Welcome him to the podium. He's gonna be talking about Diagnostic Upper Endoscopy. Dr. Zakur is at University of Michigan. He's a pediatric gastroenterologist who did advanced endoscopy training in the fourth year and is there now. Welcome. Thank you very much. Thank you, Jason and Catherine. Thank you for the invite. Honored to be here, doubly honored to be here because I was invited back from last year. So thank you and thank you to the ASGE and the coordinators and directors. It's great to be here. Welcome, everybody. I have no disclosures. They don't really care what pediatric gastroenterologists think about their devices, so we don't have any disclosures. But anyways, today I hope you will understand the indications for upper endoscopy. We're gonna review some technique basics. We're gonna outline the components of a normal, complete examination and we're gonna become familiar with abnormal conditions. So let's start out with a question. Which is not an appropriate indication for an upper endoscopy? A, dyspepsia symptoms in a 65-year-old female. B, persistent reflux symptoms for 10 years in a 70-year-old obese male. C, 25-year-old male with heartburn symptoms not responding to H2 blocker treatment. D, a 35-year-old female with symptoms of dysphagia. And E, 25-year-old male with iron deficiency, anemia and melanoma. I feel like I'm watching the Kentucky Derby. Come on, horse. Come on. Come on, A. How are we doing? Got about almost everybody voting. OK. Let's see what we got. The C's have it. Yes. So 25-year-old male with heartburn symptoms, not responding to H2 blocker treatment. That does sound like a not or inappropriate indication for heartburn endoscopy. So let's talk about the indications. Upper abdominal or upper GI symptoms, including dyspepsia in a patient who's older than 60 years, new-onset GERD in a patient age older than 45 years with persistent reflux symptoms despite treatment, persistent vomiting of unknown cause, dysphagia, and odynophagia, looking for things like eosinophilic esophagitis, among others. Iron deficiency anemia, suspected upper GI bleeding, diagnosis and or treatment of esophageal varices and portal hypertension, abnormal imaging, food impaction or cause of congestion, as well as foreign body removal, as well as confirmation of things that's now more in the pediatric realm, but confirmation of celiac disease in certain respects, as well as upper GI for looking for Crohn's disease, ulcerative colitis, IBD. But these alarm symptoms are sort of triggers for you to think about moving forward with an upper endoscopy or EGD sooner rather than later. So unintentional weight loss, odynophagia, dysphagia, hematemesis, and melanoma. Refractory acid reflux and persistent vomiting. There are more, but these are some of the general ideas of when to pursue EGD sooner rather than later. Learning to perform an upper endoscopy, there is a really nice, steep learning curve. I would suspect the muscle memory starts to develop at number 50, but in reality, the minimum number of upper endoscopy that should be performed before assessment of competency is about 130. And competency or achieving competency is sort of a technical and cognitive skill achievement. It's not just learning the maneuvers, but it's also knowing what you're looking at, knowing what your next step is going to be, and knowing how to approach what you're finding. You want to be prepared for the needs of the case and inform your team to assure success. Study the case, get to know the patient before you're pursuing your EGD. Find out if they've had procedures before and review those records. That's hugely important, especially when you get to the interventional stages of your career or training. It's really important to know what has been done in the past and where you're going. Practice a deliberate and systematic approach. I call it a dance. My fellows know that I call it a dance, and that's the muscle memory that's going to happen. You're going to start doing things without even thinking about it. You're not going to know why you did that because that's what you're supposed to do, but that's exactly where you're going to be after doing your first year's worth of upper endoscopy. Take the time and look carefully. Lesions can be subtle. Suction out your puddles, suction out your food, your mucus, things like that to make sure you're not missing anything. Don't let any stone go unturned. And then your advanced procedures will build on your basic skills. Ergonomics are really important in endoscopy. It's a hot topic these days. Be comfortable when you're doing endoscopy. The monitor should be positioned directly in front of you. The height should be just below eye level with an optimal viewing angle of 15 to 25 degrees below the horizon from the eye. And make sure that's how it is. Even if it's someone stepping in for you for a moment like an attending and then you're taking over again, return back to the right position because it is important that you maintain that comfort level. The examination table, I usually say, should be sort of at your waist or belt height but should be at or below your elbow height, about 0 to 10 centimeters below the elbow. So this is the insertion of the scope through the bite block or through the mouth with the tongue on top. And then you'll see your hypopharynx, your posterior pharynx. And when you're inserting the endoscope, make sure the patient is properly sedated. It's easier for the patient and easier for the endoscopist. You don't want someone flailing about, coughing, sputtering. It's really painful for everybody. Direct visualization is important. You want to stay midline. The tongue should be on the top view, as you can see in the cotton pictures. Examine the hypopharynx, bless you, the vocal cords, and the piriform fossa. You should know where they're at before you enter the esophagus. The UES is the level of the thyroid cartilage, approximately 15 to 18 centimeters from the incisors. And things to think about are there's always a chance there's a Zinker's dive reticulum on the other side of that UES. And just make sure you go in nice and gently and slowly. And then speed up as you get better at doing this. Some people will go down the piriform fossa to enter the esophagus. Some people will go down the middle. It's a little bit different. If they're intubated, it makes it easier to go down the piriform fossa. So here it is again. Tongue is on top. Your big dial, your big knob, you're pushing down with your thumb, so it's going back, so you're looking up. And take your time. And then those are your vocal cords, your retinoids, and your piriform fossa. Please do not dabble in bronchoscopy and go through your vocal cords, because if you do, you're going to see this, and you're in the wrong spot. So once you're there, you want to gently advance past the UES into the esophagus. If you are making any noise whatsoever, forceful noises, trying to get in there like a high school tennis player who has a wicked backhand, you're probably pushing too hard. So back up, get into a better position, find out why you're having trouble advancing the scope in, but you should not be making any grunting noises getting in through the esophagus. As you go down the esophagus, take appropriate pictures. I always tell my fellows, don't take a picture down the pipe. That doesn't help. Angulate up, down, right, left to show what you're finding. That's better for photo documentation. Examining the esophagus, once you get to the GE junction, it's an imaginary line where the esophagus ends and the stomach begins. Deflate your stomach, pause to examine it carefully. Look for the top of the gastric folds and or the palisading vessels. Measure your GE junction from the bite block. It's important, especially if you're finding things like Barrett's, which is usually or approximately at 35 to 40 centimeters. Your Z line is a visible boundary between the squamous and columnar tissue. You're allowed about one to two centimeters of columnar tissue through the chest above the diaphragm. That's not horribly abnormal. As you're going through the LES, you're insufflating. You get into the stomach, and this is what you find. You find your rugae. You're looking basically at, well, I won't tell you what you're looking at because it's a quiz question, but that's the question. Which of the following represents the anterior wall of the stomach? I think we've got enough votes. All right. Shall we? Aha. I thought I was going to stump them. At least the majority of them, I should say. So yes, the anterior wall is D. So once you start doing a lot of endoscopy, you'll start to see G-tubes and pegs and things like that. And they'll be sitting right where D is for the most part if they're in the right position. A is your lesser curvature. I think that's the next slide. Lesser curvature is what you're seeing. So the cartoon picture here, the scope sort of looking at the distal stomach with the lesser curvature on the top, the greater curvature on the bottom of your posterior wall is at 3 o'clock. And the anterior wall is at 9 o'clock. Down there, it says may require slight leftward counterclockwise torque. That's if you want to suction out the puddle that you'll usually find in that location. And then retroflect in terms of trying to find the sort of like a reverse candy cane to see the scope coming out of the esophagus to look at the upper part of the stomach. So examining the stomach, the patient's on the left side. Few declinates at the fundus. Remove that fundic pool of fluid first to reduce risk of aspiration. Avoid suction artifacts. Avoid over insufflation. May induce retching or belching. So you don't want them to start hiccuping in the middle of it because it also becomes painful for everybody. And the next thing you want to head for the pylorus, watch for pathology prior to endoscope trauma. So you want to look around, get a good look before you advance. I mentioned this before. And this is sort of the position of the scope once you are in the body starting to look towards the pylorus. As you advance to the pylorus, my fellows make fun of me all the time because I inundate them with this sort of instruction when they're first years. But you want to torque right, push in, look up. Torque right, push in, look up. Torque right, push in, look up. And you will literally get there every time. Early on, it's going to be ugly. You will get there at some point where it's going to be nice and sort of one fluid movement. So the body can also be used. Your body can also be used to steer the scope. You don't have to use dials all the time. You don't have to always use your torquing hand either. But the scope can be steered simply by changing the hand and shoulder position. So moving your hand, your left hand, the one with the controller in it, or turning your shoulders if you stiffen up your arm can be used to torque your scope. Dropping your hand down, cocking your wrist will get you sort of some of these positions without having to go to your dials. Allows for single hand scope steering. And you want to practice this technique in the stomach where there's a lot of room. But it's something that's helpful, especially if you're angulating hardcore up or hardcore down. You can really torque right or left nicely by just moving your wrist, your shoulder, or your body. And this is now looking at the pylorus. So this is the cartoon image of what it looks like. And then you start to advance. And when you want to traverse the pyloric channel, you want to apply steady pressure. You're going to form a loop. Everybody forms a loop. You want to form a loop in the stomach. And you're going to pop through the pylorus. Inevitably, at some point, you're going to kiss that duodenal bulb, the contralateral wall, cause a little bit of trauma. That's okay, just be careful. But this is essentially the diagram showing here is exactly what you're doing. You pop through. But then you want to back up and take a look. Up, down, right, left, take a look and see what's going on in your bulb. And once you're in the bulb, anterior, posterior, again, apply where your nine o'clock is anterior and your three o'clock is posterior. So you're now just through the pyloric channel. You've taken a look and now you can advance. When you want to examine the duodenum, the bulb is the first portion of the duodenum. You want to examine that bulb completely. Get the scope slightly left to prevent advancement into D2. But then once you're ready, move right, which is posterior and advance to the apex of the bulb, which is essentially that shadow that you see there sort of formed by the fold here. So once you start advancing to the apex, then you can start to do your maneuvers. So to examine the descending duodenum, the second portion of the duodenum, which is D2, once you're at the apex of the bulb, it's essentially a torque right look up or your big knob back or dial, big knob dial back. And then you withdraw around the sweep. And that's the core screw that they're talking about. It's described in cotton and that's sort of the maneuver. I will sometimes have my fellows or I will turn my shoulder, cock my wrist, performing the same maneuver. And then you start to withdraw and that paradoxical motion advances you forward because you are shortening up that loop you just made in the stomach so that you have a minimal amount of scope in the stomach. And now you are stretched out into the duodenum. So once you get through the descending duodenum or to the descending duodenum, you see the circular rings called the valvuloconivitis, which no one calls them that, at least we don't. The ampule is usually at the nine to 11 o'clock position. Please, please, please do not biopsy it. And then that paradoxical motion, yeah. The paradoxical motion upon withdrawal, as I mentioned, corkscrews you even further downstream into the distal duodenum. So the transverse duodenum is that third portion and it may require additional maneuvers to visualize, as I mentioned, and do not be upset if you have to pop out into the stomach as you're pulling back. It takes a couple of times in through the duodenum till you finally get to where you wanna get to and go from there. So once you get through the sweep, there's a corkscrew method there. You're gonna dial up or dial back and you're gonna look up. There's the ampulla to the nine o'clock. And then they're only looking at the sweep. If you were to do the full maneuver, you would end up going straight into D3. So once you pop back, you can see your major papilla usually at 12 o'clock on the way back. If you've done that full maneuver, you examine the duodenum and you come back to the stomach. There's your ampulla there, major papilla. And then once you're in the stomach retroflexion, so it's a hard up, sometimes you can do a hard left and push in and you move away. So you're in this reverse candy cane position. The way I teach it, I actually ask for retroflexion before leaving the stomach so you can look for any pathology because sometimes doing these maneuvers in the duodenum results in some pathology in the stomach and you don't want that. You wanna examine the stomach. Sorry, I'm going almost over. Examining the stomach on withdrawal, you wanna insufflate, but you wanna be systematic and thorough, learn that dance and that muscle memory. As I mentioned, retroflex to examine the incisor, incisor, cardia and fundus. When you're retroflexed, both knobs are toward you, as I mentioned, torque the scope to get away from the wall, pull your scope to get closer and closer, right? So you're in a reverse candy cane. So you pull out of the mouth to get closer to the top of the stomach. Okay. All right, great. Flashing light. I don't know what to do. The flash is in front of you, so you must quit. Yeah. I'm done. I'm out. Okay, good. Thanks. Thank you. Good, it's green again. Nice. So as I mentioned, as you're pulling out, you'll see the cardia and the fundus. Evaluate this. This is where you can find some hiatal hernia and other abnormalities. Sometimes you'll have to do interventions in the retroflex position. That's when you can use the locks on your dials or on your scope. And when and where to biopsy. So if you're suspecting gastric ulcer, think about eight to 10 bites from the margin. Candidal esophagitis, brushing with your cytology brush, going through cytolite, and biopsy sending to PATH. CMV, you want to get the ulcer base. HSV, you want to get the ulcer margin. H. pylori, you're looking at the antrum and body, especially if they're on PPIs, you want to make sure you get that body. And then ruling out celiac disease, six total, so basically four from the duodenum and two from the bulb, or at least one, if not more, from the bulb, so that you can compare if you're putting them all in the same jar. But when in doubt, biopsy. And keep your pathologist in the loop. So label your jars really well so that everybody knows where you're at. And also keep your tech, your nurse, your scrub tech, whoever's with you, getting the biopsies for you. Make sure they know where you're at, too, so they can appropriately document and put them in the correct jars. Because sometimes you get these results back and you have no idea what you did because you scoped 100 patients in a week, and you have no idea where you put that biopsy. You're finishing up the procedure. After complete examination of the stomach, you want to deflate it, collapse it down, suck out that puddle on the left if there's anything left over. Withdraw slowly through the entire esophagus. You want to examine the upper esophagus, especially for inlet patches and webs. Take good pictures throughout, because photo documentation is just as important as your typing documentation or prose documentation. As a recap, esophageal intubation. Be patient and deliberate. Like I said, learn the dance, make it your dance, so that when you guys are done, when everybody's done and graduating, it's your way of doing it. But most importantly, be safe and be efficient. Keep that tongue on top as you're getting into the esophagus. Patients in the piriform fossa, no forceful pushing, no grunting, no tennis player sounds. Esophageal examination. Keep the lumen in view, so keep it centered. Pause at the GE junction. Don't rush on exit. You will sometimes have to do a little sort of maneuver through that LES to get into the stomach. And then once you're in the stomach, you want to insert, take good pictures, take a look around, suction the fluid, especially on the left, which is almost where it's going to be. Always minimal inflation at first. Then head right to the pylorus. Patience and pressure at the pylorus, you gently pop through. And then when you are withdrawing, fully inflate or insufflate and be systematic. Again, going back to your dance. Retroflex to take a look at the cardiac fundus. In the duodenum, complete the bulb exam first before advancing on. Corkscrew and withdraw around the sweep into D2 and D3. And as a recap also, develop and practice a deliberate systematic approach. It's really important. It makes it smooth. It makes for a good scope, good day. And it's safe ultimately for your patients. Use torque and body positioning to direct the tip and then use your dials for fine tuning. That's essentially what I do and what I teach. Use routine cases to refine precision and technique. Don't ever be too cool for school to do EGDs, even when you're a third year about to graduate and going on to your advanced endoscopy fellowship. Do a full day of EGDs just to practice. There's absolutely nothing wrong with that. So practice, practice, practice. You can always get better and it's so true. You can rate me without pressure. Thank you. Questions, please. Virtual hands, anybody in the virtual world? Questions? Question, yes, sir. Push the button. I think that's it. So what's the best way to keep the lumen in the center when you're going down? So you're going down the esophagus? Esophagus, yeah. So every once in a while, you may need to use a little bit of a right left dial, but essentially up, down and torquing. I teach my fellow students, I teach my fellows that I never touch the right left dial during upper endoscopy, unless it's to fine tune or target biopsy or target an intervention. I use a lot of wrist, hand, shoulder, body, and then torquing. So I use torque for my right, left and up, down with my thumb. It's sort of the more straightforward and easy way, but that's how I do it to keep things in the center. But every once in a while, you're gonna get some of these esophagi that are not cooperating. So you have to fine tune a little bit with your right, left dial, which you can sometimes use your helper fingers. But if you have to let go, let go and use your right hand. Good question. Anybody else? Yes. For quality metrics for documentation, do we have any set images or areas we need to take images off? Let's say like for colonoscopy, the AO or the valve for the upper, do we have any areas that we really must image? I don't know if there's any specifically in the adult world. I think it's important to take a look at your LES and measure your LES, at least when I was doing my adult training or my advanced training with the infamous Dr. Parak in the back. Those areas are important. Obviously you wanna document, photo document abnormalities in pathology. From a quality improvement, quality assessment standpoint, I don't think there's anything specific. I teach my fellows that I want three pictures in the esophagus, upper, mid, lower, because obviously we're dealing with a lot of EOE and that sort of thing. So I wanna know what I'm biopsying, what it looks like before I biopsy. Stomach, I get one big picture of the entire stomach as best as possible. So looking at the greater curve. And then I want pylorus and I want retroflexed. And then again, two or three in the duodenum. So bulb just beyond the sweep. So D2 and then D3. That's how I teach my fellows and that's systematic. Again, that can be quick, especially when everything's normal. If there are abnormalities or if there is pathology, you wanna focus. Obviously there's the adult gastroscope that has additional tools such as near focus. We also have NBI in our pediatric scope. So use your NBI. But from a quality assessment or a standardized picture taking, I don't think there's anything specific in the adult world from an upper endoscopy standpoint, unless anybody has any... No, I don't think there is. Great question. We have one more question from the virtual attendees. So when withdrawing, how do you prevent getting kicked out from the sweep, especially if you have a lesion or bleed in the sweep? It's hard not to get kicked out. I think if you've done your full maneuver and you have reduced that loop, you're gonna get kicked out. I think the main thing is to, if you are intervening in the sweep, you gotta be in the long position, sort of forming a loop in the stomach. It's hard not to get kicked out, especially if you've withdrawn and corkscrewed through into D3. Other than having a good grip on the shaft of the scope, you're gonna get sort of kicked out if you've done that full maneuver. But going into the long position and reforming that loop keeps you sort of in position. Anybody else? I was just gonna add that as you withdraw, if you do so very cautiously and there's a lot of back and forth, so instead of just a steady withdrawal, you're sort of more staccato, then that puts you in a slightly better position to anticipate the moment you're about to be slingshotted back into the stomach. And that, at least in principle, allows you to sort of drive forward and prevent that sort of slingshot. But it is hard, especially when you're in the throes of trying to stop a bleed or something like this. Dr. Paraka, question? Comment? Push the button. Oh, give him a button. Yeah, it's okay. Leftward torque will shorten you when you're in your, so if you're in a torque position already, whatever the torque will lengthen you, so if you're in a torque to the left, calm yourself down, put yourself in, you don't have to. You're working to find that balance between withdrawal and maintaining the loop contact. So the forward tension moves leftward torque, it's not a reaction to that. Actually, it's not in everybody's head, but it's in everybody's mind. That's great, I agree, yeah. Other questions? What, one more. Can you hear me? Last one. Might be like a silly question. Do you have any advice for esophageal intubation in a patient who is intubated with an ET tube? I think it seems silly because it's only one way to go, but I've had difficulty, I don't know if it's because the tube is in the mouth, you don't know where to position the scope, and pushing through the esophagus itself seems to be a little bit more difficult because maybe from the ET tube cuff that's inflated. So if you have any advice. When someone's intubated, I usually try to go down the piriform fossa, but in the pediatric world, we don't have to worry about this as much as in the adult world, but I ask for jaw thrusts on every case, intubated or not. Sometimes, depending on what you're doing, flexing the head forward sometimes helps relieve some of the pressure on there. There's different ways, but I would ask for jaw thrusts as long as you're not, you don't have a TMJ patient or some patient that has a loose jaw or abnormal jaw anatomy, but try the jaw thrust. That usually helps at least open things up a little bit more. Depending on the situation, sometimes I will ask the anesthesiologist to at least reduce the cuff, but it's rare because you can cause some problems there and you don't want them to aspirate because you'll be pushing goop or saliva or whatnot back into their trachea, but go down the piriform fossa in those patients rather than going straight down the middle and ask for a jaw thrust. That's usually my go-to. Thank you.

pediatric gastroenterologist

diagnostic upper endoscopy

upper GI symptoms

systematic approach

ergonomics

biopsy techniques