All right, everyone, we're after getting a great session to kick off our course, we're going to move on to session two, upper endoscopy challenges. And it's my great pleasure to introduce my friend and colleague, Dr. Peter Dragunov from the University of Florida. Good morning. One of my favorite parts, the video case discussion, and we start with Sawani, and the topic will be atrophic gastritis, intestinal metaplasia and gastric dysplasia. Oh, okay. I was told that I have to introduce the whole panel. So let's do that and get it out of the way. We have Dr. Ara Shakayan and Vani Kondal and Dr. Dennis Yang. Good morning, everyone. So we start with this first case. We have a 60-year-old female who was referred to the GI clinic for family history of gastric cancer. She was originally from China, but moved to the United States 20 years ago. The only complaint is she has chronic dyspepsia and intermittent bloating, but otherwise denied all the GI symptoms, no weight loss, never has an upper endoscopy, no family history. But she has a family history of gastric cancer in her mother and was diagnosed at age of 50. Her labs are unremarkable. So she is at an increased risk of gastric cancer because, one, she's come from high Eastern country, and two is she has family history in her first degree relatives. So we recommend an upper endoscopy to first detect and risk stratify pre-cancerous gastric lesions, such as gastric atrophy and gastric intestinal metaplasia. And second is to detect gastric dysplasia and early gastric cancer and potentially treat them before they turn to advanced cancer. But to examine the stomach in these patients, we have to perform high-quality endoscopy. First, ensure mucosal visibility. We have to clean the stomach carefully, remove all the debris, bubbles, use mucolytic until you don't see any bubble or minimal bubbles or mucus left that does not obscure view. Like the lower pictures, it's still not adequate cleaning, and we need to continue to clean more before we start examination. The second is ensure adequate distention of the stomach. In this picture, you can see a partial distention of the stomach, and it looks okay. But when we fully distend the stomach, you can see advanced gastric cancer. So we can miss even advanced gastric cancer if we don't fully insufflate the stomach. Next is how long we have to examine the stomach. In this study, it showed that the endoscopies that spend at least seven minutes performing endoscopy in a high-risk patients, there has been about two and a half fold increase in chance of detect high-risk gastric lesions. So it's recommended that we at least spend seven minutes performing an upper endoscopy in these high-risk patients. And we need to use enhanced imaging to improve detection of gastric metaplasia. And for this white light image, it looks normal. But when we apply NBI, you can see multiple whitish patches. And in close-up view, you see rich pattern. This is suggestive of gastric metaplasia, and targeted biopsy confirmed gastric metaplasia. So the combination of enhanced imaging and targeted biopsy increased detection of gastric metaplasia. So this patient underwent endoscopy. And first you see, so you can see the large lesion, displaced lesion at the incisor, and above it, you can see gastric metaplasia. Come back to this displaced lesion, there's no ulcer. On the NBI, there's irregular surface pattern. So this is non-ulcerated lesion and depressed morphology. At least we're concerned that this is high-grade dysplasia or early gastric cancer. So the biopsy of this lesion, in fact, show intramucosal adenocarcinoma in the background of gastric metaplasia. And the targeted biopsy of other patient's lesion also confirmed metaplasia somewhere else. And gastric mapping biopsy was negative for H. pylori. CT scan and endoscopic ultrasound was negative for lymph node involvement or metastasis. So what we will do next, EMR, ESD, or gastrectomy. Endoscopic resection can be offered for gastric nepoplasia that has a low or minimal risk of lymph node metastasis. And typically, we accept 1% or lower risk of lymph node metastasis to perform endoscopic resection and has a long-term clinical outcome of endoscopic resection comparable to surgery. So this guideline show that the absolute and expanded indications. This patient look like to be mucosal lesion, no ulcer, and two centimeter or smaller. And this is a differentiated type lesion. So it's point to the red box category that we can offer endoscopic resection. And this category has risk of lymph node metastasis less than 1%. So we elect ESD rather than EMR to increase chance of curative resection. And on-block resection was performed. And you can see the lesion in the center of the specimen. And the final pathology show intramucosal cancer, moderately differentiated type, tubular adenocarcinoma, negative deep and lateral margin, and no lymphovascular invasion. And on the pathology, also negative for evidence of ulcerations. So this fit the curative resection criteria. So the patient can avoid surgery. But what next? Because this patient has overall increased risk of synchronous, metachronous, or recurrent lesion after endoscopic resection. And most of these recurrent, local recurrent, occur in the first year. So it's recommended to perform surveillance endoscopy for T1A cancer. We perform endoscopy at six months, twice, and then annually. These patients need follow-up long term. Thank you.

upper endoscopy challenges

mucosal visibility

stomach distention

gastric metaplasia

endoscopic resection