So this is a really fun talk, actually I think this is one of my favorites. So I'm very happy to introduce Dr. Kunal Jaju from Brigham and Women's Hospital. I've worked with Kunal a lot over the years in our Park City Therapeutic course that we do in conjunction with Brigham and University of Utah. So it's a pleasure to introduce Dr. Jaju for this talk. And then after this one, you guys will have like a quick, a 10-minute break and then you'll go over to the conference room and do the tools of the trade. Thanks Catherine, thanks Mihir, thanks to the ASGE for having me. I hope you guys have had a great first couple of weeks of being a consultant. I completely agree with Dr. Wah that isn't it great to be a consultant and not the one getting the first call when the patient is sick. So just remember, when you have that really tough call night or that tough call week, you're not the one getting called for the fever. You're not the one getting called for pain meds. And that makes that late night consult just, it made it easier for me, I remember very much so. I have no disclosures pertinent to this talk. So just to walk you through a mock endoscopy report. So a first year fellow writes up this report about Mr. Bleeding who came in with hematemesis and we performed EGD with control of bleeding, saw some gastritis, a bleeding ulcer, gave it some epi, we cauterized, and that's that. So you guys, at this point, you really just want to be able to get the scope done correctly. You want to be able to do whatever therapeutics we can do. And the report might be the last thing on your minds. The report might be considered scut work or whatever. But just one of the things I try to tell the fellows every year is when you write that report, I want you to write that report in a way that if that patient came back in 48 hours, you knew exactly what happened and you knew what you want to do next. Because when your co-fellow's on call the next night, you don't want to be the one who wrote allows you a report that didn't help that person help that patient. Or if you know that a patient has to go for surgery, you're describing it in a way that you know this will help the surgeon find the lesion or whatever might be the case. So I don't yet consider myself a senior attending, so we'll say mid-level attending. But we want to be able to describe everything that we've seen, describe that the esophagus was normal, normal Z-line, moderate diffuse erythema in the gastric body, 20-millimeter round ulcer. And we're saying where it is along the lesser curvature. We talked about in the upper endoscopy talk, recognizing anterior, posterior, lesser curvature, greater curvature. Oozing vessel at the center of the ulcer, so now you've classified the type of ulcer. You've treated with epi. How much epi did you give at what dilution? And then you followed up with gold probe electrocautery, and you were able to achieve hemostasis. So it tells us a lot more. It tells us that if that patient were to bleed again 48, 72 hours later, you know which side the ulcer is on. If you have to reposition the patient, because there's so much blood in the stomach, you might be able to reposition the patient to optimize your view of the lesser curve so you can get a look again and get to the right spot. So I know at this point, we don't think of our notes as very important, but it is so important. And I would even, when I do US and I do ERCP, when you're doing endoscopic ultrasound, writing the report is part of learning how to do US, part of learning how to describe what you're seeing. Same with EGD and colonoscopy, describing what you've seen, describing what the pathology is. Because I'll tell you right now, one of my biggest disappointments with becoming attending, there's no such thing as pathognomonic anymore. You learned in med school there was such a thing as pathognomonic. You learned in residency there was pathognomonic. We can only describe. The pathologist is going to say clinical correlation, could be, could be, should be, might be this. What we describe is what we know and what will help us for the next procedure. So getting to the poll, how should the endoscopic findings in this image be described? Portal hypertensive gastropathy, gastritis, patchy punctate erythema in the gastric fundus, or a Cameron's ulcer? about half the group now, right? So we're not looking for the 90s anymore. Excellent, excellent, yep. Sorry. Okay, so patchy punctate, erythema, and the gastric fundus. How about here? Linear erythema in the antrum, gastritis, gave portal hypertensive gastropathy. Linear erythema in the antrum. And those of you who chose GAVE, this might be GAVE, but it also might just be gastritis. So we don't know for sure right now. So we really can only be descriptive at this point. How about this one? Looking a little different from our other two types of gastritis that we've already described. Punctate erythema, scattered gastric erosions, visible oozing, gastritis, GAVE, or NSAID-related gastropathy. And this might be NSAID-related gastropathy. It might be gastritis for other reasons. It didn't really look like GAVE, but it could be GAVE that was actively oozing. And that's why we can only describe what we see to help ourselves along and understand what's going on next. Which of these two, A or B, represents an erosion? So here we're trying to get to the point that the terminology for erosion would imply that something is a little bit more superficial than an ulcer. So A would be an erosion, whereas B may be an ulcer. And technically, the pathologic definition would be that the erosion is a shallow break in the mucosa. It can reach to the muscularis mucosa, but should not go through the muscularis mucosa. Whereas an ulcer would be a full thickness break in the mucosa, penetrates the muscularis mucosa, so that you're getting to the point of the submucosa, but could even go deeper. Does this project well enough, or is it too bright? Identify the finding. Is this A, Barrett's esophagus, B, LA grade B esophagitis, C, gastric heterotopia, or D, an inlet patch? So here we're looking at the distal esophagus. You can see some gastric folds at the very bottom of the picture, and some salmon-colored mucosa coming up. So A, Barrett's, B, LAB esophagitis, gastric heterotopia, or an inlet patch. Good. A little bit split here, but this would be Barrett's esophagus. You don't really see active esophagitis in the sense that there's no erosions here, and you see the salmon-colored mucosa extending above the gastric folds. So as you know, Barrett's is an acquired condition, replacement of the normal stratified squamous epithelium by metoplastic columnar epithelium in teslametoplasia. We see salmon-colored mucosa, and then on pyopsies, we see intestinal metoplasia, and results, of course, from chronic GERD. I often explain to my patients that it's the esophagus' way of kind of protecting itself, making it more like the stomach, because we know that the columnar mucosa can tolerate acid. We know that it can tolerate constantly being hit by acid, and so it's a bit of a protective mechanism. How do we describe Barrett's esophagus? Which classification scheme do we use? Is it Paris classification, Kudo classification, L.A. grade classification, or Prague classification? Good. PROG classification. And we'll talk about the others as well so that you'll know what they're referring to. So PROG classification. So this is the normal state, normal physiology, where we have, excuse me, the diaphragmatic pinch, the Z line, or the squamous columnar junction, and the lower esophageal sphincter pinch are all in the same location, right? So there's no hiatal hernia, there's no displacement of the columnar epithelium above the level of the gastric folds. Whereas here, we have the lower esophageal pinch, the lower esophageal sphincter pinch, but you actually see salmon-colored, or a little more orange in this depiction, but salmon-colored mucosa that extends two centimeters above the top of the gastric folds. And then we have some tongues of barrets that are extending another two centimeters above the circumferential. So PROG classification is circumferential extent and maximal extent, right? So this would be C2, so two centimeters of it is circumferential, M4, the maximal extent of the barrets is four centimeters long, C2, M4 barrets in this example. So for this one, we have maybe a centimeter of circumferential from 40 to 39, we have tongues of barrets up to 37-ish, and then we have a couple of islands above the tongues of barrets. So remember, the islands do not count in the C and M classification. We can describe those separately as scattered islands at around 35 centimeters. But this would be C1, M3, with islands of barrets at 35. And then here's C5, M7, just to look at an endoscopic view as opposed to a cartoon view. And this becomes important in terms of following longitudinally in surveillance. It also becomes important for those patients who I might have done radiofrequency ablation on to understand where the barrets was to hone and train our eye in looking for any recurrent barrets after ablation. When we have a hiatal hernia, we have gastric folds displaced above the level of the diaphragm. So here we would describe that the diaphragmatic pinch is at 39. Usually we would say top of the gastric folds, TGF, or you can say lower esophageal sphincter pinch is at 36, so a 3-centimeter hiatal hernia with 2 centimeters of circumferential barrets and another 2 centimeters of tongues of barrets. So this would still be C2, M4, but with a 3-centimeter hernia. So in this picture, where is the diaphragmatic pinch? Is it A, B, or C? We have mostly A's, and a couple of B's, and a couple of C's. Oops, sorry. Correct. So the mostly A's are correct. This is the diaphragmatic pinch. You can see that something is holding these gastric folds in. Sometimes when people have a wide open hernia, it can be a little hard to tell. And you can wait till they take a breath. You can wait till they take a breath, and you will see this move. Here we have the top of the gastric folds all the way around. Here's the retroflex view of this hernia, and you can see that the gastric folds are sliding up and down across this diaphragmatic pinch. So just again, this was the original poster from the Prague meeting when the Prague classification was first described. But here we have the same story with the top of the gastric folds are at 36. We have 3 centimeters of circumferential barrettes, and then an additional 4 centimeters of tongues of barrettes. So we have C3M7 barrettes in this situation with a hiatal hernia as well. Gastric inlet patches, I don't know if you all have seen any yet in your first few weeks of endoscopy. They're actually more common than you'd think. So these are heterotopic gastric mucosa in the upper esophagus that kind of get left over during development. And when the foregut and the midgut are stretching, you can get a little bit of stomach gastric mucosa remaining in the upper esophagus. And this can be found just under the lower esophageal sphincter, around 18 centimeters from the incisors. So narrowband imaging, and I will say, for those of you who do not use Olympus scopes, any of the electric filtered light, whether it be Fujifilm link color imaging, Pentax iScan, or Olympus narrowband imaging, what can it be used to help? Can it be used to help identify polyps, Barrett's esophagus, dysplasia, and ulcerative colitis? Can it be used to help identify gastric cancer, or all of the above? Good, yeah, all of the above. So here we see white light, and in this case, narrowband imaging. And you can tell that there's Barrett's here, even on the white light. But with narrowband imaging, you can really see the delineation of the border between the pale squamous mucosa, which becomes like a pale blue in narrowband imaging, versus the Barrett's mucosa, which becomes a deeper red or pink on narrowband imaging. And then when you're up closer and actually examining the whole area of Barrett's, you can look for irregular vessels. You can look for other irregularities that might indicate that the Barrett's has dysplasia. Why does it help us? What is it actually accentuating? Is it accentuating the muscularis mucosa, the mucosal capillaries, adipose tissue, or submucosal glands? Good. Mucosal capillaries. Now, the submucosal glands, unfortunately, cannot be visualized with narrowband imaging. The mucosal capillaries are what we see. And so this is just a schematic of how narrowband imaging works. So white light or conventional light up top, where we have multiple wavelengths of light. But in the narrowband imaging, we have the bandwidth is narrowed to limit the penetration of depth. So we see capillaries on the surface. And those would look brown. And you might see submucosal veins. And those would be displayed as kind of they look a little more bluish, bluish green. So this is the NBI classification or the NICE or NICE classification, N-I-C-E. And so here, more hyperplastic looking, pale, maybe a little stippling, but not seeing much of a network of capillaries. Here maybe class II, maybe a little more adenomatous, a little more of a lacy network of capillaries, a little more cerebral looking. And then we start having disorder. We have disorder of the capillaries. They're no longer in this nice, lacy network. They're getting a little bit disordered. You're getting truncated. You're having some gaps in between where you don't see the vessels, bigger gaps here in an invasive cancer, a lot of irregularity and almost knuckling of the vessels as they're getting affected by the invasive cancer around them. So now going back to some of the other classifications that we utilize, name the classification scheme used to describe this condition, Paris, Kudo, LA grade, or Prague. Good. Excellent. L.A. grade classification, that's right. So this would be – are you guys getting tired of the polls? We could say that this would be B, grade B, and the description, again, from – if you guys haven't figured it out, it's just where these meetings were held. So this meeting was held in L.A., and the description is L.A. grade A is one or more mucosal breaks no longer than five millimeters in length. So these little yellow ovals are supposed to be the small mucosal breaks. So L.A. class A would be no more than five millimeters, L.A. class B would be five millimeters, but do not extend between the tops of mucosal folds. C, they do break across mucosal folds, but less than 75 percent the circumference of the esophagus, and then D, at least 75 percent of the circumference of the esophagus. So here we have a cirrhotic patient who you're screening for varices. Would you call these large varices, small varices, grade one, grade two, or grade three? Oh, good, a little bit of a split. So the correct answer is small varices. We've really moved away from the grading system of grade 1, grade 2, grade 3, which can be quite subjective. And these would really be small, which would be less than 5 millimeters in diameter. So if they're identified, they should be graded as small or large. And then we should be mentioning whether there are red whales or red spots, because they have been identified as a risk factor for future bleeding. So the one before this was the first picture that we had voted on. So these would be small. These would be large, greater than 5 millimeters. And then here, red signs, which are usually little hematomas on top of the varices, can look different across these four pictures. And then here, we have a big cluster of gastric varices best seen on retroflexion in the fundus. And so remember, there is a classification scheme for gastric varices as well. So gastroesophageal varices that extend from the esophagus down to the cardiac, GOV1. GOV2 extend to the fundus. And then IGV, meaning isolated gastric varices in a patient who does not have esophageal varices. So this might be more in a situation of what sinistral portal hypertension, splenic vein thrombosis, what's called left-sided portal hypertension. So IGV1 are those that are in the fundus, whereas IGV2 can be anywhere else in the stomach. Correctly identified lesion noted on this endoscopy performed for hematemesis. Is this a Cameron's erosion? Is this esophagitis? Is it a Mallory-Weiss tear? Or is it peptic ulcer disease? Good. Mallory-Weiss tear. I'm not a fan of this cartoon, but Mallory-Weiss tears should be seen at the GE junction, produced by a sudden increase in intra-abdominal pressure, bouts of coughing, bouts of vomiting. The cardiac is kind of pulsed through the LES over and over again. Usually single and longitudinal, like the picture we showed, but multiple tears can be seen in as many as a third of cases. And so all of this is building on itself, right? You learned about doing retroflexion. Sometimes this can be missed if you don't do a really good, tight retroflexion around the cardiac and make sure that you're twerking all the way around to see this tear. We showed you front-showing views on these first pictures, which were obvious, but often you have to do a good, tight retroflex for you to make sure that you're excluding this as the diagnosis. Here we have three different pictures of a specific thing. And sorry, ABC does not refer to these three options. But are each of these, are all of these representing Cameron's ulcers, Mallory-Weiss tear, an asthmatic ulcer, or a malignant ulcer? And I'll editorialize a little bit. But I think A is not the most typical appearance of this, but can be seen. Get a little bit split, but about half of you thought it was Cameron's ulcer. Correct. So Cameron's ulcer, you know, occurs in a hiatal hernia patient at the level of the hiatal hernia, usually longitudinal, goes with the folds because of the friction and traction that can occur over and over as it goes up and down around the diaphragm. And now we've asked about a bunch of other classifications, but now talking about Paris classification. Paris classification can be used to describe which of the following types of lesions, colon polyps, superficial gastric lesions, superficial esophageal lesions, or all of the above. Good, quite split. Colon polyps, so it is true that you most commonly hear it referred to regarding colon polyps, but that's just because we most commonly see colon polyps, but it can be used to describe any raised lesion. So this is the Paris classification for superficial neoplastic lesions. They're split up into being protruding or superficial or flat. Type 1P is pedunculated, 1SP is sub-pedunculated or semi-pedunculated, some people call it. 1S would be sessile, 2A superficial with elevation, 2B superficial flat, 2C superficial depressed. This is actually a 2C and a 2A in the same lesion, and this would be both a 2A and a 2C in the same lesion. So the way that you would distinguish between flat with an elevation versus sessile is that it's greater than 2.5 millimeters elevated, and basically a closed forceps, depending on which company's forceps you use, is somewhere between 2 and 1 half and 3 millimeters when it's closed. So this would be less than a closed forceps, this would be more than a closed forceps. So taking this classification into mind and looking at this polyp, what would you call this? And the 0 is, or the O is because these are all superficial, right? All of these are superficial, and then you're classifying further once they're superficial. So 1S, 1P, remember sessile, pedunculated, SP, which is subpedunculated, or 2C. Good. So the right answer is actually 1s. But I see why some people have done subpedunculated, because there's not a great distinction between subpedunculated and sessile. But the difference being that you don't really see it come around to trying to become pedunculated. It actually is a bit flat or straight at both ends. Straight at both ends. So this would be a 1s. But I can see why somebody, I was anticipating that that might be part of the answers. I went quickly, I guess. I hope I didn't speak too quickly. There's one question from the virtual audience. So does NBI help identify sessile serrated polyps during endoscopy, is the question. So NBI can help both identify, or any filtered light can help both identify. And more importantly, in my mind, identify the margins or the borders of a sessile lesion. So it might help us, because of the difference in color contrast, might help us to identify a sessile serrated polyp that otherwise looked very similar to the surrounding mucosa. And that would also help us to identify the borders when we go to resect them with endoscopic mucosal resection, or ESD. We have lots of time, and this is a smaller group, so please ask questions. We have the virtual audience still on this session, so when you do ask a question, just turn your mic on. So he resected a polyp. I was wondering if NBI could see if there was some of it left. Yeah. Any questions? What about the KUDO classification that you mentioned? You went over that one. Yeah, because the KUDO pit pattern is a little bit harder to describe. It takes a little more time. I think for first year fellows course, I think the ones going over narrowband imaging classification, going over esophagitis, going over Barrett's becomes really the most important. KUDO pit pattern, you can look a little bit more closely and try to identify how invasive the polyp may be and what type of polyp may be. Has not taken on as much as some people would like it to have taken on in American medicine. So I think it was one of the reasons it was left out. Not as important, not as vital, important to know about, especially if you want to go into the resective techniques when advancing asthma therapy. I have a question. Yeah. With the endoscopic features of whether it's hyperplastic, adenomatous, does it correlate well with pathological features? Is it one on one? So the question is, how well do endoscopic features correlate with pathologic features? They correlate quite well, but not 100%. So depending on which study you look at, I think the highest I've seen is about 85% to 90%. I don't think I've seen the high 90s. And so in a cost containment situations, you could argue that 90% is high enough that you could remove and discard and not send for pathology. I don't know. My American patients would not take that. I get asked why I wrote a letter that said four polyps when I took out five polyps, because the fifth polyp actually ended up coming back as normal mucosa, so I didn't bother putting it in a letter. But before I got on the flight yesterday, I got an epic message that said, what about the other polyp? What about the other polyp? And so I had to reply. I didn't comment on it, because it wasn't clinically relevant. I hope I didn't go too far. Go ahead. OK. I had a question more so about technique to measure diaphragmatic pinch, because do you have any advice? Do you tend to insufflate less when you are trying to measure your diaphragmatic pinch? Because I obviously have a very hard time understanding where it is when I'm very insufflated in the esophagus and I'm withdrawing. Good question. And just measuring how far down it is from the incisors, or how big the hiatal hernia is? Or both, I guess. Both, I guess, yeah. So in most patients, an axial hiatal hernia is going to be a sliding hiatal hernia. So it's going to move while they're taking breaths. It's going to move if they started getting propofol hiccups. It's going to move if they're moving around. So it might not just be that you are insufflating too much or not waiting to deflate enough. I do use the technique relatively often to wait until the patient takes a breath, so that I can make sure that I'm seeing the diaphragmatic pinch. Because sometimes in a large hiatal hernia or a larger bodied patient, it can be a little bit hard to tell. So I use that a lot, honestly. I wait until they take a breath and I watch. And I make sure that I've seen it both, if I'm really unsure, that I've seen it both straight on and retroflexed. So I think that would be my boast. I do think that we don't do enough insufflation and desufflation in general in routine endoscopy. I take care of a lot of the polyposis patients and inherited gastric cancer patients. So I do a lot of insufflation, desufflation, insufflation, desufflation, washing, because you want to know about compliance. Remember, one of the first things that goes in a diffuse gastric cancer is compliance before you ever even see a mass. So that lineitis plastica, it creates a stiff stomach. So I think I would, my suggestion or my advice would be to not worry so much about whether you're using too much air or suction enough, but whether you've done enough back and forth suctioning and deflating so that you've seen everything well. Yeah. Yeah. So the LA grading for esophagitis, is that only for reflux esophagitis, or can it be used for other types as well? LA grading was for reflux esophagitis. There is the Savory-Miller-Caustic scale for ingestions. Yeah. So one follow-up question. So when you're doing the grading, what helps you to determine five? I know it's just a guess, but what helps you determine five millimeters, less or more? Yeah, and so how do you tell whether something's less than five millimeters or more than five millimeters if that's the inflection point for the grading between A and B? You can. I mean, presumably, if this is new esophagitis, you're going to be doing biopsies. So you can put out a biopsy forceps. And on the package of the biopsy forceps, depending on which brand you use, it'll show you how big it is when it's open. It doesn't always show you how big it is when it's closed. But most of them are about 2 and 1 half millimeters when they're closed. Or you can interpret that based on what size channel it says it needs to go through. Because if it can fit through a larger therapeutic channel, then it's probably more than 3.2 millimeters. If it's for a smaller therapeutic channel, then it's probably at least, at the most, 2.8 millimeters. So you can use the forceps to help you. And then over time, you will train your eye. And so back to the theme of do those normal endoscopies, because you'll learn normal and you'll learn abnormal. Same thing. When you're doing those endoscopies, think about how big it is. Things are about 30x magnified. If you talk to Olympus or Fuji, they won't actually tell you exactly how magnified our screens are. But you have to train your mind to be able to interpret that magnification and what you're looking at. And so whether it be opening a snare and thinking about how big that snare is compared to the polyp that you're removing, every time you open a snare, I want you to be thinking, OK, I used a 10-millimeter snare. I thought that polyp was actually an 8-millimeter polyp, but look at how small it is compared to this 10-millimeter snare. Let me think about what size it actually was, so the next time I can be closer in my estimation. Every time we do anything, we should be thinking like that. Because it is. It's a sport. It's a sport. We should be the best at everything we do. Everything should be practiced. Ergonomics should be an athletic stance every time we look. And so when I'm training my eye to do that, at the same time, I'm listening to the pulse ox. I'm thinking, is the pulse ox starting to dip? Is the pulse ox starting to go fast? Because I don't want my eye to be distracted looking at the pulse ox monitor. I only want to be looking at my high-definition screen of my endoscopic image. So I listen to my ear, the pulse ox, and I listen to my ear how my suction is. I don't want to turn around and look at what's wrong with my scope. I'm going to tell my tech that my suction doesn't sound right. Figure it out. If something, if I feel tension on this, we are using all senses, all senses at all time. If you feel too much tension on the scope, don't push. Figure out why there's too much tension on the scope. All senses at all times, and then it is. We all have to be at the top of our game. Because if you know if you're at the top of the game and one of those complications occur, you cannot be faulted. You did everything you could to be at the top of your game.

endoscopy

gastrointestinal disorders

detailed reporting

narrowband imaging

Barrett's esophagus

endoscopic classifications

Dr. Kunal Jaju