Duodenal Ulcer
Duodenal Ulcer with Visible Vessel.

Video Endoscopic Sequence 1 of 4.

Duodenal Ulcer with Visible Vessel.

This 65 year-old male with long standing symptoms of gastroesophageal reflux disease, patient presented with melena, two years ago a surgical excision of melanoma malignant of its left leg was performed. Approximately nine years ago, a previous duodenal ulcer was found at endoscopy.

Because non-bleeding visible vessels (NBVV) of gastric peptic ulcers have the potential to re-bleed, endoscopic hemostatic treatment may be necessary during the first emergency endoscopy. However, not all NBVV re-bleed, and endoscopic hemostasis sometimes causes fatal side-effects. Therefore, we have evaluated the risk of re-bleeding from various NBVV in gastric peptic ulcers to determine which types should be treated by endoscopy to prevent re-bleeding.

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 4.

Although endoscopic examination in patients with bleeding of the upper gastrointestinal tract has improved diagnostic accuracy, it has not been useful in predicting clinical outcome and has not been shown to improve the patients' prognoses.

Upper gastrointestinal (UGI) bleeding secondary to peptic ulcer disease is a common medical condition that results in high patient morbidity and medical care costs. While the majority of patients with bleeding peptic ulcers will stop bleeding spontaneously and not rebleed during hospitalization, a subgroup of patients is at high risk for recurrent hemorrhage and requires endoscopic therapy to decrease this risk If endoscopic therapy fails, interventional angiography or surgery may be required.

 

Barrett's Esophagus

Video Endoscopic Sequence 3 of 4.

Endoscopy revealed asymmetric migration of metaplastic epithelium upward into the esophagus. Biopsies confirmed the presence of intestinal metaplasia diagnostic of Barrett's disease.

 

Barrett's Esophagus

Video Endoscopic Sequence 4 of 4.

Enhanced Magnification Endoscopy.

Zoom endoscopy of a tongue of Barretts mucosa showing cerebriform villous architecture.

 

Endoscopy of Giant Ulcer of the Duodenum

Video Endoscopic Sequence 1 of 3.

Endoscopy of Giant Ulcer of the Duodenum

This is the case of a 85 year-old male, who had had upper GI bleeding having manifested with melena. his hemoglobin falls to 8.0 gr / dl.

Melena is black, tarry stool and typically indicates upper GI bleeding.

Giant duodenal ulcers (GDUs) are a subset of duodenal ulcers that have historically resulted in greater morbidity than usual duodenal ulcers. Until recently, few cases had been successfully treated with medical therapy. However, the widespread use of endoscopy, the introduction of H-2 receptor blockers and proton pump inhibitors, and the improvement in surgical techniques all have revolutionized the diagnosis, treatment and outcome of this condition. Nevertheless, GDUs are still associated with high rates of morbidity, mortality and complications. Thus, surgical evaluation of a patient with a GDU should remain an integral part of patient care. These giant variants, while usually benign, can frequently harbor malignancy. A careful review of the literature highlights the important differences when comparing GDUs to classical peptic ulcers and why they must be thought of differently than their more common counterpart.

 

Endoscopy of Giant Ulcer of the Duodenum

 

Endoscopy of Giant Ulcer of the Duodenum

Video Endoscopic Sequence 2 of 3.

Endoscopy of Giant Ulcer of the Duodenum

The true incidence of H pylori in standard sized duodenal ulcer formation is not known, but recent data suggests that it exceeds 85%.

Endoscopy of Giant Ulcer of the Duodenum

Video Endoscopic Sequence 3 of 3.

Endoscopy of Giant Ulcer of the Duodenum

The endoscopic image displays a blood clot that is the exact site of bleeding

"kissing" Duodenal Ulcer

"kissing" Duodenal Ulcer

Ulcers opposite from each other on the anterior and posterior walls in the duodenal bulb.

Video Endoscopic Sequence 1 of 5.

Image and Video Clip of Duodenal Ulcer.

 

Video Endoscopic Sequence 2 of 5.

A close up to the ulcer

 

Video Endoscopic Sequence 3 of 5.

Image and Video Clip of Duodenal Ulcer

 

Video Endoscopic Sequence 4 of 5.

Endoscopic Image of Duodenal Ulcer.

 

Video Endoscopic Sequence 5 of 5.

Endoscopic View of Duodenal Ulcer.

 

Video Endoscopic Sequence 1 of 3.

Duodenal Ulcer

Helicobacter pylori infection, now considered to be a cause
of gastric cancer, is also strongly associated with gastric
and duodenal ulcer disease.

 

Video Endoscopic Sequence 2 of 3.

The image and the video clip display a deformed duodenal
bulb due to a duodenal ulcer.

Duodenal ulcer (DU) is a common condition characterized by thepresence of a well-demarcated break in the mucosa that mayextend into the muscularis propria of the duodenum. More than95% of DUs are found in the first part of the duodenum; most areless than 1 cm in diameter.

Video Endoscopic Sequence 3 of 3.

Duodenal ulcer after spraying methilene blue.

Pathophysiology: The duodenal mucosa resists damage from theeffect of aggressive factors, such as gastric acid and theproteolytic enzyme pepsin, with the help of several protectivefactors such as a mucous layer, bicarbonate secretion, andprotective prostaglandins.

Video Endoscopic Sequence 1 of 2.

Multiple Ulcers of the duodenal bulb.

Duodenal ulcer (DU) is a common condition characterized bythe presence of a well-demarcated break in the mucosa that mayextend into the muscularis propria of the duodenum. More than95% of DUs are found in the first part of the duodenum; most areless than 1 cm in diameter Causes: The understanding of theetiology of DU has changed dramatically in the latter part of the20th century. Historically, DU was thought to be a disease relatedto diet and environmental stress alone. Subsequent studiesrevealed the importance of pepsin and acid secretion in thepathogenesis of DU. The most revolutionary change in theknowledge of DU was the discovery in 1982 that thebacterium H pylori was present in most patients with DU.

 

Video Endoscopic Sequence 2 of 2.

Duodenal Ulcer and Pseudo Diverticulae.

H pylori

H pylori are small, microaerophilic, spiral-shaped, gram-negative rods. The presence of H pylori in the stomach and duodenum probably is the most common bacterial infection in the world. H pylori infection is generally regarded as the most important etiologic factor in the development of DU. Most authors regard H pylori as the cause of 85-95% of DUs.

H pylori can be cultured from up to 95% of DUs. Moreover, areas with a higher prevalence of H pylori infection have a higher incidence of DU. Several mechanisms exist by which the bacterium can induce duodenal mucosal damage. All evidence supports the assertion that H pylori is the major cause of DU. However, the risk of developing a DU in an individual infected with H pylori is only about 1% per year, and only 10-15% of individuals with H pylori infection develop a DU at any point in life. Therefore, other pathogenic factors must function either independently or in concert with H pylori to produce DUs.

“Mirror Ulcers”.

Are observed on the opposite wall of the duodenum.

 

Duodenal Ulcer and Pseudo Diverticula.

Pseudo diverticular scar of the anterior wall of duodenal
bulb due to sequel of duodenal ulcer. A semi circular
ulcer is observed.

 

Duodenal Ulcers at the bulb “ Mirror Ulcers”.

A 33 year-old female, from the republic of Costa Rica,
living in El Salvador, some antral and chronic erosions
and hyperplasia lymphoid was found her brother died of
gastric cancer.

 

Kissing Ulcers

Kissing ulcers of the anterior and posterior walls of the
duodenal bulb.
The ulcer at the anterior wall is covered with hematin.

 

Duodenal ulcers that had severe bleeding.

The video clip shows pylorus with difigurating scar as
sequel of old ulcer.

 

Anterior wall duodenal ulcer with deformed bulb.

Pseudo diverticular scar.

The image and the video clip display a pseudo diverticular
scar of the anterior wall of duodenal bulb due to sequel of
duodenal ulcer.

A 63 year-old female, she had duodenal ulcers within
different periods of time. 

 

Erosive Gastroduodenitis.

A 59 year-old male with portal hypertension due to liver
cirrhosis.

 

Duodenal ulcer of the anterior wall of the duodenal bulb.
 

Erosive Duodenitis.

The etiology of duodenitis is not completely understood.
However, the gastric acid hypersecretion and the
helicobacter pylori play an important role in
the pathogenesis.

 

Brunner Gland Hyperplasia.

Brunner gland hyperplasia in the duodenal bulb with
associated giardia lamblia infection.
Giardia lamblia is prevalent throughout the world.
In the developing countries the prevalence rates are high.
These organism infects the small intestine and may cause
acute diarrhea. Frequently there is sudden of explosive,
watery, foul-smelling diarrhea accompanied by
abdominal distention and flatulence or chronic
malabsorption, abdominal pain or any class of dyspepsia.

 

Brunner’s Gland “Adenomata”

Brunner's gland adenomas are uncommon benign
duodenal tumors. They are an infrequent cause of upper
gastrointestinal hemorrhage and duodenal obstruction.

 

Posterior wall duodenal ulcer and pseudo diverticula,
duodenal bulb due to an old scar at the anterior wall.

Video Endoscopic Sequence 1 of 4.

Endoscopic intervention in acute gastrointestinal
bleeding due to duodenal ulcer of the posterior wall.
This sequence of endoscopies display an interventional
therapy in which the ulcer is injected with absolute alcohol.

 

Video Endoscopic Sequence 2 of 4.

After suction of the blood, the image becomes more
clearly.
The ulcer is seen with some blood inside.
Endoscopic treatment of an exposed or visible vessel in
a large, deeply penetrating, posterior duodenal bulb
ulcer may cause significant bleeding if a large serosal
artery, the gastroduodenal artery, is involved.

 

Video Endoscopic Sequence 3 of 4.

The ulcer is observed in the posterior wall of the
duodenal bulb, Bleeding actively, for which it needed an
emergency procedure to stop the hemorrhage.

 

Video Endoscopic Sequence 4 of 4.

Successfully injected, bleeding did not recur.
The control of upper gastrointestinal bleeding is one of
the fields in therapeutic endoscopy.
It is critical that the endoscopist determine whether an
ulcer is in the anterior or posterior wall.
To inject a vasodestructive solucion (alcohol) is intended
to destroy a bleeding vessel. 

 

Video Endoscopic Sequence 1 of 4.

Upper gastrointestinal hemorrhage due to duodenal ulcer.

 

Video Endoscopic Sequence 2 of 4.

The image and the video display a duodenal ulcer at the
anterior wall. The ulcer has some vessels that are the
etiology of the bleeding.
Argon photocoagulation is carried out for the hemostasis.

 

Video Endoscopic Sequence 3 of 4.

Therapy with Argon photocoagulation of vessels of
duodenal ulcer.


Video Endoscopic Sequence 4 of 4.

The image and the video display the procedure.

Duodenitis linfocítica.

Micro Erosion of the Duodenal Bulb.

This micro erosion is observed using a magnifying
endoscope 150x.

 

Video Endoscopic Sequence 1 of 4.

Endoscpic image of Duodenal Ulcer

This 50 year-old male with anuric chronic renal failurepresented upper gastrointestinal bleeding manifested with hematemesis and melena his hemoglobin was 6.6 Gr / dl.

Patients with anuric chronic renal failure represent aserious problem in their management by the condition thatno urine which limits the number blood transfusions at mostone, unless have the hemodialysis unit at his side and therisk of medical complications is great.

Emergency surgery in patients with CRF is associated withpoor survival rates. Colonic ischemia is a significantproblem among these patients. Survival among chronic renalfailure patients requiring major abdominal surgeryJournal of the American College of Surgeons, Volume 188,Issue 3, Pages 310-314 L.Newman.

 

Video Endoscopic Sequence 2 of 4.

The duodenal ulcer is observed and edema of the walls

 

Video Endoscopic Sequence 3 of 4.

Endoscopy of The Duodenal Ulcer

 

Video Endoscopic Sequence 4 of 4.

Endoscopy image of The Duodenal Ulcer

 

Mirror ulcers of the Duodenum

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