Variceal Banding, IPMN Surveillance & Complex Ulcers
WhatsApp Notes · June 8, 2025 → June 19, 2025
Hello,
This past week in the EndoCollab WhatsApp group, a fascinating discussion unfolded around the best approach for an actively bleeding esophageal varix: should you band below the bleed or target the 'white nipple sign' directly?
That was just one of several challenging clinical questions tackled by our global members. We've summarized the key insights for you below, including opinions on surgical referral thresholds for side-branch IPMN, the differential diagnosis for a complex duodenal ulcer, and practical strategies for managing post-radiotherapy dysphagia.
Dive into the key take-aways from your colleagues.
Upper-GI
Regarding an endoscopic image from a patient with macrocytic anemia, one member stated it did not seem to be atrophic gastritis, while another provided a list of key endoscopic features for the condition, including mucosal pallor, a visible vascular pattern, and loss of gastric folds. A participant suggested taking fundal biopsies and checking anti-parietal and anti-intrinsic factor antibodies in cases of macrocytosis.
For a patient experiencing dysphagia one week after radiotherapy for esophageal squamous cell carcinoma, members advised this is likely due to initial edema and that early dilation may lead to complications. One participant suggested waiting 6-8 weeks post-RT before considering dilation.
In a complex case involving a pinpoint esophagus at the UES after radiotherapy, a member proposed that if a neonatal endoscope can pass into the stomach, a PEG tube could be placed by grasping the guidewire with a baby snare passed through the scope's working channel.
A retroflex image from a patient with two prior hernia repairs and recurrent reflux prompted a discussion of possible findings, including a paraesophageal hernia, a fundal pseudo-diverticulum, or a "Type A failure" of a previous fundoplication. One member observed that the cardia was "wide open" and no fundoplication cuff was visible.
In a discussion about benign pyloric stenosis secondary to peptic ulcer disease, one member suggested reviewing the topic and then considering G-POEM. Another participant questioned this, noting G-POEM is traditionally indicated for gastroparesis and hypertrophic pyloric stenosis.
A case was presented of a 60-year-old male with ischemic heart disease, on multiple antiplatelets, who presented with melena and a large duodenal ulcer. While the presenter inquired about Crohn's disease, other participants suggested alternative diagnoses including an ischemic ulcer, a Dieulafoy's lesion, lymphoma, or H. pylori-related "kissing" ulcers. The possibility of pill-induced esophagitis was also raised.
Colon / Small Bowel
A member inquired about recommended diathermy settings for saline immersion ESD for colorectal lesions using both ERBE and Olympus systems.
In a case of a young male presenting with pain on defecation, a participant viewed an image and suggested a hypertrophic papilla.
An unusual, prominent lesion found in the second/third part of the duodenum led to a diagnostic discussion. Initial thoughts included an adenoma (classified as Paris IIa+c or JNET IIb). One member cautioned that performing a biopsy could induce fibrosis and complicate a subsequent resection. Resection via conventional or underwater EMR was suggested as a course of action. The final histology was reported as gastric heterotopia; a participant noted that if asymptomatic, this can be left alone.
For an image showing colitis in a 55-year-old smoker, members proposed a differential including ischemic colitis, infectious colitis, or preparation-induced erythema.
Members discussed a polyp covered by normal-appearing mucosa, identifying it as a possible colonic mucosubmucosal elongated polyp (CMSEP). The endoscopist who presented the case confirmed they performed a polypectomy with prophylactic hemoclipping.
A case of two polyps was shared where the histology revealed intense fibrosis and arteriosclerosis; the suggested differential diagnoses included elastofibromatous polyps or CMSEP.
Pancreato-Biliary
A participant asked for bibliographic resources and practical advice on performing ERCP in a patient with a distal papilla, specifically asking if the biliary access remains at the 11 o'clock position.
A question was posed regarding the optimal timing of ERCP in cases of acute biliary pancreatitis, considering different clinical scenarios: patients with acute cholangitis, those with signs of biliary obstruction, and asymptomatic cases.
Regarding surveillance for side-branch IPMN without worrisome features, a participant asked about the practical cyst diameter threshold used for surgical referral. Members noted that in practice, some use a 4 cm or 5 cm cutoff, while one participant mentioned an UpToDate algorithm that uses a 3 cm threshold for invasive assessment.
Portal / Vascular
For a case of an actively bleeding esophageal varix with a "white nipple sign" and a "jet of blood," members discussed banding strategy. The consensus leaned towards banding below the bleeding point first, then the bleeding area, adhering to the general principle of banding "from below upwards." This approach was explained by the "uphill" nature of esophageal varices and the underlying palisade vein concept.
A member inquired about "downhill varix," which another participant confirmed is associated with central vein thrombosis or superior vena cava obstruction and is typically not as prone to bleeding as varices from portal hypertension.
In the case of a non-cirrhotic patient with extensive portal, SMV, and splenic vein thrombosis, a member asked when to resume oral intake. A respondent suggested that if there are no signs of obstruction or ischemia, the patient could be allowed to eat.
Procedural & Room Setup
To prevent damage to the endoscope's main connector, members discussed ideal suite layouts. Suggestions included positioning the processor tower behind the endoscopist and utilizing a ceiling-mounted monitor on an articulated arm to improve ergonomics.
One-Line Take-Aways
For bleeding esophageal varices, a commonly discussed approach is to band below the bleeding point first before targeting the active site, following a "below upwards" strategy.
A prominent, non-papillary duodenal lesion may represent an adenoma or gastric heterotopia; members debated the merits of biopsy versus direct resection due to the risk of inducing fibrosis.
In patients with dysphagia immediately following radiotherapy for esophageal cancer, symptoms are often due to edema, and dilation should be delayed (e.g., by 6-8 weeks) to mitigate complication risks.
The entity of colonic mucosubmucosal elongated polyp (CMSEP) was discussed in response to images of polyps with normal-appearing overlying mucosa.
Members suggested that positioning the endoscopy tower behind the operator with a ceiling-mounted monitor can improve ergonomics and protect equipment.
You've Read the Highlights. Now Join the Live Discussion.
This bi-weekly summary gives you a glimpse into the incredible discussions happening inside our private EndoCollab WhatsApp group. But it's just the tip of the iceberg.
While these notes capture the key learning points, they can't replicate the experience of getting immediate feedback on a challenging case, seeing the original high-resolution videos, or asking a follow-up question in the moment.
When you upgrade to a premium membership, you move from being a reader to being a participant.
With a premium membership, you can:
Get Real-Time Feedback: Post your own tough cases—images, videos, and questions—and receive immediate advice from a global faculty of endoscopists, 24/7.
Engage in Live Conversations: Don't just read the answers—ask the questions. Participate in dynamic discussions with hundreds of passionate colleagues as they happen.
See the Full Picture: Access the complete, unedited chat transcripts, including all the original high-resolution images and video files that can't be included here.
Build Your Global Network: Join a curated and supportive community of gastroenterologists from over 80 countries dedicated to collaborative learning.
Don't wait two weeks for the highlights. Get the insights and support you need, right when you need them.