Crohn´s Disease, El Salvador Atlas of Gastrointestinal Video Endoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 
Crohns Disease (Regional Enteritis, Granulomatous Colitis). This sequences display severe endoscopic lesions. A 42 year-old Salvadorian woman, that has been living in The United States of America for more than 20 years. The patient presented with weigh loss of 22 pounds, abdominal pain and diarrhea during two years. This lesions display ulcerations and retraction of the sigmoid mucosa. Causing some difficulties when advancing with the endoscope forward. After some maneuvers the stenosis was overcome. A second colonoscopy was performed shortly after some treatment. In that colonoscopy we were able to find that the terminal ileum was affected.

Video Endoscopic Sequence 1 of 28.

Crohn´s  Disease

(Regional Enteritis, Granulomatous Colitis).

 This sequence display severe endoscopic lesions.

 A 42 year-old Salvadorian woman, that has been living in
 The United States of America for more than 20 years. 
 The patient presented with weigh loss of 22 pounds,
 abdominal pain and diarrhea during two years.

 This lesions display ulcerations and retraction of
 the sigmoid mucosa. Causing some difficulties when
 advancing with the endoscope forward. After some
 maneuvers the stenosis was overcome.
 A second colonoscopy was performed shortly after some
 treatment. In that colonoscopy we were able to find that
 the terminal ileum was affected. 

 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. 

Another view of the lesion describes before. Some ulcers were found in the sigmoid colon. Many lesions were found in the entire colon, with severe inflammation, edema, fibrosis, ulcers and nodules. Large and deep, penetrating ulcers surrounded by areas of normal appearing mucosa were also found.

Video Endoscopic Sequence 2 of 28.

Crohn´s  Disease.

 Another view of the lesion describes before. Some ulcers
 were found in the sigmoid colon.
 Many lesions were found in the entire colon, with
 severe inflammation, edema, fibrosis, ulcers and nodules.
 Large  and deep, penetrating ulcers surrounded by areas
 of normal appearing mucosa were also found.

Crohns Disease. Nodular stenosis due to Crohn's disease. The transverse colon has two nodular and ulcerated stenosis. However, this stenosis was overcome by passing the colonoscope to the next lesion. The severity of the diseases varies widely between individuals. Some suffer only mild symptoms, but othershave severe and disabling symptoms. Some have a gradualonset of symptoms, some develop them suddenly. About half of patients have mild symptoms, the other half suffer frequent flare-ups.Pathophysiology: The exact cause of Crohn diseaseremains unknown. Current theories implicate the role ofgenetic, microbial, immunologic, environmental, dietary,vascular, and even psychosocial factors as potentialcausative agents. It has been suggested that patients have an inherited susceptibility for an aberrant immunologic response to one or more of these provoking factors.

Video Endoscopic Sequence 3 of 28.

Crohn´s  Disease.

 Nodular stenosis due to Crohn's disease.
 The transverse colon has two nodular and ulcerated
 stenosis.  However, this stenosis was overcome by passing
 the colonoscope to the next lesion.

 The severity of the diseases varies widely between
 individuals. Some suffer only mild symptoms, but others
 have severe and disabling symptoms. Some have a gradual
 onset of symptoms, some develop them suddenly.
 About half of patients have mild symptoms, the other half
 suffer frequent flare-ups.
 Pathophysiology: The exact cause of Crohn disease
 remains unknown. Current theories implicate the role of
 genetic, microbial, immunologic, environmental, dietary,
 vascular, and even psychosocial factors as potential
 causative agents. It has been suggested that patients have
 an inherited susceptibility for an aberrant immunologic
 response to one or more of these provoking factors.
      

A close up of the first nodular stenosis of the transverse colon. This is Crohn's disease affecting part or all of the colon. This form comprises about 20% of all cases of CD.Various patterns are seen. In about half of these cases CDlesions may be seen throughout one continuoussubsegment of the colon. In another quarter, skip areas areseen between multiple diseased areas. In the remainingquarter, the entire colon is involved, with no skip areas.

Video Endoscopic Sequence 4 of 28.

Crohn´s  Disease.

 A close up of the first nodular stenosis of the transverse
 colon.
                                           
 This is Crohn's disease affecting part or all of the colon.
 This form comprises about 20% of all cases of CD.
 Various patterns are seen. In about half of these cases CD
 lesions  may be seen throughout one continuous
 subsegment of the colon. In another quarter, skip areas are
 seen between  multiple diseased areas. In the remaining
 quarter, the entire colon is involved, with no skip areas.
 
The video clip displays passing of the colonoscope through to the first nodular stenosis, displaying a second transverse colon lesion which is nodular and ulcerated also. Crohns Disease. Microscopically, the initial lesion starts as a focal inflammatory infiltrate around the crypts, followed by ulceration of superficial mucosa. Later, inflammatory cells invade deep layers and, in that process, begin to organize into noncaseating granulomas. The granulomas extend through all layers of the intestinal wall and into the mesentery and the regional lymph nodes. Although granuloma formation is pathognomonic of Crohn disease, absence does not exclude the diagnosis.

Video Endoscopic Sequence 5 of 28.

Crohn´s  Disease.

 The video clip displays passing of the colonoscope
 through  to the first  nodular stenosis, displaying a second
 transverse colon lesion which is nodular and ulcerated
 also.

 Microscopically, the initial lesion starts as a focal
 inflammatory infiltrate around the crypts, followed by
 ulceration of superficial mucosa. Later, inflammatory cells
 invade deep layers and, in that process, begin to organize
 into noncaseating granulomas. The granulomas extend
 through all layers of the intestinal wall and into the
 mesentery and the regional lymph nodes. Although
 granuloma formation is pathognomonic of Crohn disease,
 absence does not exclude the diagnosis.

This lesion belong to the second stenosis of the transverse colon, which is nodular and ulcerated. The orifice is very small and impossible to pass through. We performed a second colonoscopy, after 7 days of treatment. See the sequence below, where this stenosis was overcome and the terminal ileum was visualized.

Video Endoscopic Sequence 6 of 28.

Crohn´s  Disease

 This lesion belong to the second stenosis of the transverse
 colon, which is nodular and ulcerated. The orifice is very
 small and  impossible to pass through.
 We performed a second colonoscopy, after 7 days of
 treatment. See the sequence below, where this stenosis
 was overcome and the terminal ileum was visualized.
Transverse colon, high grade nodular stenosis. The biopsies were taken from different ulcerated nodules. Crohns Disease. Transmural inflammation results in thickening of the bowel wall and narrowing of the lumen. As the disease progresses, it is complicated by obstruction, fistulization, abscess formation, adhesions, and malabsorption.

Video Endoscopic Sequence 7 of 28.

Crohn´s  Disease.

 Transverse colon, high grade nodular stenosis
 The biopsies were taken from different ulcerated nodules.    

 Transmural inflammation results in thickening of the bowel
 wall and narrowing of the lumen. As the disease
 progresses, it is complicated by obstruction, fistulization,
 abscess formation, adhesions, and malabsorption.    

The rectum seen in retroflexed view. A polyp is observed We were not sure if this polyp was caused by the Crohn?s disease itself. However, we observed after a short time of treatment, administered with steroids and antibiotics, we observed that this lesion appeared as a hypertrophic papillae.

 Video Endoscopic Sequence 8 of  28.

Crohn´s  Disease.

 The rectum seen in retroflexed view.  A polyp is observed
 We were not sure if this polyp was caused by the Crohn’s
 disease itself. However, we observed after a short time
 of treatment, administered with steroids and antibiotics,
 we observed that this  lesion appeared as a hypertrophic
 papillae. See video endoscopic sequence 27.
Crohns Disease after short-time treatment. Prominent rectum vessels were found, giving a congestive appearance after a short-time treatment with steroids.

Video Endoscopic Sequence 9 of  28.

            Crohn´s Disease after short-time treatment.

 Prominent rectum vessels were found, giving a congestive
 appearance after a short-time treatment with steroids.
Some polyps are founded into the sigmoid colon, not seen by the previous colonoscopy. It may be due to a better colon preparation.

Video Endoscopic Sequence 10 of  28.

 Crohn´s Disease after short-time treatment.

 Some polyps are founded into the sigmoid colon,
 not seen by the previous colonoscopy. It may
 be due to a better colon preparation.

“ Pseudo polyps.”    

The video clip displays the difficulties in advancing the colonoscope throughout recto-sigmoid junction due to the narrowing caused by the ulcer.

Video Endoscopic Sequence 11 of  28.

Crohn´s Disease, after a short-time treatment.

 The video clip displays the difficulties in advancing the
 colonoscope  throughout recto-sigmoid junction due to
 the narrowing caused by the ulcer.

The patient was hospitalized and received 50 mg. oral prednisone daily, 500 mg IV ciprofloxacin every 8 Hrs.and 500 mg IV metronidazole every 8 Hrs. Its is Important to remark that the therapeutical effectiveness of these medications are seen in the new colonoscopy, performed 7 days after the initiating the treatment. We could overcome the nodular stenosis previously described, by finding the ileocecal valve destroyed, by the disease; after passing throughout the valve, we could exam around 30 cm of the terminal ileum finding an active disease. The colon was found to measure 120 CM.long.

Video Endoscopic Sequence 12 of  28.

Upgrading information.

     Long and serpiginous ulcers and nodules of sigmoid.

 The patient was hospitalized and received 50 mg. oral
 prednisone daily, 500 mg IV ciprofloxacin every 8 Hrs.and
 500 mg IV metronidazole every 8 Hrs.
 Its is Important to remark that the therapeutical
 effectiveness  of these medications are seen in
 the new colonoscopy,  performed 7 days after the initiating
 the treatment. We could overcome the nodular stenosis
 previously described, by finding the ileocecal valve
 destroyed, by the disease; after passing  throughout the
 valve, we could exam around 30 cm of the terminal ileum
 finding an active disease.
 The colon was found to measure 120 CM. long.
Ulcers and nodules of the sigmoid and descending colon. Though any portion of the gastrointestinal tract may be involved with Crohn's disease, the small intestine--and the terminal ileum in particular--is most likely to be involved.

Video Endoscopic Sequence 13 of  28.

  Ulcers and nodules of the sigmoid and descending colon.

 Though any portion of the gastrointestinal tract may be
 involved with Crohn's disease, the small intestine--and the
 terminal ileum in particular--is most likely to be involved.

The video clip displays a colonoscopy of the transverse colon, displaying a narrowing with nodules and ulcers.

Video Endoscopic Sequence 14 of 28.

Crohn´s Disease.

 The video clip displays a colonoscopy of the transverse
 colon, displaying a narrowing with nodules and ulcers. 

The image and the video clip display a lesion caused by this disease. Theses are nodularity, deformed and stenosis with ulcers.

Video Endoscopic Sequence 15 of 28.

Crohn´s  Disease.

 The image and the video clip display a lesion caused 
 by this disease. Theses are nodularity, deformed and
 stenosis with ulcers.
  

Crohns Disease after short-time treatment. The cecum and the ileocecal valve are destroyed due to nodules and ulcers.

Video Endoscopic Sequence 16 of 28.

Crohn´s  Disease.

 The cecum and the ileocecal valve are destroyed due to
 nodules and ulcers. 

The appendiceal orifice is observed. There are some tiny rounded ulcers like the aphthous ulces or hyperplasic follicles.

Video Endoscopic Sequence 17 of 28.

 The appendiceal orifice is observed. There are some tiny
 rounded ulcers like the aphthous ulces or hyperplasic
 follicles.
The ileocecal valve is destroyed by the disease itself, this valve is nodular and ulcerated.

Video Endoscopic Sequence 18 of 28.

 The ileocecal valve is destroyed by the disease itself,
 this valve is nodular and ulcerated.
 

Terminal ileum. The image and video of this sequence reveals the passage of the colonoscope through the ileocecal valve to terminal ileum.

Video Endoscopic Sequence 19 of 28.

Terminal ileum.

 The image and video of this sequence reveals the passage
 of the colonoscope through the ileocecal valve to terminal
 ileum.

      You must see the video by clicking on the image.
Terminal ileum. Irregular ulceration, erithema and nodules are appreciated. When we look at the spectrum of Crohns disease, probably one-half to two-thirds of the patients have the disease, involving the last portion of the small intestine and the first portion of the colon Maybe another quarter of patients have disease only in the small intestine,and another quarter only in the large intestine. So the distribution of Crohns disease in the intestinal track is important because we now have different medical therapies that can actually be targeted to sites along the intestine both the anti-inflammatorytherapies, called the five ASA agents and new steroid treatments are actually targeted to the ileum and the first portion of the colon. So the location of the disease is very important, to begin with.

Video Endoscopic Sequence 20 of 28.

Crohn´s Disease.

 Terminal ileum.  Irregular ulceration, erithema and nodules
 are appreciated.
 
 When we look at the spectrum of Crohns disease, probably
 one-half to two-thirds of the patients have the disease, involving the
 last portion of the small intestine and the first portion of the colon
 Maybe another quarter of patients have disease only in the small
 intestine,and another quarter only in the large intestine. So the
 distribution of Crohns disease in the intestinal track is important
 because we now have different medical therapies that can actually
 be targeted to sites along the intestine  both the anti-inflammatory
 therapies, called the five ASA agents and new steroid treatments
 are actually targeted to the ileum and the first portion of the colon.
 So the location of the disease is very important, to begin with.
   

Terminal ileum "ileitis". At one time, Crohn´s Disease was thought to affect only the ileum, and for this reason the name "ileitis" was at one time synonymous with CD but now simply refers to Crohn's disease of the ileum.

Video Endoscopic Sequence 21 of 28.

Terminal ileum   “ileitis”.

 At one time, Crohn´s Disease was thought to affect only the
 ileum, and for this reason the name "ileitis" was at one
 time synonymous with CD but now simply refers to Crohn's
 disease of the ileum.
 
Junction of the cecum with the ascending colon. The condition occurs in both sexes and among all age groups, although it most frequently begins in young people Jewish people are at increased risk of developing Crohn's, while African Americans are at decreased risk, which indicates the genetic link in this disease.

Video Endoscopic Sequence 22 of 28.

 Junction of the cecum with  the ascending colon.
 The condition occurs in both sexes and among all age
 groups, although it most frequently begins in young people
 Jewish people are at increased risk of developing Crohn's,
 while African Americans are at decreased risk, which
 indicates the genetic link in this disease.

The video clip display a long segment of the colonoscopy displaying from the appendiceal orifice to the sigmoid.You should see the video clip, which is quite long and takes some time to download.

Video Endoscopic Sequence 23 of 28.

 The video clip display a long segment of the
 colonoscopy displaying from the appendiceal orifice
 to the sigmoid.

 You should see the video clip, which is quite long and
 takes some time to download.
 
Crohn?s is a serious inflammatory disease of the gastrointestinal tract that causes diarrhea, abdominal cramps, fever and rectal bleeding. The cause of Crohn?s disease is unknown.

Video Endoscopic Sequence 24 of 28.

 Crohn’s is a serious inflammatory disease of the
 gastrointestinal tract that causes diarrhea, abdominal
 cramps, fever and rectal bleeding. The cause of Crohn’s
 disease is unknown.
(Serpiginous linear ulcers) Inflammatory bowel disease (cobblestone like mucosa).

Video Endoscopic Sequence 25 of  28.

  (Serpiginous linear ulcers) Inflammatory bowel disease
 ("cobblestone" like mucosa).
Rectum.

Video Endoscopic Sequence 26 of 28.

Anus.
 

Crohn´s Disease. Rectum Retroflexed Image. For more endoscopic details download the video clip by clicking on the endoscopic image.

Video Endoscopic Sequence 27 of 28.

Rectum Retroflexed Image.

Antrum: gastric wall thickening resembles chronic erosions. Crohns disease is an inflammation of the digestive track that can affect any portion of the digestive track.

Video Endoscopic Sequence 28 of 28.

Gastric Crohn´s  Disease.

 Antrum:  gastric wall thickening  resembles chronic
 erosions.
 Crohns disease is an inflammation of the digestive track that
 can affect any portion of the digestive track.

 

 

                                                                                    Medline.                                           

Crohn´s Disease of the iliocecal valve and terminal ileon. This 73 year-old male, has been suffering of fever, abdominal pain, anorexia and anemia, his hemoglobin level was 8.7 g/dL.

 Video Endoscopic Sequence 1 of 5.

Crohn´s Disease of the ileocecal valve and terminal Ileum

 This 73 year-old male, has been suffering of fever,
 abdominal pain, anorexia and anemia, his hemoglobin
 level was 8.7 g/dL.

 

 
Colonoscopic examination revealed deformed ileocecal valve with ulcerations and stenotic areas.

Video Endoscopic Sequence 2 of 5.

 Colonoscopic examination revealed deformed ileocecal
 valve with ulcerations and stenotic areas.

 
General clinical features of Crohn disease are fever, abdominal pain, diarrhea, and fatigability. Weight loss is also associated. Diarrhea and pain are the most common symptoms of colonic involvement. Rectal bleeding is less common. Anorectal complications are fistulas, fissures, and perirectal abscess. Involvement of the small intestine can lead to steady and localized right lower quadrant pain; ileitis is fairly common. Physical examination may reveal right lower quadrant tenderness with an associated fullness or mass. Patients may also have mild anemia, leukocytosis, and an increased erythrocyte sedimentation rate.

Video Endoscopic Sequence 3 of 5.

 General clinical features of Crohn disease are fever,
 abdominal pain, diarrhea, and fatigability. Weight loss is
 also associated. Diarrhea and pain are the most common
 symptoms of colonic involvement. Rectal bleeding is less
 common. Anorectal complications are fistulas, fissures, and
 perirectal abscess. Involvement of the small intestine can
 lead to steady and localized right lower quadrant pain;
 ileitis is fairly common. Physical examination may reveal
 right lower quadrant tenderness with an associated fullness
 or mass. Patients may also have mild anemia, leukocytosis,
 and an increased erythrocyte sedimentation rate.

 
Intestinal obstruction is a frequent complication. In the initial stage, obstruction from edema and inflammation commonly in the ileum are reversible. As disease progresses, fibrosis develops, leading to decreasing diarrhea and more constipation and intractable obstruction from fixed luminal narrowing.

Video Endoscopic Sequence 4 of 5.

 Intestinal obstruction is a frequent complication. In the
 initial stage, obstruction from edema and inflammation
 commonly in the ileum are reversible. As disease
 progresses, fibrosis develops, leading to decreasing
 diarrhea and more constipation and intractable obstruction
 from fixed luminal narrowing.

 
Fistula formation is common and can cause indolent abscess, malabsorption, cutaneous fistula, persistent urinary tract infection, or pneumaturia. Although uncommon, free intestinal perforation can occur as a result of transmural involvement of the disease. Extraintestinal manifestation of Crohn disease includes oral aphthous ulcer, erythema nodosum, osteomalacia, and anemia due to chronic malabsorption; osteonecrosis due to chronic steroid therapy; gallstone formation due to ileal involvement of disease leading to poor bile salt reabsorption; oxalate kidney stones due to colonic disease; pancreatitis due to sulfasalazine, mesalamine, azathioprine, or 6-mercaptopurine therapy; bacteria overgrowth due to surgical resection; and miscellaneous manifestations such as amyloidosis, thromboembolic complications, hepatobiliary disease, and primary sclerosing cholangitis.

Video Endoscopic Sequence 5 of 5.

 Fistula formation is common and can cause indolent
 abscess, malabsorption, cutaneous fistula, persistent
 urinary tract infection, or pneumaturia. Although
 uncommon, free intestinal perforation can occur as a result
 of transmural involvement of the disease.

 Extraintestinal manifestation of Crohn disease includes
 oral aphthous ulcer, erythema nodosum, osteomalacia, and
 anemia due to chronic malabsorption; osteonecrosis due to
 chronic steroid therapy; gallstone formation due to ileal
 involvement of disease leading to poor bile salt
 reabsorption; oxalate kidney stones due to colonic disease;
 pancreatitis due to sulfasalazine, mesalamine, azathioprine,
 or 6-mercaptopurine therapy; bacteria overgrowth due to
 surgical resection; and miscellaneous manifestations such
 as amyloidosis, thromboembolic complications,
 hepatobiliary disease, and primary sclerosing cholangitis.

 

Comparisons of various factors in Crohn's disease and
 ulcerative colitis.

 

Crohn's disease

Ulcerative colitis

 

Terminal ileum  involvement

Commonly

Seldom

Rectum involvement

Seldom

Usually

Involvement around the anus

Common

Seldom

Bile duct involvement

No increase in rate of primary sclerosisng cholangitis

Higher rate

Distribution of Disease

Patchy areas of inflammation (Skip lesions)

Continuous area of inflammation

Endoscopy

Deep geographic and serpiginous (snake-like) ulcers

Continuous ulcer

Depth of inflammation

May be transmural, deep into tissues

Shallow, mucosal

Fistula

Common

Seldom

Stenosis

Common

Seldom

Autoimmune disease

Widely regarded as an autoimmune disease

No consensus

Cytokine response

Associated with Th1T helper cell

Vaguely associated with Th2

Granulomas on biopsy

Can have granulomas

Granulomas uncommon

Surgical cure

Often returns following removal of affected part

Usually cured by removal of colon

Smoking

Higher risk for smokers

Lower risk for smokers

 
Crohn´s Colitis, Multiple small aphthous erosions (1 to 2 mm) with erythematous rims. This 36 year-old male, Swedish it had arrived at El Salvador by vacations, has antecedent of long evolution to suffer from abdominal pain, diarrhea with occasions with mucus and some periods of fever.

Video Endoscopic Sequence 1 of 3.

Crohn´s Colitis

Multiple small aphthous erosions (1 to 2 mm) with erythematous rims.

 This 36 year-old male,  Swedish it had arrived at El
 Salvador by vacations, has antecedent of long evolution to
 suffer from abdominal pain, diarrhea with occasions with
 mucus and some periods of fever.
Terminal Ileum shows tiny red spot with scanty fibrinoid areas.

Video Endoscopic Sequence 2 of 3.

Terminal Ileum shows tiny red spot with scanty fibrinoid areas.

 

 
All the length of the colon shows multiple small aphthous erosions.

Video Endoscopic Sequence 3 of 3.

All the length of the colon shows multiple small aphthous erosions.