This ASG video tip is sponsored by Braintree, maker of the newly approved Souflave and Sutab. I will again walk through my process of evaluating the G-junction. So again, another cartoon, in a patient with normal findings, these three landmarks should really be coinciding. So again, we have the Z-line, which is a spemocolumnar junction, we have the top of the gastric folds, and then we have the diaphragmatic hiatus. Now what happens when there is a hiatal hernia? The hiatal hernia basically is the anatomic herniation of the proximal part of the stomach into the thoracic cavity, and in this case, you would have the gastroesophageal junction and the spemocolumnar junction proximal to the diaphragmatic hiatus. The third important condition that we should be all aware of is that when the spemocolumnar junction is proximally displaced from the gastroesophageal junction, we then begin to suspect if the patient has intestinal metaplasia of the esophagus or Barrett's esophagus. So in this instance, you can see that the spemocolumnar junction is proximally displaced. This is the top of the gastric folds, and then typically a lot of these patients will have a hiatal hernia, so all three landmarks are now separated from each other, and in this case, we should be thinking if the patient has Barrett's esophagus. So again, to reiterate, we should be assessing the GE junction and the spemocolumnar junction carefully, defining the end of the tubular esophagus, avoiding overinflation, sometimes partially inflating and deflating with the help of the endoscope, and of course, any time you're suspecting a columnar-lined esophagus, wherein the spemocolumnar junction is proximally displaced from the GE junction, we should be looking for any focal abnormality and biopsying that separately. And of course, one of the important findings that we look for at the GE junction is esophagitis, so this gives us a good segue into how should we be looking, assessing, and reporting esophagitis, and in this instance, the recommendation from societies is to use the Los Angeles classification system. So why do we use the Los Angeles classification system? We use this because this is the best standardized description of reflux esophagitis, and in fact, this was a long process of developing the grades of esophagitis, assessing inter-observer agreement, and it has been shown that when multiple observers report esophagitis with the Los Angeles classification, the inter-observer agreement, though not perfect, is still reasonable. It defines erosions as indicative markers of esophagitis and really has four grades of erosive esophagitis, and this is just an example of severe esophagitis with not only esophageal inflammation and erythema, but also ulceration, and I will talk to you a bit about what the grades would be from grade A through B to C to D. So again, so let's start with grade A esophagitis. So grade A esophagitis is reported when you have a linear erosion which is less than equal to five millimeters in diameter and does not straddle any of the gastric folds. So this is isolated, it is five millimeters or less, so this would be grade A esophagitis. Grade B esophagitis, as you can see, is wherein the erosion is longer. So it is 10 millimeters or more, it again does not straddle the top of the gastric folds, and the only difference between A and B is that this is five millimeters and this is 10 millimeters or more, but they are not straddling the gastric folds. Now what happens when they do straddle the gastric folds, then we enter into Los Angeles classification C or D, and the only difference between when they straddle the gastric folds is whether the circumference involved is less than 75% or it is more than 75%. So if it is less than 75%, that is Los Angeles classification C, and if it is more than 75%, as you can see in this picture, this would be LA classification D. So again, this is something that we should all be looking at and indeed has been incorporated into some of the endoscopy reporting software as well. So why is this important? Why does this make a difference? It makes a difference because the presence and grading of the esophagitis, if a patient with reflux symptoms has erosive esophagitis, we know that from prospective randomized studies that these patients are going to need PPI therapy indefinitely. If we take them off a proton pump inhibitor, they are going to have a high rate of recurrent esophagitis. So that's number one. The second important thing to remember is that it also changes our follow-up recommendation. So given the instance, the severity of the esophagitis and the presence of Barrett's, if you treat patients, particularly with the severe ends of esophagitis, Los Angeles classification B, C, and D, we want to confirm that the esophagitis has healed in about eight to 12 weeks. And second, we also want to make sure that they don't have underlying Barrett's, which may not have been evident on the initial endoscopy, and that rate can be as high as 10 to 12%. And then the third is a softer standpoint that at least some institutions use, including ourselves, that if we do an endoscopy for someone with, for a Bravo pH pro placement, and they have severe esophagitis, particularly if they have LA grade C or D esophagitis, it may obviate the need for even placing a Bravo, because then we are thinking that this patient has severe reflux enough that we don't need additional testing to confirm whether they have reflux or not. So again, these are some of the reasons why looking and grading the esophagitis would be clinically important. So let's move on to some examples as to whether, how do, how can normal appearing GE junctions look like? So again, this is an endoscopic picture where we are looking at the landmark. So again, we have the squamous columnar junction, which is right here. We have the top of the gastric folds, nicely deflated and the folds and the top of the gastric folds are coming together. And then this would be really, we don't have a video here, but, but I think we can all appreciate that this would be the diaphragmatic hiatus as well. So again, this would, there's, there's some irregularity perhaps on the left side, but this is maybe a few millimeters. And this is not someone we would really think about whether they have barrett's esophagus or not. Now, what about this patient? Now here we can again, see a little bit of irregularity here. And, and we might think, well, is this someone with quote unquote, an irregular Z line? In my opinion, again, this does not exceed one centimeter. And we will in subsequent talks, we will talk about what is needed for the diagnosis of barrett's. And again, this is a patient I would probably not biopsy as with a concern for barrett's esophagus. So why is this important? We know that if we are not careful about the assessment of these landmarks and we don't spend some time in assessing the G junction, we can over-diagnose barrett's. This was a result of a, of a study that was actually performed in Minnesota published about eight years ago now, where three referral practice endoscopists actually got education in landmark identification, very similar to what we are just talking about in terms of assessing the anatomy on endoscopy. And then they reassessed about 130 patients who had been diagnosed with barrett's in the community. And again, these are some pictures, which I think make this very, very clear. So again, if you over-inflate the esophagus, you might think that this, this side of the esophagus in, in section A may, may have maybe the, in the tubular esophagus, but as you can see, when you, when you deflate with panel B again, compare panel C and panel D, you see that the top of the gastric folds are really coming well up to the spermocolumnar junction. So again, here we are making the assessment that the G junction and spermocolumnar junction are coinciding. And as long as they are coinciding, we would not think that they actually have barrett's esophagus. And again, if you over-inflate, you might make you might overestimate the presence of barrett's esophagus. So in this study, almost a third of the patients actually had the diagnosis of barrett's reversed. And they were reversed because there was no evidence of columnar lined esophagus proximal to the top of the gastric folds and goblet cells were not found on, on, on histology either. So again, it's important to reassess and carefully evaluate the G junction with some time and effort. So again, this is important for a variety of reasons. If we biopsy an irregular Z line and we, we think that they have intestinal metaplasia of the G junction, does it really matter? And at least our current evidence seems to suggest that if you biopsy an irregular Z line with a zigzag line of only less than a centimeter versus true barrett's wherein the length of the tubular esophagus intestinal metaplasia is at least a centimeter or more, the natural history is very different. These were two studies published by, by us from Mayo Clinic and as well as from Dr. Tota's group, which clearly showed that if you have an irregular Z line and you biopsied and you follow these patients, you'd really do not develop high-grade dysplasia or cancer over a fairly long time frame. And of course, if you truly have barrett's esophagus, then there is a definite risk of progression in these patients. So again, it is, it is important for us to carefully evaluate these patients and, and avoid perhaps biopsying what we may think is just an irregular Z line. And indeed the ACG guidelines talk about the, the same concept that barrett's should be, should be diagnosed only when there is an extension of at least a centimeter, if not more proximal to the G junction, and that we should not be biopsying either a normal Z line or an, or just an irregular Z line. And again, these guidelines are very similar to the ASGE guidelines, which were updated in 2018 as well. How much should we be biopsying? How many biopsies should we be taking? If we think someone has barrett's esophagus, if you have adequate length of mucosa, take at least eight random biopsies to maximize the yield of intestinal metaplasia on biopsy. Of course, we know if the segment is very short, eight biopsies may be unobtainable. And there you can go with perhaps four biopsies from a circumferential segment and one biopsy per centimeter in tons of barrett's. Now, what happens if you do not see intestinal metaplasia, but you're suspecting that a patient has barrett's esophagus? In this instance, you can bring the patient back in perhaps a year or two to confirm or exclude the presence of intestinal metaplasia. And up to a third of these patients will turn out to have intestinal metaplasia on repeat evaluation. Other pointers towards biopsying barrett's appearing mucosa at index endoscopy. Now, a common challenge might be if the patient has esophagitis, should you really be biopsying the esophagus? Now, it all depends on how comfortable you are, how good of an exam you are getting. If the patient is already on, say a PPI, and you're doing this for non-responsive disease, you could biopsy the patient. But if the patient has severe esophagitis, then perhaps best to put them on a high dose PPI, bring them back in eight to 12 weeks, allow for the healing to happen, and then do a good examination and repeat the endoscopy. Thank you.

gastroesophageal junction

Spiemocolumner junction

hiatal hernia

Barrett's esophagus

Los Angeles classification system