And again, nothing to disclose, the objectives here to define upper GI endoscopy to learn the indications, contraindications, and pre-procedure prep, 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 to discuss the components of proper post-procedure follow-up. Starting with a polling question here, upper GI endoscopy is indicated for routine re-evaluation of duodenal ulcer, routine re-evaluation of gastric ulcer, yearly biopsy surveillance of short segment barrets, or is it colorectal cancer screening once per decade in normal risk individuals? Only one's correct. Which one is it? Wonderful. We have a really smart group of professionals on this meeting. So, remember that we don't routinely re-evaluate duodenal ulcers, but we do for gastric ulcers, because we want to make sure that that's healing when we re-look, because those can be cancer. We don't biopsy short segment barrets esophagus every year. That's indicated to be done once every half decade. And we don't perform upper endoscopy for colon cancer screening. I kind of put that on there as a joke. Okay, question two, upper GI endoscopy is always performed through the mouth, indicated for workup of lower abdominal pain, indicated for primary investigation of biliary type upper abdominal discomfort, indicated for workup of esophageal dysphagia, otherwise known as transit dysphagia, or is the most important study in the workup of oropharyngeal or transfer dysphagia? That's right. Perfect. Yeah, we use it for the workup of transit dysphagia, for sure. The most important study for working up oropharyngeal dysphagia, where you're having trouble transferring the food bolus from your mouth into your esophagus, that's a modified barium swallow. And that is done by speech pathologists, not us. It's not always done through the mouth. Sometimes we do this through the nose. It is not indicated for workup of lower abdominal pain, and you won't be able to bill for that either. And it isn't what's indicated for biliary upper abdominal discomfort. You're probably going to start with an ultrasound for that symptom. Okay. The term upper GI endoscopy is identical to the term EGD. Includes EGD, or rather esophago-gastroscopy, esophago-gastroduodenoscopy, single balloon endoscopy, but not double balloon endoscopy. Includes esophago, or esophagoscopy, esophago-gastroscopy, esophago-gastroduodenoscopy, single balloon endoscopy, and double balloon endoscopy, or those and also video capsule endoscopy. And I'm trying to make a point here, or a couple of points. Yeah, this is not the easiest question, but I want to ask you this because I think it's important to understand a certain distinction that wasn't clear to me as a gastroenterologist for years. Yeah. All right. And I can see the answers are all over the place and I'm glad because that helps me underscore a point here. Okay. Upper GI endoscopy is not identical to EGD. EGD is esophago-gastroduodenoscopy. So it's basically three procedures. One to look at the esophagus, one to look at the stomach and one to look at the duodenum, usually just the bulb and second portion. Okay. But upper GI endoscopy is actually a more ambiguous description than that. Basically any flexible endoscopic procedure that's done through the mouth qualifies as an upper GI endoscopy. And that includes any of the push and enteroscopy or deep enteroscopy procedures that are performed to look farther down into the upper GI tract. And if you want to be technical about it, upper EUS and ERCP are basically upper GI endoscopies that have other adjunctive imaging and therapeutic modalities associated with them. So, you know, upper GI endoscopy is a more inclusive term and that includes EGD and other deeper upper GI flexible endoscopic procedures. That is the point of my asking this polling question. However, by convention, it does not include video capsule endoscopy because that's not flexible endoscopy, even if it's being used to image the esophagus, stomach and proximal duodenum. Okay. Very good. Which type of endoscope is not used to perform upper GI endoscopy? Yeah. Okay. So that's right. I gave you the answer, which is video capsule endoscopy, because that's not a type of flexible endoscopy, even if it's looking at that area. You may not know that we do sometimes use a colonoscope to look at the upper GI tract. If we need to look at the distal duodenum or the proximal jejunum, we call that a push enteroscopy. There is no such scope called a push enteroscope. We repurpose a pediatric or adult colonoscope to perform that procedure. Okay. Very good. So, you know, the upper GI tract anatomy that we're usually looking at with an EGD, that's the esophagus, the stomach, and the duodenum. And we consider each part of the anatomy of each of those organs distinctly. So it's actually three procedures in one, and you will see that our reports report out that way. And this is where those organs are in relation to the rest of the gut, within the abdomen for the stomach, most of the time, and duodenum within the thorax and the neck for the esophagus. So we just said any endoscopy, the upper GI tract that's with a flexible endoscope qualifies. Occasionally, we'll go through the nose instead of the mouth. And the term is broadly encompassing, as I described. So this is what it looks like as the scope is passed. The patient is typically in the left lateral decubitus position to perform the procedure. Flexible endoscopes largely all follow the same format for specialty scopes for performing EUS and ERCP and a few other procedures. There are some additional controls that are available on the head of the scope. But the general theme is the same. There's a bending section of the scope at the tip that can go left, right, up, down, which is controlled with the two dials that you see, the two knobs. And then the two valves, one of them allows air or carbon dioxide to be insufflated into the viscous of the lumen to puff it out so you can see. And also, when you push it down, it allows wash water to wash the lens of the scope. That's separate from the wash water with the scope having a water jet that's directed towards whatever you're looking at. That's controlled with your foot. That's not controlled with either of the buttons that you see on the head of the scope. The back button or valve that you press down is for suction. That allows for you to use that instrument channel or accessory channel as a suction channel to aspirate contents out of the lumen of the gut. In most scopes, there's a projector bulb in a box called the light source. And fiber optics carry that from the bulb all the way through that umbilical cord that's connected to the scope to shine the light out of the lens at the distal end of that optical fiber bundle that carries the projector lamp light all the way to the tip of the scope. There's also a lens, and behind that lens is a camera chip, kind of like the one that's in your cell phone that you use to take pictures. And then there is electrical wiring that carries that signal through the scope to the processor box that sits on top of the light source that then converts that electrical signal to one that displays it as an image on your monitor or your video display. We're not talking about capsule endoscopy in this talk, so we're skipping that. All right, so what's included within the category of upper GI endoscopy we kind of already touched on. Some of it can be categorized by where you're going in the anatomy, but also, you know, what type of scope you're using. ERCP and EUS require specialized scopes to perform, and then there may be specialized devices that can be inserted through specialized scopes to perform any number of interventions. So continuing on, what does it look like? Well, here's an ulcer that you're seeing in the stomach, and you see how the scope is positioned there, looking towards the antrum of the stomach. Can you start this video for me, Sam? I don't seem to have an ability to toggle it. Great, thank you very much. So here we are. This patient's under general anesthesia. You can see that they have an ET tube in. Now you can see the tongue is on the top. What's on top looks like it's on the bottom, and what's on the bottom looks like it's on a top. That's just the nature of looking at something through a lens. Okay, there is the epiglottis at the bottom of the field. It's not covering the airway because that airway is held up open by the ET tube. Now we're going below the epiglottis to try to get into the esophagus because the esophagus is dorsal to the airway. All right, so can we fast forward this to about maybe the one minute point? Yeah, there we go. So we're going down the esophagus now. We're about to enter the stomach. There's the Z line that demarcates the white tissue of the esophagus and the pinker tissue of the stomach. We're about to enter the stomach. If you can go forward another 20 or 30 seconds for me there, Sam. Yeah, there we go. Now there's the antrum and the pylorus. That's the water jet which is cleaning the area and I'm working that with a foot pedal. So that's the antrum of the stomach. We also get the scope to look back on itself there to visualize the insusura angularis and also the fundus and cardia. So the scope's looking back towards itself. And then if you can fast forward another 30 seconds or so, there's the antrum, the pre-pyloric antrum going through the pylorus. That's the duodenal bulb. When it freeze frames, that's when I've taken a still shot picture to add to my report and there is the second portion of the duodenum and that's usually about as far as you can reliably get with a forward-viewing gastroscope. That thing in the upper left, that little thing that looks like a polyp is actually the ampulla of vater or the major papilla, which is the opening of the ventral pancreatic duct and the common bile duct. It looks like I was able to get to the proximal third portion of the duodenum here. Okay, great. So some periprocedural considerations. Is the indication appropriate? Are there any contraindications or anatomical or medical issues that we need to be aware of? What's the urgency? Can you obtain informed consent? If it's an emergency, maybe you can't, but you still have to go for it. What type of sedation to undertake? What's available? Preparation for the procedure. We just got done talking about that in a full lecture. Potential for adverse events and post-procedure assessment and instructions. The indications for upper GI endoscopy you see below. There are a number of diagnostic indications. There are a number of screening or surveillance indications as well. And there are also various treatments, therapies that we're able to perform using this powerful platform, as you can see below. But remember, at the end of the day, endoscopy is just a tool for the overall management of disease. So it's not a standalone. Its importance is in the context of disease management, which means communicating with the patient and the entire treatment team is where the value is. Because they ask you to do the procedure because they either need information, they need tissue, or they need treatment, or any and all of the above. And all of that needs to be communicated in an understandable way to all of the stakeholders. And there are multiple phases to this care, as I've enumerated. What to do is in the blue box there. Talk to the patient before and after. We talked about explaining indications, alternatives, potential risks and benefits, alternatives, and to also discuss sedation or anesthesia and the risks therein. Here's some things you might see in upper GI endoscopy, such as different degrees or severities of esophagitis. In upper GI bleeding situations, there can be a number of different causes of upper GI bleeding. You see a number of them demonstrated for you here with their endoscopic appearance. As you can see, we can see very, very clearly with upper GI endoscopy. There are a number of devices that can be used for fluid and tissue acquisition. That's an aspiration catheter on the left. We might use that to aspirate duodenal juice to investigate for small intestinal bacterial overgrowth. There's different kinds of biopsy forceps to biopsy the mucosa to get a tissue diagnosis, or a brush to brush plaque to see if it's candida, or to brush a stricture to see if there may be malignant cells. Adverse events in upper GI endoscopy overall are very infrequent. That's the take-home message. It's hard for patients frequently to understand what these numbers mean, so you need to couch all of this in a general discussion by explaining to them that it's rare, but that the risk is not zero, that we can frequently handle many of these adverse events at the time of very effectively, but we can never completely eliminate the risk. There are better and larger number of good quality indicators for colonoscopy than for upper GI endoscopy, but there are a few priority quality indicators for EGD, which you see here, which have a lot to do with whether you do the right thing or not during the endoscopy. Now, these aren't the latest ASGE quality indicators for EGD. There are some new ones that were just published in January, so we're really hot with new quality indicators in ASGE. They were just published, as you can see here, this year in gastrointestinal endoscopy, and these were jointly published with AGA and ACG also. The reason why I wanted to show you the old ones is they're a little bit less pithy about telling you what to do. The new ones are more of a discussion of over 20 purported or proposed quality indicators and a discussion regarding the capability of applying these to practice, whether they should or not, and what evidence exists out there. So to me, I think both are worthwhile to look at and to consult. There are few indications for antibiotic prophylaxis for upper GI endoscopy, and I enumerated these in my earlier lecture, but provide this slide for you again. After the provider, be a good egg. Visit the patient. Make sure they're recovering well, even if there are other caregivers that are there to do that. The patient trusts you as a provider. Assess for adverse events. You don't want to be the last to know. Go over the follow-up instructions. Make sure that somebody does that and provides contact information. Review any dietary instructions, activity limitations, instructions for restarting medications, particularly blood thinners of various sorts, and then remind the patient to call if they have any questions or concerns or symptoms that are not expected. Practice pearls. Always ascertain that you're doing the EGD for the right indication and the right patient. Diagnostic EGD is frequently performed and is overall very safe, but no procedure is risk-free. Therapeutic EGDs do have a higher risk of serious complications, but the risk of not doing them is higher as well, so discuss this with the patient consent appropriately. Remember that informed consent is a process. We already talked about that. We talked about the few antibiotic prophylaxis indications in upper GI endoscopy. Observe best care, not just intra procedure, but pre and post. Observe quality metrics. I showed you where to look for those on the ASGE site, and as one of my mentors, a hepatologist named Al Baker, used to say to me all the time, John, it's easier to stay out of trouble than to get out of trouble. Thank you very much.

upper GI endoscopy

pre and post-procedure care

diagnostic and therapeutic applications

informed consent

antibiotic prophylaxis

patient safety