Esophagitis. El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 

Stricture of the gastroesophageal Junction due to longstanding heartburn.

Video Endoscopic Sequence 1 of 2.

 Stricture of the gastroesophageal Junction due to
 long standing heartburn.

 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.

 

 

 For more endoscopic details, download the video clip by
 clicking on the endoscopic image. Wait to be downloaded
 complete then Press Alt and Enter for full screen. All
 endoscopic images shown in this Atlas contain video clips.
 We recommend seeing the video clips in full screen mode.

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.

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.

 

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.

Video Endoscopic Sequence 1 of 7.

 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.

 

                                           

 

                                       Medline. 

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

Video Endoscopic Sequence 2 of 7.

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

 

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

 

Another image of the enormous ulcer.

Video Endoscopic Sequence 3 of 7.

 Another image of the enormous ulcer.

 Medline: Gastroesophageal reflux disease: then and now.



 
 

This ulcer has a pseudo diverticulum appearance.

Video Endoscopic Sequence 4 of 7.

 This ulcer has a pseudo diverticulum appearance.






                                           Medline.

The antrum has many erosions with necrotic margins.

Video Endoscopic Sequence 5 of 7.

The antrum has many erosions with necrotic margins

The pre-piloric antrum. Several erosions are appreciated.

Video Endoscopic Sequence 6 of 7.

 The pre-piloric antrum. Several erosions are observed





 

The duodenal bulb has multiple erosions.

Video Endoscopic Sequence 7 of 7.

 The duodenal bulb has multiple erosions.

 

Severe Reflux Esophagitis and  Hiatal Hernia.    This 80 year-old lady, who had a severe and long-standing GERD.

Video Endoscopic Sequence 1 of 4.

 Severe Reflux Esophagitis and Hiatal Hernia.

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

 

 

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 2 of 4.

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. 

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.

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

SevereEsophag4

Video Endoscopic Sequence 4 of 4.

Lugol´s Stain.

 

RefluxDivertzxcv1

Video Endoscopic Sequence 1 of 2.

Reflux Esophagitis with a pseudo diverticulum

RefluxDivertzxcv2

Video Endoscopic Sequence 2 of 2.

 Endoscopy of Reflux Esophagitis with a
 pseudo diverticulum.

Reflux esophagitis with a esophageal squamous cell papilloma. A 53 year-old male with long standing reflux disease, this upper endoscopy was the first one that he ever had.

Video Endoscopic Sequence 1 of 10.

 Reflux esophagitis with a esophageal squamous cell
 papilloma.

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


 

Erosions with whitish exudate involving the longitudinal folds and extending into the valley between folds. A esophageal squamous cell papilloma is appreciated.

Video Endoscopic Sequence 2 of 10. 

 Erosions with whitish exudate involving the longitudinal
 folds and extending into the valley between folds. A
 esophageal squamous cell papilloma is observed.

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 3 of 10.

 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.

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

Video Endoscopic Sequence 4 of 10

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

 

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 5 of 10.

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.   

 

High resolution magnifying endoscopy with chromoendoscopy using methylene blue. The multi-lobulated squamous papilloma is appreciated 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 6 of 10.

 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.

Another view of the Esophageal squamous cell papilloma.

Video Endoscopic Sequence 7 of 10.

  Another view of the Esophageal squamous cell papilloma

High resolution magnifying endoscopy with chromoendoscopy using methylene blue.

Video Endoscopic Sequence 8 of 10.

 High resolution magnifying endoscopy with
 chromoendoscopy using methylene blue.


 

 

 

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 9 of 10.

 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.

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

Video Endoscopic Sequence 10 of 10.

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


 

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 the lesion and the length of time it has been present, but most likely will require control of reflux, and may also include relative voice rest, and/or surgery and voice therapy. Surgery by itself, without other measures, will often result in the regrowth of the lesion in a short period of time.

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 the
 lesion and the length of time it has been present, but most
 likely will require control of reflux, and may also include
 relative voice rest, and/or surgery and voice therapy.
 Surgery by itself, without other measures, will often result
 in the regrowth of the lesion in a short period of time. 

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

Video Endoscopic Sequence 2 of 2.

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

 

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

                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 reflux 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.

                                          Medline.  

Severe Esophagitis. Is appreciated by the presence of several, confluent erosions and whitish exudate on the mucosa. A hiatal hernia is observed (video clip). Esophagitis is a common medical condition usually caused by gastroesophageal reflux. Less frequent causes includeinfectious esophagitis (in patients who are immunocompromised), radiation esophagitis, and esophagitis from direct erosive effects of ingested medication or corrosive agents

Severe Esophagitis

 Is observed by the presence of several, confluent erosions
 and whitish exudate on the mucosa. A hiatal hernia is
 observed (video clip).

 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 the high relapse 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.

Severe Reflux Esophagitis.

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

 The most frustrating aspect of GERD treatment is the
 high relapse 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. Gastric 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 Barrett Esophagus.

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.
 Gastric 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

 Barrett Esophagus.
                                           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.

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.

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.

        
 

Mild Esophagitis. Is appreciated by the presence of severe non confluent red streaks just above the esophagogastric junction.

Mild Esophagitis.

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

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.

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.
        

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

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.

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.                            Extensive and coalescing ulceration. The ulcers are long and extend well above of the esophagogastric junction. 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.

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.  

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 2 of 2.

 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.

 

 Medline. Review article: oesophageal complications and
 consequences of persistent gastro-oesophageal reflux
 disease.
 

Hemorrhagic Esophagitis due to alcoholic beverages. An 80 year-old male presents 3 months of having hiccups patient has been drinking alcoholic beverages for several years.

Video Endoscopic Sequence 1 of 4.

 Hemorrhagic Esophagitis due to alcoholic beverages.

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

 

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

Video Endoscopic Sequence 2 of 4.

Hemorrhagic Esophagitis.

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

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

Video Endoscopic Sequence 3 of 4.

Hemorrhagic Esophagitis.

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

 Hemorrhagic Esophagitis. The image displays the cardias with multiple ulcers.

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.