This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Now a full examination is never complete until you've done a good retroflection. And this is very important when you are dealing with patients with gastroesophageal reflux disease or trying to screen for Barrett's esophagus and also in those patients who have a known history of Barrett's esophagus for surveillance. Here is an early cardiac adenocarcinoma, which is very clearly visible in the retroflex view. You have to take your endoscope retroflex, get into the hernia sac, and then do a very good examination within the hernia sac in a retroflex position to do that. After you've done that, make sure that you are obtaining high quality images of key landmarks and that you're documenting abnormal findings and looking for it. Here's, for example, looking at Barrett's esophagus very carefully and grading the landmark, the gastroesophageal junction. And this patient has a C0M2 Barrett's esophagus. On the other hand, this patient has a very small hiatus hernia, but there is no Barrett's esophagus endoscopically at best. It's an irregular Z line. Here are some examples endoscopically how you can make a diagnosis, or more importantly, don't overcall a diagnosis in that situation. This is something very important, and I'll try and pause here for a second also. Here's as you're doing a standardized pullback, and this is during the pullback when I do all my measurements. If you see my mouse, the first area that you see, the pinch that you're seeing is the diaphragmatic pinch. You always measure this extent from the incisors. And then as you're coming back, what you will see is that the top of the gastric folds are coming back and they will be converging here. And this top of the gastric folds right here, if you see, this is the gastroesophageal junction. And so from the gastroesophageal junction to this diaphragmatic pinch, this is your endoscopic measurement of the hiatus, which you should be doing in all patients rather than just saying that there was a hiatus hernia or that there was a small hernia or a large hernia is just measure and say where there is. Now let's look at this example. Again, you're doing your standardized pullback, you're coming back, and there is no diaphragmatic pinch here and no impression here. And all you will see directly are the top of the gastric folds and the squamous columnar junction. And in this situation, the patient does not have a hiatal hernia. And you can see that this is the GE junction. If it's at 40 centimeters in your endoscopy report, just write that the gastroesophageal junction was at 40 centimeters. What you don't want to do is that even if the endoscopy is normal, just say normal EGD and that's the only thing in your endoscopy report. Please take the time to measure the landmarks and report that in your endoscopy report. And it's a clear idea that you should be doing. You could start seeing the presence of a Schatzky's ring here, which is shown as well as multiple erosions. And what you will do in that situation also, and let's try to play the video again, is that you will measure your landmarks, the presence of a hernia, and then report endoscopically what you're seeing. And you can again see in all of these that the picture is very clear and there is no bile or debris, which is in the way of you doing your examination. Once you've done that, I've alluded to this, is that you use standardized classification systems for your abnormal findings. And I'll just go over a couple of them. Here's using the Prague CNM criteria. And what you do is measure the G-junction and then the circumferential extent. And if the circumferential extent is from this area to the G-junction, this is a C2 and an M5 Barrett. So rather than saying this patient has a short Barrett's or a long Barrett's or an ultra long Barrett's, whatever you might think, that's great. But just mention using standardized classification systems. For example, for Barrett's using the Prague classification, for EOE, ECO will be going over the EREF. So again, make sure that you're using that. If you see reflux esophagitis, I think we are all tempted to call it mild esophagitis or severe esophagitis. And these are, again, very arbitrary terms. So use the Los Angeles classification, which is shown here, both in the cartoon form on the left and pictorially on an endoscopic image on the right with some markings on it for you as well. So look at these different grades of esophagitis and then call it LA grade A, B, C, or D. And again, it will help you not just standardize it, but we know that LA grade C and D are more difficult to treat endoscopically. And those patients may need a repeat endoscopy after healing to rule out the presence of Barrett's esophagus. So it's not only something just a fancy tool to use, but it also dictates management and patient outcomes. So that's how you should be doing it. And again, this is talking about the EREFs and saying that this is how you should be looking. And these are pictures of edema, rings, exudate, furrows, and strictures that you should be doing. Now, something that I think we don't use enough of is the Paris classification. And this is for any luminal GI tract lesions that you see. So always in your mind, and in our endo unit, we've put this up in our dictation room as well as in one of our endoscopy suites. And so this is important to recognize. On the left, just keep this in mind when we say, oh, this is a pedunculated polyp or a pedunculated lesion. Just look at it as is it a 1P, is it a 1SP, or is it a 1S? So always look at protruded lesions and report it as such. If you see flat lesions, is it a 2A, which is a flat elevation? Is it a 2A plus C, which has a flat depression in it? Is it a 2B, which is absolutely flat? So something with Barrett's esophagus that you may see only on NBI or BLI or eye scan. If there is a depression, it is a 2C. And if it's an ulcerator excavated lesion, it's a 3. So remember these and try to use this as part of your vocabulary, as well as part of your looking at lesions and starting to report based on this, because we are all used to saying that, oh, I saw a flat lesion. Well, I mean, is it a flat elevated lesion or an absolutely flat? So I think that will help you, whether it's a 2A or a 2B. And so I think it's important to recognize the Paris classification for that. Finally, upper endoscopy, we may think, let's go ahead and do a very quick EGD. That's what most people say. And I think that's, of course, a not good thing to do. But also be mindful that there are adverse events and things could go bad even after doing upper endoscopy. So do not ignore signs and symptoms of possible adverse events, depending whether it's a diagnostic EGD or whether you're doing EMR or tight stricture dilation. Your risk may vary between these patients. Always look for these different signs and symptoms. And again, just be aware of these different problems which may happen related to perforation, bleeding after the procedure that you've done. So for example, you can see here is that after a stricture dilation, you could sometimes unfortunately have a perforation. And then again, on the right, you can see is that after resection, there is bleeding, which has happened. So do that. Finally, don't overuse upper endoscopy. And I think this is true for all endoscopic procedures because we have to be mindful, are we doing the right thing for our patients? So set up endoscopy surveillance schedules appropriately and don't overuse it. Here is a good list of things that do not require a repeat endoscopy. So again, if you see an inlet patch, that doesn't need it. If there's LA grade A or B or less than a centimeter of columnar line esophagus, we will be hearing about different gastric lesions, which don't require a follow-up endoscopy. So duodenal ulcer, for example, right? So be mindful of what the guidelines are saying and use that in your practice to do that. So hopefully I've set up the stage for all our other experts and given you some tips for how to perform an upper endoscopy to the best of your ability. And that will improve, you know, your detection rate as well as lead to better utilization and better patient outcomes.

upper endoscopy

retroflexion

gastroesophageal reflux disease

Barrett's esophagus

abnormal findings