El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Variceal hemorrhage. A 74 year-old female. Two months previous had her first episode of bledding due to esophageal varices, at that time six varices were ligated, the patient did not returned to her appoinment for a new session of variceal ligation.

Video Endoscopic Sequence 1 of 4.

Variceal Hemorrhage.

 A 74 year-old female. Two months previously had her first
 episode of bledding due to esophageal varices, at that
 time six varices were ligated, the patient did not returned
 to her appoinment for a new s
ession of variceal ligation.

 Each endoscopic image of this atlas has a video clip

 

Another image and video of the site of bled, two scars are observed of the previous treatment.  Bleeding from the varices in the region of the gastroesophageal junction is a life threatening medical emergency usuallly occurring in the setting of cirrhosis and portal hypertension. The risk of bleeding is related to the degree of portal hypertension and variceal size. It often occurs without obvious precipitating cause.

Video Endoscopic Sequence 2 of 4.

 Endoscopy Shows the exact site of the bled

 Another image and video of the site of bled, two scars
 are observed
of the previous treatment.

 Bleeding from the varices in the region of the
 gastroesophageal junction is a life threatening medical
 emergency usually occurring in the setting of cirrhosis and
 portal hypertension. The risk of bleeding is related to the
 degree of portal hypertension and variceal size. It often
 occurs without obvious precipitating cause. The usual
 presentation is massive hematemesis with or without
 melena. However, many patients with varices bleed from
 other lesions such as peptic ulcers or gastritis.

Endoscopic application of rubber band onto the bleeding site.   Technique uses a device attached to the tip of the endoscope that allows the varix to be suctioned into a banding chamber, whereupon an elastic band is then deployed around the base of the captured varix. After 3 to 7 days the ligated tissue sloughs, leaving a shallow ulceration with scar tissue.

Video Endoscopic Sequence 3 of 4.

 Endoscopic application of rubber band onto the bleeding
 site.

 
Technique uses a device attached to the tip of the
 endoscope that allows the varix to be suctioned into a
 banding chamber, whereupon an elastic band is then
 deployed around the base of the captured varix.
 After 3 to 7 days the ligated tissue sloughs, leaving a
 shallow ulceration with scar tissue.

The varix was successfully ligated. Endoscopic variceal ligation is associated with lower rebleeding rates and a lower frequency of esophageal strictures. Fewer sessions are required to achieve variceal obliteration when compared to sclerotherapy. Endoscopic variceal ligation is considered the endoscopic treatment of choice in the prevention of rebleeding. Sessions are repeated at 7- to 14-day intervals until variceal obliteration (usually 2-4 sessions).

Video Endoscopic Sequence 4 of 4.

The varix was successfully ligated.

 Endoscopic variceal ligation is associated with lower
 rebleeding rates and a lower frequency of esophageal
 strictures. Fewer sessions are required to achieve variceal
 obliteration when compared to sclerotherapy. Endoscopic
 variceal ligation is considered the endoscopic treatment of
 choice in the prevention of rebleeding. Sessions are
 repeated at 7- to 14-day intervals until variceal obliteration
 (usually 2-4 sessions).

 

This endoscopic sequence displays another videos and  images of variceal banding some video clips and images are appreciated using a magnifying endoscope.     A 56 year-old female, 3 weeks previously was hospitalized due her second upper gastrointestinal bleeding due esophageal varices, a that time we ligated 6 varices. The image and the video shows the statust post ligation.

Video Endoscopic Sequence 1 of 11.

 Endoscopy of Variceal ligation

 This endoscopic sequence displays more videos and
 images of variceal banding some video clips and images
 are appreciated using a magnifying endoscope.
 A 56 year-old female, 3 weeks previously was hospitalized
 due her second upper gastrointestinal bleeding due
 esophageal varices, a that time we ligated 6 varices.
 The image and the video clip show the status post ligation.

The images and the video clips display some varices that have been ligated and some post ligated ulceration.

Video Endoscopic Sequence 2 of 11.

 The images and the video clips display some varices that
 have been ligated and some post ligated ulceration.

The image displays several scar with fibrin at the cardias The portal venous system, formed by the confluence of the superior mesenteric vein and the splenic vein ( drains the stomach, the large and small intestine, the pancreas, and the spleen. An important feature of this system is that a number of its tributaries also communicate with the systemic circulation. These include the intrinsic and extrinsic veins of the gastroesophageal junction; hemorrhoidal veins of the anal canal; paraumbilical veins and the recanalized falciform ligament; the splenic venous bed and the left renal vein; and the retroperitoneum.  In portal hypertension, these venous collaterals dilate and allow portal venous blood to return to the systemic circulation.  Clinically, the most significant collaterals are the intrinsic veins of the gastroesophageal junction, which are located close to the mucosal surface. They are the collaterals most likely to bleed when dilated because of increased blood flow.

Video Endoscopic Sequence 3 of 11.

 The image displays several scar with fibrin at the cardias.
 
The portal venous system, formed by the confluence of the
 superior mesenteric vein and the splenic vein ( drains the
 stomach, the large and small intestine, the pancreas, and the
 spleen. An important feature of this system is that a number
 of its tributaries also communicate with the systemic
 circulation. These include the intrinsic and extrinsic veins of
 the gastroesophageal junction; hemorrhoidal veins of the
 anal canal; paraumbilical veins and the recanalized falciform
 ligament; the splenic venous bed and the left renal vein; and
 the retroperitoneum.
 In portal hypertension, these venous collaterals dilate and
 allow portal venous blood to return to the systemic
 circulation.
 Clinically, the most significant collaterals are the intrinsic
 veins of the gastroesophageal junction, which are located
 close to the mucosal surface. They are the collaterals most
 likely to bleed when dilated because of increased blood flow.

A esophageal varix that was ligated seen with magnifying.

Video Endoscopic Sequence 4 of 11.

 An esophageal varix that was ligated seen with magnifying.

Another varix appreciated with a magnifying endoscope.

Video Endoscopic Sequence 5 of 11.

 Another varix appreciated with a magnifying endoscope.

The video clip displays some varices that have been ligated as well as several scars with fibrin. (Post ligated status).

Video Endoscopic Sequence 6 of 11.

 The video clip displays some varices that have been ligated
 as well as several scars with fibrin. (Post ligated status).

More images and videos of this endoscopic sequence.

Video Endoscopic Sequence 7 of 11.

 More images and video clips of this endoscopic sequence. 
 Shallow ulcers at the site of each ligation are the rule and
 rarely bleed.

 

The image and the video clip displays one varix that has  been ligated as well as a status post banding (3 weeks)  retroflexed image.

Video Endoscopic Sequence 8 of 11.

 The image and the video clip displays one varix that has
 been ligated as well as a s
tatus post banding (3 weeks)
 retroflexed image.

It is essential to identify and treat those patients at highest risk because each episode of variceal hemorrhage carries a 20% to 30% risk of death, and up to 70% of patients who do not receive treatment die within 1 year of the initial bleeding episode.

Video Endoscopic Sequence 9 of 11.

 It is essential to identify and treat those patients at highest
 risk because each episode of variceal hemorrhage carries a
 20% to 30% risk of death, and up to 70% of patients who
 do not receive treatment die within 1 year of the initial
 bleeding episode.

One ulceration post varix ligation is appreciated.

Video Endoscopic Sequence 10 of 11.

 One ulceration post varix ligation is appreciated.

Risk factors for variceal bleeding.

Video Endoscopic Sequence 11 of 11.

 Risk factors for variceal bleeding.

 1. Portal pressure HVPG >12 mm Hg

 2. Varix size and location
 Large esophageal varices
 Isolated cluster of varices in fundus of stomach
 Variceal
 appearance on endoscopy ("red signs")
 Red wale marks (longitudinal red streaks on varices)
 Cherry-red spots (red, discrete, flat spots on varices)
 Hematocystic spots (red, discrete, raised spots)
 Diffuse erythema.          

 3. Degree of liver failure
            Child-Pugh class C cirrhosis
            Presence of ascites
            Tense ascites.

 Banding of Esophageal Varices. This endoscopic sequence displays multiple images and video clips concerning the technique of banding of esophageal varices. A 65 year-old female who ten years ago presented ascitis due to Ovarian carcinoma, for which she underwent chemotherapy. Apparently the carcinoma was overcome, and she had been asymptomatic ever since. Ten days previously to the endoscopy, the patient presented ascitis. A CAT scan confirmed the ascitis and micro nodular cirrhosis was detected. We found multiple varices when we performed an upper endoscopy, never had bleeding. Primary prophylaxis: Patients with cirrhosis who have esophageal varices but who have never had a bleeding episode may be treated medically or endoscopically. Without treatment, approximately 30% of cirrhotic patients with varices bleed and this risk is reduced by approximately 50% with therapy.

Video Endoscopic Sequence 1 of 19.

            Banding of Esophageal Varices.

 This endoscopic sequence displays multiple images and
 video clips concerning the technique of banding of
 esophageal varices.
 A 65 year-old female who ten years ago presented ascitis
 due to Ovarian carcinoma, for which she underwent
 chemotherapy.
 Apparently the carcinoma was overcamo, and she had been
 asymptomatic ever since. Ten days previously to the
 endoscopy, the patient presented ascitis. A CAT scan
 confirmed the ascitis and micro nodular
 cirrhosis was detected. We found multiple varices when
 we performed an upper endoscopy, never had bleeding.
 Primary prophylaxis: Patients with cirrhosis who have
 esophageal varices but who have never had a bleeding
 episode may be treated medically or endoscopically.
 Without treatment, approximately 30% of cirrhotic patients
 with varices bleed and this risk is reduced by approximately
 50% with therapy.

 Banding of Esophageal Varices. The cardias presents varices; some with the red sign. Studies of endoscopic therapy with ligation (endoscopic banding) demonstrate that in select patients (those with large varices), endoscopic banding may reduce the risk of first bleeding episode when compared with propranolol. Patients with large varices may benefit from a combination of banding with nonselective beta blockers. Secondary prophylaxis: After an initial variceal bleed, the risk of a second bleed is high and therapy is warranted to reduce the risk of rebleeding. The options are similar to those for primary prophylaxis.

Video Endoscopic Sequence 2 of 19.

 The cardias presents varices; some with the red sign.
 Studies of endoscopic therapy with ligation (endoscopic
 banding) demonstrate that in select patients (those with
 large varices), endoscopic banding may reduce the risk of
 first bleeding episode when compared with propranolol.
 Patients with large varices may benefit from a combination
 of banding with nonselective beta blockers. Secondary
 prophylaxis: After an initial variceal bleed, the risk of a
 second bleed is high and therapy is warranted to reduce the
 risk of rebleeding. The options are similar to those for
 primary prophylaxis.

 Banding of Esophageal Varices.Cardias in retroflexed view, there are many varices with the red sign, meaning that a possible bleeding was near. The combination of endoscopic therapy with medical therapy is the initial approach to prevent variceal rebleeding. Endoscopic banding is preferred to sclerotherapy because banding is associated with lower bleeding rates and fewer complications.

Video Endoscopic Sequence 3 of 19.

 Cardias in retroflexed view, there are many varices with
 the red sign, meaning that a possible bleeding was near
.

 The combination of endoscopic therapy with medical
 therapy is the initial approach to prevent variceal
 rebleeding. Endoscopic banding is preferred to
 sclerotherapy because banding is associated with lower
 bleeding rates and fewer complications.

 Banding of Esophageal Varices. Red brillant varices of the cardias are appreciated at the lower portion of the esophagus. The proceeded to do the banding of these varices. It is important to notice that if we do not proceed aggressively when we find this sign, a possible bleeding from this varices may be presented shortly.

Video Endoscopic Sequence 4 of 19.

 Red brillant varices of the cardias are appreciated at the
 lower portion of the esophagus. The proceeded to do the
 banding of these varices. It is important to notice that if we
 do not proceed aggressively when we find this sign, a
 possible bleeding from this varices may be presented
 shortly.

 Banding of Esophageal Varices. We can observe in the image and video the technique of banding of varices. We can see how the varix is suctioned and a rubber band is shot at the bottom. The patient complained from chest pain a day later

Video Endoscopic Sequence 5 of 19.

 We can observe in the image and video the technique of
 banding of varices. We can see how the varix is suctioned
 and a rubber band is shot at the bottom. The patient
 complained from chest pain a day later.

Through the banding apparatus several varices can  be  seen at the cardias.

Video Endoscopic Sequence 6 of 19.

 Through the banding apparatus several varices can be
 seen at the cardias.

 Banding of Esophageal Varices.         Another example of how the varix is succtioned and a band its placed.

Video Endoscopic Sequence 7 of 19.

 Another example of how the varix is succtioned and a band
 its placed.

 Banding of Esophageal Varices.           In this image and video we can observe another band placement and other varices already treated at the lower portion of the esophagus.

Video Endoscopic Sequence 8 of 19.

 In this image and video we can observe another band
 placement and other varices already treated at the lower
 portion of the esophagus
.

 Banding of Esophageal Varices.                                                                     In the video you can observe the varix already with its  band. Other varices with bands can also be seen.

Video Endoscopic Sequence 9 of 19.

 In the video you can observe the varix already with its
 band. Other varices with bands can also be seen
.

 Banding of Esophageal Varices.           You can observe the strangulated varix. Other varices with bands can be seen.

Video Endoscopic Sequence 10 of 19.

 You can observe the strangulated varix. Other varices with
 bands can be seen.

 Banding of Esophageal Varices.

Video Endoscopic Sequence 11 of 19.

 More images and video clips
 
 
Another image of the sequences that we have been
 discussing.

   A follow-up 8 days later.  The varices shown signs of necrosis.

Video Endoscopic Sequence 12 of 19.

 A follow-up 8 days later.

The varices shown signs of necrosis.

We demonstrate in this past sequence that banding of esophageal  varices is an effective method. Showing minor or no complications, it can be performed as the preferred method for prophylactic or therapeutical management of esophageal varices, especially when bleeding occurs.

Video Endoscopic Sequence 13 of 19.

 We demostrate in this past sequence that banding of
 esophageal varices is an effective method. Showing minor
 or no complications, it can be performed as the preferred
 method for prophylactic or therapeutical management of
 esophageal varices, especially when bleeding occurs. 
    

 Banding of Esophageal Varices.                    Gastric Cardias, retroflexed image, a necrotic ulceration of the varix is observed.

Video Endoscopic Sequence 14 of 19.

 Gastric Cardias, retroflexed image, a necrotic ulceration of
 the varix is observed.
 

Five months later a new banding of the esophageal varices  was performed and 6 varices were ligated. The image and the video clip display some scar of the previous treatment.

Video Endoscopic Sequence 15 of 19.

 Five months later a new banding of the esophageal varices
 was performed and 6 varices were ligated.
 The image and the video clip display some scar of the
 previous treatment.

Some varices of the cardias in retroflexed image.

Video Endoscopic Sequence 16 of 19.

 Some varices of the cardias in retroflexed image.

 The video clip displays a long tract of the esophagus displaying multiple varices.                                                                       The video clip displays a long tract of the esophagus displaying multiple varices.

Video Endoscopic Sequence 17 of 19.

 The video clip displays a long tract of the esophagus
 displaying multiple varices.

 Banding of Esophageal Varices.            Six varices were ligated at this time.

Video Endoscopic Sequence 18 of 19.

 Six varices were ligated at this time.

 Banding of Esophageal Varices. The image and the video display several scars are seen in this area of previous treatment and multiple varices were ligated Repeat banding is performed.

Video Endoscopic Sequence 19 of 19.

 The image and the video display several scars are seen in
 this area
of previous treatment and multiple varices were
 ligated.

 Repeat banding is performed.

 

Banding of Esophageal Varices. Narrow endoscopic view through the rubber band delivery attachment placed on the tip of the endoscope.  The variceal banding technique is similar to hemorrhoid banding and involves placing small elastic bands around varices in the distal 5 cm of the esophagus. Varices are suctioned into the banding device and bands are released around the base of the varix by pulling a trip wire via the biopsy channel. The advantages of band ligation over sclerotherapy include fewer local complications (secondary bleeding from ulcers or strictures), no systemic side effects, and the need for fewer treatments for variceal obliteration. Some of the drawbacks of band ligation include a restricted endoscopic view (due to the banding device and blood pooling within the hood mechanism), difficulty-performing treatments in the etroflexed position in the fundus of the stomach.

 Video Endoscopic Sequence 1 of 4.

Banding of Esophageal Varices.

 Narrow endoscopic view through the rubber band delivery
 attachment placed on the tip of the endoscope.
 The variceal banding technique is similar to hemorrhoid
 banding and involves placing small elastic bands around
 varices in the distal 5 cm of the esophagus. Varices are
 suctioned into the banding device and bands are released
 around the base of the varix by pulling a trip wire via the
 biopsy channel. The advantages of band ligation over
 sclerotherapy include fewer local complications (secondary
 bleeding from ulcers or strictures), no systemic side effects,
 and the need for fewer treatments for variceal obliteration.
 Some of the drawbacks of band ligation include a restricted
 endoscopic view (due to the banding device and blood
 pooling within the hood mechanism), difficulty-performing
 treatments in the retroflexed position in the fundus of the
 stomach.

Banding of Esophageal Varices.  Two neighboring esophageal varices, which have been successfully banded. Note the improved view through the clear multi-banding apparatus. Note the raised mucosal bleb (the varix) with a black band at the base.

Video Endoscopic Sequence 2 of 4.

Banding of Esophageal Varices.

 Two neighboring esophageal varices, which have been
 successfully banded. Note the improved view through the
 clear multi-banding apparatus. Note the
 raised mucosal bleb (the varix) with a black band at the
 base.

Banding of Esophageal Varices.

Video Endoscopic Sequence 3 of 4.

             Banding of Esophageal Varices.

Banding of Esophageal Varices. Multiple studies have demonstrated that variceal ligation has a remarkably low complication rate. A number of studies have been completed to compare the efficacy and safety of endoscopic sclerotherapy versus endoscopic variceal ligation. These studies demonstrate that ligation is equally as effective as sclerotherapy in achieving control of acute variceal bleeding. rebleeding and mortality are less after variceal ligation. Also, the number of procedures required to achieve obliteration of varices is less with variceal ligation than with sclerotherapy in nearly all comparative studies. Finally, complications, both minor and major, appear to be less with variceal ligation than sclerotherapy.

Video Endoscopic Sequence 4 of 4.

 Multiple studies have demonstrated that variceal ligation
 has a remarkably low complication rate.
 A number of studies have been completed to compare the
 efficacy and safety of endoscopic sclerotherapy versus
 endoscopic variceal ligation. These studies demonstrate
 that ligation is equally as effective as sclerotherapy in
 achieving control of acute variceal bleeding.
 
rebleeding and mortality are less after variceal ligation.
 Also, the number of procedures required to achieve
 obliteration of varices is less with variceal ligation than
 with sclerotherapy in nearly all comparative studies.
 Finally, complications, both minor and major, appear to be
 less with variceal ligation than sclerotherapy.