Video Endoscopic Sequence 1 of 2.

Stricture of the gastroesophageal Junction due to long standing heartbur.

Patients may present with heartburn, dysphagia, odynophagia, food impaction, weight loss, and chest pain. Progressive dysphagia for solids is the most common presenting symptom. This may progress to include liquids.

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All endoscopic images shown in this Atlas contain video clips. We recommend seeing the video clips in full screen mode.

Video Endoscopic Sequence 2 of 2.

Biopsies obtained just below the squamocolumnar junction (six o clock) revealed specialized metaplastic epithelium (intestinal metaplasia), diagnostic of Barrett's disease, short segment of Barrett's, confirmed on biopsy.

Peptic strictures are sequelae of gastroesophageal reflux–induced esophagitis, and they usually originate from the squamocolumnar junction and average 1-4 cm in length.

Video Endoscopic Sequence 1 of 2.

Alcoholic Hemorrhagic Esophagitis

Gastroesophageal reflux disease, commonly referred to as GERD, is one of the most common disorders, and its incidence and prevalence have increased over the last two decades. GERD is characterized by the sensation of substernal burning caused by abnormal reflux of gastric contents backward up into the esophagus. GERD has two different manifestations, reflux esophagitis (RE) and non-erosive reflux disease (NERD), depending on the presence or absence of esophageal mucosal breaks. Symptoms of GERD are chronic and can significantly impair quality of life. Therefore, it has been regarded as a considerable health problem in most of the world. Recommendations for lifestyle modifications are based on the presumption that alcohol, tobacco, certain foods, body position, and obesity contribute to the dysfunction in the body’s defense system of antireflux.

Alcohol is one of the most commonly abused drugs and one of the leading preventable causes of death worldwide (Lopez et al., 2006). Heavy drinking puts people at a high risk for many adverse health events, potentially including GERD. Alcohol consumption may increase symptoms of GERD and cause damage to the esophageal mucosa. In many cases, symptoms of GERD can be controlled after withdrawl of alcoholic beverages. So patients with symptomatic GERD are frequently recommended to avoid alcohol consumption or to consume moderate amount of alcohol. However, evidence on the association between GERD and alcohol consumption has been conflicting.

Video Endoscopic Sequence 2 of 2.

Image and video of Alcoholic Hemorrhagic Esophagitis

GERD results from the excessive reflux of gastric contents backward up into the esophagus. Under normal conditions, reflux is prevented by the function of the antireflux barrier at the esophagogastric junction (EGJ) and the delicate interplay of a host of anatomic and physiologic factors, including the lower esophageal sphincter (LES) that prevents the backflow of gastric contents. Generally, the LES yields with pressure and relaxes after each swallow to allow food to pass into the stomach. Reflux occurs when LES does not sufficiently contract or the pressure in the stomach exceeds the pressure created by the LES. Factors that may contribute to the mechanism of GERD include defection of the LES, damage of esophageal peristalsis, delayed gastric emptying, and gastric acid production as well as bile reflux.

Video Endoscopic Sequence 1 of 7.

Severe Reflux Esophagitis.

A 79 year-old male with severe reflux esophagitis. This endoscopic sequence displays a hiatal hernia, several reflux ulcers, a pseudo diverticula in an ulcer, a big ulcer, erosive gastritis at the antrum and erosive duodenitis.

Gastroesophageal reflux disease (GERD) is the most common esophageal disease. Besides the typical presentation of heartburn and acid regurgitation, either alone or in combination, GERD can cause atypical symptoms. An estimated 20 to 60 percent of patients with GERD have head and neck symptoms without any appreciable heartburn. While the most common head and neck symptom is a globus sensation (a lump in the throat), the head and neck manifestations can be diverse and may be misleading in the initial work-up. Thus, a high index of suspicion is required. Laryngoscopy can confirm the diagnosis of laryngopharyngeal reflux. Erythema of the posterior larynx may be seen, and the true vocal cords may be edematous. Treatment should be initiated with a histamine H2 receptor blocker or proton pump inhibitor. Lifestyle changes are also beneficial. Untreated, GERD can lead to chronic laryngitis, dysphonia, chronic sore throat, chronic cough, constant throat clearing, granuloma of the true vocal cords and other problems.

Video Endoscopic Sequence 2 of 7.

Endoscopy of Severe Reflux Esophagitis.

This endoscopic image displays a big ulcer, the video clip
displays several ulcers of the esophagus.

Gastroesophageal reflux is defined as the movement of gastric contents into the esophagus without vomiting. Laryngopharyngeal reflux is the movement of gastric contents into the laryngopharyngeal area. Gastroesophageal reflux disease (GERD) occurs when gastric contents irritate mucosal surfaces of the upper aerodigestive tract.


Medline: Review article: sleep and its relationship to
gastro-oesophageal reflux.

Video Endoscopic Sequence 3 of 7.

Endoscopy of Severe Reflux Esophagitis.

Another image of the enormous ulcer.

Endoscopy is, currently, the initial investigation of choice for the investigation of gastroesophageal reflux disease (GERD) in clinical practice and clinical research. Erosion severity is predictive of a patient's response to therapy and of the likelihood of relapse after therapy. It is, therefore, important to grade the severity of erosive reflux esophagitis, particularly in the context of clinical trials. The Savary-Miller endoscopic classification system is used widely but usage and interpretation are very variable.

The "MUSE" (metaplasia [M], ulceration [U], stricturing [S] and erosions [E]) classification provides clear definitions of the relevant endoscopic features, and it is based on a standardized report form, which allows the endoscopist to make a clear record of esophagitis severity. Recent studies confirm that endoscopists can identify erosions or mucosal breaks, ulcers, strictures, and metaplasia reproducibly.

Video Endoscopic Sequence 4 of 7.

Endoscopy of Severe Reflux Esophagitis.

This ulcer has a pseudo diverticulum appearance.

The "L.A." (Los Angeles) classification describes four grades of esophagitis severity (A to D), based on the extent of esophageal lesions known as "mucosal breaks," but it does not record the presence or severity of other GERD lesions.

Thus, for patients with "complicated" reflux disease, the "MUSE" classification offers a more comprehensive description of esophagitis severity.

Video Endoscopic Sequence 5 of 7.

The antrum has many erosions with necrotic margins

Endoscopy is not universally applicable: 40 to 60 percent of patients with typical reflux symptoms do not have esophageal erosions and are now considered to have "endoscopy negative reflux disease" (ENRD). Thus, endoscopy is not the final arbiter as to a diagnosis of reflux disease, and it is not, therefore, a necessary prerequisite to therapy. Endoscopy is indicated at first presentation for patients with alarm symptoms referable to the upper gastrointestinal tract. It has also been proposed that all patients with chronic GERD should have a "once-in-a-lifetime" endoscopy; in the absence of Barrett's esophagus or other complications, no follow-up is required unless the patient's symptoms change significantly. A surveillance program with multiple biopsies should be instituted if there is evidence of Barrett's esophagus. Endoscopic evaluation should document the presence and extent of esophageal erosions using the L.A. or MUSE classification systems; complications should also be documented and may be recorded using the MUSE classification. Non-erosive changes such as erythema may be ignored on the basis of present evidence, and there are no clear data to support the use of endoscopic biopsies for the diagnosis of GERD.

Video Endoscopic Sequence 6 of 7.

The pre-piloric antrum. Several erosions are observed.

Video Endoscopic Sequence 7 of 7.

The duodenal bulb has also multiple erosions.

Medline.

Video Endoscopic Sequence 1 de 4.

Severe Reflux Esophagitis and Hiatal Hernia

This 80 year-old lady, who had a severe and long-standing GERD.

Medline: Gastroesophageal reflux disease: then and now.

Video Endoscopic Sequence 2 of 4.

Severe Reflux Esophagitis and Hiatal Hernia

Los Angeles Classification of esophagitis.

Grade A Mucosal break <5 mm in length.

Grade B Mucosal break >5 mm.

Grade C Mucosal break continuous between>2 mucosal folds.

Grade D Mucosal break >75% of esophageal circumference

Presence of alarm symptoms in GERD.

Patients with alarm symptoms should have urgent endoscopy. Patients with dysphagia, odynophagia, weight loss, and/or anemia should undergo endoscopy in a facilitated manner because of a higher risk of malignancy.

Video Endoscopic Sequence 3 of 4.

The image and the video clip display a large hiatus hernia

Esophagitis severity is best predicted by hiatal hernia size and lower esophageal sphincter pressure. Of these, hiatal hernia size is the strongest predictor.

Pubmed

Video Endoscopic Sequence 4 of 4.

Video Endoscopic Sequence 1 of 2.

Reflux Esophagitis with a pseudo diverticulum.

Video Endoscopic Sequence 2 of 2.

Endoscopy of Reflux Esophagitis with a pseudo diverticulum.

Video Endoscopic Sequence 1 of 10.

Reflux esophagitis with a esophageal squamous cell papilloma.

A 53 year-old male with long standing reflux disease, thisupper endoscopy was the first one that he ever had.

Video Endoscopic Sequence 2 of 10.

Endoscopy of Reflux Esophagitis

Erosions with whitish exudate involving the longitudinal folds and extending into the valley between folds

A esophageal squamous cell papilloma is observed.

Video Endoscopic Sequence 3 of 10.

Endoscopy of Reflux Esophagitis

This image and the video clip is taken with magnification endoscope.

A multi-lobulated small tumor is appreciated. The biopsies confirmed Esophageal squamous cell papilloma.

Video Endoscopic Sequence 4 of 10.

Endoscopy of Reflux Esophagitis

Another image and the video clip of the small
multi-lobulated Esophageal squamous cell papillomas.

Video Endoscopic Sequence 5 of 10.

Endoscopy of Reflux Esophagitis

Chromoendoscopy.

The image and the video clip display a washing catheter creates a fine mist spray necessary for optimal application of reagents to the mucosa.

Video Endoscopic Sequence 6 of 10.

Endoscopy of Reflux Esophagitis

High resolution magnifying endoscopy with chromoendoscopy using methylene blue. The multi-lobulated squamous papilloma is observed with magnification.

Methylene blue is a vital stain taken up by actively absorbing tissues such as small intestinal and colonic epithelium. It does not stain nonabsorptive epithelia such as squamous or gastric mucosa.

Video Endoscopic Sequence 7 of 10.

Endoscopy of Reflux Esophagitis

Another view of the Esophageal squamous cell papilloma

Video Endoscopic Sequence 8 of 10.

Endoscopy of Reflux Esophagitis

High resolution magnifying endoscopy with chromoendoscopy using methylene blue.

Video Endoscopic Sequence 9 of 10.

Endoscopy of Reflux Esophagitis

It is believed that adenocarcinoma develops only in epithelium containing specialized intestinal metaplasia. Therefore, investigators have focused on the utility of chromoendoscopy in identifying these areas of intestinal metaplasia for biopsy.

Within this setting, results of a previous study showed that methylene blue (MB) selectively stained specialized intestinal metaplasia in Barrett's esophagus, with excellent specificity and sensitivity.

Video Endoscopic Sequence 10 of 10.

Endoscopy of Reflux Esophagitis

This image and the video clip display the reflux
esophagitis with the Esophageal squamous cell papilloma.

Video Endoscopic Sequence 1 of 2.

Laryngopharyngeal reflux (LPR).

GRANULOMA - The vocal fold on the right side of the picture has a granuloma attached to the vocal process which is causing a small reactive lesion on the opposite vocal process.

Laryngopharyngeal reflux (LPR) is the most common cause of formation of a granuloma. Another common cause is irritation from an endotracheal tube (the tube placed in the throat for breathing during a surgery under general anesthesia), which can rub against the back of the larynx.

Treatment for granuloma depends upon the size of thelesion and the length of time it has been present, but mostlikely will require control of reflux, and may also includerelative voice rest, and/or surgery and voice therapy.Surgery by itself, without other measures, will often resultin the regrowth of the lesion in a short period of time.

Video Endoscopic Sequence 2 of 2.

Laryngopharyngeal reflux (LPR).

This picture shows the diminution of the size after one month of treatment with PPI.

   Vocal Cord and GERD.

laryngopharyngeal reflux (LPR).

Demonstrating arytenoid erythema and edema.

This 35 year old male with long standing reflux disease. The upper endoscopy displayed refux esophagitis.

Findings suggestive of laryngopharyngeal reflux include the following: erythema of the arytenoid, interarytenoid area or laryngeal surface of the epiglottis; a cobblestone appearance of the interarytenoid area; edema of the true vocal cords; inflammatory lesions of the true vocal cords, such as granuloma and contact ulcer; and pooling of secretions in the hypopharynx.
Edema of the true vocal cords can range from mild to severe; severe edema has the appearance of polypoid masses.

Vocal cord edema of this degree can result in severe dysphonia, stridor or airway compromise.
The edema develops in the superficial layer of the lamina propria of the true vocal cords, also called Reinke's space. Thus, it is often referred to as Reinke's edema.

The presence of edema of the true vocal cords is highly suggestive of laryngopharyngeal reflux, even in the absence of laryngeal erythema.

Severe Esophagitis.

Esophagitis is a common medical condition usually caused by gastroesophageal reflux.

Less frequent causes include infectious esophagitis (in patients who are immunocompromised), radiation esophagitis, and esophagitis from direct erosive effects of ingested medication or corrosive agents.

Severe Reflux Esophagitis.

The cardias is seen in retroflexed view. An ulcerated cardias is observed.

The most frustrating aspect of GERD treatment is therelapse rate after successful medical healing. More than 80% of patients with erosive (grade II or higher) esophagitis will relapse within 6 months, with 50% of the relapses occurring in the first month.

This observation has led some to conclude that maintenance therapy is necessary for all individuals with endoscopically proven reflux disease.

 Ulcer caused by gastroesophageal reflux.

Seen at the cardias. The retroflexed image, the endoscope
is observed.

Pathophysiology: Reflux esophagitis develops when gastric contents are passively regurgitated into the esophagus. acid, pepsin, and bile irritate the squamous epithelium, leading to erosion and ulceration of esophageal mucosa. Eventually, a columnar epithelial lining may develop.

This lining is a premalignant condition termed.

Medline.

Reflux Esophagitis.

Radial ulcers and hiatus hernia are observed. Many patients with GERD have a normal esophagus on endoscopy. The first sign of esophageal damage may be erythema. Appearance of erosions indicates more severe disease. Deep esophageal ulcers can occur in addition to the more common shallow erosions.

As its severity increases, esophagitis can lead to obstruction through stricture formation. Severe esophagitis can also lead to cancer through the development of a columnar lining known as Barrett's Esophagus.

Severe Esophagitis.

Is evident by the presence of ulcerations.

The following factors or conditions may increase risk of reflux esophagitis:Pregnancy Obesity Scleroderma Smoking, Alcohol, coffee, chocolate, fatty or spicy foods Certain medications (eg, beta-blockers, nonsteroidal anti-inflammatory drugs [NSAIDs], theophylline, nitrates, alendronate, calcium channel blockers). Mental retardation requiring. institutionalization.

Spinal cord injury. Immunocompromised patients.

Radiation therapy for chest tumors. Pill esophagitis, thought to be secondary to chemical irritation of esophageal mucosa from certain medications (eg, iron, potassium, quinidine, aspirin, steroids, tetracyclines, NSAIDs), especially when swallowed with too little fluid.

Reflux Esophagitis

Is appreciated by the presence of severe non confluent re streaks just above the esophagogastric junction.

Video Endoscopic Sequence 1 of 2.

Superior Esophagic Sphincter.

The video clip displays a complete retroflexed maneuver from the cardias to the upper esophagic sphincter, the video clip also shows a big hiatal hernia with reflux esophagitis. An endoscopist must be sure to diagnose a hiatal hernia in the absence of vomiting and coughs, because it may give a false positive diagnosis of hiatal hernia.

Video Endoscopic Sequence 2 of 2.

Hiatal Hernia retroflexed view. The video clip shows a retroflexed endoscopic maneuver all the way until the upper esophagic sphincter.

Video Endoscopic Sequence 1 of 2.

Esophagitis and Stricture.

Extensive and coalescing ulceration. The ulcers are long and extend well above of the esophagogastric junction. The video clip displays some bilis as a reflux. A hiatal hernia is displayed, a mid-stricture is observed.

Peptic strictures are sequelae of gastroesophageal reflux–induced esophagitis, and they usually originate from the squamocolumnar junction and average 1-4 cm in length.

Peptic strictures have a reported incidence of up to 15% in patients with reflux disease. Strictures develop as a result of longstanding gastroesophageal reflux and chronic, deep inflammation (extending into the submucosa) with fibrosis and scarring. They are found in the region of the gastroesophageal junction.Most strictures are short, but some may extend for several centimeters in the distal esophagus.

The earliest change is usually a thickening of the Z-line, followed by concentric luminal narrowing that may later become eccentric and may be associatedwith a diverticulum-like outpouching of the esophagus proximal to the stricture.

Video Endoscopic Sequence 2 of 2.

Endoscopy of Esophagitis and Stricture.

A slightly stricture at distal esophagus; scarring due to long-standing reflux and recurrent ulceration.

The most common cause of esophagitis is reflux, The histologic changes are not specific. Correlation with gross endoscopic findings is necessary for diagnosis.

A stricture may result when the changes induced by reflux extend below the level of connective tissue of the mucosa and scar tissue formation is stimulated. Strictures are most commonly located in the lower portion of the esophagus near the LES.

Video Endoscopic Sequence 1 of 4.

 Hemorrhagic Esophagitis due to alcoholic beverages.

An 80 year-old male, presents with 3 months of having hiccups. Patient has been drinking alcoholic beverages during several years.

Video Endoscopic Sequence  2 of 4.

 Hemorrhagic Esophagitis due to alcoholic beverages.

The cardias is seen in retroflexed maneuver, severe ulcerated mucosa is observed.

Video Endoscopic Sequence  3 of 4.

 Hemorrhagic Esophagitis.

Several esophageal ulcers and erosions are observed across the longitudinal axis.

Video Endoscopic Sequence  4 of 4.

Hemorrhagic Esophagitis.

The image displays the cardias with multiple ulcers.

Alcohol. Heavy drinking can cause patchy inflammatory erythema of the esophageal mucosa. With abstinence, these changes are quickly and completely reversible.

Video Endoscopic Sequence 2 of 2.

Hiatal Hernia retroflexed view. The video clip shows a retroflexed endoscopic maneuver all the way until the upper esophagic sphincter.