 So, this is our forest classification for deodorant ulcer, this is all various types of ulcers that you can see for only the ulcers of 1, 1A, 1B and possibly 2A we do clipping, the rest of the ulcers there is no need for a clipping. A infusion of phantoprosol at 8 mg per hour for 72 hours is recommended because it helps in clot stabilization and stops the bleeding. So, this is how the management of upper GI abilities, endoscopy first line therapy, recommendation the world over all over the world the societies recommend for a variceal bleed you have a window of 24 hours because of the availability of drugs like tarly prasina and doctor tried to do the endoscopy. For non-variceal bleed it is a 12 hour window to go in and do the endoscopic therapy. What is the role of re-bleed? Re-bleed occurs in about 30 to 40% of deodorant ulcers if they have red signs or actively spurting value going. What is the role of interventional radiology? Active bleeding should be at least 1 cc per minute to identify the focus of bleed and embolize it. What is the role of tagged RBC scan? Very, very minimal nowadays surgery is still the last option. So, this is about GI bleed. GI bleed identification referral to an emergency department as early as possible interventional in the form of an endoscopic therapy as early as possible is required. So, therapy goals of therapy for a lower GI bleed the ABCs again arrange and transuse blood target hemoglobin 8 to 10 8 for non-cardiac patients 10 for cardiac patients we do not aim at a higher blood hemoglobin. Endoscopic therapy versus interventional radiology therapy the last option is always surgery. Foreign body in the isophagus this is a common problem you you are finding up on Saturday evening going your wife has called you somewhere and then the call comes boy has swallowed a coin end of your evening. Now the problem is most people after they swallow the coin they give them bananas they give them all sorts of thing before they send them to the ER. Now I have to wait the next 8 hours till the stomach is empty for which to do the endoscopy. So, if somebody sees a foreign body in the isophagus especially in the isophagus please do not give them anything just send them to the emergency. The further away the last nearly is from the time of the foreign body injection the easier it is for us to intervene because most of these are children and if it is an adult somehow you can take a risk go in and remove the foreign body. But pediatric case always requires an anesthesia and I have to wait that critical 6 hours before I take up the case. Suppose somebody has swallowed a foreign body and just yesterday evening I was winding up and then as usual a 6 year old boy was following pill playing with a 5 rupee coin he comes in with a foreign body injection and then I knew I was saved because the boy did not have dysphagia he did not have any hoarseness or any difficulty. I got an x-ray done the coin was sitting somewhere here so I said boss go home in 2 days the 5 rupees will be out of the system don't worry about it. So, the critical thing is if it crosses the upper isophageal spring term if it crosses the lower isophageal spring term most foreign bodies follow the law of the intestine they usually come out even if it is a sharp foreign body many a times we leave it because it comes out in a day or two. So, the crux is if it is caught anywhere in between this then you have to intervene and get it out. I will tell you a couple of cases where I had trouble person comes to you with his child having swallowed a foreign body my question to them three times repeatedly I ask is it a foreign body is the coin or is it a button battery coin or a button battery coin or a button battery because there have been instances where people have swallowed button battery just yesterday I was watching the Vion news they were mentioning about these button batteries causing trouble. So, what happens is people think that this is a coin and they do the x-ray they say okay it will go away we will wait and these button batteries if this gets stuck in any place they erode because the acid leaks the alkali leaks and they erode through and they can perforate the isophages and it becomes sort of a very catastrophic injury. So, you should always make sure through the history that it is not a button battery because a button battery makes it imperative that you do the procedure as early as possible. So, these are easy to remove though the coins this is how they are they are stuck we have we have equipments called red tooth forceps we have snares we have the nets through which we can remove this it is very easy this is how a coin looks but the biggest problem if they are not sure in the history is you never know whether it is a button battery or a coin till you go in and remove the other foreign bodies that we see is large foot bolus impactions like this sometimes dentures with sharp edges and they somehow with some ease they cross the G junction when you go in and struggle to pull it out of the stomach it never comes out. So, it is better once it crosses the G junction if there is no sharp edges leave it alone it will pass through the GI tract and come out it is called the law of the intestine even pins have come out with without causing any perforation. So, the law of intestine is a very broad law it says that whatever the object with a which is sharp nail it goes along the longitudinal flow the only other place where it can get stuck is the iliocecal junction but nevertheless I always keep my surgeon in the loop when I see a sharp foreign body which I left in the stomach telling that if the child or person comes back in the middle of the night with the pain then we probably have to intervene. So, these are various foreign bodies again the biggest drawback of a fishbone foreign body is somebody does a x-ray you cannot see it I mean you will have to you know become a radiologist to look at a fishbone here I cannot make out. So, they show some shadow very clearly a small thin line here but you can see that it is sitting here and it is about to arrow through the wall of the isopagus and these are very difficult foreign bodies to remove sometimes the isofagus is like this the fishbone is sitting like this now how do you pull it out. So, many a times I have just turned it to one side pushed it into the stomach then used a net and pulled it out. So, it is sometimes we have to do all these circles the most difficult endoscopy for a gastroenterologist is always a foreign you will have to struggle with the foreign body because sometimes they get stuck. So, this is just a brief on what you do for foreign bodies but the basic tenet is if it stuck anywhere in the isofagus you need to go in and remove it and you have to make sure that there is no structure below. So, once I remove a foreign body always go with an endoscope make sure that the upper g attract is clean. So, acute abdomen it is again my surgical colleagues per view but when they present you should keep these things in mind in these particular areas of the abdomen. If it is a right upper quadrant it is a cholecystitis, pylonephritis, uretric colic if it is radiating from loin to groin sometimes pneumonia can cause this hepatitis and of course liver abscess is something we commonly do not think of. If it is on the left upper quadrant it is an ulcer disease again a pylonephritis, colic or pneumonia of the left lung if it is a right lower quadrant these are the differential diagnosis that you think of if it is a left lower quadrant these are the differential diagnosis that you should think of but the most dangerous abdominal emergency that I see is a miscentric ischemia. Miscentric ischemia is something patient is ridding in pain but you do not find any clinical signs. When there is more symptoms disproportionate to the signs always think of an ischemia when do you suspect an intestinal. The intestinal ischemia is suspected in the right category of patients an elderly patient who has diabetes, who is CKD, who has got ischemic heart disease this is a good concoction to have a thromboemboleic disease or a ischemia of the intestine just like a heart attack. So you should keep this in mind rarely you come across this abdominal aortic hermism and other rare causes for acute abdomen but the common things are always common keep it in mind when the signs are less and symptoms are more always think of miscentric ischemia in the correct group of patients. This again a broader thing about the same there is something else which I want to mention about dysphagia. Elderly people sometime come with acute dysphagia with a foreign bolus infection or you know this is just nothing but a tablet which has impacted in a midisophageal stricture. So they will be having either a post radiotherapy stricture or a post GERDs related stricture and one foreign body impacts into that before that they would be somehow managing to swallow food. So this is an acute dysphagia or an underlying some small narrowing which can be because of a previous injury to the isophagus in the form of GERD in the form of radiation or in the form of some other corrosive injury which has happened during childhood they would be functioning very well but some foreign body goes and sits there that is again a difficult foreign body to remove mostly the food bolus foreign because you go and catch it with a snare it breaks you go and catch it with a snare it breaks. So in such cases what we do is we go in with the endoscope blow the air we widen the isophagus a little bit and push it down into the stomach so that it gets digested and goes once it crosses the G junction the problem is mostly solved.