INTRODUCTION TO UPPER

Satish Nagula, MD Associate Professor of Medicine Icahn School of Medicine at Mount Sinai NYSGE First Year Fellows Course July 14, 2018

Early “endoscopes” 1805: Bozzini Lichtleiter 1853: Desormeux Cystoscope 1957: Hirschowitz Fiberoptic Endoscope Current generation gastroscopes Learning to Perform Upper Endoscopy

• The good news • Learning curve for EGD at 100 cases • Competency • Both technical and cognitive skills • Keep track of your progress • You can always get better • Advanced endoscopic procedures build on fundamental skills learned with diagnostic EGD Indications for Diagnostic EGD

• Dyspepsia • w/ alarm symptoms or • age > 45 • Unresponsive to therapy • • Odynophagia • New onset GERD in older adults • Refractory GERD Indications for Diagnostic EGD

• Persistent of unknown cause • FAP • Abnormal UGI tract x-ray • GI bleeding • Iron deficiency anemia (normal colonoscopy) • Sampling of small bowel fluid • Portal HTN: Document or treat esophageal varices • After caustic ingestion Indications for Diagnostic EGD

• Basically any indication where the findings will change management! • New onset GERD in 25 year old – EGD or empiric PPI? • Acute with nausea/vomiting? • Abdominal pain, weight loss, early satiety? NOT an indication for EGD

• Distress which is chronic, nonprogressive, atypical for known organic disease, and is considered functional Setting the Scene

• Left lateral position • Mouth guard/bite block • Consider topical anesthesia, esp if conscious sedation • Check the scope for proper function • Air, Water, Dials Insertion of the Endoscope

• Direct Visualization • Examination of the hypopharynx • Vocal cords and piriform sinuses • UES • Level of the thyroid cartilage • 15-18 cm from incisors • Special considerations • Zenker’s diverticulum • Esophageal strictures Diagnostic EGD Epiglottis Epiglottis Aryepiglottic fold

False vocal cord

Vocal cord

Arytenoid

Piriform sinus Cricopharyngeus Caveats : Oropharyngeal Cancer Caveats : Zenker’s Diverticulum

Black arrow shows lumen! What if the Endoscope Won’t Go Down?

• Apply GENTLE pressure • Try the opposite piriform sinus • Try blind passage (encourages swallow reflex) • Consult a more experienced endoscopist • Consider a pediatric scope • Obtain a radiologic contrast study Be aware of the DEATH grip! Examining the

• GE junction usually around 40 cm from incisors • Look for the top of the gastric folds • Squamocolumnar junction / z-line • Hiatal • Sliding • Paraesophageal Normal GE Junction Reflux Infectious Esophagitis

HSV CMV Candida Partial Schatzki’s Ring Barrett’s Esophagus Esophageal Cancer Esophageal Varices Entering the Examining the Stomach

• Avoid full insufflation upon entering the stomach • Often induces retching or belching • Remove fundic pool of fluid • Avoid suction artifacts • Head for the first / listen to your attending. ☺ • But keep your eyes open for pathology prior to endoscope trauma Moving Through the Stomach Examining the Pylorus

• Follow antral peristalsis if pylorus hard to find • Use small, coordinated movements • If pylorus is stenosed, consider balloon dilation • Irregular shape may indicate prior ulcer • Usually easier to examine upon withdrawal Pylorus and Antrum

Your Month 1 nemesis! Erosions and Ulcers Gastric Cancer/Malignant Ulcers Bleeding Lesions Unexpected Findings Examining the

• Bulb:First portion of the duodenum • Turn right (posteriorly) • Turn further right (inferiorly/caudally) • Descending duodenum • Valvulae conniventes (circular rings) • Paradoxical motion upon withdrawal (gastric looping!) • Multiple duodenal intubations may be required Moving Through the Duodenum

Right rotation of the insertion tube as well as full upward and right tip deflection Straightening in the Duodenum

Normal Villous Pattern Celiac Disease Ampulla Duodenal Ulcers Duodenal Carcinoma Aortoenteric Fistula BEWARE: The elderly patient with a suspected UGI bleed…and a long midline abdominal scar

Abernethy and Sekijima NEJM 1997;336:27 Return to the Stomach

• Angulus (incisura angularis) • 2/3 down the lesser curve • Common site for gastric ulcers • Take time to examine completely Retroflexion

• Requires gastric distension • Begin in the antrum • Consider locking the wheels • Withdraw to advance • Rotate to obtain 360o view • Biopsy may be difficult due to tip deflection • Avoid getting stuck in hernia or esophagus Retroflexed View: Incisura/Angularis and Body Hiatal Hernia Cameron Erosions Gastric Varices

Do not biopsy! Mallory-Weiss Tear Surgical Fundoplication Biopsy technique Complications of EGD • Discomfort • Sore throat, Bloating • Bleeding • Rare in diagnostic EGD • Infection • Aspiration pneumonia • Medication Reaction • Perforation • 1:5000 – 1:10,000 Summary

• Respect the EGD –simple, yet needs time and practice! • Mindful of proper indications for EGD • Be familiar with all the therapeutic tools • Visual exam on the way in AND on the way out! • Have fun!