I will get us going in terms of GI diseases, and again, we're going to start by focusing on the top of the tube, which is the esophagus and the stomach. And I'm going to be taking us through just a little refresher on anatomy, structure, and function, and how those really start to play into structural disorders. So we'll tackle hiatal hernias, and then rings, webs, and diverticuli. And then there are clinical disorders, so symptomatic issues, including reflux disease, EOE, which we won't really talk about today because that's all day tomorrow, motility disorders, and then a couple miscellaneous things. And yes, by the time you leave here, you will always swallow water whenever you take a pill. So in terms of the anatomy, what you want to know, remember, is that the esophagus really starts in the mouth. Here's the teeth from the incisors all the way down, can be 35 to 40 centimeters in most adults. And again, places that people get things caught up is the cricopharyngeal junction. The lower esophageal junction is an important piece of this, just should be a tube. And it is. It's running all alongside the heart. Here's the heart sitting on top of the diaphragm, which is frankly right over the stomach. So that's why, again, we call it the cardia. So what kind of symptoms can people have? So you can feel something in your chest and say, oh, I'm having heartburn. And that is really the most common esophageal symptom. And I'm doing this because the FDA actually considers this the patient-reported outcome. I am having heartburn. It's discomfort. It's a burning sensation. Sometimes it is accompanied by, but you can also have regurgitation, which is basically stuff that sort of effortlessly seems to come into the mouth, into your pharynx. You can have symptoms in the other direction, where you're eating something and you experience what's called dysphagia, or a feeling of food sticking or even lodging in the chest. And again, we'll talk a lot about that tomorrow. That is different from odynophagia, which is pain. And you'll see some conditions that you should think of when you have odynophagia versus dysphagia. Globus is a symptom we deal with a lot in pediatrics. I'm sure you experience it in adults. That is the perception of the lump in the throat. It's really a sense of when you can't swallow because something's right up here. And it might be even without swallowing. So that's a globus sensation. And it is almost always there's nothing back there. But you have to go through a lot to convince the patient of that. And then there's something called water brash, which is excessive salivation, or it can be a compensatory response to reflux, but really a sense that you're salivating a lot. Symptoms that are in the esophagus are transit-related in that they may involve stuff going down, like food impaction or dysphagia. Or they can be retrograde in that your stuff is coming up, like when you regurgitate. Or you regurgitate to the point that it's in your mouth, and now you swallow it into your lungs, which is aspiration. Or you can, of course, just swallow it, go straight into your lungs. That's also aspiration. There's also a lot of perception-related symptoms, so discomforts, chest pain, pressure, and heartburn. So what are all these etiologies of symptoms? Really the way to start to sort it out is to figure out if you're dealing with a structural abnormality. And so this is something that's keeping it difficult for stuff to go down. So that's that difficulty swallowing or dysphagia. And if it's with solids, that's when we're starting to talk about endoscopy. Let's try to understand things. But you really want to know there could be a lot of structural different things going on. So we'll be talking about many of these momentarily. You can have propulsive disorders. So I spent a lot of time at the beginning of this morning talking about all of the function that the esophagus does. And it does that by propulsing things along using those muscles, the smooth muscles and the striated muscles. And so if you can't propulse, that's when you have peristaltic weakness. You might even have no peristalsis. You can get something called a nutcracker, where the esophagus literally is spasmed. You can just have spasm. You can have achalasia, which we'll be talking about. You can have functional obstruction. So there's a sense that things aren't moving, but there's actually nothing in there when we try to take a look. And then reflux can be part of propulsive disorders. In terms of sensory abnormalities, these really have to be differentiated into solids and liquids. And here, again, you're sort of trying to sort out what's going on. So you might think of it as a sensory abnormality for swallowing when you have a negative endoscopy. And we start to try to sort out why are you feeling like you can't swallow when it looks like everything should be OK. OK. So all of these together can overlap, and they all can be associated with GERD. So really, GERD, or gastroesophageal reflux disease, is sort of our number one thing we think about with the esophagus. All right. So talking about hiatal hernias, hiatal hernias are a great reason to have GERD. These are basically all about wanting to have things set up correctly. So normal, correctly organized diaphragm, and a hiatal hernia is when stuff moves above the diaphragm that it shouldn't. So a normally organized diaphragm coming into the esophagus, leaves the esophagus above and the stomach below, kind of obvious. You get into what's called a hiatal hernia. So the hiatus is the hole in the diaphragm that allows the esophagus to come through to the stomach. When you have that hole in the diaphragm set up in a way that some of the stomach can wind up above the diaphragm, nothing works correctly. Now you all of a sudden are having a total setup for reflux. And this is a type 1 sliding hiatal hernia, meaning it goes up and down. But it certainly predisposes you to reflux. Very common. It's actually 95% of hiatal hernias, meaning don't be scared by the next stuff I'm going to show you. So these are the other types of hiatal hernias. Some of them are absolutely terrifying to me. I've actually rarely seen them, thank goodness. But we do have in pediatrics, we have what's called congenital diaphragmatic hernia, where you simply weren't born with the diaphragm closed the way it's supposed to be. But these are paraesophageal hernias. And basically what you're seeing is stuff, all kinds of stuff, winding up above the diaphragm. So you really get some extraordinary somersaulting going on there of the stomach inside the chest. You would reflux a lot if that's going on. I'm not sure what else I'm going to say on this stuff. But it's mildly terrifying. OK, moving along. So what else do we need to think about in the esophagus? So one thing we definitely think about are rings and webs. And the number one ring is called a Schatzky ring, named after Dr. Schatzky, I will assume, who is basically a lower esophageal mucosal ring. So it's the mucosa that's making a ring. 15% of people who have this are asymptomatic, which is extraordinary, because remember, food has to go through this. They will notice the symptoms if the diameter gets smaller than 13 millimeters. Remember, normal diameter of the esophagus is 20. It can expand up to 30. But when this ring is less than 13 millimeters, that's when you have dysphagia. Usually you won't notice it till you're older than 40. And therefore, we don't really know when it might have come about. It's probably acquired and, in fact, has been associated greatly with EOE. So I think we'll be talked about more. But it's also treated with esophageal dilation. So once you've figured out you have a Schatzky ring, you can treat it. You can also have congenital rings and webs. And sort of the classic is what's called a cervical web. These are usually higher in the esophagus than the Schatzky ring. And they can be congenital. They can also be inflammatory. It's not as many patients will have this issue. And again, you can treat this with dilation. I'm going to skip the plumber Vincent syndrome, because I looked it up, and it wasn't one of the questions you guys have. So you're OK. Let's talk about diverticulum. So what happens with any wall of the intestinal tract is if it gets weak, it can actually start to have this outpouching going on. And when you have this in the esophagus, at the top of the esophagus, you get this Zanker's diverticulum, which is a sac-like outpouching of the mucosa and submucosa through a muscular area called Killian's triangle. And it's about 2 in 100,000 people who will develop this, usually men. You usually don't see it until you're in your 70s or 80s. But it's like a little pouch where stuff is now getting stuck. And so those patients are very much at risk for pulmonary aspiration. They may have really bad breath, regurgitating, a sense of neck fullness, gurgling in the throat. Very interestingly, we're going to be doing pig stomachs. These pigs are long gone. But I have had the experience of doing endoscopy in live pigs. And I will tell you, they all have a Zanker's, just to know that. So it's like one of those things you learn about when you scope pigs. So esophageal diverticulum, there's a couple other diverticulum we can think about in terms of where they can be. But again, the same symptoms of regurgitation and dysphagia. OK. GERD. So as I said, GERD is something that you really want to think about with pretty much any esophageal issue could predispose you to GERD. But to some extent, everybody refluxes a little bit. And when the refluxate comes up into the esophagus in a way that is now starting to damage the mucosal barrier, and we don't fully understand when and why that happens in some patients, but without a doubt, it starts with stuff refluxing up above the diaphragm into the esophagus. That is when you can start to get reflux disease. And the mechanism of disease is all dependent on the lower esophageal sphincter being too relaxed or at least relaxing too often and staying open too long. So when the diaphragmatic ligaments keep the esophagus closed, you're not in danger of getting GERD. But when it's relaxed and opening too often, that is when you are having reflux. So causes of GERD, again, is a little bit because you're set up for this. There's a bit of normal physiology to this. But you will have it in response to food boluses. You certainly can have it if you have one of those sliding hiatal hernias or some other anatomic abnormality that makes it easier for the lower esophageal sphincter to relax. Eating foods can predispose you. And the classic is coffee definitely relaxes things, chocolate, so good stuff in life, alcohol. All of these things do relax the lower esophageal sphincter. And then certainly medications also can be instigators of more relaxation of the lower esophageal sphincter. So the most common symptom is that, oh, I'm having heartburn. But some people will really experience it as acid regurgitation, so stuff coming up they can tell it's acid. Less common is over time you're having irritation and inflammation of the esophagus and erosion of the esophagus even. And now food is starting to get stuck as it goes down. So you're having dysphagia. You can have chronic cough. Even just if you have lots of reflux up into your larynx, you can have laryngitis. And then there's a whole body of literature on how it may or may not overlap with asthma. And that sort of remains a bit of a holy grail to start talking about GERD and asthma. So there's some relationship, but it's not as straightforward, I think, as we had once thought it was. So what do we do about GERD? Well, the first thing we do is say, well, we know we need to get you up. And so even while you're sleeping, we're trying to sort of raise you up, so elevating the head of the bed. Certainly lifestyle changes like weight loss can make an enormous difference because being overweight does put more pressure, backwards pressure on the lower esophageal sphincter. And again, avoiding those foods if you know they're exacerbating things. We certainly have treated acid reflux now for 50 years almost with acid suppressing medications and almost 40 years of proton pump inhibitors. And then, yes, we can do surgery where we wrap the bottom. I don't think we actually have a picture of this, which would be nice for future slide decks, but we do have a way of wrapping basically the stomach around at the bottom of the esophagus, and that's called a Nissen fundoplication. OK, so what happens when you have a lot of reflux is you get inflammation of the esophagus, and again, all those symptoms. And this is an endoscopic picture of esophagitis. So before, I had shown a picture that had a nice vascular pattern. You're totally missing that vascular pattern. You have some erosion going on. You have lots of erythema and discomfort. And we have ways of classifying reflux esophagitis, and this is a nice schema just showing the concept of mucosal breaks and how much of the esophagus is involved. So Barrett's esophagus is a very specific thing that seems to happen. It seems to be related to reflux, which basically involves replacement of the normal lining of the esophagus with a lining similar to that of the small intestine. I'm going to repeat that one. I think among your toughest questions on your pre- and post-test, guys, so everybody should remember this one. So replacement of the normal lining of the esophagus with small intestinal mucosa is basically the origins of Barrett's esophagus. And that we can pick up by doing biopsies. Again, this is sort of that Z line. So you just can tell it's like a long, long bit of it. It looks more than what we've been showing before. This is considered a precancerous condition, and it does put you at risk for esophageal adenocarcinoma. And I think a very scary thing about Barrett's is often there's no symptoms. So there's really no way to know when it's either happening or when it makes this change from being a Barrett's over to the precancerous to the cancerous. And this is actually a very nice schema that just came out recently. I think it was in Gastro. But it's basically here it's showing you here's Barrett's starting. As you can see, it's taking up more of the esophagus. And now you're starting to get dysplasias. So you can go from low-grade dysplasias to high-grade dysplasias, and then ultimately to esophageal cancer. And I think anybody who specializes in Barrett's, this has become a holy grail. How do we know when this is going to happen? And the jury's still out. They're still trying to figure this out, what's the right way to attack Barrett's. You can work to get rid of it. So this is a picture of what's called radiofrequency ablation, which is one way to go after it. And you can basically burn it off. So this is a picture after that. You can also resect. And so John was showing a lot of this, but this is using EMR to basically inject saline and start to lift off the mucosa and do this endoscopic mucosal resection. All right, I'm going to flip over to esophageal motility disorders. These again have very similar symptoms. So you can have that dysphagia, difficulty swallowing. You can have pain with swallowing or chest pain or heartburn. And that's a little bit because motility disorders put you at risk for more reflux. You often have overlap of GERD with your motility disorder. The way we tend to try to diagnose, or I would say I send all my patients to my motility colleagues. I should preface this. But the way we definitely have come to diagnose functional disorders where the esophagus is not swallowing correctly because of the muscles not working correctly is actually to use a tool called manometry. And this is a very brave guy. This is done awake. You basically drop the catheter up the nose, down the nose, and you leave it there for a while. And usually my group is 24 hours-ish where they're walking around with the manometry catheter to better understand things. And this is how you start to diagnose that the esophagus is not moving the way you want it to. So this is how we get to achalasia or different types of spasms. Or even that you have a sclerosis going on, so systemic sclerosis, which would essentially mean that you have changes in the lining that means it just can't move. So achalasia comes from Greek. It means it doesn't relax. The hallmark of achalasia is you lose peristalsis, and the lower esophageal sphincter does not relax. And so this sort of classic bird beak appearance is what they call it. But this is a non-relaxing lower esophageal sphincter and just all the barium sort of building up and not able to drain out. So that is achalasia. And achalasia is something we're increasingly treating with botulinum toxin, so basically a Botox injection. And somebody came and asked questions about this. But the goal is to actually put it into the lower esophageal sphincter, so to inject it not into the submucosal space, but actually into the muscle. And you have to do injection sites at all four quadrants of the esophagus. And I have colleagues right now trying to bill for this because it's very hard to get reimbursed. But it's worth it because the patients feel better, and we're working on that. Another thing you can do is pneumatic dilation, which basically you just blow up a balloon and open up the lower esophageal sphincter that way. And then our surgeons can get involved. So the sort of classic way to go after achalasia is actually to go from the outside. Ask the surgeons. They'll go in laparoscopically or basically through the right into the skin. They're going into the outside, and they're going to make an incision from the outside of the esophagus so that they can see the mucosa. But they've basically cut the muscle right by the lower esophageal sphincter. OK. I am going to flip over to something totally different, which is infectious esophagitis. So you can get infections in your esophagus. And the most common one is candidal esophagitis, so basically like having thrush in your mouth, except now it's going down your esophagus. This is a picture of it right here. What you guys want to notice is it gives a lot of white plaques. And for a long time, when we would diagnose EOE, we would also get brushings because we're like, what if it's yeast? Now we don't do that so much anymore. But it really does look a lot like EOE, frankly. But there's no rings. There's just basically this white plaques. These are patients who present with oedynophagia, dysphagia. And if you diagnose yeast, you need to treat it. So we do oral fluconazole for 14 days. It's sort of classic, but some sort of antifungal. OK. Next is herpetic esophagitis. This can be HSV1 or 2. Has a very different look. But again, you're seeing very classic lesions. These are punched out ulcerations. And usually, this is going to go away. It's on its own. It's basically like having a cold sore, except a bunch of cold sores in your esophagus. And so it's self-limited. But you can use acyclovir or valciclovir or ganciclovir if you need to. And then CMV esophagitis is really probably something we're only going to see in truly immunocompromised patients. But it does have a very classic look, which is what they call serpiginous ulceration. So sort of like a linear ulceration that looks like a little snake. And the treatment for this is ganciclovir. All right, so this is pill esophagitis. So if everyone remembers, the top place, the narrowest part of your gastrointestinal tract is right at the top, right, at the cricopharyngeal junction or the upper esophageal sphincter. And of course, you also have the lower esophageal sphincter. The pill can get lodged there. It can frankly just get stuck on the esophageal wall. So the classic is the pill was taken, I deal with kids, was taken by the teenage boy on their way out the door. They took some ibuprofen because they had soccer practice the day before. They feel sore. They take their ibuprofen for it. And it sticks to the esophageal wall. And it will hurt a lot. Another classic is teenagers with acne medication. So doxycycline, tetracycline is a really big pill. Quinidine, I didn't know that, phenytoin. And basically, this can happen with any pill at all. It gives a very impressive pain. This is basically showing the bad ulcer right here. Rawr. And the worst thing is they show up in the ER. And we say, oh, you have pilosophagitis. And we don't want to do very much. And the parents aren't very happy. And the kid's not very happy. And we tell them it's going to get better soon. I mean, there's just not much you can do for it. So it's self-limited. But you could try some PPI and some carafate. And we'll usually try something. But it's mostly a matter of saying, next time, drink water. OK, I'm really not going to go through poem because I think you did a good job with it. And it was where John talked about it. And this is like, you do not do poem for pilosophagitis. This is something you do for achalasia. And basically, it is definitely something that people are, frankly, now creating whole careers where they, you know, Mimi, you talked about you do many, many endoscopies all day long where you're doing dilations. There are people who are spending their days doing poems now. But they are doing what's called third space endoscopy, where they're doing incisions into the submucosal space, creating this tunnel, and then basically getting down to the muscle where they do the myotomy incisions. So that is poem. OK, moving to the stomach. So the stomach is, again, probably most commonly is to have peptic ulcer disease. And this is a mucosal break in the GI tract. This does not occur from acid. The peptic part is from acid. This does not occur in the esophagus. This is something that will happen in the stomach. And it could also happen in the first parts of the duodenum. And an ulcer is basically a sore. So I think my parents of my patients, when I talk about an ulcer, they imagine I'm, like, seeing straight through the stomach into the kid's abdomen. And that is not what it is. It's just, like, a little sore in the lining. The most classic cause of ulcers are there's really the number one cause is helicobacter pylori. That particular association between H. pylori and peptic ulcer disease won somebody the Nobel Prize. But it's really important to recognize that for many, many patients, it's an infectious discussion. So they have helicobacter pylori. And that's what's caused their peptic ulcer disease. Also NSAID, so again, to the teenagers who are really popping ibuprofen like it's over the counter and why can't you just keep taking it, just one dose of ibuprofen is enough to cause a good stomach ulcer. These patients certainly have pain and discomfort. But they also can present with bleeding. So we'll talk about that. They can also get gastric outlet obstruction depending on where the ulcer is. And then a really, really bad ulcer, yes, you can see through to the abdomen. But we would not know that. They're having severe acute abdominal pain and lots of bleeding. Kind of go down there and get everything under control and then try to patch it up. So we diagnose ulcers with upper endoscopy. Here's an endoscopic image of an ulcer. Definitely, if there's H. pylori involved, you want to treat it. And then a lot of ulcer treatment involves keeping acid suppressed for a while while things heal up, so proton pump inhibitors. In terms of the bleeding, this bleeding, when it comes from peptic ulcer disease would be in the stomach, which is above what's called the ligament of trites. The ligament of trites is right here, which is where the first part of the small intestine, the duodenum, makes its turn into the ileum. And basically, if anything above it, you're going to see bright red blood, usually vomiting, sometimes melanin. So these are different ways of talking about blood in the GI tract. You can vomit blood. So that's hematemesis. You can have dark black colored emesis, which is usually your coffee grounds. That's usually oxidized blood. That's going to also be just blood that was sitting in your stomach for a bit. You can have hematochezia, which is bright red blood per rectum. And then melanin is a very distinct type of GI bleed that is black and a tarry colored stool. And certainly, when you have it all going on, a little bit of hematemesis, a little bit of melanin, that's when you're really like, uh-oh, that patient's hemoglobin's going to be impressive. You know, what's causing it? So we've been talking about many of these things, but varices, the ulcers. You could just have bad gastropathy, ulcers in the duodenum. I'm trying to think. There's something called a Mallory-Weiss tear, which can happen after you've been vomiting a lot. You can get a little tear in your esophagus. I think I'll move on. Okay, so what do we do for people bleeding? Well, the first thing we do is make sure that we keep them euvolemic. So we want to resuscitate them with a lot of IV fluid. So not necessarily blood right away. First, lots of IV fluid. But often, we move to blood if we need to. The other thing we do, we know that the stomach's really good at healing itself, and it does help. It's very clear now that it does help if you suppress acid. So we will start proton pump inhibition. And then, yes, you call your friendly endoscopist. They have been on call for the week. They come in for the third time that week, and they start to do different things to try to control the bleeding. And we have talked through many of these now. Gastric outlet obstruction is just one more thing to think about. So that would be anything that starts to obstruct either right at the bottom, so the drain of the stomach, so the pylorus itself, or right below it in what's called the duodenal bulb or the duodenum itself. But something right below the stomach would mean the stomach can't empty. And the causes can be many. Often, they're benign. So an ulcer in just the right spot, an ulcer just at the pylorus is enough to sort of swell everything up and actually cause some bleeding. Certainly, ulcers in the duodenal bulb, which are very common, could cause problems. Pancreatitis, another reason we can see this. And then, you can certainly have bad malignancies, so gastric cancer, pancreatic cancer. The symptoms look very similar to everything else. So they might have nausea, vomiting, abdominal pain. Sometimes, they have early satiety. So they've had a period now of not being able to eat well. And they're saying, I just haven't been hungry. There can be distension and then weight loss. Diagnosis does involve usually some imaging to realize, wow, that's the stomach that's full with a lot of stuff. And then, you can do an endoscopy to realize, gee, how's anything getting out of that stomach? For these, we do need to decompress the stomach. So we'll place a nasogastric tube and help to get stuff out of the stomach because it's very uncomfortable sitting there with a stomach that can't empty. For especially malignancies, you can do stents where you'll basically place a stent across the pylorus. This is a radiology image of that. I don't know if you guys can see the stent, but here it is. Can you guys see that, the stent? Yes? Okay. All right. Oh, and that's an endoscopic picture of the stent across the pylorus. That can really help people feel better. If necessary, you can do a surgery. And this is sort of a classic Bill Roth II or what we call a gastrojejunostomy, where you're basically pulling the jejunum up to the stomach and suturing it together so the stomach can empty directly into the jejunum. And you're trying to figure out why someone can't empty their stomach. Sometimes it's just the stomach is paralyzed. It's just not moving. So again, this is not a mechanical obstruction. This is a motility disorder, and this can come from diabetes. It can be post-surgical, post-infectious. That's sort of the classic is idiopathic. We don't actually know what makes some people's stomachs empty badly. The symptoms look the same, so you have to sort of do all your different tests to try to figure out what you're dealing with. And a classic test you might do here is what's called a gastric emptying study. So I have normal here on the right, and abnormal is on the left. And a gastric emptying study is you have the patient eat or drink, so it's usually for liquids or solids, usually an egg, sort of, and it's a radioactive egg, not a dangerously radioactive egg, but it has a radioisotope in it that you can actually measure. And here's the study going on. So you're seeing at 10 minutes, you have the egg in your stomach, and you sort of start to watch, and over 30 minutes, still in the stomach. And what are you seeing here? You're seeing in the abnormal, not in, sorry, this is now backwards, but in the, one of them, it's not emptying. It's sort of staying in the stomach longer. And this one, it's really starting to get out of the stomach. Am I reading that correctly? So I will, I'm going to. One on the right's retained, yeah. Yeah. Okay, and this is 120 minutes after you had that egg, and what you're seeing is, in this one, is it's still very much in the, just hasn't really moved, and in this one, it has emptied all the way out. Everybody seeing that? I think I'm reading that correctly. Or did I get that backwards? No. Okay. Somebody, other way around. Okay. Somebody else do that. Gastric emptying, so you always say it's like nuclear medicine, unclear medicine. Wait, I will go backwards. How did I really get that wrong? I don't know. Somebody has to demystify for me. This is stomach. Stomach on the right, and duodenum small bowel on the left. So it's emptied on the left. It's empty, yeah. It's not, it empties here. Emptied there. And this one. Not emptied there. It didn't empty. Ah, okay. I don't think I like these images very well. I have to rely on the cartoons there. Okay. I'm going to rely on the cartoons, too. But I will tell you, what you want is your nuclear medicine physician helping you read your nuclear medicine studies sometimes. And they will say, oh, 30% emptied out or 40% emptied out. They usually give you sort of not exactly black and white answers as to whether or not it's delayed. So, okay. All right. So what do you do for these patients? You try to have them eat slower, smaller, frequent meals, et cetera. And then some medicines that may help. You can have subepithelial masses. So these are some things we can see inside the GI tract. And the key to these things is, are they inside the wall of the stomach or are they outside and pushing in? And so these are various pictures. They could be something very benign. And then they also can be malignant. And really the key, I think, to subepithelial masses is using EUS. So that's really the best way to figure out where the mass is and really to identify it as being inside the wall or from the outside. And you can also stick needles in, as John talked about, and get stuff out. Okay. I had the question. It turned out. But we'll wait. Anybody else have a question or any? Questions. Everett. For Barrett's, if you do an EMR, how long is the healing process? Well, EMR, healing process. It usually takes a couple of months. A couple of months for the ulceration to be completely healed. And then you would bring the patient back in two to three months to reassess the site. Yes. Yes. Yeah. A lot of patients on Barrett's are on PPI sort of without stop. We didn't really talk about this, but anything in the esophagus is going to probably cause it to swell and the mucosa to get a little thicker. And it actually essentially draws it up. So anybody, as soon as you've done any interventions, you're actually almost causing reflux too. So you really have to suppress. Any other questions about the esophageal diseases that we see? Question over here. With the myotomy that you do for achalasia, which layers are cut during that procedure? Is it anything beyond just the musculature? The endoscopist is usually in the submucosa. And then they cut the deeper, which the muscularis propria is deeper than that. And they cut that and excise it completely so that the spasm of that muscle is no longer causing an obstruction, outflow obstruction for the patient. Okay. Thank you. You mentioned with colonoscopies, you have both like screening and diagnostic measures that you take. Do you do that with Barrett's as well? Yeah. So it's a very big discussion is what should the screening be for Barrett's? And, you know, they're basically, they come out with guidelines and then they'll revise the guidelines and they keep coming out with newer modalities, which has been helpful. And I think the ultimate is hopefully better biomarkers, better ways of really being able to tell where you are. So, again, great review last year. That was helpful on Barrett's, but. Okay. Join me in thanking Dr. Leite.

gastrointestinal tract

esophagus

stomach

reflux disease

motility disorders

symptoms

treatments