Video Endoscopic Sequence 1 of 17.

Multiple Gastric Angiodysplasias

 This 91-year old lady had medical history of multiple
 hospitalizations, her family reported that she had at least
 20 hospitalizations at another hospital (public) due to upper
 gastrointestinal bleeding, patient is refered to our
 endoscopic unit for evaluation and therapeutic treatment.

 Angiodysplasia is ectasia of intestinal submucosal veins
 and overlying mucosal capillaries. Lesions occur most often
 in the stomach, followed by the duodenum. Most lesions
 are less than 10mm in size, and multiple lesions are
 frequent. Concomitant lesions in the colon occur in 1/3 of
 cases. Anatomic clustering of acquired or sporatic
 angiodysplasia is a well described observation.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter; thus you can observe
 the video in full screen.

 All endoscopic images shown in this Atlas contain
 video clips.           

Video Endoscopic Sequence 2 of 17.

 The endoscopic image as well as the video clip show
 multiple angiodysplasias

 Gastric angiodysplasia is associated with several systemic
 diseases, most notably hereditary hemorrhagic
 telangiectasia (HHT), or Rendu-Osler-Weber syndrome.

 The first approach to therapy should be to replace and
 maintain iron. Endoscopic control of bleeding lesions
 (sclerotherapy, contact probes, and lasers) is well
 described but the recurrent bleeding rate is high.

Video Endoscopic Sequence 3 of 17.

This is a large submucosal vassel that seem to be ulcerated

 Aberrant blood vessels are frequently found in the
 gastrointestinal tract, where they are probably more
 common than anywhere else in the body. Some are present
 from birth or develop as part of inherited syndromes, but
 the vast majority are acquired later in life. The reasons for
 the distortion of vascular structures observed with
 advancing age are poorly understood.

Video Endoscopic Sequence 4 of 17.

Mallory-Weiss tears occurring during endoscopy

 Due to the age of the patient the anestesiologist
 administered little amount of sedatives so the
 endoscopic procedure was suspended for a moment
 because patient iniciates with nausea and vomiting
 causing this image

 Mallory-Weiss tears occurring during the course of upper
 gastrointestinal endoscopy are apparently rare, Iatrogenic
 Mallory-Weiss tears are rare and generally have a benign
 course. They tend to occur mostly in patients who have
 experienced excessive retching or struggling during
 endoscopy. Mallory-Weiss tears complicating endoscopy
 occur especially in elderly, female patients with hiatal
 hernias.

Video Endoscopic Sequence 5 of 17.

Mallory-Weiss tears occurring during endoscopy

Video Endoscopic Sequence 6 of 17.

The argon plasma therapy is initiated

 Vascular anomalies associated with congenital or systemic
 diseases, such as blue rubber bleb nevus syndrome,
 Klippel-Trenaunay-Weber syndrome, Ehlers-Danlos
 syndrome, the CREST variant of scleroderma, and
 hereditary hemorrhagic telangiectasia (Osler-Weber
 -Rendu syndrome).

 Acquired and sporadic lesions, such as angiodysplasias,
 gastric antral vascular ectasia, radiation-induced vascular
 ectasias, and Dieulafoy's lesions.

 Angiodysplasias are by far the most common vascular
 anomalies encountered in the gastrointestinal tract. This
 topic review will cover the pathogenesis and clinical issues
 arising from these lesions. One of the most common
 complications associated with angiodysplasias is bleeding,
 which is often occult.

Video Endoscopic Sequence 7 of 17.

 PATHOGENESIS — Angiodysplasias are composed of
 ectatic, dilated, thin-walled vessels that are lined by
 endothelium alone or by only small amounts of smooth
 muscle. Their anatomy has been best demonstrated by
 studies in which casts of the vessels were made by
 injecting a silicone material. These studies demonstrated
 that the most prominent feature in angiodysplasias are
 dilated tortuous submucosal veins. Small arteriovenous
 communications are present due to incompetence of the
 precapillary sphincter. Enlarged arteries are also present
 in bigger angiodysplasias and may be associated with
 arteriovenous fistulas, which explains why bleeding can be
 brisk in some patients

Video Endoscopic Sequence 8 of 17.

 Histologic examination demonstrates dilated vessels in the
 mucosa and submucosa, sometimes covered only by a
 single layer of surface. These features are shared by
 angiodysplasias in the colon and stomach.

 The pathogenesis of angiodysplasias is not well understood.

Video Endoscopic Sequence 9 of 17.

A pulsaltile vassel is observed

 CLINICAL MANIFESTATIONS — Angiodysplasias can
 remain clinically silent or cause bleeding. Patients who
 bleed typically present with occult blood loss and are more
 likely than other patients with gastrointestinal bleeding to
 have had prior admissions for gastrointestinal bleeding.
 However, marked acute bleeding, causing orthostasis or
 hypotension, can occur.

Video Endoscopic Sequence 10 of 17.

Control of bleeding was achieved by argon plasma therapy in the vessel.

Video Endoscopic Sequence 11 of 17.

 CLASSIFICATION — The terms "angiodysplasias,"
 "arteriovenous malformations," and "vascular ectasias"
 have been used synonymously. Angiodysplasias are usually
 distinguished from telangiectasias, which, although
 anatomically similar, are usually referred to in the context
 of systemic or hereditary diseases.

 Since most vascular abnormalities are detected during
 endoscopy, a taxonomy based upon endoscopic appearance
 has been proposed. The classification system recognizes
 the location, size, and number of angiodysplasias.

Video Endoscopic Sequence 12 of 17.

 Most angiodysplasias are detected in patients older
 than 60 , although presentation in patients in their 30s has
 been described . They may be asymptomatic or cause
 occult or overt gastrointestinal bleeding.

Video Endoscopic Sequence 13 of 17.

 More than one angiodysplasia is present in approximately
 40 to 60 percent of patients] . These lesions tend to be
 clustered within intestinal segments, suggesting that the
 local environment predisposes to their development.
 However, synchronous lesions exist elsewhere in the
 gastrointestinal tract in approximately 20 percent of
 patients.

Video Endoscopic Sequence 14 of 17.

There are more small lesions.

 CONDITIONS WITH INCREASED
 PREVALENCE — The prevalence of angiodysplasias is
 increased in older populations, those with gastrointestinal
 bleeding, and those with certain predisposing conditions
 such as end-stage renal disease.

 End-stage renal disease — Angiodysplasia is the second
 most common cause of gastrointestinal bleeding in elderly
 patients with end-stage renal disease. These lesions
 account for about 20 and 30 percent of upper and lower
 gastrointestinal bleeds, respectively, and approximately
 one-half of recurrent upper gastrointestinal bleeds. They
 can occur anywhere along the gastrointestinal tract and are
 usually multiple.

Video Endoscopic Sequence 15 of 17.

 Vascular lesions of the gastrointestinal tract are clinically
 highly relevant, and are a common cause of
 gastrointestinal bleeding. Among these lesions,
 gastrointestinal angiodysplasia is frequently encountered,
 whereas Dieulafoy lesion and gastric antral vascular
 ectasia (GAVE) are less common. An understanding of the
 other described lesions is important, despite their rarity,
 because they are frequently misdiagnosed and mistreated.
 For example, historically most rectal hemangiomas were
 misdiagnosed and mistreated as internal hemorrhoids.

Video Endoscopic Sequence 16 of 17.

Video Endoscopic Sequence 17 of 17.

Video Endoscopic Sequence 1 of 3.

 Gastric Angiodysplastic lesions and argon plasma
 coagulation treatment.

 Gastric Angiodysplastic lesions may be encountered at
 any location, but they tend to occur primarily within the
 corpus. The tree images and video display ablative
 therapy with argon plasma coagulation APC.

Video Endoscopic Sequence 2 of 3.

 Gastric Angiodysplastic lesions with argon plasma
 coagulation treatment.
 Argon plasma coagulation (APC) is a method ofcauterizing
 the vascular abnormality using a non-contact probe.

Video Endoscopic Sequence 3 of 3.

 Gastric Angiodysplastic lesions with argon plasma
 coagulation treatment.
 Argon Plasma Coagulation has been used for more than 10
 years in open surgery, laparoscopy and Thoracoscopy,
 especially for hemostasis of large surface bleeding. It
 conducts monopolar electrosurgical current to tissue via an
 ionized argon gas stream (argon plasma).