Gastric Ulcer
ouble pylorus

Video Endoscopic Sequence 1 of 8.

Acquired double pylorus

70-year-old male, presented with abdominal pain. nausea and vomiting 6 months before, an endoscopy had been performed in another clinic where was detected a pre-pyloric gastric ulcer see photograph 5-5.
Ddyspeptic symptoms persist and is referred to our unit for evaluation, finding this image and video clip.
In this endoscopy the new pylorus is clearly visible.

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.

 

 




ouble pylorus

Video Endoscopic Sequence 2 of 8.

Double Pylorus

Double pylorus (DP), or duplication of the pylorus, is an uncommon condition that can be either congenital or acquired. Acquired DP (ADP) occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach.

ouble pylorus

Video Endoscopic Sequence 3 of 8.

Double Pylorus

Double pylorus (DP), also called double-channel pylorus, is a rare condition involving a double communication between the gastric antrum and the duodenal bulb. DP is observed in 0.001% to 0.4% of upper gastrointestinal endoscopies and is twice as frequent in males than females. In most cases, DP is a complication of a penetrating ulcer, a condition that is called acquired double pylorus (ADP), pyloric duodenal fistula, antral duodenal fistula and peripyloric gastroduodenal fistula. DP occasionally occurs as a congenital abnormality, either isolated or in combination with other congenital abnormalities, such as heterotopic pancreatic tissue, pancreatic divisum or gastric duplication. Herein, we describe four cases of gastric ulcer disease complicated by ADP and discuss risk factors for the occurrence of this disease.


ouble pylorus

Video Endoscopic Sequence 4 of 8.

Double Pylorus

lDP can be congenital or acquired. The first case of congenital DP (CDP) was reported by Christien et al in 1971, and only a few additional cases have been reported since that time. In CDP, a defect in canalization appears to occur during early embryonic development. Diagnosis is based on normal histology of both channels, the coexistence of another congenital abnormality, a bridge between the two channels with a normal muscle layer, a lack of a peptic ulcer disease history, and a lack of radiologic or endoscopic evidence of an ulcer. Conversely, ADP is a complication of a prepyloric or duodenal ulcer that perforates the gastric and duodenal walls to create a fistula. Although the first reported cases was in 1861, this condition was not considered a real entity until 1969.

ADP has no specific autonomous clinical manifestations and is not associated with upper abdominal pain or dyspepsia. ADP can present with chronic upper abdomen pain and/or discomfort, dyspepsia, vomiting and gastrointestinal bleeding due to an associated peptic ulcer or other diseases.

 

ouble pylorus

Video Endoscopic Sequence 5 of 8.

Endoscopy photography 6 months previous

First endoscopy performed in another clinic, six months before, the arrow points to the gastric ulcer that evolved into a fistula to the duodenal bulb.


ouble pylorus

Video Endoscopic Sequence 6 of 8.

Three months later a follow up endoscopy is performed

 

ouble pylorus

Video Endoscopic Sequence 7 of 8.

Double Pylorus

In this image and video clip there is a retroflexion maneuver entering through one of the pylori and exiting through the other, in the image the edge of one of the two pylori is observed with the endoscope in retroflexion from the duodenal bulb.


ouble pylorus

Video Endoscopic Sequence 8 of 8.

Double Pylorus

 

 

Ulcera Gastrica sangrante

Video Endoscopic Sequence 1 of 9.

Massive gastrointestinal bleeding due to gastric ulcer

This is a 62 year-old female, who had been taking NSAIDs. The clinical picture begins with abundant hematemesis and melena, hypotension with generalized pallor, is hospitalized. An emergency therapeutic upper endoscopy is practiced.

The image and video show an ulcer with active bleeding and visible vessel which was found in the in the lesser curvature of the pre-pyloric antrum.

Four years earlier we had performed an endoscopy in which was found two gastric ulcers.

 


Ulcera Gastrica sangrante

Video Endoscopic Sequence 2 of 9.

Hemostatic therapy with infiltrations of absolute alcohol

In the video clip as well as the image show the active bleeding.

Peptic ulcer bleeding is a common and potentially fatal condition. It is best managed using a multidisciplinary approach by a team with medical, endoscopic and surgical expertise. The management of peptic ulcer bleeding has been revolutionized in the past two decades with the advent of effective endoscopic hemostasis and potent acid-suppressing agents. A prompt initial clinical and endoscopic assessment should allow patients to be triaged effectively into those who require active therapy, versus those who require monitoring and preventative therapy. A combination of pharmacologic and endoscopic therapy (using a combination of injection and thermal coagulation) offers the best chance of hemostasis for those with active bleeding ulcers.

 

Hemorragia Ulcera gastrica

Video Endoscopic Sequence 3 of 9.

It continues with infiltration of absolute alcohol

Since the late 1980s, endoscopic hemostatic therapy has been widely accepted as the first-line therapy for upper-gastrointestinal bleeding. Numerous clinical trials and two meta-analyses have confirmed the efficacy of endoscopic therapy in this setting. Most clinical trials demonstrated a reduction in both recurrent bleeding and the need for surgical intervention when endoscopic hemostasis was used.

Endoscopic therapy can be broadly categorized into injection therapy, thermal coagulation, and mechanical hemostasis.

 


Ulcera Gastrica sangrante

Video Endoscopic Sequence 4 of 9.

A close up of the to the ulcer

múltiples ulceras gástricas gigantes

Video Endoscopic Sequence 5 of 9.

A close up of the to the ulcer

Hemorragia Ulcera gastrica clips endoscopia

Video Endoscopic Sequence 6 of 9.

Combined Therapy

After performing hemostasis with infiltration of absolute alcohol a second therapeutic treatment is performed with hemostasis with hemoclips.

Mechanical devices have been used for the treatment of variceal hemorrhage, but rarely in the treatment of peptic ulcer disease. Hemoclips have gained popularity in the past few years.

Many endoscopists favor combined therapy.



Hemorragia Ulcera gastrica

Video Endoscopic Sequence 7 of 9.

Status after placement of the first hemoclip

 



Hemorragia Ulcera gastrica

Video Endoscopic Sequence 8 of 9.

One second hemoclip is placed

Hemorragia Ulcera gastrica

Video Endoscopic Sequence 9 of 9.

Final status of hemostasis.

The patient was discharged two days later

 




Gastric Ulcer

Video Endoscopic Sequence 1 of 1.

Gastric Ulcer of the fondus

82 year-old female with abdominal pain nausea, vomiting and anorexia, biopsies rule out malignancy.

 

 

Multiple Gastric Ulcers.

Video Endoscopic Sequence 1 of 2.

Multiple Gastric Ulcers.

An 87 year-old female with multiple gastric ulcers. The Patient had a history of severe epigastric pain for several months and had been under non-steroid analgesic treatment. There are several larger ulcers in the fundus and gastric body.


Endoscopic Image of multiple Gastric Ulcers

Video Endoscopic Sequence 2 of 2.

Endoscopic Image of multiple Gastric Ulcers

Gastric ulcers are observed at the corpus and fundus.


Ulcer on the red scar

Video Endoscopic Sequence 1 of 2.

Ulcer on the red scar

In this endoscopic sequence an ulcer on the red scar is observed, the video displays between the normal image an the image displayed using magnification endoscope.










red scar

Video Endoscopic Sequence 2 of 2.

The image and the video clip display the red scar with magnification.



Gastric ulcer proximal to the gastric angle.

Endoscopic View of a Gastric Ulcer

Gastric ulcer proximal to the gastric angle.

 

 

Gastric Ulcer.

Gastric Ulcer.

The margin is smooth and there no evidence of surrounding
mucosal discoloration or nodularity.
Multiple four-quadrant biopsies are indicated to rule out
carcinoma.


Gastric Ulce

Gastric Ulcer of the antrum.

The video clip displays when the biopsies are taken.



Endoscopy of a Gastric Ulcer

Video Endoscopic Sequence 1 of 2.

Endoscopy of a Gastric Ulcer

A 69 year-old female with severe epigastric pain that
worsens at midnight. The patient was under treatment for
one month after this endoscopy was performed. We found a
large ulcer in the posterior wall of the proximal corpus
which displayed rounded edges. See the next image and
video of this sequence (below).




Endoscopy of a Gastric Ulcer

Same case as above, one month afterwards. The ulcer is in the healing process. fresh ulcer scar surrounded by prominent capillaries are displayed.

Video Endoscopic Sequence 2 of 2.

Endoscopy of a Gastric Ulcer

Same case as above, one month afterwards. The ulcer is in the healing process. fresh ulcer scar surrounded by prominent capillaries are displayed.




 

 

 

 


Video Endoscopic Sequence 1 of 3.

A very large and ramified ulcer. The healing process can
be observed in the follow images and videos shown below.
Note: The dark and reddish tone of the images are due
to the fact that a 150 light bulb was being used in the
endoscope light source as an emergency measure,
instead of the standard 300 watts bulb.


Video Endoscopic Sequence 2 of 3.

After 16 days of treatment (anti H2) a control endoscopy
showed signs of healing and scarring. Narrowing of the
ulcer and appearance of hyperemic margins are observed.


Video Endoscopic Sequence 3 of 3.

One and half months of treatment, lineal healing with
fresh read scar is found.
For more endoscopic details download the video
clips by clicking on the endoscopic images, if you like
to see the video in full screen, wait to be downloaded
complete click on the video screen then press Alt and
enter.

 

 

An 82 year-old woman, Gastric ulcer at the antrum induced
by by non-steroidal anti-inflammatory drugs (NSAID).


 

Giant Gastric Ulcer.

A 54 year-old male was hospitalized due to hematemesis.
An enormous antral ulcer was found. Malignancy was
ruled out by multiple biopsies and subsequent endoscopies.


Fresh stellate ulcer scar.

 

 

Scars of Ulcers

A 60 year-old schizophrenic female.

Image of gastric ulcer scars, with an image such as the
above is imperative to rule out carcinoma with the biopsies.

 

Scars of Ulcers,

A 60 year-old schizophrenic female. Image of gastric ulcer
scars, with an image such as the above is imperative to
rule out carcinoma with the biopsies.


Video Endoscopic Sequence 1 of 2.

A 74 year-old male with abdominal pain
A endoscopy displays a large ulcer in the proximal body,
seen best by retroflexing the endoscope, which enables
visualization of the upper portion of the stomach from
below. A small diverticulum is seen at the fornix.


Video Endoscopic Sequence 2 of 2.

After 5 years a new endoscopy was performed and a
diverticulum image was found at the fornix, as we
described above, The patient has a small diverticula
5 years previously, but this image appears as a ulcers scar


A 74 year-old male with hematemesis.

Endoscopy displays a big ulcer with a prominent visible
vessel.

 

An 89 year-old female with vomiting and epigastric pain.

A gastric ulcer with smooth borders is seen.


Multiple small gastric Ulcers.

Multiple small gastric Ulcers.

This 80 year-old woman with multiple small gastric ulcers.

 

An 82-old male with a large, deep ulcer niche and smooth

Gastric Ulcer at the proximal body.

An 82-old male with a large, deep ulcer niche and smooth
margins.


Upper Gastrointestinal Bleeding.

Upper Gastrointestinal Bleeding.

Anterior wall gastric ulcer

The patient has his first hemorrhage as a cause of anterior
wall of the antrum and portal hypertensive gastropathy,
after that, he had five hemorrhages as a cause of acute
variceal bleeding.


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