Case Discussions & Teaching Points | January – February 2026

About This Issue

This newsletter compiles 24 cases and discussions shared by the global EndoCollab community between January 1 and February 16, 2026. Topics span gastric neuroendocrine tumors, difficult ERCP cannulation, achalasia management, variceal bleeding, hemostasis strategies, EoE, and more. Each case is accompanied by expert commentary and distilled teaching points for immediate clinical application.

Cases in This Issue

1. Classification and Workup of Gastric Neuroendocrine Tumors
2. Difficult ERCP Cannulation — The Submucosal Injection Technique
3. Botox Injection Technique for Achalasia
4. Hemorrhagic Ascending Colon — Ischemic Colitis on Anticoagulation
5. Duodenal Ulcer with Visible Vessel — Hemostasis Strategy Debate
6. Gold Probe Hemostasis — Technical Recommendations
7. Large CBD Stone Management — Sphincteroplasty and Stenting Strategy
8. The Versatile Distal Clear Cap — Applications in GI Endoscopy
9. Management of Small Esophageal Squamous Papilloma
10. Portal Hypertensive Duodenopathy and Ectopic Varices
11. Progressive Mid-Esophageal Varices in PSC Cirrhosis
12. Elevated Lipase Without Pancreatitis — Think Beyond the Pancreas
13. Celiac Disease — Outpatient Management and Follow-Up Practices
14. Fish Bone Impaction — Lessons on Delayed Presentation
15. Duodenal Bulb Lesion — NET vs. Adenoma Debate
16. Large Prepyloric Ulcer with Gastric Outlet Obstruction in a Young Patient
17. Pedunculated Juvenile Polyp — Safe Removal Strategy
18. Eosinophilic Esophagitis — Step-Down Therapy and Long-Term Management
19. ERCP in a Patient with Tracheostomy — Overcoming Esophageal Access
20. Inflammatory Polyp Arising from a Diverticular Orifice
21. EUS Tissue Acquisition for Pancreatic Masses — When Is It Mandatory?
22. Recognizing Scope Trauma vs. Pathology During Colonoscopy
23. Pneumobilia in the Setting of Biliary Ascariasis
24. RFA vs. APC for Radiation Proctitis — When to Escalate

Teaching Points

• Gastric NETs are classified into three types: Type 1 (80%, autoimmune atrophic gastritis/pernicious anemia), Type 2 (Zollinger-Ellison/hypergastrinemia), and Type 3 (neuroendocrine carcinoma — solitary, >1 cm, most dangerous).
• Types 1 and 2 are associated with hypergastrinemia but via different mechanisms; both are usually well-differentiated, multiple, and <1 cm.
• A solitary gastric NET is more concerning (Type 3); multiple lesions suggest Type 1 or 2.
• NBI/I-scan cannot differentiate Type 1 from Type 2; differentiation relies on clinical features and labs (gastrin levels, anti-parietal cell antibodies).
• EUS and DONET assessment should be considered for lymph node staging.

Teaching Points

• Use a tapered-tip sphincterotome with a 0.025-inch guidewire for difficult cannulations.
• If the guidewire enters the pancreatic duct, consider a 5 Fr protective plastic stent (4–6 cm) and reattempt biliary cannulation.
• The submucosal injection technique can aid cannulation by elevating papillary tissue — have a fully covered metal stent available in case of perforation.
• Needle knife precut sphincterotomy is an option if the papilla is visible intraduodenally.

Teaching Points

• Injection site: 1–1.5 cm above the Z-line, in 4 quadrants. Dose: 25 units per quadrant (100 units total).
• Account for dead space of the injection needle — flush with 1.2 mL of saline to ensure accurate dosing.
• No reliable endoscopic method confirms muscularis propria injection depth — clinical response is the endpoint.

Teaching Points

• CT angiography is the first step — assess for vascular compromise and transmural necrosis.
• Antibiotics are reasonable given the risk of bacterial translocation in ischemic colitis.
• In stable patients without active bleeding, expectant management with repeat colonoscopy after INR normalization is acceptable.
• Restarting anticoagulation requires multidisciplinary discussion — balance recurrent ischemia vs. thromboembolic risk.

Teaching Points

• Dual therapy (injection + clips) is preferred over thermal therapy alone in the duodenal bulb — thermal therapy carries higher perforation risk.
• Place TTS clips near the ulcer as a marker for interventional radiology before referral for embolization if endoscopic hemostasis fails.
• Hemospray can provide temporary hemostasis as a bridge to IR embolization.
• Always inject epinephrine before applying gold probe in the duodenum — thermal therapy without prior injection can precipitate bleeding.

Teaching Points

• Standard ulcer/Dieulafoy: 15–20W for 8–10 seconds per pulse. Thin-walled areas (cecum/right colon): 10–15W for 3–5 seconds.
• Coaptive coagulation is critical — firm mechanical compression of the vessel before and during energy delivery.
• Always irrigate through the probe during and after energy delivery to prevent tip adherence to eschar.
• Treatment endpoint: 'tanning effect' — a white, depressed area. Typically requires 3–5 applications per station.

Teaching Points

• Generous sphincterotomy and balloon dilation are more important than the mechanical lithotripter itself.
• Balloon sphincteroplasty with CRE balloons (10–12 mm esophageal type) followed by basket or balloon extraction.
• After sphincteroplasty, place 2–3 plastic stents (or fcSEMS + inner plastic stent) to allow remodeling and prevent post-sphincteroplasty perforation.
• CRE balloon size must not exceed the CBD diameter — never overdilate.

Teaching Points

• Large caps: foreign body extraction. Small caps: Barrett's visualization, colonic fold management, cap-clip hemostasis.
• Essential for ESD, POEM, STER, and deep enteroscopy (DAE-ERCP with hepaticojejunostomy).
• Caps improve EMR stability in the colon and duodenum, and assist underwater EMR.

Teaching Points

• HPV infects the basal epithelial layer — incomplete removal not including the base leads to recurrence.
• Preferred approach: lift and perform EMR for complete removal including the base at the index procedure.
• If only biopsied, schedule follow-up — the site may be unidentifiable on repeat endoscopy.

Teaching Points

• In cirrhosis: patients can develop PHD, DAVE, nodularity, angiodysplasia, and focal lymphangiectasias in the duodenum.
• NO biopsies in this setting — risk of hemorrhage from inadvertently biopsying an ectopic varix is significant.
• APC near ectopic varices requires extreme caution — be prepared for massive bleeding.
• CECT abdomen is recommended to map ectopic variceal anatomy.