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

 

UlcerGiantStanley1

Video Endoscopic Sequence 1 of 11.

Giant Gastric Ulcer

 This 75 year-old male, who was referred to our endoscopic
 unit to evaluate, adynamia, anorexia and nauseas, had
 been with , aspirin, antihypertensives drugs and
 oral hypoglycemic agents.

 Multiple biopsies were taken to ruled out malignancy,
 finding Helicobacter Pyloris. Given treatment with
 Proton-pump inhibitors (PPIs) for six weeks, but not at this
 moment to Helicobacter Pyloris, practicing new endoscopy
 finding the scar of ulcer.

 See this video clip in YouTube

 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.

UlcerGiantStanley2

Video Endoscopic Sequence 2 of 11.

 The giant stomach ulcer can be defined as a crater
 measuring more than 30 mm in diameter. This variety of
 stomach ulcer represents 10-15% of the whole range of
 gastric ulcers, but they are not quite different from the
 nosologic point of view. It appears effectively that no
 etiopathogenic clinical or evolving particular factors can
 distinguish this kind of ulcer from the niches of normal size.

 See Endoscopic Animation concerning Gastric Ulcers in
 YouTube.

 

                                          Pubmed

UlcerGiantStanley3

Video Endoscopic Sequence 3 of 11.

Multiple biopsies were obtained from different angles showing no malignancy.
 

Peptic ulcer disease (PUD) is a common problem.

 Data from the pre-H. pylori, pre-proton pump inhibitor (PPI)
 era provide important to insights into the natural history of
 PUD. Untreated, peptic ulcers have a widely variable
 natural history]. Some heal spontaneously, but recur within
 months or sometimes within a year or two.

 Other ulcers cause complications or remain refractory
 despite antisecretory therapy. The patient's prior ulcer
 history tends to predict future behavior; those with a
 history of complications have an increased risk of future
 complications. Ulcers that take longer to heal initially are
 more likely to recur rapidly and ulcers that have recurred
 frequently are likely to continue to do so, unless the
 underlying cause (eg, H. pylori or nonsteroidal
 antiinflammatory drugs [NSAIDs]) is removed. A long
 duration of symptoms prior to presentation is more likely
 to be associated with a poor response to medical therapy.

 See in YouTube: Endoscopic Animation
 

UlcerGiantStanley4

Video Endoscopic Sequence 4 of 11.

 Giant gastric ulcer is uncommon. Patients are more
 seriously ill than those with smaller ulcers. 

 Distal antral ulcers, especially prepyloric ulcers (within 2 to
 3 cm of the pylorus), may have a different pattern of
 healing than ulcers at or proximal to the incisura because
 of different levels of acid secretion and the distribution of
 gastritis. Many studies did not analyze gastric ulcers by
 location, and available data are conflicting. Nevertheless,
 prepyloric ulcers appear to heal more slowly and may be
 more likely to recur.

 Giant ulcers are marked by higher operative mortality and
 the late-term results of surgical treatment of these patients
 yield to those in cases of usual gastric ulcers. Giant ulcers
 occur most frequently in the elderly.

UlcerGiantStanley5

Video Endoscopic Sequence 5 of 11.

 More biopsies of ulcer edges

 Treatment of H. pylori in infected individuals dramatically
 alters the incidence of ulcer relapse. In a meta-analysis
 that included 14 studies, duodenal ulcers recurred in fewer
 than 10 percent of patients successfully treated for H.
 pylori compared with 65 to 95 percent of those who
 remained infected. However, newer data from the United
 States suggest that recurrences after successful H. pylori
 antibiotic treatment may be more frequent. By contrast,
 relapse is the rule in the absence of successful anti-H.
 pylori therapy.

UlcerGiantStanley6

Video Endoscopic Sequence 6 of 11.

Another irregular area is observed at the incisura angularis biopsies were taken.

 Upper GI endoscopy has largely replaced upper GI barium
 x-ray series for the evaluation of upper GI tract disease
 or symptoms because it allows direct visualization,
 tissue acquisition, and therapeutic interventions.

UlcerGiantStanley7

Video Endoscopic Sequence 7 of 11.

In the gastric fundus shows an ulcerated nodule, also some biopsies were obtained.

 The gastric ulcer are staged, by using of the endoscopic staging system of Sakita, into 3 stages (active, healing, scarring) as follows.

 Stages

Manifestation
 Active stage

 A1 The surrounding mucosa is edematously swollen and
 no regenerating epithelium is seen endoscopically
 A2 The surrounding edema has decreased, the ulcer
 margin is clear, and a slight amount of regenerating
 epithelium is seen in the ulcer margin. A red halo in the
 marginal zone and a white slough circle in the ulcer margin
 are frequently seen. Usually, converging mucosal folds can
 be followed right up to the ulcer margin

 Healing stage

 H1 The white coating is becoming thin and the
 regenerating epithelium is extending into the ulcer base.
 The gradient between the ulcer margin and the ulcer floor
 is becoming flat. The ulcer crater is still evident and the
 margin of the ulcer is sharp. The diameter of the mucosal
 defect is about one-half to twothirds that of A1
 H2 The defect is smaller than in H1 and the regenerating
 epithelium covers most of the ulcer floor. The area of white
 coating is about a quarter to one-third that of A1 

 Scarring stage

 S1 The regenerating epithelium completely covers the
 floor of ulcer. The white coating has disappeared. Initially,
 the regenerating region is markedly red. Upon close
 observation, many capillaries can be seen. This is called
 ‘‘red scar’’
 S2 In several months to a few years, the redness is
 reduced to the color of the surrounding mucosa. This is
 called ‘‘white scar’’ 

UlcerGiantStanley8

Video Endoscopic Sequence 8 of 11.

In addition small ulcer in the gastric fundus

 In patients with NSAID-associated peptic ulcers,
 discontinuation of NSAIDs is paramount, if it is clinically
 feasible. For patients who must continue with their NSAIDs,
 proton pump inhibitor (PPI) maintenance is recommended
 to prevent recurrences even after eradication of H pylori.
 Prophylactic regimens that have been shown to
 dramatically reduce the risk of NSAID-induced gastric and
 duodenal ulcers include the use of a prostaglandin analog
 or a PPI. Maintenance therapy with antisecretory
 medications (eg, H2 blockers, PPIs) for 1 year is indicated
 in high-risk patients.

UlcerGiantStanley9

Video Endoscopic Sequence 9 of 11.

A follow up endoscopy was performed after six week of
 treatment, the scar was found.

Most peptic ulcers heal within 4 to 6 weeks of treatment.

 The recommended primary therapy for H pylori infection is
 proton pump inhibitor (PPI)–based triple therapy. These
 regimens result in a cure of infection and ulcer healing in
 approximately 85-90% of cases. Ulcers can recur in the
 absence of successful H pylori eradication.

UlcerGiantStanley10

Video Endoscopic Sequence 10 of 11.

 Gastric ulcers usually undergo a repeat endoscopy to
 ensure that the ulcer has healed and to ensure that the
 ulcer does not contain cancer cells.

 Most patients with PUD are treated successfully with cure
 of H pylori infection and/or avoidance of nonsteroidal
 anti -inflammatory drugs (NSAIDs), along with the
 appropriate use of antisecretory therapy.

UlcerGiantStanley11

Video Endoscopic Sequence 11 of 11.

 In this second endoscopy, multiple biopsies were obtained
 again , which also showed no malignancy. At this time the
 patient was prescribed with specific treatment for
 Helicobacter Pyloris.

UlceronaPerezx1

Video Endoscopic Sequence 1 of 8.

Gastric Ulcer

 Case of big gastric ulcers and multiple ulcers at the gastric
 antrum as well as duodenal bulb with multiple scars.

 67 year-old, male who was referred to our endoscopy unit
 to evaluate abdominal pain, nausea, vomiting and
 anorexia.

UlceronaPerezx2

Video Endoscopic Sequence 2 of 8.

More images and video clips

UlceronaPerezx3

Video Endoscopic Sequence 3 of 8.

Duodenal Ulcer

In this image as well as the video clip show the duodenal ulcer.

UlceronaPerezx4

Video Endoscopic Sequence 4 of 8.

 The antrum is deformed with inflammatory reaction
 around the ulcer.

 

UlceronaPerezx5

Video Endoscopic Sequence 5 of 8.

More images and video clips

UlceronaPerezx6

Video Endoscopic Sequence 6 of 8.

Multiple biopsies were obtained from all quadrants of the ulcer.

UlceronaPerezx7

Video Endoscopic Sequence 7 of 8.

This image shows the status after taking some biopsies

UlceronaPerezx8

Video Endoscopic Sequence 8 of 8.

 In the lesser curvature of pre-pyloric antrum, there is a scar and an ulcer in the bulb.

Endoscopic Image of Gastric Ulcer. This 76 year-old male smoker, presented nausea vomiting and non-specific abdominal pain at endoscopy displays a well circumscribed smooth, regular, rounded edge with a flat smooth base and surrounding mucosa.

Video Endoscopic Sequence 1 of 3.

Endoscopic Image of Gastric Ulcer.

 This 76 year-old male, smoker, presented nausea vomiting
 and non-specific abdominal pain at endoscopy displays a
 well circumscribed smooth, regular, rounded edge with a
 flat smooth base and surrounding mucosa.

 

 

Multiple biopsies were taken to ruled out malignancy.

Video Endoscopic Sequence 2 of 3.

Multiple biopsies were taken to ruled out malignancy.

 A gastric ulcer is a break in the normal tissue that lines the
 stomach.

 Ulcers develop when the normal defense and repair
 mechanisms of the lining of the stomach or duodenum are
 weakened, making the lining more likely to be damaged by
 stomach acid
.

 By far, the two most common causes of peptic ulcer are
 infection of the stomach with
Helicobacter pylori bacteria
 and use of certain drugs
.

Ulcer in red Scar. A follow up endoscopy was performed after six week of  treatment with PPI.  Smoking  Studies show smoking increases the chances of getting an ulcer, slows the healing process of existing ulcers, and contributes to ulcer recurrence.

Video Endoscopic Sequence 3 of 3.

Ulcer in red Scar

A follow up endoscopy was performed after six week of
 treatment with PPI.

Smoking
Studies show smoking increases the chances of getting an ulcer, slows the healing process of existing ulcers, and contributes to ulcer recurrence.

Four stages of gastric ulcer healing have been established by correlating endoscopic findings with those obtained from stereoscopic microscopy and histologic observations: I. initial healing stage; II. proliferative healing stage; III. palisade scar stage; IV. cobblestone scar stage. The palisade scar and cobblestone scar stages roughly correspond to Sakita's red and white scar stages, respectively. It is suggested that healing is not complete until the cobblestone stage with attendant micropit formation is achieved.

Case of multiple ulcers. A 76 year-old, female, presented with a three day history of melena without any abdominal pain. She had one episode of hematemesis (about 100 ml blood) in the emergency room, patient has a strong alcoholic drink abuse. An upper endoscopy with magnification was performed. multiple ulcers was detected across of the gastric camera, esophageal varices was also detected.

Video Endoscopic Sequence 1 of 10.

 Case of Multiple Ulcers.

 A 76 year-old, female, presented with a three day history
 of melena without any abdominal pain. She had one episode
 of hematemesis (about 100 ml blood) in the emergency
 room, patient has a strong alcoholic drink abuse.
 An upper endoscopy with magnification was performed.
 multiple ulcers was detected across of the gastric camera,
 esophageal varices was also detected.

 

The image displays a high magnification Endoscopy displaying one of the ulcers.

Video Endoscopic Sequence 2 of 10.

 The image displays a high magnification endoscopy
 displaying one of the ulcers.

 Symptoms of peptic ulcer disease include epigastric
 discomfort (specifically, pain relieved by food intake or
 antacids and pain that causes awakening at night or that
 occurs between meals), loss of appetite, and weight loss.
 Older patients and patients with alarm symptoms indicating
 a complication or malignancy should have prompt
 endoscopy.

The image and the video clip display several ulcers across of the entire stomach.

Video Endoscopic Sequence 3 of 10.

 The image and the video clip display several ulcers
 across of the entire stomach.

 For younger patients with no alarm symptoms, a
 test-and-treat strategy based on the results of H. pylori
 testing is recommended. If H. pylori infection is diagnosed,
 the infection should be eradicated and antisecretory
 therapy (preferably with a proton pump inhibitor) given for
 four weeks.

Retroflexed image shows multiple ulcers.

Video Endoscopic Sequence 4 of 10.

 Retroflexed image shows multiple ulcers.

 Surgery is indicated if complications develop.
 Administration of proton pump inhibitors and endoscopic
 therapy control most bleeds. Perforation and gastric outlet
 obstruction are rare but serious complications. Peritonitis
 is a surgical emergency.

 

A panoramic view of the gastric body, retroflexed image.

Video Endoscopic Sequence 5 of 10.

 A panoramic view of the gastric body, retroflexed image.

Chromoendoscopy using indigo carmin.

Video Endoscopic Sequence 6 of 10.

Chromoendoscopy using indigo carmine.

 

A close up of generative epithelium at the border of the  ulcer, magnifying image.

Video Endoscopic Sequence 7 of 10.

 A close up of generative epithelium at the border of the
 ulcer, magnifying image.

More images and video clips of multiple ulcers with indigo carmin stain.

Video Endoscopic Sequence 8 of 10.

 More images and video clips of multiple ulcers with indigo
 carmin stain.

Chromoendoscopy using lugolīs solution.

Video Endoscopic Sequence 9 of 10.

Chromoendoscopy using lugolīs solution.

In addition of multiple ulcers, patient shows esophageal  varices.

Video Endoscopic Sequence 10 of 10.

 In addition of multiple ulcers, patient shows esophageal
 varices.

Pre-Pyloric ulcer surrounding with regenerative epithelium.

Video Endoscopic Sequence 1 of 9.

 Pre-Pyloric ulcer surrounding with regenerative epithelium.
 

More evident the regenerative epithelium is observed, surrounding the ulcer using a magnifying endoscope. Recently, magnifying endoscope has been used clinically for its developments in amplifying power, definition and operational capability. Magnifying endoscopy is helpful for more correctly distinguishing hyperplastic lesions from adenomatous and cancerous lesions, and for improving detection of early flat and depressed cancer.

Video Endoscopic Sequence 2 of 9.

 More evident the regenerative epithelium is observed,
 surrounding the ulcer using a magnifying endoscope.
 Recently, magnifying endoscope has been used clinically
 for its developments in amplifying power, definition and
 operational capability.
 Magnifying endoscopy is helpful for more correctly
 distinguishing hyperplastic lesions from adenomatous and
 cancerous lesions, and for improving detection of early flat
 and depressed cancer
.

A magnifying close up. Magnifying endoscopy may have an obvious value in diagnosing chronic atrophic gastritis, intestinal metaplasia and H pylori infection .

Video Endoscopic Sequence 3 of 9.

 A magnifying close up.

 Magnifying endoscopy may have an obvious value in
 diagnosing chronic atrophic gastritis, intestinal metaplasia
 and H pylori infection.
 

Magnification chromoendoscopy dye- methylene blue. The new detailed images seen with magnifying chromoendoscopy are unequivocally the beginning of a new era where new optical developments will allow a unique look on cellular structures.

Video Endoscopic Sequence 4 of 9.

 Magnification chromoendoscopy dye-methylene blue.
 The new detailed images seen with magnifying
 chromoendoscopy are unequivocally the beginning of a new
 era where new optical developments will allow a unique
 look on cellular structures.
 

High-resolution chromoendoscopy.  Chromoendoscopy, the intravital staining of gastrointestinal epithelia, provides additional diagnostic information with respect to the epithelial morphology and pathophysiology. Based on experience gathered, chromoendoscopy is now in more widespread use, in particular to identify preneoplastic and neoplastic lesions.

Video Endoscopic Sequence 5 of 9.

 High-resolution chromoendoscopy.
 Chromoendoscopy, the intravital staining of gastrointestinal
 epithelia, provides additional diagnostic information with
 respect to the epithelial morphology and pathophysiology.
 Based on experience gathered, chromoendoscopy is now in
 more widespread use, in particular to identify preneoplastic
 and neoplastic lesions.
 

Another image and video clip, Chromoendoscopy with methylene blue. Tissue staining during endoscopy (chromoendoscopy) is a technique used to study the fine details of the mucosa throughout the gastrointestinal tract. Chromoendoscopy combines high resolution endoscopy with various methods of vital staining of epithelial structures. In these methods, during endoscopy, tissues are coloured by a stain introduced through a spray catheter. The staining techniques are technically simple, economical and easy to perform.

Video Endoscopic Sequence 6 of 9.

 Another image and video clip, Chromoendoscopy with
 methylene blue. Tissue staining during endoscopy
 (chromoendoscopy) is a technique used to study the fine
 details of the mucosa throughout the gastrointestinal tract.
 Chromoendoscopy combines high resolution endoscopy with
 various methods of vital staining of epithelial structures. In
 these methods, during endoscopy, tissues are coloured by a
 stain introduced through a spray catheter. The staining
 techniques are technically simple, economical and easy to
 perform.
 Various stains produce different optical effects. Contrast
 staining with indigo carmine fills folds, villi and other
 uneven areas and hence emphasises the structure. A
 different image is obtained by using absorptive stains such
 as methylene blue or Lugols solution which are directly
 taken up by the cells, thus staining them.

 An even more differentiated investigation is possible using
 zoom or magnification endoscopy. This uses special
 endoscopes capable of enlarging the endoscopic images up
 to 150 times. It does not take much imagination to predict a
 dynamic development of chromo- and zoom endoscopy
.

For more endoscopic features download the video clip by clicking on the endoscopic image.

Video Endoscopic Sequence 7 of 9.

 For more endoscopic features download the video clip.

  Multiple erosions are observed

Video Endoscopic Sequence 8 of 9.

 Multiple erosions are observed

Dye-Scattered picture (Methylene blue) multiple erosions are appreciated.

Video Endoscopic Sequence 9 of 9.

 Dye-Scattered picture (Methylene blue) multiple erosions
 are appreciated.

91 year old female presented epigastric pain, nauseas and vomiting for 3 months. The biopsies were benign.

Video Endoscopic Sequence 1 of 5.

Giant Gastric Ulcer.

 91 year old female presented epigastric pain, nauseas and
 vomiting for 3 months.

 The biopsies were benign.


 

Retroflexed image.

Video Endoscopic Sequence 2 of 5.

 Retroflexed Image.

 A peptic ulcer is a defect in the gastric or duodenal wall
 that extends through the muscularis mucosa
 (the lowermost limit of the mucosa) into the deeper layers
 of the wall (submucosa or the muscularis propria). Signs
 and symptoms of PUD include dyspepsia, GI bleeding,
 anemia, and gastric outlet obstruction. Dyspepsia is a
 nonspecific term denoting upper abdominal discomfort that
 is thought to arise from the upper GI tract. Dyspepsia is
 a common symptom, affecting 10% to 40% of the general
 population.4,5 Although the majority of patients with
 dyspeptic symptoms have functional dyspepsia for which no
 organic etiology can be identified, PUD is found in 5%
 to 15% of dyspeptic patients.

Posterior wall of the gastric corpus.

Video Endoscopic Sequence 3 of 5.

 Posterior wall of the gastric corpus.
 

Adenomatous polyp near of the giant ulcer.

Video Endoscopic Sequence 4 of 5.

 Adenomatous polyp near of the giant ulcer.

 

 

 See the video sequence of this polyps after six week of
 treatment, of that ulcer is appreciated with magnifying
 endoscopy with chromoscopy
.

 A follow up endoscopy was performed after six week of   treatment a scar was found.

Video Endoscopic Sequence 5 of 5.

 A follow up endoscopy was performed after six week of
 treatment, a scar was found.