BackTable / VI / Podcast / Transcript #179

Podcast Transcript: Happiness is a Warm Coil: Treating GI Bleeds

with Dr. Donald Garbett

Interventional Radiologist Donald Garbett and our host Sabeen Dhand discuss their standard workups and procedural decision making for GI bleeds, including radial vs. femoral approach and preferred embolics. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Understanding GI’s Workup for Bleeds

(2) Catheter Selection

(3) Embolic Selection

(4) Contrast Techniques

(5) Provocative Angiograms

(6) How Techs Can Help

(7) Exceptional Cases

(8) Arterial vs Venous GI Bleeds

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[Dr. Sabeen Dhand]:
I'm Sabeen Dhand, an IR in LA and I'd like to welcome back another interventional radiologist, Dr. Don Garbett from Radiology Associates in Eugene, Oregon. Welcome back.

[Dr. Donald Garbett}:
Thanks, Sabeen. Thanks for inviting me to chat.

[Dr. Sabeen Dhand}:
Of course, I really enjoyed your prior episode on acute limb ischemia. It’s episode 118 for our listeners to know. Not only did I learn some tips, but I saw a lot of similarities between both our practices, especially how we handle vascular. We're going to switch gears and talk about something way more bread and butter. I mean, it's pretty much any hospital-based IR practice provides services for GI bleeds. And so like anything IR, there's a million ways to skin a cat. So I want to know, and I want to compare how our practices both handle this. In your practice, how do you approach or workup a GI bleed?

[Dr. Donald Garbett}:
Yeah. I think we do a lot of GI bleed. I think most people in our field do at this point. And I think it's developed over the years. Like I know in training, I came out of training in 2015, it was sort of changing. We used to just bring everybody to angio and then check every artery, shoot all three: SMA, IMA, Celiac. These days we just tend to get a GI bleed CTA for most patients, and that's whether they're inpatient on a regular floor. Or if they’re ICU or if there have just been scoped, we'll still generally get the CTA, just so we have a roadmap. And we'll do the non-con CTA venous delay.

[Dr. Sabeen Dhand}:
Triple-phase, the triple-phase to see the bleed.

[Dr. Donald Garbett}:
Yeah. And we taught our techs. We taught our CT techs that if it says GI bleed and it's an inpatient, just, that's what you're doing. So if the hospitalist ends up ordering it, it already gets changed, which is nice.

[Dr. Sabeen Dhand}:
I like that. I'm glad you brought that up because there's a lot of stuff, people talking about, really not even taking to angio unless you get a CTA. So are you guys pretty hard and fast? I mean like would you always get the CTA or would you go to angio directly on these on these patients?

[Dr. Donald Garbett}:
I'd say it's rare to bypass, but we still do. I think the default is to get the CTA and someone calls and says “the hemoglobin has dropped. There was some bright red blood, a few hours ago, we're getting a CTA.” But I've definitely got ICU calls at like midnight and they haven't had any imaging. And they'll just say “it is profusely. We have a profuse bleed. We're crashing.” And I'll just say “send them down and I can get there in eight minutes in the middle of the night.” So we'll go fast.

[Dr. Sabeen Dhand}:
That's pretty awesome. So you live that close to work?

[Dr. Donald Garbett}:
Well Eugene's small, no traffic. I am driving at a nighttime speed. I can get there pretty fast.

[Dr. Sabeen Dhand}:
Faster than they can even bring down the patient.

[Dr. Donald Garbett}:
Yeah, the techs aren't even there yet. Like I'm open in the pac.

(1) Understanding GI’s Workup for Bleeds

[Dr. Sabeen Dhand}:
That's awesome. And so even before CTA, it's funny because I think there's been a shift of workups on GI bleeds. I mean, when we were training with GI, we finished the same year. So we're totally the same year. I remember in training, it'd be like, GI has to scope the patient. Is that happening 100% of the time in your practice now?

[Dr. Donald Garbett}:
I think it is a lot, I think it is probably 90% of the time because almost every patient would get called on. GI scoped, and they can't find it or they found it and can't get to it. It's one of those.

[Dr. Sabeen Dhand}:
We sometimes get this, like if it's a lower GI bright red blood per rectum. Sometimes our GI is, and maybe this is just my practice in my hospital, they'll be like, “there's too much blood in the colon. Like we're not even gonna take them.” And that might be time of day dependent, but I basically just say F it like, fine. I'll just take it. I don’t know if that's something that happens in Eugene.

[Dr. Donald Garbett}:
That's interesting. Sabeen remind me, are you at a university? I don't remember.

[Dr. Sabeen Dhand}:
No I'm at a private practice. We have like three hospitals, but it's a community private practice.

[Dr. Donald Garbett}:
Okay, so it's similar. I think it may just be the GI situation. Maybe they're just overconfident, or I shouldn't say overconfident. Maybe they’re very confident. They will go in.

[Dr. Sabeen Dhand}:
Yeah, that's awesome.

[Dr. Donald Garbett}:
Like I've walked in to consent and they're in there scoping already.

[Dr. Sabeen Dhand}:
That's awesome. I wonder, when they do scope how often do they find, like in a lower GI bleed that’s profusely bleeding, do they give you that final answer as far as like, oh, there's too much blood? Or do they find it a lot?

[Dr. Donald Garbett}:
No, we'll hear that. We'll definitely hear that. I don't know their percentages, their success rates, but they still seem to do it. So I wonder. But they're high level. They they're all doing ERCP. Some of them do like really advanced ERCP. So I think they're just coming from, I feel like we're on the same page. I feel like we're doing really advanced stuff and I feel like they are too.

[Dr. Sabeen Dhand}:
That's great.

[Dr. Donald Garbett}:
So we’re all battling for who's got the best skills.

[Dr. Sabeen Dhand}:
GI and IR work so close together. I think we have very different groups between our three our hospitals. We have some that are really good and some that are on the other side. Having a really good relationship with any IR practice. You've talked about building an IR practice in rural. I mean, having a GI group is really vital to doing these bread and butter procedures. We talked about getting a CTA, you get it most of the time, us too. Now there's a school of thought that if the CTA is negative, you do not take to angio. Is that what you do? Or do you go to angio still?

[Dr. Donald Garbett}:
Well, in general not go to angio if it's negative. There’s very few exceptions. If the CT was negative, but GI has really identified at abnormal area we'll then in that case, we'll still take them and maybe empiric, you know, empirically take something.

[Dr. Sabeen Dhand}:
Yeah, that's pretty cool. That's a good point. Like if they find some sort of lesion that’s not necessarily seen on CTA, would you just empirically embolize where you? Like give an example of what you would empirically embolize.

[Dr. Donald Garbett}:
Yeah. I think we see a lot of duodenal ulcers.

[Dr. Sabeen Dhand}:
So that GDA embo, right? That GDA sweep kind of embo. Yeah, those are kind of fun. Those are the ones. I know exactly what you’re talking about. You got the duodenal and they're like there's ulcers that are bleeding. So you're like, okay, I'm just going to go and embolize the gastroepiploic and GDA.

[Dr. Donald Garbett}:
Right, you're in and done and you're not hunting. You just go.

(2) Catheter Selection

[Dr. Sabeen Dhand}:
Yeah. So why don't we talk about technique? Say you're taking them to angio. You talked about shooting the Celiac, SMA, and IMA, generally going transfemoral. Do you do any transradial now?

[Dr. Donald Garbett}:
I didn't think we'd talk about that. So I do so much radial now that it's almost easier for me. And then especially if any of them, I guess not aspirin we don't worry about that. But if they're on anticoagulants, though they're usually off by then because they're bleeding. But if they're even like a bit heavy where I don't want to deal with the groin, I'll just go radial and my tech already know everything. I have like a list. They just open up the list.

[Dr. Sabeen Dhand}:
It's great to have that right. I mean, in our practice too, we go radial for a lot of things. GI bleeds I would still say majority is femoral in our group. But we have been doing more transradial, especially now that we have longer microcatheters. For femoral, I usually use like a 130 length microcatheter, just in case I got to go distal in the SMA. From radial, are you using the super long, like the TruSelect? The 175?

[Dr. Donald Garbett}:
I'll have it ready. If they're tall, I'll just go straight TruSelect. And they got the burn shape on that too which is nice.

[Dr. Sabeen Dhand}:
So you like the shaped microcatheters. We pretty much just use straight and curve our wire. But do you like the curve shapes?

[Dr. Donald Garbett}:
I do. I didn't care for them initially. And now I've noticed, and maybe I saw somebody do it, but you can just put that little three CC syringe on the back. And I can almost just drive those without the wire sometimes.

(3) Embolic Selection

[Dr. Sabeen Dhand}:
That's awesome. Yeah. I got to try and see another little tip and trick. I love this stuff. So you just drive it. That's I think what the direction was meant to be. Right. They kind of designed it to be a kind of a microcatheter without a wire. So are you coiling generally for these if you see a positive lead? Any other kind of embolic that you're using?

[Dr. Donald Garbett}:
I did use glue years ago. I think it's just so easy to do the coils now that I've veered away from it. I did use to do it before. But depending where it is I’ll grab a detachable and then I'll shove a few Cook coils behind it. I hate when they don't occlude immediately.

[Dr. Sabeen Dhand}:
Yeah, it's so true. Especially since the Rubies don't have any fiber sometimes it doesn't occlude immediately. Right? So you're like injecting and you're selectively injecting. You still see it, like, is this going to eventually block off or what? And you just throw some kind of fibered coil. The Cook ones are nice, but I've been loving detachables. I'm not gonna lie. it's just so much more control.

[Dr. Donald Garbett}:
Especially for that first coil, it is expensive. Well, that's why I'll put the Cook behind him.

[Dr. Sabeen Dhand}:
If you're using a Lantern, which is a little bit bigger of a catheter, you have any issues pushing a pushable? Or using a typical .018 coil or interlock or any other ones?

[Dr. Donald Garbett}:
I'll mostly use the detachables and then the pushables. I'll just inject them.

[Dr. Sabeen Dhand}:
Yeah. There's nothing better than just like pushing them in. And then why'd you move away from liquid? Why'd you move away from glue?

[Dr. Donald Garbett}:
Why did I move away? I guess it's just, I'm scrubbed in, and then I've got to tell the tech what to do. And I get a lot of new techs. Like there's a lot of turnover and I have to be training all the time.

[Dr. Sabeen Dhand}:
Yeah. I mean, it's peculiar, right? You have to get everything kind of D5 and all of this, keep everything clean and whereas you can just get it coil really quickly. That's a good point.

[Dr. Donald Garbett}:
Yeah. I think if I had steady techs. We do neuro too. And if I always had the neurotech, I'd be like, yeah, Let's do it. I don't know. But it's easy. The coils are easy enough with the detachables that it's, I don't worry so much.

[Dr. Sabeen Dhand}:
Have you ever used like Onyx or anything like that? We've been trying Lava in our trial, which is basically Onyx. But have you tried Onyx in GI bleeds?

[Dr. Donald Garbett}:
I haven't for GI bleeds. Vascular mouths, but I haven't used it for GI bleeds. That's cool.

[Dr. Sabeen Dhand}:
You bring up the same, a good point though. I mean it takes us training. You gonna mix it, dry and all that. It's a lot damn easier to just throw in a coil. Especially at night.

[Dr. Donald Garbett}:
Lava? Is that another company? I'm not familiar with it. What is that?

[Dr. Sabeen Dhand}:
Lava is basically Onyx for peripheral. It's very similar to Onyx and they're trialing it basically as a peripherally indicated liquid embolic. But it's basically Onyx, so they're going undergoing trials right now. Speaking of embolizing then, you ever use particles?

[Dr. Donald Garbett}:
Ah, Is there a case? I'm trying to think of a situation in GI bleed.

[Dr. Sabeen Dhand}:
I personally don't. Sometimes I've used a little gel foam to get a little occlusion, like a little sandwich, little gel foam, especially on the GDA thing. But I haven't used particles. Although I've seen some talk about it. But I personally haven't.

[Dr. Donald Garbett}:
Yeah. I've done the gel foam thing, but I haven't done particles in GI bleed.

[Dr. Sabeen Dhand}:
So coils are pretty much your go-to. You’re transradial, you’re coiling, usually through a microcatheter. So on a negative, you've shot your celiac, SMA and IMA. It's negative so far. Are you then selecting out branches? Or are you just staying in those three?

[Dr. Donald Garbett}:
That's a good one. Well hopefully they have some clips somewhere from before. And then you might think oh, maybe they re-bled in some old spot. So then I might coil something like that. But I will go select stuff. I'll generally see nothing and I shot the main vessels. I'll go shoot the GDA and I'll bring it down deep and shoot. And then I'll go to back to SMA. And I'll pick one or two branches going off to the right, usually.

[Dr. Sabeen Dhand}:
Okay. Like ileocolic and middle or something.

[Dr. Donald Garbett}:
Yeah. I'll probably sub select three or four vessels total. I remember in training, like you shot three vessels negative, done. I just it's coming back to me the next day. I'm trying to get it. We're trying to get it, done.

(4) Contrast Techniques

[Dr. Sabeen Dhand}:
Exactly. Are there any tricks? I mean, I one time read, I think it was on the SIR forum that some people are using CO2. I don't personally. And then some people are either doing a lot of saline flushes or diluting their contrast a bit. Because they say that the contrast is too thick and if its thinner you'll be more sensitive to GI bleeds. Have you heard of any of that or do any of that? I don’t

[Dr. Donald Garbett}:
That's interesting. I think our contrast for doing power injections is already diluted 60. So I don't dilute more. But I wonder what are people, do you know how much they're diluting?

[Dr. Sabeen Dhand}:
I don't know. I just remember reading it one time and I thought that was interesting. We do 100% on ours. For peripheral angios we'll dilute ours. But you don't find that it decreases like you're visualization? Like on a big person. If you're diluted, are you seeing all the vessels pretty good? That's my worry.

[Dr. Donald Garbett}:
I’ll turn up the juice on the fluoro as soon as I can't see a catheter. If the catheter is like see-through, we’re turning the juice up. So it's usually not an issue. We have a brand new, I mean, our angio suite is one year old. It’s Phillips so we can see pretty well.

[Dr. Sabeen Dhand}:
Nice. That's good. In our main lab, we have like two Siemens labs, but they're like 10- years old. So they need an upgrade.

[Dr. Donald Garbett}:
The new Siemens ones are really great.

[Dr. Sabeen Dhand}:
Yeah. We're looking into it and they’re real nice, you know?

[Dr. Donald Garbett}:
We went from a 14-year-old suite that I couldn't see anything. Triple mag, all the way, fluoro rate at max, one grade per minute. I couldn’t see anything.

[Dr. Sabeen Dhand}:
And now it's like life-changing right.

[Dr. Donald Garbett}:
Yeah. It's, it's so different.

(5) Provocative Angiograms

[Dr. Sabeen Dhand}:
What about, and it's something that our group has worked a lot on. I kind of picked up this technique from training called provocative angiograms. So let, let's talk about that. Are you doing them by the way? And then, what type of patients are you taking?

[Dr. Donald Garbett}:
Yeah, it's I think it's certainly not a normal in our practice, so we don't have a protocol or anything written up. And then I'd say it's pretty rare. So that step two. It's pretty rare that we get one that's negative. But in that case I'll do the hunt. And then I will, we keep 4 TPA in the fridge in the room. I'll just get that. And I know people are doing like big infusions. I've heard this. I'll inject 4 TPA in the SMA and then reshoot the whole SMA. Yeah. But I haven't done anything more than that.

[Dr. Sabeen Dhand}:
Yeah. I liked the way how you guys have organized or workup. Basically if the CTA is negative, you're generally not doing an angio, right? Our practice is kind of mixed. It might be time of day dependent, all right. If it's like 4:30 pm and the CT’s kind of backed up, it's like all right, just bring them in quick. So we actually have a little bit more than I like have a negative angio rate. We frequently we'll take them, but we also take negative CTAs to angio and every once in a while they're positive. So we haven't come up with a really hard and fast rule in our group. Everyone's a little different. We've had these like kind of negatives that we do provocatives on quite often and it's pretty amazing. I mean, you’ve seen it work even just with four milligrams of TPA, I'm sure. And it's pretty well controlled. I think people were really kind of scared about it before and like, oh my God, you're injecting TPA in a bleeder. Like that sounds about as cowboy-ish as an IR is. But we've liked the results that we've gotten so far. And we're kind of one of the crazy ones. We'll do big infusions, like 50 milligrams.

[Dr. Donald Garbett}:
50? Oh, holy cow.

[Dr. Sabeen Dhand}:
That's our upper limit, yeah. But we'll get some people that'll be like, a year or two of just these intermittent bleeds and they've been getting chronic transfusions. No one can find it and yada yada ya. So, so we'll do those and in a good half of them we'll find something.

[Dr. Donald Garbett}:
Really interesting. And so how do you do it? Are you just parking a catheter in SMA or what are you doing?

[Dr. Sabeen Dhand}:
Yeah. It's either SMA or IMA the majority of the time. Sometimes there'll be a left colon and bleed, so, so then we'll do the IMA, and we're just parking there. And then every five minutes we're injecting another five milligrams of TPA. We'll give some heparin and nitro as well. And yeah, it takes a lot of contrast. And we'll do them with anesthesia. Do you do, how's anesthesia availability in Eugene?

[Dr. Donald Garbett}:
So it varies. We do stroke and they automatically come for that. Right. So they’re part of that.

[Dr. Sabeen Dhand}:
So you're a stroke. You guys are doing all strokes with GA or with anesthesia at least.

[Dr. Donald Garbett}:
With anesthesia, not always GA. But it's not an automatic for GI bleed. And we’re trying to get them in fast.

[Dr. Sabeen Dhand}:
Yeah, you don't want any slowdowns and stuff too. So I agree. I mean, ours are mostly conscious sedation. Are you, sometimes one trick I do, I've totally forgot. Sometimes I use glucagon. Have you ever tried that? It literally stops small bowel, like the peristalsis. But it only lasts for like three minutes.

[Dr. Donald Garbett}:
Yeah. I guess if you had a crazy bowel moving all over, it'd be great. Yeah.

[Dr. Sabeen Dhand}:
I know if some of our patients are real gassy.

[Dr. Donald Garbett}:
Yeah. Yeah. Or if they’ve had had a recent scope, they're going to be all insufflated.

[Dr. Sabeen Dhand}:
Exactly. So, yeah, it's cool. I mean we just use like one milligram. Try it out. It's pretty cool. It works, but again, it works for like three minutes and then it goes away. I don't know the upper limit, but I haven't done more than two milligrams of IV glucagon.

[Dr. Donald Garbett}:
I’ll definitely try that next time I have one of those.

[Dr. Sabeen Dhand}:
Yeah. Any other kind of words of wisdom on GI bleeds that you've kind of learned? I mean, again, it's a bread-and-butter procedure. But you ask all these people. I mean, how your practice deals with it is different than how our practice, I mean, I feel like we lack a little bit of guidelines in my practice. But you guys are more, it seems more kind of uniform in your practice.

[Dr. Donald Garbett}:
We’ve been pretty cohesive about it.

[Dr. Sabeen Dhand}:
Yeah. Anything that you've kind of learned after training that's kind of helped you with these cases? Whether it's been ones that you select to go come down or after post management, anything else that you kind of recommend?

(6) How Techs Can Help

[Dr. Donald Garbett}:
I think probably two things. One thing is that the techs set up. So they've built, might be a little funny. They build a moat around the patient.

[Dr. Sabeen Dhand}:
Ah. You’re going to have to submit a picture of this at some point so we can put it on our website. What do you mean? I have a moat sometimes when we do like a PleurX catheter. Cause ascites or effusions are going to jump out at you. Is that what you mean? Like a little like towel? I don't know, wall?

[Dr. Donald Garbett}:
Kind of, yeah. They take the blankets all the way around the patient. But just below the butt and then up to the shoulders. And they build like a capture for the blood. Cause sometimes, you know if we get a crashing one, it is a huge mess.

[Dr. Sabeen Dhand}:
This is interesting.

[Dr. Donald Garbett}:
One of the techs came up with this years ago, I guess.

[Dr. Sabeen Dhand}:
You have to share this. Whether it's on your socials or on Twitter or something. Obviously not with the patient. There is something about it. That's pretty interesting. Yeah, it can get messy. Like literally like a horror show. Like GI bleeds like lowers. Maybe it gets kind of hidden under the blue towel, but like an upper, and then they're like a horror show. It can be really, really bad.

(7) Exceptional Cases

[Dr. Donald Garbett}:
Yeah. One other interesting thing that happened one time is an accident. We were doing an upper GI bleed. It was like a fundal. So it was like, quick left gastric catheterization. You could see all the clips and I shot the pic. Everything spasmed. Couldn't get in. It's all spasm, but you can still see it going. It's not occluded. And then I thought I called out nitro. I was like, I need nitro. But I think I said epi. They put epi on the table and a syringe and I assume it's nitro. And then I inject.

[Dr. Sabeen Dhand}:
Did you just slam it in?

[Dr. Donald Garbett}:
I slammed it right in and nothing happened to the patient, but the whole left gastric just occluded immediately. And I looked at it and I was like, are we done? Is that? You know because GI injects epi.

[Dr. Sabeen Dhand}:
Yeah. No, apparently that's how they would also treat GI bleeds in the past too. They would drip vasopressin. And like, this is back in the day, they would just drip vasopressin in the SMA or something. I don't know, like in the ICU. That was one of the ways they would treat it. So then did the bleed stop or did it come back?

[Dr. Donald Garbett}:
No, it stopped. It stopped, but you couldn't see any more active bleed. I had a little bit more vessel, so I just punched one coil into it and called it good. And they never re-bled. So, but that’s an anecdote.

Dr. Sabeen Dhand}:
Yeah. Speaking of the left gastric, I find that vessel, you can do whatever you want to it. You can slam, like you can do particles there. Right? I mean, that's what they do for bariatric embo. You can throw gel foam. Like if you're suspecting a left gastric bleed you can just like take out the vessel. And there's like, knock on wood, there's been no badness. I mean, have you seen gut ischemia on any of your embolizations? I personally have not. it's just such a robust organ system. But have you had any ischemia?

[Dr. Donald Garbett}:
I haven't. I’ve heard stories, but I haven't had any. I haven't seen any.

[Dr. Sabeen Dhand}:
I mean, whether you go really selective. Or I remember one or two cases early in my career when I couldn't get into and I had to embolize the marginal artery a little bit. And that still was okay. So, I mean, I don't know, but its just such a robustly collaterally flowed system. I don't understand why not ischemic, but great.

[Dr. Donald Garbett}:
Yeah, I think it's helpful for it.

[Dr. Sabeen Dhand}:
Great. Well, the one last question I got for you, Don, and this might not be just for GI bleeds. But as our listeners probably don’t know that you have really damn good taste in music. So, you're going in, you’re getting pumped up for an angio. Whether it's GI bleed, what's your tiered music choice to get you really in the zone?

[Dr. Donald Garbett}:
So, I'm an EDM fan. And so one of my techs has really fantastic taste in music. And if she's there, she'll just do it. She'll just put it on. She has great taste and I just love it. But if not, I have a playlist that's like my go-to and it just spans like everything in EDM that I've liked for the last 10 years.

[Dr. Sabeen Dhand}:
That's okay. Yeah. It's so important. I can't work without music, so I always have it. Although some of my techs call my EDM Roomba music, it's fun. I try to play the chill stuff, but yeah, it's great. I mean, it's great to talk about these bleeds. Everyone coming out of training programs learns how to approach these and it's important for our listeners to know that there's a lot of ways to approach them. Whether you coil, whether you glue. Looks like you're doing all of them transradial, which is awesome.

[Dr. Donald Garbett}:
Well, I'll caveat. If they're the crashing GI bleed, I'll go groin. Just because it’s easier for the techs to set up.

[Dr. Sabeen Dhand}:
Yeah. Oh yeah, true. I don't know what's on the frontier as far as GI bleeds. I'm sure GI, it would be really interesting to talk to them one day and see what's new for them? I mean, are they doing anything new or is that just kind of a, “hey, there's been no development”, I don't know. But it's something that will stick with all of us. Its a great way to help patients and really stop bleeds. It's pretty amazing when you see like a hypotensive crashing bleeder and boom, you embolize, and literally by the time they're getting out of the room they’ve been stabilized. There’s something great about that.

[Dr. Donald Garbett}:
It’s funny because we'll get the coils, you see the active bleed, you put the coils in and you occlude it. And you've, I'm sure you've seen it where it's just the tachycardia stops and it's like almost instant. It’s deceiving how quick it is.

[Dr. Sabeen Dhand}:
Yeah. It's pretty addictive. I think that's probably something that when I saw it the first time, probably in training, I was like this is really, I mean, it draws me. One of my favorite things is to embolize in IR. I think if I'm not re-canning a vessel, I still love that little youthful part of just “hey I'm going to embolize this.” Like a GDA embo, like, oh, that's great. I'm just going to embolizes, make it look nice, go to the origin and just, I don't know. I just kind of have fun with it almost, you know?

[Dr. Donald Garbett}:
I just want to share one good case because it was just a dramatic one. So, I'm at our smaller hospital and I'm doing some biopsy or something. And I got a call from the ER that the GI is in the ER with the scope in. And he's got the scope aimed at the duodenum, at a duodenal ulcer. And he's just suctioning because there's so much profuse bleeding that it's like airway compromise. So he's just suctioning. And he said, I guess he told the ER doc, see if iR is available because I can keep doing this until they're out of blood.

[Dr. Sabeen Dhand}:
Oh man.

[Dr. Donald Garbett}:
So then somebody grabbed me, like they literally came over. I was doing a lung biopsy and I just finished. And they're like, just come over. And I came over and I look on the screen and he's like, there's the ulcer. He points at it. And he says, how soon can we get you in? Or how soon can you get the patient in? And so we went like rapid fire. I just ran over to the cath lab. It was empty. It happened to be empty.

[Dr. Sabeen Dhand}:
Perfect fate.

[Dr. Donald Garbett}:
Yeah, so we just ran everything with the scope in, you know. He just kept it in just suctioning at the ulcer. We get to the cath lab. The surgeon is right there as well, cause he's ready to open . And it's like all of us and we're all in there and we get them on the table. He starts coding, like immediately starts coding. Of course.

[Dr. Sabeen Dhand}:
Of course. Of course, they’re fully fine in the ER, you know, suctioning units of blood.

[Dr. Donald Garbett}:
So, and we've got three nurses or four nurses. We got an ER doc, we got surgeon, we got everybody. So I hurry up and just get access, no imaging, just the old school. And betadine, just betadine. No drapes. Nothing.

[Dr. Sabeen Dhand}:
Oh, okay. This is legit.

[Dr. Donald Garbett}:
I’m just like, we’re going unsterile, don’t worry about anything.

[Dr. Sabeen Dhand}:
Yeah. This is saving this person's life right now.

[Dr. Donald Garbett}:
These are the fun moments when you have a med student and they're like, I want to do IR now.

[Dr. Sabeen Dhand}:
Yeah.

[Dr. Donald Garbett}:
So they're literally doing chest compressions. We get access. I’m: “guys, are you cool just getting x-rayed?” And they say yes. And we just shoved the catheter up. We already know where it is. So I just shove it into the GDA pretty much without imaging. It caught it. I saw it go over. I'm like, I guess we're in. I inject a little bit of dye and you just see the waterfall of blood.

[Dr. Sabeen Dhand}:
I'm guessing you use a Cobra to get into the celiac?

[Dr. Donald Garbett}:
Yeah.

[Dr. Sabeen Dhand}:
I love it because then it'll just go to that. And boom.

[Dr. Donald Garbett}:
And then just drop the kitchen sink, every coil boom, boom, boom, boom, boom. And he suddenly got his rhythm all back. It was just wild. It was one of those. And at the end there was blood all over the room. The whole room was full of blood.

[Dr. Sabeen Dhand}:
Ah, I see where the moats come into handy there now. Yeah. Oh, that's insane. I have to say, so that's like adrenaline and having a good outcome. It’s something that's great. That's crazy

[Dr. Donald Garbett}:
And you know, it's the visual. We had a general surgeon on top of the patient doing compressions. GI still has the scope in while we're doing it. Like the whole thing. It was pretty wild.

[Dr. Sabeen Dhand}:
Yeah, I bet you made a lot of friends at different services.

[Dr. Donald Garbett}:
We did.

[Dr. Sabeen Dhand}:
Oh yeah. That's a total win for your service.

[Dr. Donald Garbett}:
Yeah. I was just wondering, do you want to talk about, I mean, I know it's a whole other
Topic. But you do the triple phase and then you see like there's varices and it's not arterial.

(8) Arterial vs Venous GI Bleeds

[Dr. Sabeen Dhand}:
That's a good one. That's a really good point. And that's something really important to mention. Yeah. We have to talk about that. Where not all bleeds are arterial. We've seen and it’s been weird. Sometimes it's not even like a typical cirrhotic or something. It's like these weird jejunal varices or some nonsense, right? I don’t know, for some reason to have this portosystemic shunt in a non-cirrhotic. Maybe they were born with it. I'll tell you what we do once, I want to know what you do for those. We've only had a couple, I can think of a handful, like five cases like that.

[Dr. Donald Garbett}:
We're probably the same. We're going to handful.

[Dr. Sabeen Dhand}:
What do you do?

[Dr. Donald Garbett}:
If you didn't do the imaging, you probably wouldn't know.

[Dr. Sabeen Dhand}:
I have one case where one of my damn smart partners, none of us saw it, but then when you look back, you see it. It was like, you carry out the run late and then he saw these varices on the late run. I'm just looking for the SMV, and he saw these things in the corner. And he was totally right. So, if you don't
do the imaging, aside from that case, you probably wouldn't know and call it negative. Do you go direct portal and embolize them. Do you do a TIPS or what do you do?

[Dr. Donald Garbett}:
I guess it depends on what you see. If it's a totally cirrhotic liver, I might go to TIPS. But I think these are usually like the surprise, right? Where it's like, there's some weird shunt. There's some weird varices. Maybe fatty liver, but not quite cirrhotic. So in those I'll just stick direct portal and go embolize the varices directly. And then we'll key them in to follow up to see if they need portal hypertension treatment or something.

[Dr. Sabeen Dhand}:
More stuff. And aside from those varices, even so gastric varices, which is an upper GI bleeding issue. In cirrhotics, are you a believer of TIPS? Are you a believer of some sort of retrograde obliteration or both?

[Dr. Donald Garbett}:
Yeah. Wasn't it Sabri that was on not that long ago?

[Dr. Sabeen Dhand}:
Yeah

[Dr. Donald Garbett}:
I mean, he's the master and there's a few masters out there.

[Dr. Sabeen Dhand}:
He’s the master. Yeah, exactly.

[Dr. Donald Garbett}:
But I do. With the BRTO, you have a bunch of gastric varices they're actively bleeding. You BRTO it in that situation and you do push out some blood, invariably, they're going to pop.

[Dr. Sabeen Dhand}:
It’s been pressurizing.

[Dr. Donald Garbett}:
So I guess I've done some BRTOs when they've bled recently. But I do expect that they're going to bleed so we’re actively replacing fluids and blood.

[Dr. Sabeen Dhand}:
And would you do a TIPS in those too or do you just see how the BRTO does or the CARTO, PARTO?

[Dr. Donald Garbett}:
I think if they're isolated gastric, we've generally gone to BRTO. But if there's varices all over, then we'll go to TIPS as long as they're not like MELD 25.

[Dr. Sabeen Dhand}:
Yeah. I know.

[Dr. Donald Garbett}:
Or in florid heart failure. Then you're kind of hosed.

[Dr. Sabeen Dhand}:
No, these are great points. I mean, GI bleeding can be venous and as IR we need to be able to approach both of those and the imaging can show all of that. So that's a really good advantage of having triple-phase CT, to show you it might be a cirrhotic. Hopefully they see that in their scope, but sometimes they may not. Those are big topics. We talked about BRTO and stuff with others. I think that pretty much gets all of GI bleeding. Anyone who's listening to this hopefully can just go out there and hopefully don't have a crazy case, like you mentioned, but get some of those wins. I think every IR has a story somewhat to that degree of embolizing and just creating a win.

[Dr. Donald Garbett}:
Yeah. Do you know the rule of twos? I learned this from GI.

[Dr. Sabeen Dhand}:
This sounds really familiar.

[Dr. Donald Garbett}:
It's the rule of too’s. It's a too sick for me to scope. Too stable for me to scope. Call IR. That’s the rule of too’s.

[Dr. Sabeen Dhand}:
I like it. That's quite true. No, it does seem to give an awesome GI service and it great in having that. So, for our listeners, if you have any questions about GI bleeds or anything like that feel free to contact any one of us, both of us are on socials on Twitter. and we're happy to talk about it. So, yeah, Don, thanks for being here and thanks for your time.

[Dr. Donald Garbett}:
Thanks for having me, Sabeen. Great chatting with you.

[Dr. Sabeen Dhand}:
We'll see each other soon. I'm sure.

[Dr. Donald Garbett}:
Yeah, man.

Podcast Contributors

Dr. Donald Garbett

Dr. Donald Garbett is a practicing Vascular and Interventional Radiologist at Minimally Invasive Specialists in Eugene, Oregon.

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Cite This Podcast

BackTable, LLC (Producer). (2022, January 17). Ep. 179 – Happiness is a Warm Coil: Treating GI Bleeds [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.