Gastrointestinal Endoscopy¶
Chapter 333 | Harrison's 22e · Part 10 – Gastrointestinal Disorders
Detailed clinical reference synthesised from Harrison's Principles of Internal Medicine, 22nd Edition
🔑 Key Clinical Points¶
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📑 Table of Contents¶
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RAW CONTENT¶
[PAGE 2464] 2464 PART 10 Disorders of the Gastrointestinal System for nausea in first-trimester pregnancy. Peppermint oil and caraway acute cholecystitis in patients unable to undergo cholecystectomy. seed oil products and herbal preparations such as STW 5 (a nine- Transjugular intrahepatic portosystemic shunts are performed for herb mixture) are useful for functional dyspepsia and IBS. Low- variceal hemorrhage not amenable to endoscopic therapy. Litho- potency pancreatic enzyme preparations are sold as digestive aids tripsy is rarely performed to fragment gallstones in patients who but have little evidence to support their efficacy. are not surgical candidates. Radiologic approaches are often chosen over endoscopy for gastroenterostomy placement. Radiographic THERAPIES TARGETING GUT DYSBIOSIS assistance is sometimes needed for placement of central venous Antibiotics are prescribed to treat H. pylori–induced ulcers, infec- catheters for parenteral nutrition. tious diarrhea, complicated diverticulitis, and small intestinal SURGERY bacterial overgrowth. Some cases of diarrhea-predominant IBS respond to the nonabsorbable antibiotic rifaximin. Probiotics con- Roles of surgery in GI conditions include disease cure, symptom taining bacterial cultures and prebiotics that selectively nourish control, maintenance of nutrition, and palliation of unresectable nonnoxious commensal bacteria have been given as adjunctive neoplasm. Surgery cures medication-unresponsive ulcerative coli- therapy for infectious diarrhea and IBS, with limited evidence of tis, diverticulitis, cholecystitis, appendicitis, and intraabdominal efficacy. Postbiotics are metabolites made by probiotic organisms abscess, but only reduces symptoms and treats complications in that inhibit pathogenic luminal bacteria. Transplanting donor feces Crohn’s disease. Surgery is performed for ulcer complications like into the colon by colonoscopy or enema is effective treatment for bleeding, obstruction, or perforation and intestinal obstructions recurrent Clostridioides difficile colitis. Commercial oral and rectal that persist after conservative care. Gastroesophageal fundoplica- microbiota-based products have been approved or are in develop- tion is performed for refractory acid reflux. Acid exposure time ment for this indication. on pH testing helps select candidates for fundoplication. Achalasia responds to operations to reduce lower esophageal sphincter tone. THERAPEUTIC ENDOSCOPY Operations for motor disorders include implanted electrical stimu- In addition to its diagnostic role, endoscopy has numerous thera- lators for gastroparesis and electrical devices and artificial sphinc- peutic capabilities. Cautery techniques and injection of vasocon- ters for fecal incontinence. Surgery can place a jejunostomy for strictor substances can stop hemorrhage from ulcers and vascular long-term enteral feedings. Other common indications for surgery malformations. Endoscopically placed clips can occlude arterial include hernias, hemorrhoids, and nonhealing anal fissures. bleeding sites, while hemostatic powder sprays can stop brisk per- PSYCHOLOGICAL APPROACHES AND PHYSICAL THERAPY sistent GI bleeding. Endoscopic encirclement of esophageal varices and hemorrhoids with constricting bands stops hemorrhage from Psychological therapies, including psychotherapy, cognitive behav- these sites. Bleeding gastric varices can be injected with thrombin or ioral therapy, and hypnosis, show efficacy in DGBIs and are most cyanoacrylate. Endoscopy can remove polyps in the stomach, small beneficial for patients with significant psychological dysfunction. bowel, or colon. Decompressive colonoscopy withdraws excess Behavioral therapists provide instruction in diaphragmatic breath- gas in some cases of acute colonic pseudoobstruction. Endoscopic ing for belching or rumination. Biofeedback methods administered mucosal resection, submucosal dissection, and radiofrequency by physical therapists can treat refractory fecal incontinence or techniques ablate some cases of Barrett’s esophagus with dysplasia constipation secondary to dyssynergia. and resect superficial cancers or subepithelial tumors elsewhere in the gut. Obstructions of the GI lumen and pancreaticobiliary tree ■ FURTHER READING are relieved by endoscopic dilation or placing plastic or expandable Benech N et al: Update on microbiota-derived therapies for recurrent metal stents. Endoscopic sphincterotomy of the ampulla of Vater Clostridioides difficile infections. Clin Microbiol Infect 30:462, 2024. treats choledocholithiasis. Cholangioscopy can facilitate stone lith- Gergely M et al: Management of refractory inflammatory bowel otripsy in the common bile duct, ablation of small ductal tumors, disease. Curr Opin Gastroenterol 38:347, 2022. and placement of gallbladder stents to facilitate drainage in nonop- Hossain B et al: Prevalence and impact of gastrointestinal manifesta- erative candidates. Interventional EUS is used for pancreatic cyst tions in COVID-19 patients: A systematic review. J Community Hosp gastrostomy using lumen-apposing metal stents, pancreatic necro- Intern Med Perspect 13:39, 2023. sectomy, and placement of fiducial markers to direct pancreatic and Jain S et al: Optimal strategies for colorectal cancer screening. Curr rectal radiotherapy. EUS also can facilitate endoscopic access to the Treat Options Oncol 23:474, 2022. excluded distal stomach in patients who have undergone bariatric Orpen-Palmer J et al: Update on the management of upper gastroin- gastric bypass surgery using similar stents so that ERCP can be testinal bleeding. BMJ Med 1:e000202, 2022. done for pancreaticobiliary conditions. EUS-directed stent place- Shakir SM et al: Updates to the diagnosis and clinical management of ment can manage postsurgical stenoses after pancreatic resection. Helicobacter pylori infections. Clin Chem 69:869, 2023. Endoscopy is used to insert gastric feeding tubes. Peroral endo- scopic myotomy is performed on the lower esophageal sphincter in achalasia, the pylorus in gastroparesis, and the upper esophageal sphincter for Zenker’s diverticulum. Endoscopic treatments for acid reflux including transoral incisionless fundoplication have been developed as potential alternatives to surgery. Endoscopic bariatric methods, including intragastric balloons, sleeve gastroplasty, and duodenal resurfacing and diversion, have been devised. 333 Gastrointestinal INTERVENTIONAL RADIOLOGY Endoscopy Interventional radiology techniques offer benefits in selected set- tings. Angiographic embolization or vasoconstriction decreases Louis Michel Wong Kee Song, Vinay bleeding from gut sites not amenable to endoscopic intervention. Chandrasekhara, Mark Topazian Angiographic embolectomy, stent placement, and thrombolysis also manage mesenteric ischemia. Dilatation or stenting under fluoroscopic guidance relieves luminal strictures. Contrast enemas can reduce colon volvulus. CT- and ultrasound-directed drainage of Gastrointestinal endoscopy has been attempted for over 200 years, abdominal fluid collections can obviate the need for surgery. Per- but the introduction of semirigid and flexible gastroscopes in the cutaneous transhepatic cholangiography relieves biliary obstruction mid-twentieth century marked the dawn of the modern endoscopic when ERCP is contraindicated. Percutaneous cholecystostomy treats era. Since then, rapid advances in endoscopic technology have led to
[PAGE 2465] Gastrointestinal Endoscopy 2465 CHAPTER 333 FIGURE 333-1 Gastrointestinal endoscope. Shown here is a conventional colonoscope with control knobs for tip deflection, push buttons for suction and A air insufflation (single arrows), and a working channel for passage of accessories (double arrows). dramatic changes in the diagnosis and treatment of many digestive diseases. Innovative endoscopic devices and new endoscopic treatment modalities continue to expand the use of endoscopy in patient care. Flexible endoscop
Flowcharts & Algorithms¶
Reproduced from Harrison's 22nd Edition.
Flowchart 1¶
Caption: FIGURE 333-58 Endoscopic management of an esophagogastric anastomotic stricture. A. electroincision of stricture. C. Improvement in luminal opening after therapy.
Figures & Illustrations¶
Reproduced from Harrison's 22nd Edition.
Figure 1¶
Caption: FIGURE 333-11 Ulcerated colon adenocarcinoma narrowing the colonic lumen.
Figure 2¶
Caption: FIGURE 333-18 Endoscopic diagnosis, staging, and palliation of hilar obstructive jaundice demonstrates a malignant-appearing stricture of the biliary demonstrating a stricture with dilated, tortuous vessels with a malignant appearance. C. the submucosa of the bile duct wall (arrow). (Image courtesy of Dr. Thomas Smyrk.) D. posterior, and left systems relieves the biliary obstruction.
Figure 3¶
Caption: FIGURE 333-11 Ulcerated colon adenocarcinoma narrowing the colonic lumen.
Figure 4¶
Caption: FIGURE 333-19 Bile leak. A. Site of leak (arrow) from the cystic duct after laparoscopic into the gallbladder fossa (arrow).
Figure 5¶
Caption: FIGURE 333-16 Endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. A. Faceted bile duct stones are demonstrated in the common bile duct and common hepatic duct. B. After endoscopic sphincterotomy, the stones are extracted with a stone extraction balloon.
Figure 6¶
Caption: FIGURE 333-16 Endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. A. Faceted bile duct stones are demonstrated in the common bile duct and common hepatic duct. B. After endoscopic sphincterotomy, the stones are extracted with a stone extraction balloon.
Figure 7¶
Caption: FIGURE 333-18 Endoscopic diagnosis, staging, and palliation of hilar obstructive jaundice demonstrates a malignant-appearing stricture of the biliary demonstrating a stricture with dilated, tortuous vessels with a malignant appearance. C. the submucosa of the bile duct wall (arrow). (Image courtesy of Dr. Thomas Smyrk.) D. posterior, and left systems relieves the biliary obstruction.
Figure 8¶
Caption: FIGURE 333-18 Endoscopic diagnosis, staging, and palliation of hilar obstructive jaundice demonstrates a malignant-appearing stricture of the biliary demonstrating a stricture with dilated, tortuous vessels with a malignant appearance. C. the submucosa of the bile duct wall (arrow). (Image courtesy of Dr. Thomas Smyrk.) D. posterior, and left systems relieves the biliary obstruction.
Figure 9¶
Caption: FIGURE 333-19 Bile leak. A. Site of leak (arrow) from the cystic duct after laparoscopic into the gallbladder fossa (arrow).
Figure 10¶
Caption: FIGURE 333-17 Endoscopic sphincterotomy. A. A normal-appearing ampulla of Vater duct stones are extracted with a balloon catheter. endoscope have been used for many years to treat bleeding lesions, and the development of larger over-the-scope clips has facilitated endoscopic closure of gastrointestinal fistulas and perforations not previously amenable to endoscopic therapy (Video V5-7). Endoscopic suturing can be used to close some perforations and large defects (Fig. 333-27), anastomotic leaks, and fistulas. Endoscopic suturing may also be used to prevent stent migration (Fig. 333-28, Video V5-8) and to
Figure 11¶
Caption: FIGURE 333-18 Endoscopic diagnosis, staging, and palliation of hilar obstructive jaundice demonstrates a malignant-appearing stricture of the biliary demonstrating a stricture with dilated, tortuous vessels with a malignant appearance. C. the submucosa of the bile duct wall (arrow). (Image courtesy of Dr. Thomas Smyrk.) D. posterior, and left systems relieves the biliary obstruction.
Figure 12¶
Caption: FIGURE 333-17 Endoscopic sphincterotomy. A. A normal-appearing ampulla of Vater duct stones are extracted with a balloon catheter. endoscope have been used for many years to treat bleeding lesions, and the development of larger over-the-scope clips has facilitated endoscopic closure of gastrointestinal fistulas and perforations not previously amenable to endoscopic therapy (Video V5-7). Endoscopic suturing can be used to close some perforations and large defects (Fig. 333-27), anastomotic leaks, and fistulas. Endoscopic suturing may also be used to prevent stent migration (Fig. 333-28, Video V5-8) and to
Figure 13¶
Caption: FIGURE 333-17 Endoscopic sphincterotomy. A. A normal-appearing ampulla of Vater duct stones are extracted with a balloon catheter. endoscope have been used for many years to treat bleeding lesions, and the development of larger over-the-scope clips has facilitated endoscopic closure of gastrointestinal fistulas and perforations not previously amenable to endoscopic therapy (Video V5-7). Endoscopic suturing can be used to close some perforations and large defects (Fig. 333-27), anastomotic leaks, and fistulas. Endoscopic suturing may also be used to prevent stent migration (Fig. 333-28, Video V5-8) and to
Figure 14¶
Caption: FIGURE 333-31 (Continued)
Figure 15¶
Caption: FIGURE 333-41 Gastrointestinal vascular ectasias. A. Gastric antral vascular ectasia ectasias. B. Cecal vascular ectasia. C. Radiation-induced vascular ectasias of the rectum
Figure 16¶
Caption: FIGURE 333-41 Gastrointestinal vascular ectasias. A. Gastric antral vascular ectasia ectasias. B. Cecal vascular ectasia. C. Radiation-induced vascular ectasias of the rectum
Figure 17¶
Caption: FIGURE 333-54 Schatzki’s ring at the gastroesophageal junction.
Figure 18¶
Caption: FIGURE 333-30 Buried bumper syndrome. A. Migration of the internal disk bumper of B. Close-up view of the disk bumper (arrow) buried in the gastric wall.
Figure 19¶
Caption: FIGURE 333-9 Causes of colitis. A. Chronic ulcerative colitis with diffuse inflammation. B. adherent pseudomembranes. D. Ischemic colitis with patchy mucosal edema,
Figure 20¶
Caption: FIGURE 333-30 Buried bumper syndrome. A. Migration of the internal disk bumper of B. Close-up view of the disk bumper (arrow) buried in the gastric wall.
Figure 21¶
Caption: FIGURE 333-3 (Continued)
Figure 22¶
Caption: FIGURE 333-54 Schatzki’s ring at the gastroesophageal junction.
Figure 23¶
Caption: FIGURE 333-9 Causes of colitis. A. Chronic ulcerative colitis with diffuse inflammation. B. adherent pseudomembranes. D. Ischemic colitis with patchy mucosal edema,
Figure 24¶
Caption: FIGURE 333-9 Causes of colitis. A. Chronic ulcerative colitis with diffuse inflammation. B. adherent pseudomembranes. D. Ischemic colitis with patchy mucosal edema,
Figure 25¶
Caption: FIGURE 333-44 Esophageal food impaction. Meat bolus impacted in the distal esophagus.
Figure 26¶
Caption: FIGURE 333-30 Buried bumper syndrome. A. Migration of the internal disk bumper of B. Close-up view of the disk bumper (arrow) buried in the gastric wall.
Figure 27¶
Caption: FIGURE 333-39 (Continued)
Figure 28¶
Caption: FIGURE 333-3 (Continued)
Figure 29¶
Caption: FIGURE 333-33 Contact coagulation for ulcer hemostasis. A. Duodenal ulcer with a C. Obliteration of the treated vessel (arrow).
Figure 30¶
Caption: Gastrointestinal Endoscopy FIGURE 333-35 Over-the-scope clip placement for ulcer hemostasis. A. Pyloric channel ulcer with visible vessel (arrow). B. Hemostasis secured following placement of an over-the-scope clip. in ~50% of patients. Removable, fully covered lumen-apposing metal stents (LAMS) may also be used to treat benign pyloric stenosis (Video V5-16). Malignant gastric outlet obstruction can be relieved with endoscopically placed expandable stents across the obstruction in patients with inoperable malignancy (Video V5-17) or by EUS-guided B
Figure 31¶
Caption: FIGURE 333-9 Causes of colitis. A. Chronic ulcerative colitis with diffuse inflammation. B. adherent pseudomembranes. D. Ischemic colitis with patchy mucosal edema,
Figure 32¶
Caption: FIGURE 333-33 Contact coagulation for ulcer hemostasis. A. Duodenal ulcer with a C. Obliteration of the treated vessel (arrow).
Figure 33¶
Caption: Gastrointestinal Endoscopy FIGURE 333-35 Over-the-scope clip placement for ulcer hemostasis. A. Pyloric channel ulcer with visible vessel (arrow). B. Hemostasis secured following placement of an over-the-scope clip. in ~50% of patients. Removable, fully covered lumen-apposing metal stents (LAMS) may also be used to treat benign pyloric stenosis (Video V5-16). Malignant gastric outlet obstruction can be relieved with endoscopically placed expandable stents across the obstruction in patients with inoperable malignancy (Video V5-17) or by EUS-guided B
Figure 34¶
Caption: FIGURE 333-3 Normal upper endoscopic examination. A. Esophagus. B. G. Duodenal bulb. H. Second portion of the duodenum.
Figure 35¶
Caption: FIGURE 333-3 Normal upper endoscopic examination. A. Esophagus. B. G. Duodenal bulb. H. Second portion of the duodenum.
Figure 36¶
Caption: FIGURE 333-3 Normal upper endoscopic examination. A. Esophagus. B. G. Duodenal bulb. H. Second portion of the duodenum.
Figure 37¶
Caption: FIGURE 333-6 Barrett’s esophagus. A. Salmon-colored Barrett’s mucosa extending nodule (arrow) identified during endoscopic surveillance. C. Histologic finding of the esophageal submucosa (arrow). D. Barrett’s esophagus with locally advanced
Figure 38¶
Caption: FIGURE 333-6 Barrett’s esophagus. A. Salmon-colored Barrett’s mucosa extending nodule (arrow) identified during endoscopic surveillance. C. Histologic finding of the esophageal submucosa (arrow). D. Barrett’s esophagus with locally advanced
Figure 39¶
Caption: FIGURE 333-8 Normal colonoscopic examination. A. Cecum with view of appendiceal
Figure 40¶
Caption: FIGURE 333-8 Normal colonoscopic examination. A. Cecum with view of appendiceal
Figure 41¶
Caption: FIGURE 333-8 Normal colonoscopic examination. A. Cecum with view of appendiceal
Figure 42¶
Caption: FIGURE 333-8 Normal colonoscopic examination. A. Cecum with view of appendiceal
Figure 43¶
Caption: FIGURE 333-24 Endoscopic full-thickness resection (EFTR) of a gastrointestinal stromal from the fourth layer (muscularis propria) at endoscopic ultrasound. C. Full-thickness
Figure 44¶
Caption: FIGURE 333-38 Gastric varices. A. Large gastric fundal varices with stigmata of varix. C. Obliterated varix following glue injection on endoscopic follow-up at 1 month
Figure 45¶
Caption: FIGURE 333-42 Colonic diverticula. A
Figure 46¶
Caption: FIGURE 333-63 Small-bowel vascular ectasia. A. Actively bleeding mid-jejunal vascular with argon plasma coagulation (APC). C. Hemostasis secured following APC.
Figure 47¶
Caption: FIGURE 333-54 Schatzki’s ring at the gastroesophageal junction.
Figure 48¶
Caption: FIGURE 333-31 (Continued)
Figure 49¶
Caption: FIGURE 333-31 (Continued)
Figure 50¶
Caption: FIGURE 333-31 (Continued)
Figure 51¶
Caption: FIGURE 333-39 (Continued)
Figure 52¶
Caption: FIGURE 333-42 Colonic diverticula. A
Figure 53¶
Caption: FIGURE 333-48 Acute colonic pseudoobstruction. A. Acute colonic dilation occurring in a patient soon after knee surgery. B. Colonoscopic placement of decompression tube with marked improvement in colonic dilation.
Figure 54¶
Caption: FIGURE 333-48 Acute colonic pseudoobstruction. A. Acute colonic dilation occurring in a patient soon after knee surgery. B. Colonoscopic placement of decompression tube with marked improvement in colonic dilation.
Figure 55¶
Caption: FIGURE 333-3 (Continued)
Figure 56¶
Caption: FIGURE 333-3 (Continued)
Figure 57¶
Caption: FIGURE 333-11 Ulcerated colon adenocarcinoma narrowing the colonic lumen.
Figure 58¶
Caption: FIGURE 333-25 (Continued)
Figure 59¶
Caption: FIGURE 333-38 Gastric varices. A. Large gastric fundal varices with stigmata of varix. C. Obliterated varix following glue injection on endoscopic follow-up at 1 month
Figure 60¶
Caption: FIGURE 333-39 (Continued)
Figure 61¶
Caption: FIGURE 333-44 Esophageal food impaction. Meat bolus impacted in the distal esophagus.
Figure 62¶
Caption: FIGURE 333-1 Gastrointestinal endoscope. Shown here is a conventional colonoscope with control knobs for tip deflection, push buttons for suction and A air insufflation (single arrows), and a working channel for passage of accessories (double arrows).
Figure 63¶
Caption: FIGURE 333-1 Gastrointestinal endoscope. Shown here is a conventional colonoscope with control knobs for tip deflection, push buttons for suction and A air insufflation (single arrows), and a working channel for passage of accessories (double arrows).
Figure 64¶
Caption: FIGURE 333-26 (Continued)
Figure 65¶
Caption: FIGURE 333-51 Causes of esophagitis. A. Severe reflux esophagitis with mucosal esophagitis with target-type shallow ulcerations. D. Candida esophagitis with white
Figure 66¶
Caption: FIGURE 333-3 Normal upper endoscopic examination. A. Esophagus. B. G. Duodenal bulb. H. Second portion of the duodenum.
Figure 67¶
Caption: FIGURE 333-3 Normal upper endoscopic examination. A. Esophagus. B. G. Duodenal bulb. H. Second portion of the duodenum.
Figure 68¶
Caption: FIGURE 333-3 Normal upper endoscopic examination. A. Esophagus. B. G. Duodenal bulb. H. Second portion of the duodenum.
Figure 69¶
Caption: FIGURE 333-3 (Continued)
Figure 70¶
Caption: FIGURE 333-3 (Continued)
Figure 71¶
Caption: FIGURE 333-25 (Continued)
Figure 72¶
Caption: FIGURE 333-25 (Continued)
Figure 73¶
Caption: FIGURE 333-38 Gastric varices. A. Large gastric fundal varices with stigmata of varix. C. Obliterated varix following glue injection on endoscopic follow-up at 1 month
Figure 74¶
Caption: FIGURE 333-24 Endoscopic full-thickness resection (EFTR) of a gastrointestinal stromal from the fourth layer (muscularis propria) at endoscopic ultrasound. C. Full-thickness
Figure 75¶
Caption: FIGURE 333-26 (Continued)
Figure 76¶
Caption: FIGURE 333-33 Contact coagulation for ulcer hemostasis. A. Duodenal ulcer with a C. Obliteration of the treated vessel (arrow).
Figure 77¶
Caption: FIGURE 333-42 Colonic diverticula. A
Figure 78¶
Caption: FIGURE 333-56 (Continued)
Figure 79¶
Caption: FIGURE 333-25 (Continued)
Figure 80¶
Caption: FIGURE 333-38 Gastric varices. A. Large gastric fundal varices with stigmata of varix. C. Obliterated varix following glue injection on endoscopic follow-up at 1 month
Figure 81¶
Caption: FIGURE 333-38 Gastric varices. A. Large gastric fundal varices with stigmata of varix. C. Obliterated varix following glue injection on endoscopic follow-up at 1 month
Figure 82¶
Caption: FIGURE 333-41 Gastrointestinal vascular ectasias. A. Gastric antral vascular ectasia ectasias. B. Cecal vascular ectasia. C. Radiation-induced vascular ectasias of the rectum
Figure 83¶
Caption: FIGURE 333-52 (Continued)
Figure 84¶
Caption: FIGURE 333-16 Endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. A. Faceted bile duct stones are demonstrated in the common bile duct and common hepatic duct. B. After endoscopic sphincterotomy, the stones are extracted with a stone extraction balloon.
Figure 85¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 86¶
Caption: FIGURE 333-25 (Continued)
Figure 87¶
Caption: FIGURE 333-54 Schatzki’s ring at the gastroesophageal junction.
Figure 88¶
Caption: FIGURE 333-26 (Continued)
Figure 89¶
Caption: FIGURE 333-42 Colonic diverticula. A
Figure 90¶
Caption: FIGURE 333-51 Causes of esophagitis. A. Severe reflux esophagitis with mucosal esophagitis with target-type shallow ulcerations. D. Candida esophagitis with white
Figure 91¶
Caption: FIGURE 333-52 (Continued)
Figure 92¶
Caption: FIGURE 333-52 (Continued)
Figure 93¶
Caption: FIGURE 333-56 (Continued)
Figure 94¶
Caption: FIGURE 333-63 Small-bowel vascular ectasia. A. Actively bleeding mid-jejunal vascular with argon plasma coagulation (APC). C. Hemostasis secured following APC.
Figure 95¶
Caption: FIGURE 333-30 Buried bumper syndrome. A. Migration of the internal disk bumper of B. Close-up view of the disk bumper (arrow) buried in the gastric wall.
Figure 96¶
Caption: FIGURE 333-52 (Continued)
Figure 97¶
Caption: FIGURE 333-63 Small-bowel vascular ectasia. A. Actively bleeding mid-jejunal vascular with argon plasma coagulation (APC). C. Hemostasis secured following APC.
Figure 98¶
Caption: FIGURE 333-16 Endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. A. Faceted bile duct stones are demonstrated in the common bile duct and common hepatic duct. B. After endoscopic sphincterotomy, the stones are extracted with a stone extraction balloon.
Figure 99¶
Caption: FIGURE 333-63 Small-bowel vascular ectasia. A. Actively bleeding mid-jejunal vascular with argon plasma coagulation (APC). C. Hemostasis secured following APC.
Figure 100¶
Caption: FIGURE 333-16 Endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. A. Faceted bile duct stones are demonstrated in the common bile duct and common hepatic duct. B. After endoscopic sphincterotomy, the stones are extracted with a stone extraction balloon.
Figure 101¶
Caption: FIGURE 333-1 Gastrointestinal endoscope. Shown here is a conventional colonoscope with control knobs for tip deflection, push buttons for suction and A air insufflation (single arrows), and a working channel for passage of accessories (double arrows).
Figure 102¶
Caption: FIGURE 333-49 Obstructing colonic carcinoma. A. Colonic adenocarcinoma causing a self-expandable metal stent. C. Radiograph of expanded stent across the obstructing
Figure 103¶
Caption: FIGURE 333-49 Obstructing colonic carcinoma. A. Colonic adenocarcinoma causing a self-expandable metal stent. C. Radiograph of expanded stent across the obstructing
Figure 104¶
Caption: FIGURE 333-19 Bile leak. A. Site of leak (arrow) from the cystic duct after laparoscopic into the gallbladder fossa (arrow).
Figure 105¶
Caption: FIGURE 333-49 Obstructing colonic carcinoma. A. Colonic adenocarcinoma causing a self-expandable metal stent. C. Radiograph of expanded stent across the obstructing
Figure 106¶
Caption: FIGURE 333-60 Placement of biliary and duodenal self-expanding metal stents (SEMS) for obstruction caused by pancreatic cancer. A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a distal bile duct stricture (arrow). B. A biliary SEMS is placed. C. Contrast injection demonstrates a duodenal stricture (arrow). D. Biliary and duodenal SEMS in place.
Figure 107¶
Caption: FIGURE 333-60 Placement of biliary and duodenal self-expanding metal stents (SEMS) for obstruction caused by pancreatic cancer. A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a distal bile duct stricture (arrow). B. A biliary SEMS is placed. C. Contrast injection demonstrates a duodenal stricture (arrow). D. Biliary and duodenal SEMS in place.
Figure 108¶
Caption: FIGURE 333-9 Causes of colitis. A. Chronic ulcerative colitis with diffuse inflammation. B. adherent pseudomembranes. D. Ischemic colitis with patchy mucosal edema,
Figure 109¶
Caption: FIGURE 333-19 Bile leak. A. Site of leak (arrow) from the cystic duct after laparoscopic into the gallbladder fossa (arrow).
Figure 110¶
Caption: FIGURE 333-60 Placement of biliary and duodenal self-expanding metal stents (SEMS) for obstruction caused by pancreatic cancer. A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a distal bile duct stricture (arrow). B. A biliary SEMS is placed. C. Contrast injection demonstrates a duodenal stricture (arrow). D. Biliary and duodenal SEMS in place.
Figure 111¶
Caption: FIGURE 333-48 Acute colonic pseudoobstruction. A. Acute colonic dilation occurring in a patient soon after knee surgery. B. Colonoscopic placement of decompression tube with marked improvement in colonic dilation.
Figure 112¶
Caption: FIGURE 333-60 Placement of biliary and duodenal self-expanding metal stents (SEMS) for obstruction caused by pancreatic cancer. A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a distal bile duct stricture (arrow). B. A biliary SEMS is placed. C. Contrast injection demonstrates a duodenal stricture (arrow). D. Biliary and duodenal SEMS in place.
Figure 113¶
Caption: FIGURE 333-19 Bile leak. A. Site of leak (arrow) from the cystic duct after laparoscopic into the gallbladder fossa (arrow).
Figure 114¶
Caption: FIGURE 333-26 (Continued)
Figure 115¶
Caption: FIGURE 333-27 (Continued)
Figure 116¶
Caption: FIGURE 333-27 (Continued)
Figure 117¶
Caption: FIGURE 333-27 (Continued)
Figure 118¶
Caption: FIGURE 333-27 (Continued)
Figure 119¶
Caption: FIGURE 333-49 Obstructing colonic carcinoma. A. Colonic adenocarcinoma causing a self-expandable metal stent. C. Radiograph of expanded stent across the obstructing
Figure 120¶
Caption: FIGURE 333-49 Obstructing colonic carcinoma. A. Colonic adenocarcinoma causing a self-expandable metal stent. C. Radiograph of expanded stent across the obstructing
Figure 121¶
Caption: FIGURE 333-19 Bile leak. A. Site of leak (arrow) from the cystic duct after laparoscopic into the gallbladder fossa (arrow).
Figure 122¶
Caption: FIGURE 333-49 Obstructing colonic carcinoma. A. Colonic adenocarcinoma causing a self-expandable metal stent. C. Radiograph of expanded stent across the obstructing
Figure 123¶
Caption: FIGURE 333-44 Esophageal food impaction. Meat bolus impacted in the distal esophagus.
Figure 124¶
Caption: FIGURE 333-44 Esophageal food impaction. Meat bolus impacted in the distal esophagus.
Figure 125¶
Caption: FIGURE 333-26 (Continued)
Figure 126¶
Caption: FIGURE 333-44 Esophageal food impaction. Meat bolus impacted in the distal esophagus.
Figure 127¶
Caption: FIGURE 333-9 Causes of colitis. A. Chronic ulcerative colitis with diffuse inflammation. B. adherent pseudomembranes. D. Ischemic colitis with patchy mucosal edema,
Figure 128¶
Caption: FIGURE 333-29 Bleeding from percutaneous endoscopic gastrostomy (PEG) tube internal disk bumper of the PEG tube revealed active bleeding from within the PEG tract.
Figure 129¶
Caption: FIGURE 333-29 Bleeding from percutaneous endoscopic gastrostomy (PEG) tube internal disk bumper of the PEG tube revealed active bleeding from within the PEG tract.
Figure 130¶
Caption: Gastrointestinal Endoscopy FIGURE 333-35 Over-the-scope clip placement for ulcer hemostasis. A. Pyloric channel ulcer with visible vessel (arrow). B. Hemostasis secured following placement of an over-the-scope clip. in ~50% of patients. Removable, fully covered lumen-apposing metal stents (LAMS) may also be used to treat benign pyloric stenosis (Video V5-16). Malignant gastric outlet obstruction can be relieved with endoscopically placed expandable stents across the obstruction in patients with inoperable malignancy (Video V5-17) or by EUS-guided B
Figure 131¶
Caption: FIGURE 333-27 (Continued)
Figure 132¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 133¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 134¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 135¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 136¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 137¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 138¶
Caption: FIGURE 333-23 Peroral endoscopic tumorectomy (POET). A. Mid-esophageal lesion. C. Submucosal dissection and tunneling to the site of the lesion. D. Dissection of through the muscularis propria. F. Mucosotomy site. G. Closure of mucosotomy site with
Figure 139¶
Caption: FIGURE 333-11 Ulcerated colon adenocarcinoma narrowing the colonic lumen.
Figure 140¶
Caption: FIGURE 333-11 Ulcerated colon adenocarcinoma narrowing the colonic lumen.
Figure 141¶
Caption: FIGURE 333-33 Contact coagulation for ulcer hemostasis. A. Duodenal ulcer with a C. Obliteration of the treated vessel (arrow).
Figure 142¶
Caption: FIGURE 333-33 Contact coagulation for ulcer hemostasis. A. Duodenal ulcer with a C. Obliteration of the treated vessel (arrow).
Figure 143¶
Caption: FIGURE 333-60 Placement of biliary and duodenal self-expanding metal stents (SEMS) for obstruction caused by pancreatic cancer. A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a distal bile duct stricture (arrow). B. A biliary SEMS is placed. C. Contrast injection demonstrates a duodenal stricture (arrow). D. Biliary and duodenal SEMS in place.
Figure 144¶
Caption: FIGURE 333-60 Placement of biliary and duodenal self-expanding metal stents (SEMS) for obstruction caused by pancreatic cancer. A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a distal bile duct stricture (arrow). B. A biliary SEMS is placed. C. Contrast injection demonstrates a duodenal stricture (arrow). D. Biliary and duodenal SEMS in place.
Figure 145¶
Caption: Gastrointestinal Endoscopy FIGURE 333-35 Over-the-scope clip placement for ulcer hemostasis. A. Pyloric channel ulcer with visible vessel (arrow). B. Hemostasis secured following placement of an over-the-scope clip. in ~50% of patients. Removable, fully covered lumen-apposing metal stents (LAMS) may also be used to treat benign pyloric stenosis (Video V5-16). Malignant gastric outlet obstruction can be relieved with endoscopically placed expandable stents across the obstruction in patients with inoperable malignancy (Video V5-17) or by EUS-guided B
Figure 146¶
Caption: FIGURE 333-11 Ulcerated colon adenocarcinoma narrowing the colonic lumen.
Figure 147¶
Caption: FIGURE 333-56 (Continued)
Figure 148¶
Caption: FIGURE 333-56 (Continued)
Figure 149¶
Caption: FIGURE 333-56 (Continued)
Figure 150¶
Caption: Gastrointestinal Endoscopy FIGURE 333-35 Over-the-scope clip placement for ulcer hemostasis. A. Pyloric channel ulcer with visible vessel (arrow). B. Hemostasis secured following placement of an over-the-scope clip. in ~50% of patients. Removable, fully covered lumen-apposing metal stents (LAMS) may also be used to treat benign pyloric stenosis (Video V5-16). Malignant gastric outlet obstruction can be relieved with endoscopically placed expandable stents across the obstruction in patients with inoperable malignancy (Video V5-17) or by EUS-guided B
Figure 151¶
Caption: FIGURE 333-24 Endoscopic full-thickness resection (EFTR) of a gastrointestinal stromal from the fourth layer (muscularis propria) at endoscopic ultrasound. C. Full-thickness
Figure 152¶
Caption: FIGURE 333-24 Endoscopic full-thickness resection (EFTR) of a gastrointestinal stromal from the fourth layer (muscularis propria) at endoscopic ultrasound. C. Full-thickness
Figure 153¶
Caption: FIGURE 333-24 Endoscopic full-thickness resection (EFTR) of a gastrointestinal stromal from the fourth layer (muscularis propria) at endoscopic ultrasound. C. Full-thickness
Figure 154¶
Caption: FIGURE 333-24 Endoscopic full-thickness resection (EFTR) of a gastrointestinal stromal from the fourth layer (muscularis propria) at endoscopic ultrasound. C. Full-thickness
Figure 155¶
Caption: FIGURE 333-27 (Continued)
Figure 156¶
Caption: FIGURE 333-6 Barrett’s esophagus. A. Salmon-colored Barrett’s mucosa extending nodule (arrow) identified during endoscopic surveillance. C. Histologic finding of the esophageal submucosa (arrow). D. Barrett’s esophagus with locally advanced
Figure 157¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 158¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 159¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 160¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 161¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 162¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 163¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 164¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 165¶
Caption: FIGURE 333-22 Peroral endoscopic myotomy (POEM) for achalasia. A. Dilated (LES) region. C. Mucosal incision (mucosotomy) 10 cm proximal to the LES. D. mucosotomy site into the submucosal space. E. Completion of submucosal tunnel to the site. G. Completion of myotomy to the cardia. H. Closure of mucosotomy site with clips. I.
Figure 166¶
Caption: FIGURE 333-6 Barrett’s esophagus. A. Salmon-colored Barrett’s mucosa extending nodule (arrow) identified during endoscopic surveillance. C. Histologic finding of the esophageal submucosa (arrow). D. Barrett’s esophagus with locally advanced
Figure 167¶
Caption: FIGURE 333-6 Barrett’s esophagus. A. Salmon-colored Barrett’s mucosa extending nodule (arrow) identified during endoscopic surveillance. C. Histologic finding of the esophageal submucosa (arrow). D. Barrett’s esophagus with locally advanced
Figure 168¶
Caption: FIGURE 333-48 Acute colonic pseudoobstruction. A. Acute colonic dilation occurring in a patient soon after knee surgery. B. Colonoscopic placement of decompression tube with marked improvement in colonic dilation.
Figure 169¶
Caption: FIGURE 333-48 Acute colonic pseudoobstruction. A. Acute colonic dilation occurring in a patient soon after knee surgery. B. Colonoscopic placement of decompression tube with marked improvement in colonic dilation.
Figure 170¶
Caption: FIGURE 333-51 Causes of esophagitis. A. Severe reflux esophagitis with mucosal esophagitis with target-type shallow ulcerations. D. Candida esophagitis with white
Figure 171¶
Caption: FIGURE 333-51 Causes of esophagitis. A. Severe reflux esophagitis with mucosal esophagitis with target-type shallow ulcerations. D. Candida esophagitis with white
Figure 172¶
Caption: FIGURE 333-51 Causes of esophagitis. A. Severe reflux esophagitis with mucosal esophagitis with target-type shallow ulcerations. D. Candida esophagitis with white
Figure 173¶
Caption: FIGURE 333-51 Causes of esophagitis. A. Severe reflux esophagitis with mucosal esophagitis with target-type shallow ulcerations. D. Candida esophagitis with white
Figure 174¶
Caption: FIGURE 333-6 Barrett’s esophagus. A. Salmon-colored Barrett’s mucosa extending nodule (arrow) identified during endoscopic surveillance. C. Histologic finding of the esophageal submucosa (arrow). D. Barrett’s esophagus with locally advanced
Generated from Harrison's Principles of Internal Medicine, 22nd Edition.