Thank you so much. I hope everyone enjoyed the lunch break. So our next series of talks are going to dive right into GI endoscopic procedures, the very things that we've been preparing for with the last set of talks. So I'm going to start us off with upper GI endoscopy. So here we go. And again I have no relationships to disclose. So the objectives of this talk are to define upper GI endoscopy to learn the indications contra indications 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 which is so important. All right, I'm going to start you with a couple of polling questions I'm going to skip three of them. Upper GI endoscopy is indicated for is it a routine reevaluation of do a Dino ulcer be routine reevaluation of gastric ulcer. See yearly biopsy surveillance of short segment Barrett's esophagus. Or is it D colorectal cancer screening once a decade in normal risk individuals, which one is it only one is correct. Most of you got this right, we do not routinely reevaluate do a Dino ulcers we don't annually biopsy short segment Barrett's and colorectal cancer screening, obviously is not an upper GI procedure. Skip two, three, and four you have those in your slide set in the interest of time. I'm going to go to number five, which type of endoscope is not used to perform upper GI endoscopy. Is it a capsule endoscope trans nasal endoscope single balloon enter a scope side viewing do a Dino scope, or is it a colonoscope which one is not used to perform upper GI endoscopy ever. So, this is a little bit of a tricky question and that is why I included it, because we do in fact use a colonoscope sometimes to perform upper GI endoscopy. A video capsule endoscope can be used to evaluate parts of the upper GI tract. When we in medical vernacular talk about or use the term upper GI endoscopy. It doesn't refer to the use of a capsule refers to the use of any flexible endoscope to view the upper GI track so if you want to look beyond the second portion of the do a Dino you're going to need to use a colonoscope or even perhaps and enter a scope. So, if you got this wrong. I'm actually glad you got it wrong, because it helps you to understand the nature of what we're going to delve into with the rest of this talk. Okay, so here we go. So when we talk about upper GI tract anatomy. Typically we're talking about the esophagus stomach, and the do a Dino. So it's actually three organs, not just one. So, when we document upper GI endoscopy, we're actually documenting in a fashion where we're almost talking about three different organs because they are three different organs, and they have three very different roles in our digestive tract, looking at some more pictures here I'm not going to go into all of the anatomy because that's outside the scope of this talk, but technically when we talk about upper GI endoscopy includes the esophagus, the stomach, and the do a Dino, all of the do a Dino to the ligament of trite, which is the demarcation between the do a Dino and the June now when we do enteroscopy through the mouth, we may go quite far actually which by medical definition being south of the ligament of trite is technically not in the upper GI tract, it's in the middle of the gut or actually some would even consider to be lower GI but if we're talking about upper GI endoscopy, we generally are technically procedurally talking about a flexible endoscopic procedure that's done through the mouth so if we happen to peer into the June, that can be included so just want to make that distinction between anatomical language and clinical language. So upper GI endoscopy is any endoscopy of the upper GI tract, the natural orifice of insertion can be the mouth, but also the nose, or even if there's something like a spit fistula or a gastrostomy and we insert a scope through their flexible scope through those non natural orifices then that can count as upper GI endoscopy so the term is pretty broadly encompassing and include several procedures so upper GI endoscopy is not synonymous with a GD, it can be less than that, it can be just an esophagoscopy, or it can be more than that, to even encompass the June. So any endoscopy of the upper GI tract or even beyond the ligament of tripes, as we were saying if it's done through the mouth with a flexible endoscope or any natural orifice or even surgically created orifice that enters the upper GI tract that can be called upper GI endoscopy. It's almost, well I should say most of the time is done with an upper GI endoscope sometimes it's called a gastroscope sometimes it's called an endoscope. The terms are basically clinically synonymous, but you could also use a colonoscope or pediatric endoscope or some other devices to do it, depending on what you're going after. The light source, or actually the light source is a projector bulb that's inside a box that contains the air pump and a fan to cool the lamp and fiber optics carry that light glass fibers, all the way to the tip of the scope where it shines on whatever you're looking at. The scope, of course, also needs a lens, so that you can see whatever it is that you're looking at and that lens is just a piece of glass, with a little camera chip behind it, just like in your, your cell phone, and then wiring carries that signal up to the which then processes that signal and provides you the view of the scope on a monitor screen, that's just like what's sitting on your desk or on your, your laptop. There's also an accessory channel which is just a plastic tube that runs from the biopsy valve here, and the suction valve up here, they're connected in a Y configuration here, so that you can pass accessories through it suction through that opening. And that, of course, ends up coming out the suction connector here into a bottle, a trap. And you can also aspirate specimen through that and place any of the devices you're working with through the same channel by driving stay a four separate snare through here. And it would come out this opening, the same one that is used for suctioning. So, we don't consider upper GI endoscopy the vernacular there the term to include a capsule endoscope although capsule endoscope can see parts of the upper GI tract procedures that technically included upper GI endoscopy include not only esophagoscopy or esophageal gastroscopy, you're also looking at the stomach or EGD esophageal gastro duodenoscopy for examining the duodenum, as well. But also push enteroscopy which is looking at the distal duodenum and maybe the proximal June I'm using a colonoscope and deep enteroscopy or balloon enteroscopy which is used to look off and far into the June. You can also classify upper GI endoscopy not only based on where you're going or what part of the anatomy you're looking at, but also what what what you're using so a certain type of upper GI endoscope is used to perform biliary and pancreatic endoscopy which you see here, and an echo endoscope, which has an ultrasound machine built into the tip of the scope is used to perform endoscopic ultrasound or us and various interventions can be performed through various scopes performed in the upper GI tract including advanced section, advanced esophageal therapies and so forth third space endoscopy drainage procedures, bariatric therapies, and stem thing, and anastomosis creation. So this is what it looks like similar picture to what you saw before and some of the common things you might see or ulcers like this one you see here. Looking in this upper GI endoscope but what's better for describing all of this, then to show you a video right so I'm going to speed this up a little bit in the interest of time. You're going to see the endotracheal tube this is the epic a lot of us and we're going to want to aim down here, because we want to go in the esophagus which is dorsal. Remember that this is a lens on the end of the scope so whatever is up is on the bottom and whatever's down is on the top everything's flipped. When you're looking through a lens right. So we're trying to get through the upper esophageal sphincter here, and we're going to pop right through it here in a second, that little freeze frame was where I took a picture for the patient's procedure report. So we're in the proximal esophagus now usually take a picture there and then I'll go down to the middle of the esophagus. I'll take another picture there usually for photo documentation. And then I'll usually snap another picture in the distal esophagus. You can see the Z line where the squamous mucosa of the esophagus converts to the columnar mucosa of the stomach, we're going to pop into the stomach here you're looking in the antrum and washing it. Now I'm turning the scope up and sort of a J configuration, which will let me see the incisor angularis where the stomach takes that dog leg turn. And if I tip the scope up where it's looking back at itself now we're looking up in the body of the stomach and you'll see the fundus and the cardia. So if we take a moment, the area surrounding the EG junctions the cardia, this arch of the stomach up here is the fundus of the stomach. And we usually get a 360 view of that by twirling the scope or working it as we call it, and photo document that view because you really can't see that looking head on, or on FOSS, as we call it. Now, put wash water in. We usually want to lavage it out so the patient doesn't risk aspiration from that you actually can aspirate even if you have an endotracheal tube and it makes that less likely, but it doesn't eliminate that possibility. So that ring muscle that pylorus there demarcates where the ball but the duodenum starts you see that here. And now we're going to navigate in a little bit farther to the second portion of the duodenum and that's usually about as far as you can get with a gastroscope you want to get any deeper you need to use a colonoscope or an endoscope to do that sometimes with a gastroscope you'll be able to see the major papilla there that's where the bile duct and the pancreas duct empty into the intestine. So there you go. That's a normal upper GI endoscopy so there are some Perry procedural considerations for the overall theme here you want to make sure that you have an appropriate indication before considering any endoscopy. So the major indications the anatomic or medical issues. How urgent is it are you going to be able to obtain informed consent. You're going to do this awake are you going to use sedation, or are you going to use anesthesia. What about other preparation of course the patient needs to be NPO or you can't sedate or anesthetize them what are you going to do about the meds that they're on. We talked about that in great detail potential adverse events that you might encounter. You always need to be prepared like you were back in scouts when you're a kid. And of course post procedure assessment and visiting and reviewing findings with the patient, and the accompanying person discharging rather discharge instructions diet instructions prescriptions and next steps are every bit as important as the procedure There are diagnostic and screening or surveillance reasons to do upper GI endoscopy which I've listed for you. They are numerous, and this is not an exhaustive list. These are just some of the common indications, but we don't just do looking with upper GI endoscopy. We also do some, some fixing. So there's therapeutic maneuvers that can be involved, and I've listed some of those for your consideration as well. Upper GI endoscopy is only a tool for total disease management and the upper GI tract it's not an end all. It's not a standalone the importance of any procedure is in the context of overall disease management and communicating with the patient and the is the absolute key to focusing the procedure for the highest potential clinical value and safety phases of care of course include the clinic visitor the hospital consultation followed by pre procedure care. The procedure itself and then of course post procedure care and then communication messaging and procedure related documentation so talk to the patient before the procedure, explain the indication alternative alternatives technical aspect to the procedure in language that's understandable discuss the sedation in anesthesia versus awake endoscopy aspects what to expect recovery afterward address potential adverse events in an understandable way couch all of that, with the risks of not doing the procedure and then invite and allow time for questions, address fears anxieties and phobias as needed. We talked about informed consent before so I won't overstress it remember that it's a process it's not just signing that piece of paper it's important to involve involve others, both in terms of relieving anxiety for the patient, as well as witnessing the patient we talked about the components already. But remember always to give the patient an opportunity to ask questions and document that you did that. You might see all kinds of interesting things one of the most frequent things you'll see is esophagitis with upper GI endoscopy, and there is a way to grade that and I have placed that along with the pictures for you here. You might see some bleeding sources sometimes whether that might be esophageal varices erosive or all sort of disease the mucosa gastropathy that's not ulcer. You might see ulcers, not only in the esophagus but also in the stomach or the duodenum Mallory Weiss tears and mucosal tear at the esophagus gastric junction that can actually cause bad bleeding and that is trauma that's caused by vomiting. You might see gastric central vascular tasers which are little abnormal mucosal blood vessels that can bust open and and bleed acutely or chronically, you might see varices not only in the esophagus, but also in the stomach and you can see to land lesions that are called angio dysplasia or angio ectasia those two words mean the same thing. Here's some diagnostic devices that you might commonly see if you want to obtain a specimen for example to diagnose small intestinal bacterial overgrowth, you might use an aspiration catheter or to get mucosal biopsies, you might use a biopsy for step or to get cells instead of tissue, you might use a brush. There are all sorts of guidelines available for you at a sgp.org they're free for you to access even if you're not a member, you get free access as g.org from your computer, or even from your phone. We also prefer to discuss the potential adverse events, even though they're rare particularly with diagnostic endoscopy, and we covered these details in my earlier talk. There are quality indicators for EGD, there are fewer of them than there are for colonoscopy so far, but that's subject to change over time. So consult these frequently come back because there might be something new there. We used to do more antibiotic prophylaxis for upper GI endoscopy there are a few indications for that anymore. Really, it's just a couple of them for patients who you're going to put in a peg tube and endoscopic g tube placement, you're going to want to cover skin organisms, every time so that's usually gram positive coverage with a cephalosporin and for patients who have known cirrhosis who come in with acute upper GI bleeding, every one of those patients need to be needs to be placed on anti microbial or gut organisms, usually with a fluoroquinolone or a cephalosporin. We don't provide antibiotic coverage for upper GI endoscopy for vascular grafts or cardiovascular devices or prosthetic joints anymore that is not recommended and not indicated after the procedure visit the patient. Assess for any adverse events to know ascertain that recovery is well going well and review the findings with them assess for any adverse events again you don't want to be the last person to know you want to be involved and let the patient know that you care. Provide instructions provide contact information review any dietary instructions activity limitations, and those related to not just the procedure but also to sedation or anesthesia provide instructions regarding any new medication or prescriptions that you are going to provide review any reinitiation of anti thrombotic therapy therapy, specifically, what you're going to do with that, when did they, the patient needs to start it, and how much remind the patient to call if they have any concerns or questions or adverse symptoms or science and tell them some practice pearls of upper GI endoscopy with a picture of one of my mentors the late Alfred Baker, who was really, really expert and scholarly transplant hepatologist always ascertain the proper indication of the procedure, make sure it needs to be done before you do it, and assure the patient's candidacy for the procedure diagnostic EGD is frequently performed and overall it's very safe, but the risk is not zero, and any therapies that you add can add substantial risk to the risk of adverse events. So know that divulge that to the patient as well discuss in detail and consent properly and specifically. Inform consent remember it's a process it's not a piece of paper alone review the procedure the indication the risks couch it in the proper way. Talk about the benefits the alternatives, and the potential for missed diagnosis. Remember antibiotic prophylaxis is not indicated frequently. It is for cirrhotic patients coming in with an acute GI bleed, as well as for peg patients peg placement patients but not for other EGDs observe the best care practices, not just for the post procedure, but also pre and post procedure and observe quality metrics. Remember they do exist, and are defined for upper GI endoscopy for pre intra and post procedure phases of care, and as my mentor Dr. Baker used to say to me frequently john, it is easier to stay out of trouble than to get out of trouble. All right, thank you very much, and we're going to travel south now I'm going to hand off to my erstwhile colleague and friend, Dr. Joe vicari who will come to us again to present to you on colonoscopy Joe, take it away.

upper GI endoscopy

indications

procedure components

documentation

post-procedure follow-up

informed consent