Atlas of Enteroscopy

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Video Capsule Endoscopy in the Emergency Department. Patency Capsule. Michel Delvaux, Louis Y.

Video Atlas of Gastrointestinal Endoscopy | Clinical Gate

Korman, Martin Keuchel. Duodenoscopy and Ileocolonoscopy. Push Enteroscopy. Double-Balloon Endoscopy.

INTRODUCTION

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Atlas of Enteroscopy

Advanced Book Search Browse by Subject. Make an Offer. Find Rare Books Book Value. Sign up to receive offers and updates: Subscribe. Operations for motor disorders have been introduced including implanted electrical stimulators for gastroparesis and electrical devices and artificial sphincters for fecal incontinence. Surgery may be needed to place a jejunostomy for long-term enteral feedings. The threshold for performing surgery depends on the clinical setting. In all cases, the benefits of operation must be weighed against the potential for postoperative complications.

In some conditions, GI symptoms respond to treatments directed outside the gut. Psychological therapies including psychotherapy, behavior modification, hypnosis, and biofeedback have shown efficacy in functional bowel disorders. Patients with significant psychological dysfunction and those with little response to treatments targeting the gut are likely to benefit from this form of therapy. Gastrointestinal endoscopy has been attempted for over years, but the introduction of semirigid gastroscopes in the middle of the twentieth century marked the dawn of the modern endoscopic era.

Since then, rapid advances in endoscopic technology have led to dramatic changes in the diagnosis and treatment of many digestive diseases. Innovative endoscopic devices and new endoscopic treatment modalities continue to expand the use of endoscopy in patient care.

Current flexible endoscopes provide an electronic video image generated by a charge-coupled device in the tip of the endoscope. Operator controls permit deflection of the endoscope tip; fiberoptic bundles or light-emitting diodes bring light to the tip of the endoscope; and working channels allow washing, suctioning, and the passage of instruments. Progressive changes in the diameter and stiffness of endoscopes have improved the ease and patient tolerance of endoscopy.

Upper endoscopy, also referred to as esophagogastroduodenoscopy EGD , is performed by passing a flexible endoscope through the mouth into the esophagus, stomach, and duodenum. The procedure is the best method for examining the upper gastrointestinal mucosa. While the upper gastrointestinal radiographic series has similar accuracy for diagnosis of duodenal ulcer Fig.

Intravenous conscious sedation is given to most patients in the United States to ease the anxiety and discomfort of the procedure, although in many countries EGD is routinely performed with topical pharyngeal anesthesia only. Patient tolerance of unsedated EGD is improved by the use of an ultrathin, 5-mm diameter endoscope that can be passed transorally or transnasally. Ulcer with a clean base. Ulcer with a visible vessel arrow in a patient with recent hemorrhage. Benign gastric ulcer. Malignant gastric ulcer involving greater curvature of stomach.

Histologic finding of intramucosal adenocarcinoma in the endoscopically resected nodule. Tumor extends into the esophageal submucosa arrow. Colonoscopy is performed by passing a flexible colonoscope through the anal canal into the rectum and colon. Colonoscopy is the gold standard for imaging the colonic mucosa. Colonoscopy has greater sensitivity than barium enema for colitis Fig. Computed tomography CT colonography is an emerging technology that rivals the accuracy of colonoscopy for detection of some polyps and cancer, although it may not be sensitive for the detection of flat lesions, such as serrated polyps Fig.

Conscious sedation is usually given before colonoscopy in the United States, although a willing patient and a skilled examiner can complete the procedure without sedation in many cases. Chronic ulcerative colitis with diffuse ulcerations and exudates. Pseudomembranous colitis with yellow, adherent pseudomembranes. Ischemic colitis with patchy mucosal edema, subepithelial hemorrhage, and cyanosis.

Pedunculated colon polyp on a thick stalk covered with normal mucosa arrow. Sessile rectal polyp. Appearance of the lesion under conventional white-light imaging. Mucosal patterns and boundary of the lesion enhanced with narrow band imaging. Submucosal lifting of the lesion with dye methylene blue injection prior to resection. Flexible sigmoidoscopy is similar to colonoscopy, but visualizes only the rectum and a variable portion of the left colon, typically to 60 cm from the anal verge.

This procedure causes abdominal cramping, but it is brief and is usually performed without sedation. Flexible sigmoidoscopy is primarily used for evaluation of diarrhea and rectal outlet bleeding. Three endoscopic techniques are currently used to evaluate the small intestine, most often in patients presenting with presumed small-bowel bleeding. For capsule endoscopy , the patient swallows a disposable capsule that contains a complementary metal oxide silicon CMOS chip camera.

Color still images Fig. Capsule endoscopy enables visualization of the small-bowel mucosa beyond the reach of a conventional endoscope and, at present, is solely a diagnostic procedure. Push enteroscopy is performed with a long endoscope similar in design to an upper endoscope. The enteroscope is pushed down the small bowel, sometimes with the help of a stiffening overtube that extends from the mouth to the small intestine.

The proximal to mid-jejunum is usually reached, and the instrument channel of the endoscope allows for biopsy or endoscopic therapy. Deeper insertion into the small bowel can be accomplished by single — or double-balloon enteroscopy or spiral enteroscopy Fig. These instruments enable pleating of the small intestine onto an overtube see Video e With balloon-assisted enteroscopy, the entire intestinal tract can be visualized in some patients when both the oral and anal routes of insertion are used.

Biopsies and endoscopic therapy can be performed throughout the visualized small bowel Fig. Ileal stricture causing obstructive symptoms. Balloon dilatation of the ileal stricture. Appearance of stricture after dilatation. During ERCP a side-viewing endoscope is passed through the mouth to the duodenum, the ampulla of Vater is identified and cannulated with a thin plastic catheter, and radiographic contrast material is injected into the bile duct and pancreatic duct under fluoroscopic guidance Fig.

When indicated, the sphincter of Oddi can be opened using the technique of endoscopic sphincterotomy Fig. ERCP is often performed for therapy but remains important in diagnosis, especially for sphincter of Oddi dysfunction and for tissue sampling of ductal strictures.

Faceted bile duct stones are demonstrated in the common bile duct. After endoscopic sphincterotomy, the stones are extracted with a Dormia basket. A small abscess communicates with the left hepatic duct. A normal-appearing ampulla of Vater. Sphincterotomy is performed with electrocautery. Bile duct stones are extracted with a balloon catheter. Final appearance of the sphincterotomy. Endoscopic retrograde cholangiopancreatography ERCP in a patient with obstructive jaundice demonstrates a malignant-appearing stricture of the biliary confluence extending into the left and right intrahepatic ducts.

Intraductal ultrasound of the biliary stricture demonstrates marked bile duct wall thickening due to tumor T with partial encasement of the hepatic artery arrow. Intraductal biopsy obtained during ERCP demonstrates malignant cells infiltrating the submucosa of the bile duct wall arrow. Endoscopic placement of bilateral self-expanding metal stents arrow relieves the biliary obstruction.

GB, gallbladder. Image C courtesy of Dr. Thomas Smyrk; with permission. Contrast leaks from a small right intrahepatic duct into the gallbladder fossa and then flows into the pigtail of a percutaneous drainage catheter. EUS utilizes high-frequency ultrasound transducers incorporated into the tip of a flexible endoscope.

Ultrasound images are obtained of the gut wall and adjacent organs, vessels, and lymph nodes. By sacrificing depth of ultrasound penetration and bringing the ultrasound transducer close to the area of interest via endoscopy, high-resolution images are obtained. EUS provides the most accurate preoperative local staging of esophageal, pancreatic, and rectal malignancies Fig. EUS is also useful for diagnosis of bile duct stones, gallbladder disease, submucosal gastrointestinal lesions, and chronic pancreatitis.

Fine-needle aspirates and core biopsies of masses and lymph nodes in the posterior mediastinum, abdomen, pancreas, retroperitoneum, and pelvis can be obtained under EUS guidance Fig. EUS-guided therapeutic procedures are increasingly performed, including drainage of abscesses, pseudocysts, and pancreatic necrosis into the gut lumen see Video e-2 , celiac plexus neurolysis for treatment of pancreatic pain, ethanol ablation of pancreatic neuroendocrine tumors, treatment of gastrointestinal hemorrhage, and drainage of obstructed biliary and pancreatic ducts.

In each example, the white arrowhead marks the primary tumor and the black arrow indicates the muscularis propria of the intestinal wall. T1 gastric cancer. The tumor does not invade the mp. T2 esophageal cancer. The tumor invades the muscularis propria. T3 esophageal cancer.

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The tumor extends through the muscularis propria into the surrounding tissue and focally abuts the aorta. AO, aorta. Ultrasound image of a gauge needle passed through the duodenal wall and positioned in a hypoechoic pancreatic head mass. Micrograph of aspirated malignant cells. Image B courtesy of Dr. Michael R. Henry; with permission. NOTES is an evolving collection of endoscopic methods that entail passage of an endoscope or its accessories into or through the wall of the gastrointestinal tract to perform diagnostic or therapeutic interventions.

Some NOTES procedures, such as percutaneous endoscopic gastrostomy PEG or endoscopic necrosectomy of pancreatic necrosis, are well-established clinical procedures see Video e-2 ; others, such as per-oral endoscopic myotomy POEM and endoscopic full-thickness resection of gastrointestinal mural lesions Fig. NOTES is currently an area of intense innovation and endoscopic research. Subepithelial lesion in the proximal stomach. Hypoechoic lesion arising from the fourth layer muscularis propria at endoscopic ultrasound. Full-thickness resection defect. Closure of defect using an over-the-scope clip.

In addition to providing larger specimens for more accurate histopathologic assessment and diagnosis, these techniques can be potentially curative for certain dysplastic lesions and focal intramucosal carcinomas involving the esophagus, stomach, and col o n.

Several devices are also available for closure of EMR and ESD defects, as well as gastrointestinal fistulas and perforations. Endoscopic clips deployed through the working channel of an endoscope have been used for many years to treat bleeding lesions, but the development of more robust over-the-scope clips has facilitated endoscopic closure of gastrointestinal fistulas and perforations not previously amenable to endoscopic therapy see Video e Endoscopic suturing is also feasible, and the technique can be used to close perforations and large defects Fig.

Other potential indications for endoscopic suturing include stent fixation to prevent its migration Fig. These technologies are likely to have an expanding role in patient care. Large flat distal rectal adenoma with central lobulation. Marking the periphery of the lesion with coagulation dots. Rectal defect following endoscopic submucosal dissection.

Specimen resected en bloc. Ulcerated inflammatory fibroid polyp in the antrum. Large defect following endoscopic submucosal dissection of the lesion. Closure of the defect using endoscopic sutures arrows. Resected specimen. Esophagogastric anastomotic stricture refractory to balloon dilation. Temporary placement of covered esophageal stent. Endoscopic suturing device to anchor stent to esophageal wall. Stent fixation with endoscopic sutures arrows. Medications used during conscious sedation may cause respiratory depression or allergic reactions.

All endoscopic procedures carry some risk of bleeding and gastrointestinal perforation. Bleeding and perforation are rare adverse events with flexible sigmoidoscopy. The risk of adverse events for diagnostic EUS without needle aspiration is similar to that for diagnostic upper endoscopy. Infectious complications are uncommon with most endoscopic procedures. Some procedures carry a higher incidence of postprocedure bacteremia, and prophylactic antibiotics may be indicated Table Management of antithrombotic agents prior to endoscopic procedures should take into account the procedural risk of hemorrhage, the agent, and the patient condition, as summarized in Table ERCP carries additional risks.

Young anicteric patients with normal ducts are at increased risk. Post-ERCP pancreatitis is usually mild and self-limited, but may result in prolonged hospitalization, surgery, diabetes, or death when severe. Ascending cholangitis, pseudocyst infection, retroperitoneal perforation, and abscess formation may occur as a result of ERCP.

Fasciitis, pneumonia, bleeding, buried bumper syndrome, and colonic injury may result from gastrostomy tube placement. Endoscopy is an important diagnostic and therapeutic technique for patients with acute gastrointestinal hemorrhage. Although gastrointestinal bleeding stops spontaneously in most cases, some patients will have persistent or recurrent hemorrhage that may be life-threatening. Clinical predictors of rebleeding help identify patients most likely to benefit from urgent endoscopy and endoscopic, angiographic, or surgical hemostasis.

Decreases in hematocrit and hemoglobin lag behind the clinical course and are not reliable gauges of the magnitude of acute bleeding. This initial evaluation, completed well before the bleeding source is confidently identified, guides immediate supportive care of the patient, triage to the ward or intensive care unit, and timing of endoscopy. The severity of the initial hemorrhage is the most important indication for urgent endoscopy, since a large initial bleed increases the likelihood of ongoing or recurrent bleeding. Patients with resting hypotension or orthostatic change in vital signs, repeated hematemesis, or bloody nasogastric aspirate that does not clear with large-volume lavage, or those requiring blood transfusions, should be considered for urgent endoscopy.

In addition, patients with cirrhosis, coagulopathy, or respiratory or renal failure and those over 70 years of age are more likely to have significant rebleeding. Bedside evaluation also suggests an upper or lower gastrointestinal source of bleeding in most patients. Melena can result from bleeding in the small bowel or right colon, especially in older patients with slow colonic transit. Conversely, some patients with massive hematochezia may be bleeding from an upper gastrointestinal source, such as a gastric Dieulafoy lesion or duodenal ulcer, with rapid intestinal transit.

Early upper endoscopy should be considered in such patients. Endoscopy should be performed after the patient has been resuscitated with intravenous fluids and transfusions, as necessary. Marked coagulopathy or thrombocytopenia is usually treated before endoscopy, since correction of these abnormalities may lead to resolution of bleeding, and techniques for endoscopic hemostasis are limited in such patients. Metabolic derangements should also be addressed.

Tracheal intubation for airway protection should be considered before upper endoscopy in patients with repeated recent hematemesis, encephalopathy, and suspected variceal hemorrhage.


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Most patients with significant hematochezia can undergo colonoscopy after a rapid colonic purge with a polyethylene glycol solution; the preparation fluid may be administered via a nasogastric tube. Colonoscopy has a higher diagnostic yield than radionuclide bleeding scans or angiography in lower gastrointestinal bleeding, and endoscopic therapy can be applied in some cases. In a minority of cases, endoscopic assessment is hindered by poor visualization due to persistent vigorous bleeding with recurrent hemodynamic instability, and other techniques such as angiography or emergent subtotal colectomy must be employed.

In such patients, massive bleeding originating from an upper gastrointestinal source should also be considered and excluded by upper endoscopy. The anal and rectal mucosa should be visualized endoscopically early in the course of massive rectal bleeding, because bleeding lesions in or close to the anal canal may be identified that are amenable to endoscopic or surgical transanal hemostatic techniques. Endoscopic therapy is often considered for an ulcer with an adherent clot. This finding generally leads to endoscopic therapy to decrease the rebleeding rate.

Gastric antral ulcer with a clean base. Duodenal ulcer with flat pigmented spots arrows. Duodenal ulcer with a dense adherent clot. Duodenal ulcer with active spurting arrow. In conjunction with endoscopic therapy, the administration of a proton pump inhibitor decreases the risk of rebleeding and improves patient outcome. Pyloric channel ulcer with visible vessel arrow. Ulcer hemostasis with placement of an over-the-scope clip. Local therapies, including endoscopic variceal band ligation, endoscopic variceal sclerotherapy, and balloon tamponade with a Sengstaken-Blakemore tube, effectively control acute hemorrhage in most patients, although therapies that decrease portal pressure pharmacologic treatment, surgical shunts, or radiologically placed intrahepatic portosystemic shunts also play an important role.

Endoscopic variceal ligation EVL is indicated for the prevention of a first bleed primary prophylaxis from large esophageal varices Figs. EVL is also the preferred endoscopic therapy for control of active esophageal variceal bleeding and for subsequent eradication of esophageal varices secondary prophylaxis. During EVL, a varix is suctioned into a cap fitted on the end of the endoscope, and a rubber band is released from the cap, ligating the varix Fig.

Complications of EVL, such as postbanding ulcer bleeding and esophageal stenosis, are uncommon. Endoscopic variceal sclerotherapy EVS involves the injection of a sclerosing, thrombogenic solution into or next to esophageal varices. EVS also controls acute hemorrhage in most patients, but it is generally used as salvage therapy when band ligation fails because of its higher complication rate compared to EVL. These techniques are used when varices are actively bleeding during endoscopy or more commonly when varices are the only identifiable cause of acute hemorrhage.

Bleeding from large gastric fundic varices Fig.



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