Cameron Ulcer
Cameron Ulcer.

Video Endoscopic Sequence 1 of 2.

Cameron Ulcer.

This is a 79 year-old lady, who had been hospitalized because of GI bleeding, an upper endoscopy displays a gastric ulcer in the gastric fundus in the edge of a hiatus hernia, being the exact site of bleeding

Cameron lesions are seen in 5.2% of patients with hiatal hernias who undergo EGD examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernia sac, with an increased prevalence the larger the hernia sac. In about two thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. Historically, Cameron lesions present clinically with chronic GI bleeding and associated iron deficiency anemia. With increased awareness of the existence of this lesion, however, it is now more frequently seen as an incidental finding during EGD. Cameron lesions can also present as acute upper GI bleeding, occasionally life-threatening, in up to one third of cases. Therefore, Cameron lesions should be considered in any patient in whom a hiatal hernia is noted during endoscopic examination. Concomitant acid-peptic diseases are seen in a majority of individuals, especially reflux esophagitis and its complications. Mechanical trauma, ischemia, and acid mucosal injury may play a role in the pathogenesis of Cameron lesions. The choice of therapy of Cameron lesions, medical or surgical, should be individualized for each patient. Of those patients who were treated with a spectrum of medical therapy and who have had long-term follow-up, about one third have had a recurrence of the lesion and 17% (8/48) have developed complications, most commonly either acute upper GI bleeding (6.3%) or persistent and recurrent iron deficiency anemia (8.3%).

Cameron Ulcer.

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Cameron Ulcer.

Secuencia Video Endoscópica 2 de 2.

Cameron Ulcer.

First described in 1986, Cameron ulcers are always associated with hiatal hernias. They can be a serious, sometimes fatal, complication and need to be considered during any gastrointestinal examination.

Cameron lesions are becoming an increasingly important diagnosis in the evaluation of patients with iron deficiency anemia

Cameron lesions represent linear gastric erosions and ulcers on the crests of mucosal folds in the distal neck of a hiatal hernia (HH).

 

The Cameron Erosion.

The Cameron Erosion.

Hiatal Hernia with 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 prevalence of Cameron lesions seems to be dependent on the size of the hernia sac, with an increased prevalence the larger the hernia sac. In about two thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. Historically, Cameron lesions present clinically with chronic GI bleeding and associated iron deficiency anemia. With increased awareness of the existence of this lesion, however, it is now more frequently seen as an incidental finding during EGD. Cameron lesions can also present as acute upper GI bleeding, occasionally life-threatening, in up to one third of cases. Therefore, Cameron lesions should be considered in any patient in whom a hiatal hernia is noted during endoscopic examination. Concomitant acid-peptic diseases are seen in a majority of individuals, especially reflux esophagitis and its complications. Mechanical trauma, ischemia, and acid mucosal injury may play a role in the pathogenesis of Cameron lesions. The choice of therapy of Cameron lesions, medical or surgical, should be individualized for each patient.

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.

 

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.


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.



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.





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).

 

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.



Gastric Ulcer

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.



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.


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.



Video Endoscopic Sequence 10 of 15.

Again, we can observed several giant ulcers.


Video Endoscopic Sequence 11 of 15.

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


Video Endoscopic Sequence 12 of 15.

Multiple ulcers were treated with APC successfully
stopping the bleeding.


Video Endoscopic Sequence 13 of 15.

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

 

 

Video Endoscopic Sequence 14 of 15.

Another image and video clip of the ulcers, now we 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 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.


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.


Video Endoscopic Sequence 2 of 4.

The image displays the afferent and efferent loops.


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.

.

 


Video Endoscopic Sequence 4 of 4.

Peptic jejunal ulcers at the efferent loop.


 

Gastric Ulcer at the corpus, anterior wall.

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.

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).

 


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.

 


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


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.


Video Endoscopic Sequence 2 of 2.

Same case describes above. The peristaltism is observed. 

 


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