All right, thanks to the course directors for having me here. Thanks Tom. Tom was actually one of my mentors when I was an advanced endoscopy fellow at Jefferson. And you know, he taught me a lot, even some upper endoscopy. But I'm grateful to be here, and hopefully you guys can get a little bit out of this talk. So one disclosure, Neptune Medical. So today's objectives will be understanding indications for upper endoscopy, review the basic techniques, outline components of a normal complete exam, and then we'll become familiar with some abnormal conditions that you'll see when you're doing upper endoscopy. So we'll start off with a question. Which of the following is not an appropriate indication for an upper endoscopy? All right, well, looks like you guys are doing great. You're well on your way. You're not private practice GI docs yet, right? Just kidding. No. But it's a... So as you can see, C is the correct answer. So you know, all the following other ones are appropriate indications. Anybody with dyspepsios, 65 years old, really should get an upper endoscopy. Anybody with persistent reflux, again, in an elderly male, should certainly get an upper endoscopy. Symptoms of dysphagia warrant that. Iron deficiency, anemia, and melanoma, these are sort of red flag issues where you should be doing an upper endoscopy. You know, the 25-year-old with heartburn who's on an H2 blocker, that really does not warrant an upper endoscopy. So here are your indications. Again, dyspepsia in a patient above the age of 60, new onset GERD in a patient over the age of 45 with persistent reflux symptoms besides treatment, vomiting of unknown cause, that can indicate a gastric outlet obstruction. So that's why we want to investigate that. Dysphagia and or dynaphagia are very important because they can indicate a potential malignancy, ulcers, esophagitis. So those are reasons we do an upper endoscopy for that. Again, iron deficiency, anemia is a very common one you guys will see. And again, it's typically to rule out some sort of malignancy. Any suspected upper GI bleed, esophageal varices, whether you're doing it for screening or surveillance purposes, or even someone with an active variceal bleed. Abnormal imaging, this is one that you may get just based on how good our radiologists are getting now at seeing various things. Food impaction, this is one that you will get called at 2 in the morning. That's the optimal time when this happens, but it is sort of an urgent indication for an upper endoscopy. You guys are going to get another talk about that later during the session, but look forward for that. Alarm symptoms, so these are ones that really should not wait for an upper endoscopy. This isn't someone that should wait months and months. This is someone that you really should get into your clinic or get into endoscopy sooner rather than later. So again, weight loss, dynaphagia, dysphagia, hematemesis and melanoma, that one's pretty obvious. You see those patients in the hospital. Refractory reflux and persistent vomiting. So learning to perform upper endoscopy, the ASGE typically says that doing about 130 of these is about the time that we can actually evaluate you for competency. So 130 doesn't necessarily mean that, hey, I'm done, I can graduate fellowship. It just means that really that's what you need to get pretty comfortable with what you're doing. It's really important to think about both the cognitive and the procedural aspect of what you're doing. Both the technical and cognitive skills are important, and that's why we're physicians. Again, be prepared for the needs of the case. It's important to sort of understand what you might be doing during the procedure. So for example, if you know someone has dysphagia, they may have a stricture, talk to your nurses and techs. Let them know, hey, we may be using a balloon dilator. We might be using a bougie or a savory dilator. Having things prepared really helps the case go much more smoothly, and you can kind of think about things even before you start. Practice a very deliberate, systematic approach. I think being very systematic in how you're doing things will keep you from missing things, for example. So if you are very systematic about where you look, where you take pictures, being thoughtful in that, you'll really do a nice, comprehensive exam. So again, really take the time. Look carefully. I know oftentimes we're rushed and we're trying to do many procedures, trying to finish a long list of cases, but this is really your opportunity to learn. But even moving forward, when you're out in practice, it's very important to be very meticulous in how you're doing things, as oftentimes lesions can be subtle. You know, those people who are interested in doing advanced procedures, really until you master the basic skills, you can't do the advanced procedures. So you know, there is a lot of, you know, work that should go into even mastering the simple things. Ergonomics. This is really important, and honestly, this was not around when I was a fellow, and I am not that much older than you guys. So I think it's really important to pay attention to this. It's important to be comfortable when doing endoscopy. I can't tell you how many first-year fellows I've seen as contortion artists, you know, they're trying to move the scope in one direction to really get to a certain area. And I get it. You know, you want to get there. You want to get into the bulb. You want to get into the second portion. But you have to be gentle with your body, because at the end of the day, you're going to be doing thousands of these throughout your career, and you really want to minimize the amount of tension and trauma that goes on your joints, your knees, your back. You know, really 50 to 60% of gastroenterologists have some sort of mechanical injury because of the repetitive motions of what we're doing. So when you're doing endoscopy, it really should feel comfortable. The scope is designed that way. One of the things I do in my unit also is I put a pad underneath my feet. You know, it's like a cushion, so again, it takes the pressure off your knees, your hips. That helps. The monitor should be positioned directly in front of you, and the monitor height should be just below eye level with an optimal viewing angle about 15 to 25 degrees below the horizon. And the examination table should be at or below elbow height. That's really going to kind of minimize pressure on your joints. You are going to get a talk right after this, so I won't go too much into detail, but these are just some pointers to take. This is an upper endoscopy. This is going into the hypopharynx with the tongue at the top. And here, once you get here, you're going to see this is your hypopharynx, your retinoid cartilage, your vocal fords, and your piriformis sinus here, where your upper esophageal sphincter will be. So when you're inserting the endoscope, obviously the first thing you want to do, make sure the patient's sedated, right? So the last thing you want to do is patient's awake, they're talking to you, and you're sticking the scope down. I know some of the VA patients are totally fine with that, but we really should avoid that if we can. You know, now with the way anesthesia works, in our unit we have CRNAs that work with us, and so I will always ask them, you know, do you think the patient's ready? Should we start? But if you don't have a CRNA, there are ways that you can make sure that the patient is well sedated. So taking the suction or the yank hour and going into the back of the throat to see if they have a gag reflex. If they don't, then they're probably ready, deeply sedated. You can brush their eyelids sometimes, and if they don't open their eyes or they don't move around after that, that means they're well sedated. You really want to make sure you do that before you start. For direct visualization, you want to stay midline. Always try to keep the tongue in the top half of your screen. That's going to help with your orientation. When you're examining the hypopharynx, you'll be able to see the vocal cords and the piriformis sinus as well as the cricoarytenoid cartilages here. The upper esophageal sphincter is right past the piriformis sinus. It's at the level of the thyroid cartilage, about 15 or 18 centimeters from the incisors. It's important to really take your time when you're doing this. If you're rushing and trying to go right through the upper esophageal sphincter, sometimes you might encounter patients that have a Zanker's diverticulum. For those of you who don't know that, it's a false diverticulum that looks like it's where the upper esophageal sphincter should be, but you don't want to go through that because that can actually cause a perforation. You really want to look for that small opening that is the upper esophageal sphincter. Take your time when you're doing this. Again, you want to keep the tongue on the top, big wheel back or towards you. Pops you into the hypopharynx. Again, take your time to visualize things. One of the things I always tell my fellows is you can use air here so you can visualize things and open up the upper esophageal sphincter, but don't use water. You don't want it. This is not the time to clean your lens. It's happened. It's even happened to me. Anything is possible, but at the end of the day, you really want to be thoughtful because endoscopy is going to become very easy for you at some point, but these little things are going to really prevent complications in the future. So it's important to keep that in mind. If you see this, please pull out. This is not eosinophilic esophagitis. It certainly happened again to fellows before. This is the trachea and the bronchi in case you guys were wondering. So this is advancing your scope again to piriformis sinus and then the upper esophageal sphincter. Use gentle leftward torque in the air to kind of get in and here we're going down the esophagus keeping the lumen straight and you've reached the GE junction and you can see this is sort of where the squamo-columnar junction is going to be. When you're examining the esophagus and get to the GE junction, you're looking really for that imaginary line where the esophagus ends and the stomach begins. You want to deflate the stomach, pause to carefully examine. You can find subtle lesions here. This is where you're going to look for Barrett's esophagus. Sometimes you can find subtle esophageal cancers here, GE junction cancers. You'll look for the top of the gastric folds. That's going to be where the GE junction is or palisading vessels. And you always want to take your measurements. Very important to take your measurements, either remember them or have someone write them down if that's easier for you. And it's typically measured from the bite block. So that's kind of how far you know you're in. You'll see usually between 35 to 40 centimeters from the incisors. The Z line is the visible boundary between the squamous and columnar mucosa. And again, if the Z line is well above the GE junction, that's going to indicate Barrett's esophagus. So that's why it's really important to take those measurements because it's going to give you an idea of what the pathology is. So here we're advancing past the GE junction and you can see you've now gone into the stomach and you can see the gastric folds sort of off to the left a little bit. So we have another question here. Which of the following represents the anterior wall of the stomach? All right, well, looks like most of you got the right answer, which is great. So again, the anterior wall is actually going to be off to the left. And the posterior wall is going to be the right, or the lesser curvature. So when you get your scope into the stomach initially, you may require a little bit of a slight leftward torque. And the first picture gives you a depiction of what the scope actually looks like. And the one on the right shows you the image that you're going to get. When you're examining the patient, remember, they're always on their left side. What that means is that fluid is actually going to accumulate into the fundus. So the first thing I do is I actually aspirate all the fluid in the fundus. Because if they're coughing, if they're retching, they can very easily aspirate some of that fluid. So you really want to do that before you even begin your stomach examination. Once you remove it, you want to really avoid suction artifacts. That means that if you're suctioning, really stay nicely above the pool of fluid that you see. You don't want to be within it. Because if you suction mucosa, you're going to get sort of a suction mark on it. And now you're not going to know, is this pathology, or is this from suction per se? So really try to stay above that fluid pool. You want to avoid insufflation. Obviously, we want to be able to see. But if you distend too much, again, it may induce retching. It may induce belching. So just be mindful of that. And once you've seen the body of the stomach, you want to head for the pylorus. So this is the view that you're going to get when you're heading towards the pylorus. You can see the lesser curvature is sort of near the top of your screen. You're going to bear right and follow the folds. And that's what's going to take you to the pylorus. You can see as we're pushing in here, we're actually going to be creating a loop in the stomach to get to the pylorus. The scope can be steered simply by changing the hand and the shoulder position. And this is something that's really going to help you when you're learning upper endoscopy, as opposed to colonoscopy. You don't have to use your right hand so much for torque to move left and right. Because the EGD scope is much shorter in length, moving your left hand left and right and towards your shoulder is really going to be able to steer you right and left. And that allows your right hand to be free for any kind of therapeutics that you want to do. So if you want to take a biopsy or you're controlling bleeding, by being able to use your left hand going right and left, you'll have a lot more freedom with your right hand. It'll make endoscopy a lot smoother. So really practice this as you're going through the stomach. This is the view of the pylorus once you've advanced there. And again, you're going to apply steady pressure to get through that gastric loop to pop in through the pylorus into the duodenal bulb. And here you can see you're taking a nice sort of four quadrant view of the duodenal bulb as you're popping in. Again, once you see the duodenal bulb, you want to examine all four quadrants. So do a 360 motion to look at it. The anterior side is going to be the left. The posterior will be the right. When you're examining the duodenum, examine the bulb completely first. And then you're going to keep the scope slightly to the left to prevent going into the second portion of the duodenum. And then as you're trying to get into the second portion, you will move slightly right and advance to the apex of the bulb. I think this is a video here. No. All right. When you're examining the duodenum, the descending duodenum is also known as a second portion of the duodenum. From the apex, it's actually a corkscrew maneuver. So you will turn right, little wheel to the right or knob forward, and then big wheel back or towards you. And those three maneuvers all in conjunction are going to pop you into the second portion of the duodenum. And sort of as you withdraw, it will help you get around that sweep. When you're looking at the descending duodenum, you'll be able to see the valvula, which are the circular rings. You may even see the ampulla in the 9 to 11 o'clock position. Important not to biopsy that. You can cause pancreatitis. So unless you're doing it for a particular reason, you want to avoid biopsying it. And then, again, you're going to get paradoxical motion as you withdraw. So what that means is once you pop into the second portion and you pull back, your scope will actually move forward. And the reason is you form that loop in your stomach, and now you're pulling that loop out. And as you pull that loop out, it actually propels your scope forward. So you may even get to the end of D2 or even D3 by doing that. Just remember the duodenum can be a tricky place. It's easy to fall out of the duodenum. So just be patient. Go back in again. You can go multiple times. It's OK. That's completely normal. Here again, we're going into the apex. We're going to move the little wheel to the right, big wheel back. And then we're going to start pulling back. And you can see, as we start pulling back, we actually slipped back into the duodenal bulb. So this can happen. And this happens if you don't keep enough really rightward rotation of the scope. You know, the more left you move as you're pulling out, the easier it is to actually fall out of the sweep. So you want to make sure you maintain that rightward position as you're pulling back. Again, you can see here, this is what the major papilla would look like. If you saw it, it might be at 9 to 11 o'clock. This is what retroflexion looks like. So remember, this is where the scope is actually looking completely back on itself. And the reason we do this is when you go in the forward view, you're not going to get the complete view of the cardia of the stomach as well as the fundus. So being able to retroflex will give you that complete view. The other reason we also do a retroflexion is to really look at the incisora. Oftentimes you will see ulcers in this location. So again, be systematic in the way that you're doing. You're going to be looking at a lot of parts of the stomach. Just develop your own system as to, I'm going to do these steps as I go along so you don't miss anything. Again, during retroflexion, both knobs are towards you. So that's big wheel back, little wheel to the left. And then you're going to pull the scope, which is going to get you to the cardia and the fundus. This is a little bit of slides on when and where to biopsy, depending on what you're looking for. So if you see a suspicious gastric ulcer, again, we may be worried about malignancy in that standpoint. And so it's important to take at least 8 to 10 good pieces to ensure that you have adequate samples for your pathologist. If you suspect candida, these are sort of white plaques that you might see throughout the esophagus. You can need to do brushings or biopsies to get the diagnosis. For patients that are either immunocompromised or may have AIDS, HIV, you may be thinking about ulcers that have CMV or HSV esophagitis. If you're suspecting CMV, you want a biopsy at the ulcer base. The way I sort of remember that is C is for center. So that's really where you're going to get your diagnosis. HSV is actually the opposite. It's on the ulcer margin. H. pylori. Our guidelines typically recommend taking at least 5 biopsies from the antrum and body. So I typically take 2 from the antrum, 1 from the incisora, and 2 from the body. And that gives you a good representation. And for celiac disease, again, all of our studies show that really we need to be taking 6 biopsies, typically 4 from the second or third portion, and 2 from the bulb. Because sometimes celiac can be confined to just the bulb. And so that's why we have to take all those biopsies. One of the most important things I will say is it's important to give a history in the pathology specimens that you're sending. The pathologists rely on that. So if you just say gastric biopsy, they are not going to have the context they need to look for the things that you're looking for. So make sure you give them an idea of what it is that you think might be going on. And that will help your pathologist as well. It's a very multidisciplinary approach and definitely one of the things I like about GI. For procedure completion, again, you're going to deflate the stomach. You want to take all the air out. And again, withdraw slowly. So once you've completed the exam, it's important not to just zip the scope out. You really want to take a look at the esophagus as you're coming back. You're going to pick up subtle things like strictures, webs, inlet patches. Now those are benign, but you still may pick them up. So it's important to kind of be patient. Again, just to recap for esophageal intubation, again, be patient, be deliberate. Remember to keep the tongue on top. Be very, very patient in the piriformis sinus. Sometimes it's difficult to get through that upper esophageal sphincter. But again, maintain gentle pressure, a little bit of air, and leftward torque to kind of get you through. And again, no forceful pushing. So if you feel resistance, and this is really for any endoscopy, whether it's colonoscopy, upper endoscopy, if you feel a lot of resistance, you should not push through. Because that's when complications can happen. That's when difficult things can happen. And that's why you have your attendings here, to really kind of give you a sense of is this too much pressure or not. So just be mindful of that. For the esophageal examination, keep the lumen in view. Make sure to pause at the G-junction, and again, don't rush on your exit. For the stomach, again, the first thing you should do is suction the fluid that's in the fundus, minimize inflation. To get to the pylorus, you're going to head right. And again, a little bit more patience and pressure at the pylorus. For withdrawal, you'll fully insufflate. Be systematic, and do your retroflexion in the duodenum. Make sure you look at the complete bulb, and use the corkscrew maneuver to get into the second portion of the duodenum. I think these sort of points have been iterated multiple and multiple times. At the end of the day, it's easy to get disheartened, especially in the beginning, and say, hey, we can't do this, I'm not getting into the esophagus, I'm not getting into the pylorus. I can guarantee you guys will all get there, and everyone gets there on their own path. So just practice, and you'll definitely be able to do it. Thank you.

upper endoscopy

indications

techniques

considerations

competency

biopsy