Overview of Pathological Findings in the Stomach

Table 3.9 Pathological findings in the stomach Table 3.9 Pathological findings in the stomach Fig. 3.76 Billroth II gastroenterostomy 96 Fig. 3.76 Billroth II gastroenterostomy 96 Acute and chronic gastritis are reactions of the gastric mucosa to various noxious agents. They are entirely different conditions, each presenting its own clinical, endoscopic, and histological features (Table 3.10). Both conditions, especially the chronic form, pose a special challenge to the endoscopist because the...

Upper Gastrointestinal Stenoses Malignant Strictures

Stenoses in the upper gastrointestinal tract can result from benign and malignant diseases. The causes are listed in Table 4.13. The most frequent site of occurrence is the esophagus. A less common site is the gastric outlet. Significant stenoses of the duodenum, usually a result of adjacent malignancies, are very rare (Table 4.14 ). Table 4.13 Causes of upper gastrointestinal stenoses - Inflammatory, cicatricial peptic stricture, corrosive ingestion, radiation - Postoperative fundoplication,...

PEG Placement Principle Indications and Contraindications

PEG provides a rapid, simple method for long-term enteral feeding. Although the method can generally be used without complications, there are still some significant risks that should be kept in mind. PEG placement is a technically simple procedure (Figs. 4.32, 4.33). A cannula is passed through the abdominal wall, and a guide suture is threaded into the stomach through the cannula. It is retrieved endoscopi-cally, withdrawn through the mouth, and used to pull the PEG tube down the esophagus and...

Bleeding Esophageal Varices and Fundic Varices Medications and Tubes

The mortality rate due to variceal bleeding (Fig. 4.10) is high, at 15-30 . The recurrence rate after an initial bleed is approximately 60 during the first two weeks. One third of varices will stop bleeding spontaneously. The following treatment methods are used - Sengstaken-Blakemore tube (for esophageal varices) - Linton-Nachlas tube (for fundic varices) Besides the control of bleeding and prevention of rebleeding, additional therapeutic measures may be taken depending on the clinical...

Handling the Endoscope

The control head of the endoscope is held in the left hand. The index and middle fingers activate the suction and air water valves. Many examiners operate the angulation control wheels with the right hand, but an endoscopist with large hands can also manage these controls with the left hand. This leaves the right hand free to manipulate the insertion tube, which is advantageous in some situations. The control head is used to control the four functional systems listed in Table 1.8. In a...

Bleeding Ulcers Management after Primary Hemostasis and in Special Cases

Management after Primary Hemostasis Figure 4.25 outlines the follow-through regimen after primary hemostasis has been achieved. Scheduling an early repeat en-doscopy does not improve the prognosis. When rebleeding occurs after primary hemostasis, the success rate of repeat endo-scopic hemostasis is 50-70 . Hemostasis of a Mallory-Weiss Lesion A Mallory-Weiss lesion (Fig.4.26a) is infiltrated with epinephrine diluted 1 10000 in physiological saline solution, or it may be obliterated with fibrin...

Bleeding Ulcers Pharmacological Therapy and Injection Techniques

Pharmacological Therapy of Bleeding Ulcers Hemostasis cannot be achieved with medical therapy alone. PPI are used, but their benefit is still unproved. If H. pylori is de- tected, eradication therapy should be performed. This can expe- dite healing and lower the risk of recurrence. NSAIDs should be discontinued. The treatment of choice is endoscopic hemostasis (injection therapy, hemoclips, thermal methods). - Safe, economical, can be used to treat rebleeding after prior hemostasis with...

Treatment and FollowUp

If H. pylori is detected, the following regimen is used for eradication 1. PPI, for example, pantoprazol, 40 mg 1-0-1 2. Clarithromycin, 500 mg 1-0-1 Irritants, nicotine, and NSAIDs should be withdrawn. Massive hemorrhage (treatment, see p. 151 ff.) Endoscopy is repeated at four to six weeks, and new specimens are obtained. Additional follow-ups are scheduled according to the progression of healing. Dieulafoy ulcer (see p. 155) Predominantly fibrin-coated ulcer with...

Crohn Disease of the Esophagus

Crohn disease may affect the entire gastrointestinal tract, including the esophagus. Involvement of the esophagus alone is rare, however. Endoscopic diagnostic criteria (Fig. 3.44) - Erythema, diffuse or focal edema, blistering - Pseudomembrane, ulcer, slough - Squamous cell carcinoma (caustic ingestion) Endoscopic findings are easy to interpret in patients with a typical history. Endoscopic diagnostic criteria (Fig. 3.45) Morphology of the individual lesions Number and size of the lesions...

Sedation and Analgesia

The use of benzodiazepines is often associated with a decrease in arterial oxygen saturation, but this is rarely significant. The risk is increased in older patients, patients with chronic respiratory failure, coronary heart disease, or hepatic insufficiency, and in emergency endoscopy. The principal risks are a fall in blood pressure and hypox-emia-induced cardiac arrhythmia. Myocardial infarctions during endoscopy are rare. Respiratory complications can range from...

Differentiation of Benign Esophageal Tumors

Leiomyomas are the most common benign esophageal masses. They are usually found in the lower third of the esophagus and rarely cause complaints. Most are detected incidentally. They are located in the submucosa. Lipomas, fibromas, and neurinomas are virtually indistinguishable from leiomyomas by their endoscopic appearance. They are very rare mesenchymal tumors. Hemangiomas that are covered by normal mucosa are difficult to distinguish from leiomyomas endoscopically. Some, however, have a...

The Operated Stomach Endoscopically Identifiable Lesions and Diseases

Granuloma Distal

It is very common to find erythematous and sometimes bile-tinged mucosa just proximal to the stoma in the operated stomach. Histologically, inflammatory mucosal changes are found in 60-90 of cases. It is likely that the reflux of bile and alkaline pancreatic juice has causal significance. The degree of macroscopic and histological changes does not correlate with the severity of the complaints, and many patients are asymptomatic. The endoscopic picture is characterized by edema, erythema, and...

Characterization of Abnormal Findings

- Oval, round, irregular, spotty, patchy, linear, stippled, confluent - Broad, constricted, pedunculated - Smooth, furrowed, glistening, fissured - Solitary, scattered, multiple, numerous, ubiquitous Mobility of lesion or mucosa Degree of luminal narrowing Resistance to instrument passage - Location in centimeters from the incisors, relation to physiological constrictions, relation to the Z-line - Extent longitudinal extent, circumferential extent, degree of luminal narrowing - Extent of peptic...

Overview of Pathological Findings in the Duodenum

Duodenal Ulcer With Giant Visible Vessel

Table 2.26 Pathological findings in the duodenum Table 2.26 Pathological findings in the duodenum Fig. 3.136 Polypoid lesions in the duodenal bulb Fig. 3.136 Polypoid lesions in the duodenal bulb Fig. 3.139 Inflammation and necrosis in the duodenum of a patient with pancreatitis Fig. 3.139 Inflammation and necrosis in the duodenum of a patient with pancreatitis Duodenal ulcer is an epithelial defect in the bulbar or descending duodenum that penetrates the muscularis mucosae and extends into the...

Acute Gastritis

Acute gastritis can be caused by a variety of exogenous and endogenous agents Table 3.11 . More often than in chronic gastritis, endoscopy reveals signs that point to the correct diagnosis Table 3.12 Fig. 3.78 . The endoscopic features do not suggest a specific causative agent of the gastritis, however. The diagnosis of acute gastritis often relies on the clinical presentation upper abdominal pain, anorexia, nausea, vomiting plus the en-doscopic findings, with histology showing little or no...

Impression from the Pancreas

The pancreas often makes an oblong impression in the area of the body-antrum junction Figs. 2.522.54 . Figure 2.55 shows the topography in the endoscopic image. Fig. 2.52 Impression from the pancreas. Typical appearance of the posterior stomach wall in the area of the body-antrum junction Fig. 2.52 Impression from the pancreas. Typical appearance of the posterior stomach wall in the area of the body-antrum junction Fig. 2.53 Relation of the stomach and pancreas. Conventional anatomical view...

Esophageal Varices Grading

Proximal esophageal varices secondary to upper inflow stasis Fig. 3.58 Downhill varices. Proximal esophageal varices secondary to upper inflow stasis - Abb. 3.60 Grading of esophageal varices The grades are based on size and luminal narrowing I Distended veins at the level of the mucosa II Isolated, straight varices that project into the lumen with no significant narrowing lt 5 mm III Large, tortuous varices that cause significant luminal narrowing gt 5 mm II...

Antral Peristalsis

The endoscope tip is at the approximate center ofthe air-filled stomach, in the junctional region between the body and antrum a . Observe the rosettelike appearance ofthe contracted pylorus at the center ofthe image. As the rosette pattern dissolves, the next peristalticwave appears at upper left in the image b . The concentric waves propagate from the periphery ofthe image the distal body to the pylorus c-f . The next contraction appears injust 15 seconds g . It moves toward the pylorus h, i ,...

Cardiac Notch Impressions from the Heart and Spleen

The endoscopic appearance of the fundus and cardia is influenced by the adjacent diaphragm, spleen, and and heart. Understanding this appearance requires an adjustment in thinking due to the U-shaped deflection of the endoscope for inspecting the fundus and cardia Fig. 2.63 . The diaphragm creates the deep fold of the cardiac notch. The impressions from the spleen and heart can be identified in the dome of the fundus Figs. 2.60-2.63 . The spleen may bulge deeply into the fundus, but in some...

Components of Retroflexion

Stomach Retroflexion

Since the entire upper gastrointestinal tract is inspected and evaluated with a forward-viewing endoscope, retroflexion is necessary to obtain a complete view of the cardia and fundus. The angulus and body are also examined in retroflexion Figs. 2.43, 2.44 . The retroflexion maneuver consists of the following components The large inner control wheel moves the instrument tip in the plane of the wheel - Turning the wheel backward counterclockwise deflects the endoscope tip forward and upward into...

Gastroesophageal Junction

Lower Esophageal Sphincter and Diaphragmatic Hiatus - 33 Swallowing and Esophageal Motility - 35 2 Examination Technique and Normal Findings Examining the Stomach During Insertion - 36 Body-Antrum Junction and Antrum - 41 Body-Antrum Junction and Antrum - 41 Relations of the Stomach Pancreas - 49 Views Fundus-Body Junction and Gastric Body - 37 Relations of the Stomach Liver - 50 Views Body-Antrum Junction and Antrum - 38 Relations of the Stomach Heart and Spleen - 51 Views Bulbar and Proximal...

Esophageal Motility Disorders in Systemic Diseases Scleroderma

Esophageal involvement is found in more than half of patients with systemic sclerosing diseases. Peristalsis and LES tonus are markedly diminished, allowing reflux of corrosive gastric juice. Other causes of impaired esophageal motility are diabetes mellitus, renal failure, neuropathies, and myopathies. Fig. 3.55 Manometric findings in nutcracker esophagus. The traces show hypertonic propulsive contractions of prolonged duration in the tubular esophagus. The LES shows a normal resting pressure...

Anatomy

Esophageal varices are distended submucous veins that project into the esophageal lumen. They are part of the collateral circulation that develops between the portal vein and vena cava in response to portal hypertension. They develop from the plexus of esophageal veins that drain into the azygos and hemiazygos veins. They receive blood from the left gastric vein and its esophageal branches and also from the short gastric veins via the splenic vein Fig. 3.56 . Portal vein Superior mesenteric...

Passage through the Upper Esophageal Sphincter

Contrast Piriform Recess

Unless the patient swallows, it is extremely difficult to advance the endoscope through the upper esophageal sphincter without causing injury or significant discomfort. Endoscope insertion is contraindicated while the patient is coughing or taking a deep breath, as this will inevitably lead to tracheal intubation Fig. 2.2 . The period immediately after coughing, when the patient is swallowing saliva, is a favorable time for entering the esophagus. At this time the larynx is in an elevated...

Views Fundus Body Junction and Gastric Body

Gaping Pylorus

- Fig. 2.27 View of the fundus-body junction - Fig. 2.27 View of the fundus-body junction The endoscope tip is straight upon entering the stomach. The gastric body is visible at the 9-o'clock position in the distant part of the field. The initial part of the fluid pool that is usually seen in the fundus is visible at the 3-o'clock position. The lesser curvature is in the 12-o'clock position, and the greater curvature is at the 6-o'clock position. As the endoscope is advanced further and air is...

Views Descending Duodenum and Superior Duodenal Angle

Superior Duodenal Angle

The complex maneuver described above usually advances the endoscope tip quickly down the descending duodenum. When the instrument is now pulled back, the redundant loop of shaft within the stomach straightens out, causing the endoscope tip to advance again by several centimeters. The lumen is centered in the image, and the duodenum is evaluated while the endoscope is withdrawn. The papillary region is easily recognized but cannot be adequately evaluated with a forward-viewing instrument. The...

Interventional Procedures and Extended Endoscopic Examination Methods 142

Junction Endoscopy Reflux Esophagitis

Overview of Interventional Endoscopy Incidence and Signs 145 Incidence 145 Causes 145 Symptoms 145 Hemodynamic Stabilization 146 Maintaining Adequate Respiration 146 Identify the Source of Bleeding and Stop the Bleeding 146 Bleeding Esophageal Varices and Fundic Varices Medications and Tubes 147 Treatment Methods 147 Pharmacological Therapy of Bleeding Esophageal Varices 147 Balloon Tamponade 147 Bleeding Esophageal Varices Sclerotherapy 148 Endoscopic Treatments 148 Sclerotherapy with...

Diagnosis

Typical history of Mallory-Weiss lesion retching followed by bloodless vomiting, then vomiting of blood Identify the bleeding source. Endoscopic hemostasis see p. 155 Complete esophagogastroduodenoscopy EGD to detect or exclude a concomitant bleeding source. Longitudinal blood-stained or bleeding tears Figs. 3.19, 3.20 Located at the gastroesophageal junction Oral contrast examination with a water-soluble medium en-doscopy is contraindicated in patients with a suspected perforation or if...

Contraindications

Cough With Barrett Esophagus

An absolute contraindication to elective upper GI endoscopy is lack of informed consent from a mentally competent patient. Relative contraindications are organ perforations and states of cardiac or respiratory decompensation Fig. 1.2 . b Upper abdominal pain, heartburn, Barrett esophagus, peptic stricture, achalasia a Dysphagia, swallowing difficulties, retrosternal pain a Dysphagia, swallowing difficulties, retrosternal pain b Upper abdominal pain, heartburn, Barrett esophagus, peptic...

Grade IIV Reflux Esophagitis

Pictures Reflux Esophagitis

The inflammatory lesions of reflux esophagitis are currently graded according to the Savary-Miller classification, which is summarized in Table 3.4. Grades I-III. Grades I-III Fig. 3.25 reflect a more or less pronounced acute attack. These grades may be complicated by superficial bleeding, but some cases initially resolve without sequelae. Grade IV. Grade IV Fig. 3.26 represents the chronic, complicated stage of reflux esophagitis, which is subject to its own dynamic. The most serious...