Endoscopic Features: Pancreatic rests often have a central umbilication, while diverticula are typically smooth outpouchings. However, the appearance can be variable, making a definitive diagnosis on imaging alone difficult.

Case 8: A Rare but Important Complication - Post-Colonoscopy Ischemia

Case Summary: A 60-year-old male smoker developed unilateral acute lower limb ischemia after a colonoscopy, a rare but important complication to be aware of.

Key Teaching Points:

•Mechanism of Injury: The ischemia was thought to be due to dehydration or hypotension from anesthesia in a patient with pre-existing vascular disease.

•Clinical Awareness: This case serves as a crucial reminder to be vigilant for this rare complication, especially in high-risk patients.

Here’s What You Missed in December...

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P.S. Next month’s cases are already rolling in—we’ve had 3 complex procedures posted this week. You can read about them in February’s summary—or you can be part of the conversation as it happens. Join the WhatsApp group now.

P.P.S. The appendiceal orifice case from December 2nd? It generated 30+ messages with insights from endoscopists across 4 continents—all within 6 hours. That’s the power of real-time collaboration.

Barrett’s Esophagus comes in many shapes and sizes. Sometimes it appears as multiple tongues of cylindrical epithelium; other times, it is a single tongue or a completely tubular segment where the esophagus is replaced by columnar-lined epithelium.

Because of this variability, describing findings in a free-text format often leads to confusion. It is essential to have a uniform system to communicate about Barrett’s esophagus so that others can understand our findings and base clinical decisions on accurate data.

The Prague Classification is the gold standard for this communication—it is simple, thorough, and internationally recognized.

This guide breaks down the technique into actionable steps, exactly as demonstrated in the procedure.

Step 1: Evaluate the Hiatal Hernia

Before measuring the Barrett’s segment, you must characterize the environment it lives in. This starts with the hiatal hernia.

🖥 VISUAL ANALYSIS @ 1:46

The screen displays two endoscopic views side-by-side. On the left, an antegrade view looking down the esophagus into a hernia sac. On the right, a retroflexed view looking up from the stomach, visualizing the hiatus and the flap valve.

Significance: This comparison highlights the importance of using both views to accurately assess the hernia’s length and diameter.

While some experts only perform a retroflexed view to evaluate the diameter and flap valve (Hill classification), it is recommended to use both antegrade and retrograde views.

• Antegrade View: As you enter the distal esophagus and pass into the hernia, use the centimeter markings on the endoscope to determine the length of the hernia.

• Retroflexed View: Evaluate the diameter or width of the hernia.

The Pitfall of “Pseudo Folds” A common mistake is confusing “pseudo folds” for gastric folds. Usually, the esophagus has no folds; folds begin in the stomach. However, in extensive Barrett’s esophagus, the distal esophagus is dilated and can form folds that mimic a hiatal hernia.

Pro Tip: Look for islands of squamous epithelium. If you see squamous islands on the folds, you are still in the esophagus, not the stomach.

Step 2: Locate the Gastroesophageal Junction (GEJ)

Accurate measurement relies on a fixed starting point: the GEJ.

Method A: Proximal Limit of Gastric Folds The standard method is to identify where the gastric folds end. In a healthy esophagus, this meets the squamous epithelium (the Z-line). In Barrett’s, this junction is replaced by columnar-lined epithelium.

Method B: The Palisade Veins (Kyoto Classification)

🖥 VISUAL ANALYSIS @ 7:27

The screen shows a high-definition image using Narrow Band Imaging (NBI). Thin, longitudinal vessels are clearly visible running parallel to each other.

Significance: These are palisade veins. They are anatomically located in the distal esophagus and are typically covered by squamous epithelium. In Barrett’s, they become visible through the columnar mucosa.

We recommend using the palisade veins to define the GEJ. If you see palisade veins, you are anatomically in the esophagus, even if the mucosa is columnar.

Step 3: Determine the Extent of Metaplasia

Once the GEJ is fixed, you must assess how far proximal the columnar epithelium extends. You are looking for two specific measurements:

1. Circumferential Extent (C): The level where the circular coverage of columnar epithelium ends.

2. Maximal Extent (M): The tip of the longest tongue of columnar epithelium.

Step 4: Measuring the “C” (Circumferential)

Pull the endoscope back slowly from the GEJ. Stop at the point where the circumferential columnar mucosa ends.

🖥 VISUAL ANALYSIS @ 8:58

The endoscopic view shows a tubular esophagus with reddish columnar mucosa coating the entire circumference. A yellow arrow indicates the precise line where this full-circle coverage stops, transitioning into tongues.

Significance: This is the upper limit for the “C” measurement.

The Calculation:

1. Locate GEJ (e.g., at 36 cm from incisors).

2. Locate top of circumferential extent (e.g., at 33 cm).

3. Subtract the two: 36 - 33 = C3.

Step 5: Measuring the “M” (Maximal)

Continue pulling the endoscope back to find the absolute highest point of any Barrett’s tongue.

🖥 VISUAL ANALYSIS @ 10:47

The view shows a long finger-like projection of Barrett’s tissue extending upwards into the pale squamous mucosa.

Significance: The tip of this tongue represents the maximal extent of the disease.

The Calculation:

1. Locate GEJ (e.g., at 36 cm).

2. Locate tip of the longest tongue (e.g., at 32 cm).

3. Subtract the two: 36 - 32 = M4.

Result: This patient has C3M4 Barrett’s Esophagus.

Summary of the Prague Workflow

• Find GEJ: Note the distance (e.g., 36 cm).

• Find C-limit: Note the distance (e.g., 33 cm).

• Find M-limit: Note the distance (e.g., 32 cm).

• Math:

  • C = GEJ - C-limit

  • M = GEJ - M-limit

Advanced Biopsy Protocols & Clinical Pearls

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The is the probably the most practical course on Barrett’s esophagus ever presented on an endoscopy platform. The course has all you need to know to understand how to diagnose and treat Barrett’s esophagus but will also stimulate you to develop your own hypothesis and ideas on Barrett’s esophagus. The aim is to make you an expert in the field.

This course demonstrates practical tips and tricks. It deconstructs complex concepts and explains them in practical manner, making them applicable in any part of the World. In other words, any endoscopist around the World can become an expert in diagnosing and treating Barrett’s esophagus and dysplasia, even in the absence of expensive endoscopic equipment. For example, acetic acid chromoendoscopy using white light endoscopy (traditional endoscopy) is accessible, cheap and state-of-the-Art for detecting dysplasia in Barrett.

Furthermore, there are various ablation therapies for dysplasia, ranging from argon plasma coagulation to cryotherapy and radio frequency ablation.

Lastly, Barrett’s esophagus is an evolving field and numerous concepts such as using Paris classification for describing lesions may be impractical, and novel and simple ideas to classify those lesions are appearing. Having more experts in the field will allow for “thinking outside the box” and contributing to the knowledge of this fascinating condition.

Enjoy the course.

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A patient presents with obscure GI bleeding (OGIB). The initial EGD and colonoscopy are negative. The next step seems obvious: order a capsule endoscopy or schedule a deep enteroscopy. But what if that’s the wrong move?

In this expert walkthrough, Dr. Klaus Mönkemüller (Professor of Medicine) breaks down the most common mistakes in managing small bowel bleeding. He begins with a critical error that happens before a deep enteroscopy is ever considered—an error that, according to data, could be sending 30% of patients for unnecessary procedures.

This article analyzes Dr. Mönkemüller’s key insights, providing a clinical framework for avoiding this common pitfall.

Why Is Small Bowel Endoscopy So Challenging?

Before discussing mistakes, Dr. Mönkemüller provides context on why small bowel endoscopy is inherently difficult and high-risk.

• Anatomy: The small bowel is long and convoluted.

• Access: Simply reaching the lesion is significantly harder than in a standard EGD or colonoscopy.

• Technique: The small bowel’s narrow lumen and very thin wall make it more challenging to maneuver and maintain an adequate resection position.

• Risk: These factors (especially the thin wall) make the procedure more risky and prone to complications like bleeding and perforation.

• Tools: The right accessories are not always available.

The First Mistake: Rushing to Deep Enteroscopy

The single biggest mistake, according to Dr. Mönkemüller, is performing a deep enteroscopy or capsule endoscopy too soon.

The reason this is a mistake is that in a significant number of cases, the bleeding source is not in the small bowel. It’s in a location that was missed by the initial EGD or colonoscopy.

To understand this, he first redefines the clinical problem.

Practice Point: Think “Mid-GIB,” Not “Small Bowel Bleeding”

Dr. Mönkemüller argues for using the term “mid-GI bleeding” (mid-GIB). He defines this as persisting or intermittent GI blood loss originating in the small bowel or an excluded stomach.

Why include the excluded stomach?

“Lots of patients have gastric bypass,” Dr. Mönkemüller explains, “and when you do an upper endoscopy or even a push enteroscopy, you will never reach the stomach... It’s in the mid-GI tract now.”

This diagnosis of mid-GIB is contingent on one key condition: a negative EGD and (ileo)-colonoscopy.

But what if that “negative” scope was a false negative?

The Evidence: 30% of Lesions Are Missed

Dr. Mönkemüller highlights data from a study he was involved in at the University of Magdeburg. The study looked at patients referred for double-balloon enteroscopy (DBE) to find the source of their obscure bleeding.

The findings were striking: “A lot of patients that were sent for us to undergo... DBE actually had lesions that were within the reach of EGD and ileocolonoscopy.”

A pie chart on screen (Lucia Fry et al. APT 2008) visualizes the findings:

• 54% of lesions were found in the small bowel.

• 16% had no lesions found.

• 30% had lesions outside the small bowel (i.e., within reach of standard EGD/colonoscopy).

This 30% represents the missed lesions. [PARAPHRASE] These initial scopes may have been performed in suboptimal conditions—for example, as an emergency, with significant blood in the stomach, or with poor colon preparation—all of which can lead to a missed lesion.

The “Must-Not-Miss” Lesions (That Are Frequently Missed)

So, what lesions are being missed 30% of the time? Dr. Mönkemüller provides a comprehensive list.

Frequently Missed Stomach Lesions

• Cameron lesions

• Dieulafoy lesions

• Angiodysplasias

• GAVE-syndrome (Gastric Antral Vascular Ectasia, or “watermelon stomach”)

Frequently Missed Colon Lesions

• Angiodysplasias

• Portal hypertensive colonopathy

• Polyps or tumors

Other Missed “Upper GI” Causes

• Hemosuccus pancreaticus

• Hemobilia

• Esophagitis

The presentation shows several powerful examples of these missed lesions:

• GAVE: The top-left image shows the classic linear, erythematous streaks of watermelon stomach.

• Cameron Lesions: The top-middle image reveals an ulcer found within a large hiatal hernia.

• Duodenal Ulcer: The top-right image shows a duodenal ulcer, which the speaker notes was caused by radiation damage from SIRT therapy.

• Stomach Angiodysplasia: A capsule endoscopy image clearly shows a stomach angiodysplasia that was missed on the initial EGD.

To see Dr. Mönkemüller’s analysis of the second major mistake in small bowel bleeding, his advice on negative capsule endoscopy, and his full list of 8 total mistakes to avoid, consider becoming a paid subscriber.

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The First Take-Home Message: Repeat the Scopes

Based on this evidence, Dr. Mönkemüller’s first take-home message is clear and actionable.

First Take-Home Message

“EGD... and colonoscopy should be repeated before proceeding with capsule or deep enteroscopy.”

He emphasizes this may need to be done “two or three times.”

The rationale is simple: 30% of patients might have lesions that are within the reach of these standard scopes.Repeating the procedures, perhaps with a more experienced operator or in a non-emergent setting with a perfect prep, is a lower-risk, higher-yield next step than immediately advancing to a deep enteroscopy.

The Second Mistake (Teaser)

After solving the first mistake, Dr. Mönkemüller introduces the next common pitfall: “Relying too much on negative results of capsule endoscopy.”

He concludes this preview by noting he will discuss 8 total mistakes in his full lecture.

Poll & Discussion

How often do you repeat a “negative” EGD/colonoscopy in an OGIB workup before ordering a capsule?

🎁 Bonus Materials

1. Quick Reference Card: Missed Lesions in OGIB Workups

(Based on)

Before ordering a capsule/enteroscopy, repeat EGD/Colonoscopy and actively hunt for:

• Stomach:

  • ☐ Cameron Lesions (in hiatal hernia)

  • ☐ Dieulafoy Lesions

  • ☐ Angiodysplasias

  • ☐ GAVE / Watermelon Stomach

• Colon:

  • ☐ Angiodysplasias

  • ☐ Portal Hypertensive Colonopathy

  • ☐ Polyps / Tumors

• Other/Rare:

  • ☐ Hemosuccus pancreaticus

  • ☐ Hemobilia

  • ☐ Aortoenteric Fistula

  • ☐ Ulcerative Celiac Disease

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The small bowel is not only the body’s largest surface area but also its largest immune organ, housing billions of white blood cells and interacting closely with the microbiota. Despite its importance, inspecting its intricate villous structure can be a challenging task. However, mastering this inspection is key to identifying a range of subtle and significant pathologies.

In this guide, based on a lecture by Dr. Klaus Mönkemüller, we will cover the fundamental principles for characterizing high-quality small bowel villi.

“Advanced Imaging” is a Foundational Skill

The concept of “advanced imaging” is not new; it has been part of endoscopy from the beginning. Dr. Mönkemüller points to a 1974 paper on the “Dye Scattering Method” as an early example of this principle. This early technique involved applying dyes like indigo carmine or methylene blue to enhance mucosal visualization.

Today, this same principle extends to digital chromoendoscopy, but the fundamental goal remains the same: detailed and enhanced visualization of the villi.

Key Steps for High-Quality Villi Observation

Dr. Mönkemüller outlines a systematic approach, shown on his slide, to ensure you can clearly assess the small bowel mucosa.

1. Prepare the View

• Remove debris with water.

• Remove bubbles, often using simethicone, to clearly appreciate the mucosal surface.

2. Observe Methodically

• Always observe before advancing the scope or performing biopsies. This allows you to capture clear images before potential bleeding or manipulation obscures the view.

• Avoid too much insufflation, as this can stimulate motility. The speaker notes he prefers to use CO2.

3. Use Augmentation Techniques

• Underwater Endoscopy: This technique provides inherent magnification, augmenting visibility by approximately 1.6 times.

• Contrast Agents: Using contrast agents allows for better delineation and characterization of mucosal structures.

• Artificial Chromoendoscopy: This includes modern technologies like BLI, NBI, FICE, and i-scan.

• Capsule Endoscopy: This modality can also provide “marvelous” views of the small bowel.

What Do Normal Villi Look Like?

Normal villi have different lengths and sizes depending on their location in the intestine. Using modern tools like zoom endoscopy (up to 110x magnification) and NBI, you can visualize the intra-villous capillaries and even see the blood flowing through them.

The video clip shows a highly magnified NBI view of normal villi. The villi are distinct, uniform, finger-like projections. Within each individual villus, a dark, looped capillary structure is clearly visible. The speaker narrates that with this view, “the vessels become more visible and clear”.

To see Dr. Mönkemüller’s breakdown of specific pathologic findings in Whipple’s Disease, IPSID, and more, including key visual differentiators, consider becoming a paid subscriber.

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A Framework for Pathologic Findings

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The definitive solution is Endoscopic Submucosal Dissection (ESD), an advanced technique that allows for en bloc (single piece) removal of large lesions, offering the highest chance for a curative, R0 oncological resection.

But ESD is not just “big EMR.” It’s a different conceptual approach. In this masterclass from Dr. Klaus Mönkemüller, we break down the fundamental principles of ESD, focusing on the single most critical step for success and safety: creating the perfect submucosal cushion.

The Core Concept: ESD is a “Submuc-osectomy”

To master ESD, we must first redefine our terms. A standard polypectomy is, in effect, a mucosectomy—it removes the mucosal layer.

In contrast, both EMR and ESD are fundamentally submuc-osectomies. The goal is to cut below the submucosal layer to ensure the entire lesion is removed, achieving a “safety base” of healthy tissue.

The slide contrasts a “Piecemeal EMR” (center), which shows a large, fragmented specimen, with an “ESD” specimen (right). The ESD specimen is a single, large, perfectly intact piece, allowing for precise histopathological analysis of deep and lateral margins. This visual underscores the oncological superiority of an en bloc resection.

The ultimate objective for any of these procedures is a complete endoscopic and, more importantly, oncological resection (R0). This means the entire neoplasia has been resected with clear margins. ESD provides the most reliable path to this goal for large lesions.

The essential concept of ESD, regardless of the specific knife or tool used, is a three-part process:

1. Inject: Create a deep submucosal cushion to lift the lesion and create a safety plane.

2. Incise: Use an ESD knife to make a circumferential incision in the mucosa around the lesion.

3. Dissect: Carefully tunnel under the lesion, dissecting it from the underlying muscularis propria.

Mastering step 1 is non-negotiable. Here are Dr. Mönkemüller’s top tips for getting the submucosal cushion right every time.

To see all 13 expert tips, Dr. Mönkemüller’s 7-step protocol for a perfect injection, and visual analysis of the techniques, consider becoming a paid subscriber.

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13 Pro-Tips for a Successful ESD

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Imagine you’re scoping a patient with a posterior duodenal ulcer. It’s spurting, and the angle is difficult. You apply clips, but they slide off. You inject, but the bleeding continues. This is a classic scenario where endoscopists are now turning to hemostatic powders, not as a final therapy, but as a critical temporizing measure.

This is the concept of “down-staging”—one of several key applications for these agents. We’ll explore this, along with rescue therapy and the critical differences in how these powders are made and, most importantly, how they are applied.

Part 1: The First Generation – Hemospray (TC 325)

The first-generation agent, Hemospray (TC 325), is an inorganic mineral powder.

The Mechanism: “It’s Clay”

The speaker simplifies the product’s composition: “it’s clay”. Specifically, it is a bentonite powder, a type of kaolin, which is a naturally occurring aluminum phyllosilicate mineral.

Its mechanism is purely mechanical and topical. The powder is “highly absorptive” and works in three main ways:

1. Absorption & Concentration: When the powder hits the blood, it rapidly absorbs water. This action concentrates the body’s own platelets, red blood cells, and clotting factors at the bleeding site.

2. Clot Initiation: This concentration “initiates coagulation” and “accelerates” the natural clotting and fibrin polymerization times.

3. Mechanical Barrier: The powder forms a stable “mechanical barrier” over the wound, which helps stabilize the new blood clot.

The video shows the white catheter tip near a bleeding vessel. A sudden, forceful burst of white powder (Hemospray) erupts from the catheter, propelled by CO2. The force of the application completely obscures the endoscopic field in a “white out” before the powder settles. This demonstrates the explosive, non-targeted nature of this first-generation application system.

Key Clinical Applications

Professor Mönkemüller highlights two primary use cases for this type of powder.

1. “Down-Staging” an Active Bleed

This is perhaps the most valuable application. In a video from Prof. Jacques Bergman, a patient has a spurting ulcer that continues to bleed despite initial therapy. Hemospray is applied, which achieves temporary hemostasis. This “buys time” and successfully “down-stages” the bleed from an active spirt to a controlled, oozing lesion. This controlled field then allows the endoscopist to successfully apply definitive therapy, such as clips, which may have failed on the actively spurting vessel.

2. Rescue Therapy The powder is also effective as a rescue therapy for iatrogenic bleeding. The speaker shares a case of post-polypectomy bleeding in a patient who was later found to have acquired von Willebrand disease. After conventional therapies failed, Hemospray was applied to stabilize the bleeding site.

Clinical Pearl: Data on Non-Variceal GI Bleeding

The speaker cites a 2022 study (Lau J Y et al., Ann Intern Med) that found Hemospray was “not inferior” to standard endoscopic therapy for non-variceal upper GI bleeding. The study of 224 patients showed no significant difference in recurrent bleeding within 30 days (8.1% for Hemospray vs. 8.8% for control).

A Critical Limitation: Variceal Bleeding

The speaker issues a strong warning against using Hemospray for variceal bleeding.

He references a 2022 pilot study (Ibrahim M et al., Gut) that attempted to use Hemospray for this indication. While it did stop bleeding, the speaker notes the study was “problematic” and the results are not reproducible in most clinical practices for several reasons:

• Rapid Endoscopy: The intervention group received endoscopy within 2 hours of presentation, while the control group waited up to 24 hours. This is not a feasible protocol for most hospitals without a dedicated on-call team.

• Scope Requirement: The study used a 10 Fr catheter, which requires a therapeutic gastroscope. Many practices do not have these readily available for an emergent bleed.

• Flawed Comparison: The control group was not managed according to Baveno guidelines.

“In my eyes,” Prof. Mönkemüller concludes, “Hemospray is not an option for variceal bleeding”.

To see Professor Mönkemüller’s analysis of the 2nd and 3rd-generation powders, including the “powder-gel” concept that offers a much more controlled application, consider becoming a paid subscriber.

Part 2: The Second Generation – Endoclot

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Andres Gutierrez, MD, Gastroenterology Fellow, Clinica de Gastroenteroogi “Prof. Carolina Olano”, Hospital de Clinicas, Universidad de La Republica, Uruguay and Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

85-year-old female patient with hypothyroidism, hyperlipidemia and iron deficiency anemia who was on oral iron supplementation (ferrous sulfate tablets, 325 mg once daily) presented with a 3-months history of abdominal pain and nausea. On EGD a round, 8-10 mm ulcer was seen in the distal body of the stomach (Figure 1).

The gastric ulcer biopsies demonstrate an ulcerating active gastritis. The gastric ulcer biopsies also contained embedded yellow-brown crystalline material in the lamina propria, which were positive by Prussian blue iron staining. No Helicobacter pylori organisms were seen on the biopsy specimens.

These findings confirmed with an iron pill gastropathy/gastritis.

Oral iron tablets or pills can cause both focal and diffuse erosive gastritis. Iron has been noted to cause a focal erosive mucosal injury like that caused by a chemical burn (1). Iron deposits a brown-black crystalline hemosiderin into the mucosa (1). It is thought that iron erodes the mucosa through a direct corrosive effect that subsequently produces a local injury in a concentration-dependent manner (1). In some patients, particularly those with other comorbid conditions such as hemochromatosis, gastric antral vascular ectasia, and gastric adenocarcinoma, among others, the degree of iron deposition extends to the lamina propria and even the gastric glands (1). On endoscopy the spectrum of findings includes erosion, ulceration, focal hemorrhage or diffuse gastritis. In our experience the focal lesions are most commonly located in the greater curvature of the stomach body such as in this patient. Clinical presentations include epigastric pain, nausea, microcytic anemia, and occult gastrointestinal bleeding. This is a great irony, as iron is causing a big problem. . It is therefore important to consider this entity in patients with gastric ulcers who are on oral iron supplementation and in whom the search for more common causes of gastric ulceration including NSAID use and H pylori infection has been negative (2). Iron pill–induced mucosal injury can be reversed by discontinuing the offending agent or switching to a less toxic form such as a liquid iron preparation (2).

In sum, iron pill gastritis may present as gastritis, multiple gastric erosions and ulcers.

The irony of iron: a treatment for anemia causing gastric ulcers is a crucial reminder that a diagnosis is not always straightforward. When common causes like H. pylori and NSAID use are ruled out, where do you turn next?

To master the full spectrum of GI bleeding, from common culprits to rare presentations like iron pill gastropathy, get your copy of our definitive book, ‘The EndoCollab Guide for GI Bleeding’. https://amzn.to/40ugFRB

For ongoing learning and to discuss challenging cases like this with a global community of peers, elevate your practice by becoming a paid member of EndoCollab. https://endocollab.com/join-endocollab/

References:

1. Hashash JG, Proksell S, Kuan SF, Behari J. Iron Pill-Induced Gastritis. ACG Case Rep J. 2013 Oct 8;1(1):13-5. doi: 10.14309/crj.2013.7. PMID: 26157809; PMCID: PMC4435261.

2. Parsi MA, Yerian LM. Iron ulcers. Clin Gastroenterol Hepatol. 2009 Oct;7(10):A22. doi: 10.1016/j.cgh.2009.01.005. Epub 2009 Jan 24. PMID: 19558995.

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