Good afternoon. My name is John Martin. I'm from Mayo Clinic in Minnesota, and not only is it a pleasure and a privilege to be here and to have your attention for the next hour or so, but I always want to share with you that being able to have an invitation to the faculty of the First-Year Fellows course is a great gift to us because we all totally envy where you are in your career right now. We love seeing your enthusiasm. All this stuff is new. You're bright-eyed and bushy-tailed, and you can't wait to learn more. And for those of us that have been doing this a long time, we have great memories of that time and have not forgotten what that feels like, but in the day-to-day performance of what we do, you have no idea how much it means to have that feeling of rejuvenation with the refreshment of actually witnessing what it's like to learn these things and do some of these things for the first time. So I and many of us consider this to be the most important course of every year. I've taught this course just about every year since its inception, and it holds tremendous importance in my heart. So you'll never forget this course the rest of your career, and I think and hope that you not only understand the value of the education that you're receiving, but also the value of collegiality. Maybe this is the first time you've been at a meeting with colleagues at the same point in training in your chosen specialty. That is one of the best things about being a specialist physician, is going to meetings where you have peers from other practices and other institutions, and you not only exchange ideas, but you get to know each other as individuals, and some of you that meet at this meeting are going to be in touch for the rest of your career or the rest of your lives. Some of you may end up being colleagues at the same institution, maybe not in your first job or maybe even 20 years from now. All kinds of things happen, and it all starts right here. So thank you for letting us be a part of that. Congratulations on where you're at, and know that we envy you. So here we go. We're going to talk about upper endoscopy pathology and terminology, and we're going to start with the terminology part, and I'll tell you why in a second. So just to disclose that I have no financial relationships to disclose. So the reason why we start with terminology and documentation is that you know that you're doing the best job you know how when you do your procedure. That is kind of silly, right? And the patient assumes that you're doing the best job you know how, and the person who referred the doctor or APP that referred the patient to you probably thinks you're a great endoscopist too, or they wouldn't have sent you the patient. But once you're done with the procedure, they haven't seen you do the procedure. They've heard about your reputation, but they're not in the room watching you, and you might have time to talk to the patient or the patient's family, but maybe they forget about the details because they were still waking up from their sedation or whatever. And these days, where does the patient then go? They go to the patient portal, and they read your report. And the person who referred you to the patient reads your report. And the lawyer who deposes you reads your report. And the biller and coder who has to try to get the insurance company to pay your employer fairly for the work that you just did and the liability you just assumed reads your report. So at the end of the day, or at least at the end of the procedure, your representative is that. And so this is what you look like after the procedure to the referring provider, to your patient, to the biller and coder, and to the malpractice attorney. You don't want it to look like that. You're an excellent endoscopist. You want an excellent note that reflects your excellent work. And we're going to talk about what you need to do to make sure that that happens every time. Patient name, Mr. Bleeding, endoscopist, doctor, first-year fellow. Not you, because you'd never write a note like this, God forbid. Indication for examination, hematemesis, procedure performed EGD with control of bleeding. And the findings. And in the findings, you're supposed to describe morphologically what you actually saw with your eyes through the scope. Some gastritis, gastritis, itis is inflammation. Can you really see inflammatory cells with a scope? Gastritis in the stomach and a bleeding ulcer. We injected epinephrine and cauterized. How much? What dilution? Cauterized with what? At what power for how long? None of that's there, right? So the endoscopic diagnosis, cut and pasted from the findings. That ain't right. Look at this, because this is Dr. Senior attending, whoever she is. And the indications for examination, hematemesis is the same, of course. And the procedure is EGD with control of bleeding. Findings. OK. So an EGD is called an esophagogastroduodenoscopy because you're evaluating three separate organs, esophagus, stomach, and duodenum. If you're looking, you know, hand, arm, shoulder. If you're looking at three different organs, describe it as three different organs. OK. The first organ, the most proximal is the esophagus, normal mucosa, normal Z line, which is the squamo-columnar junction, at 40 centimeters from the incisor teeth. The stomach, moderate diffuse erythema, right? That's a good description of what the endoscopist is seeing. She's telling you she sees moderate, not severe, not mild, but moderate. How much? Diffuse all over the place. Not patchy erythema. It looks red. In the where? The whole stomach? Nope. Just the gastric body and the antrum. Not the cardia. Not the fundus. The body and the antrum. Specifically, there was a 20-millimeter round gastric ulcer along the lesser curvature in the gastric body. It's exactly where it was. You can visualize that. The ulcer was covered with an adherent clot. The clot was removed with lavage, and that was successful, after which you could see an oozing vessel in the center of the ulcer. The vessel was treated first with injection of 6 milliliters of 1 in 10,000 dilution epinephrine, and then a gold probe, a bipolar coagulation probe, was applied for durable hemostasis. And then, not to forget that third organ you're evaluating, because this isn't an EG, it's an EGD, normal duodenal mucosa to the second portion. So the impression or the diagnosis is diffuse non-erosive gastritis. You could argue whether you want to use a histological term like gastritis if you don't have a biopsy with microscopic examination to prove that, but I guess I'll accept it here. You're not including it as a finding, right? Gastric ulcer with adherent clot endotherapy was performed with clot removal, epinephrine injection, and gold probe with successful hemostasis. You should probably say bipolar probe because gold probe is a trademark of a particular vendor. So the point is to be morphologically descriptive rather than overly diagnostic in the description, to describe all three organs if you're evaluating three organs, and to be detailed in one's description, which should be precise and accurate, yet concise, particularly the impression. Much as with a clinic note where you have an assessment and plan, with limited time, the referring's probably going to go to the assessment and plan of your clinic note first, and in analogy, they're going to go to your impression and recommendation on an endoscopy report, and if they need to, will read and slog through the descriptive part, which should be precise, accurate, and complete. Questions before I move on from this? I don't want to belabor it, but if you take one thing away from this part of the lecture, please remember that after the fire, after the procedure is over, that document right there is your representative to your patient who reads it on the portal, to the referring provider, to the billers and coders who get you properly paid, and to the insurance company who wants to try to deny your claim, and to any people in the legal profession who may be questioning you. Okay. Great. Now, we're going to go on to some Q&A, and we're going to get away from the documentation, but let's talk about being properly descriptive and diagnostic. How should the endoscopic findings in this image be described in a procedure report? Look at this picture carefully, because it's going to disappear when you start to enter your answers, so you're going to key in your answers, and it's going to be either A, portal hypertensive gastropathy, B, gastritis, C, pachypunctate erythema in the gastric fundus, or D, Cameron's ulcer. And when this picture disappears, you'll be able to enter your answer now. Portal hypertensive gastropathy, gastritis, pachypunctate erythema, Cameron's ulcer, and of course, you're all brilliant, so you all got this right. And of course, you want to be descriptive, which usually means when given a choice, it's going to be the longest answer, right? Yeah. Okay. Very good. And it is indeed pachy, because, I mean, you don't see it here. You don't see it here. So it's not all over the place. It is pachy. It's punctate, because there are spots of erythema. And it is in the gastric fundus, because what position is this scope in? Yeah, it's in retroflexion, because you can see the scope. It can see itself. So it must be j-hooked back looking at itself. In fact, enough so that what is this line that I'm drawing here? It's the squamo-columnar junction, right? So it's the z-line. This is columnar gastric mucosa. This white stuff, this pale stuff, is the squamous mucosa of the esophagus. So that's the z-line. Good job. This is the fundic arch, or the fundus up here. Okay. How should the endoscopic findings in this image be described in a procedure report? Is it A, linear erythema in the antrum? Is it B, gastritis? C, gave, which is gastric anterovascular actasia? Or is it D, portal hypertensive gastropathy? And we're talking about the findings part of the procedure report, not your clinical impression. Okay? Which one is it? A, B, C, or D? Imprint those pictures in your brain and tell me what you think of those four that you see listed there. Okay. We're getting close to totals being in. So you're right. Linear erythema in the antrum. You want to be morphologically descriptive. Very good. Now what's your clinical impression here? Yeah, it's probably gave. This is the pylorus, so this must be the antrum. And you see red stripes there, gastric anterovascular actasia, ectatic mucosal blood vessels, right? Okay. How about this one? How would you describe this? A, punctate erythema with scattered gastric erosions, visible oozing and fresh blood? Or is it B, gastritis? C, gave? Or D, NSAID-related gastropathy? Which one of those is that? You are speedy, almost all the results in, and of course it is. It's the longest one, again, because it's most descriptive, right? You want to be morphologically descriptive. What is this, actually, from a clinical impression standpoint? I mean, you're just guessing here. We're allowed to be wrong, because we're not taking biopsy of it, right? Yeah, I guess it probably is gastropathy from NSAIDs, right? This looks like it's the antrum, and it frequently looks like this. I don't know that I'd call this fresh blood. I think it's hematin, actually, right? The fresh blood's already been converted, the oozing blood's been converted to hematin. You can see little erosions here and there. This isn't high definition, so you can't really see it, but I think that's definitely an erosion there. Okay, so it probably is NSAID-related gastropathy. And you could list that in your differential diagnosis of the potentials in your impression. But when you're trying to describe what you're seeing with your eye through the scope, it would be A. All right, which one of these is an erosion? A or B? Look at it again. A or B, which is an erosion? Boy, that's frenetic. So this is the erosion. What is the characteristic that defines what's an erosion versus an ulcer? That's right. So it's depth, right? It's depth. Which one is shallower, an erosion or an ulcer? Yeah, the erosion is the shallower one. Now, people could argue and say, well, I would call this a shallow ulcer rather than a deeper erosion. So there's some gray area there, right? It is subjective to some extent. I don't think anybody's going to argue that here, where I'm seeing the muscularis, nobody's going to call that an erosion. But somebody might take this erosion and say, well, that's a shallow ulcer. All right, I'll buy that. So my point is that it is subjective, sort of where the two are close. But some are obviously ulcers. And nobody would argue that it's an erosion. It's an ulcer. But there is a definition, and this slide underscores that, that they are both mucosal disruptions or breaks in the mucosa. But histologically speaking, an erosion may reach but not penetrate the muscularis mucosa. Whereas if it breaches the muscularis mucosa and penetrates more deeply than the muscularis mucosa, which is to say that it is either submucosa deep or actually drilled down to the muscularis propria, then that's an ulcer. Now, you're not doing a full thickness biopsy with your diagnostic endoscopy, at least not on purpose. So you're not going to see this. You can't see that. So you have to use your eye and your brain and take your best guess based on what you're seeing. And if it's deep, if it has perceptible depth to it, you're probably dealing with an ulcer. If it looks pretty shallow, it's an erosion. And that's pretty much what your note's going to say. Because when you write your endoscopy report, it's not going to include this view. You have to do it based on what you're seeing with the scope. OK? Moving on. Identify the finding that you see in this picture. Is this Barrett's esophagus, A? Los Angeles grade B esophagitis, B? Gastric heterotopia, C? Or inlet patch, D? What are you seeing here? We can talk about that after you take a good guess. Okay, I'm glad there's some discordance in the results because that gives us something to talk about. Most of you, or close to half of you, thought that this was Barrett's esophagus. And I'm going to suggest to you that, in fact, it is Barrett's esophagus. And the reason why I know that is this is the top of the gastric rugal folds, which represents the gastroesophageal or esophagogastric junction. And the Z line, or squamo-columnar junction, is displaced proximally to the line that I'm tracing here. So the Z line no longer coexists at the location of the proximal limit of the gastric rugal folds. That proximal displacement of the squamo-columnar junction, where it's no longer at the esophagogastric junction, represents metaplastic columnar epithelium, which is to say that it is probably Barrett's esophagus. However, being able to absolutely say that it is truly Barrett's metaplasia requires biopsying, looking under a microscope, and demonstrating that that columnar metaplasia is specifically of the specialized intestinal type of conversion of squamous to columnar. Does that make sense? So if you do this report, you're going to describe it morphologically and in your impression say possible Barrett's or probable Barrett's esophagus. If the biopsies come back demonstrating intestinal metaplasia, then it is Barrett's. If it shows gastric metaplasia, is it Barrett's? No, it's not. It needs to be intestinal. So it is the pathologist who definitively determines that it's Barrett's, not the endoscopist. And I want to make that clear. Are there any questions about that? Yes. Does the Z line have to be a certain number of centimeters above the junction to count as endoscopically Barrett's esophagus? It doesn't. If it doesn't coincide, then it is an abnormal Z line. And if it's an abnormal Z line, you may well biopsy that to determine whether there is columnar mucosal change there. And the pathologist will tell you what kind. Does that make sense? Yes. But you cannot call it Barrett's short or long segment, any kind of Barrett's, until there is a biopsy definitively demonstrating intestinal metaplastic change. That's a great question. Other questions? OK. Let's delve into a bit of detail here. So Barrett's is an acquired condition that's characterized by replacement of the normal squamous esophageal epithelium. That turns into a metaplastic columnar epithelium that is specifically of the intestinal type, presumably because chronic acid reflux onto squamous mucosa, which, as you know, doesn't secrete mucus to protect itself because it doesn't have goblet cells, will then undergo a cellular change to become metaplastic columnar epithelium so that it has goblet cells to secrete mucus to protect itself from acid injury. But with that cell change going on, there are opportunities for mutation. And that is the importance of Barrett's change, is that it is associated with an increased longitudinal risk of conversion to what kind of esophageal cancer? Adenocarcinoma. Not squamous cell carcinoma of the esophagus, which is a different disease, but higher risk over time of malignant degeneration to esophageal adenocarcinoma. We identify columnar metaplasia. Say that again. We identify the presence of columnar metaplasia by noting that the esophagogastric junction or gastroesophageal junction, however you want to say it, which is demarcated by the proximal limit of the gastric rugal folds and the, if visible, pinch or contraction of the lower esophageal sphincter, and the squamo-columnar junction, which is the Z-line. If the Z-line does not meet the esophagogastric junction as defined by the proximal limit of the gastric rugal folds and or the lower esophageal sphincter pinch, and instead that columnar-looking mucosa and the Z-line associated with the end of it has migrated proximally from that location I just described. That defines columnar metaplasia of the distal esophagus. However, you cannot call it Barrett's specifically until examined histologically and demonstrated to be specialized intestinal epithelium. There, I just gave you a pearl for a board question, and that's a very legitimate and definitely a board question. But that's not the most important reason to learn it, of course. Name the classification scheme that's used to describe Barrett's esophagus. Is it Paris, Kudo, Los Angeles, or Prague? Which city is it? And before I go to the result, does anybody have any question about what I just said? Yes, sir, in the back. Can you say that louder? Yeah. Do any of your calculations change if it's a sliding hiatal hernia? We're going to talk about that in a second. You're smarter than the slide deck. Yes, sir. You call it exactly what you just said. Okay. It ain't Barrett's. It doesn't qualify. Very good. It's the Prague classification. It is the beautiful Czech city of Prague because that's where that system was devised was an international meeting that happened to be held in Prague, which is how most of these city names for these classification schemes come about. Right. So, the Prague classification depends on your properly identifying the esophagogastric junction, which again is defined as the top of the gastric rugal folds, which should coincide with the LES contraction or pinch, which is not the same thing as the impression of the crura of the diaphragm, also called the diaphragmatic pinch. I usually call it what it is anatomically, which is a diaphragmatic crural impression, and the Z line. Those are all different things, and I want you to make sure you have that straight. This, white to pink, is the Z line. This is where the white squamous epithelial tissue ends, and the pinker columnar mucosa of the stomach begins. And normally, that coincides with the top of the gastric rugal folds because that's where the stomach ends, and you should see that that is where the LES pinch is, and it so happens to be that the diaphragmatic crura are impressing upon the esophagogastric junction at the very same location where the LES is contracting in that picture. That is normal, okay? With the Prague classification, you are measuring, from what I just told you was the anatomical, not mucosal, anatomical esophagogastric junction up to the maximum extent at which the Barrett's, presumably Barrett's, metastatic or metaplastic change is fully circumferential. That's the C part of the C and M Prague classification, that measurement. And the M, or maximal extent, is measuring from the esophagogastric junction up to the highest tongue of metaplastic columnar change that you see. Now, the M is not the length of the tongue above the circumference. Don't make that mistake. This isn't C2M2. It's C2M4. So it's the circumferential extent of the change and the maximal extent of the change. Does that make sense? So it's the C2 plus the tongue two that makes it M4, okay? There isn't a T measurement. I'm just telling you, don't misreport the M part by just giving the measurement of how far above the circumferential extent the tongue goes. Is that clear? Okay. None of this has anything to do with a hiatal hernia, which has nothing to do specifically with Barrett's, okay? So this is circumferential Barrett's to here, and this is the maximal extent of the Barrett's tongue, which is reported as M, okay? What's the C and M here? What are these things in this cartoon? They're Barrett's islands. What's the C and M value? How are you gonna report this out in the C and M classification system? The same way you did the last one. The islands, it's not that the islands aren't important. The Prague classification doesn't account for them. That's the point, okay? So this doesn't suddenly become, you know, C1M, you know, like six or whatever. No, it's M3. You report the islands out in the text of your report. It's not part of the C and M classification. Don't ignore them. You need to say that you saw them, and you can biopsy them, but they don't get reported out into, they don't get calculated out into the C and M length. Does that make sense? So if there were an island up here, up here, it's not gonna become M8. It's still M7, okay? And then you're gonna talk about the island separately. If there is a hiatal hernia, you will see stomach pooching up above the diaphragmatic crural impression. So you'll see the diaphragmatic pinch here. You'll see rugal folds extending up above that. And that is the part of the stomach that has herniated through the diaphragmatic hiatus into the chest. And from that diaphragmatic crural impression, measuring from there to the top of the gastric rugal folds, which will coincide with the LES contractile spot, that is the axial length of your hiatal hernia. Does that make sense? Barrett's is not measured from down here. It's measured, like I told you, from the top of the gastric rugal folds to the circumferential proximal extent and the maximal proximal extent, excluding any islands, which you would report out separately. Questions before I move on? Gentleman in the corner, that was what you were talking about. Did I answer your question? Yep, thank you. Thank you. Okay, identify the diaphragmatic pinch or diaphragmatic crural impression. Is it A, which is right here? Is it B, which is right here? Or is it C, which is right there? Which one is it? Where's the diaphragmatic pinch in that picture? You guys are really good. I gotta teach you something you don't know. All right. So yeah, this is where the diaphragmatic crural impression is and you can see that there is some stomach extending above the diaphragm, herniating above the diaphragm into the chest and that's a hiatal hernia. Right there. Here's the top of the gastric folds. We were talking about that. What's the scope position? Retroflexed. What is this circle right here? Diaphragmatic. Diaphragm, excellent. And what is this pink tissue upstream from the diaphragm? Stomach. Hiatal hernia. What is this line of demarcation between the whiter stuff upstream and the pinker stuff downstream? Z line, right? That's the Z line right there seen in retroflex. And the white tissue is what kind of tissue? Squamous. Nailing it, okay? What are you looking at here endoscopically in forward view? Where's the diaphragm? Probably right here. What kind of tissue is this? Stomach. You see the gastric rugal folds extending above the diaphragm? That's a hiatal hernia. And what is this line right here? Z line, right. And it actually does meet the gastric rugal folds up here. You just can't see it. And if you sucked some of the air out, you shouldn't be at full distention when you're looking for gastric rugal folds because they'll flatten out. So if you're wondering if this is Barrett's or not, suck some of that air out and I'll bet you this will pucker and that fold will go right up to here and meet the Z line. It's probably not Barrett's. Now you could use NBI and that'll help you identify whether it's Barrett's or not. Of course, it'll really only identify whether or not it's metaplastic columnar mucosa. You have to biopsy and send it to the pathologist to see if it's intestinal type. And if it is, then you can finally say it's Barrett's. Okay. This graphic, I'm not gonna go through it blow by blow because you have it and it demonstrates everything we just talked about 10 times. I wanna nail this in to your brain. This isn't Barrett's. This is an inlet patch. Okay. This is in the proximal esophagus and it's pink and it's columnar. And if you biopsy it, what organ's mucosa would it look like? Stomach. So this is like in embryology, instead of the entire esophagus turning squamous like it's supposed to, it stays columnar and it is gastric heterotopia or heterotopic gastric mucosa. It does secrete acid. So while it's usually asymptomatic in some individuals, it can cause GERD type symptoms, cough and stuff like that because it's usually in the proximal esophagus. It could cause esophagitis. It can cause scarring, webs, rings, strictures, TE fistulas and stuff like that supposedly, although I've never seen it do that. But it does secrete acid. So if it were causing acid secretion related symptoms, what would you do to treat? Some kind of acid suppression, right? PPI or HT receptor antagonist or something of that sort. What's NBI? Narrow Band Imaging. It's like sticking a filter over a lens of your scope or the light source, either way. And instead of white light, which combines the full electromagnetic spectrum of visible light, you're filtering out and using shorter wavelength light, i.e. blue and green. And I'm gonna give you this one. The answer is usually all of the above, and it is. And it can help you identify these things better because it gives you simply a different view, okay? And the way that it gives you a different view of all kinds of things, including polyps, sparrits, dysplasia and IBD and gastric malignancies is that the blue and green light enhance your ability to visualize small mucosal and submucosal blood vessels, capillaries and submucosal veins, okay? That's what appears dark with blue-green light, which is called NBI. That's just, NBI is just a trade name for one scope manufacturer. So this is barrets with white light, and this is barrets as seen with NBI. And you need both. You toggle back and forth, switch it on, switch it off. Helps you to see in a different way. May be better. NBI enhances visualization of which of these structures. I just told you. Is it A, muscularis mucosa, B, mucosal capillaries, C, adipose tissue, or D, submucosal glands? Please, please, please get this right. I didn't tell you it was submucosal glands. I told you it was submucosal veins. All right, so it's mucosal capillaries and submucosal veins, okay, and this is a cartoon that you already have, so I won't go through it blow by blow. Blue light is shorter in wavelength than green, so it doesn't go as deep, but shows you the capillaries on the surface dark, and it's absorbed by the veins in the submucosa, the green is, and demonstrates that as blue. What you're seeing in NBI that's dark in these lesions is the superficial capillaries, and as you can see, as the dysplasia gets worse, you get more and more disorganization of the anatomy of the blood vessels, and that's what you're actually seeing with NBI, okay. Now what's this? With this particular condition that you're seeing in this picture, which classification scheme would you use, Paris, KUDO, Los Angeles, or Prague? First ask yourself what this disease is, and then which of these classification schemes goes with it. All right, L.A. grade classification, because what is that disease that you were just looking at? Yeah, it's esophagitis, right? What's this whitish-looking thing right here? Is it an ulcer or an erosion? Okay, that's the point, right? Some might call it an erosion, because it's kind of a deeper erosion, others might say it's a shallow ulcer, and that's okay, either is okay. It's a breach of the mucosa, right? It's mucosal denudation of whatever depth. What L.A. grade is this, if you know the L.A. grade? If you don't, that's okay. Take a wild guess. Let me know what you think. Is it Los Angeles A, B, C, or D? You don't really have to memorize this stuff, right? You can look it up on your phone or on your workstation or whatever. It's a beautiful thing these days. You don't have to memorize stuff like we used to have to do. Okay, so this is L.A. B, and I'll tell you why in a second. So here is an erosion on one fold. Here's an erosion on another fold. Imprint that picture in your mind, and with L.A. grade A, you have one or more mucosal breaks, but they can't be more than five millimeters. Well, that's more than five millimeters, so it ain't A. Is it B? One or more breaks that are more than five millimeters long, we just decided that they are that, but they don't extend between the tops of two mucosal folds, so this doesn't creep over to this one, which in this picture, they don't creep. They don't connect to each other, but they're more than five, so that makes it B. If it were C, do you see how this becomes confluent between folds? That makes it C, and if that involves more than 75% of the esophageal circumference, it's D. Don't memorize it. Just search it on your phone, okay? After a while, if you see it all the time, it'll just be memorized, but you don't have to memorize it. What's the correct endoscopic description of this finding? Are these large varices, small varices, grades one, two, or three? Which one is it? How big do they have to be to be large? Somebody said it. Five millimeters is the dividing line, okay? All right, good job. They're small varices. Now, those of you who said grade one or two, you could be right. If I were scoping and these are small and they flatten, that would be grade one. We tend not to use the one, two, three classification anymore, but we go with small and large. That's preferred. Of course, what's really preferred is what you're attending wants you to write, but just doing away with that, just know that we're largely doing away with the numbered one, and we're going with small and large, and five millimeters is the demarcation point between them, okay? That's basically what this is telling you, and also reminding you that if you see any red findings, those are stigmata that increase the risk of bleeding, and so those should be reported out as well, like these things. If they're red lines, they look like whip marks, and that's why they're called red whale, right? Whereas if they're spots, they tend to be round. What are these things? I think they're vasovasora are what they are of these varicose veins. I think that's what these red markings are, but they are known to be associated with a greater risk of bleeding and re-bleeding, okay? Yes? Is there a way to just look in your endoscope without using devices that measure width to kind of guess what your five millimeter length is, or without having to measure from Z-line? You just look at it, and you go, that's about five for me. If you're not using fluoroscopy, not really, because you don't have anything down there that's a known static thing that's already measured, so you have to put a device down there that you know the diameter of. The most common thing is a closed forcep, which is about two and a half millimeters, an adult one. Yeah. So no, you have to throw something down there. There really isn't something that's a known, just with the scope alone. Now, there's one caveat to that, which is if you retroflex the scope and look back at the scope, you know what the diameter of that scope is. So if you have a nine millimeter diameter scope, and you retroflex, and you have the insertion to the scope up against or right near whatever you're measuring, whatever you're measuring as a ratio or proportion of the diameter of that scope you're looking at could be a constant. Does that help? Does everybody understand what I'm just describing here? So this, if this were a diagnostic gastroscope, this distance from here to here, if it's high def, it's 9.4 millimeters. It's almost a centimeter. So if somebody asked me, how big is this gastric varix? Well, it's bigger than nine millimeters, right? It's probably about 12 or 13, something like that. That's a static. That's a comparative. If it's something smaller, stick a forcep down there. It's two and a half, give or take, when closed. This is a gastric varix, a scope looking back at it, okay? And they are graded as gastroesophageal, spelled with an O, varices one, gastroesophageal varices type two along the fundus here, intragastric varices that do not cross the esophagogastric junction. Type one is up here in the fundus, and type two down in the antrum. What is this lesion right here? It looks like a cut at the EG junction. What is that? Is that a Cameron? Is it esophagitis? Is it a Mallory-Weiss tear, or is that peptic ulcer disease? Right, so you know what it is. It's a Mallory-Weiss tear, which is a traumatic injury sustained by usually the gastric mucosa, but it can extend up into esophageal as well, from some kind of violent valsalva, whether it's vomiting or coughing, that is putting diaphragmatic muscular stress on the EG junction, resulting in a disruption of the mucosa, which can then bleed. Love that cartoon. It's so exaggerative. We already described what it is. Identify this lesion right here. This scopes in retroflexion, obviously. Is it a Cameron lesion or Cameron ulcer? Is it a Mallory-Weiss tear? Does it look like what you just saw? Is it an anastomotic ulcer? Do you really see an anastomosis there? Or is it a malignant ulcer? How would you know that just from looking? What is it? All right, great job. It is, in fact, a Cameron ulcer. And the point of this is that while most Cameron ulcers, as classically described, are these mucosal disruptions that you find in a hiatal hernia sac, usually larger ones where the stomach is going back and forth across the diaphragm, herniating thousands of times a day or whatever, that causes basically traumatic ischemic injury. It's like a decubitus ulcer, basically, on the other side, right? They're classically described as being linear, but they don't have to be. I just saw one of these with my colleague, Lillian Wang, who was sitting next to me over here. She and I were scoping together a couple days ago, and we just saw a Cameron. And it was round. And we were like, yeah, see, there's a round one. You don't see that every day. But we did biopsy it because we do want to exclude a malignancy, but it probably isn't that. So it's an ulcer or an erosion in a hiatal hernia sac. And these are primarily of clinical importance because they most often present with what? Iron deficiency anemia. Some people with big hiatal hernias with a bunch of these synchronicity will even get a diaphragmatic crural repair to correct that hiatal hernia so that they don't have to get 100 units of blood a year to make up for it. Paris classification. Do you use that for colon polyps, superficial gastric lesions, superficial esophageal lesions, or all of the above? What did I tell you about all of the above? Right. All of the above. You don't have to memorize this either. And I think this is more controversial than some of the other classification schemes that I have talked to you about. But know that it exists. And I did tell you earlier that this is any part in the GI tract. But you tend to see more of these lesions in the colon as a proportion of all of your endoscopy. So you tend to think of this as being for colon polyps, but it can be anywhere in the endoscope GI tract. And type 1s are protruding. So they're what you think of as a polyp, whether they're sessile, pedunculated, or something in between. Or they could be these type 2s, which are superficial or actually inverted lesions. So types 2a, b, and c, a is above the surface, b is at the surface, and c is depressed. And of course, they can be combined. And it's just a way for you to describe something in fewer words with more agreement between observers. Although, much as with the erosion ulcer argument, there's going to be subjectivity here as well. And don't forget that the closed forceps are a good way to measure. All right, so knowing this scheme, what type is this? It must be some type 1 because it's protruding, right? So don't pick this. But is it sessile? Is it pedunculated? Or is it somewhere in between? Don't you hate that tweener stuff? Where do you draw the line with that? So it is subjective. All right, so I'm going to tell you that I said what you said. I think it's SP, too. And that's important to underscore. You can't see under this to see if it curves down a little bit. So I think you can't tell. So it's either this or it's this. It's not hanging on a stock like a toadstool. So it isn't this. And it isn't superficial. It's sticking out. So it's either this or this. And I agree. I thought it was this, too. Before I thank you for being a wonderful audience and for giving me the privilege to spend the last hour with you, may I answer any questions for you? Let's share a drink together. Thank you very much. Thank you.

upper endoscopy

pathology

terminology

endoscopy reports

findings

diagnoses

classification schemes

narrow band imaging

mucosal structures