El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
This is a 63 year-old male, previously admitted on 4 different occasions for massive lower gastrointestinal bleeding, needing multiple blood transfusions. He is referred to our unit for evaluation. Findings included multiple arterial malformations compatible with cecal Angiodysplasia. Sessions with argon plasma coagulation were initiated. 10 days after therapy patient presents with a new episode of massive lower gastrointestinal bleeding, again requiring multiple blood transfusions. New colonoscopy revealed ulcerated nodules in ascending colon not visualized on previous colonoscopy, raising clinical suspicion of a paraneoplasic syndrome. Chest, abdominal, and pelvic CT were normal. Alcaline phosphatase and serum creatinine levels were normal. During the night, a sudden jerk of the left arm produced a pathological fracture of the left humerus. Pictures below.

 Video Endoscopic Sequence 1 of 24.

Colon Angiodysplasia and Multiple Myeloma

 This is a 63 year-old male, previously admitted on
 4 different occasions for massive lower gastrointestinal
 bleeding, needing multiple blood transfusions. He is
 referred to our unit for evaluation. Findings included
 multiple arterial malformations compatible with cecal
 Angiodysplasia. Sessions with argon plasma coagulation
 were initiated. 10 days after therapy patient presents with
 a new episode of massive lower gastrointestinal bleeding,
 again requiring multiple blood transfusions. New
 colonoscopy revealed ulcerated nodules in ascending colon
 not visualized on previous colonoscopy, raising clinical
 suspicion of a paraneoplasic syndrome. Chest, abdominal,
 and pelvic CT were normal. Alcaline phosphatase and
 serum creatinine levels were normal. During the night, a
 sudden jerk of the left arm produced a pathological
 fracture of the left humerus. Pictures below.
Angiodysplasia is the most common vascular lesion of the gastrointestinal tract, and this condition may be asymptomatic, or it may cause gastrointestinal (GI) bleeding. The vessel walls are thin, with little or no smooth muscle, and the vessels are ectatic and thin

Video Endoscopic Sequence 2 of 24.

 Angiodysplasia is the most common vascular lesion of the
 gastrointestinal tract, and this condition may be
 asymptomatic, or it may cause gastrointestinal (GI)
 bleeding. The vessel walls are thin, with little or no smooth
 muscle, and the vessels are ectatic and thin.

 Colonic angiodysplasia occurs in approximately 1% of the
 adult population and is one of the most common causes of
 massive lower GI bleeding in patients over the age of 65.
 The lesions seen here are typical cecal angiodysplasia.
 While angiodysplasia can be found anywhere along the
 colon, significant bleeding occurs most frequently from
 those lesions located in the cecum.

Angiodysplasia is a degenerative lesion of previously healthy blood vessels found most commonly in the cecum and proximal ascending colon. Seventy-seven percent of angiodysplasias are located in the cecum and ascending colon, 15% are located in the jejunum and ileum, and the remainder is distributed throughout the alimentary tract. These lesions typically are nonpalpable and small (<5 mm).

Video Endoscopic Sequence 3 of 24.

 Angiodysplasia is a degenerative lesion of previously
 healthy blood vessels found most commonly in the cecum
 and proximal ascending colon. Seventy-seven percent of
 angiodysplasias are located in the cecum and ascending
 colon, 15% are located in the jejunum and ileum, and the
 remainder is distributed throughout the alimentary tract.
 These lesions typically are nonpalpable and small (<5 mm).

 
Argon plasma coagulation (APC) has been adopted into general gastrointestinal practice as an effective and theoretically safer approach to cauterization. The advantage of APC is a decreased depth of penetration and a tendency for the ionized arc of electrical current to deflect away from coagulated tissue to surrounding areas making complications such as intestinal perforation rare.

Video Endoscopic Sequence 4 of 24.

 Ablative Therapy with Argon Plasma

 Argon plasma coagulation (APC) has been adopted into
 general gastrointestinal practice as an effective and
 theoretically safer approach to cauterization. The
 advantage of APC is a decreased depth of penetration and
 a tendency for the ionized arc of electrical current to
 deflect away from coagulated tissue to surrounding areas
 making complications such as intestinal perforation rare.

 
The exact mechanism of development of angiodysplasia is not known, but chronic venous obstruction may play a role. This hypothesis accounts for the high prevalence of these lesions in the right colon and is based on the Laplace law. The Laplace law relates wall tension to luminal size and transmural pressure difference in a cylinder, whereby the wall tension is equal to the pressure difference multiplied by the radius of the cylinder. In the case of the colon, wall tension refers to intramural tension, the pressure difference is that between the bowel lumen and the peritoneal cavity, and cylinder radius is the radius of the right colon. Wall tension is highest in bowel segments with the greatest diameter, such as the right colon.

Video Endoscopic Sequence 5 of 24.

 The exact mechanism of development of angiodysplasia is
 not known, but chronic venous obstruction may play a role.
 This hypothesis accounts for the high prevalence of these
 lesions in the right colon and is based on the Laplace law.
 The Laplace law relates wall tension to luminal size and
 transmural pressure difference in a cylinder, whereby the
 wall tension is equal to the pressure difference multiplied
 by the radius of the cylinder. In the case of the colon, wall
 tension refers to intramural tension, the pressure
 difference is that between the bowel lumen and the
 peritoneal cavity, and cylinder radius is the radius of the
 right colon. Wall tension is highest in bowel segments with
 the greatest diameter, such as the right colon.

Video Endoscopic Sequence 6 of 24.

 

Video Endoscopic Sequence 7 of 24.

 

Video Endoscopic Sequence 8 of 24.

 Ten days after the therapy with argon plasma, patient
 presents with a new episode of massive lower
 gastrointestinal bleeding,  again requiring multiple blood
 transfusions.

Video Endoscopic Sequence 9 of 24.

 

Video Endoscopic Sequence 10 of 24.

 A new colonoscopy revealed ulcerated nodules in
 ascending colon not visualized on previous colonoscopy,
 raising clinical suspicion of a paraneoplasic syndrome.

Video Endoscopic Sequence 11 of 24.

 

Video Endoscopic Sequence 12 of 24.

A submucous mass is detected in the ascending colon that could be compatible with lipoma or amiloide deposit due to the multiple myeloma.

Angiodysplasia Myeloma13

Video Endoscopic Sequence 13 of 24.

The cecum is display with ulcers due to a previous therapy with APC.

Video Endoscopic Sequence 14 of 24.

 
This ulcer is consequence of the preious therapy with APC, 10 day before.

Video Endoscopic Sequence 15 of 24.

This ulcer is consequence of the preious therapy with APC, 10 day before.
The ulcer was managed with hemoclip and infiltration of absolute alcohol achieving the hemostasia.

Video Endoscopic Sequence 16 of 24.

 The ulcer was managed with hemoclip and infiltration of
 absolute alcohol achieving the hemostasia.

Angiodysplasia Myeloma18

Video Endoscopic Sequence 17 of 24.

Left Humerus with pathologic fracture due to a multiple myeloma

 

 To enlarge the image in a new windows click on it.

Radiographic survey demonstrates lytic lesions. The preferred initial radiographic examination for the staging and diagnosis of myeloma remains the skeletal survey. Patients suspected of having multiple myeloma based on bone marrow aspirate results or hypergammaglobulinemia should undergo a radiographic skeletal survey. Conventionally, this skeletal survey has consisted of a lateral radiograph of the skull, anteroposterior (AP) and lateral views of the spine, and AP views of the pelvis, ribs, femora, and humeri. Inclusion of these bones is important for both staging and diagnosis.

Video Endoscopic Sequence 18 of 24.

Radiographic survey demonstrates lytic lesions

 The preferred initial radiographic examination for the
 staging and diagnosis of myeloma remains the skeletal
 survey. Patients suspected of having multiple myeloma
 based on bone marrow aspirate results or
 hypergammaglobulinemia should undergo a radiographic
 skeletal survey. Conventionally, this skeletal survey has
 consisted of a lateral radiograph of the skull,
 anteroposterior (AP) and lateral views of the spine, and AP
 views of the pelvis, ribs, femora, and humeri. Inclusion of
 these bones is important for both staging and diagnosis.

 The finding of more than one lytic lesion in a patient with
 myeloma indicates stage III disease. Focused examinations
 of newly painful bones are of value in assessing for
 impending pathologic fracture.

 
Radiograph of the left humerus. This image demonstrates a destructive lesion of the diaphysis. Pathologic fracture is seen. In one third of patients, MM is diagnosed after a pathologic fracture occurs; as it did happens in our patient, such fractures commonly involve the axial skeleton.

Video Endoscopic Sequence 19 of 24.

 Radiograph of the left humerus. This image demonstrates
 a destructive lesion of the diaphysis. Pathologic fracture is
 seen.

 In one third of patients, MM is diagnosed after a
 pathologic fracture occurs; as it did happens in our patient,
 such fractures commonly involve the axial skeleton.

 
Lateral radiograph of the skull. This image demonstrates numerous lytic lesions, which are typical for the appearance of widespread myeloma.

Video Endoscopic Sequence 20 of 24.

  Lateral radiograph of the skull. This image demonstrates
 numerous lytic lesions, which are typical for the
 appearance of widespread myeloma.
Multiple myeloma is the most common primary neoplasm of the skeletal system. The disease is a malignancy of plasma cells. Radiologically, multiple destructive lesions of the skeleton as well as severe demineralization characterize multiple myeloma. The etiology of the disease is the monoclonal proliferation of B cells, with a resultant increase of a single immunoglobulin and its fragments in the serum and urine. Electrophoretic analysis shows increased levels of immunoglobulins in the blood as well as light chains (Bence-Jones protein) in the urine.

Video Endoscopic Sequence 21 of 24.

 Multiple myeloma is the most common primary neoplasm
 of the skeletal system. The disease is a malignancy of
 plasma cells. Radiologically, multiple destructive lesions
 of the skeleton as well as severe demineralization
 characterize multiple myeloma. The etiology of the disease
 is the monoclonal proliferation of B cells, with a resultant
 increase of a single immunoglobulin and its fragments in
 the serum and urine. Electrophoretic analysis shows
 increased levels of immunoglobulins in the blood as well as
 light chains (Bence-Jones protein) in the urine.
Angiodysplasia Myeloma23

Video Endoscopic Sequence 22 of 24.

 
Bone marrow biopsy demonstrating sheets of malignant plasma cells in multiple myeloma.

Video Endoscopic Sequence 23 of 24.

Bone marrow biopsy demonstrating sheets of malignant plasma cells in multiple myeloma.

 
The presentation of multiple myeloma can range from asymptomatic to severely symptomatic with complications requiring emergent treatment. Systemic ailments include bleeding, infection and renal failure; local catastrophes include pathologic fractures and spinal cord compression. Although patients benefit from treatment (ie, longer life, less pain, fewer complications), currently no cure exists. Recent advances in therapy have helped to lessen the occurrence and severity of adverse effects of multiple myeloma.

Video Endoscopic Sequence 24 of 24.

 The presentation of multiple myeloma can range from
 asymptomatic to severely symptomatic with complications
 requiring emergent treatment. Systemic ailments include
 bleeding, infection and renal failure; local catastrophes
 include pathologic fractures and spinal cord compression.
 Although patients benefit from treatment (ie, longer life,
 less pain, fewer complications), currently no cure exists.
 Recent advances in therapy have helped to lessen the
 occurrence and severity of adverse effects of multiple
 myeloma.