Thank you, everybody. That was a great morning, very interactive sessions. Please remember to keep sending your questions as we go. We'll answer them during our Q&As. Our next series of talks are going to really dive into those GI endoscopic procedures, and we'll talk about preparing patients and then go into some expected outcomes. So it's my pleasure to introduce Dr. John Martin to start us off. Dr. Martin is a full-time practicing gastroenterologist at the Mayo Clinic in Rochester, Minnesota. In addition to his clinical practice, Dr. Martin's interests center on endoscopy unit operations and efficiency, technological innovations in endoscopy, and endoscopic training and simulation and hands-on training and education. He has served on the ASGE Governing Board and currently serves on the ASGE Practice Operations Committee. John, the audience is yours. So we're going to start at the top, which means upper GI endoscopy. And here we go. I have no disclosures. So first, for the objectives of this talk, they are to define upper GI endoscopy. What does that mean exactly? To learn the indications, contraindications, and pre-procedure preparation, including informed consent. To describe the components of upper GI endoscopy, both diagnostic and therapeutic. To determine the best practices for procedure documentation and photo documentation. And also to discuss the components of proper post-procedure follow-up. So let's start with some polling questions. First, upper GI endoscopy is indicated for routine reevaluation of duodenal ulcer, or is it routine reevaluation of gastric ulcer? Or yearly biopsy surveillance of short segment Barrett's esophagus? Or is it colorectal cancer screening once per decade in normal risk individuals? Only one is correct. Excellent. You're doing great. So that lunch must have helped. So the right answer is routine reevaluation of gastric ulcer. The others are incorrect. You're certainly not doing an upper endoscopy for colorectal cancer screening. Most duodenal ulcers don't require routine reevaluation with EGD. And we don't biopsy short segment Barrett's on an annual basis either. Good job. All right. Polling question number two, the informed consent process does not always include a discussion about procedure indication, a discussion of procedure-related risks, the written signature of the patient undergoing the procedure, or is it an opportunity for the patient or the patient's parent, guardian, or power of attorney to ask questions? Excellent. So, so far, I'm not doing a good job of being tricky. So you're right. The answer is the written signature of the patient undergoing the procedure. The patient may not be the one to sign the form, right? So if there's a power of attorney or a parent or legal guardian, they may actually be the one signing on the dotted line. So the patient may not be the one to sign the form. But you do always need to discuss the indication of the procedure as well as the risks related to the procedure and give the patient or the patient's representative an opportunity to ask questions. So those things absolutely need to be done. Excellent. Good job. So question number three, upper GI endoscopy is A, always performed through the mouth, or is it is indicated for workup of lower abdominal pain, or is indicated for primary investigation of biliary type upper abdominal discomfort, is indicated for workup of esophageal dysphagia, or is the most important study in the workup of oropharyngeal dysphagia? All right. So think about this. Upper GI endoscopy, tricky here, is not always performed through the mouth. Sometimes we have to perform it through the nose for various reasons. The nose and the mouth both get to the hypopharynx and posterior pharynx, and then the scope goes through the upper GI tract. We don't use upper GI endoscopy for workup of lower abdominal pain. We don't use it for workup of biliary type pain either. It is indicated for esophageal dysphagia, and while we do use upper endoscopy for the workup of oropharyngeal dysphagia, it really isn't the most important study. There are other studies, including swallowing studies and modified barium studies, that are done by speech pathologists that are arguably more important in the workup of transfer dysphagia. All right. Question number four. The term upper GI endoscopy, A, is identical to the term EGD, or esophagogastro-duodenoscopy, includes EGD, includes EG, esophagogastroscopy, single balloon endoscopy, but not double balloon endoscopy, includes esophagoscopy, esophagogastroscopy, esophagogastro-duodenoscopy, or EGD, single balloon endoscopy, and double balloon endoscopy, or includes esophagogastroscopy, esophagogastro-duodenoscopy, single balloon endoscopy, double balloon endoscopy, and video capsule endoscopy. This is a little bit of a technical question. Which of those is most correct? Okay. So this is tricky. So when we talk about upper GI endoscopy, we're basically talking about any endoscopy that is performed by the provider, that is performed through the mouth or the nose, and investigates the upper GI tract. However, curiously, we don't generally group capsule endoscopy in that vernacular, even if it is true that the capsule is swallowed through the mouth, or placed with an upper endoscope. When we talk about upper GI endoscopy, we're usually talking about an EGD, or some type of enteroscopy, whether that's push enteroscopy, or balloon enteroscopy, which is otherwise known as deep enteroscopy. We generally also aren't sort of grouping endoscopic ultrasound, or ERCP, in the upper endoscopy category, although technically, and from a billing standpoint, both ERCP and upper GI EUS are technically an upper endoscopy plus something additional. So, you know, plus biliary investigation, or plus ultrasound. So this is, this question is really meant to teach you the difference between the terms EGD and upper GI endoscopy. Upper GI endoscopy is a grouping that includes more than EGD, and that's really the teaching point here. Very good. All right, so we have a fifth one. Which type of endoscope is not used to perform upper GI endoscopy? And I just gave you a clue here. Is it video capsule endoscopy? Is it trans, or rather, is it video capsule endoscope? Is it a transnasal endoscope? Is it a single balloon enteroscope, a side-viewing duodenoscope, or a colonoscope? A little bit of trickiness here. And the point here is that scopes can be used for more than what you might think of as their intended use, okay? So a colonoscope is actually the device that's most commonly used to perform what's called push enteroscopy, so enteroscopy without some kind of a balloon overtube. So a colonoscope is actually used for upper GI endoscopy. A side-viewing duodenoscope, which is actually an ERCP device, is actually used to perform upper GI endoscopy, particularly in the duodenum, because it gives you a very good view of the apex of the duodenal bulb, which is the area most commonly associated with a bleeding duodenal ulcer. So sometimes a duodenoscope can be used for upper endoscopy or for EGD. A single balloon enteroscope can be used if you're trying to look into the jejunum. A transnasal endoscope might be used if you want to place a nasojejunal tube or the patient can't open their mouth big enough, you might want to use that to perform an upper GI endoscopy. While a video capsule endoscope might be used to look at the upper GI tract, we don't generally group video capsule endoscopy into the term upper GI endoscopy, as I mentioned earlier. So that is the teaching point. I mainly wanted you to understand that we do use colonoscopes to perform upper GI endoscopy sometimes, and that's the most important teaching point here. Okay, excellent effort, thank you. Okay, so let's first remember our anatomy. Most of you remember the upper GI anatomy, which includes the esophagus, the stomach, the duodenum, and frequently parts south of the duodenum in the intestine. While we frequently refer to the upper GI tract as anything north of the ligament of trites, so esophagus, stomach, and duodenum, we're often from a clinical standpoint including the jejunum, and that is we can reach with deep endoscopes and sometimes even the proximal jejunum when we're doing a push endoscopy with a colonoscope. And so here is the ligament of trites in this area, the duodenum ends there, and then the small bowel downstream from that is the jejunum, and here's the upper GI tract in relation to the other organs in the abdomen, as you may recollect from anatomy class. So what is upper GI endoscopy? We just talked about it's any endoscopy, the upper GI tract, although the term isn't generally used to group in capsule endoscopy, even if the capsule endoscopy is intended to look at the upper GI tract. The natural orifice of insertion we talked about is usually in the mouth, but can sometimes be the left or right narus. So the the term is broadly encompassing more than the specific term esophagogastroduodenoscopy. Upper GI endoscopy can mean more than that alone, and when it's performed it's usually performed with the patient left lateral decubitus, usually through a bite block which isn't represented in this artist's rendition, and here's the scope advancing through the esophagus into the stomach, not yet in the duodenum. Generally speaking, endoscopes follow sort of a particular pattern in terms of the way that that they are constructed. There's sort of the area of controls which include dials, a small dial moves the tip of the endoscope left and right, the large dial moves it up and down. There are various programmable buttons that are used to do things like take pictures or freeze the image, while you lock or while you look. Both of the dials have locks, you can still move the dials when the dials are locked, they just hold the dials wherever you leave them so that they don't automatically move back to a neutral position if you have them locked, and that can be helpful if you're performing interventions so that the scope doesn't in and of itself move out of the position that you want it in to perform your intervention, so they can be useful. As you can see here, there is a light source as well as an air pump. The light is basically a projector lamp and that light is conducted by fiber optics, glass fibers, through the scope to the tip where the light shines out of the tip so that you can see what you're looking at. There is also an air-water channel, and if you put your finger over the air-water valve, that allows the air or carbon dioxide that's being pumped through to exit the scope here and insufflate the the lumen of the viscous so that you can see, and if you hold that air-water valve down, that air or carbon dioxide will push the water out of the water bottle, out the tip of the scope here, and that water is not to wash and clean what you're looking at, but it's meant to, it's a windshield washer, it washes the lens so that mucus and other debris can be washed off the objective lens so that you can see what you're trying to view well. There is also what's called an accessory channel, and that channel allows for two things. When you depress the suction valve here, it allows the suction that is communicating with the scope through the connector here to aspirate through the accessory channel so that you can get say fluid out of the stomach so that the patient doesn't accidentally regurgitate and aspirate that. That happens to also be the same channel that's connected through a Y connector to the biopsy valve so that if you're passing a biopsy forcep or any other device through the scope here, it actually is going through the accessory or suction channel to get to the lumen of the viscous that you're looking at or working on. So that's how that works, and we were saying upper GI endoscopy, the term doesn't generally reflect or include video capsule endoscopy. This is what a video capsule endoscope looks like, just so that you know what we're referring to, and that is not included in upper GI endoscopy as a term. Upper GI endoscopy, the procedures are plural, not just one, and can be defined different ways, so it might depend on where you're going. Are you just looking at the esophagus or the esophagus in the stomach or the duodenum? Also with push enteroscopy, you might get far down the duodenum or even into the very proximal part of the jejunum. And with balloon enteroscopy, you can frequently get to the mid-jejunum and occasionally farther. And we said earlier, you can use different types of scopes. A duodenoscope, which is generally used for ERCP, can be used to look at the duodenum. An EUS scope is generally not used for upper endoscopy alone. It's used to perform endoscopic ultrasound only. Upper endoscopy or EGD specifically can be used for all sorts of therapeutic indications, such as advanced resection procedures or endoluminal Barrett's therapies, GERD therapies, third space drainage or debridement in some cases, bariatric therapies and stenting, et cetera. These will just be described to you more in upcoming lectures by Drs. Shields and Call. So I emphasize again that the procedure is generally done with the patient in the left lateral position. And as the scope is advanced through the esophagus into the stomach and the duodenum, this is what it looks like. This is demonstrating a duodenal ulcer, which you see here in the apex of the bulb, which is the most common place to see a peptic ulcer. This is actually a video of an endoscopy so that you can see what we're talking about. So in this case, you see an endotracheal tube and this patient is someone who I performed an upper endoscopy on a few weeks ago. And the endoscopy was done to screen for esophageal varices and somebody who has primary sclerosine cholangitis and was undergoing ERCP to obtain brush cytology of some biliary strictures. And so the patient was under general anesthesia because they were having the ERCP rather than just for the EGD. And as you can see here, we just passed the airway and we're attempting to get through the upper esophageal sphincter into the proximal esophagus. You'll see it freeze frame once in a while because I'm taking pictures for the benefit of the report. Here is the esophagus. And you can see the squamous epithelium of the esophagus as we are going through it and we're entering the stomach. That is the Z line that separates the esophagus from the stomach. Now we're in the stomach. It's always a good idea, particularly if the patient is not intubated to aspirate out that fluid before you continue. And we will insufflate the lumen, which is usually collapsed at the beginning with air or carbon dioxide so that we can see better. So there's the antrum and the pylorus, that opening, the pylorus is a muscular opening that separates the stomach from the duodenum. To see the fundus and the cardia of the stomach as well as this fold, which is the incisor of the stomach, you need to sort of flip the scope into a J configuration so that it sees backwards toward itself and then draw the scope back up to the proximal stomach. And this is the area of the cardia here, just south of the esophagogastric junction and the fundus, the arch of the stomach up here. And so we retroflex to see those areas and I'm washing so that we get a good view of the entire mucosa. I'm gonna fast forward this a bit here. So we're back to the pyloric area, which we're gonna traverse then and go into the duodenal bulb. This is the first portion of the duodenum. You don't tend to see as many folds there. You'll see some little bumps that sometimes are larger in some patients called Brenner's glands that secrete bicarbonate to neutralize stomach acid. This is a second portion of the duodenum. You see the folds called the valvular coniventes. This is the major papilla where the pancreas duct and the bile duct secrete their secretions into the duodenum. And in some individuals, you're able to get the upper GI endoscope farther down than the second portion of the duodenum. Although the second portion is often as far as you can actually push the scope. In most patients in this instance, we were able to get to the third portion, the mid third portion of the duodenum. So then you'll look on the way in and on the way back. You'll frequently see some things better on the way back than you might on the way in. So you wanna look carefully in both directions. Some people do the retroflexion in the stomach afterwards. So there you have it. That is upper GI endoscopy. There are some periprocedure considerations because the procedure itself isn't all that's important here. So some important considerations periprocedure include the indication. Is it appropriate to perform EGD or not? What about contraindications, anatomical or medical issues that the patient may have which you have to consider? Does the procedure need to be done now? Is informed consent obtainable? What about sedation? We talked about this earlier. Procedure can actually be done awake in some patients and there may be good reasons to do that. Do you need just anxiolysis, moderate sedation or do you actually have to involve anesthesia? Is preparation to consider including NPO status which may be different if anesthesia is involved. They may require a longer wait after eating or drinking. Medication management was discussed earlier including antithrombotics, glycemic management and antibiotics occasionally required. Potential adverse events as well as post-procedure assessment. Now, upper endoscopy can be performed for diagnostic indications as well as for screening or surveillance. And I've listed some of these indications for you here. Diagnostic might include things like gastroesophageal reflux, dyspepsia, abnormal imaging studies or unexplained diarrhea. Screening or surveillance might be done for esophageal varices as I was showing you in my video there, the patient didn't have any. Or for Barrett's esophagus in patients who are known to have that disorder or patients who have intestinal metaplasia, the stomach or patients who have celiac sprew for compliance with their diet. There might also be therapeutic indications for upper endoscopy including hemostasis or ablation or resection of pre-neoplastic or neoplastic lesions. He might perform stricter dilation, feeding tube placement bariatric therapies, et cetera. So there are many indications but regardless of indication, important to remember is that endoscopy isn't a standalone. It's really just a tool in the spectrum of clinical involvement for disease management. So communicating with the patient and the entire team is key to focusing the procedure to extract the highest clinical value and safety out of the procedure. So the phases of care include not only the procedure but the clinic visitor hospital consultation, pre-procedure care, the procedure itself, post-procedure care and then afterwards communicating, messaging and procedure related documentation. So talk to the patient prior to the procedure, explain the indication alternatives, technical aspects of the procedure in understandable, plain language. Discuss sedation versus anesthesia versus awake endoscopy and why, what to expect and the recovery afterwards. Address potential adverse events in an understandable fashion so that if one results the patient isn't surprised and shocked and then invite and allow time for questions and address fears, anxieties and phobias. Informed consent is important. First to remember, it's not just that piece of paper. It's not the form. The form is just an attestation that the process of informed consent was undertaken. The concept of informed consent really came from the concept that the patient owns their body and that they decide what is or isn't done with their body. And there are various historical happenings and legal issues that have arisen over decades over a century, frankly, that has led to the concept of informed consent and the process that it is. And who can be involved includes not only the patient but in patients who are not able to fully understand or may not be old enough to grasp the concept of informed consent. There may be others such as parents, guardians and powers of attorney that are involved. And the components of informed consent include indications, which are really the reasons for the procedure, the risks, potential benefits and alternatives, the expectations of the procedure and what it's to yield, the potential for failure and what the plan B or plan C might be in that situation. And again and again, the opportunity for the patient and their representative if that's the case to ask questions. And then the form is signed. Some of the things you might see in upper GI endoscopy might include things like mucosal disease here in the esophagus. Grade A, B, C and D esophagitis is shown for your interest here. You might see some bleeding sources in upper GI endoscopy in the esophagus. There might be esophageal varices like we were looking for in my video or a Mallory-Weiss tear, which is a mucosal level tear that can be induced at the esophagogastric junction when somebody vomits violently. In peptic ulcer disease, there might be erosions or an ulcer like you saw before. There might be vascular ectasias or gastropathy that produce erythema in different patterns. You can have varices in the stomach as well, which are called gastric varices, usually in the proximal stomach. You saw a duodenal ulcer before or there might be angio dysplasias, which are abnormal vascular ectasias that you can see at the mucosal level. We use various diagnostic devices as well as therapeutic devices in upper GI endoscopy. For example, this is an aspiration catheter that's used to aspirate fluid in the duodenum or the stomach. Here are biopsy forceps that are obtaining, that are used to obtain mucosal specimens. Here's a brush that can be used to brush the esophagus if you're looking for hyphae and esophageal candidiasis. Adverse events can occur in upper endoscopy. Thankfully, they're not frequent, they're infrequent. Many of them are cardiopulmonary, particularly in diagnostic upper endoscopy, the morbidity and mortality is exceedingly low when the proper safety measures are observed. So major adverse events or complications are rare in diagnostic endoscopy, but they can be higher, much higher in therapeutic endoscopy and that needs to be taken into consideration in the consenting process. Quality indicators exist for upper GI endoscopy and they are available for you in various ASGE documents, which are free for you to pull up on your phone or on any PC. But the point that I wanted to make is many of the priority quality indicators for EGD have less to do with the procedure itself than to do with pre-procedure and post-procedure care. So what you do before and after the procedure can be super duper important. And this underscores that the actual procedure is just a tool in overall patient care. These days, there are few indications for prophylactic antibiotics in upper GI endoscopy. And so I wanted to point that out here in issues like synthetic vascular grafts or prosthetic joints where we used to use pre-procedure antimicrobial prophylaxis. That's not recommended anymore, but it's very important in patients who are having a PEG tube placed or patients who have known cirrhosis that come in with an upper GI bleed acutely. Both of those types of patients absolutely need antibiotics and that's a quality measure. After the procedure, remember to visit with the patient, ascertain that recovery is going well and review the findings. Assess for adverse events, remind patients about the possibility of delayed adverse events. Go over follow-up instructions, provide contact information and review any dietary restrictions or activity limitations, including those related to the sedation and anesthesia. Provide instruction regarding new medication or prescriptions that you might provide after the procedure and review initiating antithrombotic therapy. And remember to remind the patient to call you if you have any concerns, questions, adverse symptoms or signs. And to wrap up here with practice pearls for upper GI endoscopy, always ascertain proper indication and patient candidacy before any procedure. Diagnostic EGD, remember, is a frequently performed and overall very safe procedure, but not risk-free. And therapeutic EGD can be much more risk-prone than diagnostic EGD. Informed consent is not just a form, it's a process. So remember what you need to review. Remember that antibiotic prophylaxis is indicated for cirrhotic patients coming in with an active upper GI bleed and for PEG2 placements, but generally not for other upper GI endoscopies. Remember to observe best care practices, not just for the procedure, but in pre-procedure and post-procedure care. To observe quality metrics in upper endoscopy pre, intra and post-procedure phase. And as Dr. Alfred Baker, who passed away this year, a great friend and mentor of mine, used to tell me from time to time, John, it is easier to stay out of trouble than to get out of trouble. Thank you, Dr. Baker. And thank you all for your attention.

upper GI endoscopy

indications

procedure components

informed consent process

nose endoscopy

mucosal disease

practice pearls