Gastric Ulcers, El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Upper intestinal bleeding deriving from a multiple giant gastric ulcers which provided multiple bleeding sites. A 76-year-old female which had a daily dose of aspirin, presents with abundant hematemesis and melenic stools, paleness, and hypotension a ay before the endoscopy. The image and video shows a giant ulcer and a visible vessel at the incisura angularis.

           Video Endoscopic Sequence 1 of 15.

 Upper Gastrointestinal bleeding deriving from a multiple
 giant gastric ulcers which provided multiple bleeding sites.

 A 76 year-old female which had a daily dose of aspirin,
 presents with abundant hematemesis and melenic stools,
 paleness, and hypotension a day before the endoscopy. The
 image and video shows a giant ulcer and a visible vessel at
 the incisura angularis.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images.
 All endoscopic images shown in this Atlas contain video
 clips.

In the image and video you can observe active bleeding emerging from the giant ulcer. The patient received several gastric lavages with ice cold water by the doctor who sent us the patient. During the endoscopy, we suctioned abundant blood.

           Video Endoscopic Sequence 2 of 15.

 In the image and video you can observe active bleeding
 emerging from the giant ulcer.

 The patient received several gastric lavages with ice cold
 water by the doctor who sent us the patient. During the
 endoscopy, we suctioned abundant blood.

Retroflexed image of multiple ulcers, several which presented blood clot at their center. Pathophysiology: The normal stomach maintains a balance between the protective factors, mucus and bicarbonate secretion, blood flow and aggressive factors, acid secretion, pepsin. Gastric ulcers develop when aggressive factors overcome the protective mechanism.

           Video Endoscopic Sequence 3 of 15.

 Retroflexed image of multiple ulcers, several which
 presented blood clot at their center.

 Pathophysiology: The normal stomach maintains a balance
 between the protective factors, mucus and bicarbonate
 secretion, blood flow and aggressive factors, acid
 secretion, pepsin. Gastric ulcers develop when aggressive
 factors overcome the protective mechanism.

Another image and video of the multiple ulcers with blood clots. Peptic ulcer disease is one of the most common diseases affecting the GI tract. It causes inflammatory injuries in either the gastric or duodenal mucosa, with extension beyond the submucosa into the muscularis mucosa. The etiologies of this condition are multifactorial and are rarely related simply to excessive acid secretion. Even though gastric ulcer is a common disease, diagnosis can be difficult because it has a wide spectrum of clinical presentations, ranging from asymptomatic to vague epigastric pain, nausea, and iron-deficiency anemia to acute life-threatening hemorrhage.

           Video Endoscopic Sequence 4 of 15.

 Another image and video of the multiple ulcers with blood
 clots.
 Peptic ulcer disease is one of the most common
 diseases affecting the GI tract. It causes inflammatory
 injuries in either the gastric or duodenal mucosa, with
 extension beyond the submucosa into the muscularis
 mucosa. The etiologies of this condition are multifactorial
 and are rarely related simply to excessive acid secretion.
 Even though gastric ulcer is a common disease, diagnosis
 can be difficult because it has a wide spectrum of clinical
 presentations, ranging from asymptomatic to vague
 epigastric pain, nausea, and iron-deficiency anemia to acute
 life-threatening hemorrhage.
The video shows the water spray which cleans out the blood clots of 2 ulcers. The 2 major etiological factors for Peptic ulcer disease are Helicobacter pylori infection and the consumption of nonsteroidal anti-inflammatory drugs (NSAIDs).

           Video Endoscopic Sequence 5 of 15.

 The video shows the water spray which cleans out the blood
 clots of 2 ulcers.

 The 2 major etiological factors for Peptic ulcer disease are
 Helicobacter pylori infection and the consumption of
 nonsteroidal anti-inflammatory drugs (NSAIDs).
Here you can observe active bleeding at the gastric fundus. Cigarette smoking can affect gastric mucosal defense adversely. Cigarette smoking is believed to play a facultative role in H pylori infection, ie, people who smoke tend to develop frequent and recurrent ulcers and their ulcers are more resistant to therapy. No evidence indicates that dietary habits or alcohol consumption predisposes individuals to gastric ulcer.

          Video Endoscopic Sequence 6 of 15.

 Here you can observe active bleeding at the gastric
 fundus.

 Cigarette smoking can affect gastric mucosal defense
 adversely. Cigarette smoking is believed to play a
 facultative role in H pylori infection, ie, people who smoke
 tend to develop frequent and recurrent ulcers and their
 ulcers are more resistant to therapy. No evidence indicates
 that dietary habits or alcohol consumption predisposes
 individuals to gastric ulcer.

At some ulcers, we vigorously used Argon Plasma Coagulator, especially if blood vessels were visible. Special note: Due to technical difficulties with the APC which gave us electrical interference with the video, we will only show part of the treatment. APC is the preferred in this case over the titanium clips.

             Video Endoscopic Sequence 7 of 15.

 At some ulcers, we vigorously used Argon Plasma
 Coagulator, especially if blood vessels were visible.
 Special note: Due to technical difficulties with the APC
 which gave us electrical interference with the video, we will
 only show part of the treatment. APC is the preferred in this
 case over the titanium clips.
You can observe 2 giant ulcers at the gastric body with are cover with blood clots.

            Video Endoscopic Sequence 8 of 15.

 You can observe 2 giant ulcers at the gastric body with are
 cover with blood clots.

 Several modalities of endotherapy are available, such as injection therapy, coagulation therapy, hemostatic clips, argon plasma coagulator, and combination therapy. Injection therapy is performed with epinephrine in a 1:10,000 dilution or with absolute alcohol. Thermal endotherapy is performed with a heater probe, bipolar circumactive probe, or gold probe. Pressure is applied to cause coagulation of the underlying artery (coaptive coagulation). Combination therapy with epinephrine injection followed by thermal coagulation appears to be more effective than monotherapy for ulcers with a visible vessel, active hemorrhage, or adherent clot.
Different hemoclips have been used successfully to treat an acutely bleeding ulcer by approximating 2 folds and clipping them together. Several clips may need to be deployed to approximate the gastric ulcer folds. In treating high-risk bleeding ulcers, combined therapy with epinephrine and hemoclips seems to be more efficacious than injection alone. However, it is not clear if hemoclip use or thermal coagulation is more effective in treating an acutely bleeding ulcer; both modalities are used depending on physician experience and equipment availability.

 
The bleeding persisted, and a 2nd endoscopy was performed. We suctioned abundant blood of bright and dark red color. Several bleeding sites were present.

           Video Endoscopic Sequence 9 of 15.

 The bleeding persisted, and a 2nd endoscopy was
 performed. We suctioned abundant blood of bright and dark
 red color. Several bleeding sites were present.
Again, we can observed several giant ulcers.

         Video Endoscopic Sequence 10 of 15.
 

 Again, we can observed several giant ulcers.

 
Several ulcers at the incisura angularis an gastric body seen in retroflexion.

         Video Endoscopic Sequence 11 of 15.
 
 Several ulcers at the incisura angularis an gastric body
 seen in retroflexion.
Multiple ulcers were treated with APC successfully stopping the bleeding.

           Video Endoscopic Sequence 12 of 15.

 Multiple ulcers were treated with APC successfully
 stopping the bleeding.

 
Multiple giant ulcers which presented several bleeding sites treated with Argon Plasma Coagulator (APC).

          Video Endoscopic Sequence 13 of 15.

 Multiple giant ulcers which presented several bleeding sites
 treated with Argon Plasma Coagulator (APC).
Another image and video clip of the ulcers, we now observe little signs of bleeding. After the second endoscopy, the bleeding was stop entirely. This can be seen in the video, that the bleeding was fully controlled.

         Video Endoscopic Sequence 14 of 15.

 Another image and video clip of the ulcers, we now observe
 little signs of bleeding. After the second endoscopy, the
 bleeding was stop entirely. This can be seen in the video,
 that the bleeding was fully controlled.
Another image and video of this endoscopic sequence.

          Video Endoscopic Sequence 15 of 15.

 Another image and video of this endoscopic sequence.

 
Gastric Ulcer at the fundus. A 69 year-old female with severe epigastric pain nausea and vomiting.

Gastric Ulcer at the fundus.

 A 69 year-old female with severe epigastric pain nausea
 and vomiting.
 
 
Huge ulcerated necrotic ulcer at anastomosis of a Billroth II gastrectomy. 65 year-old man, 17 months previously had gastric surgery due to acute abdomen due to a perforated gastric ulcer After his surgery, he drank alcoholic beverages. See the sequences of the images and videos displayed below.

Video Endoscopic Sequence 1 of 4.

 Huge ulcerated necrotic ulcer at anastomosis of a Billroth
 II gastrectomy.
 65 year-old man, 17 months previously had gastric
 surgery due to acute abdomen due to a perforated gastric
 ulcer
 After his surgery, he drank alcoholic beverages.
 See the sequences of the images and videos displayed
 below.
 
The image displays the afferent and efferent loops.

Video Endoscopic Sequence 2 of 4.

 The image displays the afferent and efferent loops.   

The video clip displays a long segment of a jejunum during withdrawal maneuver to the ulcerated anastomosis, a retained suture is seen.

Video Endoscopic Sequence 3 of 4.

 The video clip displays a long segment of a jejunum during
 withdrawal maneuver to the ulcerated anastomosis, a
 retained suture is seen.
 
    

Peptic jejunal ulcers at the efferent loop.

Video Endoscopic Sequence 4 of 4.

 Peptic jejunal ulcers at the efferent loop.

 
Gastric Ulcer at the corpus, anterior wall.

Gastric Ulcer at the corpus, anterior wall.



 
 
Antral irregular ulceration with aspect of malignancy, many biopsies were taken, as well as the scar in the follow up endoscopy after the treatment.


 Antral irregular ulceration with aspect of malignancy,
 multiple biopsies were taken, as well as the scar in the
 follow up endoscopy after the treatment.

 Similar image and video but malignant in nature are
 displayed at Gastric Cancer chapter, press here to
 appreciate that image and video.
 
A 31 year-old male with hepatic cirrhosis and jaundice. The endoscopic image and the video clip display multiple yellowish erosions, the yellow color is due to the jaundice.

 A 31 year-old male with hepatic cirrhosis and jaundice.
 The endoscopic image and the video clip display
 multiple yellowish erosions, the yellow color is due to the
 jaundice.

 
Gastric Ulcers and Myasthenia Gravis. A 61 year-old female with Myasthenia Gravis. Multiple ulcers at the antrum.

Gastric Ulcers and Myasthenia Gravis.

 A 61 year-old female with Myasthenia Gravis.
 Multiple ulcers at the antrum.

Ulcers in the pyloric channel. Patient had a history of severe epigastric pain for several months due to treatment of non-steroid analgesics (NSAID).

Ulcers in the pyloric channel.

 Patient had a history of severe epigastric pain for several
 months due to treatment of non-steroid analgesics
 (NSAID).

 
The cameron erosion. Erosion that located on the top of the rugal folds comprising the distal rosette of a hiatal hernia. An 84 year-old female with upper gastrointestinal hemorrhage presenting with melena.

The Cameron Erosion.

 Erosion that located on the top of the rugal folds
 comprising the distal rosette of a hiatal hernia.
 An 84 year-old female with upper gastrointestinal
 hemorrhage presenting with melena.


 
Acquired double pylorus caused by ulcer perforation. An 88 year-old dentist man, one year ago had a big gastric ulcer at the body . See the scar at the image, below.

Acquired double pylorus caused by ulcer Scar

 An 88 year-old dentist man, one year ago had a big gastric
 ulcer at the body .
 See the scar at the image, below.
Ulcer Scar at the corpus. This image belong an active ulcer that was one year previously see the image above.

Ulcer Scar at the corpus.

 This image belong an active ulcer that was one year
 previously see the image above.
 
The video clip displays several scars and atrophic gastritis of the body.

 The video clip displays several scars and atrophic gastritis
 of the body.

 
Gastric Ulcer at the pre-piloric antrum. This 42 year-old female, who presented severe epigastric pain. A small ulcer is observed at the anterior wall, giving the sensation that this ulcer has been divided in two Satellite ulcers. Multiple biopsies were obtained to rule out malignancy.

Video Endoscopic Sequence 1 of 2.

       Gastric Ulcer at the pre-piloric antrum.

 This 42 year-old female, who presented severe epigastric
 pain.
 A small ulcer is observed at the anterior wall, giving the
 sensation that this ulcer has been divided in two Satellite
 ulcers. 
 Multiple biopsies were obtained to rule out malignancy.

Same case describes above. The peristaltism is observed.

Video Endoscopic Sequence 2 of 2.

 Same case describes above. The peristaltism is observed.