Hello, good morning, everyone, and welcome to Weekend Endoscopy Live, which is live from the IT&T Center, the ASG headquarters here in Chicago. I'm Prateek Sharma. I'll be the moderator for today's session. And this is just another one of those series brought to you by ASGE for education in endoscopy. This is a free offering for all ASG members, and we are also pleased to announce the generous support of Medtronic for this series. For today, we will be discussing esophageal testing, endoscopy, pH monitoring, high-resolution manometry, and beyond. And before we get into this, I'd like to introduce two esteemed guests and experts for today's session. On my right is Vani Konda, who is a gastroenterologist at Baylor University Medical Center and one of the leading esophageal experts in the country. Welcome, Vani. Thank you. It's a pleasure to be here. And to my left is John Panolfino. John is a professor of medicine and chief of gastroenterology, actually here in town in Chicago at Northwestern. And both HRM, Chicago classification, synonymous with that. So welcome, John. Thank you very much. Welcome to Chicago. OK. Thank you. Glad to be here. So just as we've done in our previous series of this Weekend Endoscopy Live, this is case series. It's videos. It's images. It's going over what we face every day in our clinical endoscopy and GI practices. And what we'll be doing is discussing a number of esophageal testing today. And right from using upper endoscopy videos for looking at landmarks in the esophagus to HRM tracings to FLIP tracings. And so all of you at your homes, grab your cup of coffee and spend the next hour with us. So we'll first start off with some videos looking at important esophageal landmarks because endoscopy is the key for evaluating the esophagus. And so we will look at some images and videos to do that. So, Vani, why don't you get us started with some of those images and videos? Fantastic. As Prateek said, we often start with endoscopy when it comes to esophageal testing. And we all know we should do it. But the question is, how well do we do it and how well do we document it? So when we first look in the esophagus, it's important to start with landmarks. And we want to look at the squamo-culmonary junction, the esophagogastric junction, and the diaphragmatic impression. And we can see here when they all line up together, that is a normal complex. Now we can see here in this video, they all line up beautifully together. And Prateek, would you biopsy this? No. So this looks like absolutely normal gastroesophageal junction. I haven't seen one of those patients in a while. So I'm glad you reminded me about that. But that looks absolutely normal. No reason to biopsy anything. I would agree. Yes. But we want to still identify and document these landmarks in our report. So that way we know that our colleagues know that we looked. Now here, we have displacement of the esophagogastric junction or the top of the gastric folds from the diaphragmatic impression. That indicates a hiatal hernia. And we want to measure and document that distance between those two to be able to show the axial length of that hiatal hernia. And we can see here when we start, we want to actually start with the stomach slightly deflated. So we don't want to over insufflate. And so we can see the folds as we come back through that hernia sac. Now, Vani, I noticed in that video that you have a cap at the tip of the endoscope. And I'm sure you may be talking about it later. But why don't you tell us why is that cap there and what's its importance? So out of all the tools in the endoscopy, I think that distal attachment cap is my favorite tool. It allows me to really look at the mucosa, especially at the gastroesophageal junction. I can look at the mucosa on FOSS. It really gives me stable imaging and views. John, do you use that routinely? Or is this something just for some specific cases that you would do? No, I don't use it routinely. In fact, I rarely ever use it. But seeing these images now, I think it obviously has value. I think for me, most of my cases are going to wind up being very diagnostic as opposed to therapeutic. And that's probably why I haven't used it as much. But certainly you can clearly see by the use in this video that it does improve the visualization. So when we look at our retroflex exam, so often we just take that one little picture with our up dial and then snap it and move on. But I really encourage you all to spend a little bit more time looking at the hill grade. This allows us to really understand what's going on with that valve. And I think we often think of hill grade one as easy and hill grade four as easy and then sometimes have trouble with in between. Hill grade one here, we can see that there's a nice prominent fold. We can see that that ridge or that tissue is maintained and that the tissue hugs the scope for most of the time. Sometimes we even see the squamo-culmonary junction hug or pull with the scope. And that, I think, would be a hill grade one. Do you? Yeah, so before you go into the different grades, hill to me is climbing up a hill, right? So what is hill? What do you see there? Why is it? Why should we even bother with it? In that image on the left, what is it that you're looking at which tells you that it's a hill grade one? And what are we looking at? Yeah, so it's a way to assess the valve. And it allows us to see basically how competent it is and gives us a lot of information. And it actually has implications in treatment for what kinds of treatments you might consider for a patient that you're considering for a hiatal hernia repair or anti-reflux surgery. And it really gives us that other accurate and clinically relevant information about hiatal hernias, even more so sometimes than axial length. And right here, we can see this ridge right along the scope. And that is prominent in a hill grade one, which shows the anatomy in a way that we're going to see in the other hill grades that we're going to start to lose. So here is hill grade two. And this is when that fold is less prominent. And instead of the mucosa hugging that scope the whole time, we start to see more variability with the respiratory efforts. And so we might see it open and then close and open and close. And this is more of a hill grade two. And here, to give you an example, is a hill grade three. And I sometimes think these are a little bit more difficult to really capture and sort of feel confident about saying, oh, that's a hill grade three. It's basically the fold is not prominent at all. And the scope is not gripped by the tissue at all. But you see space all around the scope around that. Now, John, from a physiologic standpoint, does this help? I mean, does this play a role in reflux and how much? And is there a good correlation, let's say, between this and the esophageal acid exposure or symptomatology or anything from a clinical perspective? Yeah. I think the early studies do support that there is a step-wide or step-wise incremental increase in acid exposure as you go through the hill grades. We actually studied this. We did a study looking at the wireless capsule placement and exercise and showed that exercise-induced reflux was actually correlated with these hill grades. And physiologically, it makes sense. It's really a flat valve that's there to protect you against strain-induced reflux. So when you're straining, you're bending over, it closes upon itself. So it's not just a physiologic sphincter that has toned, but it's also this anatomical musculomucosal fold that does flap down and close with high levels of intergastric pressure. So it's a beautiful anatomical area that definitely has some value. And I think looking at it faced and herniated, you can appreciate why patients will get reflux. And then here we have a hill grade four. And here, there is no fold. And the lumen of the esophagus is completely open. And I often think about it as when I look up there, I see a whole other room, which is that hernia sac. And you can pretty much appreciate the hernia sac, as you can see in this view right here, and easily get the scope up into the hernia sac in that retroflexed position. It's a beautiful image. So these are things that we can add to our endoscopic examination and documentation. In addition to that, we want to look for displacement of the squamo-columnar junction from the esophagogastric junction, because that lets us know that there might be columnar-lined epithelium that could be consistent with Barrett's esophagus. And so again, we want to go from the top of the gastric folds, which we just passed. And then we can see here there's salmon-colored mucosa going up into the tubular esophagus. And as you can see, this is a long segment of Barrett's esophagus. And there we transition to the squamo-columnar junction. We want to identify each landmark consistently and accurately every single time. So that way, we're not getting confused about Barrett's esophagus, or including those numbers that are actually part of the hernia in the Barrett's. If we go through and take our landmark measurements every time, we'll be consistent in identifying a hiatal hernia, a Barrett segment, or a Barrett segment in a hiatal hernia, or normal state. Now, I'm going to show some examinations here. First, starting from the stomach and coming back up. And we can see here, we have a small hiatal hernia with a diaphragmatic impression at 40, and then the gastroesophageal junction at 39. And then we can see the circumferential extent of the columnar-lined epithelium, and then the maximal extent of the columnar-lined epithelium, which allows us to identify the length using the Prague criteria, which in this case would be C0M3, taking those distances between the circumferential extent and the maximal extent from the top of the gastric folds, respectively. And then we can also note there is a diminutive island. Now, that island would not be included in our measurement, but we can report that separately. Now, this is good, Samin, because in most of the endoscopy reports that we see, specifically those patients who are referred, it would just say short segment Barrett seen, right? Whereas here, you've told us very nicely. So how frequently do you think your fellows or trainees are able to translate this into their endoscopy reports? And how important is it for them to be doing it? So I will say sometimes we sit down after a case, and we will map out and diagram out exactly what we're talking about in terms of the top of the gastric folds, the diaphragmatic impression, and the circumferential extent, and the maximal extent. I think this has been around, as Dr. Sharma published, for over a decade. But unfortunately, we're not incorporating it into all of our reports. But this is a validated way to communicate about length of segments, and it does make a difference, because a short segment versus a short segment could be two totally different things. And I think especially as we're trying to plan treatment or know what to expect for a case, it'd be helpful to know what the previous endoscopist found. And we know that the penetration of these classification systems, unfortunately, is quite low. The LA classification was developed back in the 1990s, and a survey done a few years ago showed that only 60% to 70% of the endoscopists were actually using it. So unfortunately, we're not very good when it comes to using or spending a little bit of extra time in noting these and having a very standardized way of measuring and reporting these landmarks. So this is actually very good. And then here's another example of a segment. So this is just one quick pull-through, and then we're going to go back through and look at it again. So we can see the diaphragmatic impression here at 36, and then the top of the gastric fold, so indicating a small hiatal hernia. And then we're looking for that circumferential extent of the columnar lined epithelium, which we can see here with those arrows, at 32. And the maximal extent is about 30 centimeters. And then still going above that, we can see some changes in the lining, which might be consistent with erosive esophagitis. Yeah, that's what I was going to say, that there appears to be erosive esophagitis. Yeah. What would you do in this situation as a next step during your endoscopy? Pull out the biopsy forceps? I'd probably treat the erosive esophagitis. What do you think, John? I think I would, too. I mean, obviously, you're going to want to heal that, and then go back and take a look. And obviously, the extent will probably be the extent of the Los Angeles C esophagitis, and you'll do your biopsies. And then you don't have to worry also about the confounding of the inflammation in terms of the dysplasia calls that you'll get from your pathologist when they have this type of inflammation. So yeah, I would definitely treat this person, bring them back, reevaluate them endoscopically, and then do my biopsies. So one question that we have coming on from our audience is related to how long would you treat, and how much would you, in a situation like this, go to BID therapy or once-daily therapy? And would you bring the patient back in a month, or three months, or six months? Any sort of suggestions to our audience? Generally, I do BID, PPI therapy for eight weeks, and then bring them back for an endoscopy. That's exactly what I do. I'm going to hit this person with double dose. I want to make sure that they're healed, so that I don't waste their time and my time when they come back. So I think you can be very confident with a good standard dose twice a day, taken appropriately, that that'll heal, and you'll be able to perform a good endoscopy and get biopsies. So in this case, we're going to take a look. And we can see... I see some polyps. Yeah. There are some stomach polyps. So that was a diaphragmatic pinch, and a large hiatal hernia. And Prateek, feel free to jump in and tell me what you see. I see something abnormal at the one o'clock position there. So yeah, very transiently visible, but again, with the cap, as you have, you can see that, Vani, you're doing a good job in pushing that away. And you can almost... There appears to be a central ulceration, so almost like a Paris 2C lesion in there. So I'd classify that as a 2A plus 2C. You see some elevation, but there's also some ulceration in there. I classify that as worrisome. Okay. So, and this is the same patient, but a different view. Retroflex now? So that's key, right? So what you're seeing is this retroflex view, Vani? Yeah. And you saw that it was sort of hiding under the lip of the hernia sac. And we could see it, but it wasn't a perfect view. And so looking at pulling your scope up into the hernia sac actually gets us a much better view of this lesion than that forward view did. Yeah, right there at the G-junction, and that's one of those danger zones, right? I mean, there's always at the G-junction, do a careful examination. Doesn't mean that you don't do a careful examination elsewhere, but the retroflexed view really helps there, Vani. So... Yeah, I think it's much easier to see the extent of the lesion, the size of the lesion, and the characteristics of the lesion in that retroflexed view in this case. So in this case, this was resected with ESD, and the path came back T1A with invasion into muscularis mucosa and negative margins. So it's important, really, to do that careful inspection in and around the hernia, the gastroesophageal junction. As Prateek said, tip deflection and the cap really helped. And as we just looked, that retroflexed view really helped. And Prateek, feel free to comment as you see. And John, please comment as you see this case. This is the second case. I wonder if there was something at that eight o'clock position or nine o'clock position when you went in. You're going in too fast. You're driving too fast. Driving too fast. Don't worry. I'll come back. Okay. My fellows make fun of me, how long I spend in the esophagus. I may not use a cap, but I sit and insufflate quite often for five minutes sometimes, and it drives my fellows nuts. And as you're doing this, how about the saliva and the mucus? Do you have a good way of removing it? Do you typically use muco mist or just water or simethicone? What's your favorite agent? So sometimes I use water, and sometimes I use muco mist. So I tend not to use simethicone as much, just because of the biofilm. And so here, this is an interesting one where I feel like really insufflation and deflation help to help define the contour of the lesion, because in an over-insufflated esophagus, sometimes you can miss subtle lesions, especially ones that are flat. And so although there's an area that might protrude in the 9 o'clock area, what I want to do is call our attention to about the 4 o'clock area. And especially as you deflate and insufflate and then deflate again, we can see some abnormal contours at that 4 o'clock area. Would something like NBI or BLI help in this situation? Ask and you shall receive, Prateek. Look at that. So here we can see, again, the use of a cap, tip deflection. And then here we can see under narrowband imaging some distorted pit patterns, some friability, irregular vascularity. What we're looking for with those blood vessels is we want the blood vessels to follow the mucosal pattern in a well-behaved manner. And when they don't do that, and they start to do their own thing, that's when we start to worry about irregular vascular pattern. So we're looking for irregular, distorted mucosal pit pattern, irregular vascular pattern. And that makes us concerned for neoplasia. Actually, in this case, what you also nicely highlighted is that the extent of the lesion was significantly more than what it appeared initially. It almost extended from the 12 o'clock position up to the 4 o'clock position, right? I mean, it appeared initially just as a very focal area. But I think the extent's much more bigger than that. And that's important if you will do resection in this case, right? That is right. Right now, you can't see it. But it's probably right there at the 12 o'clock position. You're right. 12 o'clock to 4 o'clock, which is actually why I performed a wide-field EMR with five pieces. And the pathology actually, again, demonstrated a T1A M3 lesion with invasion in the muscularis mucosa and negative deep margins. With wide-field EMR, the lateral margins, you can't always tell if they're truly they could be positive but not positive for the extent of the resection site. And so again, taking time to interrogate the G-junction, I think this case really showed nicely how the insufflation and deflation and that dynamic examination can help define the contour. And it was a lovely demonstration of narrowband imaging. And this particular one had the narrowband imaging with near-focus, which allowed that zoom magnification to look at the mucosal patterns and the vascular patterns. So Vani, another question coming up is related to your use of this virtual chromoendoscopy. Do you do that in every Barrett's case for esophageal examination? Or is it limited in certain cases? How do you decide that? I would say I probably use narrowband imaging in all my cases for Barrett's surveillance or treatment. I think that when you have a Barrett's case for surveillance, you want to use the best scope that you have. You want to use high definition. You want to have available to you some sort of virtual chromoendoscopy. And that really helps us define some subtle characteristics. And I would say that pretty much I routinely use it in all my Barrett's surveillance and treatment. So this is another case. And feel free to chime in. And these are just examples of why we want to look carefully at the gastroesophageal junction. We talked a little bit about not biopsying the normal areas. But we really want to inspect carefully. We don't want to just say, oh, I'm not biopsying and I'm not going to look. We actually want to do a really careful job looking, interrogating, inspecting to see if there's any areas of concern or mucosa irregularities that we should biopsy. So I really want us to encourage each of our examinations to spend a lot more time looking at the G-junction, maybe biopsying a lot less cases. But make sure if you're going to biopsy, you biopsy something because you've done a good job looking and you might identify something. Now in this case, here we are washing a little bit, getting rid of that extra saliva. And this case is, we can see there's an area around 2 o'clock that Pratik had just pointed to. And I like how you're going circumferentially and looking at the entire SC-junction and the G-junction area. And that area of abnormality, as opposed to the other ones that you showed, actually appears a little bit more redder. And even on white light, I think you get a very good look at that area. And it's a small focal area, which extends probably a little bit more up to the 2 o'clock position there. And excellent demonstration of the patterns there, Rani. Yeah, so we start to see a little bit of a focal loss of the mucosal pattern. And as Pratik said, there's discoloration on that white light examination that we can see. And then the area can be, you can look with narrowband imaging everywhere else and you can see that there's still preservation of the mucosal pattern. So in this case, and here we have the areas circled. This is the forward view with that area at 2 o'clock with the discoloration. And then this is it in the retroflex view. Again, you can even see a slight raised area, especially when you sort of under-insufflate the esophagus. This area was treated with focal EMR and, again, was T1A M3 with negative margins. I think this case shows that discoloration is an important feature to look for, that loss of pit pattern and vascularity under narrowband imaging. And again, I really like that ability to insufflate and deflate because I think it defines the contour and sees those subtle raised lesions a little easier. And again, the retroflex examination can help show that lesion in a different way. These are all cases that I don't want to scare you and make you feel like you have to be worried, but I just want to encourage you that we can see these lesions and we can find them, but we have to train our eye to look for those subtleties and take the time to look. And the more time we spend looking, the more likely we are to find these irregularities. And I'd rather spend more time looking and less time biopsying normal GE junctions. Right. No, absolutely. And I think it, I'd say we should be concerned. We should be scared because we are missing these lesions, right? I mean, there's good data to show that the majority of the Barrett's cancers which are found are found within 12 months of the index endoscopy. Now they didn't appear within 12 months or grow in 12 months, right? It's very similar to interval colon cancer that we don't want to miss any prevalent cancer. And this is, I think, exactly the point of that. So great, Vani. I think you've shown us endoscopy is king and is one of the best tests that we have to look at the esophagus, but can't do everything. So we move to you, John, is to now look at HRM and high-resolution manometry. And those cases that endoscopy can't pick up is, how can we use manometry for esophageal testing? So walk us through what happens in manometry after you've placed the catheter. What is it that somebody who may be just starting off to look at these manometric tracings, what should they be looking for? So let's look at that, John. Yeah, sure. So I just want to emphasize, too, I completely agree, this issue of these very superficial evaluations of the esophagus. The esophagus is not just a conduit to the stomach during endoscopy. And when you have someone who, in particular, comes in with the chief complaint of reflux, their pretest probability for having something bad is higher than someone who comes in with dyspepsia or something like that. So I think it's very important in that context, when you see someone with reflux and a hernia, you really need to be careful. And you need to look carefully at the squamous columnar junction, the EGJ, and definitely in the retroflex view. I think people ignore that. They flip around. They identify it. And then they just flip right back around. So definitely important. And even though I am a physiologist, I still am an endoscopist. And I still think endoscopy is king. And it really is the fork in the road, because you don't get to manometry until you really have a negative endoscopy, or at least an endoscopy that suggests you have an esophageal motility disorder. So if you have someone who comes in with dysphagia, chest pain, maybe transient perception of food impaction, or maybe even a food impaction, and you do an endoscopy, about half of the time, you will find something that may lead you to believe that that's the cause, a mechanical process, eosinophilic esophagitis. But many times, you're left with a normal endoscopy or an endoscopy that suggests a motility disorder. And that's where you will perform manometry. And typically, the patient is referred back at a later date, typically after a four to six hour fast. And that's mostly, to be honest, to protect the motility technician, who's when they're placing that transnasally, is not going to be vomited on, for the most part. It doesn't affect the exam all that much, because we find that we do these exams, and the patients are in various stages of the fed fasting state when you look at these. But once again, similar to what Vani said, anatomy is really important also in manometry. So here's an example, and I'm not going to quiz the audience. This is a normal patient, and this is typically how I would view a manometry in my clinical practice. So I would look at this, and the beautiful thing about this is that the pictures really help you. Because right off the bat, as I expand this, and I start to look at the study in and of itself, just here, I start to see beautiful peristalsis. I know that this is most likely going to be a very normal exam. Now, the first thing that you want to do, though, when you're actually evaluating these cases, is really get a good perception and feel for what the anatomy is here. So in this particular case, I typically always have my motility technician or nurse do good deep breaths. So some people like to do a sniff or a deep breath, and some people even do a leg raise or a valsalva. But you really want to induce this negative pressure in the chest. I'm going to get rid of the impedance signal here, which is that purple signal. And you want to see that curl contraction, and then you want to see the rise in pressure here. So I'm going to put this line here, and then I'm going to take this pressure inversion tool. And what you see here, all the pressure tracings across these three one centimeter space lines are all deflected down. And as you move this down, all of a sudden here you see them flip up. And now this one is down, and these two are up. That allows you to be comfortable and confident that that catheter now is through the curl diaphragm into the abdominal cavity. Now you can be through the LES, but still be located in the interthoracic cavity if you do not have that pressure inversion point. So very important to get good anatomy, to identify whether there's a hernia, to identify whether or not you even got the catheter down, or sometimes you can even see it coiled up and it has a butterfly appearance when it's not in the right position. Because if the catheter is not in the right position, you will not be able to do a good evaluation. So as I mentioned, you have the upper sphincter here, the lower sphincter here. This was a pretty good exam, no hernia. And you will then proceed to look at the study. And how I typically do this, because we do a Chicago classification where we start in the supine position, we typically do 10 swallows. In my practice, I move people into the upright position, then do five upright swallows, doing some multiple rapid swallows. We challenge the patient with some solids, and then do a rapid drink challenge in the end. I typically start in the middle here. I find my landmarks. And I think people are sometimes a little bit too finicky about their landmarks. I think as long as you're pretty close. So here you can see I'm moving these cursors here, which are lined up. John, for somebody who's just starting doing HRM, want to incorporate this in their unit, they have this, they're looking at this. Tell us about the colors. I mean, what do these, besides looking pretty, I mean, what are they telling us? Yeah, so the colors are on a hot-cold scale. Blue is low, and red and maroon here are very high. So what you see here are these high pressures at the sphincter. So red here is around 100, and green-yellow here is around 40 to 60. So you can see that the lower satchel sphincter is quite competent, has a nice tone. And you can clearly see also that the upper sphincter is very, very tight in terms of its contraction here. And that's typically normal. We typically see these types of pressures. And you will see classically a change in the pressure signal with respiration. So when I'm trying to get my landmarks here, I'm really trying to get these cursors, which is the, I'm going to move this up and down here so you can see it, the top of the, or the proximal aspect of the high-pressure zone, and the lower aspect of the high-pressure zone. You know I'm calling it the high-pressure zone because the high-pressure zone is made up of both the LES and the coral diaphragm. So once I have a pretty good position, I also make sure the gastric sensor is at least two centimeters below and not intersecting the high-pressure zone. So now that I have a good reference of gastric pressure. And as I scroll through this, I will look at each swallow individually. So here what we're looking at now is the IRP, which is nine millimeters per mercury, which is in the normal range below 15. I'm looking at the peristaltic sequence here. The distal latency value here is 5.4, which is in the normal range. I will tell you that I would probably measure it here as opposed to here because the contractile deceleration point is probably better located here. One simple thing though is once it's above 5, 5.5, I don't really care. So as long as I'm seeing that it's there, you don't have to nitpick to where that is. And then I'm getting a nice DCI value here of about 3,400. So this is a nice normal swallow. It has a normal LES relaxation denoted by the normal IRP. The peristaltic sequence is propagating in a very nice antergrade fashion with good latency suggesting that it's not spastic. And it's also right in that normal range of DCI. The contractile vigor is about 3,400. The normal range is quite large. It ranges anywhere from 450 to 8,000. So if you think about it, it's a pretty large range. But once again, I take that with some granularity because the esophagus can change contractile values very quickly depending on what it eats, what position it's sitting in, and also the volume of the bolus that it's taking. So I typically go through this very quickly, looking at all of this, focusing mostly on the pattern, but not really the measurements as much. Because once I've made the measurements, I feel pretty comfortable. And how many of these would you like to see before you call it a day and say, OK, this is normal. I'm happy with this. Let's move to the next one. Yeah, so typically, we like to see seven normal swallows, to call it normal. In my practice. But if you look at the way the Chicago classification is defined and whether or not someone has ineffective esophageal motility now, now patients can actually have seven weak swallows and be further characterized as having ineffective esophageal motility. So now, technically, that seven normal swallows is not, in effect, a Chicago normal diagnosis. But for me, if I'm going to qualify someone for a research study or look at them as someone who I would really classify as normal, I like to see seven really intact swallows. And maybe they can have a failed or a couple weak there. Certainly don't want to have three hypercontractile or three spastic swallows. Although I have to say, if I have seven normal swallows and three spastic swallows and three hypercontractile swallows, I'm still a little suspect of calling that person truly spastic or jackhammer for hypercontractile. So I do disagree a little bit with the Chicago classification. Good to see you're disagreeing with yourself. Yes. You always have to question yourself. And then once we go through that, I have my techs do position changing. So when you move them in the upright position, I have them do another three deep breaths, just to confirm position. And then I will start looking at the upright swallows. And the key here is the upright swallows are important because when you change position, you can see that an abnormal IRP in the supine position can normalize. And if you have a normal value in either the supine or the upright, there's probably a normal LES relaxation or normal opening. If you see that persist in both the supine and upright swallows, that's where I get a little bit worried. Now that being said, as I progress through this swallow, and I'm looking at these upright swallows, eventually we will do a multiple rapid swallow. And Dr. Gawale is really the person who really made this a very popular provocative maneuver to do. Because what he showed was that if you get pretty good augmentation here, or even see a very normal-looking contraction there, that is suggesting that these people are going to do quite well with the fundoplication. So here you have someone doing multiple rapid swallows, anywhere from 2 to 5 mLs. I usually use 2 to 3 mLs of liquid. And you want them to do this every 2 to 3 seconds, not longer. And you should see beautiful inhibition of the contraction. And then on that last swallow, that beautiful stripping wave helping you remove all the bolus there. So that's the multiple rapid swallow. And then I'll do a few other maybe viscous swallows or solid swallows. But then in the end, I will do the rapid drink challenge. And I'm going to switch to the impedance here, which gives us an idea of how well that patient is actually swallowing liquid. And then in the end, after they're able to swallow it, get an idea. And this person here, you can see, although they struggled a little bit here, were able to eventually get that entire bolus out of the esophagus. So a pretty normal rapid drink challenge. You don't see a lot of pressurization here. So I would qualify this as a pretty normal study with a normal augmentation and a normal rapid drink challenge. Excellent. Let's move to some abnormal cases there. And while John is doing that, Vani, how much time does this take? And how much time do you set aside for the patient? Let's talk from the patient perspective. So in terms of the patient perspective, we actually spend a fair amount of time actually even from the get-go. As soon as they walk in, our motility technicians spend that time getting to know the patient to make them feel comfortable. And because the procedure itself is a little anxiety provoking, and it's a difficult procedure. So we actually build that relationship, talking to them, getting them ready, and using all that prep work to get them going. The procedure itself probably takes them only 20 to 30 minutes itself. But it's all the before and after care as well that we take into account. We book an hour for each motility study. That's probably standard an hour. And I think it is a difficult study. And I think it's important to not be cavalier when you're sending people for manometry. We've had people come back and tell us it was the worst experience of their life. So if you're going to ask someone to do this, there really has to be a good indication. And that goes part and parcel with a good endoscopy suggesting non-obstructive dysphagia where this is important. Now this study here that I opened up, you don't have to be a genius or a manometric genius on this one. This is obviously abnormal. And some would even say that you don't have to do all the fancy measurements in this particular instance. And I'm not going to fight people here. There's obviously no peristalsis. There's absent peristaltic sequences with pan-esophageal pressurization and an obvious obstruction. There's a very high pressure in the esophageal body here. And you can see the stomach is very low pressure. So this is a study that would be pretty consistent with type 2 achalasia or non-spastic achalasia. Someone who most likely doesn't have significant dilatation on the exam. And someone who's going to probably respond quite well to any therapy that targets the LAS here. So anything like a pneumatic dilation, a POM, or a laparoscopic hellermyotomy with door fundoplasty is going to help this person get almost immediate relief in terms of that obstruction. And obviously there is some tailoring. In our practice now, we do prefer doing a little bit shorter myotomy, a tailored shorter myotomy or a pneumatic dilation in these patients as our first line, as we discussed all day today in our course. But this is a very nice example of a pretty classic finding. So if you see that, does this patient get a barium study as well? No. In my practice- Or are you OK with just this? Yeah. I think if you've got a good endoscopy, and my mentor Peter Kourilas was never a big fan of esophagram. He always did a very good endoscopy, looked for dilatation, saliva, and if it's consistent with that. Now if this was a completely normal-looking exam on endoscopy and I was questioning this, or there was a patchless EGJ on endoscopy and then I saw this, I'd start to wonder, could there be something mechanical there maybe and want to get an esophagram? Sometimes you're surprised. You may see this shelf-like appearance on the esophagram. It looks like a type II achalasia, but really there's an infiltrating mass. So I think if you have a good endoscopy that is suggestive of achalasia, you don't have to get an esophagram on everyone. But certainly if there's anything that's discordant in your evaluation and you're questioning things, an esophagram is helpful. How about post-treatment follow-up? Do you think a baseline barium would be helpful if you had something to compare post-treatment? The patient's still a little bit symptomatic. You want to see whether they're clearing their barium in a timely fashion or not. Does that baseline help you or not really? Yeah. I mean, I think it certainly helps in research, but in clinical practice, I don't know how valuable it is. I certainly think barium esophagram is the best test to evaluate patients who are symptomatic post-treatment and also as a follow-up. That test in my practice, if someone comes in and they're having symptoms of regurgitation or dysphagia, I'm going to get an esophagram as the first-line test. It'll give me an idea of what I'm working with so I can plan what I'm going to do during the endoscopy. I rarely get a manometry as a standard follow-up for my achalasia patients. And in fact, one of the greatest things I can tell my patients now is that it is highly unlikely that you will ever need to get a manometry again because I typically use an esophagram if I'm concerned that there's an incomplete myotomy or a spastic feature there or maybe there's a bomb brewing. I will do a FLIP exam now during that endoscopy and never put my patient through a high-resolution manometry again. Okay, what's the next one, John, you're showing us? Well, I'm just going to show you the antithesis of that. And this would be something that would be absent contractility, but with, you can see a more hypotensive EGA, and this is a scleroderma patient. So here you can see, obviously, in various positions that the EGA signature here is really just the curl contraction. If you look at in between the curl contractions, you can obviously see that the lower satsal cincture is almost nonexistent. So this is the classic scleroderma esophagus. The important thing to recognize here, though, is that even in scleroderma esophagus, these patients can have bolus retention. And the reason for that is it's purely fluid dynamics and pressure gradients. Remember, the chest is a negative pressure chamber, and the stomach is a positive pressure chamber. So even if the pressure at the sphincter is zero, there is very poor gradients of flow from the chest into the stomach, and you can still see these patients have retention here. So be very careful when you're evaluating these patients, because I see a lot of these cases come in with the quandary of, is this achalasia or scleroderma? And obviously, if the patient has clinical scleroderma, it's scleroderma. It can look like achalasia, though, and you have to be careful with that. But certainly, you've got to go with what the baseline evaluation shows. John, you mentioned FLIP. Can you show us, when would you use FLIP versus high-resolution manometry? Yeah, so I think if you asked me this question five or 10 years ago, I would tell you that I use FLIP in these equivocal cases, where I wasn't sure what was going on at the esophagogastric junction. I was trying to distinguish whether this was a real EGJ outflow obstruction, and when I say real, I mean evolving into achalasia, so an early achalasia case, because you should be able to pick up a mechanical obstruction on your endoscopy if you do it carefully. But certainly, the FLIP can pick up a stricture. You see a very narrow band that doesn't move. It's very fixed in its diameter when you see a stenosis, as opposed to something more akin to an evolving achalasia. But now in my practice, I will tell you that our approach at our institution is to perform the endoscopy at the index exam for dysphagia, because it still is king, as you said. It's the fork in the road. And if that shows a non-obstructive pattern, or maybe suggests an esophageal motility disorder, we will place a FLIP balloon, inflate the balloon using a standard protocol. And in that particular case, if we see a normal pattern of RACs, which is repetitive antegrade contractions, I'm done with my motility evaluation. I'm almost certain that that patient has a normal motility, or maybe borderline ineffective esophageal motility, which will reveal that they actually have pretty decent bolus transit. So in that particular case, I shift my mindset more towards acid peptic disorder, gastroesophageal reflux disease, or potentially thinking about a functional disorder. I certainly also will get biopsies, just because I'm there to rule out EOE. But certainly the FLIP also gives us an indication of whether or not that is even a possibility. So in my practice now, during that index endoscopy, they get a FLIP. If it's normal, suggestive of pretty normal peristalsis, they don't get a manometry. If I see something that looks discordant, it looks like achalasia, then those patients, depending on what their exam looks like, if I see classic achalasia, hard LES to pass through, dilated esophagus with saliva pooling, and they have a FLIP that's consistent with nonspastic obstruction, I don't think I need to put that person through a manometry. I might get an esophagram in that case, just to make myself feel a little bit better. But that's where I'll start. So do you have another case of HRM, or can you show us how the FLIP is placed? Yeah, we can go to FLIP. And I will tell you that if you've ever placed a Bravo or any type of transoral catheter, a FLIP's pretty easy to place. It's actually very soft. And if you're ever having any trouble, you just put the scope down. You can direct it down. And really, the way you're really placing this is actually looking simultaneously at the image on the screen. And I'm going to go to our mode here, so we get a little bit better image here. So when you first place it down, before it's actually inflated or infused, I should say. I always say inflated, but it's actually being filled with liquid. What you're looking for is that narrow zone. So as you fill it, so here it's at 20, you start to see this narrow band here. And as you fill it a little bit more, then you start to see the esophagus reacting a little bit here with a little contraction. You see it waving down here. And then here you see the stomach. You see that bowing out and that narrow area here, which is the high pressure zone, which now is the low diameter zone. And as you infuse more liquid and you go up to 40, you start to see this beautiful pattern. And I say this, this is really an elegant physiologic example of what the esophagus is really supposed to do. Here you have a bolus sitting in the esophagus and the esophagus is trying to push it down into the stomach. And the beautiful thing about this is it has a beautiful rhythm that synchronizes with respiration. It's almost every other crural contraction, which makes sense because Don Costell showed us that there is a refractory period in the esophagus. The esophagus cannot contract every five seconds like the quiet respiratory rate. It needs a little time to reset. And this is a beautiful example of this housekeeping effect of these repetitive antigrade contractions. So if I see this, I'm done. We've published studies, at least two or three studies now, that have shown that if we go back and look at high resolution manometry in these patients, it's almost uniformly normal or borderline ineffective esophageal motility. And I will tell you that if you find an EGJ outflow obstruction on the manometry, when you see this pattern, the manometry is wrong. You'll get an esophagram and that esophagram will be normal and that tablet will pass into the stomach. Awani, what's your practice? Would you also do the flip on the same time, or do you usually then talk to the patients and then decide about the flip, or how do you do that? We have incorporated endoflip pretty early into our workup. So we do it on that initial endoscopy for patients with dysphagia. And I think we've been really happy with the additional information that it provides. We probably use it more complementary to motility and have not used it necessarily as the definitive branch point quite yet. But I can see how it can evolve there, but we use it routinely as complementary information. And any special instructions or stuff, it's just through the scope? Is that how you're doing it? We just place it during the endoscopic procedure. It is placed trans-orally, and you can use the scope to help guide it if you need to. OK, so one of the areas where I think there's a lot of interest in flip is after treatment of achalasia, right? Is that, was that a good enough myotomy or not? Was it a good enough PD or not that you've done? So John, walk us through a flip in that situation. What are you looking for, and how does that help guide treatment? Yeah, so another place where this is really entered into our armamentarium in terms of treatment is in pneumatic dilation. So here's an example of a patient. Right before their pneumatic dilation, they undergo a flip. And this is someone who could have come in. We get patients who obviously have achalasia on endoscopy. They can't tolerate a manometry. They have a positive barium. But people still want to know what's going on at the sphincter before they do some definitive therapy. So here's an example of a pretty classic achalasia pattern. The EGJ is just not opening. The maximal diameters here are 5, 6. You know, the DIs are less than 2. You're getting adequate pressures when you start to fill this up with a little bit more volume here later on. And you can feel very comfortable that this is achalasia. So this is what it looks like after a pneumatic dilation. So this is the same patient. And you can clearly see that the EGJ is wide open here. The high pressure zone, which is the low diameter zone, is much more effaced and thinner. And we're opening this up to around 12, 13 millimeters with less than 30 millimeters per mercury. I like to see the Schatzky diameter, 12 and 1 half, reached before 30 millimeters per mercury. And I feel like I have a pretty good response. And what's the DI you're looking for in this situation? So the DI, you know, it's interesting. Because if you look at some of the studies from the helomyotomy groups and the PONE groups, they really want to get people above 4 and 1 half, 5, to feel really comfortable. But then if you look at the data from Ian Cook's group and the Australians, they like to see a doubling of it. You know, for me, I have to say that, you know, you can see someone double and they go from, you know, a DI of 1 to 2. That's not satisfactory to me. You know, I really want to see them up in that normal range, above 3 at least. And I want to see them get a good diameter with low pressure. So this is a case that was done by my partner, Dustin Carlson. Really great effect here and did a really nice pneumatic dilation. So this person just happened to be right in the sweet spot before they're going to get GERD. OK. Thanks, John. So in the remaining couple of minutes, Vani, why don't you show us some pH tracings, which I think a lot more endoscopists are comfortable doing, placing a Bravo. And in our patients, we had a very good discussion also earlier about talking about reflux disease, persistent symptoms. And you're trying to really look for esophageal acid exposure. You've placed in a Bravo. Tell us what is it that somebody who's just getting started with this, what should they be looking for? Sure. So first, this is a Bravo tracing for someone who's been off of therapy. And we actually placed a 96-hour Bravo monitor. And we can look at this tracing and sort of see across the board. I'm looking for any evidence of pooling, or stasis, or just seeing if it's even across. And then we can take a look at the acid exposure time. What we look for is basically a cutoff of four or less for being physiologic or normal. So that would be the normal reflux episodes that we all are going to experience and that is not pathologic in nature. Four to six will be borderline or inconclusive. And then above six would be abnormal. And in this case, we see 12.7 across the study. And so that would be considered abnormal for the total acid exposure time. Another parameter that we can look for is the Demester score, which is a composite score, including acid exposure time as well as the other parameters. And that we're looking at 14.7 for our threshold, with less being normal and above that being abnormal. So Ani, your question is about doing 96 hours. Is that pretty much your standard now? I mean, we still call it 24-hour pH monitoring. Should we not be calling it that anymore? So 24-hour pH monitoring is great for that catheter that has to sit in your nose and no one's going to tolerate it for much more than 24 hours. The nice thing about the wireless capsule device is that you can place it for longer than 24 hours, with 48 hours being a reasonable option, but 96 hours being even a greater option, giving us four days' worth of data. So we can see if somebody's just getting one day positive, which is a little bit equivocal, versus three or four days positive, which is much more clinically significant. So John, out of those four days, let's say two are normal, two are abnormal. What do you do then? Yeah, you know, we just studied this and published on this, looking at the number of days being positive as a marker of being able to stop your PPI. And what we found was is that when you hit that two days positive out of the four, you pretty much are likely to require PPI therapy. Those people had a really hard time staying off their PPI, whereas the people who were zero and one day positive had a much easier time staying off the PPI. So yeah, so you know, I remember Tom Demeester said to me, when we were early on in Bravo doing 48 hours, you know, the people who were two days positive were a lot different than the people who were one day positive, and now we're seeing that even accentuated with the 96 hours. The people who are three or four days positive are typically pretty severe. The people two are definitely moderate, you know, need chronic therapy, but I agree. One day, you know, they may get away with antacids or an H2 blocker. And the zero, you know, they just don't have reflux. They can be, you know, evaluated for a functional disorder or potentially maybe even have an underlying motility disorder. And then some other complementary information we can glean for this includes the number of reflux episodes. Now this is not something you want to use by yourself to hang your hat on, but certainly in inconclusive cases it can help guide us one way or another. And so with 80 being the threshold, and in this case having 149 would be abnormal. And then the other thing is symptom index. The two parameters that we can see here would be the symptom index and the symptom association probability. And symptom index is just looking at the number of reflux episodes over the number of the total number of symptoms. And we are looking for a cutoff of 50, with greater than 50 being abnormal or concerning for symptom association. And the symptom association probability is actually a statistical score that looks at the chance or probability, so looking at that 95 percent correlation of symptom association. It is helpful to know when patients have symptom association by the symptom index and the symptom association probability to help guide sort of your next steps. But it's not necessarily something that we can always use as much as we want to. John, do you have anything to add about that? Yeah, I think certainly it's not a perfect assessment. There are some problems with it. Patients are not sitting there waiting with the sensor and going to hit the buzzer every time they have symptoms, so they miss things. So it's not perfect. But if it's positive, it gives you a little bit more comfort. So I do feel like when I see that it's positive, meaning that the symptom index is showing that there's a relationship between the symptoms and the reflux events. And then on top of that, the SAP shows you that that's not just random chance. They're not just hitting it perfectly. There's probably some relationship there. I feel like, okay, I'm barking up the right tree, I'm addressing this. And we do see some of these people who are highly sensitive, and they may be better candidates for gut-directed hypnosis, cognitive behavioral therapy, because they do have this kind of visceral hypersensitivity. So yeah, I don't hang my hat on it, but definitely like to see when it's positive. And it's negative, I don't discount that they do have reflux or are having reflux symptom relationships. Okay, team, we've hit the one-hour mark, and I think we could have gone on for another hour, I mean, talking about this. So to our audience, I hope you've enjoyed your morning, spending it with us at the IT&T Center. We've given you, in 60 minutes, a worldwide tour, quickly, of esophageal testing, again, talking about endoscopy, landmarks. We talked about high-resolution manometry, excellent demonstration of normal from abnormal, talked about FLIP. So a whole sort of slew of different investigations which are available for esophageal testing. So again, I'd like to thank all of you for joining us this morning and for your questions. We'll try to address the rest of them online at a later stage. And again, this is ASG Weekend Endoscopy Live from the IT&T Center, brought to you from Medtronic, and we will see you next time. Thank you.

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