I beg to differ. Scotch whiskey that's single malt is safe for the liver, helps clean the liver out. So tonight, I think in general, I think it was right on the money. It's a moderation thing and it's drinking like every day heavily gets you in trouble, especially with the pancreas too. But for some people, they're more sensitive. Low body weight women, if you have a problem with liver disease or hepatitis C, then it's bad. So in moderation, I think one to two per day, but not every day. How's that sound? That's my philosophy with whiskey. So this is the fun part. This is where we're going to talk about going into the GI tract. You've heard about the GI tract, what can go on with it, what's good in health, what's bad in disease. Now let's go visit it. And you get a chance to do this on hands on today. So it'll be really fun to have you at our tables today. So in general, we're talking about upper endoscopy, that's the top track, the lower endoscopy, colonoscopy, and some of the tools we have to go through the scope. And you'll get to play with most of those tools today or tomorrow. And then the fancy stuff, ERCP, and then EUS, which we do. And we just briefly talked about the pancreas and biliary tree. So upper endoscopy, just what it says, we're gonna be able to go down your GI tract and head down the esophagus into the stomach and into the duodenum and take a look around. It's esophagogastro-duodenoscopy, we all use abbreviations like EGD and we can't, no one can remember what ERCP is. That should be a question we ask them, what does ERCP stand for? So anyway, so what are the indications? Well, if someone's having any sort of pain that involves the upper GI tract, usually above the umbilicus, that's what we call the epigastric pain, they have reflux symptoms, and of course the main reason we're talking here is dysphagia, which is a big presentation for us for EOE. And then we'll jump down to foreign body removal, which is the one thing we hate to do in the middle of the night. Someone's had that big piece of meat, it's stuck there, they give me a call, I have to go in, and most times now, particularly in a male, it's EOE is why that piece of food is stuck there. And that can be an actual emergency and bad things and aspiration and perforation can occur. If someone is low in blood and iron deficient, we look, if they're bleeding anywhere, vomiting blood, or having dark black stool, which we call melana, we should look. And then we're putting feeding tubes in, G-tubes or pegs we call them. So how do we look? Well, we already talked about this briefly, here's the palate coming through, and we head on down, this is the view you look, so here's the true vocal cords, okay, these are called the arytenoids, and these things on the side are the piriform sinuses. So it's funny, each one of us has a different technique. I roll to the right, go inside this piriform sinus, then I roll in. That's how I scope, that's how I teach my fellows. And we won't have to do that with the pig though, since the pig is actually separated right here, so you guys will go in and don't have to go through this. But I can't tell you how many times the first few fellows give me a little look into the trachea when they go in this area here that they're not supposed to go into. And the patient lets me know, trust you. So when you head down the esophagus, the next thing you see is where that junction is. Someone mentioned the Z-line earlier, this is the classic Z-line, this is the squamous lining of the esophagus, and this is the stomach which is columnar, and you can see a nice little separation there. This is usually where the top of the stomach folds are right there. And the Z-line is very important to identify, and when you biopsy for EOE, you want to biopsy above the EOE, usually about 5 centimeters, then further up the esophagus too, because as you get too close to this Z-line, you can get increased eosinophils and reflux disease, and it can be a little confusing. So I always want to make sure you tell your pathologists where you're biopsying and what you're looking for. So here we are heading down through, here's the scope coming down, and we'll give you a picture of scope in a little bit. And heading down, here's a perfect Z-line, very healthy, these are the gastric folds here, and there really isn't much of a heart or hernia on this one. Then you pop into the stomach, and you'll do this today, and pig stomachs are always filled with junk and mucus, so even though this looks really perfect for a human stomach, the pig stomach is not that healthy looking. So when you head down here, you see and you blow it up properly, you're looking at, here's the lesser curve, which is this part of the stomach, here's the greater curve on the outside, you blow this up, here's the rugae blown up, you want to get a good look, and you're heading to the antrum of the stomach. Here's the antrum, and right here you'll see in a second, here's our pylorus. And a fellow told a patient, you know, we went through this hole in your stomach, and then afterwards she was panicked, she goes, they put a hole in my stomach. I said, no, no, no, no, no, I showed the patient, this is supposed to be here, this is the gateway, this whole donut concept tube thing, into the small intestine. And then here's the duodenum, we always look for celiac disease here, there's a bunch of other diseases, and ulcers can be there, but this is what the duodenal bulb looks like, you can start to see the villi here, and here's the fold as you head on down. And then here's the area that I spent a lot of time hanging at, okay, this, you're looking down, this is the second portion of the duodenum, this is the lateral fold going up to the ampulla here, and that's, and trust me, you don't see those big tubes, you're lucky, you can see it's closed down, you have to go into a one millimeter pancreatic duct, or a two or three millimeter bile duct can be quite challenging, we have these tiny wires that are very, that make it a lot easier to do. And then this is the retroflexion we're talking about, and you will do this in your pig stomachs today, where you'll go down there, you'll put the scope backwards, you put air in, and it'll insufflate, and then here is the greater curve over here, this is the fundus, and here's the lesser curve here. And then this is where the scope's coming through, we always want to look at that valve to see how intact it is, and there's a hill classification for how big, or how wide that opening is, whether someone needs surgery or not. So here's where we have this picture, I won't beat it up, but essentially, you know, it's, this is the entire colon, starting at the cecum, ascending colon, transverse, and down to here, scope obviously goes in here, we work our way all the way around, and we can pop it into the small intestine too. We won't be doing that today, but a lot of our time is spent there doing colonoscopies for screening purposes. So what is colonoscopy? Well, the most important thing about colonoscopy for us as gastroenterologists is stamping out colon cancer, but there's a lot of diseases, inflammatory bowel disease, we have some of the experts here who spend a lot of time doing these. The most important thing when we do look is getting it cleaned out, and that's why patients hate colonoscopy. They don't mind the scope because they're asleep and stuff like that, but no one likes to poop 15 times, okay? No one likes to have their day interrupted and stuff like that. Endoscopy is easy. You just fast for six to eight hours, and you're good to go. Colonoscopy is a big deal. It's laxatives, and people just don't appreciate it, and some people do fine with it. It's a brutal thing, and I've had patients pass out and go into atrial fibrillation, but generally, if you stay hydrated, the preps are very safe nowadays. People do fantastic with the prep, and the next, as soon as they leave my office, they eat, and the next day, they're 100%. So most of the time, it's very not a difficult thing, and my team that you have around you prepares the patient for that. So why do we do this for colon cancer screening? This is a lot of physiology and stuff like that, but essentially, you have this lining change of your colon where it slowly goes into small polyps. Hyperplastic polyps are not precancerous. Adenomas are, and they start to become larger and larger, and we can still intervene as gastroenterologists here, and even here nowadays with new techniques called EMR and ESD, we can intervene and take out a malignant cancer and polyp and save the patient operation, but once the cancer is invasive like this, then you're getting surgery, and we never really want to get to this. If we do colonoscopies properly, very few people will ever get this. Most people that we see now with widely advanced cancer have not had a colonoscopy or they're young people before they got surveyed like we talked about. So screening is an asymptomatic person and surveillance is once we find the polyps, you get put into our surveillance program. Usually it's every five years, but it depends on the type and size of polyps. So why do we do colonoscopies? I think the biggest thing they said is screening, but the other one is diagnostic. So someone comes to me and they have belly pain. I'm diagnosing someone who may have inflammatory bowel disease. They may have IBS, or they may have iron deficiency anemia, and they're bleeding. I see red blood per bottom doctor, and they're scared about that. And of course, diarrhea is a big thing. We're looking for inflammatory bowel disease, something called microscopic colitis, other things we look for. And a lot of times I chase down these images. There's a PET scan positive, or the CT says, oh, the sigmoid colon's a little thick. Well, yeah, then we have to go do it. And usually after someone has about a diverticulitis, which is where the diverticulosis gets infected, then we'll go ahead and do a colonoscopy. So a therapeutic, which I spend a lot of time doing, is taking polyps off, particularly big polyps. If someone's bleeding, we go in there and treat it. Although it's very difficult sometimes to find bleeding. If there's red blood coming down in the colon, you're trying to go upstream with your colonoscopy, it's very difficult because blood absorbs light. So that's why the bowel prep's extremely important during that. If someone's bowel twists, we can untwist it. We're very good at untwisting the left colon volvulus, but the right colon one, we're not very good, and usually that requires surgery. And sometimes people get ill and their colon gets extremely large. It's called Ogilvy syndrome, and we have to decompress it. So you'll get to play with all these tools. So we have forceps, we have snares, we have baskets and nets to get things. We have clips to close holes and to stop bleeding. And then we have heater probes. You'll get to play with APC, argon plasma coagulator, and then band ligations. And we'll talk about that in a second. So these are the biopsy forceps. There's nothing fancy about them. They're tools that go through and they open up and then we can close the tissue and pull out and get samples. Some of them have spikes, you can do multiple biopsies and put them on there. And some of them are serrated so they grab a little better. And this is a very important part of our job. We're trying to sample for EOE. You're going to need these to get samples of the esophagus and the pathologist will talk to you about quality samples and give us quality diagnoses. And another thing to do is when I'm one of the GI cancer guys, and it always bugs me when some of the gastronomists will get two bites of a mass. Usually you want to get six to eight bites because you really want to make sure you make the diagnosis and have enough tissue for genetic testing too in the end. So snares. So this is the bulk of how we get polyps off. Essentially exactly what it is. It's this metal ligature of different shapes and sizes. They can rotate and we're using this to get around and get the polyp off. If it's not invasive cancer, we can completely remove it using these techniques. So the snares, you want to put it over. The easiest ones to get off are these stalked ones. Obviously you can get down here, put it around the stalk, you know you've gotten the whole polyp off. But most polyps that we actually take off now are flat. So there's techniques we can put down there and try to bring the whole polyp up and take it off. And you can use cold, which is now when we first started, you know, you had to heat everything. Then it was you can cold it to five millimeters. Then it was 10 millimeters. Now I'm cold snaring 15 millimeter polyps piecemeal because cautery increases your risk for delayed bleeding and having some problems. But for a large polyp, you do need cautery. So that's generally the larger ones and you're doing something called EMR or ESD. So, and then when you get the polyp off, you have to retrieve it. And we'll have a little video showing that. Here's our first video. Okay. So here we go. Here's a polyp here. There is the snare. This is a hot snare. It looks like a 11 or 12 millimeter one. They've grabbed the stalk. You'll see when they apply the cautery, it turns white and then it comes off now. Sometimes the polyp sticks. So I'll have to pull the polyp off this way. So, um, this is a, a, a fairly good size pop. I might try cold these days and I would probably use cold on this one too. Nowadays, it's like I'm hardly ever using cautery anymore. The good thing about cold, it bleeds right away. You can stop it. It usually doesn't have delayed bleeding. When you use cautery, it doesn't bleed right away. They can bleed up to a week later, which is very annoying. And now it seems like half my patients are on Eloquence or Coumadin or a blood thinner. So I'd rather use cold, have them bleed right away and put clips on it. That's what the site looks like. You can see a week later that could bleed and the patient has red blood perectum and I've got to go running back up there and do it. So we really want to avoid that situation at all costs. And we are doing very good now with our cold snares and closing appropriately if needed to. So how do you get these things? These polyps are in there. A lot of times we need to suck them to the scope. If they're less than a centimeter, you can usually can suck it right through. Otherwise you had to grab them. And it's very annoying. Trust me, none of the gastroenterologists love this. We take a huge polyp off on the right side of the colon. We've got to pull that whole sucker back out and go all the way back in. So the patient gets two colonoscopies or three colonoscopies because if you pull it through the scope, you damage the anatomy of the polyp. And if you're worried that it could be cancer or dysplasia in the polyp, you want the polyp intact. So we have to do that. And you really can't do a good evaluation of the colon on the way out, dragging the polyp afterwards. So the different things we have, we have the basket to catch and then this Rothnet, which is a great, it came out about 20 years ago and it's been, it's revolutionized so we can do. So here's how we get polyps. So this is a polyp they've done EMR on. You can see the blue and they're just pulling that out there. This is, they're just going to suck the little polyp in. So if it's like less than 10 millimeters, you can suck the polyp right in. It goes all the way through and we catch it in a trap. This one will have to drag all the way out, attached to the scope like that. That's probably, you know, a 15, 16 millimeter polyp. Here's the Rothnet. They're going to put that over that giant polyp they took out and they're going to have to bring that all the way back out. And you'll get to practice that because we'll have some foreign bodies in the pig stomachs and you can take them out. It's fun. So injection. So we can tattoo things, we can put dye, we can put things that stop bleeding, um, or sclerosis, blood vessels and there's different kinds of sizes and they come out of there about five millimeters out of the scope here. And we use that primarily for me for getting polyps off, but I'll do it for bleeding additionally too. So, so if somebody has any bleeding, we can stop with epinephrine. That's not enough to complete it, but it gives us time if someone really has a lot of bleeding, uh, to control it and then either burn it with cautery or clip it closed or sew it if necessary. Um, so the one thing they're showing here is the lift. So here's the flat polyp. So it's hard to get off sometimes even with a cold sneer. So you put this contract, this agent in here that, uh, becomes more jelly like at body temperature and then you can use this whole thing and cut it off. Um, so we do that to get in. This is, this would probably be ideal for an EMR and ESD. We actually drive the scope inside here under and tunnel out that way. And then poem is the same thing. They, they tunnel into the lining of the esophagus and cut the muscles. If you have akalasia, I tattoo a lot when it's a big cancer, I can't get out. Um, and then Botox. So people don't like wrinkles in their stomachs. Well, Botox their stomachs. It won't have wrinkles. Just kidding. Uh, the Botox is like we do when someone has the sphincters too tight, like at akalasia, we can do it. It's only temporary. It buys us time, but we do do it. And also sometimes he will Botox the pylorus if there's a pylorus spasm, but the data is not so great for that. So let's see here. Boom. So here we go. So here's a, how they would take it off using the, uh, snare. So here's another picture of that. This is injection therapy. So this would be, this is a rather big polyp. It's probably gets almost two centimeters. So they're going to go on the backside of the polyp. They're going to inject and you can see it putting in. Now the substances have a little blue, like methylene, uh, blue dye in them. And, um, and what they do is that helps us see it. Sometimes people put epinephrine in. Most of us don't use that. And you want to get this big cushion. So you're creating this cushion where you're separating out the mucosa from the submucosa. And with that, you can then use cautery and very safely take things off. And you'll see when we come back, they're really injecting a large amount here. Uh, and then they're going to come around and look at the front of the polyp here in a second. So you can see the bluish hint. You can see the polyps being raised up. So there's a cushion now and you'd be much easier now to get that off and it'd be much safer and you won't get the risk of perforation goes dramatically down when you do this first. Plus if a polyp lifts like this, it tells us it's not an invasive cancer either. You can see it looks like a brain. Uh, that's a classic adenoma appearance. So then you've now made this hole by taking this polyp off and then we can close it. Here's the closure of, uh, of a defect here. They're also good for bleeding too. If someone has bleeding and it's an ulcer, it's perfect. I can, I can close that up or at least put her clips on the actual bleeding spot. There's a thing called a Dullafoy's lesion, which is a submucosal artery that we can close off. And it's not as if we have perforated it inadvertently, um, we can close the defect with these clips and usually that saves the patient operation. So the probes, this is called a gold probe. These are gold bands. This is actually a bicap probe. So the carter goes back and forth across here so you don't need a pad for the carter and you place this on the bleeding vessel and press very firmly. It's called coactive coagulation and often it'll stop bleeding. It's one of our biggest tools for bleeding ulcer of the stomach and small bowel besides clipping. Um, and so the carterize, um, you actually will have, uh, you'll take the bustle, you'll press firmly, carterize it and it works just like the old cartery in the wild, wild west where you put the branding iron on there, but we're doing in the stomach. Luckily they didn't talk about this too much. Your gut doesn't really feel any of this. I can have the patient awake and doing most of this. When I put too much air in, the patient feels the distension, but I can cut, freeze and inject the, the, any part of the gut and people don't feel it. This is, you're going to love this. This is the favorite thing. This is, this is Darth Vader, okay? This is argon plasma coagulation. So we're going to run a stream of a noble gas argon and then run an electric current through it. So you're going to be able to actually paint your initials inside the stomach or the pay, which I know it's your been your lifestream. And, um, and, but also we use it to treat blood vessels that clean up polyps sometimes. And then for bleeding and there's a thing called gave where people have these, uh, sub mucosal, uh, blood vessels and then radiation proctitis. So you want to burn. And the nice thing about this, it's a superficial burn. Once you have the char, it won't burn much deeper. So it's very good for superficial bleeding like radiation, proctitis, and then cleaning up a polyp. Um, so it's a, if it's a fun technique and you'll enjoy that, that's a, that sort of came out about a decade ago and it really has made a nice impact in GI. So the band ligators. So when you have, you've drunk too much alcohol, too much single malt whiskey, okay? And you have varices, the blood vessels get dilated up because the blood can't go through the liver. So it has to find other ways to get back to the heart. And you have, uh, these things called varices and the esophagus and stomach actually can be anywhere. Duodenum and rectum. Um, so these band ligators, so there's these rubber bands that are forced onto the end of this cap and then you have these strings and you can release each band at a time and we use it to actually suck up the blood vessels and then they clot and fall off. So you'll see a picture here. So here you are with the scope with the banding cap on. You then suck the varics into there. Then you release the band and the band collapses down. Then you have this little cherry looking thing and we'll do two to four of those at a session and then we'll get the varic, the varices ablated. So here's the fancy stuff, ERCP. So the scope here is a totally different scope. The scopes you're going to use today, it looks forward. These scopes look sideways because I'm sitting here in the duodenum and if I looking forward, I wouldn't see anything. So my optics all are staring this way. So I gotta get a little wire up the pancreatic duct, up the bile duct, into the minor propeller here. And we also use fluoroscopy to help us do, we'll show a little contrast agent and see that. Um, so if there's a stone and we, most of my work is spent with cancer and stones really with, and then post liver transplant. So stone can fall out of the gallbladder, be in, in the bile duct here that can make you turn yellow or have a infection called cholangitis. So then we make the opening bigger here. We go up with a catheter called a papillotome or cannulotome, put a wire up here and we can pull this out. Um, and it's a, it's immediately, it's a very satisfactory. In the old days they'd have to operate and do a big expiration or put a thing called a T-tube in. So this way now we save the patients and they go home that day. This is an outpatient procedure. It really is revolutionized. This has been around for about 30 years or so. It's revolutionized, probably more like 40 years. Um, so this is what the x-ray looks like. So here's the scope, the dark thing here. Here's the balloon catheter up here. This is a balloon. So once you make the opening bigger, if the stones below here, I'll just pull the balloon out. It's called the balloon trowel method. And the stones come out. Sometimes we have the stones are too big. We've got to crack them. We have different methods for that. We can use laser, we can have baskets and we have a, something called a electro hydraulic lithotripsy. So it's sort of fun. We take biopsies. If people have cancers of the bile duct, we can put stents in, we can make biopsies. So here's the difference of the scopes. This is a scope you're going to be using today. It's a forward viewing scope. So it's going to have, this is your channel our devices go through. The light's going to shine here and then the camera's here air and then the newer scopes have a water channel here. Here's that side viewing scope. So all the optics are on the side looking almost at a right angle. Plus there's a channel here which has an elevator so I can actually move my device. Um, and these are the scopes. I don't know if you've written in the press five years ago, had big issues because these channels could get dirty and where they were tough to clean and we were worried about infection with patients. These scopes are actually very easy to clean. There's really been no problems with contamination. But the key is that today the scopes we use on animals cannot be used on humans. So, uh, so don't worry about that. I know, I know you're thinking about it. So anyway, so here's the side viewing scope. Here's a clangogram. So this would be a, this looks, it's a little dilated to me, but here's the ampula down here. Here's the pancreas duct and coming up and splitting into the left and the right intra-hepatic ducts there. And remember the gallbladder is attached. You can see the cystic duct here, but you can't really see the gallbladder with this picture. And this is the kind of images we get. So we're doing a lot of radiology, you know, doing fluoroscopy at the same time we're doing ERCP. And here's where you cannulate the pancreatic duct when you're trying to. Usually you try to avoid the pancreatic duct when we're doing the bile duct because we can cause something called pancreatitis. But sometimes we have to go into the pancreatic duct and you can see it's very tiny. It goes all the way out. This is the tail, body, neck, and here's the head of the pancreas here and the ampula is right here. And the bile duct you can see is a larger duct. And usually if you over inject this pancreatic duct you start to see the little side branches and we usually don't want to do that because it can cause pancreatitis. Here's the thing, the newest kid in town for scope technology was endoscopic ultrasound, but now we're still talking 25, 30 years ago. So it's really good for staging cancers and for looking at the ducts, looking for stones. And so you can see here, here's the images. We talked about this different layers. So this dark layer is the muscle. That's the outer longitudinal. There's the inner linear. This white here, this whitish is fat. Fat's always white by ultrasound. Um, so, uh, that's the submucosa and the mucosa you can barely see here. There's two little layers right there. That's the mucosa. And here's a polyp that looks like it's still contained in the mucosa. And that's probably a small lymph node right there. So it's very, the detail you can get with this is amazing. And when you're staging a cancer, you want to see is this cancer going through the wall or not? Because that changes everything. If it's tumor of the GI tract is contained in the, the wall of the track, we may be able to do endoscopically or the patient has a much better prognosis. Once it escapes out through the wall, the lymph nodes become positive and it changes everything. And now the standard for most of us now for all these lesions is they get pretreated with chemotherapy radiation before we do that. So staging of cancer, all the things in mucosal esophageal, stomach, duodenal, rectal. We don't do much EUS for colon cancer except rectum because the scopes are hard to negotiate around. It doesn't really change the prognosis that much. We can also needle things through this scope. I'll show you that in a second. We can take fluid out of cysts. We can diagnose tumors. And then these submucosal lesions, there's, there's different lesions that are muscle or they can be fat or they can be fibrous tissue. It's important to know. And then gallstone disease, it's the most sensitive test for detecting gallstones in the bile duct. It's about equal to percutaneous ultrasound for the gallbladder. And then the pseudocysts, which are collections of fluid from people get pancreatitis, we can drain those too. So here's the different scopes. You won't see them today. This is the radial scope that looks this way and it gives you an image similar to a CAT scan when you move it around, but you can't biopsy with this. This is a linear scope where the transducer, the piezoelectric crystals are aligned here in an array and they shoot out this way and you can real time needle and I can see my needle actually going into the tissue. So here's a picture here. So here's the radial scope and here's a small cancer here. Unfortunately it doesn't project very well. This is a probe and you can just see it's very superficial. These muscle layers are intact. So it's a T1 cancer. And here's the linear scope. Here's a lymph node right here next to the aorta. Here's the lymph node here and there's the needle going into that. This node's probably only a centimeter. We can biopsy nodes pretty easily down to five millimeters and get samples and it really can change the prognosis for a patient, particularly for lung cancer and certain other cancers of the GI tract. So that's the whirlwind view of endoscopy and you're going to get to do it today. It's going to be fun. We'll have five or six at the table. We have the pigs are all excited and ready to go.

endoscopy

upper endoscopy

gastrointestinal procedures

colonoscopy

colon cancer

ERCP