Good evening and welcome to tonight's small animal webinar. I'm delighted you're able to join us. My name's Rich Daly and I'm the head of sales for the webinar vet.

So, on to our webinar for this evening, entitled Gastrointestinal Endoscopy by Simon Tappin. I'm sure Simon's done many webinars for us previously, and I'm sure many of you are aware of Simon, but Simon graduated from the University of Cambridge and after 2 years in practise undertook a residency at the University of Bristol in small animal medicine and intensive care, where he gained his European diploma in Small Animal Medicine. He's currently head of internal medicine at Dick White Referrals, where he sees cases in all areas of internal medicine.

So hopefully Simon will get through the next hour interrupted and it's over to you. Thank you very much and welcome everyone to the webinar, this evening. This evening's webinar is about gastroenterology and endoscopy of the, the GI tract, and endoscopy is one of those things that's always really quite fun to do.

It's, the opportunity as medics to do something that's interventional and, and gives us nice images of the, of the GI tract. But it's also quite challenging as well, and I'm very lucky to work in a very large referral centre and we have very good endoscopes and Hopefully we'll be able to show you some pictures of those, but realised in practise, it's perhaps not something that's done every day. We, we literally do this every day and I've literally just come upstairs, from removing a fish hook from a dog's stomach.

So this is something we do all the time. But if you're not doing it all the time, it can be something that creates a little bit of a challenge. And in that respect, it's something that is nice to have some confidence in terms of what looks normal and what looks abnormal.

And how to differentiate the two, but also to complete an endoscopy of the full gastro or a gastroentoinal tract. If we're going to do a procedure, understanding that we've done it effectively and really trying to get the most from that procedure is really important. So hopefully this evening we'll have a chance to go through a little bit about endoscopes to talk about which scopes we should use and how we want to use them and how we handle the scopes.

And then we'll talk about the direct endoscopy of the of the gastrointestinal tract and we'll start at the top of the animal and work through the oesophagus, through the stomach, through the duodenum, thinking about what's normal for those areas and how we would evaluate the normal tissues, but also the things that can be abnormal and the things that we would look at that are that are unusual in those locations, and how we would biopsy. The areas in the stomach and the duodenum, and some of the interventions that we might do. So for example, placing a peg tube in the stomach or considering taking foreign bodies out of the oesophagus or of the stomach, or thinking about polypectomies or the more advanced endoscopic procedures that can sometimes be done when you've got lots of kit as we do, if there's a polyp or something that's bleeding, we cauterise or we can effectively removes small polyps in both the stomach and in the in the colon, which is, which is always good.

So lots of things that we can do with the endoscope that really requires us to to have a good understanding of what's happening with the equipment, but also a good understanding of the anatomy and the physiology of what happens in the gut. So we can really understand what's normal, but also understand what's abnormal. We'll see, we'll talk through the indications of doing endoscopy as well, and, and that's really important because endoscopy is a standalone procedure, isn't going to be something that gives us all the information in cases.

So in vomiting cases, and diarrhoea cases, workup including blood work and ultrasound and and diet trials and responses to treatment and parapsychology, gonna be really important in understanding what's happening with the cases. But in those instances, endoscopy will often be the final part of that jigsaw puzzle, and without that, it's sometimes difficult to understand what's happening with the case, but we shouldn't rush to do endoscopy without having all of that information. So probably not time in the hour that I've got to talk about endoscopy, to talk about the indications absolutely for why we would do it, but it's important to only do endoscopy in the cases where we feel it would be useful and to have a good rationale and at the right point during the investigation.

So when we're thinking about the gastrointestinal tract, we, we usually are using a flexible endoscope and have an insertion tube which is the long, and flexible part of the tube which goes into the animal, and the handle part which has the, camera part that that creates a picture for us. Marscopes are all video endoscopes, and that's what's, pictured here, in that there's a small chip just at the end of the, insertion. It they're very similar to a video camera does, and that's transmitted along the insertion tube, so the part of the animal through hand eating and the omnious tube, camera to picture what you're on the screen.

These are obviously more expensive scopes. There are also fibroscopes as well, and fibroscopes will have a lot of light carrying, image carrying, optics within the insertion tube, and you have either a camera. The hand piece here, or just an eye piece where you can look into and see what's happening with governments.

Ily looking into the endoscope is much more challenging than using a camera. Using a camera, you can, you can stand up and you can use your hands away from the endoscope to manoeuvre the scope. But if you're using the eyepiece, you have to look into the scope.

So you end up being sort of slightly hunched over and looking down into the animal. It's much more challenging to do that. Appreciate the cost of the camera is, is more, but if we can use either video scopes or a fibre optic scope with a camera attached, you will.

There are lots of companies that are offering quite cost effective, medium sized scopes, that will be useful for lots of utilities. So I guess we're using, different size gas scopes. Maybe using cash in small, small, patients 1011 sorry to interrupt, Simon, your sounds just, keeps going out as if it's a bit wobbly, .

It, it that sounds all right now. Are you on the headset, were you? Yes, I am.

OK, that sounds all right again now. It just went, when you talk to me now it just seems right. So if we just give it another go and if, it doesn't improve, I'll just ask you to jump onto the, telephone if that's OK.

Yeah, of course, that's fine, thank you, yeah. So, we, we would obviously use, the video scopes wherever possible because they give us good images. And the, the mid-size scope, so looking at an 8 mil or a 10 mil gastroscope, would give us a good image in, in most of those instances and give us a, a good understanding of, of what's happening.

So 10 mil flexible gastroscope is a, a very useful tool for most of the patients that we have. So these are flexible endoscopes, and we've talked through that. They vary dramatically in length and diameter, probably looking for something that is sort of 8 to 10 mils in diameter and maybe a metre or so in length, to try and get to most of the, the gastrointestinal tract.

And these flexible endoscopes will give us a, a really good understanding of what's happening within the, within the GI tract. So this is our sort of standard gastroscope, and these are the parts that we talk through. This is the insertion tube that is present, which is the part that goes into the animal, the tip here, which has the camera on it, which you want to keep as clean as is possible, so to keep away from any sort of lubrication or problems that might be present.

And then this is the insert. The tube, which has marks along it, which gives us an idea as to the length of the tube, which is inserted into the patient. Also working channel that's present through which we place our forceps, and those forceps will help us to take biopsies or to remove any foreign bodies that might be present if we have a GI tract problem.

And then the handle piece here with the manoeuvrability of the deflection, so the wheels will enable the scope wheel to move the tip in different directions, left and right up and down, and that enables us to manoeuvre the scope into different parts of the GI tract and help us to understand what's happening, but also angle to any areas of interest that might be present. The larger scopes like this is a colonoscope. Essentially, the difference with a colonoscope is just the diameter and the length.

So here, this is a 160 mil of insertion tube compared with a 110 milroscope. So this is just a longer scope, which is better for, bigger patients, and also evaluating the whole of the large intestine if we're thinking about the colon, or other areas of the, of the gut where we need to get into, to some areas. So this will be helpful with, with larger patients.

So when we're handling the scope, there are areas that will help us to deflect it. So if we're using bronchoscopes, which you use in the respiratory tract, we just have two-way deflection, which is up and down, which is fairly straightforward. But with the GI tract, we have the ability to move in four directions, so left and right and up and down.

And as a result of that, the endoscope has two deflection wheels. There's the main deflection wheel, which still gets us up. Down, and that's probably the wheel we use most often.

If we're right handed, left handed, we hold the scope in our dominant hand and our non dominant hand uses the insertion tube to push it back towards in patient. We hold the scope handle as in the picture, so we use our thumb to manoeuvre the wheels backwards and forwards and our index finger and forefinger to manoeuvre the buttons, which are for water. For air and for suction, which helped to allow us to evaluate the the gut by insulating it.

So it's, it's air filled so we can see what's happening and suction so we can remove that air afterwards if there's any problems. Using your thumb against these wheels is, is helpful. It's one of the things when we're doing endoscopy and you're trying to explain to somebody how you're driving the endoscope.

It's one of those things that is very subconscious. You make a deflection change. With your finger, you manoeuvre the scope to move in the direction you want it to go in.

You don't consciously think, I need to move this hand or move this wheel to move the scope. So a lot of it comes with practise. And if you don't do very much endoscopy, don't, don't worry.

It will take you a long time to do endoscopies. And the more you practise, the better you'll get at doing it. So, very good endoscopists, and I wouldn't claim to be a very A good endoscopist, but we do endoscopies, evaluate the whole of the upper GI tract in maybe 10 to 15 minutes.

The first time you do a gastroenteroscopy and you're looking at the stomach and small intestine, it's likely to take you an hour or so, if not longer. So set aside that time and don't get frustrated if you're not able to complete the procedure in that sort of period of time. It will be something that takes time to be able to do.

Then the buttons that are on the endoscope for air and for suction depends a little bit on the scope. This button at the bottom is usually for air. So there's a little hole which air comes out of.

And if you hold your finger over it, air is deflected down the working channel and comes out at the end of the scope. So it fills the stomach or the small intestine with air, and then that allows a better evaluation of that body organ cavity. Usually if you Hold this button down, you get water, which comes across the end of the screen.

So if there's mucus or blood or something on the end of the scope, you flush it and get a much better picture. And the top button is usually suction, so that's attached to the scope tower, and that allows you to to suction air out at the end of the procedure, which just reduces the risk of anything like a GDV or or gastric torsion that might cause a problem after the end of the endoscopy. This is the sort of tower unit that we have for our endoscopy procedures.

So we have a nice big screen, which gives us a good picture. We have a laptop which records all other images, and then there's a lightbox that provides light for the endoscope and a, and a simulation box, which records the images, allows a manipulation of colour if we need to in terms of changing the, red to green to blue ratio of the scope, so we get a nice picture, of what's happening. We have suction, which is really important to make sure we can empty air out at the end of the procedure.

And we have a wash bottle, which is really important for, for washing the scope as well. And the, the wash bottle should be filled with distilled water. There is a temptation to fill it just with tap water, but if you work in an area with hard Water, then the limescale deposits will flare up on the inside of the scope and that can be quite difficult.

So looking after endoscopes is really important and just making sure there aren't any problems with, with that sort of deposit in the scope, will be really helpful to make sure you get the best longevity from your scope. So this is the, the lightbox that we have. This is for the rigid scopes.

So this is a lighter good light source that's, and these are the light sources that we have the more, camera scope to the scope. So we have a good light sources on the, working channel scope, and then connection to the processor that comes from the video. Chip.

And there are lots of things that we can do to manipulate the image that will help us to understand what's happening. We can adjust the light level so we can make it brighter or darker. If we're in a very large dogs stomach, we may want to increase the light.

But if we're in a small stomach, we may want to reduce the light that's present. A lot of the video scopes will do that automatically, but on some of the older scope. If they're ex-hospital models, then you may have to do that yourself.

And you can also, adjust the insulation that's present. You can adjust the amount of, of air that's coming out, in terms of, of trying to fill the stomach with air so you can visualise. Simon, yes, keeps going, sorry.

Would you be able to dial in for us, is that OK? Yeah, of course, thank you. Oh, no problem, these things happen.

It's just a bit intermittent at the moment. So, in some of the older scopes, if we're looking to try and correct the balance when we're looking at a video scope, we do need to tell the scope what is white and what is not white so it can adjust for different situations. So if the scope has a facility to do white balancing, then we will always white balance the scope before we use it.

So that's something that just helps to adjust for the shades of red that we can sometimes see. So if we want balance to something that's pinkish or off you, it can sometimes make the structures of the GI tract look very odd. And if we're assessing for inflammation and we're looking for red changes, then the balance that we have as to knowing that white is actually white can make a big difference.

So it's important to make sure that the scope is balanced before we start the procedure and doing that is very helpful. And then this is the working channel of the scope. So this is the important bit if we're doing interventions, there's a small channel that varies on the size of the insertion tube that goes into the into the animal that allows us to pass different forceps.

So this is our 10 mil gastroscope, and this is a 2.8 mil working channel which is present in the scope. So these are relatively large forceps that allow us Take quite nice biopsies of the gastrointestinal mucosa.

So both the gastric mucosa and the intestinal mucosa, and that's really helpful to get nice samples. In a smaller scope, so if it was a 6 or maybe an 8 mil scope, the scope channel would be smaller and the forcep size would be smaller. So it may be more tricky to try and get a good picture.

So just looking at the end of the scope here, we have the camera, which is the circle at the bottom, two light sources which sort of adjust for the size of the animal by reducing and increasing the amount of light that's transmitted. And then the working channel which our forceps will come through, but also air and suction will come through as well. And you can instil air and you can also suck through the channel with the forceps in place so you can still use those features of the endoscopy.

And there were large array of forceps and, and interventions that you can use through that working channel. We obviously have the biopsy forceps and we'll talk in a second about which biopsy forceps might be best, but there are also array of forceps for removing things as well. So a large range of, of grasping forceps, pronged grabbers, basket forceps, loops that can go round things, as well as some of the, more sort of.

All things where we can cauterise through the endoscope or use laser fibres through the endoscope or injecting into the into the mucosa, for example, steroids, if we had a stricture or if we were doing a polypectomy, sometimes you inject saline into the base to try and make it a bit bigger, and that can be really helpful. So lots of things that are useful to have as a sort of forceps and there's always a different type of force that you'd like to have if you're trying to remove a foreign body for specific situations. But most of the time, just some biopsy forceps, maybe some grasping forceps and a loop or a basket forceps.

So the loops over here, these different round forceps, all these basket forceps that have these nice curly wires and would be really handy for removing foreign bodies because you can get round, round things like stones or balls and have different wires on different sides to enable the foreign body to be removed. So these are our biopsy forceps, and there are lots of different biopsy forceps that are available. And generally, we tend to use what we call cups.

So these are cup-based forceps. So on the right of the screen here, where we've got a nice dish that the biopsy sample can be taken into. We tend to use them without a forcep.

Without a spike, so without something serrated in the centre. These can sometimes be useful if we're fixing samples. So if it's difficult to take a mucosal biopsy using the spike, it can be helpful to fix the forceps.

But this, if we're moving around in the stomach or intestine can also cause laceration. So we try not to use those wherever possible. And they're also serrated edged forceps, which are sometimes used as well, and these can be helpful, although we try not to use them because they look pretty evil unless we can't get biopsies with the non-serrated forceps.

So usually for the intestine and the stomach, we start with these, we would never use the serrated ones in the intestine, but if we were struggling to get gastric biopsies, then we may use these serrated forceps with a slightly sharper edge, to get a nicer biopsy of the gastric mucosa and then tissue that's present. We also need to make sure that the scope's clean. In the GI tract, we just need the cloak to be the scope to be clean, not overtly sterile before we do the procedure.

So usually, cold sterilisation is done beforehand. If we're doing respiratory work with a bronchoscope, we would try to sterilise that as much as it is possible or urinary tract work. But with the GI tract, it just needs to be clean in that regard because we wouldn't regard the GI tract as a, as a sterile environment.

So as long as. Scope has been cleaned and afterwards, we need to make sure the wash channel is cleaned as well. So it's flushed through with saline, but also using a brush through the working channel to remove any deposits or mucus that might be present.

Also, just leak checking the scope just to make sure there isn't any damage to the working channel is important because if we are submerge the scope with damage to the insertion tube, then that can wreck the electrics inside the scope and that can be really costly then when we're repairing it. So repairs of the scopes are always costly and, and we always need to, to look after them. So storing them in a dry place is really helpful, making sure that they can't be damaged, keeping them well out of the way and usually try to keep the insertion tube straight is helpful.

So here they're hanging on the wall just in some Piping just to make sure that they can't be damaged. If you're not able to hang them like that, then, keeping them in their box, usually is the way forward just with the insertion tube lightly coiled, and just make sure that they don't get trapped in the box as it shuts because that can also, kink and damage the insertion tube. And then just lastly, before we start talking about the GI tract, finishing off thinking about different types of scope, we've been talking just about flexible endoscopy so far.

The the rigid endoscopes, we will sometimes use for esophage or foreign bodies. We obviously know about rigid scopes when we're thinking about the nose or if we're thinking about joints, but rigid endoscopes when we're thinking about the GI tract is essentially just using the tubular structures which look pretty mediaeval and like some sort of torture type instrument, but they're actually really handy for removing esophageal foreign bodies. With the flexible scope, it's sometimes difficult to get big forceps around things like lamb knuckles or chicken bones and things that are present.

So these nice tubes just slots in under the larynx into the esopha. And allow removal of front bodies with with large forceps, and these are endometrial biopsy forceps are used in horses, so they're large, grabbing forceps, and these can be really handy for removing esophageal front bodies. So, obviously not something that is available to every one of these custom made for us, but these sorts of rigid endoscopes can be really handy for esophageal work when we're removing foreign bodies.

When we're thinking about gastroenterology, it's really important that we write down our findings as vets. We're really bad at doing that most of the time. I am personally, so making a record for clinical and legal reasons is really handy, so we have good endoscopy sheets.

And there are nice grading systems developed by the, the, the World Veterinary Society, WSAVA, for scoring the gastrointestinal scheme. So this is a Rhinoscopy report, but there are nice schemes for scoring visual changes within the oesophagus, within the stomach and within the intestine to help us to grade areas of inflammation. So, using those scoring schemes are really helpful.

I mean you can find all of those on the WSAVA website if you're, if you're interested in looking, or, or draw a line and I'm very happy to to provide those sheets for you. It'd be very easy to to do. So let's move on and think about why we do gastroenteroscopy.

We thought about the types of scopes that we have available and the different ways that we would want to use them. But we would use gastroentero endostroscopy as part of an investigation of the gastrointestinal tract. So we use it for a lot of the things that we would see as regular GI cases.

So dysphagia, usually as a part of investigation with some dynamic. Imaging, regurgitation to to look at the oesophagus, but we can't evaluate dynamic changes and oesophagus endoscopically, and we wouldn't usually use endoscopy to diagnose things like mega oesophagus because the stomach, sorry, the oesophagus is always distended and dilated under anaesthesia. So it's sometimes hard to see that there's a risk of an aspiration event if we were to anaesthetize the dog with a micro oesophagus.

We'll use endoscopy as part of investigation of chronic vomiting, or chronic diarrhoea. So to vacate the stomach and the asthma intestine, and for us to take biopsies of those areas. We always do it if there's bleeding in those areas so we can look for evidence of ulceration or areas where there may be blood loss, and also for evidence of of any weight loss or or abdominal discomfort as part of those investigative procedures.

But also for interventions like placing feeding tubes, potentially removing foreign bodies. We're talking about esophageal foreign bodies and potentially gastric foreign bodies and visualisation of esophageal strictures, so we can balloon dilate in the areas that might be causing narrowing, and that's always quite a nice thing to be able to visualise and see. So when we start off doing endoscopy, we'll have the animal anaesthetized.

We will always have the animal in left lateral recumbency so that any fluid that is present in the stomach will fall into the cardio, so it falls away from the pylori, so we can visualise that nicely. And we'll have a mouth gag in place. So if the animal is to become light, then any ability to to jump or chew on the endoscope is, is hopefully averted for a short period whilst we remove the endoscope.

And it also allows for the scope to be passed without any damage to the insertion tube on the, on the teeth or anything else that could potentially cause a problem. So we're going to aim the endoscope over the top of the larynx. So hopefully over our endotracheal tube down into the oesophagus so we can pass the scope into the stomach.

And we would always have animals in each time, so a nicely c each tube, so we've got a solid prevention for any aspiration that might take place. Usually our anaesthesia, we would pre-med with something like a methadone or. Morphine because there can be some discomfort after endoscopy.

It's usually a fairly comfortable procedure, but usually using a full opioid would be would be sensible, and then anaesthetize patients in the normal way. And this allows us then to pass the endoscope and to visualise the GI tract. So this is the upper esophagealvita.

This is us just moving the scope over the top of the larynx, passing down into the oesophagus. And once we move into the oesophagus, we would then instil a little bit of air so that we can inflate the oesophagus, and we can visualise what's happening. This is the normal canine oesophagus.

So the oesophagus is running over the top of the trachea, and that's what's causing these ridges at the bottom of the screen. This is the trachea at the bottom, so this is perfectly normal. It's not completely round because the oesophagus is running over the top of the trachea.

There's a blood vessel here on the right of the screen, and this is one of the aortic arches just coming over the top of the oesophagus, and you will sometimes see that these puls quite nicely, so you know that the animal is, is, is, is nice and asleep and still beating heart rate is is normally you can count this if you, if you want if there's any problems, but usually we move through this be the narrowest. The area that we see with the oesophagus as we go over the heart base. And then as we move down, we'll see that the trachea branches into the left and the right mainstem bronchuss as it goes off to either side.

So that will help us to know that we've got the midpoint of the thorax, and then we head down towards the lower esophageal sphincter, which is where we would enter into the stomach. The cat looks slightly different. In the dog, we've got this nice sort of even pale pink appearance all the way through the oesophagus, and it looks very similar all the way down the esophageal length.

In the cat, we do have this change as we get to the distal third of the oesophagus where we have this sort of Herringbone type appearance. That's because in the cat we start off with smooth muscle in the 1st 2/3 of the oesophagus, and that changes to skeletal muscle in the last third of the oesophagus, which has this ridged and rounded pattern that is present, which gives a very different appearance when we look at things endoscopically. And from there we can move through the lower esophageal sphincter and move into the stomach.

Before we do that, obviously we want to assess for anything that looks abnormal and the sort of things that we would see would be any evidence of, of inflammation, and this is what esophagitis would look like. This is actually fairly mild esophagitis. Usually you can pick up an esophageal inflammation very easily and it will look very angry if there's esophageal inflammation present.

So this is mild but quite diffuse change that's present in the oesophagus. And then as we move down and start to look at the lower esophageal sphincter, you can see this is a hiatal hernia. So this is the gastric mucosa and the cardia pushing forwards into the oesophagus.

And the temptation would be to think that this is a mass. It looks very abnormal. This is the cardio, so this is the lower esophageal sphincter.

This will be the entrance through into the stomach, maybe be pretty tricky to get through that, but this looks very much like a mass that is pushing towards you. But this is. This is caused by a diaphragmatic instability, so that the oesophagus is being pushed back on itself by the stomach coming through the rents in the diaphragm, and this is what's causing that hiatal hernia that's present.

So this isn't an esophageal or gastric mass. This is a hiatal hernia that's present and surgery would hopefully do do well, although some do do well with conservative management as well they're not very severe, but this is is quite a severe one. So hopefully we don't see any evidence of any inflammation.

We don't see any evidence of vital hernia, and we would hope really not to see any evidence of anything like a stricture. This is a very narrow point within the oesophagus that's been caused by a stricture formation, either as a result of a foreign body or severe esophagitis or reflux into the oesophagus. And this is a very narrow point in the oesophagus.

We wouldn't be able to get the scope through there, so food is very likely to have difficulty going through that. So the idea would be to try and dilate this to to pass a balloon catheter into that hole and to really try and dilate up that opening to allow food to move through. And usually in dogs and cats, these do take several dilations to maybe 3 or 4 occasions to try and keep things open.

It's not impossible that it might not need to be done on, on more occasions and, and very rarely we need to place stents in these to keep them open, to, to make sure that they don't narrow down, and these can be quite tricky things for us to try and manage. So if then we can pass down to the bottom of the oesophagus and think about entering the stomach, and this is the lower esophageal sphincter here, so this is the opening of the oesophagus as we go through into the stomach. And very occasionally we will see that there is a little bit of inversion of the gastric mucosa around the end of the oesophagus.

So this is the cardio opening here, but there's also a gastric mucosa that's just coming through. And this is a very normal finding, and this can sometimes be misinterpreted that this is inflammation around the lower esophageal sphincter. This is just a version of the gastric.

Cosa, you can sort of start to see that there's some ridges here that the normal gastric regal folds that are just starting to come into the oesophagus. So don't overinterpret this sort of change here around the lower esophageal sphincter. If you do see that sort of red pattern change from the nice pink structure of the oesophagus into this dark red area around the cardio itself.

So then we would aim the endoscope through the opening through the lower esophageal sphincter into the stomach, and we would be able to move the scope through into the stomach itself. So the stomach will have 3 areas. We have the cardia, the body, and the pylo counttrim and the pylo outflow track that goes into the intestine.

And generally when we're in the stomach, we try to move through the stomach as quickly and practically as is possible so that we can evaluate the duodenum and the small intestine before we come back to look at the stomach. And that's really important because the more time we spend in the stomach, the more distention there'll be within the stomach, and the more difficult it will be then to go through the stomach into the small intestine, you end up with a, a longer length of scope that's needed to go through into the intestine and that can be a problem. So most of the time we try and bypass through the stomach as quickly as possible so that we get into the intestine, then look at the intestine in as much detail as we can, take some biopsies, and then come back to the stomach and look at it and make sure we've evaluated all of those areas.

So if we're doing a full upper gastrointestinal endoscopy, that would include evaluation of the oesophagus, stomach and the duodenum, we evaluate the oesophagus on the way in, quickly go through the stomach, evaluate the intestine as much as possible and then work our way backwards. So we take our biopsies from the intestine, the stomach, and then have another look at the endoscopy of the oesophagus on the way out. But just because we're talking through things logically, I'm gonna talk a little bit about the stomach now, but we would normally try and go through the stomach into the small intestine in as much sort of speediness as possible as to not cause a problem.

So as we come through the cardia, we'll see the greater curvature of the stomach in front of us. So we'll be looking straight ahead of the endoscope and if we flex the endoscope left and right, we can visualise all of the greater curvature of the stomach. So obviously if we're looking forward, we can't see back on ourselves.

So we'll need to move the scope down to start to look forward towards the pylo outflow tracks so we can move into the stomach to try and look at these regal folds. And going through the stomach and looking to the pyloris, the trick is always to follow those regal folds because they will take you towards the pylori. So if you ever get lost in the stomach, just keep going towards the regal folds and eventually you'll end up in the pylori out flow track.

So follow those regal folds and it will take you through the stomach towards the entrance of the pyloris. So we would follow the scope round. The scope would come round the greater curvature of the stomach and start to look at the gastric outflow tracks.

But obviously that's looking straight ahead of us. If we want to look back towards where the scope has come through, we need to retroflex the scope. So to pull on the wheel, the up and down wheel that will bring the scope through 180 degrees.

So we're looking back on ourselves. And then one of the things that's always a little bit sort of counterintuitive is to take the scope a little bit backwards towards you, because this will move. Scope up and then you can do what's called the the J manoeuvre, and this is obviously because of the shape of the scope makes.

It's like a J or a hockey stick or an umbrella handle, and you end up being able to look around the cardia as you retroflex the scope up towards you. And normally we would do this when we're investigating the stomach and evaluating the stomach because we wouldn't normally do this at the beginning part of the endoscopy because we don't want to overfill the stomach, but that will give us a good view of what's happening up at the car. Yeah.

So here's our endoscope coming into the stomach. This is the cardio, which is open. This can be normal during endoscopy, so it wouldn't be overly concerned about that.

But the scope is is moving to round towards ourselves and we're looking back up towards ourselves. So the scope is in that 180 degree flex position, and we're looking up at the cardia. So this is the cardia here, we're looking back towards ourselves.

So that just allows us to look at all of the stomach, evaluate all of the area that's present. Important that we recognise the different areas. We've got the card here, the fundus and the antrum as we said.

And then on the lesser curvature, we have the incisor ura, which is the angularis that's here, the shelf of tissue between the fundus of the body and the antrim. And this is always an important area to visualise because this is the area where we see gastric ulceration, both with neoplastic events and also with benign ulceration that can occur in that area. So looking at that area and visualising it is really important.

As you said, it's really important not to over extend the stomach because it firstly creates a longer length to the greater curvature, which means that the scope has to be inserted further to get towards the polo outflow tract. But it also means that as the body fills with air, it narrows the the polar outflow tracks. It makes it harder for the scope to pass through.

So be careful with the amount of air that you're putting into the stomach to enable you to go through, into the duodenum and and out into the tissue, the other side. And this is sort of classic retroflex view. This This is allowing you to look from the cardia and the scope is now lying around the greater curvature and you're looking at the pylo outflow tracks at the bottom.

So this is the cardia the incisor your the yo outflow track at the bottom. So just looking at that in terms of sort of visualisation as to what's happening, you've come in through the cardio with the scope. It's lying around.

The greater curvature of the body of the stomach and the end of the scope is looking at the antrim in the pyloic outflow tract, which is giving us this this picture here that we've seen with the scope coming through the shelf of tissue, which is inside of you, which is a really nice place to take a gastric biopsies and then the po outflow track at the bottom. So this is sort of classic view of looking at the lesser curvature that allows us to evaluate the stomach. And this is the sort of thing that we're looking for in that location.

This would be a really classic site for us to see gastric ulcers. This is a fairly benign looking gastric ulcer, although it's really important that we don't differentiate them just on what they look like, but classically a benign ulcer will have a nice crisp, sharp edge to it. So this is a nonsteroidal induced gastric.

Ulcer. So it's a very sharp, well defined, delineated ulcer. There's another shallow ulceration area just down here.

And this is in comparison with the more malignant looking ulcers, which are usually these big kind of irregular type tumours that they look very angry, that have ulceration as part of the tumour that is present. And these are usually gastric adenocarcinomas, and these usually have a fairly poor prognosis but important not to overinterpret that we would try to, to biopsy in the edge of the crater and keep biopsying in the same location because if we biopsy the necrotic tissue on the surface, it can be really hard to make a specific diagnosis from that. And just sort of looking, visually, this is a video of one of those ulcers.

This is a nasty looking ligament ulcer that has quite a wide sort of crusty pit around the ulcer in the centre, biopsying the tissue just on the edge of that crater would be the best way of making a diagnosis. We would want to avoid biopsying in the centre of the ulcer for a risk of perforating it or causing a problem, but also, we would just get necrotic tissue and that would be quite difficult. So biopsying from the edge is really helpful.

We can sometimes see masses, so polyploid masses in the stomach are quite common. They're not usually something that overtly causes too much of an issue unless they're in the outflow tracks. So sometimes they don't cause an issue.

We try to aspirate them and orographically if possible because we have things like liomyomas and, and, and, benign tumours, but there are also some more aggressive tumours as well. But finding small little polyptoid masses on the stomach is not unusual in that respect. And then the stomach can often be quite motile.

You'd like the stomach to be really still, especially if you're just starting doing that so you can identify the features, but sometimes it can be really motile and we see these migrating rings of peristalsis. Here this is the pile outflow track. This is the pyloris just here, and we've got a ring of muscular contractions, which is taking food material down towards that pylo outflow tract and and that's really what we need to try and go through with our endoscope.

So that can increase the sort of challenge to endoscopy. To try and get through the pylora. So this is the canine pylori.

So this is at the end of the pylo outflow tracks. This is coming around the greater curvature into the Antrim and then trying to find the junction between the polar outflow track and the small intestine. He very helpfully the pyloris is open, so we would hope to be able to drive the endoscape through that hole into the intestine.

And this would be a really easy entry. This would be a really easy pyloric intubation. Hopefully we could get the endoscope through that.

They never normally this easy. Normally it's much harder for us to get the endoscope through that, in which case it may be a little bit more of a challenge and that can be a bit trickier. This is the same sort of situation, the cat again, the cat tends to be a bit more easy to intubate compared with the with the dog, because usually the scope is directed towards the poloris, whereas in the dog, you have to kind of angle the scope a little bit more to get towards it.

And it can be really difficult. How intubation is probably the most difficult skill when they're teaching endoscopy, and it's one of the things that when we're teaching endoscopy, it does take some time. It can be really challenging and frustrating.

You know, somebody trying to do it for a really long period of time and then somebody more experienced just comes and pops through the pyrois into the into the stomach, and that can be difficult. But what you're aiming to try and do is to line it up with the small dots. It looks like a little bit of a star between the mucosal.

Stripes that are present on the tract and to then gently twist and push the endoscope through into the small intestine. So you fix the scope by using a little bit of suction, then using a small amount of air just to gently open the pyloris, and then that should allow the endoscope to feed through into the small intestine. So it does sometimes require sort of a more forceful action, not saying to be really quite rigid, rough with the scope, but sometimes You do have to sort of move the scope forward maybe 5 to 10 centimetres in a sort of direct and firm action to go through the pyloris.

I think one of the things that's always difficult when people are learning endoscopy is that you do very gently try to move it through the pyloris, and that can be tricky to do. So it's it's a definitive action that takes the scope through into the small intestines. So important that we understand that.

And if it's really difficult, if the scope is finding it hard to find where the. Is the stomach is really motile or the pyros is an unusual angle or if there's any mass lesion that's causing an issue, you can use forceps in a closed fashion through the working channel to go through the pyloris. So you'd blindly catheterize the pyloris with the guide wire and then follow the endoscope with the over the top of the guide was using the forceps of the guide for the scope to go through into the small intestine and that can work really nicely.

So hopefully we can then go through the pyloris into the small intestine and if as we go through the small intestine, the first thing we'll encounter is the first duogenial flexure, and then we'll come to the second splenic flexure a little bit further on. So usually as we go through the pyloris, we can see a short straight distance ahead of us, and then there'll be quite a sharp turn to go around and that can be tricky to negotiate because our scope is pointing straight ahead, and what we need to try and do as we go forward is to then flex and Angle the scope round the bend so we can see ahead of us and try and go as far through the small intestine as we can so we can visualise as much of it as possible. So we're aiming to go through the first two fletchers, the Fletcher to really try and evaluate as much of the gastrointestinal tract as possible.

In larger animals, it may not be possible to do that. We may only be in 10 to 15 centimetres, but trying to go as far into the GI tract as possible to visualise as much as it as you can would be the way forward. Sometimes getting around corners can be tricky.

So often we will go forwards and try and steer around them. If you're not particularly experienced, putting the angulation on and then putting, pushing the scope forwards can be helpful, so you're not trying to do two things at once. And that's one of the things that is a skill of endoscopy.

You're trying to do different things at different times, so using your hand to manoeuvre the wheel to turn the scope left and right, but also using the insertion tube to twist it backwards and forwards. If you put angulation on the scope and then twist the insertion tube, you will move the way that the scope is looking. So there are different ways of moving the end of the scope.

And so trying to move that angulation and move the scope forwards and backwards at the same time can be tricky. So having a little bit of angulation on the scope and then moving it can often be helpful in that regard. So getting around the flats, you can do it that way, or you can drive around them if you're a little bit more experienced.

But what we should see in the duodenum is that the duodenal surface looks nice and smooth. This is the sort of appearance that we would see within a normal duodenum, a nice sort of pink, often referred to as sort of crushed velvet appearance to the duodenum mucosa, nice and even, nothing. Actually lumpy or bumpy, it's not particularly inflamed, very even appearance all the way down its length.

So this is a, this is a dog, but the cat looks very similar, often a little bit more washed out and perhaps like less texture to it compared with the dog, but a nice surface for us to look at. And this is sort of the, sometimes more reticulous pattern that we have. There's a little bit of bile that's present here, so it's giving it a little yellowish issue, which is, which is something that can sometimes happen, always really important to starve animals before endoscopy.

So we're usually fairly insistent of at least an 18 hour star before we do endoscopy because any food in the stomach. Makes it more difficult. So if you have starved for that length of time, you do sometimes get spontaneous emptying of the gallbladder, which means that there is a little bit of bile within the GI tract, and that's, that's not something you would expect to to sort of overinterpret that can be a very normal finding.

So, so don't be too worried if you see that it's not something that is is a problem in that respect. And then we'll see the, the normal structures in the gut. So we'll see that the papillae as things enter, and we'll also see the pas patches on the axial border of the gut as well.

So this is the, the major giardinal papillae. So we have two papilllion dogs, only the major one in cats, but as we come down into the duodenum, we'll see the, the major Giordino pappella, which is from the gallbladder, and from the major pancreatic dogs, and then the Ginape a little bit further along. And as we're looking into the intestine as we go forward, we'll see the major Ginal propeller at about the 9 o'clock position.

So on our left hand side, about halfway up the gut wall, and it looks like this sort of little nipple that's present. So it's not something that's overly important. We don't have to identify it.

It's not important that we see it, but if we do see it, it's important that we identify that it is the Major Giordino propelli, and we don't start doing things like trying to biopsy it or disrupt it because that can cause problems. So this is a major gin or propeller, the minor gin or propeller will be a bit further down and it's usually in the 12 o'clock position. So right at the top of the screen, so maybe about another 5 centimetres along here, sometimes a little bit more tricky to try and see and to try and identify in that location.

But again, we would try not to biopsy that. Another important structure to identify is the pair's patches, and these will look like a sort of crater-like depressions within the endoscopic mucosa. This is a pair's patch here, and these are important to identify, not because we need to assess them or visualise them.

They can have very different appearances in in normal animals. They can look granular, they can look white, slightly yellowish, but it's important not to biopsy. Because what we're wanting to biopsy is the normal intestinal mucosa.

If we biopsy from a pas patch, we'll just get lymphoid tissue. If we just all of our biopsies from the ears patches, and the pathologist will just have lymphoid tissue and we'll end up with a diagnosis of lymphoma just on the basis of the of the changes that are present. So really important that we stay away from those and we biopsy the normal tissue that's present.

But what we're trying to assess is, is whether there's any abnormality or any change, and it's really difficult just visualising the gastrointestinal tract to show whether there is any inflammatory change that's present and how severe that might be. That's really something that we need to assess on the basis of biopsies, and we're notoriously bad at being able to assess and visualise inflammation and assess what that equates to. So both of these dogs do have inflammatory bowel disease and the pictures sort of suggests that the gastrointestinal mucosa doesn't look as normal as we would expect.

Here there's haemorrhage and digestion of blood and this looks pretty horrible, but here there's just kind of mild and diffuse looking inflammation that's present but on endoscopic biopsies. This is really severe lymphocytic plasmacytic disease and this one on the left of the screen is just quite mild and scopic change. So we need to look at things in association with the gross impression, but also to take biopsies to be able to understand that.

So it's important not to overemphasise the changes that we might see. Hopefully, we don't diagnose parasites on endoscopy, but if you do see gastrointestinal parasites, they can be quite exciting. This is a tapeworm in a cat.

So, hopefully, we've managed to diagnose this in other ways, so we would know that that's there. You can remove them if you fancy it. I just grasp them, take them out.

I mean tapeworms have a sort of fairly similar appearance, these roundish worms that you can. You come across in the GI tract. Again, we'd have hoped to have got to the point where you exploded parasitic disease before we've got to endoscopy, but sometimes we do see them inadvertently, so recognise them when they're there.

And then lymphatic changes, lymphatic tasia is, is important because we see that both as a consequence of inflammatory disease, but also as a primary cause of protein losing enteropathy. And this is where we have abnormalities or dilation within the lymphatic vessels that are present in the gut, and this gives us a sort of white stippling type effect that we see within the gut wall as the lymphatics fill with fat and don't sort of drain away in a normal fashion. And this can cause a very odd appearance in the gut.

This is a video of moving through a dog with really severe lymphaticasia, and you can see the whitish. And dilation of the lymphatic vessels that are present and these little sort of finger like protrusions and the lymphatic vessels that are there. And often as you move the endoscope over the top of those, they will start to burst and we can get small amounts of sort of colourless material that comes out that gives us those sort of whitish impressions that are present.

So and that's really helpful to be able to see and to be able to document that that's there. So we go through the intestine as far as it's possible to try and evaluate everything and then as we come back, we would want to assess the mucosa. And as we come back, we can sometimes see that the endoscope has caused a little bit of irritation, and this is usually at the ventral part of the screen, just at the bottom here.

The scope is moved through the mucosa, which just caused a little bit of damage, which is just very mild erythema that's present. This will heal up very quickly. Don't, don't be overly worried about this obviously be as gentle as possible, but that will usually settle quite quickly as a result of the endoscope moving over the top.

So, we've visualised everything and as we've visualise everything, we would want them to take some biopsies. So really important that we take biopsies to, to help us to assess our visual changes. And there's several ways that we can take biopsies.

The first is to just use the forceps ahead of us to go into a wall. And when we're taking a biopsy, we would want to try and take the biopsy at 90 degrees to what we're trying to biopsy. So we And open our forceps, so they go straight ahead and we can pinch into the tissue.

So we try and get a nice bit of mucosa and a little bit of submucosa that's underneath. So either we can do that going ahead to one of the flexors and just biopsy straight ahead of us, or we can angle the scope into the wall and take a biopsy or if we're going around the bend to try and take a biopsy from the side. So usually the sort of most straightforward way if you're starting off is to do.

Like this to just biopsy straight ahead of you and to try and get some nice pieces of tissue. And we know from studies that we should be aiming to get maybe 6 to 10 nice decent chunks of endoscopic material. Studies show that 6 is probably what you're aiming for if you get good 6 good biopsies, but we often play a bit safer name for for 10 or 12, to make sure we've got some really nice chunks of tissue that we can look at.

The other way, which is perhaps a little bit better if we're in areas where we can't direct against the wall ahead of us, is to flex the scope. So what we would do in that location is to push the forceps out, to open them, to pull them back onto the end of the scope, and then to flex the scope 90 degrees to the wall. So that the scope is then pointing towards the wall and the forceps are open like that sort of alligator crocodile type appearance.

Push the forceps out very slightly and then close them and then take them back into the working channel of the scope, and that should give us enough material to be able to evaluate and to biopsy. The other technique that sometimes is quite useful is this sort of scooping type technique, and this is something that we use sometimes in combination with normal biopsies, and this is just to push the forceps out the end of the scope and open them, and then using the blade of the forcep to sort of swipe it and scoop it through the wall of the intestine, to take a nice chunk of the mucosa so that we can evaluate that and that often is really helpful. And this is just a, a video of us doing this in, in this dog.

This is a a dog that has sort of slightly. On the mucosa, we're just going to pull the scape out the forceps out, open the forceps, pull them back a little bit on the end scape angle upwards, and then sort of open the forceps and sort of swipe through the mucosa. So you're taking a nice sort of chunk of the mucosal tissue that's present.

So just watching that again the forceps out, we're opening the forceps, bringing them back towards the scape, angling upwards and then taking a nice bite of the mucosa as you're going forward. So a nice piece of mucosa that's present. Let's just go into to formalin, and then can be sent to the lab.

Some people like to use these little cartridges, so you've got nice pieces of tissue that are present. That just keeps the biopsies a little bit safe and just make sure there isn't a problem. So, just putting them in formula usually works quite well.

And sending through a lab that are used to looking at GI biopsies would be really handy because if they're not used to looking at small pieces of tissue, then they can get lost and then that can be difficult. So, making sure they're orientated correctly would be a good way forward in that respect. Gastric biopsies can be a bit trickier.

The intestinal mucosa is usually quite friable and it's usually easy to take pieces of intestinal tissue, but the stomach is a lot more elastic and it's often a bit more tricky to try and take biopsies. So usually we're after 6 biopsies from the stomach as well, 2 from the pyloris, 2 from the laser curvature. So from that nice shelf of tissue at the insideura, and 2 from up by the cardia.

But it'll be more difficult to get chunks of tissue. We often have to use those serrated forceps or larger swing jaw type forceps to take chunks of the. Intestine mucosa, sorry, gastric mucosa, so we've got nice pieces of tissue.

So you often have to be a little bit braver with the stomach to take biopsies, a bit firmer to take pieces of tissue that we can evaluate endoscopically. So, 6 biopsies, 2 from the pylos, 2 from the car and 2 from the cardio is, is usually a good starting point. Normally then once we've done that, we've biopsied the small intestine, we've come back, evaluated all of it, evaluated the stomach and taken our gastric biopsies.

We would then want to think about the end of the procedure and it's really important that we take all the air out of the stomach really so that their area isn't present so that it's not uncomfor. On recovery and there's no risk of of gastric torsion. And usually by usually by tradition, we give them a single dose of a car fate on recovery just to make sure that there is a covering of the gastric biopsy site so there can't be any sort of development of ulceration or anything that's causing a problem.

And these are usually day cases, they come in and they go home the same day. It's not something that is uncomfortable afterwards. We just want to make sure that they've made a good recovery from anaesthetic and can generally go home the same day.

There generally isn't too much risk of complications. The risk of gastrointestinal perforation is reported, but usually only in association with ulceration. So you're sort of extending the stomach with a, a very thin ulcer within the gastric mucosa or within the intestine.

So it's not something that we would worry overtly about as a risk. There are obvious anaesthetic risks, and there is a risk from reduced venous returns. So often as you sort of inflate the stomach, you will see that the heart rate starts to come up as a result of distension of the abdomen and reduced venous return.

So just reducing some of the gas in the stomach can often help if that's the case. And you just want to make sure that's removed afterwards for patient, comfort and to reduce the risk of a GDV afterwards. And acute, changes are sometimes seen with the acute bradycardia, sometimes a reaction to that extension of vasovagal response, very uncommon, usually responds to, atropine or or glycopylate and the reduction in the distension of stomach, the mucosal haemorrhages.

Really rare to see that any anywhere significant. This sort of bleeding that we see after GI biopsy looks significant and spectacular when we're looking at it just because of the magnification of the endoscope. So normally if we were to escape the animal the following day, not the ethically we would do that.

But if you were to, you would see that those areas had healed completely and there wouldn't be any areas of bleeding that are causing a problem. So that's pretty much looking at the upper gastrointestinal tract, just finishing off thinking about looking at the lower gastrointestinal tract. When we're thinking about the lower gastrointestinal tract, we're looking at the rectum, the large intestine, and the secum.

And if you're good at endoscopy and the patient has been prepared properly, you can drive through the cal colic junction and also visualise the ileum as well. And the ileum is it's not something that we will always get to when we're doing gastrointestinal endoscopy, but actually if you were to have a dog with an inflammatory. Disease looking at the ileal biopsies are often much more elusive than looking at the duodenal oral biopsy.

So sometimes it's something that is helpful to to look at. But essentially when we're looking at lower endoscopy, we're looking at colitis, investigation of large intestinal diarrhoea, any bleeding that might be present or any problems with narrowing or the shape or size of the faecal palate that's being passed and so evaluating those endoscopically would be the way forward. Obviously, we want to try and make sure that there's nothing within the colon, so preparation is really important, and the colon is often longer, especially in large animals.

So typically we use a colonoscope, which is a lengthier scope, but you'll be just fine using a typical endoscopy, endoscope or gastroscope in most of the patients that we look at. So you don't have to have the scope with the right name for the right orifice to go into. So before we do a lower endoscopy, we need to make sure that the animal has been prepared properly so that there isn't faecal material within the rectum and the colon, so we can visualise all of the colon correctly.

So classically we will do that by providing an enema. Usually that's a laxative based solution, so it's clean prep, which some dogs will drink. So some Labradors, for example, will drink that quite nicely.

Other animals we need to give by no tube or a gastric tube. On a couple of occasions before the procedure to try and flush everything through. And then after we've done that, we would give a felt enema afterwards afterwards to try and make sure that there isn't a problem with faecal material being retained within the colon.

So a Higgs and pump or warm water enema would help to remove that, or that helped to remove faecal material just before the anaesthetic. So, making sure that the colon is as empty as possible. Well it's helpful.

And again, we would always do this endoscopies, I mean left later recumbency, so any fluid that is present within the large intestine moves away from the colic junction. So we're going to look at the rectum through the colon, which is the descending colon up through the first splenic flexture, up through the transverse colon, then through thepatic flexure, up to the ascending colon, which is quite a short piece of colon, and then we should see a junction with the colic junction through to the ileum and also the blind ending pouch of the sum. So yeah, again, we, we sort of do the same thing as we would do with the duodenum in terms of we can look visually ahead of ourselves.

And this sort of visualises what we would see as we go through the gastrointestinal tract. And the clonic mucosa has much less pattern to it compared with the duodenum. It's very flat, and It should be quite nice and smooth, and you will see the submucosal vessels within the mucosa.

So these are the submucosal or colonic vessels that are present. And this is very normal. It's very normal to see those vessels in the mucosa.

If there's inflammation, they will start to be a bit more prominent. I mean you can see them a little bit more, obviously. There's also some ridges as well.

So this is a normal colon looking forward. There's a little bit of faecal material here, so the prep isn't 100%, but this is pretty good. We'd be fairly happy with that.

And this sort of linear regal type folds and these circumferential round osteopparistaltic waves are very common to see within the, within the colon. So this is sort of normal parents of the colon, looking forward. If they are massive, we'll see them as polyps or or growths from the wall, and these often have these sort of friable quite angry looking appearance, and this is what we would see with no carcinoma.

If there's inflammation, we'll often see that as inflamed change within the wall, so the subcosal vessels become more prominent and we can see these little doughnut type lymphoid hyperplastic follicles that are present, and these are very suggestive of inflammatory bowel disease. So lymphocytic plasmacytic colitis in terms of the inflammatory change that's present. And this is the sort of really severe lymphocytic plasmacytic colitis with a sort of bumpy appearance that's present, and we want to try and take some biopsies of some of the surfaces of those to try and understand what's causing a problem.

And this is a dog with multiple colonic polyps that are present, these sort of raised and bumpy friable looking lesions, and these are all gastric adenocarcinomas that are present. And this is going to be quite difficult for us to treat. You can see that there are multiple areas here that look abnormal and we would take little biopsies of Friable areas as well as the more normal areas at the top of the screen.

So the, the mass here is lying between about 5 and 9 o'clock, and the rest of the, the colon is, is very normal in that respect. So it's it's not a circumvential lesion, but it is involving a lot of the clonic wall in that area. So hopefully then we'll be able to go up and evaluate the colon so up through the descending part across the transverse part and around the ascending part and that allow us to look at the colic colic junction.

So as we get up towards that part, often the ascending part is quite short. This is going around the second flexion and looking towards the late colic sequel junction. And this is what the cholic sequel junction looks like.

This is the a junction through to the ileum at the top of the screen, and this is the sum at the bottom, which is that blind and the pouch. And if we're feeling keen, we can go through the iles colic junction here, so we can go through into the ileum to take some ilbiopsies and intubation. Helium is much trickier than the pylorus because the scope is already going around 25 flexures.

It can be really tricky to get through, but this is what you'd expect the normal lium to look like. It's got a nice smooth mucosal surfaces and have that ridge or textured surfaces you would expect with the duodenum, it looks a lot smoother, and then we can take some biopsies of this area as well. So it's a nice site to get biopsies from if we can get to, but it often can be quite tricky to go through that area.

Often, the reason that you can't get to that area is poor preparation, that there is just faecal material that means that you can't pass it. And if you're sort of, coming up against a lot of very watery liquid diarrhoea like this, it can be really difficult to get, good samples and to visualise the GI tract. So there's usually an abandonment of the procedure if that's the case, and then we go on to, to think about doing it on another day or we would use warm water enemas to try and remove as much of that as possible, and get biopsies from areas that we can.

But again, as with the stomach and the small intestine, really important that we combine visual inspection with biopsies. So we would take between 6 and 12 biopsies of the of the colon, the ascending the transverse and descending colon, so we can pair all of those areas. And normally it's, it's fairly straightforward to get colonic biopsies.

Collic wall obviously is thinner, so we don't biopsy repeatedly in the same place and we're a bit careful with any areas of, of ulceration or irritation, but it's important that we take colonic biopsies to, to really understand what's causing the pathology in those areas. So hopefully that's the last part of evaluation of the gastrointestinal tract. If we look at the oesophagus or stomach and the small intestine, and if we're thinking about the large intestine for large intestinal disease, then we'll look at the colon.

And just lastly, we just wanted to think about some of the interventional procedures. So we'll think a little bit about PEG tube placement just in a couple of slides, some of the foreign body removals and how we've removed them, and then just how we might sort of approach removing polyps and things endoscopically just to, to finish off in the last few minutes. So peg tubes are percutaneously endoscopic guided gastronomy tubes, and these are tubes that are placed for long term nutritional support.

We don't place them lightly because we have better options in terms of esophageal feeding tubes or nas esophageal tubes, but we can use endoscopy to guide the placement of gastrootomy tubes, and this has been well done in people for long periods of time. And these gastronomy tubes can be placed very straightforwardly. So we use the endoscope to help guide the placement of the tube, and this is, this is a box here with a meroesophagus that's got a peg tube in place, and this tube is present in the stomach here, and this is just a mushroom tip tube that is present, which is just placed through the gastric wall that enables us to feed this dog directly into the stomach.

And they're quite tricky things to to place they're very straightforward in terms of of the procedure, but we just need to be a little bit fiddly in terms of how you place them. We would place the endoscope down to the stomach and inflate the stomach so we can feel it on the body wall. Poke into the body wall so we can see that deflection with our finger endoscopically using a needle, we go through the body wall into the stomach and pass the wire through from from the tube, which is grasp in the stomach and we pull that wire out through the mouth, and then we attach that wire onto the tube.

So this loop at the end of the tube here, which enables us to be able to pull this tube back through the dog, which means that this end comes out through the body wall, and then we pull the rest of the tube out so this button is attached on the inside of the stomach and the rest. The tube is allowed on the outside and this just anchors the stomach against the body wall so we can feed into the stomach and stomach is fixed in that position. So using the endoscope allows us to place them a little bit of a risk of potential leakage and and, but they're they're quite safe things for us to place and and we do them.

I know with with patients that need medium to long term feeding, so tetanus patients, for example, or patients that have esophageal disease that we need to try and get some nutrition on board for and they're usually very well tolerated in that respect. I guess the most frequent, sort of, a complication would be that there's a bit of infection, but usually that settles down without too much of a problem. This is sort of one of the more advanced things that we might do with the endoscope.

This is a little polyp that's here with the yellow arrow. This is the poly outflow tract, and this polyp was obstructing the poly outflow tract. So we could surgically remove this polyp, but what we did in this instance here was just to go in and place a quarry snare around it.

So this is just a loop which we're replacing with with endoscopy, just allows us to snare around the base. Of that polyp and then just using a quarry or electric current applied to that quarter leap snip through the polyp and then we can just grasp the polyp and we can remove it and that's remove the obstruction. So a really neat way of alleviating the problem is about 5 minutes and the recovered very well and the symptoms were alleviated very nicely.

Polyp didn't recur. So a very neat way of resecting it rather than leaving. To go for open surgery, and we do this sort of endoscopic polypectomy in the colon quite frequently just with with polyps just to remove them, works very well for the benign ones, but not so well for the malignant ones.

So sometimes we do use that technique as a biopsy to try and see whether we need to do anything further or we take biopsies first before we make a decision as to how to remove it usually depends what they look like as to how we go forward with that. And then lastly that the most common reason for using the endoscope would be to retrieve foreign bodies, and it's always amazing what foreign bodies we can remove from the stomach, as we said at the beginning, I've just removed a fish hook from a, from a dog's stomach this week, but I've also removed part of the Kinder egg, and some more toys associated with that. We've also removed a pair of ladies' underwear from the dog's stomach.

I hope they belong to the owner of the chaps. In trouble, and various other things that can be seen. So this is just an example from a few weeks ago.

This is some coins, always funny when dogs eat coins because it's a good game to play with the nurses on X-rays to try and guess how much money is present. And these are some socks that were present. So dogs like eating those for various reasons and always nice to be able to retrieve them.

It can be difficult to remove them if the stomach is empty. He then usually it's fairly straightforward to identify them. If the stomach is full of food or this other material that's present, it can be difficult to remove them.

And usually what we're trying to do is to use grasping forceps to try and grab the foreign body. So with this this coin, we try and grab either side of it and remove it, take it back onto the endoscope and then remove the whole of the endoscope while removing the foreign body. So nice big grasping forceps would work well.

Baskets work really nicely for round balls or for stones to get the wires either side of those so you can go around them and remove them, and snares, so just loops that are quite useful for things which they can dig into. So things like avocado stones can be really quite tricky things to remove endoscopically so it's hard to get purchase on them. So you're using a snare and digging that snare into the surface of the foreign body, it's really helpful to try and do that.

So thrombodies can be quite tricky. Usually they'll lodge in the cardia. So if you've got the dog in left later recumbency, our standard endoscopic positioning, they'll be up by the passage of the scope.

They'll be up in the cardio, which is why this TP here is right by the cardiac because that's the most dependent part of the stomach. So it's quite difficult to get to them because you've got a retroflexion right round to be able to see them. So moving them into the opposite lateral, so either sternal or into right lateral can move the foreign body onto the opposite side and that can sometimes make it a little bit easier to see and to grasp and to visualise.

But this is just removal of a foreign body. This is a dog that ate its bandage, which is always embarrassing. So, the dog was anaesthetized for its bandage changed.

We just went in with the endoscope, grasped the bandage. So we just grab, grabbing hold of it. And then once we've got hold of it, we're going to move the scope out on its own.

So here we're just coming through the lower esophageal sphincter into the oesophagus. It's got a little bit stuck. Caria.

So then you need to hold the forceps quite tightly, sometimes hold on to the dog a little bit just to make sure you're not pulling it forward. But usually if you're just sort of gently retracting it, it will come out quite nicely, and that will allow passage of the foreign body and hopefully you can remove it, which is, which is great. So usually very rewarding and and quite easy things for us to do.

So I think that's a whistle stop tour of the spinal tract and indications for endoscopy. Can't really cover everything with just an hour talking and it's always difficult talking about something practically, in terms of something that is a very physical thing for us to, to do. But hopefully you get the idea of what is normal, and what you can do and what you should be looking for, .

And the idea would be to just go in and have a go and really try and do your best because it's one of those things that can be really rewarding and there is quite a really steep learning curve in doing it. So if on the first occasion you just get really frustrated, have another go, keep doing it, you will gain the skills to do it quite quickly. I mean you have a lot of information for your patients as a result of that.

So thank you very much for listening. I'm very happy to answer any questions. Thank you for that, Simon.

That was brilliant and a lot of really useful tips there. I think sometimes people can be a bit, cautious, in attempting these things, but I think, you know, anyone watching that will feel a lot more confident now in attempting, some of the, procedures that you've, just gone over. So, as Simon says, he's got, a little bit of time to answer a couple of questions, and fortunately he wasn't called away, so, that was obviously a bonus.

So please do, type any questions you may have in the Q&A box. I've got a couple of questions that have come in already for you, Simon. I think probably, one of it's the first question is from Catherine, and Catherine's asking, would you attempt to remove a GI foreign body, e.g.

The fish hook from earlier, from a recently fed dog, or would you obviously leave it a bit to, . Yeah, I think, I think it's really difficult because it's, it's always hard to know what else you're going to encounter in the stomach. The owners of the dog with the fish hook that we've just removed claimed the dog wasn't fed, but actually when we went in there was all sorts of other stuff that was in the stomach as well, like bits of grass and bread and things that look like digested fish, so lots of stuff that's there, and you can see quite a lot because you're going to inflate the stomach and insufflate it and you can have a Look around.

So it really depends what the foreign body is and what you're looking for. Something like a fish, you'd hope to understand the position. So looking radiographically, you should see it.

And if you know that it's got a piece of line attached to it, that often makes it easier, which is a good clue as to where it might be. If ever dog swallow fish hooks never cut the line off, always tied to the collar so that you've got something to follow endoscopically. But in, in that respect, yes, that.

We would always try to have the stomach as empty as possible, but sometimes that's not possible. And if we're trying to remove something that could cause a problem like a fish, we usually go in sooner rather than later with the understanding that if you can't remove it, you can always have a little look 12 to 24 hours later. So yes, I would look sooner rather than later, but also just be sort of understanding that it might not be possible to do that and have another look on a later occasion.

No problem. Yeah, so, I see, that was something else that Annette then just followed up with was how long would you starve, if it wasn't sort of an emergency and you could wait a bit longer, how would you starve, how long would you starve the animal for, for an upper GI? Is it sort of similar to a human in that sort of respect, or is it?

Yeah, I mean, there's always a debate with whether we should starve dogs for a length of time for anaesthetic, but really here you want the GI chat to be empty, so. At least 18 hours is what we would do for upper GI endoscopy. It's always a bit difficult because hospitalising a dog can sometimes create gastric stras through nerves.

So that is difficult. But usually if we're doing an endoscopy sort of late morning, we would want the dog not have had any food sort of after sort of 4 or 5 o'clock the night before and to be quite a light meal on that occasion. So whilst it seems mean, we would use the, we would usually hospitalise the dogs here for the day before the endoscopy just to make sure they're not fed anything.

But if we trust the owners. Then we would, we'd want them to not have any feed after about 4 or 5 o'clock the day before. The colonoscopy, it's a bit more different, different because you're doing prep, so you're often not feeding the all sort of 36 hours prior to doing the colonoscopy.

So using the osmotic laxatives as as a liquid prep that will go through for 24 hours first and then doing the warm water enemas or the flex and afterwards to try and remove faecal material. So, and that can take a little bit of time. So, so you would start them for longer to do that.

Yeah, fantastic. Thank you. Susan, Sue's a, a regular attendee, and she said superb thank you.

So that's some nice feedback there for you as well. And Annette has, come up with another question. Excuse me, just I'll read this.

What do you do if a foreign body is stuck in the caudal area of the oesophagus? She's got just crown of the oesophagus sphincter, do you try to retrieve or could you consider pushing it into the stomach if you can't retrieve? Yeah, absolutely.

E, either of those two things is, is perfectly fine to do. So if you can try to retrieve it would be the best way forward, but it's very difficult sometimes to get forceps around a foreign body that's lodged. So that can be quite tricky to get either side of something to try and remove it.

So it's perfectly reasonable to push it into the stomach, either then to try and collect it and remove it again, or to wait for Which is dissolved so things like bones, so there's some classic lamb bone that's got stuck over the heart basically, if you can push it further forward, you can push it through into the stomach, then that's a perfectly reasonable way of trying to address things. Just being a bit careful if it's got anything sharp over it. But usually if something's got all the way down to the cordless esophageal lower esophageal think to just cranial to the stomach, it's, it's going to be, you know, big enough to to go.

Through without causing too much of a problem. So yeah, pushing it further forward is is perfectly reasonable either than to wait for it to dissolve and and the temptation would be to give things like antacids to try and alleviate any risk of esophagitis, but not giving those to allow the gastric acid to dissolve from what is really important. And if it's not something that could be dissolved, then, you know, there's a site there for either endoscopic retrieval or a gastrostomy to remove it.

Fantastic. No, that's great. See if there's any other questions coming in.

One, the one for me was, obviously you talked about how to sort of get past the plus. In terms of when you talk about helium, and would it be the same sort, some sort of techniques in terms of, you know, pumping a bit of air in, just trying the different things just to try and open up and be able to pass through, or is there a different light, it's, it's exactly, it's exactly the same technique. It's just a.

Trickier because your scope is retroflex. So you've got much less flexibility. So it is much harder to do the ileal intubation than it is to do that the pyloric intubation.

So in that regard, it just because the scope mobility is a little bit lower, but yeah, essentially you're trying to line up for the the sort of star shape opening and just gently pushed through, so using a little bit of air to try and get it to open and gradually go forward. But again, you needing to put Little bit of pressure and and sort of a forceful sort of confident movement with the scope forward to try and push through the opening, because if you're advancing the scope forward, you're also pushing the escape into the transverse colon. So you need it to be able to sort of slide through.

So it's often sort of 5 to 10 centimetres forward that you're moving the scope, just to get a few centimetres through the opening, but it is more difficult to do that. I say practise makes perfect. Yeah, I find that tricky.

So it is one of the more difficult things. Yeah. I just got a question from Laura.

Laura, is there a specific technique, such as pushing down for the safe insertion or removal of the endoscope regarding prevention of damage of upper GI structures? I'm a first year vet student yet to do the first GI module. So, so if you're moving the scope over the top of the larynx into the oesophagus, it's normally fairly easy to do that.

So we use a little bit of water soluble lubrication just on the scope so it's KY jelly or something similar. And yeah, it's just, just, it's just gradually pushing the scope down. So it's very similar to placing a feeding tube or a gastric tube if we had a distension.

So, no, it's, it's really just passing the scope over the top of the of the laryn. It's very easy. You you can visualise it using a laryngoscope, or most people just do it blindly, and it's just generally pushing the scope forward.

If ever using endoscopy, the scope doesn't seem to want to go forward. You're probably pushing against, a wall or something, so you need to come back and redirect the scope and then go forward. So, yeah, there's a little bit of experience that helps us with that, but you don't really want to be pushing too hard.

If you're pushing, you know, finger against your arm to the point that it was hurting, that's the sort of thing that you Don't want to do is sort of gentle pressure that you want to push forward. It's not something that would be a very dynamic action. Yeah.

No problem. Well, hopefully that has helped you, Laura, and it'll put you top of the class when it does come around to your GI module. And, please do, signpost any of your other fellow, students, to this webinar afterwards, if they would also like to have a look, because it is complimentary for BVA students to, get, get involved with this.

So I think that is it for the question, Simon. So all it leaves me to do is to say thank you to Lewis, for being on hand to answer any technical queries this evening. And getting Simon set up in the first place.

Thank you to yourselves for attending. I would encourage you at the end of this webinar, there will be a short survey, so please do complete that survey as it really helps just help shape our future content and also provide some great feedback for Simon as well. And obviously thank you to Simon.

For, I know it's been quite a fraught day for you, so thank you very much for giving your time to actually continue to deliver this webinar, really appreciate it and hopefully we'll see you all on our webinar soon.