So, what we're doing now is talking about each of the areas that we just went through of the gastrointestinal tract in terms of disease, and we're going to talk about everything except EOE, which is going to be talked about at length tomorrow. No, later. Today. We're excited. Yes, we're excited. Okay. So, what else can go wrong in your esophagus and your stomach? So, just reminding everybody, we are talking about the esophagus. I'm not going to talk about the liver, and I'm going to talk about the stomach. Leave the small bowel. So, really, you have to think about what can go wrong in terms of anatomy, structure, and function, how the whole thing functions. Structural disorders are when things are sort of not constructed the way you think they are, and the classic that can be acquired, where you may have started out with the correct structure, but now it changes over time is what's called a hiatal hernia, so I'll explain what that is. Then, I guess, stuff I do see in pediatrics, and I'm sure my adult colleagues see them as well, is you have to be aware that people can have congenital issues with rings or webs or pockets that sort of develop diverticuli, and there are some classics in the esophagus, so we'll talk about a Schottky ring. I think we talked about a Schottky ring. Then there are also a number of clinical disorders, so I'm going to talk us through GERD. I'm not going to talk through EOE. We'll talk a little bit about motility disorders, and then just some miscellaneous stuff that can go wrong in your esophagus, including pill esophagitis, why you want to swallow your aspirin or Excedrin or whatever you're taking after you have your single-malt whiskey with a lot of water. Okay. So, again, this is just a very brief and another look, I guess, at the esophageal anatomy. And so, remember, you sort of have this vertical tube. It is running through the mediastinum into the abdominal cavity, and there's a lot of cardiac structures in there. So esophageal symptoms are really – people are pretty good at describing them. So the classic is heartburn. People will say, oh, I'm feeling a lot of discomfort or burning sensation behind the sternum, and people will describe it as heartburn or like they are having a heart attack. And yeah, this happens at all ages, except little, little, little kids can't tell you that. They just don't feel good. But certainly a teenager can tell you they're having heartburn, and of course, many of us have experienced heartburn. It is something we'll talk more about in terms of GERD. Other things you might see is regurgitation. So this is stuff that comes straight up into your mouth without nausea or retching. So there's really no muscles involved in it or that you can figure out. And some classic regurgitation that we can see is rumination, where some people do have this ability just to bring stuff up quickly into their mouth. There is dysphagia, which is when people feel food get stuck, and they can really point to where they think it is. And that's different from odynophagia, which is pain that's caused by swallowing. Then there's a condition called globus. I will tell you about two nights ago, I was on call, and I was waked in the middle of the night by an ER doctor, and I really couldn't believe this, that person woke me up for globus. But it's basically a perception that something's stuck in your throat. And obviously, if someone comes in and says, I think there's something stuck in my throat, any doctor, the primary care doctor, the ER doctor, and us should make sure there's nothing stuck in the throat. But they're often pointing right up here. And what's interesting is it can persist even though the thing is no longer gone. And sometimes it was just something scratchy that they swallowed or a hard candy or something that sort of led to that sensation, but they're feeling a perception. And then there's the concept of water brash, which is you have a lot of salivation going on, and that seems to be a compensatory response to reflux. So these are esophageal symptoms. They are transit related. So as you are moving stuff through, you can get food impaction, and you can also get dysphagia. And then the opposite is if it's going against the grade, so it's no longer making its way forward, but coming backwards, we call that retrograde. And that could be regurgitation. And you could even swallow stuff into your lungs. That's aspiration. And then there are these perception-related concepts of discomfort. So you're having chest pain or pressure or heartburn. I'm realizing what happened. So the etiologies of esophageal symptoms are structural abnormalities. There's dysphagia, which is usually for solid food. And you might do an endoscopy to figure out what's going on. And that's where you might see any of the issues that could be causing that sense of something getting stuck. You can have a propulsive disorder, which is dysphagia for solids or liquids or GERD. I'm a little worried that this is a much bigger talk that we brought forward slides that aren't appropriate. I'll just, because now I'm not sure how many slides there are. Yeah, this looks a little different from where I was looking at yesterday in my... All right. Anyway, we'll keep going, because I can do this. But it's a propulsive disorder. So these would be like something's going on where things are not moving correctly. And there are some classics that people will see. So again, we talked a little bit about achalasia, which is halfway down. But there's actually a condition called nutcracker esophagus, where the esophagus is kind of spasming. There's actually esophageal spasm. And then you can have functional obstruction, which is the lower esophageal sphincter is just not opening well. And there's GERD. And then there's also sensory. Again, there is... We talked about pain. There's actually not pain, but there's certainly sensations that people will have. And so these are... You do the endoscopy. There's nothing there. And they are really feeling something. So something's stuck, but you actually can't see it. Or they're feeling uncomfortable. Or they're feeling burning, but there's no evidence of esophagitis. So we call that functional GERD. Okay. And all of these can overlap with GERD, which we'll talk about. All right. I'm going to move us through this. So hiatal hernia is really what's going on where you have the diaphragmatic ligaments coming into the lower esophageal sphincter. And if it is... Those ligaments are a little bit on the loose side, you can wind up with the stomach essentially coming up into the chest. And a type 1 hiatal hernia is, most of the time, it's a sliding story. So it's kind of going up and down, just the diaphragmatic ligaments are too loose. And that certainly can make you reflux more. And I'll bypass hiatal hernias 2, 3, and 4. This is a picture of an esophageal ring. And sort of the classic is a Schatzky ring, named after Dr. Schatzky. It is in the lower esophagus. And people... It's actually unclear whether they're acquired. There's some discussion about whether they are something related to EOE. But about 15% of people are not symptomatic with this. And then a lot of people will notice that something seems to be getting stuck, and you find this Schatzky ring. And then there are also what we call webs, which are higher up in the esophagus. And these are often congenital or inflammatory in origin. What's tricky about the webs is they may involve the full wall of the esophagus. And there can even be fibrotic tissue in there, or cartilage, essentially. And so those are actually, for us, something to be careful of when you think you're going to dilate them. A congenital esophageal web is something to be careful dilating, because it's got cartilage in it. Oh, and I bypassed the plumber, Vincent. Okay. I am going to talk a little bit about zankers, because frankly, all pigs... And I think this one got cut out because the pig is not alive that we're about to scope. But when you do a live pig, you have to be aware that all pigs have a zankers. And then some humans have zankers, too. So these are sac-like outpouching of the mucosa. And it basically has to do with weakness in the wall. And you wind up with a piece of the esophagus that's outpouching. And it's basically mostly men. And it's something you're going to see in older people. And I'm moving past the esophageal diverticulum. So this is... Just any diverticulum anywhere at all could involve a looseness of the esophagus. And definitely would be something you have to diagnose. You can see it endoscopically. But this is nice pictures on an upper GI showing these outpouchings. All right. This is the slide I was waiting for. This is GERD, which I think we want to be talking about, because it's a very common condition. Again, all related to stuff moving from the stomach up into the esophagus, which it does for everybody physiologically. But if it's doing it a lot, it can certainly be a reason that people have a lot of symptoms. Remember, the lower esophageal sphincter does need to learn how to close. But it also needs to be able to relax. It's very uncomfortable if it can't relax. And when it's relaxed, that's when stuff can reflux up. So causes of GERD are really normal physiology. So everybody refluxes about 7% to 8% of the day, usually right after meals. But sometimes related to other things you might be doing. It also can be when you eat. So you're eating. And by definition, you want your esophagus to relax a little bit to let stuff in. So that's when people will have some reflux happen. This is a picture of a hiatal hernia, where you're seeing the diaphragmatic ligaments coming in. And some of that is the stomach has herniated up into the chest. You could have anatomic abnormalities. But the classic are foods. So I just drank some coffee. And then I don't know if anyone ate chocolate. And then, of course, yes, the single malt whiskey will officially make you reflux. So these are all very classic things to reflux. And many, many foods can cause this. And then medications can cause you to reflux more as well. So the symptoms that are common are heartburn, as well as acid regurgitation. And much less common is, indeed, to feel this sense of stuff getting stuck. So the dysphagia, chronic cough, laryngitis, or there's a lot of interest in the relationship between chronic reflux and asthma. How do you treat reflux? We do lifestyle modifications, usually. Try not to have so much coffee. Try not to have so much chocolate. When you're lying down, try to make sure that the head of the bed is elevated a bit. Being overweight can certainly predispose to reflux. So weight loss can be a good lifestyle modification. And then avoiding those exacerbating foods. Written here, a treatment is proton pump inhibitors. I might have changed that to acid suppression. So you can use acid suppression with an H2 blocker or a proton pump inhibitor. And then the surgeons can offer something called Nissen fundoplication, where they basically tighten the lower esophageal sphincter by wrapping it a little bit. So they sometimes call that a wrap. If you have a lot of stomach acid coming up into the esophagus, you will have all of the symptoms we talked about. And you might also have oedynophagia. So you can have pain with swallowing. And this will definitely see signs of esophagitis. So this is an endoscopic picture. I think this is supposed to be the cartoon, but you're seeing some signs of something happening. And we grade that. So we use grading systems. This is the LA classification of reflux esophagitis. And what you're seeing here are little breaks in the mucosal surface. And then as you get into grade B, it's becoming more. Certainly grade D is clearly an erosive esophagitis. So Barrett's esophagus is a fascinating condition. That does seem to be something that people can be predisposed to. It is when the normal lining of the esophagus is replaced with a lining that's similar to the small intestine. So I think between Alexis and myself, we really showed you how you see these different linings. You should not have small intestinal mucosa in the esophagus. And it is considered precancerous. So we know it puts you at increased risk for developing esophageal adenocarcinoma. And I think something that has been a bit of a conundrum in terms of how to really look for this and worry about it and think about it is, unfortunately, Barrett's is painless. So you don't know you have it until someone identifies it in you. But the way it looks endoscopically, you go from having this nice, normal Z line, and this is showing you normal, to now you have this very irregular-looking Z line. And when you biopsy it, you find glandular epithelium now. And the problem is, it might just be in this way, so this is not cancerous. Barrett's is not cancerous. But we know that this could go on and become low-grade dysplasia or high-grade dysplasia. And then this is what none of us want to find, which is esophageal adenocarcinoma. So you don't – you're trying not to have – you're trying to pick it up early. And it's a whole literature, and a lot of people in the room here are part of that discussion around how to think about Barrett's and how often to look for cancer, because it's not as straightforward as colon cancer, believe it or not. How do you treat Barrett's? So they use this radiofrequency ablation, where they literally burn it. That's what it looks like after it's treated. And then, actually, you can use this endoscopic mucosal resection that you were seeing, this concept of lifting, and then basically trying to cut out the Barrett's. And so that has become really mainstream at this point by specialists, like some of these guys here. And then there's motility disorders. So you can have abnormal motility of the esophagus, and again, it can cause all those same symptoms. So you're seeing this pattern of the same symptoms might be related to any one of these conditions. And to look for motility disorders, the endoscope cannot tell you what's happening. So we can look inside and see the mucosa, but we can't tell how the esophagus is functioning. So in order to do that, we use what's called a manometry catheter, and these are my colleagues who are motilists, are using the manometry catheter. And yes, it goes up your nose, down into your esophagus, and sort of sits there for a while. And when I do them in peds, we leave them there for ideally 24 hours. So we're really trying to understand how the esophagus moves over the day. And this is what it can be picking up, is the achalasia, nutcracker, esophageal spasm. And then also, it's useful for systemic sclerosis of the esophagus. The term achalasia comes from the Greek. It means does not relax. And really, the hallmark is you have no peristalsis, so this very big esophagus. And then it comes down to a bird's beak here, and that is the lower esophageal sphincter that's not relaxing. And so the lower esophageal sphincter is working too well. It's totally closed, and the esophagus is not moving. That is achalasia. The way you can treat it is indeed with Botox. So you're trying to get that esophagus to relax. So you're doing the Botox injections into four quadrants. And then another classic is to dilate. So this is pneumatic dilation. And we'll be able to play with the dilator later. You can, again, involve the surgeon. So they do surgical myotomies, or what they call a Heller myotomy, where they literally go from the chest. They're going to cut from the outside the muscle that's not relaxing. And that'll help. And actually, I've lost it, but these days we're doing a per-oral one, where we basically use the endoscope and can do a cut from the inside. OK, and now moving to some other things. This should kind of look like you've, I'm sure you've learned a little bit about EOE. This looks a little bit like EOE, but that's actually candidal esophagitis. And that will certainly cause pain and difficulty swallowing. It's got these white plaques in it. And actually, you can also have infections from herpes, either HSV1 or 2. And then you can also get CMV esophagitis. So I will tell you, I've been doing EOE since 1998. So we would see this, we would brush, make sure it wasn't candida before we called it EOE. I no longer do that. Oh, this would be the herpes that look different. And then this is sort of classic CMV, is you get these lines. Again, white plaques, but they are very different. Pill esophagitis, this occurs when a pill lodges in the esophagus. So the mid-esophagus is your most common location for this to happen. And it basically causes a very painful ulcer that is painful. So the classic is the teenager who takes doxycycline for their acne. So they take it in the morning. Mom says, drink water with that. And the kid says, sure, mom, and pops it as he goes out the door and then calls about an hour later because he's in terrible pain. And they are nasty ulcers. And there's not much to do except try to support them through it. So they're self-limited. But, you know, it's definitely a reason to drink water. Oh, and here's a picture of the per-oral myotomy. Things are... We're going to get through the talk. But I said there was stuff that was hidden, so we brought it forward. And I didn't look to see if stuff was brought forward that I didn't know I was talking on. So we're doing okay? Everybody's following me? Okay. All right. We've moved now into the stomach. So the classic is peptic ulcer disease. And these are really mucosal breaks in the stomach for the most part. And the common location is stomach, but also duodenum. So the duodenal bulb in particular is where you might get stomach ulcers. And the classic reason for this is an infection called Helicobacter pylori, which you can stain for. So you guys are getting better at recognizing eosinophils, which we're going to talk about more later. But this stain is a really... This is the stain for H. pylori. So they can really see the bugs. And this black, those are all H. pylori organisms. Okay? So the pathologist gets very excited when they see this. These days they tend to do immunofluorescence, but this is sort of the more classic stain. And then another reason you get ulcers are nonsteroidal anti-inflammatories. So anyone who's popping ibuprofen for their athletic stuff, just know that that can certainly cause ulcers. So the symptoms of ulcers is a lot of pain and discomfort. You can get bleeding from them. You can have gastric outlet obstruction, which can cause you to feel nausea and even vomit. And then you can get perforation, which is severe, acute abdominal pain, and can make you very sick, because when the ulcer perforates into the peritoneum, now all the organisms that live in your gastrointestinal tract get into the peritoneum, can cause peritonitis. So this is what an ulcer looks like on endoscopy. Sort of people think that it's like a, I can see into their peritoneum, I can't, I'm just seeing this healing wound. I have like all kinds of scars on my hand, so I'll often show them like, well, I'm looking for an ulcer that kind of looks like this. But it's not like, you know, they look white, that this one's not bleeding. How do you treat ulcers? You should get rid of H. pylori, and then if it's about, and often hydrochloric acid on top of an ulcer is not letting it heal, so we use a lot of acid suppression. So this would be proton pump inhibitors. We think a lot about GI bleeding. So where is that GI bleeding happening? Is it before the ligament of trites, which is basically in the small intestine, or is it below the ligament of trites? And we'll do a lot of trying to understand what's coming out. So is it bright red bloody emesis? Is it coffee ground? Those would be, both suggest upper tract. Intriguingly, people can bleed quickly. Blood is actually a cathartic, so it makes you vomit, and it also will cause you to poop a lot. So if you have a lot of bright red blood per rectum or melanoma, both of those could actually be upper GI tract bleeds. And what are the causes? So we've been talking about this, but these are pictures of varices. These are ulcers. This is just a gastropathy, like the stomach looks awful. Here's an ulcer that's got like healing sort of gross stuff on top of it. Yes, I'm allowed to say gross. I'm a gastroenterologist, but not everything's pretty. Here's a Mallory Weiss tear. If you vomit a lot, you can cause a little superficial tear. This looks very bloody, but it's often going to be self-resolved. This is gave. This is gastric varices. And then we also have what's called angio dysplasia, which are just little blood vessels that are causing problems. How do you treat bleeding? So they always call me. They're like, ah, the patient's bleeding. I'm like, OK, great. Focus on resuscitating them. So we really want the ER or the PICU or whoever to stabilize the patient before we're going to do anything, because I really need that patient as stable as possible. I'm sure my colleagues do as well. So we want people to focus on volume resuscitation before we try anything endoscopic. PPI can make an enormous difference. So it really is helpful if they'll start PPI and be very serious about it. That could be their IV or oral, depending on the situation. We talked a lot about different ways to stop bleeding. So you can use those clips that we talked about. You can do band ligation down here. You can burn it. There's the thermal therapy. And then moving to the top of my list here, one of the things we can do is inject epinephrine, which will cause the vessels to spasm. And that will stop the bleeding. And really, the goal of endoscopic hemostasis these days is to do combinations. So you need to pick one and then do another. So you don't just rely on one. You do two. And then in terms of gastric outlet obstruction, the mechanical obstruction of anything at the bottom of the stomach will cause everything to start coming back up. And so you need to understand what's causing your gastric outlet obstruction, or GOO, as we will call it. So you'll see discussions around GOO. Often it's benign. So it's an ulcer that's just in the wrong place, right at the drain of the stomach, causing a lot of swelling, but sometimes pancreatitis, and certainly sometimes it's malignant. So gastric cancer or pancreatic cancer. And again, this is where you have to sort of decide, I forget who said it before, but it was great. That's why you go to medical school. Is this bad? Is it very dangerous? Is it cancer? Obviously, it's uncomfortable, period, needs some treatment. But is it something that's really ominous? The symptoms of this are kind of what you'd expect if your stomach can't empty. And certainly, if it's something insidious and growing, it might be that you feel not hungry all the time, or you're feeling you're losing weight, or even that air can't get out of your stomach. So you have abdominal distension. And you know, how do we diagnose? So we can do endoscopy. So that's over here. But often, this is where we're trying to pick the right imaging. So this, we're working with our radiology colleagues to say, all right, I think I need to understand better how to image what I think I'm looking for. This is showing a very, very large stomach not emptying. That one is, too. So the definition of this is you've got to get everything out of there so the patient stops feeling so uncomfortable. So you'll put in a nasogastric tube that's designed for decompression. You might put in a stent. And there's certainly just a wonderful literature out there on different types of stents. And you can stent lots of different things. So this is a stent across the pylorus that can allow stuff to drain. This is a placement of a stent across the pylorus. It's easy to see the stent here. This is the dye that's now being, and actually, you can see the stent here. But basically, it's going across the pylorus and allowing outlet. And this is what it looks like endoscopically. And then you can involve your surgeon. So the classic is the Billroth gastrojejunostomy, which basically involves, if this part of the stomach has a big obstruction in it, this is obviously a huge surgery, you would get rid of the area that might have the cancer. You'll bring up the jejunum. And you're basically putting it straight against the stomach so the stomach can empty directly into the jejunum. What are you noticing here? The lovely pancreas that was talked about earlier is actually still able to do its job. It's just no longer that the food's passing by it. It's still doing everything it needs to do. And then I'll talk a little bit about gastroparesis. This is delayed emptying of the stomach. This is when you can't figure out, you don't see anything that's causing the stomach to have difficulties emptying, but the stomach's just not emptying well. So causes here could include diabetes, which does have an impact on the stomach, could happen surgically. And then we have a lot of people with idiopathic, just their stomach's not emptying very well, can't figure out why exactly. The symptoms are the same as the mechanical obstruction. And what we'll do to sort this out, because you can't tell it endoscopically, you're not finding anything, you can look at imaging. So the image you want to do is what's called a gastric emptying study. So basically you have a meal that is, this is nuclear medicine or what I sometimes call unclear medicine, so I switched the N and the U. But I will tell you that those nuclear medicine radiologists are able to sort of help us understand how long it can take for the stomach to empty. And this is showing the stomach on this side is emptying over here, and on this side it's not emptying at all, even though they've both been 90 minutes. So how do you treat this? Eat smaller frequent meals. You might try to work with medicines that might help the stomach move more, none of them are great. And then there's a whole world now around using what's called a gastric pacemaker. So literally trying to help the stomach to move. You can see certain masses in the stomach. So whenever you see a mass, you go, okay, what's that? And they look like a mass. You can see the scope. This is up in the cardia, you're seeing the scope here, you're retroflexed. And again, this is why you go to medical school, is it a bad mass or a normal mass? So this is actually called a pancreatic rest, it's sort of a fascinating thing that we can see in lots of people, unclear why. Some people have this little bit of submucosal, the pancreas is underneath, but it's pushing up, there are lipomas, leiomyomas, and then certainly malignant concerns. So gists and carcinoids are two pictures here. How do you look for this? Everybody knows the answer now. Endoscopic ultrasound, that's a great way to evaluate for these lesions. You're looking at them from inside the stomach, but you want to understand how many layers of the stomach they've infiltrated. So really the EUS is a great way to try to understand what the lesion looks like in terms of how many layers it goes into, how echogenic it is, how big it is, and maybe you can stick a needle into it, as was discussed. I did it, despite the extra slides.

gastrointestinal issues

esophagus

stomach

structural disorders

clinical disorders

symptoms