It is my great pleasure to introduce Vani Konda, who will be speaking on the alphabet soup of esophageal disorders from BE to EOE. Dr. Konda is a gastroenterologist with clinical expertise in the full spectrum of esophageal disorders. She completed her residency and fellowship training and remained on faculty at University of Chicago. And since 2017, she has served as the clinical director at the Baylor Scott and White Center for Esophageal Disorders at Baylor University Medical Center in Dallas, Texas, collaborating with other GI doctors, surgeons, and ENTs. She has developed a clinical multidisciplinary program for complex benign and malignant disorders of the esophagus. And she has authored over 100 articles, book chapters, and videos in really, really high yield material. So welcome, Vani. Thank you so much. Good morning. And thank you to Joanna and Amandeep and the ASGE for the opportunity to be here today. It is so exciting to see a room full of women and all of us interested in the same ideas of gastroenterology and endoscopy. And now we get to talk about, I guess, the full assortment of some of my favorite disorders, which are in the esophagus. And I think I got the challenge of the alphabet soup of esophageal disorders from BE to EOE. So our objectives in this session are to discuss the components of a high-quality endoscopic examination of the esophagus. And we will be focusing on the diagnostic considerations during the endoscopic approach for Barrett's esophagus, esophageal strictures, eosinophilic esophagitis, and motility disorders. And then we'll just briefly touch on some management considerations and common esophageal disorders. And then in a hands-on session, we'll have the ability to explore and demonstrate some adjunct tools and treatment modalities. Now, esophageal disorders can come with a lot of overlapping presentations. People can talk about difficulty swallowing, regurgitation, chest pain, heartburn, nausea and vomiting, food impactions, and upset stomach. And it's really important to take a good history, but even when we take a good history, we don't always know exactly what's going on. And sometimes we might trial with medicines like PPIs to figure out what we think is going on, like in the cases of GERD. We might do an endoscopy, and we might find esophageal strictures, cancer, or peptic ulcer disease. We might need to take biopsies to confirm a diagnosis of eosinophilic esophagitis. We might need to do further testing to diagnose achalasia, other esophageal motor disorders or gastroparesis. Or we might be left with that diagnosis of exclusion, like in functional disorders. I just want to spend a brief moment on that dysphagia history. Like we've all seen the list we've learned in medical school about characterizing dysphagia in terms of the onset and progressive nature of the disease and associated symptoms. But guess what? People don't walk in saying, I have dysphagia, because it's not part of the layperson lexicon like GERD is, which is often what they call everything, because everyone has GERD. And I think it's important to ask about dysphagia in a lot of different ways. And I always tell my fellows, you haven't asked about dysphagia unless you've asked about it five different ways, and I've called them the five S's. One is, do you have trouble swallowing? And that's the one we commonly use. But some people only associate swallowing with the pharyngeal component and don't talk about the esophageal component or think of the esophageal component for swallowing. So it's also important to ask, do food and liquids get stuck? And then sometimes you're like, well, it's not stuck like stuck forever, right? Because it's not stuck forever, but maybe it's slow to go down. And that's the third S. And then, does food or fluids stack? And finally, some people don't recognize it is getting stuck or having trouble getting to the stomach, and they actually say that they're vomiting. And so then the fifth S is spew, which is vomiting undigested food. Also, some people cope really well with dysphagia. And Iko Hirano developed the IMPACT acronym to talk about how people might compensate by imbibing fluids and modifying small pieces, prolonging mealtimes, avoiding harder texture foods, chewing excessively, and turning away tablet or pills. So we talk about the five L's being what I consider the components of a high-quality endoscopic examination. This is in a review article. It's focused on Barrett's, but I modified it to broaden it a little bit. And we're going to talk about landmarks, length, look, lesions, and levels. And we'll go through each of these in more detail. And it's in your toolkit that you will be receiving in your packets. So first is esophageal landmarks. First we want to see where the diaphragmatic impression is. We want to look at the top of the gastric folds, which is this green line right here. We want to look at the squamo-culmonary junction, which is often in a normal situation without Barrett's at the top of the gastric folds. And then we also want to appreciate that muscular ring, which is the proximal aspect of the lower esophageal sphincter. Sometimes radiologists might call that the A ring, and then that mucosal ring the B ring. And so we can see here these landmarks are things that we can assess endoscopically. And we should get in the habit of doing them and assessing them every single time and documenting every single time. I think that the assessment of the lower esophageal sphincter is something that we don't usually spend a lot of time teaching fellows during endoscopy. We focus on the other three. But they're in the stomach. They're like, the LES is patent. I'm like, OK, come on back, back, back, back, back, back, back. And then come back to the distal esophagus. And then be able to appreciate that proximal extent and any impression. You can see here when we have the scope at the Z line looking in the stomach, everything looks open. But when we bring the scope back, we can appreciate that maybe things don't open readily as, for example, in the column to the right, which is actually a patient who has achalasia. And so I think it's important to sort of come back, take your time, assess. The best time to assess is on the way in for that endoscopy to look at the lower esophageal sphincter. We also want to do a careful retroflexed examination. Look at the cardia and the fundus for any lesions or varices. Look for any post-surgical anatomy, such as fundoplication. And we also want to look at the hill grade of the valve. The hill grade allows us to see that flap valve. And we're looking for basically this prominent fold along the scope. Here it's less prominent. We can see variation with respiration, hugging the scope and not hugging the scope. And then in hill grade three, we have sort of a slightly open valve. And then hill grade four, that's when you can sort of see that whole hernia sac in that retroflex view. This is one way that's been long reported and has been used. But there is another paradigm that we can use to look at the hiatus, and that's the AFS grade, which looks at different components, including the axial length of the hiatal hernia, that flap valve that we were discussing with a little bit more specific definition, and also the aperture in terms of how much opening there is around the scope. And we can grade this in one, two, three, or four with any component of when the highest grade is or the highest component is reached. That's what determines that grade. And this is also in your toolbox. We also have LA grade esophagitis, which we can designate as A, B, C, or D, which we're all familiar with. And when we come across strictures, we can classify them as simple strictures or complex strictures. We can look at the shape, how long they are, whether they're angulated or straight, the caliber, whether or not you can get a normal diagnostic scope through. And basically, that can give us some information on how many dilations we might need with simple strictures often requiring only one or two, and then the complex strictures often being more refractory. Examples of simple strictures include Schottky's rings, esophageal webs, peptic strictures, and some post-ablation strictures. And then complex strictures often are radiation-induced strictures, caustic strictures, wild-filled endoscopic resection strictures, or surgical. In terms of the evaluation, we want to evaluate for any inflammation and treat accordingly. We want to also consider biopsy for malignancy and EOE, and then consider adjunct fluoroscopy or use of ultrathin endoscope and additional imaging as needed. We have different dilation methods, including balloon dilation and bougie dilation. Bougie dilation can be done over a wire or blindly. I pretty much often always use a guide wire with either the American or Savory dilators. The advantage of the balloon dilation is you can see what you're dilating. The advantage of the bougie dilation is you can have a tactile sensation. There's also a new dilation technique called a bougie cap, which is a distal attachment cap, which can attach and basically dilate as the scope's being advanced. We also want to pay attention to what we're seeing in the esophagus. This is a scoring system that we're developing in conjunction with Northwestern. And we are looking at the endoscopic assessment in terms of clearance of contents and concern for delayed esophageal clearance. So we can look at things like contents, dilation effect, resistance at the LES, as well as evidence of chronic stasis changes or candida esophagitis. And we're going to be calling this the CARS score. It should be coming out shortly. And when we see those kinds of things that make us concerned about a motor disorder in the esophagus, we can do other testing like high-resolution manometry, which allows us to get objective measurements like IRP, DCI, and distal latency, which can then be incorporated into what is now the Chicago Classification 4.0. And the high-resolution manometry test is the gold standard test for achalasia. We can see here the classic types of type 1, type 2, and type 3 of achalasia on high-resolution manometry. It's important to recognize the 4.0 protocol has some key updates in terms of the actual protocol itself. It's in two positions. And also, there are some key differences with EGJ outflow obstruction and ineffective esophageal motility, and specifically this concept of conclusive versus inconclusive diagnoses. And so it's important to recognize that we do need additional confirmatory testing, especially with EGJ outflow obstruction. And that can include things like radiology testing, specifically a time barium esophagram. And then we also might consider just variety of barium studies. So for example, we always get a barium tablet with our esophagram, which is a very useful thing that you can consider talking to your radiologist if you don't already have that with your standard esophagram protocol. The time barium protocol allows for assessment of a large bolus of contrast at one, two, and five minutes. And then you can also consider solid components with bagel and marshmallow. We have the endoflip, which is another adjunct tool, which we'll see a little bit more later today. And this allows us to use impedance planimetry to assess, basically, esophageal distensibility. And with the 2.0 generation, we started also getting pressure topography so we could actually see the contractile response in the esophagus. And then now we have a 300 series, which also gives us improved visualization. It's a much easier setup, and it's user-friendly, and it's easier to integrate into clinical workflows. So we can get metrics like cross-sectional area, intrabag pressure, which is the pressure within this bag catheter or balloon catheter, and diameter at one of 16 different markers. We can also get the distensibility index, which is basically the area of interest, which is where we think that high-pressure zone is in the esophagus. And the software will actually calculate out the distensibility index based on the cross-sectional area and the pressure over a set volume or time period, when often 60 milliliters, which we'll talk about later, is our key volume for that. And we can also see this pressure topography to give us a contractile response, which reflects secondary peristalsis and simulates that bolus that we might be encountering in the esophagus that can provoke symptoms. But we're able to do this now in an asleep patient. So when we see their displacement of the squamo-columnar junction from the top of the gastric folds, we want to measure that. And we can measure that a lot of different ways, but the Prague classification is a standard and validated way to measure length in the esophagus. And we want to take the distance from the top of the gastric folds to the circumferential contiguous extent of the barrettes. And then that would be designated as C. And then M would be the top of the gastric folds to the maximal contiguous extent of the barrettes. And then we can also just note islands that might be separate from that separately. So in this example here, we can encounter the diaphragmatic impression at 40, the gastroesophageal junction at 39. There's a small hiatal hernia. There's no circumferential extent. And the maximal extent is at 36. So we call this a C0M3. And those small little islands, we can say, are within 1 centimeter of the maximal extent. In this example, we can see the diaphragmatic impression is encountered. And we also see some other findings that are important to recognize when we're doing this endoscopic examination. So diaphragmatic impression is at 36 centimeters from the incisors. The gastroesophageal junction is at 35. And then we have the circumferential extent right there at 32. And the maximal extent there at 30. But in addition to that, you would have noticed on that first run that we see erosive esophagitis, which we should note. And in this case, it would be grade C esophagitis. And we would not want to biopsy this area for barrette esophagus. We'd want to treat this patient with PPIs for eight weeks and then bring them back for mapping biopsies. The foundation for a better detection is really using a good endoscope and using your eyes and your brain. So we want to use a high-resolution endoscope, which offers better detail. We want to improve our techniques with appropriate mucolytics, irrigation, tip deflection, and a stoff distal attachment cap. We can see patterns of regular villus pattern in barrette esophagus that is reassuring for nondysplastic areas, whereas when we see areas of irregularity, that might be more concerning for suspicious areas that might harbor neoplasia. It's important to not just look down, but really take time to look for any subtle areas of discoloration or mucosal irregularity. And then really use that tip deflection. And here, we also have a stoff distal attachment at the end of our scope, which is that soft cap. And we can see how irregular that is and contrast that to this area. And we can appreciate that on white light alone. So it's important to spend time looking, and barrette's inspection time, which is a metric for consideration for a quality examination, is associated with higher rates of lesions and neoplasia detection. So it also is important to take a careful examination, especially in the setting of a hiatal hernia and the GE junction with all the folds that might be obscuring certain lesions. So in this patient with a large hiatal hernia, you could start to see a lesion popping up at the top of the screen here. And again, I think that using a cap is helpful, especially around the GE junction. So you could see here at 1 o'clock that lesion. And then here, I'm just going to go here. In the retroflexed view, again, especially in these large hiatal hernias, it's possible to go ahead and bring your scope up into that hernia sac and take a good, careful view. And you see that lesion almost even better in that retroflexed view, as you can see there, sort of moving from 3 to 6 o'clock on the screen. And so this lesion was actually intramucosal cancer that was diagnosed. And we can also appreciate that when we see these lesions, we can characterize them with the Paris classification. And so that's where we'll talk about this again in another lecture or another time. But we can see that these lesions, in this case, I'd characterize that as a 1S lesion, a 0-1S lesion. Those are more concerning for harboring submucosal invasive disease. The lesions that are depressed and protruding are more concerning for those that are submucosal disease, where those are slightly raised or completely flat are usually not as concerning for submucosal disease. I'm going to skip that in terms of time. And then the other thing we want to do is look at the EREFs for eosinophilic esophagitis. This is where we can look at the esophagus and look at features such as edema and look for subtle evidence of rings. In this case, we can see mild ridges and furrows, that we can see those little vertical lines. And we can see mild exudates, as shown here. And sometimes we can also see the presence of strictures. We want to assess these during each endoscopy and score based on the highest area from the entire esophagus. And then the fifth L is to biopsy. And we want to do biopsies from multiple different levels, especially when we're looking for EOE. So we're going to look from both the distal and the mid-esophagus. We're going to take a total of six biopsies at least. And that's going to be regardless of endoscopic appearance when you are suspecting eosinophilic esophagitis or the patient has dysphagia. And this also helps guide treatment, because inflammatory features such as edema, exudates, and furrows will be likely things that we want to treat with diet and drugs. And those that are fibrostenotic features like rings and strictures are going to be those things that we want to perform dilation for. And sometimes there's going to be both that we'll have to do for a patient that's harboring both inflammatory and fibrostenotic disease. But it's helpful when you see these to help guide what you might want to do during that procedure or after that endoscopy. And then the fifth L in regards to Barrett's is to biopsy at multiple levels using a standardized protocol such as the Seattle protocol. And that's where we're going to biopsy visible lesions first and then perform multiple biopsies throughout the rest of the segment every one to two centimeters and four quadrants. Now if the patient has had a history of dysplasia, you want to do it every one centimeter. And if we should find dysplasia, we want to confirm that with an expert GI pathologist, because there's lots of different managements including surveillance as well as treatment. And the treatment varies from surgery to endoscopic resection like EMR, ESD, or non-tissue acquiring modalities like radiofrequency ablation, hybrid APC, or cryotherapy. And we're able to differentiate which one of those management strategies we want to do based on the confirmation of this dysplasia, whether patients have high-grade dysplasia or intramucosal carcinoma. We might want to go with endoscopic eradication therapy. And we do want to perform endoscopic resection for all visible lesions prior to considering ablation for the rest of the segment. And for confirmed low-grade dysplasia, those patients may be selected for endoscopic eradication therapy or surveillance is an option. And for those patients with nondysplastic barrets, we want to survey them every three to five years. And for those patients with longer segments, we want to consider those shorter intervals. So in conclusion, this is my alphabet soup of the esophagus. You want to do the five L's, landmarks, to look for LES, the Z line, the top of the gastric folds, and the diaphragmatic impression. You want to look at length and look for basically that C and M, which is the Prague classification for those barret segments. And also consider LA-grade esophagitis when you encounter esophagitis. You want to rate lesions with the PARIS classification and document accordingly. And for EOE, you want to biopsy at multiple levels and perform an endoscopic assessment with eREFs. And consider that CARS for your motility assessment. Don't forget that retroflexed examination with either using the Hill-grade, 1, 2, 3, or 4. Or you can consider using the LDF components from the AFS-grade. Thank you.

esophageal disorders

endoscopic examination

Barrett's esophagus

esophageal strictures

eosinophilic esophagitis

motility disorders