So I'll be speaking to you all today on the how-to guide to upper endoscopy. Obviously nothing can replace really you actually getting in there and doing procedures, but we're going to go through the different steps, some considerations, some areas that may be a little more challenging, and we'll go through that today during the simulations as well. That's my disclosure. So today we're going to discuss the following objectives. First, I want you to understand the indications for upper endoscopy, review the technique basics that outline the components of a normal complete examination, and then to become familiar with some abnormal conditions. So let's talk about the indications for EGD or esophageal gastrointestinaloscopy. I know, you know, I think nowadays it seems like anyone who has a complaint undergoes upper endoscopy, but you really need to sit down and make sure that you're doing it for the right reason, the right indication. So patients that you think have, you know, dyspepsia and they're greater than the age of 60, new onset GERD in a patient over the age of 45 that has persistent reflex symptoms despite treatment, for example, with proton pump inhibitor therapy, anyone with persistent vomiting of unknown cause, you know, even if you have a patient who's on opioids, for example, and has persistent vomiting, you know, you want to give them the benefit of the doubt and still consider at least doing a diagnostic upper endoscopy. And then, of course, patients with dysphagia or adenophagia, this warrants investigation. Those with iron deficiency anemia, again, you know, the GI tract has the greatest surface area for a source of GI bleeding. So unless it's a woman that has heavy menstrual cycles, you know, you really do need to consider EGD and colonoscopy for that purpose. You want it for diagnosis and or treatment of esophageal varices and portal hypertension, anyone with abnormal imaging, and also for food impaction or caustic ingestion and foreign body removal. Those are just some of the common indications that you'll be seeing in your training and when you're out in practice. So let's talk about alarm symptoms or red flags. So anyone with unintentional weight loss, that really does warrant an upper endoscopy to rule out an upper GI cancer, adenophagia and dysphagia, hematemesis, melana, refractory acid reflux, persistent vomiting. You know, when I see patients in my clinic and, you know, they've been to multiple providers or they're just not getting better, I always ask myself, what is it that I'm missing? Is there something that I'm missing? Do we need to repeat an endoscopy? You know, could something have been missed? So when it comes to learning to perform an upper endoscopy, you know, the good news is unlike, you know, EUS or ERCP, the learning curve is roughly around 100 cases, okay? And you should be able to get that by the end of your first year, if not even sooner. Competency isn't just doing the procedure, but it's also the cognitive skills. It's knowing how to interpret what you find, what you see and what you do about it. Be prepared for the needs of the case and inform your team to assure success. One thing that I always like to do is to review any prior procedures, okay? Sometimes you'll have lots of outside records, but if they're coming to see you and they're having an issue, why don't you take a peek and see what the prior endoscopy showed? It's always good to practice with a deliberate systematic approach, and that's really when we talk about the art of medicine or the art of endoscopy. You know, you're not just a technician, but you're going to form your own systematic approach to performing all these different procedures. And don't cut corners or skip. It doesn't matter what the indication for the procedure is. Always go through every station, document everything, because you never know what you'll find or what you may miss as a result of cutting corners. Take the time to look carefully. Lesions can be very subtle, and then you'll be advancing your – advanced procedures are built on these basic skills. So for those of you who may say, you know, I want to go into deep endoscopy or I want to become a therapeutic endoscopist, which is what I do, you know, you really can't, you know, walk without learning to crawl first. And so you want to be a refined endoscopist and learn how to perform a meticulous and beautiful upper endoscopy first. So ergonomics, there's so much talk about this, and it's because it's so important. Maybe a show of hands, how many of you who have been scoping have maybe after a week or two have come home sore? Everyone, I'm sure. And it's because, you know, you may – sometimes we feel rushed to, oh gosh, I've got to put my glove and gowns on. My attending is like breathing down my neck. I've got to hurry up and insert the scope. But don't let anyone push you to start a case without you first being prepared and comfortable. It's so important. It is not worth the occupational injury. You do not want a shoulder replacement 10 years from now, okay? I see it all the time in my colleagues. You got to be comfortable when you're doing an endoscopy. Do you want to be uncomfortable? No, no one does. But we think that we have to because we have to rush. Don't rush, okay? These are just some perks. And there's lots of learning videos on Video GIE. There's like a seven-minute video, I believe, that shows you the ergonomics of endoscopy. I encourage all of you to look at it. So, you know, the monitor should be positioned directly in front of you. Not in front of your face so that you get vertigo and you're straining your neck, but it should be a few feet in front of you. And the height should be just below the eye level. So one thing I learned working with physical therapists is they tell you, the screen, you should not be doing this with your neck, okay? You should be doing a chin tuck. So it should be just below the eye level. That's how you should be looking at the screen. And if the screen is not where you want it, position it before you start. And the table should be at or below the elbow height level. So if you talk to laparoscopic surgeons, so my husband's a laparoscopic surgeon, so we talk about injuries all the time. You know, this is what they do in laparoscopic surgery. You know, if you're going to scope like this Monday through Friday, you're really going to hurt your shoulders and your back. But at the same time, you don't want the table super low so that you're straining your shoulder. So you want that table like at the level of the hips. Your stance should be with both feet apart. You want to place the weight on both legs, okay? So have all of that ready before you start scoping. It will help you, I promise. So this is just the general intubation. So what you see here at the top of the screen, that was the tongue. And then you see the airway. So this is the first part, which is the insertion of the endoscope, which can usually be the toughest when you start. Surprisingly, I always found that when I was doing conscious sedation cases, that it was the upper endoscopies that were more tricky to sedate the patient than the colonoscopy because of the gag reflex or just having a foreign object down their throat. You want to make sure, again, the patient is properly sedated. And I also give my patient the expectations as well. When I do conscious sedation cases, I tell them, this is not general anesthesia. You're still breathing on your own and you can still respond. You're going to feel the scope, okay? This is under direct visualization. Again, as you saw in that video, the tongue is always at the top view. And so you're going to have to keep a very purposeful movement of the scope because the scope is quickly going to want to spin the other way, and then you're going to be backwards. And as you saw there, you're going to see the hypopharynx. You're going to see the vocal cords and the piriform fossa. And the piriform fossa is the area where you have to go in to pass through the upper esophageal sphincter. Some special considerations, you know, I have had patients with Zanker's diverticulums. So never force or jam that scope down their throat, even if the patient's uncomfortable and you just want to get it in there. You never know when you can get into a diverticulum and you can perforate the patient. It's not worth it. So again, you're going to insert the scope, keep the tongue at the top of the screen. You want to then put your big knob back so that you can slide into the hypopharynx. Keep a firm grip with your right hand on the scope, okay? So after that, you've got to get through the piriform fossa and through the upper esophageal sphincter. And again, the purpose of a sphincter is to stay closed when it needs to. So it's not going to be patchless and wide open. You're going to feel some resistance. But visualize where you're going every time, okay? Examining the esophagus, let's look at the EG junction. I know we call it the GE junction too, but, you know, I always reference things in a cranial caudal fashion. So for me, it's esophagogastric junction. This is the imaginary line where the esophagus ends and the stomach begins. So when you're there, you want to then deflate the stomach and pause to examine this area carefully. You want to look at the top of the gastric fold and or the palisading vessels as shown here. And you also want to measure the EG junction from the bite block, which is usually between 35 to 40 centimeters in an average height person. Not to be confused with the Z line, which is the visible boundary between the squamous and the columnar tissue. So these are important landmarks. And don't forget also the diaphragmatic hiatus. And this is important because an EG junction landmark may not be the same as a Z line, right? So if the Z line is above the EG junction and it looks abnormal, you have to be suspicious for possible Barrett's esophagus, right? So the diaphragmatic hiatus, or the DH, is not the same as the EG junction or the Z line. Those are three different landmarks that you should be commenting on and putting in your report. Okay, so here we're going through the EG junction. You saw the top of the gastric fold. And you could see the transition between the squamous and the columnar tissue. So let's now go into techniques of upper endoscopy. When you first get in, this is a typical view of what you're going to see. You're going to see the greater curvature around the 6 o'clock screen and the lesser curvature like around 12 and 1 o'clock. So when you're examining the stomach, most of the time your patients are on their left lateral decubitus position. And so fluid is going to naturally accumulate in the fundus. And so if the patient is not intubated, what I always tell my fellows is don't pause and start taking tons of photos in the esophagus. For me, my patient's safety is my priority. I always recommend go in and suction out the fluid in the stomach because you never know they may start coughing and the fluid can be brought up. So you want to remove fluid in the fundic pool if it's there. Avoid suction artifacts first because you can leave these little red spots. And if the patient is being evaluated for, for example, for iron deficiency anemia, it could look like maybe there was something there when it was you who did it. You want to be careful with over insufflating as well because it can induce retching or belching so always be mindful. You know, you do need insufflation to visualize, but you can also suction when needed. And so after you've examined the body, then you're going to head for the pylorus. And again, always just be mindful, inspect everything as you go in. So this is the view that you're going to see when you're advancing into the body towards the antrum. Again, not too much more different, only that now you can see the anterior and the posterior wall of the body of the stomach better. So here we're advancing to the pylorus. Again, you're going to have to bear right a little and follow the folds. It's all about purposeful movements and having a firm grip on the scope. Okay, you're really just going to have to advance. Your scope is going to be coursing along the greater curvature of the body of the stomach. So let's talk about impact of body position. You know, the scope can be steered simply by changing the hand or shoulder position. Again, this all comes down to ergonomics and finding the path of least resistance for you to get that maneuver achieved. You know, rather than just being really stiff with the scope and the thumbs, and we'll show you in the lab as well, sometimes all you have to do is just move your body and you can move the scope. Rather than creating such a tight grip on the scope, hold it like a pencil 20 to 30 centimeters from the mouth. You can do just with these very gentle maneuvers, you can get in without hurting yourself and straining your neck and your shoulders and your forearms, okay? Okay, so now we're going to be getting through the pylorus and into the duodenum. So you want to apply steady pressure. It can sometimes be a little fickle. You will create a gastric loop. It always happens. And then you're going to pop through the pylorus as shown here. Then when you're looking at the bulb, this is the typical view. You have the anterior and the posterior walls. And so the bulb is technically the first portion of the duodenum. You should always examine it completely first. And I use my big wheels, if I need to, my small ratchets if necessary. But I always want to make sure I cover a 360 view because you can miss ulcers a lot of times on that inferior portion when you poke in just past the pylorus. You can have ulcers there as well. It's very easy to pop out into the stomach, but that's okay. You want to keep the scope slightly left before advancing, you know, because it can, you can quickly move into the second portion of the duodenum. Don't be too hasty. Just take some time to examine the bulb. And then you're going to want to move to the right and advance to the apex of the bulb. The apex of the bulb is right here. So then when you get into the second portion, it does this corkscrew effect. And again, you'll see it in the lab, I'm sure, but many of you who are already scoping. I had an instructor teach me, you know, you kind of step into it. So you have your scope here. You kind of step, you torque, I mean, you torque this way, and then you do a clockwise rotation and then you reduce, okay? And then you're going to withdraw around the sweep, and that's what helps you advance into the second portion, sometimes into D3 as well. And you should be able to see the papilla going in, which will be around the 9 o'clock position. You know, this is a typical view. You'll see the valvulae coniventes. These are the circular rings. Again, the ampulla can also be visible. Do not buy it. See it. It's not a polyp. True stories that has happened to people, and you can actually induce pancreatitis. You know, one thing, if I could add something here, this is one of the things I wanted to talk about was, you know, once you get more comfortable with finding, identifying the ampulla, I usually make all my fellows find the ampulla during an endoscopy regardless of the indication. I was doing one a couple years ago, and I incidentally found a follicular lymphoma of the ampulla, and that was performing the endoscopy for other reasons related to heartburn. So again, it's part of that meticulous and systematic approach to doing an endoscopy. You know, all it took for me was that one experience that now I always document the ampulla on every endoscopy. Okay. And then after you're in your second portion, you can get into the third portion. To see the third portion, you may even have to just advance the scope a little bit. And you know, you may pop out frequently as you start to withdraw, and that's okay. Go in and out. See exactly what you need to see. You know, inspect everything that you need to inspect. So again, we go into the apex of the bulb. You're going to do this maneuver. You're going to torque big knob towards you, and then you're going to clockwise, and you're going to withdraw. And that's what's going to advance you into the duodenum. Okay. And then we get to the retroflexion. Okay. We talked about that. So then you're going to come back into the stomach and do your retroflexion. Now, retroflexion has two components. You're seeing not only the scope, we're seeing the area of the cardia and the fundus, but you're also going to need to see the incisora angularis as well. And so to retroflex, you're going to pull back into the area of the body antrum. You're going to big wheel all the way towards you, and you're going to push into advanced scope. And then you start to fine-tune with the ratchets and the torquing, okay? You do need to insufflate the stomach. Again, too much can cause retching and whatnot, but you can't see the stomach without insufflation. And I'm pretty sure now almost all endoscopic systems now use carbon dioxide, which is much safer. Okay. So this is an example here of the incisora on the left, a normal appearing incisora. And then on the right, you have an incisora with an ulcer. And why do we bring this up? Well, just as an anecdote, we once had a patient who was admitted to us for melanoma, and he had just had an upper endoscopy by another provider in the community not too long ago. We went in, and then upon our withdrawal and then retroflexion, we saw this huge, cratered ulcer in the incisora that was a gastrogadenocarcinoma that was missed because maybe someone was being hasty or didn't retroflex. I cannot emphasize enough how important it is to retroflex and document the incisora and also document the cardiac. People do miss lesions. You do not want that to happen. And then you can photodocument it as well. Okay. So again, for retroflexion, you're just going to be working with the knobs and the torquing and moving your body without over-twisting your arm. There's no need to do that. These are some very simple, smooth maneuvers. You can even do a 360 in the retroflex position. Okay. You're going to pull in here and see the cardia, and then you can just start tweaking the knobs. You see the fundus there. I've picked up gastric lymphomas of the fundus as well. All right. Let's talk a little bit about when and where to biopsy. So if you see a suspicious gastric ulcer, so what do we mean by a suspicious gastric ulcer? So if you see an ulcer in the body of the stomach or in the incisora, you know, those aren't the real typical locations of gastric ulcers that are related to H. pylori or NSAIDs. Then you might want to consider biopsying it during that session. If you do, it's recommended you take at least 8 to 10 bites because you can have sample error. So 2 to 4 bites is not enough. You need about 8 to 10. Again, if you're worried about candida esophagitis, you can brush. If you need to biopsy if you suspect the patient has some resistance, you can do that as well. You know, the teaching for CMV versus HSV, so C is at the ulcer base or the center, whereas if you're worried about HSV, you biopsy the periphery or the margin. For H. pylori, we get biopsies from the antrum body, and I get the incisora as well. And then if you want to rule out celiac disease, now the recommendations are to get 6 total samples, including at least 1 set from the bulb. So we usually do 2 sets from the second portion and 1 set from the bulb. So upon procedure completion, you know, deflate the stomach, okay, and then slowly withdraw through the esophagus, and you will need to insufflate some because you need to visualize the esophagus. And this is where a lot of times we may see lesions, whether they're benign or malignant, in the proximal esophagus, such as shown here, which is an inlet patch, which I do think is important to document, or you may see some esophageal webs. And again, you may even pick up a diverticulum that you didn't see upon the initial intubation. So upper endoscopy recap. So again, for esophageal intubation, be patient, but be deliberate with your movements, okay? Have a firm grip on the scope. Keep the tongue on top. Have patience in that periform fossa when you're trying to get through the upper esophageal sphincter. No forceful pushing. Again, don't rush. Ergonomics, very important, okay? You need to be comfortable. It doesn't matter whether you're a fellow or Joe Schmo or the chief. It doesn't matter. You need to be comfortable so you don't put yourself at risk of injuries and fatigue at the end of the day. The esophageal examination, you want to keep the lumen in view. You can pause at the EG junction. Don't rush on coming out. Again, in the stomach, suction fluid. Remember, patient safety is number one. Go to the pylorus, have patients apply some pressure when going in. Upon withdrawal, don't forget to retroflex. And then in the duodenum, always look at the bulb first, and then work on that corkscrew maneuver and withdraw around to get into the second portion. And if you can, start getting comfortable with always identifying and documenting the major papilla. Develop and practice a deliberate systematic approach. Again, regardless of the indication, have your approach. Indication on body position are going to need to be used to direct the tip of the scope. Even if it's a routine case, if you have some time, use that time to refine your skills with an endoscopy. Every endoscopy, regardless of the indication, is an important one. And practice, practice, practice. You know, there's always room to get better. Even us who have been out in practice, there's always room for improvement, okay? And with that, I'll end. And thank you so much. And I'm open to questions. Hey, Dr. Gomez. Thank you for the presentation. Is it audible? So when you're looking for the – yeah. Hi. Hi. So when you're looking for the incisora, are you retroflexing in the other direction? Or is it, like, when do you see it, essentially? Yep. So once I usually finish in the duodenum, when I pull back into the junction of the body and the antrum, that's when I start my retroflexion. I big wheel all the way towards me so that you have the tip curved in the retroflex position, and then I advance scope. And as I start doing that, usually for me, the first thing that comes into view is the incisora before I go into the cardi on the fundus. Thank you.

upper endoscopy

indications

techniques

considerations

dyspepsia

GERD