All right, so we went through some stuff before doing an endoscopy, so we're going to move on to endoscopy, which is, I think, what you guys are looking forward to. So it's a great pleasure to introduce the next speaker, Dr. Jenna Al-Hashash from the Mayo Clinic in Jacksonville, Florida. She's an IBD expert and a wonderful colleague of mine, so she's going to share with us her thoughts on upper endoscopy. Thank you so much for inviting me to speak today on upper GI endoscopy. I have no financial disclosures. The objectives for today are to understand indications for upper endoscopy, review technique basics, outline the components of a normal, complete examination, and become familiar with abnormal conditions of the upper GI tract. So we're going to start off with a question. Which is not an appropriate indication for an upper endoscopy? Dyspepsia symptoms in a 65-year-old female, persistent reflux symptoms for 10 years in a 70-year-old obese male, 25-year-old male with heartburn symptoms not responding to H2 blocker treatment, 35-year-old female with symptoms of dysphagia, 25-year-old male with iron deficiency, anemia, and melano. I think everybody answered. Do we see the results of the poll? Sorry. The mouse? Yeah, hover over. Yeah. There it is. Okay. Thanks. Perfect. I guess they don't need the talk, because they know. So all right, great. So most people answered the question correctly. So it's a 25-year-old male with heartburn symptoms not responding to H2 blocker treatment. So the indications for upper endoscopy are upper abdominal pain or upper GI symptoms, but not always. Usually in older patients over 60 with dyspepsia, patients with new onset GERD in a patient above the age of 45 years with persistent reflux symptoms despite treatment, persistent vomiting of unknown cause, dysphagia, adenophagia, iron deficiency anemia, suspected upper GI bleeding, diagnosis and or treatment of esophageal varices and portal hypertension, patients with an abnormal imaging, food impaction or caustic injuries, and when we have to do this scope for foreign body removal. Alarm symptoms are very important to keep in mind. We always have to make sure patients don't have any unintentional weight loss, adenophagia, dysphagia, hematemesis, melanoma, refractory acid reflux, or persistent vomiting. So learning to perform upper endoscopy, the minimum number of upper endoscopies that should be performed before assessment of competency is 130. Competency is not just technical competency, but we also have to look at cognitive skills. We need to be able to understand what we're doing and why we're doing it. Be prepared for the needs of the case and inform your team to assure success. So if you have a bleeder, make sure you have clips, tell your techs what they need to have ready in the room, et cetera. And if your patient had prior procedures, review these records before to orient yourself to try to prepare yourself for better outcomes. Practice a deliberate, systematic approach. I can't stress how important this is. The more you do things in a systematic way, the less you'll forget, the more you familiarize yourselves with the right way to do things. Take the time and look carefully. Lesions can be very subtle and need us to look very closely at them. These procedures build on basic skills. Ergonomics, so, so important. The older I get, the more I know that this is something that we need to focus on very, very early on. And we have an ergonomics talk. But be comfortable when doing an endoscopy. Sometimes our teachers are taller, shorter. So adjust the bed to where you want it to be. And then if your preceptor or your attending needs to pick up the scope, they can fix things to make it more comfortable for them. The monitor should be positioned directly in front of you. The monitor height should be just below eye level with an optimal viewing angle of 15 to 25 degrees below the horizon from the eye. And the examination table should be at or below elbow height. 0 to 10 centimeters is what we prefer. So just be very comfortable. A lot of times anesthesia is right in front of you. They won't get offended if you put the screen in front. Just be comfortable when you do your procedures. This is what we, this is the first part of an upper endoscopy. So when we insert the endoscope, always make sure that the patient's properly sedated. A lot of times you assume, so and then you start putting the scope and the patient's like, you know, their eyes open. So just make sure your patient's asleep before you insert your scope. Make sure that you really visualize everything you do. It's very challenging at the beginning to orient things. The tongue, so anyway, you have to stay midline. The tongue is always above, you know, it would be above, like you can see in A, tongue on top view, and you have to center yourself. Examine the hypopharynx. You look at the vocal cords, the piriform fossa. You get to the upper esophageal sphincter, and then you go into the esophagus. Don't fly down. It's okay. Everybody's looking at you, but just relax. It's okay, and don't fly down because you don't want to end up in the wrong lumen. We have a lot of patients with a Zenker's diverticulum. You don't want to perforate that without knowing. So always be cautious, be confident of what you're doing, and see, be able to see. Don't push blindly and end up somewhere where you shouldn't. Again, the tongue on top, look up, so big knob back, and take your time. Take a look. Sometimes you need anesthesia to give you a chin lift or your nurse, they'll help you be able, be very confident where you're going. Again, familiarize yourselves. These are the vocal cords. This is the piriform fossa, arytenoids, et cetera. If you push and you see this, stop. Probably your attending would maybe pull your hand back, but always familiarize yourselves with the trachea because sometimes inadvertently we may end up there. Again, this is what we want to be seeing, the esophagus. As you go down, slowly push until you see the Z line, GE junction. So you examine the esophagus, you get to the lower part, there's the GE junction. So the GE junction is the top of the gastric folds and or where the palisading vessels end in the esophagus. It's an imaginary line where the esophagus meets the stomach. Next way is really to deflate the stomach because if it's so inflated, it moves down. Pause and examine it carefully. You want to look to see if you have any kind of breaks, if you have esophagitis, et cetera. Usually the GE junction is 35 to 40 centimeters from the GE junction. The Z line is different. The Z line is a visible boundary between squamous and columnar tissue. Usually they're together, but there's certain pathologies when they're not at the same level. Again, this is passing through the GE junction and you enter into the stomach. Now as soon as you enter, oh, sorry, there's a question. Which of the following represents the anterior wall of the stomach? A, B, C, or D? I hit next, right? I know it's getting them and then once you give everyone some time, it's usually been getting to about 90 or so, and then when you're ready to do the response, then you just hover over responses and click response, and then you'll advance. Thank you. There's 20 people left. Yeah, yeah, sorry, yes, that's correct. Actually, I hope it doesn't interrupt the poll, but yeah. So A, B, C, or D for anterior wall of the stomach. I'm glad everybody's here and that we decided to continue. All right, it's okay. So which of the following represents the anterior wall? A stands for anterior, but that's not the answer. D is the anterior wall of the stomach and we'll explain to you why. So as we enter the stomach, right below us there's the greater curvature, above us is the lesser curvature, and the anterior wall is to the left and the posterior wall is to the right and we'll get to it. Just remember the patient is on their left side, always on their left side, rarely on their back if they're intubated, et cetera, but always on their left side. So as soon as you enter the stomach, remember that the fluid accumulates in the fundus because that's the gravity dependent area. So as soon as you enter the stomach, you want to suction the fluid. You remove that pool to reduce risk of aspiration and avoid, as much as you can, initially it's hard, avoid suctioning the wall because then there's blood and the attending doesn't know if the blood was there before or because of you. So try to avoid suctioning and hitting the walls right and left. Avoid over insufflation because you don't want patients to be retching and belching and after you do that and you clear the stomach and it's safe, continue straight and head for the pylorus. And again, I say it really not so much jokingly, but really avoid trauma from the endoscope because it does become difficult, particularly in someone with erosions and a very erythematous stomach. We don't know what came first and we want to make sure that we're reporting the accurate information. Again, greater curvatures under you, as you can see, lesser curvatures above you, anterior curvatures to your left and, sorry, anterior wall and posterior wall are to your right and left, is similar to what you're seeing here. Now to advance to the pylorus, you want to look straight and push straight with a little bit to the right. And as you move to the right, there's different ways that we can do that. You can either torque clockwise and as you can see, that is the pylorus. So the nice thing about the upper endoscope is not very long. So any kind of motion moves the tip. So in practice doing that before putting the scope in your patients and while you're in the stomach with an inflated stomach, you can actually move by changing your hand position, your shoulder position and this really allows sometimes for just single hand scope steering. And it becomes important when you're trying to treat a bleed or trying to take a biopsy from a difficult position. So practice this technique as you start scoping your patients. Again, this is the pylorus that now we need to go through. And traversing the pylorus, you need to apply steady pressure. Sometimes it's tricky because you feel like it's fighting against you. And what you do is you end up forming a loop in the stomach and you pop through the pylorus. So always if you're, don't push, please don't push so hard, push slightly. It's gonna be sometimes, you know, giving you a little bit of resistance, but just be cognizant of the loop that's forming because you don't wanna go straight into the duodenal bulb and you know, cause an injury there. Once you're in the duodenal bulb, to your left is the anterior wall, to the right is the posterior wall. So again, this is very important when you have ulcers, when you have pathology for accurate description. The bulb is the first portion of the duodenum. You wanna completely examine it before you go in to the second part. Again, circular motion, examine the entire bulb, and then you wanna go to the right. So sometimes the scope itself tries to push you to the second part. So you may want to move your body or torque a little to the left so you're in a steady position in the bulb, examine it all, and then you can go ahead and proceed to the second part of the duodenum. The second part of the duodenum, or what we, you know, the descending duodenum, to get to it, usually you wanna turn to the right and look up by bringing the big knob back towards you. And as you get to that area, you wanna withdraw your scope slightly. Again, baby movements as you do any endoscopy, baby movements, you don't wanna go right, left, quickly up, down, and then, you know, baby movements and everything will fall into place. Again, this is called, you know, the corkscrew by like turning to the right, torquing to the right. Sometimes you may need to use the small knob forward and the big knob back so you can look up and get into the second portion of the duodenum. You'll know because you're gonna see these circular rings, which are the valvular conventus, and many times you'll be able to see the papilla, the ampulla. I personally like to see it on almost all my endoscopies and familiarize yourself with what's normal so you can identify what's abnormal. Remember that you may face paradoxical motion upon withdrawal, and to get to the third portion of the duodenum may require additional maneuvers to get there. And of course, multiple duodenal intubations may be needed because a lot of times you fly back and then you fly back in. So just very small baby movements, very cautiously, try not to hit walls right and left, and most importantly, visualize and don't push blindly. This is going through the sweep. Again, we're going right, looking up. And now you see the circular rings so you know you're in the second part of the duodenum. Now that we've examined the entire duodenum, again, major papilla, try to look at it. It's usually located to your left. Now, after we've examined the duodenum, as we come back into the stomach, we need to retroflex. Retroflex is have the scope look back at itself in order to examine the areas that you couldn't see on FAS very, very nicely. So you insufflate the stomach in order to be able to see all the walls and be systematic and thorough. So as you insufflate, you're sitting in the antrum slash pre-pyloric area. You start looking up and you see the incisora. It's extremely important to look at the incisora and examine it from both sides. You can see there's an ulcer here. So you retroflex, examine the incisora, and then you bring the scope back and examine the gastrocardia and fundus. Now, to retroflex both knobs towards you, you start by doing the upper knob, and then you may need to do the smaller knob. Torque the scope away to get away from the walls. You, again, don't wanna be hitting walls. You will, but with time, it will get better. And then you pull the scope towards you to get to the fundus and the cardia. Again, you can see the fundus and the cardia. So when and where to biopsy? If you see a suspicious gastric ulcer, you wanna do around eight to 10 bites from the margin of that ulcer. In patients who have candida esophagitis, where you have white nummular lesions in the esophagus, brushings and biopsies are important. CMV, you would wanna biopsy the base of the ulcer. HSV, you wanna biopsy the margin of the ulcer. For H. pylori, don't just biopsy the antrum, but you wanna biopsy both the antrum and the body. And for celiac disease, remember, you need six bites in total, including at least one from the bulb. And if you see something that you're not sure about, it looks a little more red, it looks a little more polypoid, then biopsy it separately in a separate jar, of course. Now, after completing the examination of the stomach, you deflate the lumen and you start withdrawing slowly, slowly through the entire esophagus. Examine the upper esophagus. That's where we find webs and inlet patches a lot of time. As you can see here, this is an inlet patch, or it's an ectopic gastric mucosa in the upper esophagus. Sometimes there's multiple, sometimes they're larger. And in summary, just to recap, be patient and deliberate. Keep the tongue on top and really center yourself. Patience in the piriform fossa, so you can get to the right lumen, again, not blindly. And don't push forcefully. Sometimes we feel under pressure. We feel like we wanna just like, I wanna show them that I can get there quickly. Don't just push and jam things right and left without knowing. Esophageal examination, again, keep the lumen in center. You can, again, easily do that by moving your body, by torquing, by moving your left arm. You don't wanna just examine one side of the esophagus or whatever. Just keep the lumen in view, stay in the middle. Pause at the GE junction. Again, when you come back, don't rush. Oh, okay, we're done. There is an esophagus that you still need to examine. Stomach, suction the fluid, number one. Minimal inflation, then go to the pylorus. Patience and pressure at the pylorus. Again, not forceful. And when you withdraw, be systematic and retroflex. Duodenum, complete bulb exam first. And then remember, ride up and withdraw a little bit in order to get to the second part of the duodenum. Develop and practice a deliberate systematic approach, extremely important. Use torque and body positioning to direct the tip of the scope. And use routine cases to refine precision and technique. Truly, a lot of our fellows are like, we know this is gonna be normal, I'm gonna skip this case. Take, do the case, because it's, in order to start recognizing abnormal, you need to get better and better and better at seeing normal. And practice, practice, practice, because everybody can get better. So please rate the content. Hi, hello, I'm not sure if you can hear me. Not so well. Maybe I'll, for CMV and HSV biopsies, so I know one is, like CMV is from the base, HSV is from the margin. So if you're not sure, you just do both. So, yes, now there's different appearances of the ulcer, but if you have a tumor, there's different appearances of the ulcer, but if you have an immunosuppressed patient and you need to, it's not very clear, then yes, I would do both. And do you do one from each lesion or do you do multiple? It depends on how many lesions you have, and depends on the size of the ulcer. If it's a big ulcer, then you can biopsy the base and the side of the ulcer, that's great. But if you have just tiny, tiny lesions that you're gonna grasp the whole ulcer with one biopsy, then that's, you know, changes things a little bit. Yes. Thank you for that presentation. I have two questions. First, in terms, if you find food in the stomach, when do you consider aborting versus continuing? So something like you can suction. And then would you do H. pylori biopsies if the stomach looks macroscopically normal? Or would you just, would it just be like erythema, erosions, et cetera, that you would consider H. pylori? Yeah, so great question, Jessica. The first question is when to abort if you find food in the stomach. Almost always, truly, I would be very nervous, of course, if there is food in the stomach because there's a very high chance of aspiration. If someone is, most of the time I would abort. Now, if it's a small bowel transplant patient and you just need to go in and do a quick biopsy and come out, then I may, you know, of course, I contact with an anesthesiologist with me in the room, put the head of the bed up and minimal insufflation and do get the job done very quickly. But most of the time I would truly abort. Now, if I'm doing this, it's a diagnostic test. The patient's here with abdominal pain and you can't see. If there's a fair amount of the stomach, so even if you continue, it's still a suboptimal exam. The patient still needs to come back so I don't think it's worth the risk. Now, the next question is always also depending on your index of suspicion. If the stomach looks completely normal, I wouldn't biopsy it. If the patient's having symptoms suggestive of H. pylori, then I would. And also it depends on where we are, right? H. pylori is not endemic here in the US. So it depends on the patient population, your scoping, et cetera. So it depends on my index of suspicion. Sometimes if I have a very index of suspicion from a clinical symptom standpoint, I biopsy. But, because you still can have H. pylori. But if I'm doing this for someone who doesn't have any duodenal ulcers, I'm doing it for follow-up esophagitis and the stomach looks normal, then I don't biopsy. Sure. All right. Thank you. Thanks.

upper GI endoscopy

Dr. Jenna Al-Hashash

Mayo Clinic

patient safety

biopsy protocols

H. pylori infection