and clinical scenarios that an APP will be faced with and encounter in both inpatient and outpatient settings. Before we get into that though, we're gonna review best practices and patient selection by procedure. And so to start things off, we have Dr. Kaul to talk about upper endoscopy. Thank you, Dr. Kaul. My task first up is to speak about upper endoscopy, which is probably the commonest and most routine endoscopic procedures that is performed in every GI practice. So we'll go through a few of the principles related to that procedure. These are my disclosures. So upper endoscopy is a very common procedure, as I mentioned. Millions of upper endoscopies being performed in the United States and all over the world, really. The estimated cost is listed here. That keeps changing depending on which source you look at. But a lot of my focus today through the anatomy and at the end of the talk will be identifying appropriate patient selection and appropriate indications for upper endoscopy, which is where your role as an APP will come in, either as an independent pre-procedure clinic evaluator or in a shared clinic like we discussed yesterday. So case selection and timing and the appropriate indications are really where the money's at in this. So the upper endoscopy really has multiple nomenclatures in clinical lingo, so to speak. EGD, or esophageal gastroenteroscopy, is the typical clinical term, but it's also called upper endo, gastroscopy, upper, endo. So those are all kind of commonly used phrases. This schematic shows the endoscope entering through the mouth into the esophagus and then in the stomach and then going into the first part of the intestine here, the duodenum, and this is a typical finding in a patient at upper endoscopy, typically someone who presents with upper GI bleeding, and this is an ulcer with maybe a little small, what we call a pigmented spot, but mostly a clean base, and this patient is at very low risk for bleeding. So that's a typical finding in upper endoscopy. Going over the anatomy, as I mentioned, imagine that the mouth is somewhere up on top here. We enter the esophagus right there, and then this is the GE junction or where the lower esophageal sphincter lives, so to speak, and the highest portion of the stomach, just below the GE junction, is known as the gastric cardia. This is an important location because a lot of our patients with pre-cancerous or pre-malignant esophageal conditions like Barrett's, they sometimes also have dysplasia in this location. The area which is the highest, kind of rises up towards the diaphragm, is the fundus of the stomach, and typically you'll have to bend the scope backwards to look at it, the so-called retroflexion maneuver, and then from there, we go to the body of the stomach, and this typically sits almost anteroposteriorly, so the anterior wall is what is looking on the abdominal exam, and the posterior wall is towards the pancreas. The stomach also traditionally has been described as having a lesser curvature because it's kind of smaller and sharper, and this is the greater curvature, and this has some anatomic implications in, sorry about that, in endoscopy and in defining where pathology is. As we move further down, we look at this area known as the gastric antrum, and then further down, the pylorus, which is the gateway to the intestine. So again, a common location for ulcers, and then there is another sphincter here known as the pyloric sphincter, which is a natural sphincter there, that is a natural opening, and you put the scope through there into the early part of the intestine, known as the duodenum, and the major papilla, which is where the bile duct and pancreatic duct come out is somewhere over here in the second part of the duodenum, the third part of the duodenum, and then the fourth part of the duodenum until you reach the ligament of trites, which from where the formal small bowel jejunum starts. So that's kind of the anatomy, and then looking inside, this is a schematic, obviously, and this is a real picture from someone's stomach. So over here, you can see that the stomach wall, really, as most of the GI tract, has got multiple layers in it. So the innermost layer is the mucosa, and when you look at it with the endoscope, it presents this kind of this long, thready mucosal folds known as gastric rugae, and this is how it looks over here. This is more of a normal anatomy. In some conditions, such as chronic atrophic gastritis, or even in certain types of gastric cancer, the normal rugal fold appearance disappears, and may be a marker for some type of pathology there. So one has to pay close attention to the mucosal anatomy, and this is normal, this is expected, and that's what one should see. Now, I should mention that in relation to the folds as they come up and down in the stomach, if you're looking for small lesions, ulcers, polyps, and such, it is incumbent on us to actually fully distend the stomach. Nowadays, we use carbon dioxide, used to be air back in the day. Fully distend the stomach, because unless you fully flatten out these folds, you cannot say that you have seen every part of the mucosa. So that's one kind of a technical point related to the rugal folds, which we teach the fellows when they're initially doing endoscopy, because things can hide between two folds and are wrapped over each other. This is an upper endoscopy video. This is the scope entering the esophagus, and that is the GE junction right there. The esophageal squamous mucosa is right here. This is the so-called Z line, and then this is the beginning of the gastric cardia. You can see the difference in the colors. This is the earliest part of the stomach coming down here, and as the scope enters the stomach, this is a feature called narrowband imaging, which is blue light. It kind of highlights pathology, and as soon as we enter the stomach, you can see here in this particular case, there's some food in the stomach here, and that may be a sign of a condition known as gastroparesis. That is the retroflexion maneuvers. Scope is looking back at the GE junction right there, and then we'll make a brief attempt to enter the pylorus, which is the opening right here, especially when food is retained in the stomach. You wanna make sure that the intestinal tract is open, so we can see here that the intestinal tract is open, and there is no mechanical obstruction, so most likely this patient either has primary gastroparesis or has maybe a medication-induced delay, such as narcotics and such. The other thing I wanted to point out in this video was if you look at the esophagus, I'll try very gently here to interfere. If you look at this esophagus, there are some whitish blocks in the esophagus, and when I see that, my mind is always thinking that maybe there is some candida in the esophagus, or the other alternative could be that there is some medication that the patient took early morning, that some residual stuff is still there in the esophagus. But that's how basically an upper endoscopy looks like, and in this particular one, you saw a few findings that might be significant. Key considerations in upper endoscopy include, as I mentioned earlier, appropriate indication. That is true for all procedures. It's not just for upper endoscopy, but for all procedures. You need to really select the patient and do the procedure for the appropriate guideline-based indication. Candidates should be evaluated. Typically, most patients will have been seen in the clinic. There are occasional patients that we will do direct upper endoscopies for. These are typically younger, healthier patients. They're a very focused question, such as a longstanding GERD, and you want to rule out Barrett's, or some other indication in a healthy patient that might allow you to bring the patient directly to endoscopy. The patient preparation is important. They obviously need to be fasting at least overnight. If they are on anticoagulation, that needs to be managed. We discussed that yesterday in more detail. And then the sedation requirements, and whether it should be moderate sedation, whether it should be deep sedation, or general anesthesia with endotracheal intubation, that depends on what exactly the procedure you're doing. So for example, if you're doing an upper endoscopy in a 50-year-old for evaluating for Barrett's, you might be able to do it with moderate sedation. But if you're doing a management of an achalasia with peroral endoscopic myotomy, that typically is done with general anesthesia with intubation. Informed consent is a big part of any endoscopic or surgical procedure, and we spend a lot of time not only discussing with the patient, educating the patient about the procedure, but also documenting it, and making sure that that is the right person to give consent for that procedure. Potential adverse events obviously need to be monitored and anticipated in some cases, but also recognized as early as possible. Most programs have a QA process in place where quarterly or semi-annually, these are reviewed and appropriate remedial measures put in place. Many of these issues are potentially correctable, some are not, but it's always important to keep in mind what your practice is doing with the complications and adverse events, and that also is a quality metric and represents a high-quality practice. When the procedure is done and you finally have your findings and you have a plan, typically the patient is informed about that, and usually there's an attendant bringing the patient back home, and not only are these conversations held post-procedure ideally, but these are also the salient recommendations are written down, and nowadays of course digitally transmitted as well through MyChart and all the discharge summaries. So that's an important aspect of it. It has obviously a best practice connotations, but also medical legal implications. The concept of informed consent cannot be overemphasized. I'm a big fan of this at all levels. I think it's not only good patient communication, education, and disclosure, but it also is probably the best legal protection. And things to kind of emphasize, if you are, as an APP, the person designated to at least begin the conversation on consent in the clinic visit or formally taking the consent as part of the practice policy, then you have to emphasize items such as perforation, emergency surgery, and in high-risk cases, you may even want to mention that rarely death may be a negative outcome. Improper or inadequate consent is it really amounts to malpractice. And in legal cases, this is one of the first things that people look at is that the patient really understand and was appropriate consent taken. Emergencies are exceptions, but only rarely. I am not a big fan of two MD consents in the ICU. Every potential possibility should have been exhausted before you go to a two-physician consent or an emergency consent. And then, of course, competency needs to be looked at. Patients at extremes of age are not in great positions to provide a truly informed consent, so that needs to be kept in mind. The healthcare proxies, the surrogates have to be identified properly. Sedated patients, so once you start a procedure and then you decide to do something else, then that patient is not the appropriate person to provide consent. And then finally, one of the things that's not talked about is scope of consent, which means if I go in to do a screening colonoscopy and I have this large lesion in the right colon that now I'm facing, and I've not discussed with the patient that I'm gonna now do an ESD, I think that might be looked upon as something that is beyond the scope of that particular procedure. And so that has to be kept in mind. So in the informed consent realm, the nature of the procedure should be discussed. The reason for the procedure has to be explained to the patient, the risks, benefits, and alternatives. This alternatives is something that is, we kind of tend to skip a lot of the times because there's an implicit kind of a bias that patient is coming for colonoscopy and therefore we have to do the colonoscopy. I think the best practice guidance does really strongly emphasize that alternatives should be discussed. Every patient should have an alternative discussed, which is do nothing, do colonoscopy, or do something else, and that ideally should be done. But that's to be kept in mind. Pediatric consent is important. A lot of operandoscopy occurs in the pediatric population, obviously, because they're not getting screening colonoscopy. So operandoscopy is probably the most common procedure in the pediatric realm, which is why I put this slide up. So in the case of the pediatric patient, obtaining a permission from an adolescent is, or an assent from the adolescence is really highly recommended, even though the parents may be the legal signing authority. So if patients, and this varies from state to state and from institution to institution, but once you have an adolescent in their teens, they really should be on board with the procedure, and of course the official consent obtained from the parents. The adolescent may not want an elective endoscopy, and if it is performed against their wishes, it might be considered in some situations as battery. So be very careful when you are doing discussions with patients who are under 18 years of age, that what the discussions are, who are the signatories, what is the patient's personal situation with regards to giving the permission. So it's a little bit of a complex area. So if you have confusion around it, seek guidance. This is an area where, obviously, the physician will need to be involved directly as well. It's unlikely that the APP alone will be doing this consent, but I just wanted to highlight that. So shifting gears a little bit to the importance of operandoscopy in our business. As you can see here on this slide, operandoscopy really is a portal for pretty much everything we can do in the esophageal, stomach, and foregut realm. Certainly, it's part of the endoscopic ultrasound procedure and billing code. And in fact, any new patient coming in for EUS, I almost always do an operandoscopy because you just never know what anatomical challenge you might be facing. Certainly for double balloon and single balloon enteroscopies, these are all operandoscopic procedures. ERCP is a peroral procedure for the most part. And of course, the newer procedures, peroral esophageal myotomy and transoral incisionless fundoplication, which is basically an endoscopic fundoplication, are all operandoscopic procedures. Most of the bariatric procedures are operandoscopic procedures, Barrett's endotherapy, endoscopic resection, enteral stenting, and so forth. So if you don't have access easily from the upper endoscopic channels, it becomes very difficult to deliver therapy, and not infrequently, especially at referral centers, we find significant challenges to get these specialty scopes in so we can perform our work, and those have to be navigated on a case-by-case basis. Indications for a diagnostic upper endoscopy are listed here. Of course, dysphagia or difficulty swallowing, and then a host of indications. I would suspect that GERD and dyspepsia are probably the most common indications, and then there are a few others. Abnormal lesions seen on imaging is also another one that is commonly seen, but there's a host of indications for upper endoscopy. One of the specific and specialized indications for upper endoscopy is listed on this slide, is screening and surveillance. So screening and surveillance is a special subset of indications. So for example, you have a patient who was diagnosed with Barrett's esophagus, and typically, as per the guidelines, they have to come back for surveillance for dysplasia every three to five years, so that's probably one of the more common paradigms, and obviously, screening for upper GI malignancies in patients with Lynch syndrome and similar syndromes is also a common theme in referral centers. Screening for esophageal varices in patients with cirrhosis is a quality metric as well, and of course, more recently, there has been a lot of discussion around surveillance or no surveillance for gastric intestinal metaplasia, and recent guidance has suggested that in high-risk patients, such as those who have family histories of gastric cancer and such, they may be good candidates for taking a look every few years. And of course, once you remove cancer or precancerous lesions, those patients will typically come back for surveillance, such as in colonic adenoma realm. Typical common findings at upper endoscopy are listed on this slide. This is esophagitis, or inflammation of the esophagus. You can see here the LA classification is used here. It's grade A, B, C, and D. Grade D is basically circumferential inflammation with deep ulcers, and it is not subtle, and this is something that needs aggressive medical therapy, and then typically, most of us will go back in a few months and make sure that this is healed up, because if this is not managed aggressively and appropriately and completely up front, this can portend long-term complications, such as esophageal stretchers and food bolus infection. And of course, some people believe that chronic longstanding acid exposure at this level may be a harbinger for developing the Barrett's and esophageal cancer. So several causes of upper GI bleeding can be seen in upper endoscopy. Here are some esophageal varices, dilated columns of veins. Here are some erosions. They're like baby ulcers, not quite ulcers, but on their way to become ulcers. This is a condition known as gastropathy, which is seen in liver patients. Here's a ulcer in the duodenum here. There's a Malory-Weiss tear, which is a tear in the esophagus when somebody is retching and throwing up very violently. This is gastric anterovascular ectasia, which is basically small blood vessels that present in this kind of what they call watermelon stomach format here. You can imagine this is a watermelon facing you. These are gastric varices, dilated veins in the fundus and cardia of the stomach. And this is a very classic appearance of what we call an angio-dysplasia or an arteriovenous malformation. And pretty much most all of these conditions are manageable endoscopically, and these are not infrequent findings in patients who present with GI bleeding. Barrett's esophagus is a well-known entity. This is basically where the squamous lining of the esophagus transforms into a columnar lining. This is white light endoscopy showing that segment, and then the blue light or narrowband imaging, or a similar blue light imaging, will show this in stark contrast so that the segment is easy to see. This is a precancerous condition and undergoes surveillance every so often, as I mentioned. And once dysplasia is found, the patients are eligible for endoscopic therapy. The most important thing here is the vast majority of these patients are asymptomatic until they develop complications. Barrett's can progress from, obviously, the non-dysplastic state to dysplasia and then cancer, and the key is to really intervene most definitely at the high-grade dysplasia state and, in many cases, in the low-grade dysplasia state with the ablation modalities I'll discuss a little bit later. Now, moving on to therapeutic endoscopy, this is where we do, actually, treatment through the upper endoscope. So the most basic and common treatment entities is the treatment of upper GI bleeding, which is variceal or peptic ulcer disease, removal of foreign bodies. These are typically the worst cancers. They come in at 2 a.m. in the morning. Dilation of esophageal strictures is a very common paradigm, and for many of us who do therapeutic endoscopy, esophageal stent placement, or stomach or duodenal stent placement is also a very routine intervention. Endoscopic resection and endoscopic treatment of achalasia is now really caught on and is a very commonly performed procedure, as is ablation and PEG-2 placement. So the tools and techniques for management of bleeding, for example, are listed here. Most guidelines recommend that when you have a patient with active GI bleeding that you use at least two modalities of treatment, such as epinephrine injection or thermal therapy, such as shown here, and hemoclips, using only one modality is discouraged because it may not be as robust as using two. All right, some common specialized procedures with upper endoscopy. This is what I mentioned when we do Barrett's ablation. This is like a circumferential balloon, and it is delivered, loaded on top of the endoscope, or actually in this particular case, loaded on a wire, and is being watched by an endoscope right behind it. This is too large to go through an endoscope, and you can see here that the ablation is circumferential, and it's pretty highly effective with the success rates of 90% plus in eradicating Barrett's. Here's an example of a endoscopic cryotherapy for Barrett's-related cancer. This is a spray cryotherapy catheter coming through the endoscope and delivering liquid nitrogen at minus 190 degrees centigrade. Again, technology that's been around for a long time, quite effective, both in treatment of Barrett's as well as palliation of cancer, which is what's being performed here. These patients are typically seen in the outpatient setting, and they go home the same day with minimal discomfort and issues. The softening of stent placement for benign or malignant strictures is a very common intervention. These stents are highly effective. They do have some potential for migration and discomfort and so forth, but when a patient reaches this state where they have malignant dysphagia and are not candidates for surgery, this is one of the most efficient ways of improving their quality of life and keeping them outside the hospital. Endoscopic ultrasound is a very common intervention and evaluation procedure being done. It has the ability to look at the wall layers and find pathology and do sampling and so forth. So this is a schematic showing the wall layers of the esophagus, for example, and how the EOS imaging will look in correlation. This is one of my patients from years ago, and you can see a small esophageal tumor, and in how exquisite detail, high-quality EOS will demonstrate the mucosal layers of muscularis mucosa, which is the first black line, and then the first white line, the submucosa, then the muscularis propria, and then the peri-esophageal tissue. So that's the level of detail that EOS can provide and help guide the surgeons and oncologists with regards to the appropriate treatment for the patient. Obviously, FNA of pancreatic or other masses is something that EOS also facilitates, and again, this is the most efficient way of getting tissue samples for patients who come in with pancreatic or foregut malignancies, where that information is required for decision-making. PEC tube placement is a common procedure performed in most GI practices. These are typically inpatients who are unable to swallow, swallow food for one reason or another, and occasionally, there are outpatients as well, but this is a typical appearance of a PEC tube in the stomach after endoscopic placement, and again, the important thing here is that the PEC tube basically facilitates the patient's nutrition, and studies have shown that, depending on the situation at hand, it may or may not have any impact on survival. One of the things about the PEC tube that I want to mention is that consent can be an issue. This is an area where proper informed consent from family typically is the requirement, and sometimes it can be hard to identify who's the actual legal authority who's giving consent, so be a little bit careful if you're involved with these patients who may not have their own decision-making capacity. Adverse events associated with endoscopy. We cannot complete a talk in endoscopy without talking about adverse events, so even though upper endoscopy is one of the most routine and relatively straightforward procedures, it doesn't come without a potential for adverse events, so cardiopulmonary events are the most common still, and account for about two-thirds of the issues. Infection is an issue, but much less of an issue. Perforation rates are very low, and bleeding and aspiration certainly can happen, especially if you're dealing with a bleeding entity to start with. You can sometimes make it worse before you fix it. Adverse events associated with therapeutic endoscopy. Obviously, it can be more with perforation, with larger resections, bleeding from resections. There's a unique thing known as a buried bumper syndrome, which can occur with PEC tube placement where the bumper is not in the stomach as I showed you, but within the wall of the stomach, and then a variety of other issues related to stent placement, such as chest pain and bleeding and nausea and so forth, so it is a routine procedure, but still has potential for trouble. Now, finishing up here with some quality indicators. It's important to keep in mind that for all endoscopic practice, and the ASG has provided a lot of guidance on this through consensus panels and data review, there are a bunch of pre-procedure quality indicators, such as the frequency with which endoscopy is performed for the appropriate indication, because if you're performing endoscopy for the wrong indications or for unindicated situations, and then you have a complication, it becomes very difficult to justify. So I won't belabor the slide, but this information is available on the ASG website. So quality indicators for pre, intra procedure, frequency of documentation, management of bleeding ulcers, the appropriate biopsies for Barrett's, the list is pretty exhaustive. And then for post-endoscopy, the frequency with which PPI therapy is recommended for patients who have esophagitis, stuff like that, which you would think is common sense, but when you boil it down, it can be surprising sometimes to find that the adherence can be quite variable. So this is an area where we can impact patient care quality by following these guidelines, and this is an amazing level of detailed guidance from the ASG on this topic. Antibiotic prophylaxis in upper endoscopy is not typically required for non-therapeutic cases, but there are specific indications for that, such as patients coming with variceal bleeding, patients with bile duct obstruction that is incompletely drained, and so forth. We still give antibiotics in FNA of pancreatic cysts, but there's some recent papers suggesting that that may not be necessary. So this is an important chart to have in the endoscopy unit and to teach new endoscopist fellows and for the team to know. Post-procedure discharge instructions are really important because if the patient doesn't have clear guidance on what to do next, that can become a problem. So significant findings, follow-up instructions, when to resume anticoagulation, we talked about that a little bit yesterday, and then, of course, a phone number for a 24-7 call service where, if there's a catastrophic event, they know who to call and where to go. Practice pulse, to finish up the summary here, diagnostic EGD is a safe procedure. However, there are risks associated with it, and it should be performed for the appropriate indications in the appropriately selected patient. I cannot overemphasize that because a lot of the trouble in the medical legal world comes from wrong indications or from non-indications. So if you're involved with the consent process and the pre-procedure evaluation, please keep that in mind. Therapeutic endoscopy, obviously, has a higher risk of potential for serious complications because we are doing interventions as opposed to just looking, and therefore, depending on the nature of the procedure, those risks and benefits have to be carefully discussed with the patient. The importance of informed consent and the scope of consent, I have elaborated in detail, and I think the appropriate person giving the consent and the detailed discussion should be documented. There are specific indications for antibiotic prophylaxis, which should be adhered to, and that is a risk mitigation strategy in itself. And then finally, quality metrics for appendoscopy, which are available on the ASGE website, and I highlighted a few of them, should be followed for both pre-, intra-, and post-EGD scenarios. Thank you very much, and I think we have polling questions now. Antibiotic prophylaxis and upper endoscopy is indicated in all of the following except, I love except questions, so where would you not give antibiotics? PEG tube placement, endoscopy with duodenal biopsies for celiac disease, a patient with very severe bleeding undergoing band ligation, and USFNA of pancreatic cysts. So where would you not give antibiotics as per the current guidelines? Yesterday, I scored three 100s with the audience, so let's see what we do today. Oh, okay, so 82%, let's see what happens. That's good, so some folks, so PEG tube placement, we still give antibiotics. I know the data on that is not crystal clear, but the summary version is that it's infinitely better to spend a couple hundred dollars on their antibiotic and not have an abdominal infection. And then, of course, very severe bleeding requires and pancreatic cysts, we still give the antibiotic prophylaxis. Okay, next question, please. Which of the following adverse events is not typically associated with an upper endoscopy? Select one, is not associated. Bleeding, cardiorespiratory event, pancreatitis, perforation. So pancreatitis, of course, is not associated with EGD, and that is the correct answer. And cardiorespiratory events can still occur, though, with even the simplest of procedures. Thank you very much, and I hand over the floor to Dr. Joe Vicari, who will take us through colonoscopy. Welcome, Joe.

upper endoscopy

patient selection

anatomy

therapeutic procedures

adverse events

informed consent

colonoscopy