Upper GI endoscopy lecture, I have no financial relationships to disclose. So let's shift gears now and talk about upper GI endoscopy. We're going to define that term as well as learn the indications, contraindications, procedure prep, and informed consent for this procedure or this suite of procedures, describe the components of the upper GI endoscopy procedure as well as what we can do in upper GI endoscopy, talk about best practices, and discuss the components of proper post-procedure follow-up. Let's start with a few polling questions. Upper GI endoscopy is indicated for A, routine reevaluation of duodenal ulcer B, routine reevaluation of gastric ulcer C, yearly biopsy surveillance of short-segment Barrett's esophagus or D, colorectal cancer screening once per decade. Okay, so is it routine reevaluation of duodenal ulcer? No, we don't routinely re-endoscope those people. Do we routinely reevaluate a gastric ulcer? We do because we want to make sure that it's healing because if it's not healing, we're concerned that it may represent cancer. We don't yearly biopsy short-segment Barrett's and we, with this last one, colorectal cancer screening once per decade in normal risk individuals. All right, so here's upper GI tract anatomy. You remember that the upper GI tract starts with the esophagus, which is the tube that connects the oropharynx down to the stomach and basically traverses the thorax, deposits food into the stomach, which is below the diaphragm in the abdomen. The stomach is a reservoir for that food where it is disinfected with acid. It is comminuted by the antrum that grinds it up. The fundus is a reservoir. The antrum is a grinder and then the muscle of the pylorus sieves that ground up material and deposits it into the duodenum. Gastric acid is secreted into the stomach to disinfect that food and pepsin is a proteolytic enzyme that begins the protein digestion process and amylase from your salivary glands has already started to work on starch and break it down to sugar. The duodenum is the beginning of the small intestine. The small intestine is where the majority of absorption of nutrients, micronutrients and water takes place. This is where almost all digestion and nutrient absorption takes place. And the duodenum specifically is where bicarbonate is mixed with the acid from the stomach to neutralize that acid to provide a neutral pH environment for the digestive enzymes to work their best in the intestine. So here's where the upper GI tract is in the context of the rest of the abdomen. So what is upper GI endoscopy? In a general sense, it's any endoscopy of the upper GI tract. And so it's a little bit different term from esophagogastroduodenoscopy or EGD. EGD is one type of an upper GI endoscopy that's limited to those three organs. The natural orifice of insertion of the scope could be the mouth, but sometimes we insert through the nose for different reasons. So the term is broadly encompassing and it includes several upper GI endoscopy procedure of which one is an EGD. So as you can see here, in most cases, we go through the mouth, down the esophagus, into the stomach, and then into the first and second portion of the duodenum for EGD. An upper GI endoscope has a working part of the scope here that fits into the left hand and is identical to a colonoscope. And just about every scope shares the same control section. All scopes have what's called an umbilical cord that connects the scope to the light source, the air or carbon dioxide source, and also connects it to the image processor, which processes the electronic images that's delivered by the camera at the tip of the scope and delivers it to the processor. The processor then processes that electronic image and delivers it to the screen or the monitor. There's a valve that provides air or carbon dioxide to insufflate or puff up the viscous, the stomach, esophagus, duodenum. And there's also water wash that's delivered to wash the lens to keep it clean so that you can see. There's also sometimes a flushing channel to deliver wash water through the scope. You can deliver instruments or provide suction with the large channel in a scope. And there's also a suction valve that controls your ability to suction and clear liquid and some small solid particles from the gastrointestinal lumen. We generally don't include capsule endoscopy in the term upper GI endoscopy, although you can provide capsule endoscopy of the upper GI tract. These aren't controlled by the endoscopist. These are swallowed and then transmit an electronic signal to a receiver that the patient wears. And then those images are downloaded by a PC. And then the clinician reviews those images afterwards. We're not talking about that during upper GI endoscopy. But there are many different procedures that qualify as endoscopy of the upper GI tract with a manual endoscope. And you can describe this based on where you're going. So there's esophagoscopy, looking at the esophagus, esophagogastroscopy, esophagus and stomach, EGD, looking at the duodenum also. There's push enteroscopy, where we generally use a colonoscope to look far into the duodenum or sometimes even get to the most proximal part of the jejunum. Different types of balloon enteroscopy often allow us to get far into the jejunum. You can also describe upper GI endoscopy by what you're using in terms of a scope. There's an ERCP, where you use a duodenoscope to look at the bile and pancreas duct. Or endoscopic ultrasound, where you have an ultrasound machine built into the tip of the scope. And you're looking at an ultrasound image or using an ultrasound image to inject, say, dye into the pancreas duct here, for example. And there's interventional EGD, where you're doing any and all sorts of things, oftentimes to fix problems with the scope using other tools through the scope. Again, this is what that all looks like. So here's the image. This is an image of an ulcer that you can see, probably in the stomach. Here is a video. There we go. Thank you very much. So this patient's under general anesthesia. There's an endotracheal tube in place. We're advancing the scope. You can see the tongue at the top. So what's up is down and what's down is up. So the image is actually upside down. Not particularly important. There is the epiglottis at the top of the screen there. And now you see the airway. And we're going to try to go below the airway there because we want to go into the esophagus and not the airway. And because of the upper esophageal sphincter and probably because the balloon cuff on that ET tube is up, we're encountering a little bit of gentle resistance getting into the esophagus, but we've popped in now. That's the very proximal end of the esophagus, the very top there. And now we're washing the lens to get the secretions off to get a clearer view. As you can see, you can get an amazing view. You can even see the little mucosal blood vessels. We're in the mid esophagus now. We're going down into the distal esophagus. Right there is the Z line where the squamous mucosa of the esophagus joins the columnar mucosa of the stomach. Trying to get a good view, clear view of that. There are a lot of swallowed secretions, so we're constantly clearing them. And then we have now popped into the stomach where you can see the rugal folds, right? The stomach here is collapsed because the patient is NPO, so there's no food there. The stomach is collapsed, but we're going to insufflate by injecting carbon dioxide with one of those valves on the head of the scope to puff that stomach up. Now you're looking at the antrum and the pylorus is that opening into the duodenum. I'm washing to get rid of the secretions so I can see the mucosa clearly because we don't want to miss something like an ulcer that could be hiding underneath those bubbles. There's the angularis, the insussura angularis of the stomach. We're looking now in retroflexion where the scope is in a J configuration looking back at itself. So now you're seeing where the scope is coming through the esophagogastric junction into the stomach. And with the scope in a J retroflexed fashion, we're looking up at the fundic arch, that arch part of the stomach that juts up on the left side of the left upper quadrant of the abdomen. See that? And then we're going to aspirate some of that fluid so that when the anesthetist extubates the patient taking the ET tube out, we don't want the patient to suddenly vomit and aspirate gastric acid and the water that I just injected to clean the stomach. So we're going to want to aspirate that on our way out. So here's the antrum, the pylorus going through the pylorus into the duodenal bulb. This looks normal. And then we're going to go around the duodenal sweep into the second portion of the duodenum. And you're looking around the second portion of the duodenum into the proximal third portion of the duodenum there. I'm going to stop that video at that point in the interest of time. So some important peri-procedure considerations of the overall theme here. Appropriate indication or not for the endoscopy. Any contraindications to the procedure. Is the procedure urgent? If it's an emergency, you may have to bypass the consent if you can't obtain it. What type of sedation is appropriate? The preparation for the procedure, potential adverse events that you may encounter. Think about these beforehand in the context of the risk profile of the patient. And think about what you're going to need to do post-procedure. There are many different indications for upper GI endoscopy. Many of them, as you can see here, are actually diagnostic. And diagnostic procedures are often done for patients who have presented with symptoms or signs. But if patients have no symptoms or signs but are showing up for an indicated upper GI endoscopy, they're probably showing up because they need a screening or surveillance procedure, whether that is for patients who have portal hypertension, where you're screening or surveying for varices, or patients with known Barrett's esophagus, or patients who have longstanding GERD and may be at risk for Barrett's esophagus. And you can see a number of screening and surveillance indications there. And not only are there diagnostic reasons, we may be there to actually treat something. So maybe therapeutic indication for the upper GI endoscopy, such as upper GI bleeding, or the need to ablate abnormal tissue, or to dilate a stricture, and so on. Endoscopy, though, at the end of the day, isn't a standalone. It's really a tool for disease management. So the importance of endoscopy, whether upper GI or otherwise, is actually in the context of managing disease. So it's not something that has importance in and of itself, which means communication with the patient and with the entire treatment team is the key to focusing that procedure for highest clinical value and safety. So think about the phases of care, the clinic visit or the hospital consultation, pre-procedure care, and then the procedure itself, but also post-procedure care, and then communicating with everybody involved with that patient what that procedure showed and what you did. And this also includes discussing those things with the patient. We talked about informed consent before, that it's a process. It's not just that paper and what the components are and remembering always to ask the patient if they have any questions before you proceed. So here are some nice pictures of esophagitis that you might see when you perform an upper GI endoscopy, say, for a patient who has heartburn or chest pain. It's great. You might see A, B, C, and D, depending on the degree of mucosal breaks. You may also see GI bleeding in upper GI endoscopy, whether that's from esophageal varices and portal hypertension. You might see erosions or ulcers, Mallory Weiss tears that can occur at the EG junction from vigorous vomiting. You might also see varices in the stomach, not just in the esophagus. You might see telangiectatic lesions like angiodysplasias or gastroenteral vascular ectasias, watermelon stomach. Ulcers can occur not only in the stomach, like you saw before, but also in the duodenum. There are diagnostic devices such as washing and aspiration catheters, biopsy, and brush devices for acquiring tissue and cells, respectively. We talked a little about adverse event rates before. For diagnostic upper endoscopy, the risk is very, very rare. That's the bottom line. While we talk about the risk of bleeding or perforation or infection, these are very low risks, but important to remember to tell the patient that the risk is still not zero. And frankly, the main risk is cardiopulmonary related to sedation and anesthesia. There are quality indicators for upper GI endoscopy. They're available to you. Please look these over on the ASGE's guidelines site. Remember ASGE guidelines are available to you free at ASGE.org. You don't even need a membership or a subscription to reference those. With antibiotic prophylaxis for GI endoscopy, there are not a lot of them. In all patients, remember, though, that for patients who are having a feeding tube placement with upper endoscopy, you need to give them an antibiotic. And patients with cirrhosis who come in with GI bleeding, they deserve an antibiotic regardless of whether or not they're undergoing endoscopic procedures. It's that GI bleed, not the endoscopy, that's the indication for the antibiotic. However, that is about it for antibiotic prophylaxis and upper GI endoscopy. We talked about what you need to do after the procedure. Visit the patient. Make sure they're recovering well. Don't be the last to know. If they're not recovering well, go over post-procedure care with the patient. And then make sure that you review going back on medication, dietary recommendations, if any, and remind the patient to call you if they have any questions or concerns, or they have symptoms or signs that are of concern. My mentor, Dr. Al Baker, who passed recently, used to say always remember to stay out of trouble because it's easier than getting out of trouble. And the way we do this is by making sure that we have a proper indication for the procedure. Remember that EGD is frequently performed and is very safe but not risk-free. Low risk doesn't mean zero risk. Explain that to the patient. Therapeutic EGD has a higher risk of serious complications, so you need to tailor your consent accordingly. Remember that informed consent is a process and it's a requirement and that you need to document it. Antibiotic prophylaxis is rare. It's for patients with cirrhosis who come in with a GI bleed, or for patients who are undergoing upper GI endoscopy for a PEG or PEJ placement. Observe best care, not just for the procedure itself, but before and after. Observe quality metrics. Consult the ASGE guidelines. Thank you very much.

Upper GI endoscopy

Esophagogastroduodenoscopy

Gastrointestinal tract

Endoscope

Post-procedure care