# EndoCollab ## Posts - [Rodolfo Valentino Syndrome: Perforated Duodenal Ulcer Mimicking Appendicitis](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/rodolfo-valentino-syndrome-perforated-duodenal-ulcer-mimicking-appendicitis/): By Joel Joseph, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGEDepartment of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA Case Presentation: 80-year-old patient with history of lung cancer on immune checkpoint inhibitor therapy presented with acute right lower abdominal pain, elevated inflammatory markers and mild lactic acidosis. The patient had rebound pain in the right lower quadrant and right flank. CT showed free air below the liver (Figure 1). During laparotomy a perforated duodenal ulcer was found. The omentum had wrapped itself to the perforation, which was sealed. There were inflammatory adhesions globally to […] - [Tools of the Trade: The Retentia ® Clip](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/tools-of-the-trade-the-retentia-clip/): Tools of the Trade: The Retentia ® Clip Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA Figure 1. Retentia Clip. Key technical information. The Retentia Clip has some interesting and nice features:  It is rotatable, It can be deployed with scope in retroflexed position,  It can open and close repeatedly. I opened and closed one 30 times, Its catheter has a 2.5 mm outer diameter, allowing for simultaneous suction of air and liquids through the working channel. These are very convenient features, as they allow the endoscopist to […] - [Ileum Intubation Made Easy](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/ileum-intubation-made-easy/) - [Transient or “Left”-Sided Ischemic Colitis: Case Reports With Focus on its Endoscopic Spectrum](https://endocollab.com/blogs/uncategorized/transient-or-left-sided-ischemic-colitis-case-reports-with-focus-on-its-endoscopic-spectrum/): By Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Troy Pleasant, MD, and Anand Dwivedi, MD Virginia Tech Carilion School of Medicine, Virginia, USA Transient or left-sided ischemic colitis is the most common type of ischemia of the gastrointestinal tract. Indeed, ischemic colitis is the second or third most common cause of lower GI bleeding. Herein we present two cases with classic features of transient ischemic colitis and focus on its endoscopic diagnosis. Case Presentations: Case 1: Elderly patient developed abdominal pain followed by bloody diarrhea. Colonoscopy showed patchy colitis of the left colon (Figure 1), the rectum was spared. Notice the […] - [Hemostasis of Bleeding Duodenal Ulcer Using Injection Gold Probe](https://endocollab.com/blogs/uncategorized/hemostasis-of-bleeding-duodenal-ulcer-using-injection-gold-probe/): Diana Dougherty, MD, and Klaus Mönkemüller, MD, PhD, FASGE, FJGESDepartment of Gastroenterology, Carilion Memorial Hospital, VirginiaVirginia Tech Carilion School of Medicine, Roanoke, USA An 80-year-old man presented with melena. Esophagogastroduodenoscopy (EGD) revealed a large duodenal ulcer with a visible vessel, located anteriorly (Figure 1). Hemostasis was achieved with combination injection and compression electrocoagulation therapy using a injection gold probe. Figure 1. Hemostasis with an injection gold probe catheter. A. Box of injection gold probe. The probe used was 7 Fr diameter. B. Notice the gold spiraled on the tip of the injection catheter. C. The gold probe can be placed laterally […] - [Dieulafoy Lesion of the Duodenum](https://endocollab.com/blogs/uncategorized/dieulafoy-lesion-of-the-duodenum/): Dieulafoy Lesion of the Duodenum Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA An 72-year-old female with past medical history of chronic kidney disease stage IV, type 2 diabetes mellitus, atrial fibrillation presented with recurrent overt gastrointestinal bleeding (melena and hematemesis, hemoglobin 7.1 gr/dl). She had undergone two previous EGDs without significant findings. On EGD we found a bleeding Dieulafoy lesion of the duodenum (Figure 1). Hemostasis achieved with a hemoclip. Figure 1. Dieulafoy lesion of the duodenum. A. Active bleeding. B. No evidence of ulceration or angiodysplasia. […] - [The Irony of Iron: Gastric Ulcer due to Iron Pills](https://endocollab.com/blogs/uncategorized/the-irony-of-iron-gastric-ulcer-due-to-iron-pills/): Rami Musallam, MD, Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA 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 […] - [Esophageal Varix with Nipple Sign](https://endocollab.com/blogs/uncategorized/esophageal-varix-with-nipple-sign/): Rami Musallam, MD, Gastroenterology Fellow, Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA   A 50-year-old patient with a history of cirrhosis due to ethanol use presented to the emergency room with hematemesis and melena for one day. The patient had clinical features consistent of chronic liver disease (spider angiomas, ascites, palmar erythema and jaundice). The hemoglobin was 8 gr/dl. An EGD was performed (Photo). Figure 1. Large esophageal varices. A. Three columns of esophageal varices extending from the distal esophagus to the mid-esophagus. B. The stomach was […] - [Endoscopic Resection of Giant Gastric Polyp to Treat Upper GI Bleeding](https://endocollab.com/blogs/uncategorized/endoscopic-resection-of-giant-gastric-polyp-to-treat-upper-gi-bleeding/): Endoscopic Resection of Giant Gastric Polyp to Treat Upper GI Bleeding Anand Dwivedi, MD Gastroenterology Fellow, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA An elderly patient presented with massive hematemesis and drop in hemoglobin from 13 to 9 gr/dl. After hemodynamic stabilization an EGD was performed. A large antral polypoid lesion with stigmata of hemorrhage was seen (A, B). The polyp had a large and thick pedicle (C). The pedicle was injected with saline-epinephrine mix (1:10,000) (D). Endoscopic resection was […] - [Quick Endoscopic Diagnostic Tip: Kissing Ulcers of the Duodenum](https://endocollab.com/blogs/uncategorized/quick-endoscopic-diagnostic-tip-kissing-ulcers-of-the-duodenum/): Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA The term “kissing ulcers” of the duodenum describes the presence of two different ulcers facing each other, usually one located anteriorly and the other posteriorly. It appears that the original description was in the surgical literature by Stabile et al in 1979 (Arch Surg). The photo shows a spectrum of kissing ulcers. Occasionally, these may be hard to see (Panel C, yellow arrows). Multiple duodenal ulcers are a “red flag” and should always intrigue the endoscopist to think of: use of NSAIDs, […] - [Quick Endoscopic Diagnostic Tip: Iron Pill Gastritis](https://endocollab.com/blogs/uncategorized/quick-endoscopic-diagnostic-tip-iron-pill-gastritis/): Jay Bapaye, MD, Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA David Lebel, MD, Assistant Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA 60-year-old male patient with multiple medical problems, including hypertension, coronary artery disease, and small bowel angiodysplasias, was admitted for worsening anemia despite oral iron supplementation. On EGD, a diffuse gastritis and a focally enlarged gastric fold of the greater curvature of the proximal stomach were noticed (Figure 1, panel A, B). Biopsies […] - [A Pro Tip for Clipping Mallory-Weiss Tears](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/a-pro-tip-for-clipping-mallory-weiss-tears/): What’s your strategy for clipping a Mallory-Weiss tear? A common mistake is starting proximally. For a more secure closure, place the first clip distally (furthest from the scope). Then, place subsequent clips proximally to create a stable V- or Y-shape, as shown in this diagram from our new guide. This is a preview of the practical, procedural guidance packed into The EndoCollab Guide for GI Bleeding. Find hundreds of tips like this in the full guide. Available now on Amazon. Available now on Amazon   Available now on Amazon - [Endoscopic Tips and Tricks: First-Line Monotherapy with Over-The-Scope-Clip for Massive Bleeding due to Duodenal Ulcer with Huge Visible Vessel](https://endocollab.com/blogs/uncategorized/endoscopic-tips-and-tricks-first-line-monotherapy-with-over-the-scope-clip-for-massive-bleeding-due-to-duodenal-ulcer-with-huge-visible-vessel/): Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA A middle-aged patient was admitted with hematemesis and hemorrhagic shock. After hemodynamic stabilization, EGD was performed, showing active bleeding and a partially adherent blood clot on a huge duodenal ulcer. The blood and blood clot were removed with a water flush. However, if a clot is more tightly adherent, I prefer not to remove it. Inspection revealed a large ulcer (B, yellow oval) and a visible large vessel (B, C, yellow arrows). A one-stop hemostatic procedure was accomplished with an 11/6t over-the-scope clip […] - [Immune Checkpoint Inhibitor Induced Colitis or “Immune Mediated Colitis”](https://endocollab.com/blogs/uncategorized/immune-checkpoint-inhibitor-induced-colitis-or-immune-mediated-colitis/): by Hiral Patel, MD, Robert Moylan, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A 70-year-old woman with history of metastatic melanoma on treatment with ipilimumab presented with acute onset abdominal pain and bloody bowel movements.  Figure 1. Immune checkpoint inhibitor induced colitis (“immune mediated colitis”). A. diffuse mucosal edema, loss of light reflex, erythema, granularity. B. Large amount of secretion and pus (“mucopus”). C. “Tubular” colon because of severe inflammation. D. Immune mediated colitis is associated with significant neutrophilic inflammation, hence pus. E. Descending […] - [Endoscopic Therapy for Bleeding Jejunal Diverticulum](https://endocollab.com/blogs/uncategorized/endoscopic-therapy-for-bleeding-jejunal-diverticulum/): by Hiral Patel, MD, Robert Moylan, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA How Do You ACTUALLY Master GI Bleeding? Want to see how a world-renowned expert approaches the toughest GI bleeds? Dr. Klaus Mönkemüller has edited a 224-page visual guide and atlas packed with hundreds of images, practical tips, and step-by-step case studies to show you how. [Get Your Guide Now] A 70-year-old man with history of hypertension and a stroke one year prior, since then using clopidrogel, presented with acute onset hematochezia […] - [Cat Scratch Colon](https://endocollab.com/blogs/uncategorized/cat-scratch-colon/): Andres Gutierrez, MD; Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA A 75-year-old woman underwent colonoscopy for obscure gastrointestinal bleeding. Her procedure revealed a tortuous colon with numerous diverticula. Upon entering the ascending colon and cecum, multiple red mucosal lesions were found (Figure 1). Figure 1. Endoscopic findings of “cat scratch colon.” (A-C) Multiple bright red, linear marks on the mucosa of the ascending colon, resembling cat scratches. (D-F) A sharp, tight angulation in the distal ascending colon responsible for causing the barotrauma.   This was the […] - [Emesis or Prolapse Gastropathy](https://endocollab.com/blogs/uncategorized/emesis-or-prolapse-gastropathy/): by Subhash Garikipati, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A 35-year-old man presented with nausea and vomiting followed by hematemesis. During EGD prolapse gastropathy was diagnosed (Figure 1). Figure 1. Prolapse gastropathy. Upper panels show the patchy area of prolapsed stomach fundus mucosa with erythema, edema and congestion (yellow circle, arrow shows scope). The proposed mechanism of formation of prolapse gastropathy is shown in the lower graphics (C, D) (graphics source: Byfield F et al. GIE 1998). Prolapse or emesis gastropathy is an […] - [Cap-Assisted Push Enteroscopy Argon Plasma Coagulation](https://endocollab.com/blogs/uncategorized/cap-assisted-push-enteroscopy-argon-plasma-coagulation/): Jay Bapaye, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA An-year-old man presented with melena. Esophagogastroduodenoscopy (EGD) and colonoscopy were unremarkable. Capsule endoscopy showed active bleeding from the proximal jejunum, approximately 15 minutes after the capsule passed through the pylorus. The patient was sent to us for a single balloon enteroscopy. Since the bleeding was in the upper jejunum a decision was taken to perform push enteroscopy instead. A useful trick to improve performance of push enteroscopy is attaching a transparent distal cap to the pediatric […] - [Gastric Antral Vascular Ectasia (GAVE) in Heyde Syndrome](https://endocollab.com/blogs/uncategorized/gastric-antral-vascular-ectasia-gave-in-heyde-syndrome/): Jay Bapaye, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA An 80-year-old female with past medical history of chronic kidney disease stage IV, type 2 diabetes mellitus, quadruple coronary artery bypass, aortic and mitral stenosis treated with bioprosthetic aortic and mitral valves, pacemaker and defibrillator presented with recurrent occult gastrointestinal bleeding and iron deficiency anemia (hemoglobin 6.1 gr/dl). The patient had undergone multiple upper endoscopies and colonoscopies without significant findings except for small colon adenomas and “gastritis” and duodenal “polyps”. On EGD we found a linear, […] - [Device Review: How to Place a Rectal Decompression Tube Through-The-Scope](https://endocollab.com/blogs/uncategorized/device-review-how-to-place-a-rectal-decompression-tube-through-the-scope/): by Diana Dougherty, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A 40-year-old pregnant woman presented with acute constipation and abdominal distention. A sigmoid volvulus was diagnosed (Figure 1). There was a transition point in the sigmoid colon with a “mesenteric swirl sign” (Figures 1B, 1C). An emergency colonoscopy was performed to resolve the sigmoid volvulus and place a decompression tube.  Colon decompression tubes are used for other conditions such as Ogilvie’s syndrome and megacolons. In this case we used a Marcon colon decompression set […] - [Endoscopic Removal of a Pen Inside the Stomach Using the Soft, Mega, Distal Transparent Cap](https://endocollab.com/blogs/uncategorized/endoscopic-removal-of-a-pen-inside-the-stomach-using-the-soft-mega-distal-transparent-cap/): Anand Dwivedi, MD Carilion Memorial Hospital Virginia Tech Carilion School of Medicine Roanoke Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA There is a myriad of instruments to remove swallowed objects greater than 6 cm in length (such as pens, pencils, and toothbrushes) including nets (e.g. Roth net), snares, forceps, tripod prongs, overtubes, and various distal scope attachment caps (soft short, stiff, capuchon). A large transparent distal attachment cap was developed to remove small metal pieces, specifically, clip fragments of the over-the-scope clip (Remove cap, Ovesco, Germany) (1) (Figure 1).  We […] - [Cecal Volvulus](https://endocollab.com/blogs/uncategorized/cecal-volvulus/): Jacob C Davis, DO Internal Medicine Resident, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine  Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA A 61-year-old male with a past medical history significant for DVT/PE on Eliquis and HTN presented to the emergency room after a questionable syncopal episode and a ground level fall. He was found to have a right orbital fracture as well as T8 and L2 vertebral fractures. GI was consulted for abdominal distention, LUQ abdominal pain. A CT abdomen/pelvis showed a distended gallbladder with wall […] - [Therapeutic Dilemma: Barrett Esophagus in the Setting of Esophageal Varices](https://endocollab.com/blogs/uncategorized/therapeutic-dilemma-barrett-esophagus-in-the-setting-of-esophageal-varices/): by Hiral Patel, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A 50-year-old patient was sent to our endoscopy service because of Barrett’s esophagus and esophageal varices. He had been biopsied at another institution for a tongue of cylindrical epithelium in the distal esophagus. Before going into the discussion on the approach to this case we want to emphasize that one should never biopsy lesions in the setting of esophageal or gastric varices unless there is a backup plan for the obliteration of the bleeding. […] - [How to Deploy a Capsule Endoscope During EGD](https://endocollab.com/blogs/uncategorized/how-to-deploy-a-capsule-endoscope-during-egd/): by Joel Joseph, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA An elderly lady with obscure occult gastrointestinal bleeding could not swallow the capsule endoscope (CE) (PillCam) (Figure 1A). Therefore, an EGD was scheduled to introduce the capsule endoscope into the duodenum.  Figure 1 We utilized the AdvanCE capsule endoscope delivery device (Figure 1) (also see figure 3 at the end of article, which are the visual/photographic instructions from the device’s package). The key steps to deploy a CE using this device are:  Know your […] - [Endoscopic Utensil Description: The Duette Multiband Mucosectomy Device](https://endocollab.com/blogs/uncategorized/endoscopic-utensil-description-the-duette-multiband-mucosectomy-device/): by Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA The Duette device (Figure 2, Figure 1D) is essentially an endoscopic banding device for varicesaccompanied by a hexagonal snare. Let’s dwell into this practical device used for endoscopic resection. The objective of suctioning and banding gastrointestinal mucosal lesions is to a) reshape a flat or semi-sessile lesion into a “sessile” form, b) have the band at the base and assure a better endoscopic resection (R0). The other significant novelty of the Duette device is the 5Fr hexagonal snare (Figure 1). If you […] - [Top Tips for Dealing With a Colon Polyp in a Difficult Situation](https://endocollab.com/blogs/uncategorized/top-tips-for-dealing-with-a-colon-polyp-in-a-difficult-situation/): by Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA Traditionally difficult polyps have been defined by their shape (e.g. larger than 20 mm, flat, thick stalk) or location (cecum, angulated part of colon, close to appendix orifice or diverticulum). However, we believe that other “situation” factors such as colon preparation, colon motility (e.g. spams, patient respirations), bleeding diathesis (e.g. anticoagulation, low platelets) and ergonomics (e.. video monitor on endoscopy cart instead of being in the wall in front of the endoscopists) contribute to the difficulty in resecting these […] - [Stent Delivery Device with Transparent Inner Guiding Catheter and How to Place a Plastic Stent into the Bile Duct](https://endocollab.com/blogs/uncategorized/stent-delivery-device-with-transparent-inner-guiding-catheter-and-how-to-place-a-plastic-stent-into-the-bile-duct/): By Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA; Universidad de la República, Uruguay; PD at University Otto-von-Guericke, Germany; UEES, Universidad Espiritu Santo, Guayaquil, Ecuador; University of Belgrade, Belgrade, Serbia; J. Strossmeyer University, Osijek, Croatia Newsletter Stent Delivery Device with Transparent Inner Guiding Catheter.pdf 494.71 KB • PDF File Download Effective and successful ERCP is based on skills, knowledge, and devices. Often, simple devices make a huge difference in success. Herein we present such a device and dwell into the art of inserting a plastic stent into the biliary tract. Figure […] - [Microscopic Colitis: Not Always “Microscopic”](https://endocollab.com/blogs/uncategorized/microscopic-colitis-not-always-microscopic/): By Joel Joseph, MD, Troy Pleasant, MD and Klaus Mönkemüller, MD, PhD, FASGE, FJGES Virginia Tech Carilion School of Medicine, Virginia, USA Microscopic Colitis_ Not Always “Microscopic” .pdf 508.35 KB • PDF File Download 80-year-old patient with ongoing watery diarrhea for several weeks. Colonoscopy images shown here. Note that there is significant patchy edema, hypervascularity, punctate erythema, thickened folds and patchy superficial erythema. Classically, microscopic colitis (collagenous and lymphocytic) is thought to have normal colon mucosa, but several studies now have shown that many patients have abnormal colon mucosal findings, such as the ones depicted in our case (1-3). The […] - [Endoscopic Resection of an Esophageal Pseudodiverticulum in Radiation-Induced Stenosis](https://endocollab.com/blogs/uncategorized/endoscopic-resection-of-an-esophageal-pseudodiverticulum-in-radiation-induced-stenosis/): Peter Jakobs, MS, Josip Juraj Strossmayer Universität Osjiek, Croatia, Ameos Klinikum Halberstadt, Germany Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine, Department of Gastroenterology, Ameos Klinikum Halberstadt, Germany and Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A 62-year-old Caucasian male patient presented with dysphagia due to post-radiogenic esophageal stenosis. The patient had a history of transglottic laryngeal carcinoma for which he had undergone laryngectomy, neck dissection on both sides and adjuvant radio-chemotherapy. An esophageal bougienage had already been performed 4 months earlier and a dilatation from 5-6 mm to 9-10 mm had been performed 3 […] - [Technical Review: Endoscopic Resection of a Cardia Polyp Inside a Hiatal Hernia Sack Using the Duette Device](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/technical-review-endoscopic-resection-of-a-cardia-polyp-inside-a-hiatal-hernia-sack-using-the-duette-device/): by Diana Dougherty, MD, and Klaus Mönkemüller, MD, PhD, FASGE, FJGES Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A middle-aged male patient presented for EGD because of dyspepsia and heartburn. On EGD he was found to have erosive reflux esophagitis grade C based on the Los Angeles classification, a 4 cm hiatal hernia and an incidental, sessile polyp inside of the hernia sack (Figures 1A-C). The polypoid lesion was covered with some exudate and the mucosa had a cerebroid pattern, with areas of erosions and spontaneous bleeding. There were no signs of fold […] - [Technical Review: Esophageal Dilation with the BougieCap](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/technical-review-esophageal-dilation-with-the-bougiecap/): Luka K. Schöpf, MS, Josip Juraj Strossmayer Universität Osjiek, Croatia, Ameos Klinikum Halberstadt, Germany Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine, Department of Gastroenterology, Ameos Klinikum Halberstadt, Germany, UEES Guayaquil, Ecuador, Universidad de la República, Uruguay and Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA A 72-year-old man presented with recurrent meat boluses. On endoscopy a tight, fibrotic Schatzki ring was found. (Figure 1, panels A, B). Thus, the patient had a classic “steak house syndrome”. Destruction of Schatzki rings can be accomplished with dilation using Savary or Maloney dilators or bougies, balloon dilation, star-like […] - [Marking Technique for Identifying and Resection Flat Colon Polypoid Lesions or Polyps in Difficult Locations](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/marking-technique-for-identifying-and-resection-flat-colon-polypoid-lesions-or-polyps-in-difficult-locations/): By Klaus Mönkemüller, MD, PhD, FASGE, FJGES and Reid Wasserman, DO Virginia Tech Carilion School of Medicine, Virginia, USA One of the most frustrating aspects of dealing with small, flat, diminutive colon polypoid lesions or those lying in awkward location is their “disappearance” during colonoscopy, especially when the colon is not perfectly well prepped or there is increasing colon motility.  A useful trick is to focus on the lesion, push the scope towards it and suction the mucosa right next it. This creates a red submucosal suction mark, which then becomes pivotal to re-identify or relocate the polyp. We have […] - [Caps in GI Endoscopy](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/caps-in-gi-endoscopy/): Question What is the best way to inspect the papilla of Vater in the abscence or lack of availability of a duodenoscope (side-viewing scope, ERCP scope)? Answer Today we present a useful tip for inspection of the papilla of Vater using distal transparent cap. A close and detailed inspection of the major papilla may be needed in a variety of clinical situations, for example, during upper endoscopy of a patient with a familial polyposis syndrome (FAP) or duodenal adenomas Although some papillae may be seen well with forward-viewing instruments, many are partially or fully hidden behind duodenal folds and, therefore, […] - [Cronkhite Canada Syndrome (CCS)](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/cronkhite-canada-syndrome-ccs/):   A 48-year-old woman presented with chronic diarrhea and loss of taste. On clinical exam she appeared pale, had brittle nails and had partial hair loss. She was found to have severe iron deficiency anemia. Colonoscopy showed multiple reddish, edematous mucosal streaks and polyps and pseudopolyps ranging from 5 to about 20 mm. On EGD the stomach was characterized by enlarged mucosal folds, pseudoplyps and duodenal mucosal atrophy. Histology showed the above findings (see figure 2). CCS is a non-hereditary syndrome of unknown etiology characterized by diffuse gastrointestinal GI pseudo-polyposis, alopecia, hyperpigmentation, dystrophic changes in finger and toe nails Clinical […] - [The MIRacle Sign](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/the-miracle-sign/): Adil S. Mir MD FACP; Klaus Mönkemüller MD, PhD, FASGE, FJGES Virginia Tech Carilion School of Medicine, Roanoke, VA, USA Upper gastrointestinal (GI) endoscopy or esophagogastroduodenoscopy (EGD) continues to be an extremely useful diagnostic tool for perspicuous macroscopic findings. Besides, attention to detail remains of utmost significance in deciphering clinical clues to rather uncommon pathophysiology. Herein, we describe an observation and endoscopically inducible sign which could be a potential clue to diagnose borderline or overt gut ischemia. We describe the case of an 81-year-old male patient with pertinent history of multiple medical comorbidities including gastroesophageal reflux disease, coronary artery disease, […] - [Gastrointestinal Bleeding due to Amyloidosis: Investigating the Intersection of Rheumatoid Arthritis, Gastrointestinal Bleeding, and Amyloidosi](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/gastrointestinal-bleeding-due-to-amyloidosis-investigating-the-intersection-of-rheumatoid-arthritis-gastrointestinal-bleeding-and-amyloidosi/): This blog post explores one such intersection - Rheumatoid Arthritis, Gastrointestinal Bleeding, and Amyloidosis. The insights shared in this post are based on the extensive research and clinical experience of... - [Cameron Lesions](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/cameron-lesions/): By: Jonathan Rozenberg, DO, MPH, Internal Medicine Resident; Klaus Mönkemüller, , MD, PhD, FASGE (USA), FJGES (Japan), Professor of Medicine; Adil, Mir, MD, FACP  Institution: Virginia Tech Carilion School of Medicine, Roanoke, VA, USA  Cameron lesions refer to linear erosions or ulcerations of the gastric mucosal folds in patients with a large hiatal hernia that are typically located at diaphragmatic pinch, often in the case of a large hiatal hernia. First depicted by Cameron and Higgins in 1986, these lesions were originally found in those who had greater than a third of their stomach above the diaphragm on a chest […] - [Treating Upper Gastrointestinal Bleeding: An Update on Endoscopic Techniques](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/treating-upper-gastrointestinal-bleeding-an-update-on-endoscopic-techniques/): By William F. Abel, MD, Internal Medicine Resident, and   Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine  Virginia Tech Carilion School of Medicine, Virginia, USA  Upper gastrointestinal (GI) bleeding encompasses hemorrhage anywhere from the esophagus to the distal duodenum due to myriad etiologies including peptic ulcers, tumors, vascular malformations, esophageal varices, hemosuccus pancreaticus and trauma. Acute upper GI bleeding is a common reason for hospitalization, carrying a mortality rate of up to 10% (1)(1). Endoscopy serves as a powerful tool in both diagnosing and treating the source of GI hemorrhage through relatively non-invasive approaches. This article delves into the […] - [Improving Colonoscopy Prep and Achieving Better Boston Bowel Preparation Scores](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/improving-colonoscopy-prep-and-achieving-better-boston-bowel-preparation-scores/): Colon cancer is the second leading cause of cancer death in the United States, with over 50,000 deaths annually. The good news is that colon cancer is preventable with proper screening. Colonoscopies allow doctors to visualize the entire colon and detect precancerous polyps before they become cancerous. However, colonoscopies cannot accurately identify polyps and early cancers if the bowel is not thoroughly cleansed beforehand. The Importance of Colon Cleansing Proper bowel preparation is essential for successful colonoscopies. Any fecal matter or debris left in the colon can obscure the view and result in missed lesions. In fact, studies show that […] - [Natural or Biologic Chromoendoscopy for Detection of Colorectal Polyps](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/biologic-chromoendoscopy-the-eye-beats-artificial-intelligence/): By Klaus Mönkemüller, MD, PhD, FASGE, FJGES  Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, USA  The Eye Beats Artificial Intelligence: How Biologic Chromoendoscopy Improves Detection of Colorectal Polyps Introduction Colorectal cancer is one of the most prevalent and fatal cancers globally, resulting in over 900,000 deaths annually. Early detection and removal of precancerous colorectal polyps through colonoscopy screening is the best prevention strategy. While finding protruding pedunculated stalk polyps and flat, plate-like sessile polyps is relatively straightforward, identifying subtle flat and serrated lesions presents a major challenge. These difficult to detect polyps have a heightened risk of […] - [An Overview of Segmental Bile Duct Dilation and Caroli's Disease](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/focal-segmental-bile-duct-dilation/): The biliary system is responsible for transporting bile from the liver and gallbladder to the small intestine to aid in digestion. It consists of a complex network of ducts that can be affected by myriad disorders. One uncommon abnormality is segmental, or focal, dilation of the bile ducts. This refers to cystic dilatation of portions of the biliary tree, rather than diffuse dilation of the entire system. There are several hepatic conditions associated with this phenomenon, including the rare congenital Caroli’s disease. In this in-depth post, we will explore the anatomy of the biliary tract, causes of segmental bile duct […] - [Inflammatory Fibroid Polyps (IFP) or Vanek Tumors of the GI Tract](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/inflammatory-fibroid-polyps-ifp-or-vanek-tumors-of-the-gi-tract/): The images show Vanek tumors of the duodenum (left) and the stomach (right) (Stomach photo by @patholwaker) Inflammatory fibroid polyps (IFP) or “Vanek tumors” are rare submucosal lesions arising from a reactive, benign granuloma-like process of the GI tract (1). This tumor is most commonly located in the stomach (70%), ileum (29%) and colon (6%) (2-4). Other locations such as esophagus, duodenum, ileum and gallbladder account each to 1% (1-3). Patients with these tumors may present with abdominal pain, bleeding and obstructive signs. Diagnosis is made by histology. However, the endoscopic findings often show a submucosal lesion that is ulcerated or […] - [Mastering the Use of Hemoclips (Through-The-Scope-Clips)](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/mastering-the-use-of-hemoclips-through-the-scope-clips/): By: By Klaus Mönkemüller, MD, PhD, FASGE, FJGES. Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA Hemoclips, originally designed for hemostasis, are versatile tools that have revolutionized various endoscopic procedures. 1. Understanding Hemoclips Hemoclips are multifaceted tools that currently are used beyond their original purpose of hemostasis, and therefore we will refer to them as “clips”.These clips are now employed for closing perforations, post-resectiondefects, marking, and attaching devices such as stents and feeding tubes. For instance, in a procedure involving a gastric, esophageal or colon perforation, clips can effectively seal the defect, preventing further complications. Figure 1 […] - [Tips for Placement of Clips for Hemostasis](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/tips-for-placement-of-clips-for-hemostasis/): We are excited to bring you a brand new video on “Tips for Placement of Clips for Hemostasis”. In this lecture, we will delve into the important topic of clip placement for achieving hemostasis during medical procedures. >>> Click here to watch the full video Our expert speaker will be discussing the various through the scope clips that are available, emphasizing their different arm lengths and opening widths. Additionally, he will highlight the unique characteristics of each clip, including their ability to be rotated within the endoscope’s channel. During the lecture, a real case study will be presented. The speaker will focus […] - [The Hybrid ESD-EMR Technique Explained](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/the-hybrid-esd-emr-technique-explained/): Introduction: When it comes to endoscopic resection, ensuring complete lesion removal can be a challenge. However, the game-changer has arrived: The Hybrid ESD-EMR Technique. Klaus Mönkemüller sheds light on this advanced method designed for the complete resection of lesions in the colorectal, esophagus, and stomach areas. Key Takeaways: Conclusion: The Hybrid ESD-EMR endoscopic resection technique marks a significant stride forward in the realm of endoscopy, promising a safer and more efficient method for healthcare professionals globally. - [Abdominal Pain, Jaundice and Melena – Think of Hemobilia](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/abdominal-pain-jaundice-and-melena-think-of-hemobilia/): A 58-year-old patient with NAFLD, diabetes mellitus and hypertension underwent a liver biopsy for a 3 cm nodule in segment VI of the liver. About 24-hours later the patient complained of acute onset abdominal pain, followed by jaundice and chills. He also had melenic stools. On arrival to the emergency room his blood pressure was 100/50 and the heart rate was 100 ppm. The sclerae were icteric. There was right upper quadrant abdominal pain. CT of the abdomen showed dilated bile duct with possible common bile duct sludge or stones. The ERCP image is shown. Emergent ERCP demonstrated of multiple […] - [Understanding the Phrygian Cap Gallbladder: Common Congenital Variation and Its Implications](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/understanding-the-phrygian-cap-gallbladder-common-congenital-variation-and-its-implications/): Phrygian Cap Gallbladder: At a Glance What is it? A congenital abnormality of the gallbladder. Incidence: Found in 4% of the population. Appearance on Imaging: Can mimic a liver mass, leading to potential misinterpretation. Pathological Significance: None. It’s not a disease or a harmful condition. Symptoms: Typically none. However, if it causes symptoms like biliary colic or cholecystitis, medical intervention might be needed. Location: The gallbladder is a pear-shaped organ located beneath the liver. Other Gallbladder Anomalies: Variations can occur in form, location, or number. Cultural Note: The term “Phrygian cap” also has symbolic meanings in art, politics, and other […] - [Cavernous Lymphangioma in Small Bowel: Causes, Symptoms, and Treatment Options](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/cavernous-lymphangioma-in-small-bowel-causes-symptoms-and-treatment-options/): Case Presentation: About Cavernous Lymphangiomas: Symptoms & Complications: Endoscopic Recognition: Treatment Options: Conclusion: Cavernous lymphangiomas, though rare, present potential complications. Medical professionals should be well-informed about them and the available treatment options. Read more: https://www.thepracticingendoscopist.com/p/mid-gi-bleeding-of-obscure-cause - [Understanding Cronkhite-Canada Syndrome](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/understanding-cronkhite-canada-syndrome/): By Klaus Mönkemüller, MD, PhD, FASGE, FJGES  Cronkhite-Canada Syndrome (CCS) is a rare, non-inherited gastrointestinal condition of unknown etiology, often presenting as a diagnostic challenge with multiple symptoms, which may be vague and non-specific.  Case presentation:  A 48-year-old woman presented with chronic diarrhea and loss of taste. On the clinical exam she appeared pale, had brittle nails, and had partial hair loss. She was found to have severe iron deficiency anemia.  Colonoscopy showed multiple reddish, edematous mucosal streaks and polyps and pseudopolyps ranging from 5 to about 20 mm (Figure 1).  On EGD the stomach was characterized by enlarged mucosal […] - [Pneumatosis Coli: Characteristics, Diagnosis, and Etiologies](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/pneumatosis-coli-characteristics-diagnosis-and-etiologies/): An elderly patient presented with abdominal pain, diarrhea, and fever. A colonoscopy found pneumastosis coli in sigmoid colon polypoid lesions ranging from 10 to 30mm in size. This article describes the diagnosis, characteristics, and etiologies of pneumatosis coli. Key Points: Conclusion:Pneumatosis coli is a condition with multiple potential etiologies that can present in children and adults. The diagnosis is based on endoscopic and descriptive appearance, and treatment depends on the primary diagnosis. Read more here: https://www.thepracticingendoscopist.com/p/multiple-polypoid-sigmoid-colon-lesions - [(DIE) - Dabigatran-Induced Exfoliative Esophagitis](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/die-dabigatran-induced-exfoliative-esophagitis/): Non-vitamin K anticoagulants (NOAC), also known as direct oral anticoagulants (DOAC) are now commonly used for a variety of conditions requiring chronic anticoagulation. The dabigatran pellets are covered with a tartaric acid core. This strong acid may result in squamous epithelial damage with ensuing exfoliative esophagitis. Elderly patients are more prone to suffer esophageal damage due to medications as they have a) decreased salivary production, b) may not drink enough fluids and c) often have esophageal dysmotility. All these factors contribute to prolonged contact of medications with the esophageal mucosa. Other important causes of exfoliative esophagitis are: Herpes simplex Virus […] - [Tattooing - Tips and Tricks for the Best India Ink Tattoo](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/tattooing-tips-and-tricks-for-the-best-india-ink-tattoo/): India ink tattooing is a crucial technique in endoscopy, allowing surgeons to locate and resect lesions precisely, enabling minimally invasive approaches. Proper Injection Technique Avoid transmucosal or full-thickness needle insertion to prevent intraperitoneal injection and potential complications. Create a submucosal cushion by injecting saline first, followed by the ink, ensuring the ink remains contained within the submucosal space. This minimizes the risk of perforations and inflammatory reactions. Tangential Needle Approach Adopt a tangential or parallel needle insertion technique relative to the mucosal surface. This approach facilitates creating a well-defined submucosal bleb for the ink, ensuring precise marking and reducing the […] - [Gastric Hyperplastic Polyps](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/gastric-hyperplastic-polyps/): Question: A routine EGD for GERD, found to have one gastric polyp 8mm – turned out to be a hyperplastic polyp in at 45M? No H. pylori, no atrophy. Follow up? Short answer: No surveillance is necessary in this patient, especially because the patient is NOT infected with H. pylori and there was no gastric atrophy. To have some “piece of mind” I would resect that polyp on the index endoscopy. Extended discussion: Hyperplastic gastric polyps larger than 10 mm should be removed as they are associated with malignancy, i.e. harboring a cancer. On the other side, any sized hyperplastic […] - [Does the White Deposit (Chicken Skin Sign) Around the Base of the Polyps Have Any Prognostic Value?](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/does-the-white-deposit-chicken-skin-sign-around-the-base-of-the-polyps-have-any-prognostic-value/): “Chicken skin” mucosa (or “goose skin” in German-speaking countries, or “fish skin” in the Mediterranean and some Far East countries) was first described in Western countries in 1998 by Shatz et al. (Am J Gastroenterol). The authors found that CSM was associated frequently with adenomatous polyps and adenocarcinoma. Histologically, CSM is caused by an accumulation of lipid-laden macrophages. Subsequently, Nowicki et al (J Ped Gastroenterol Nutr, 2005) found that CSM is found in up to 75% of juvenile polyps. By using CD68 stain, which is specific for macrophages, the authors confirmed that CSM is due to lipid-laden macrophages and not […] - [Is a Fully Covered Self-Expanding Metal Stent an Option for Recalcitrant Duodenal Stenosis?](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/is-a-fully-covered-self-expanding-metal-stent-an-option-for-recalcitrant-duodenal-stenosis/): I have only used fully covered self-expanding metal stents for palliative situations such as malignant gastric outlet obstruction or duodenal perforation (by instruments or due to lymphoma). There are case reports of using fc-SEMS for benign conditions. Your case is very challenging as the patient likely has recalcitrant duodenal obstruction due to medications (NSAIDS). I also suspect that there is a component of ischemic duodenopathy in the setting of sickle cell disease. Your surgery team’s concerns are quite important because if this duodenal disease-stenosis is indeed due to NSAIDs, the possibility of continued or surreptitious use of NSAIDs after surgery […] - [Do You Use CO2 and Water Immersion in Diagnostic Colonoscopies on a Daily Basis?](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/do-you-use-co2-and-water-immersion-in-diagnostic-colonoscopies-on-a-daily-basis/): Yes. And Yes. - [Know Your Liver Segments](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/know-your-liver-segments/): It’s very important that you know your liver segments. This chart shows you a nice ways to memorize. It’s important that we correlate to where the segments are to the cholangiogram. As we can see here, the left liver lobes 2, 3, and 4 are drained by the left hepatic. And the right hepatic consists of the right anterior, 5, 8, and the right posterior branches, segments 6 and 7. This fist sign is quite useful to remember the drainage. Watch the full lecture on EndoCollab. - [How to Become an Expert in ERCP](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/how-to-become-an-expert-in-ercp/): Watch the Expert Rendezvous PTCD-ERCP triple-wire-technique followed by 5 plastic stents of different diameters Watch Videos, Visit Congresses, Become a Member of a Community or Endoscopic Society ERCP Models In Sum: - [Long Term POEM Success](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/long-term-poem-success/): What do you think of the Long Term POEM success? There is little long-term data. So far, we know that a significant amount of patients develop severe reflux esophagitis and stricturing esophageal disease. I still think that POEM is a good alternative for patients who are poor surgical candidates, but am still not 100% convinced that it’s the only therapy for achalasia, especially with much more long-term data from surgical interventions such as Heller myotomy. Peroral endoscopic myotomy (POEM). POEM is one the most significant progresses in interventional gastrointestinal endoscopy. The elemental concept of POEM is the performance of endoscopy […] - [Variable Stiffness Colonoscopes](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/variable-stiffness-colonoscopes/): What is the optimal way to use variable stiffness colonoscopes in difficult colonoscopies? Have you had any adverse events? Variable stiffness is a wonderful addition to colonoscopes, especially pediatric colonoscopes, which I use for most colonoscopies in the hospital where I have these scopes. At my other hospital we have a different scope brand (Fujifilm), which are also wonderful scopes. Variable stiffness is especially useful in floppy colons, elongated sigmoid colon and long colons that make turns in the pelvis. I advise to use variable stiffness mode in a “dynamic” fashion, meaning that once you feel there is some “floppyness” […] - [Colonoscopy Prep | How to Improve Boston Preparation Scales](https://endocollab.com/blogs/gi-endoscopy-tips-tricks/colonoscopy-prep-how-to-improve-boston-preparation-scales/): Can I Have Your Experience With Colonoscopy Prep? I Have Noticed That Most of the Patients We Receive Don’t Have a Good Boston Score? We had a similar experience as you and we have changed two essential aspects of colon prep. First, we created an instruction sheet for the patient and trained our nurses and secretaries to explain the preparation process, focusing on low fiber and zero seeds diet for at least three days, with a strict liquid diet the day before the procedure. In Germany, people like to eat bread with seeds. That’s a no for colon prep! The […] ## Pages - [About EndoCollab](https://endocollab.com/about-endocollab/): Advancing Endoscopy. Together. 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