INTRODUCTION: Currently there are few effective therapies for acute gastric variceal hemorrhage: endoscopic variceal ligation (EVL), cyanoacrylate injection, and endoscopic sclerotherapy (ESL). For variceal hemorrhage that is not amenable to these therapies, Transjugular intrahepatic portosystemic shunt (TIPS) or Balloon-occluded retrograde transvenous obliteration (BRTO) are recommended. For patients with contraindications to these procedures there is no effective treatment. Here we present a case of acute gastric variceal hemorrhage, in which hemostasis was successfully achieved with the use of Hemospray (hemostatic powder). CASE DESCRIPTION/METHODS: A 63-year-old hispanic man with PMH of HCV and alcoholic cirrhosis presented with coffee-ground emesis and melena. Admission vitals: T-37.7, HR-117, RR-20, BP-139/72, O2 sat-100% on RA. Physical exam was significant for only mild jaundice. Hemoglobin was 6.3. We started Protonix IV BID, Octreotide drip and Ceftriaxone QD. CT abdomen showed multiple metastatic appearing liver lesions, cirrhosis, varices, and cavernous transformation of the portal vein. Overnight his hemoglobin decreased to 4.5. During EGD, multiple gastric varices were noted including a large, actively hemorrhaging, GOV-2 varix. Unfortunately, we were unable to perform EVL due to the sheer volume of bleeding present. IR was consulted for emergent TIPS. However the patient was not a candidate for TIPS or BRTO due to the cavernous transformation of his portal vein. The decision was made to utilize Hemospray. EGD was repeated and the large GOV-2 gastric varix was seen actively hemorrhaging. A large, obstructing clot was removed and the site of bleeding was visualized. Hemospray was applied and hemostasis was quickly and effectively achieved. After application, the patient did not have recurrent bleeding. DISCUSSION: Hemostasis in the setting of acute gastric variceal hemorrhage can be very challenging to achieve. Hemospray should be considered when traditional therapies fail. It becomes cohesive and adhesive when it comes into contact with moisture, forming a stable mechanical barrier. Although there are few studies investigating its use in acute variceal hemorrhage, it was very effective in this case. Hemospray can also be useful for providing temporary hemostasis in an emergent situation; giving physicians more time to organize more definite treatments. Hemospray is a powerful endoscopic tool and should be considered when standard bleeding therapies are inadequate.

INTRODUCTION: Bowel preparation is one of the most important factors affecting diagnostic yield and reaching the cecum in colonoscopy. Poor bowel preparation is encountered in up to 25% of colonoscopies. Hospitalized patients typically have poorer bowel preparation compared to outpatients due to factors such as acute illness and narcotic use. In this study, a new bowel preparation process using multimedia and visual aids was introduced with the goal of decreasing suboptimal and incomplete colonoscopy in hospitalized patients. METHODS: The study was conducted at a single community hospital in Las Vegas, Nevada. Nurses and nursing assistants completed an online educational module consisting of interactive written and video materials. All patients scheduled for colonoscopy received a brochure and watched a short 10 minutes video detailing the colonoscopy process. This new process was implemented on February 1, 2019. Post-implementation data were collected from February 1, 2019 to March 31, 2019. This was retrospectively compared to pre-implementation timeframe from December 1, 2018 to January 31, 2019. In the post-implementation period, 46 patients were included while 13 patients were excluded due to colonoscopy aborted or not performed for reasons unrelated to bowel preparation. During the pre-implementation period, 48 patients were included and 10 patients were excluded. RESULTS: In the post-implementation period there was a decreased in the number of colonoscopies aborted due to poor bowel preparation (19% to 7%). Of the number of completed colonoscopies, the average Boston Bowel Preparation Score are comparable (6.00 versus 5.95). The percentage of adequate bowel preparation, defined as Boston bowel preparation score of 6 or greater, are also similar (58% versus 57%). CONCLUSION: There was a significant decline in the number of colonoscopies aborted due to poor bowel preparation after the new process was implemented. The educational materials likely benefited those patients with poor initial understanding of the bowel preparation who would have inadequate preparation for successful colonoscopy otherwise. In patients with adequate initial understanding, the educational materials are less likely to be beneficial or change the outcome of the colonoscopy. This is evidenced by similar average Boston Bowel Preparation Score and percentage of adequate bowel preparation in both timeframes. These findings emphasize the importance of patient advocacy and education.