Esophagus and Gastric Varices.   El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
SevereBleedingtVaricealTR1

Video Endoscopic Sequence 1 of 5.

 Severe Variceal Bleeding

 This 49 year-old alcoholic male, has had a history of
 alcoholism for more than thirty years. Two hours
 previously begun with severe upper GI bleeding, an
 emergency endoscopy was carry out without endotracheal
 intubation, this video clips shows a severe hemorrhage due
 to a rupture esophageal varix.

 See in YouTube Esophagus Gastric Varices Animation

 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.
 

SevereBleedingtVaricealTR2

Video Endoscopic Sequence 2 of 5.

 Acute variceal bleeding is a life-threatening complication in
 patients with portal hypertension. Although overall survival
 may be improving, mortality is still closely related to failure
 to control hemorrhage or early re-bleeding. Factors that
 influence this failure include severity of liver disease and
 active bleeding during endoscopy. In addition increased
 portal pressure has been proposed as a prognostic factor
 of early re-bleeding.

 

 See in YouTube Endoscopic Animation

SevereBleedingtVaricealTR3

Video Endoscopic Sequence 3 of 5.

 First we try to perform rubber bands ligation but
 Although the exact site of bleeding was identified, with the
 ligating apparatus it was more difficult to identify the
 bleeding, because this one darkens the visibility so
 sclerotherapy was used.

 We personally prefer the rubber band to sclerotherapy.

 Therapeutic aims in acute variceal bleeding The important
 point is to treat the patient and not just the source of
 bleeding. The specific aims are:

 Correct hypovolaemia; Stop bleeding as soon as possible;
 Prevent early rebleeding; Prevent complications associated
 with bleeding; Prevent deterioration in liver function.
.

 Follow in YouTube Gastrointestinal Endoscopy Animation

SevereBleedingtVaricealTR4

Video Endoscopic Sequence 4 of 5.

Endoscopic sclerotherapy

  • · Endoscopic sclerotherapy is successful in controlling acute esophageal variceal bleeding in up to 90% of patients. Hemorrhagic control should be obtained with 1-2 sessions. Patients continuing to bleed after 2 sessions should be considered for alternative methods to control their bleeding.
  • · In the United States, sodium tetradecyl sulfate or sodium morrhuate has generally been used as a sclerosant, whereas polidocanol or ethanolamine has been more popular in Europe. Variations in the technique or the sclerosant used have not been shown to influence the outcome.
  • · Serious complications related to sclerotherapy have been reported in 15-20% of patients, with an associated mortality rate of 2%.
  • · Complications of sclerotherapy may include mucosal ulceration, bleeding, esophageal perforation, mediastinitis, and pulmonary complications. Long-term complications, such as esophageal stricture formation, may also occur.
SevereBleedingtVaricealTR5

Video Endoscopic Sequence 5 of 5.

 After the bleeding was stopped the endoscope was
 advanced through the trachea and the bronchial tree in
 order to aspirate some blood that was aspirated during the
 hemorrhage.

 To avoid this, always whenever is possible, before
 the endoscopy should be performed carefully endotracheal
 intubation.

This is the case of a 49 year-old male with lgastro-esophageal varices secondary to alcoholic cirrhosis. Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients with cirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow through the liver is diminished. Thus, blood flow increases through the microscopic blood vessels within the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This dilation can be profound. The original diameter the of blood vessels is measured in millimetres while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in diameter.

Video Endoscopic Sequence 1 of 6.

 This is the case of a 49 year-old male with
 gastro-esophageal varices secondary to alcoholic cirrhosis.

 Esophageal varices are dilated blood vessels within the
 wall of the esophagus. Patients with cirrhosis develop
 Portal Hypertension. When Portal Hypertension occurs,
 blood flow through the liver is diminished. Thus, blood flow
 increases through the microscopic blood vessels within the
 esophageal wall. As this blood flow increases, the blood
 vessels begin to dilate. This dilation can be profound. The
 original diameter the of blood vessels is measured in
 millimeters while the final, fully established, esophageal
 varix may be 0.5 to 1.0 cm or larger in diameter.

 

 Endoscopic Image of Esophageal Varices, This patient has lager esophageal varices as well as gastric varices. These blood vessels then continue to dilate until they become large enough to rupture. When esophageal varices rupture, patients become acutely ill. In fact, 50 percent of patients with esophageal varices will eventually bleed from the varices. The mortality rate for esophageal variceal bleeding, on the first event, is between 40 and 70 percent. Mortality is due to multiple factors

Video Endoscopic Sequence 2 of 6.

 Endoscopic Image of Esophageal Varices

 This patient has lager esophageal varices as well as
 gastric varices.

 These blood vessels then continue to dilate until they
 become large enough to rupture. When esophageal varices
 rupture, patients become acutely ill. In fact, 50 percent of
 patients with esophageal varices will eventually bleed from
 the varices. The mortality rate for esophageal variceal
 bleeding, on the first event, is between 40 and 70 percent.
 Mortality is due to multiple factors.

 Esophageal varices are distended submucous veins that
 project into the esophageal lumen. They are part of the
 collateral circulation that develops between the portal vein
 and vena cava in response to portal hypertension. They
 develop from the plexus of esophageal veins that drain into
 the azygos and hemiazygos veins. They receive blood from
 the left gastric vein and its esophageal branches and also
 from the short gastric veins via the splenic vein.

Gastric Varices. Multiple large gastric varices can be seen in the gastric cardias and fundus. Varices are shown here in the gastric cardias, seen on retroflexion of the endoscope.

Video Endoscopic Sequence 3 of 6.

Gastric Varices.

Multiple large gastric varices can be seen in the gastric cardia and fundus.

 Concomitant fundic varices are associated with an
 increased risk of esophageal variceal bleeding

 Varices are shown here in the gastric cardia, seen on
 retroflexion of the endoscope.

Gastric varices can be a perplexing problem for gastroenterologists to manage. These vascular channels can be large and deep, and bleeding can be difficult to control

Video Endoscopic Sequence 4 of 6.

 Gastric varices can be a perplexing problem for
 gastroenterologists to manage. These vascular channels
 can be large and deep, and bleeding can be difficult to
 control.

 

Larger Gastric Varices of the Gastric Cardias.

Video Endoscopic Sequence 5 of 6.

Larger Gastric Varices of the Gastric Cardias.

See the chapter Gastric Varices

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. Esophageal varices are enlarged veins in the esophagus - usually the lower part of the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine and spleen to the liver.

Video Endoscopic Sequence 6 of 6.

This image as well as the video clip show the Red Wale Sign

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
  • Esophageal varices are enlarged veins in the esophagus — usually the lower part of the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine and spleen to the liver.

 “Red Wale” Sign: Endoscopy of a chain of varices in the
 distal esophagus showing erythematous raised areas
 indicating an increased risk of bleeding.

 

Endoscopy of Post sclerotherapy esophageal ulcer.  Severe persistent chest pain and pyrexia after sclerotherapy are clinical pointers of ulcerogenesis.

Video Endoscopic Sequence 1 of 2.

Endoscopy of Post Sclerotherapy Esophageal Ulcer.

 Severe persistent chest pain and pyrexia after
 sclerotherapy are clinical pointers of ulcerogenesis.

 

Another image and video clip.    Endoscopic ligation causes statistically fewer local complications than sclerotherapy and achieves variceal eradication more rapidly. Ligation is a viable alternative to sclerotherapy and may have some advantages as a treatment for bleeding esophageal varices. Endoscopic sclerotherapy is associated with various local and systemic complications that may limit its effectiveness. Therefore, endoscopic ligation was developed in an attempt to provide a treatment at least as effective as sclerotherapy but with fewer adverse side effects.

Video Endoscopic Sequence 2 of 2.

Endoscopy of Post Sclerotherapy Esophageal Ulcer.

 Endoscopic ligation causes statistically fewer local
 complications than sclerotherapy and achieves variceal
 eradication more rapidly. Ligation is a viable alternative to
 sclerotherapy and may have some advantages as a
 treatment for bleeding esophageal varices.

 Endoscopic sclerotherapy is associated with various local
 and systemic complications that may limit its effectiveness.
 Therefore, endoscopic ligation was developed in an attempt
 to provide a treatment at least as effective as sclerotherapy
 but with fewer adverse side effects

This 70 year-old female, presented an upper gastrointestinal bled due to Esophageal varix, six months previously had two sessions of Esophageal banding with six varices ligated each time.

Video Endoscopic Sequence 1 of 12.

 This 70 year-old female, presented an upper
 gastrointestinal bled due to esophageal varix, six months
 previously had two sessions of esophageal banding with six
 varices ligated each time.

This image shows a blood clot where identify the site of the bleeding.

Video Endoscopic Sequence 2 of 12.

This image shows a blood clot where identify the site of the bleeding.

 

 

The gastric camera has rest of blood.

Video Endoscopic Sequence 3 of 12.

The gastric camera has rest of blood.

 

After careful examination the bleeding has been reactivated.

Video Endoscopic Sequence 4 of 12.

 After careful examination, the bleeding has been reactivated.

Red brilliant blood is emerging from the site of the hemorrhage observed in the GI junction.

Video Endoscopic Sequence 5 of 12.

Red brilliant blood is emerging from the site of the hemorrhage observed in the GI junction.

To localize the exact site some vigorous washing with water  is performed, the next video clips were taken with the double channel therapeutical endoscope.

Video Endoscopic Sequence 6 of 12.

 To localize the exact site some vigorous washing with water
 is performed, the next video clips were taken with the
 double channel therapeutical endoscope that perform a
 better suction of the blood.      

This image and the video clip shows the exact site of this hemorrhage.

Video Endoscopic Sequence 7 of 12.

This image and the video clip shows the exact site of this hemorrhage.

In order to stop the hemorrhage, the argon plasma coagulator is being used.   Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series.

Video Endoscopic Sequence 8 of 12.

Efficacy of argon plasma coagulation in variceal upper gastrointestinal bleeding.

In order to stop the hemorrhage, the argon plasma coagulator is being used. The catheter of the argon
 plasma coagulator is observed that will initiate the
 therapeutical approach.

 Endoscopic variceal ligation is an established procedure
 for eradication of esophageal varices. However, varices
 frequently recur after endoscopic variceal ligation. Argon
 plasma coagulation has been used as supplemental
 treatment for eradication of varices and for prevention of
 variceal recurrence in small uncontrolled series.

 

Various methods of endoscopic hemostasis for esophageal varices have been described, sclerotherapy, rubber band ligation, hemoclips etc.

Video Endoscopic Sequence 9 of 12.

Various methods of endoscopic hemostasis for esophageal varices have been described, sclerotherapy, rubber band ligation, hemoclips etc.

 

Efficacy of argon plasma coagulation in variceal bleeding.

Video Endoscopic Sequence 10 of 12.

Efficacy of argon plasma coagulation in variceal bleeding.

 

The varix was successfully coagulated.

Video Endoscopic Sequence 11 of 12.

The varix was successfully coagulated.

This image shows the status post coagulation of the varix.     The hemorrhage has been stopped.

Video Endoscopic Sequence 12 of 12.

This image shows the status post coagulation of the varix.
The hemorrhage has been stopped.

An 83 year-old, non-alcoholic female that had an upper gastrointestinal hemorrhage. Esophageal varices are dilated blood vessels within the  wall of the esophagus. Patients with cirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow through the liver is diminished. Thus, blood flow increases through the microscopic blood vessels within the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This dilation can be profound. The original diameter of the blood vessels is measured in  millimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in diameter.

Video Endoscopic Sequence 1 of 4.

 An 83 year-old, non-alcoholic female that had an upper
 gastrointestinal hemorrhage. 
 
 Esophageal varices are dilated blood vessels within the
 wall of the esophagus. Patients with cirrhosis develop
 Portal Hypertension. When Portal Hypertension occurs,
 blood flow through the liver is diminished. Thus, blood flow
 increases through the microscopic blood vessels within the
 esophageal wall. As this blood flow increases, the blood
 vessels begin to dilate. This dilation can be profound. The
 original diameter of the blood vessels is measured in
 millimeters while the final, fully established, esophageal
 varix may be 0.5 to 1.0 cm or larger in diameter.
 Bleeding varices are a life-threatening complication of
 portal hypertension (increased blood pressure in the portal
 vein caused by liver disease). Increased pressure causes
 the veins to balloon outward. The vessels may rupture,
 causing vomiting of blood and bloody stools or tarry black
 stools. If a large volume of blood is lost, signs of shock will
 develop. Any cause of chronic liver disease can cause
 bleeding varices.

 

 Endoscopic Image of Esophageal Varices. Esophageal varices the venous structures are tortuous  in appearance.  The best predictor of variceal hemorrhage is the size of the varices. Several studies have shown that large varices are more likely to bleed than small one.

Video Endocopic Sequence 2 of 4.

 Endoscopic Image of Esophageal Varices

 Sequences of images and videos of a case on esophageal
 varices.

 Esophageal varices the venous structures are tortuous
 in appearance. 
 The best predictor of variceal hemorrhage is the
 size of the varices. Several studies have shown that large
 varices are more likely to bleed than small one
.

Small Varices of the epiglottis. Same patient as described  above.

Video Endoscopic Sequence 3 of 4.

 Small Varices of the epiglottis. Same patient as described
 above.


 
 

Large tortuous varices with red color sign. Cherry red spots are signs of imminent hemorrhage.

Video Endoscopic Sequence 4 of 4.

 Large tortuous varices with red color sign.
 Cherry red spots are signs of imminent hemorrhage.

Classification of gastroesophageal varices.

Esophageal.

 Small, straight.
 Enlarged, tortuous; occupy less than one third of the lumen.
 Large, coil-shaped; occupy more than one third of the
 lumen.

Gastric.

 In continuity with esophageal varices.
 Along lesser curve (2 to 5 cm long).
 Along greater curve extending toward the fundus Isolated
 In the fundus.
 Elsewhere in the stomach.

 String of Pearls   Varices of the Esophagus.  Portal hypertension must be present with pressures more of 12 mm Hg or greater in order for varices to develop. However the level of pressure elevation does not correlate with the risk of rupture.

“ String of Pearls “ Varices of the Esophagus.

 Portal hypertension must be present with pressures more
 of 12 mm Hg or greater in order for varices to develop.
 However the level of pressure elevation does not correlate
 with the risk of rupture. 

 Nonbleeding esophageal varices are asymptomatic. Rarely
 they are detected incidentally, but in most cases they are
 found during the work-up of liver diseases and occasionally
 in patients with acute upper gastrointestinal bleeding.

 Bleeding. The most serious complication of esophageal
 varices is acute bleeding. Approximately 30% of all
 patients with varices have an episode of variceal bleeding.
 The mortality rate is 30− 40%. The risk of rebleeding after
 an initial bleeding episode is 70%.

 

 Endoscopic Image of Esophageal Varices.  Hematocystic spots are seen that are stigmata of recent hemorrhage. A 61 year-old woman that was under hepatic transplant program in a United States Hospital. She returned to her country El Salvador, and the same day that she arrived, she was hospitalized because of her first hemorrhage.

 Endoscopic Image of Esophageal Varices

 Hematocystic spots are seen that are stigmata of recent
 hemorrhage.
 A 61 year-old woman that was under hepatic transplant
 program in a United States Hospital. She returned to her
 country El Salvador, and the same day that she arrived, she
 was hospitalized because of her first hemorrhage.

 85 year-old man with esophageal varices. Due to alcoholic cirrhosis. A variety of factors affect the prognosis of a patient with variceal bleeding. Patients with alcoholic cirrhosis usually have a poor prognosis, with few 5-year survivors irrespective of treatment. On the other hand, complete abstinence from alcohol can improve the prognosis and result in both lowering of portal pressure and reduction in the size of the varices. The main causes of portal hypertension can be classified anatomically: pre hepatic (portal vein thrombosis), hepatic (mainly cirrhosis, schistosomiasis and rarer causes) and post hepatic (Budd-Chiari and rarer causes).

 85 year-old man with esophageal varices.

Due to Alcoholic Cirrhosis.

 A variety of factors affect the prognosis of a patient with
 variceal bleeding. Patients with alcoholic cirrhosis usually
 have a poor prognosis, with few 5-year survivors
 irrespective of treatment. On the other hand, complete
 abstinence from alcohol can improve the prognosis and
 result in both lowering of portal pressure and reduction in
 the size of the varices.
 The main causes of portal hypertension can be classified
 anatomically: pre hepatic (portal vein thrombosis), hepatic
 (mainly cirrhosis, schistosomiasis and rarer causes) and
 post hepatic (Budd-Chiari and rarer causes). 

Unique Varix of the Esophagus. Finding a isolated varix of the mild esophagus is without  portal hypertension and no clinical importance.

Unique Varix of the Esophagus.

 Finding a isolated varix of the mild esophagus is without
 portal hypertension and no clinical importance.
 

Variceal Bleeding. One of the most ominous complications of portal hypertension is hemorrhage from esophageal or gastric varices. Patients who bleed from varices have a poor long-term prognosis, irrespective of treatment and fewsurvive more than 5 years. In view of the prognosis of portal hypertensive bleeding, it is essential to have an urgent treatment of acute variceal bleeding and interval management, in order to prevent rebleeding.

Variceal Bleeding.

 One of the most ominous complications of portal
 hypertension is hemorrhage from esophageal or gastric
 varices. Patients who bleed from varices have a poor
 long-term prognosis, irrespective of treatment and few
 survive more than 5 years. In view of the prognosis of
 portal hypertensive bleeding, it is essential to have an
 urgent treatment of acute variceal bleeding and interval
 management, in order to prevent rebleeding.

VarixTotalGastrecto1

Video Endoscopic Sequence 1 of 5.

Esophagel Varices and Status Post Total Gastrectomy

This 63 year-old male underwent a total gastrectomy due to a gastric cancer

VarixTotalGastrecto2

Video Endoscopic Sequence 2 of 5.

 "Total gastrectomy may be indicated in treating extensive
 stomach malignancies. This radical procedure is not
 performed when carcinoma with distant metastasis to the
 liver or pouch of Douglas or seeding throughout the
 peritoneal cavity is present. It may be performed in
 association with the extirpation of adjacent organs, such as
 the spleen, body and tail of the pancreas, a portion of the
 transverse colon, and so forth. It is also the procedure of
 choice in controlling the intractable ulcer diathesis
 associated with non-beta islet cell tumors of the pancreas
 when pancreatic tumor or metastases remain that cannot be
 controlled medically".

VarixTotalGastrecto3

Video Endoscopic Sequence 3 of 5.

Jejuno-Jejuno Anastomosis

VarixTotalGastrecto4

Video Endoscopic Sequence 4 of 5.

Esophago Jejunostomy

VarixTotalGastrecto5

Video Endoscopic Sequence 5 of 5.

The Esophagus with some varices