He's gonna be giving our pathology and terminology talk. Amr is a vice chief for education and co-director of the Advanced IBD Fellowship, also the assistant dean for medical education. So it's a pleasure to have him and welcome. Thank you. Thank you guys. Thank you to the ASGE and the course directors for inviting me. I wanna start by saying a lot of what you've heard in the first few talks, talks about things like EMR and ESD which are all very cool stuff, but this is very relevant to just run-of-the-mill germane endoscopy too. And so many of you will end up doing therapeutic work in your career to varying degrees, others of you less so, but it's really applicable to also even allow some of us IBD folks to make an appearance at the ASGE. Disclosures, nothing relevant for this talk. So this is a, except that I am on the ABIM for your board. So whenever you're attending, say to you, this will be on the boards, and 95% of them have never seen the boards. So they actually have no idea that it's gonna be on the boards or not, but it sounds like a good thing for them to say. But when I say it, I'm not allowed to say it, so it doesn't really matter. Because I signed 25 pages of documents that I can't reveal anything. But none of this is on the boards. So this is a typical, so I wanna show you an example of two contrasting endoscopy reports with a witty name. So this is a patient that came in for an upper endoscopy. You see the traditional picture on it. If you guys use various reporting systems like probation, this is what the top right would look like with the picture of the upper GI tract in the pictures. Indication of hematemesis, procedure performed upper endoscopy. And then you see findings, some gastricis in the stomach, a bleeding ulcer, we injected epi and cauterized. And then literally copying and pasting the same thing from the findings to the diagnosis. So you can see that that, if you feel that that provides the degree of information that you think it may. And so compare this to something like this, where you see it describes in the findings, the findings along each aspect of the upper GI tract, normal esophageal mucosa with the regular Z line. The stomach had what you see described there, not only the erythema in the stomach, but also specifying the size of the ulcer, the nature of the ulcer, which may help you decide later if you thought that that had malignant potential. The nature of the bleed that the ulcer had, what criteria it had for the type of bleeding it was and whether or not you think that that would be appropriate for endoscopic therapy. How they addressed it with removing the clot and treating the underlying vessel, the type of epinephrine. So as you look at your endoscopy cards, we largely overwhelmingly use one to 10,000 epi. But since a month ago, you guys were third year, many of you were third year medicine residents and running codes. And you look at that epi, that oftentimes is one to 1000 epi. So keep in mind that it does matter if you're just trying to like, oh, go over to the, don't open a crash cart for this, but if you do, it's a different type of epi. So know you're, just like you need to know your electrocautery and electrosurgical settings, make sure you understand the different aspects of the medications you're using. So that's helpful to describe and how much you used. And then what type of a thermal coagulation you use, in this case, bipolar cautery, and then the duodenum as well. And then the diagnosis doesn't just recapitulate the entire thing with a copy and paste, but briefly summarizes what you found and what you did about it. So that's much more helpful. What's not on this is another big pet peeve of mine, if you do an open access procedure. And if your plan is return to referring physician, that's a remarkably unhelpful plan. I mean, obviously, where are they gonna go unless they just want to go to a doctor? Like, of course, you're gonna return to referring physician, but they asked you for an endoscopic procedure, but probably to some degree, an intellectual opinion. And so don't just say refer to doc. I mean, if you, whatever you found, you might say continue, it might be simple. It might continue PPI or stop PPI or whatever, but try to be a little more helpful to the person that's referring to you. Because right now they don't have a choice other than to refer to you because you're the fellow that's on that day. But the day that you finish, they have options and you want to be a meaningfully helpful provider to your referring physicians. So how would you describe the endoscopic findings you see here? Portal hypertensive gastropathy, gastritis, pachypunctate, erythema in the gastric fundus, or a Cameron ulcer? So I think we have only about half the crowd, so I'll take the 49. And you see that most people said PATCHE, punctate, erythema, and the gastric fundus. A handful of people mentioned PHG or portal hypertensive gastropathy. The point here, and it may be repeated in the next set of slides, is your goal in describing findings is describe what you found, not what you think it may be. There's an opportunity later to say what you think it may be. You don't know if this person has, without histology, without imaging, without other things, you don't know that this is or isn't portal hypertensive gastropathy, which it may well be, or it could be from NSAIDs or it could be from other things. So describe what you find. In this case, you see PATCHE, punctate, erythema, and the fundus, which is helpful for the next person to know what it may be. And then, you know, you can always, in your report, then say this is concerning for portal hypertensive gastropathy. Please get a duplex to look to see if someone has cirrhosis or portal hypertension. All right. Next one is this linear erythema in the antrum, gastritis, GAVE, which is gastric anterovascular ectasia, or portal hypertensive gastropathy. So, most of you said A, which is correct, so, again, describe what you see. This very well might be GAVE with that kind of watermelon stomach appearance that you see in the antrum. What was that? It's GAVE. It could be GAVE, but it could be segmental ischemia, which it isn't, because it doesn't happen in this part of the stomach. But the point is that you should describe what you find, and then you can, of course, later parts of the report say what you think it might be and how to approach that treatment, but describe the initial endoscopic findings. There's one more of these, so you should try to catch the pattern here. How should... Don't wait, just do it. How should the endoscopic findings... We have, like, not complete control of our slides, I'm just kidding. So, how should the endoscopic findings be described? Punctate erythema with scattered gastric erosions, visible oozing in fresh blood, gastritis, GAVE, or NSAID gastropathy. And this is good, because by the third slide, everyone's caught on that you just describe what you see. Gastritis, for example, is, if you're playing semantics, is really a histologic diagnosis to see if there's inflammation. You can't really make that assessment on endoscopy, but yes, exactly, this is, as you see described in A, it could be from a variety of things that's an etiology, including NSAIDs. All right. So the next slide, which image represents an erosion? So you see pictures in A and B, and here you can vote. So the large majority of you said A, so that is correct. And so there are definitions of what's considered an erosion versus an ulcer. And so this picture represents the depth, really in broad, you don't know this when you're doing an endoscopy. You're not going to have a cross-section to which level it is gone. But if it has perceptible depth, then you can call it an ulcer. And those that lack that kind of perceptible depth are generally an erosion. Technically an erosion is shallower. It can get to the muscularis, but shouldn't penetrate beyond that. The muscularis mucosa, that is. And an ulcer can get deeper, as you can see in the picture on the right, past the muscularis mucosa into the submucosa and beyond. And so that's why A was an erosion, not an ulcer. All right, this next picture violates a lot of what I've been saying for the past 10 minutes. So I'm just doing the reporting. So identify the findings. Is this bare esophagus, LA-grade B esophagitis, gastric heterotopia. And see, this is really about irony, or an inlet patch. Or E, based on what I said, it shouldn't be any of these. But so for those of you that largely picked bare esophagus, that's correct. But technically, again, in your report, you can say that it looks like semi-colored mucosa that's extruding proximally beyond your expected line. And this is relevant. If you look 10 years ago or 15 years ago, people that had one centimeter of this might often get biopsied. And newer guidelines, new-ish guidelines, suggest that these shorter ones are just the irregularity. Remember that the Z, in one of its original descriptions, was the zigzag nature of this. It's not supposed to necessarily be exactly even. So you should be allowing for some unevenness. But certainly, if it's more than a centimeter or two more than that, then it's concerning for bare esophagus. But as you've probably seen, if you've done endoscopies already, it's really, you need that biopsy to make that histologic diagnosis of intestinal metaplasia before you call it bare esophagus. So this is, on the top, is a normal or regular squamo-columnar junction versus one in which it is up higher. And if that is, in fact, histologically intestinal metaplasia with columnar epithelium, then that is bare esophagus. And you can see that first bullet point in the middle there on the left of describing how it should look. So what is the classification scheme that is typically used, most commonly used now, to describe bare esophagus? Paris, Kudo, Los Angeles, Graves, or Prague? Pick your city. Or Kudo. All right. These are too easy. So this is the Prague classification. So it's important to get used to using it. And so for many of these, whether using these classification systems and inflammatory bowel disease, we have reporting systems for endoscopy, they're really used to create some sort of common language so that everyone can be on the same page about what you're describing. And we'll see that later in some of these other slides. So what you see here is the normal anatomy. There is an overlap of the area where the squamous epithelium of the esophagus becomes columnar epithelium of the stomach in line with where the diaphragmatic pinch is. And so you see that on the top right, where the top of the gastric folds coincides with the diaphragmatic pinch. And that is the Z line, or the squamous columnar junction. When you have intestinal metaplasia, generally from chronic reflux disease, coming up higher, then you can see that the pinch there is at 36 centimeters, for example. There is 2 centimeters of circumferential columnar appearing epithelium, and then a couple more centimeters of more patchy. And so that's this Prague classification of the C and M. So the number of centimeters that are circumferential, and then the number that are maximal. And it's additive. That is to say, so this would be an example of C2M4, as it was just on the next slide. OK. So what is this? This would be 1 centimeter of circumferential, which you can see in the bottom two arrows. And you don't include the small little islands above it. So you see that it's 1 centimeter of circumferential, likely bare esophagus, and 2 centimeters to maximal. So this would be C1M3. This is another example that is a little longer segment of Barrett's, where you see 5 centimeters of circumferential, up until the point that it's not all the way around the diameter of the esophagus, and 2 more centimeters. That is the maximal extent. That's a C5M7. So what about some unusual anatomic, not unusual, very usual anatomic variants? So remember, when you're dealing with the hiatal hernia, many of these folks with chronic reflux disease will have a hiatal hernia. And so you can see in the picture that the gastric mucosa goes above where the diaphragmatic crura are. And so the squamo-columnar junction is higher than that. So you need to start measuring not from the diaphragmatic pinch, but from the top of the gastric folds, where the squamo-columnar junction should be. So in this case, even though a lot more of it is above the diaphragm and looks columnar in appearance, this would be a C2M4, because you're only starting where the LES pinch is. So where is the diaphragmatic pinch in this picture, A, B, or C? Finally, something that's not 93% in one direction. There's an interesting science to the psychology of this. Whoever goes first. And how everyone just picks whatever that person says, because they're scared to not be like everybody else. But here, there is actually an interesting split between A and B. So what they're asking for here is not the top of the gastric folds, but where the pinch is of the diaphragm. So this, in this case, would be A. So you can see where there is a narrowing, where the crura are impinging from the outside on the stomach. And then the top of the gastric folds, which you see higher up there in B. And so this is someone who has a hiatal hernia. So the top of the gastric folds is where you see with the multiple gray arrows, which is a few centimeters higher than the diaphragmatic pinch. So that is all stomach coming up, which makes it a hiatal hernia. When you see it here, there are different grading systems. Again, if you use different endoscopy reporting systems, you can see things like the Hill and other grading criteria about how sliding hiatal hernias may appear. But if you have a normal anatomy without any hernia or anything, you usually should see a nice wrap of the diaphragm around the scope. And here, you see the difference in color of the, let's see if I can master this a little better. OK, so here you can see the, see how that works? It's amazing. It's amazing. So here you can see the squamo-calumnar junction. And then you see that it's not tightly wrapped around there. And this represents that hiatal hernia. And we'll get back to that a little later. Exactly, exactly. So this is another picture of the same. And so this is wordy, but important to just get the general sense, and we've discussed most of this, that the first thing that you do is ensure that you recognize whether or not there is a hiatal hernia or not. And then look at where that might be. Look where the diaphragmatic pinch is versus the lower esophageal, where the sphincter pinch should be versus where the lower esophageal sphincter is. And then what the displacement is that's both circumferential and maximal. And then you can use that to create your PROG classification. So this is an inlet patch. And so this is oftentimes up higher in the esophagus. A lot of people think that has no real implications other than an embryologic issue. There are some cases in which people that have very dysphagia up high, like cervical dysphagia, have had improvement of symptoms with things like APC in this area. If you biopsy it, it's actually heterotopic gastric mucosa and oftentimes can be seen. If you actually take the time to come out slowly in your esophageal withdrawal, particularly as you get closer to the upper esophageal sphincter and give a little CO2, then you can usually see this area nicely. And it's probably more common than we give it credit for. Because oftentimes, by the time you get to what you think you're done with, it's like this whipping out of the scope to get to the next case. So spend a little time when you go. It's easier to see usually on withdrawal. You can if you're carefully going on an insertion and putting some CO2. And as you slowly see the UES open, then you can see it. But it's usually easier to see on withdrawal. All right, narrowband imaging may help identify which of the following? Colon, polyps, spare esophagus, dysplasia, and ulcerative colitis, gastric cancer, or the sneaky all of the above, or not so sneaky. I am allowed to say that won't be on any ABIM exam, because that's not allowed. All right, almost everyone said all of the above. So just realize what you have at your disposal. You may, depending on what you use, Olympus, Pentax, Fuji, probably most of you perhaps have Olympus. All of you, all of the companies have some sort of virtual chromoendoscopy device or button that you can hit. And they all call them different things based on what their proprietary name is. And so this is ways to just basically change the wavelengths. And I'll be the second person to show you pictures that you thought were in physics class, but you were actually in an endoscopy fellow's course. When you just look at the narrow band of this and how it can show you patterns nicely. So this is relevant for a lot of things. So you see a few examples there of how you can use these virtual chromoendoscopy maneuvers. So here you see white light now. Pretty much all of you, I'm sure, using high definition. White light for your endoscopies. And then how something like the squamo-columnar junction or bare esophagus may appear in NBI when you click that button. So in most of your scopes that you're using, if you use something, depending on the scope, above where you take the pictures or where you freeze frame for a picture, you'll see a button for NBI. There's other things that you might use. And part of knowing your equipment, play around with it one day of which one's magnification, which one's NBI, which one's. This happens all the time. And I don't know if it's occurred to you or if you're willing to admit it. Like, take a picture. And it's like, NBI. Take a picture. And it's NBI. Do NBI. It's a picture. And it's like, give me the scope. So this is not that it happened to me. But this is a common thing. So just kind of get a sense of where those things are. The not as fun one is like, come over to band. But you're like, don't come up here to the up-down dial. And make sure you come down here. Otherwise, bad things happen to verisy. So just get really a comfortable sense of your equipment and know where these buttons are and what they do. You may not use them in many cases. But when you do, it can be helpful to kind of have that muscle memory, like Dr. Zakor mentioned, so you know what button is where. So narrowband imaging enhances visualization of which of these structures, the muscularis mucosa, mucosal capillaries, adipose tissue, or submucosal glands. So since you can only see one of these on endoscopy anyway, it is mucosal capillaries. And so this is that visualization that I mentioned about an overall bandwidth of light versus this narrow band where you can see the colors better without diving too much into the things you see on the top. The bottom line is that when you can see the capillaries have this brownish appearance, and you can use that to help understand what these might be, whether there is perhaps a risk for dysplasia in whatever you're looking at. So this is an NBI classification scheme. And the purpose of this conversation is not to tell you which one is worse or better. The ones on the left tend to be more benign. The ones on the right, more concerning for dysplasia. But the idea is that you can use NBI to give you a better sense of this. There's a lot of conversation about resect and discard, for example, or not resecting at all in very low-risk lesions to not have to incur the cost and all the other things associated. For example, if you have a colonoscopy and you really believe it's a hyperplastic polyp in the rectum, and you do NBI and confirm that or use high-definition to confirm that, it can be cost-saving, time-saving, and not removing things unnecessarily. And so getting a sense. And I think you've heard from a couple of other people, even when you don't need it, just do it. If you have the extra five seconds because your attending is walking to the thing to start doing the note, and they're not going to yell at you for the extra five seconds, click on that when you see something and just get a sense. So you get a sense in your mind of what the thing that was normal looks like. Or even if you're at a polyp and you're waiting for the snare to come to you in those three or four seconds, click the NBI and get a sense of what it is. And then think enough, like when you're redoing your path book stuff, however you do that a few days later, and kind of have it in your mind of what you saw. Ideally, you took a picture of it, and you can refer back to it and gain a greater degree of comfort with what these things are. So name the classification scheme used to describe the picture that you see there. Paris, Kudo, Los Angeles, or Prague. So L.A. is correct. I love this picture. This is the same thing, right? Oh, I skipped a thing. Well, it was B. So this is the picture of what A, B, C, and D are. I'll use an analogy, because you all just recently finished medicine residency, and you're like reporting, and you're like, yeah, the murmur, it was like 2 out of 6. I'm like, really? Like, why not a 1? Why not a 3? What is a 2 out of 6? You're like, well, I mean, it was a 2. Or like, oh, it was 2 plus edema. Really? Are you sure it wasn't a 1 plus or a 3 plus? What is the difference? So there are actual classifications of what makes a murmur or edema or esophagitis this, but when you actually are looking at whether something is, unless the person asks you, well, it looks like it's 4 millimeters, not 5, and it's technically on one mucosal break, not two. There is an actual reason that these are, I mean, there is a scheme by which these are separated, A, B, C, and D, but oftentimes you'll see people say, well, it's not that bad. Let's call it an A. Oh, it looks terrible. Let's call it a D. But there are reasons that there are break points at which it's called A, B, C, or D. As you can see there, whether there's one break that's not more than 5 millimeters, not going between the tops of two folds, and then B versus C versus D, where it takes up most of the circumference of the esophagus. So that's an A, B, C, and D, and it's helpful, again. And a lot of your reporting systems make this a little easier for you, because as you're doing drop-down menus, so probation is what we have. It's maybe what a lot of you have. And when you click down on it, a lot of times it will actually give you the description. It does it for Mayo scores for ulcerative colitis or Crohn's disease or esophagitis and others. And just, again, take an extra second to look at what those descriptions are, so it gets you in your mind of why you're choosing one versus another, or else everything turns into, like, eh, it's LEC, in the way that everything's magically a 2 out of 6 for a murmur. So what is the correct endoscopic description of this finding? Large variceae, small variceae is grade 1, grade 2, grade 3. By the way, grade one, varices, grade two, varices, grade three, varices, if that wasn't apparent in the question. So about half of you use the grading system. The other 40-something percent of you use large and small. So there has been a move to go to just small and large, because that's what's relevant to small or large. There are people who feel like when you do that, everything is always that one in the middle, and it's hard when they're not really large, but they're not that small, and that's what nice. But what we've found is no matter how many criteria you have, there's always going to be that one where the Mayo score has four from zero to three, and you're always like, well, it's like a one and a half. And if you made five of them, they'd be like, oh, well, it's a two and a half. So you're always going to find ways to kind of think that there's in between stuff, but the important part here is they're either small or large, and you can use that. That's the most commonly accepted current schemata for portal hypertensive disease like esophageal varices. So these are considered small varices, because they're less than 5 millimeters, and then that's the differentiation between small and large. So you should define whether they're small or large, and then also if there are things that are suspicious or stigmata of recent bleeding. This is particularly, obviously, important if you're doing it for a person who's had a recent upper GI bleed, and you're trying to decide if the varices were the etiology of them. And so you can see these red whales or spots that are the risk that probably are where they bled and where they can bleed again if you don't intervene. So for example, placing bands on those varices. So here are some example of these red whales, these red dots that you see on the varices. And as you start taking call or doing upper GI bleeders, you'll start gaining experience in treating these. By far, the most common way nowadays is by placing bands on the varices. And then the varices don't just live in the esophagus. These are very large gastric varices. These are harder to treat endoscopically and oftentimes aren't, but can be with certain tools. But it's important that you, again, when you get a description of your endoscopy, decide what you think these varices are. So this classification system was created in a country where esophagus starts with an O. So it's the O esophagus. And so there's a gastroesophageal varices. You see whether they're on the lesser curve or come up onto the greater curve, characterizes whether they're GOV1 or GOV2. And then isolated gastric varices that are in the fundus versus those that are further down the stomach, atypically, for example, in the antrum, which is an IGV2. And so some of the algorithms that you'll see of how to manage patients will depend on whether they're one versus another. And if you're having conversations with yourself and let's say an interventional radiologist about how to deal with a patient and whether or not they need to go for an IR procedure versus yours, these are helpful systems to speak the same language about where you think those varices are. So correctly identify the lesion on this endoscopy that was performed for hematemesis, Cameron erosion, esophagitis, Mallory Weiss, or peptic ulcer disease. So, by far, the most popular answer is the correct one, which is a Mallory-Weiss tear. This is a great picture that's not at all stereotypical of a guy holding a bottle of alcohol and vomiting blood. But what you see, importantly, is this occurs at the esophagogastric junction. With a sudden increase in abdominal pressure, you'll oftentimes see somebody that has vomited several times, and on the 4th, 5th, 8th, 11th episode of emesis will have blood associated with it. It's oftentimes single, but you can see multiple, depending on how that esophagus twisted at the GE junction to cause mucosal tears. And in some cases, you really can only see it if you retroflex from below. And so another important, even when you're doing endoscopy, make sure the critical aspect of retroflexion, as some scopes get older, I always, when I start an upper, I fully retroflex, and a lot of times it stops there. And if you really want to have a meaningful retroflexion, and you want to be able to see things well and intervene on things, you really want it to be able to come all the way down appropriately. And as scopes get older, some of that bending radius gets affected. So just make sure that you're using tools that work most effectively, and you'll oftentimes see things better on retroflexion in certain areas of the upper and lower GI tract. And this is an example you can oftentimes, if you go slow enough, you usually can see these pretty well on FOS as you're looking straight on, but particularly if you have hiatal hernias or things like that, it can sometimes be easier to see them in retroflexion, and then you can decide whether you're going to deal with them in retro or straight on. Usually easier to put your tools through when you're going straight on. So identify this lesion, a Cameron ulcer, a Mallory-Weiss tear, an anastomotic ulcer, or a malignant ulcer. So the great majority chose Cameron ulcer, which is correct. Not a big fan of epidemics, but the important thing to know is when you have an ulcer that is in or near the hiatal hernia, given how the sliding hiatal hernia is going back and forth, it can cause irritation and development ulcerations. That's called a Cameron ulcer. And you see that in all three of those pictures on the top with the arrows showing you each of them. OK, so this already has a lot of choices. You guys are very aggressive. I don't know if we can reset or if you can vote again. But now that you know the actual question, the Paris classification is used for describing which of the following types of lesions? Colon polyps, superficial gastric lesions, superficial esophageal lesions, or all of the above? Shrinking of B and C. All right, so colon polyps was the answer that you guys put. Actually, it can be used to describe a lot of different lesions. So this is looking for things that are generally not subepithelial under the skin, but things that are superficial. So you see type 1 and type 2. Type 1 being protruded, and you can see how it's listed there, along with the various ways it can either be flat or depressed in type 2 on the right. And so this is the Paris classification. And so again, in your endoscopy reporting systems, you might see this. For typical round-the-mill polyps, some people say it overly complicates things. But for others particularly, if you're going to be doing bigger polyp resection, it's helpful to know the nature and characteristics of a polyp. So many people are advocates of this system of using the Paris classification. And importantly, and we mentioned this indirectly in the past, but knowing your equipment also, get a sense when you're measuring size, get a sense of having some reference point. So know in general how wide your open or closed forceps are. If you're doing fluoroscopic cases, know the diameter of a scope, so you know what that is relative to whatever you might be seeing on the screen fluoroscopically. And so it's good to know that. Just keep in mind that there have been several studies, including one pretty recently, that when endoscopists estimate the size of a lesion and then you compare it to pathology, which is not a perfect, it's a little unfair because things can shrink, for example, when you put them in formalin. There is a large difference oftentimes in what is reported as the size of a lesion versus what it actually is. Usually the endoscopist is over-calling the size versus under-calling it. But nonetheless, it's important to get some sense. So knowing what an open and enclosed forceps size is, is helpful in determining what the size of a lesion might be. There are some newer systems where you can estimate it by putting something on the screen. And as we get more into artificial intelligence and devices that help aid computer-aided detection, that'll become more and more common. But for now, you should still know the sizes based on what your instruments are. So select the best option to describe the endoscopic morphology of the lesion shown below to the left. So 1s, 1p, 1sp, or 2c. You don't have access to the slide two before, if you did. All right, so most of you said 1sp, but if you look, let me just go back. So take a look at this. I'm seeing what the choices were. And you chose sp. So just take a look at this picture and get a sense. Personally, I feel that Paris overcomplicates things a little bit. But there certainly is value to knowing whether it's superficial or depressed. And so this is one of the most common systems now that is used to determine, traditionally, colon polyps. But they can be polyps anywhere in the superficial lesions in the GI tract. So this is an example of a 1s. So I think that is it. And I'm happy to take any questions. Thank you.

endoscopy

endoscopic findings

Paris classification

narrow-band imaging

varices classification

Mallory-Weiss tears

Cameron ulcers