El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Gastric Ulcer with Gastrocolic fistula due to a Zollinger- Ellison syndrome. A 64 year-old man that that presented a history of  weight loss of 26 pounds with several upper gastrointestinal hemorrhages. The patient had twoprevious upper endoscopies elsewhere that apparentlyreport as chronic ulcer of duodenal bulb and another one in a national public hospital. This image was thought to be a Gastric Carcinoma,the biopsies taken by endoscopy did not revel maligntissue. The patient had surgery due to obstructive symptoms and in suspicion of  malignacy but the surgical finding and pathological finding did not reveal cancer. At surgery, the ulcer was found to be penetrating into Transverse colon with fistula. A Billroth II gastrectomy was performed with partial resection of transverse colon. At that time we did not know that the patient had ZE syndrome. GASTRINA 3.460.00   PICOG/ML. normal=  0.01-100. After the surgery the patient has many episodic of esophageal obstructing at the cardias that needed to be dilated by  endoscopic procedure.

Video Endoscopic Sequence 1 of 33.

 Gastric Ulcer with Gastrocolic fistula due to a Zollinger-
 Ellison Syndrome.

 A 64 year-old man that that presented a history of
 weight loss of 26 pounds with several upper
 gastrointestinal hemorrhages. The patient had two
 previous upper endoscopies elsewhere that apparently
 report as chronic ulcer of duodenal bulb and another one in
 a national public hospital.
 This image was thought to be a Gastric Carcinoma,
 the biopsies taken by endoscopy did not show malign
 tissue. The patient had surgery due to obstructive
 symptoms and in suspicion of malignancy but the
 surgical finding and pathological finding did not reveal
 cancer.
 At surgery, the ulcer was found to be penetrating into
 Transverse colon with fistula. A Billroth II gastrectomy
 was performed with partial resection of transverse colon.
 At that time we did not know that the patient had ZE
 syndrome.

 later studies revealed:
 GASTRINA 3.460.00  PICO G/ML. normal=  0.01-100.
 The cat scan displayed thickening of the head of the
 pancreas as it gives the suspicion us of being the
 gastrinoma that was confirm with nuclear study with
 radionuclide octreotide scanning (also known as
 somatostatin receptor scintigraphy or 111In pentetreotide
 SPECT).

 One month after the sub-total gastrectomy, patient suffer
 multiple times of peptic stenosis of the cardias, refractory
 to esophageal dilation, later in spite of that
underwent a
 distal esophagectomy, refractory esophageal
 stenosis reappeared, also refractory to multiple esophageal
 dilations, surgeons decide to perform a total
 gastrectomy keeping the tumor in the head of the pancreas.

 6 years later the patient has been stable but the gastrinoma
 in the head of the pancreas has grown enough with
 non-symptoms and no metastases, the gastrina has been
 elevated to 32.250.

 As a peculiar information is that the patient has his second wife
 pregnant in April 2008

 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.
                     
                                     

 

                                          Medline.      

Gastro-Colonic fistula due to Zollinger Ellison syndrome. Colonoscopy performed previously. Due to the medical history of the patient. We performed a colonoscopy found in the image and the video displayed above. Immediately after the colonoscopy, an  upper gastroscopy was performed.

Video Endoscopic Sequence 2 of 33.


 Gastro-Colonic fistula due to Zollinger Ellison Syndrome.


         Colonoscopy performed previously.


 Retrospectively we knew that this enlarged image of the
 transverse colon was part of the gastrocolonica fistula

 Due to the medical history of the patient. We performed
 a colonoscopy found in the image and the video displayed
 above. Immediately after the colonoscopy, an upper
 gastroscopy was performed.


 

The images and videos of this sequence display a big ulcer with a blood clot and obstructing of the antrum. This image at the beginning was diagnosed as gastric carcinoma.  The Zollinger-Ellison syndrome (ZES), characterized by severe  peptic ulcer disease, gastric acid hypersecretion, and non-beta islet cell tumors of the pancreas, was first described in 1955. It is now known that the potent gastric acid secretagogue proposed originally by Zollinger and Ellison is the heptadecapeptide gastrin. Although most gastrinomas occur sporadically, about 20%. The syndrome was first reported in 1955 by Zollinger and Ellison. The true incidence is unknown, but it has been estimated that it accounts for 0.1 to 1% of peptic ulcers. It may occur at any age, but the initial manifestations are most common between ages 20 and 50. The tumors are cancerous in 50 percent of the cases. They secrete a hormone called gastrin that causes the stomach to produce too much acid, which in turn causes stomach and duodenal ulcers (peptic ulcers). The ulcers caused by ZES are less responsive to treatment than ordinary peptic ulcers. What causes people with ZES to develop tumors is unknown, but approximately 25 percent of ZES cases are associated with a genetic disorder called multiple endocrine adenomatosis.(M.E.A.) Type I. This syndrome includes hyperplasia and/or tumors of the parathyroids,  pancreatic islets and pituitary. In addition, thyroid nodules, carcinoid tumors and  hyperplasia of the adrenal cortex have often been described in family members.

           Video Endoscopic Sequence 3 of 33.

 The images and videos of this sequence display a
 big ulcer with a blood clot and obstructing of the
 antrum. This image at the beginning was diagnosed as
 gastric carcinoma.
 The Zollinger-Ellison syndrome (ZES), characterized by
 severe
peptic ulcer disease, gastric acid hypersecretion,
 and non-beta islet cell tumors of the pancreas, was first
 described in 1955. It is now known that the potent gastric
 acid secretagogue proposed originally by Zollinger and
 Ellison is the heptadecapeptide gastrin. Although most
 gastrinomas occur sporadically, about 20%.
 The syndrome was first reported in 1955 by Zollinger and
 Ellison. The true incidence is unknown, but it has been
 estimated that it accounts for 0.1 to 1% of peptic ulcers.
 It may occur at any age, but the initial manifestations are
 most common between ages 20 and 50.
 The tumors are cancerous in 50 percent of the cases. They
 secrete a hormone called gastrin that causes the stomach
 to produce too much acid, which in turn causes stomach
 and duodenal ulcers (peptic ulcers). The ulcers caused by
 ZES are less responsive to treatment than ordinary peptic
 ulcers. What causes people with ZES to develop tumors is
 unknown, but approximately 25 percent of ZES cases are
 associated with a genetic disorder called multiple
 endocrine adenomatosis.(M.E.A.) Type I. This syndrome
 includes hyperplasia and/or tumors of the parathyroids,
 pancreatic islets and pituitary. In addition, thyroid nodules,
 carcinoid tumors and hyperplasia of the adrenal cortex
 have often been described in family members. The
 diagnosis of Zollinger-Ellison syndrome is made on
 the demonstration of high serum gastrin levels. Fasting
 gastrin levels in normals and in patients with ordinary
 duodenal ulcer average approximately 60 pg/ml. Patients
 with gastrinoma almost always have levels greater than
 150 pg/ml and not uncommonly greater than 1,000 pg/ml.
 The diagnosis is also suspected on the clinical history,
 marked acid hypersecretion, prominence of mucosal folds
 in the stomach, duodenum and sometimes jejunum or SR.
 It may be confirmed by several provocative tests involving
 measurement of serum gastrin levels in response to
 calcium infusion, secretin injection or a standard test meal.
 

Gastro-Colonic fistula. The images and the videos belong to the same patient  of the case described above with enormous ulcer that was  penetrating to the pancreas and fistula to the transverse colon.

Video Endoscopic Sequence 4 of 33.

Gastro-Colonic Fistula.

 The images and the videos belong to the same patient
 of the case described above with enormous ulcer that was
 penetrating to the pancreas and fistula to the transverse
 colon.

 

Gastric Ulcer with Gastrocolic fistula due to Zollinger-Ellison syndrome.  A close up of the ulcer.

Video Endoscopic Sequence 5 of 33.

 A close up to the ulcer.

 Gastric Ulcer with Gastrocolic fistula due to Zollinger-
 Ellison syndrome.        
 

Due to unusual colonoscopic image, We publish  several images and videos of this fistula. Some videos display bloody secretion.

Video Endoscopic Sequence 6 of 33.

 Due to unusual colonoscopic image. We published several
 images and videos of this fistula.

 Some videos display bloody secretion.

The antrum is obstructed, the histopathologic report did not find any malignancy.

Video Endoscopic Sequence 7 of 33.

 The antrum is obstructed, the histopathologic report
 did not find any malignancy.

 But an experienced endoscopist can think that these
 images can belong to a gastric neoplasia

 

 

    More details download the video clip.

 

Images and videos on a case of complicated ulcer with fistula to the transverse colon.

          Video Endoscopic Sequence 8 of 33.

 Images and videos on a case of complicated ulcer with
 fistula to the transverse colon.

 

Gastroesophageal Reflux Disease with the Zollinger-Ellison Syndrome.  Zollinger-Ellison Syndrome. Gastroesophageal Reflux Disease with the Zollinger-Ellison Syndrome. Peptic stenosis of the cardias in a patient that underwent a subtotal gastrectomy due to gastrocolic fistula and Zollinger-Ellison syndrome with gastric outlet obstruction. The endoscopic image of the endoscopy that we performed was of a gastric carcinoma but no malignancy was found with the patologist. (See the chapter gastric ulcer). Approximately one month after the surgery, the patient started to develop a dysphagia to solids and liquids. We suspected the Zollinger Ellizon syndrome due to the  aberrant clinical course. Multiple repeat esophageal dilation were performed. A esophageal  Z-stent was placed.

Video Endoscopic Sequence 9 of 33.

Zollinger-Ellison Syndrome.

 Gastroesophageal Reflux Disease with the
 Zollinger-Ellison Syndrome.
 Peptic stenosis of the cardias in a patient that underwent
 a subtotal gastrectomy due to gastrocolic fistula and
 Zollinger-Ellison syndrome with gastric outlet obstruction.
 The endoscopic image of the endoscopy that we performed
 was of a gastric carcinoma but no malignancy was found
 with the pathologist.

 Approximately one month after the surgery, the patient
 started to develop a dysphagia to solids and liquids.
 and subsequently developed esophageal stricture
 We suspected the Zollinger Ellizon syndrome due to the
 aberrant clinical course.
 Multiple repeat esophageal dilation were performed but the
 stenosis was refractory in spite of to have used proton
 pump inhibitors in high doses.

  Pubmed: The gastrinoma triangle: operative implications.

The image displays a narrowing in the gastroesophagic junction. Patients with MEN1 with Gastrinomas Have an Increased Risk of Severe Esophageal Disease Including Stricture, and the Premalignant Condition, Barrett's Esophagus.

Video Endoscopic Sequence 10 of 33.

 The image displays a narrowing in the gastroesophagic
 junction.

 Patients with MEN1 with Gastrinomas have an Increased
 Risk of Severe Esophageal Disease Including Stricture,
 and the Premalignant Condition, Barrett's Esophagus.

                                          Medline.

Some bands of tissue are observed, multiple biopsies were obtained.

Video Endoscopic Sequence 11 of 33.

 Some bands of tissue are observed, multiple biopsies
 were obtained. 

 

 

 

 

 

 

                                          Medline.  

A hydrostatic dilating balloon straddled across the stricture.  Under direct observation, the stricture is dilated.           Esophageal dilatation is a procedure for opening a blocked or constricted section of the esophagus. (The esophagus is a long tube, known colloquially as the gullet,  through which food passes on its way to the stomach.) The procedure is normally performed by passing bougies, or dilators, through the constricted section of the esophagus, in order to break the constricting tissues or stretch the narrowed section.

Video Endoscopic Sequence 12 of 33.

Esophageal Dilatation.

 A hydrostatic dilating balloon straddled across the stricture.
 Under direct observation, the stricture is dilated.

 Esophageal dilatation is a procedure for opening a blocked or
 constricted section of the esophagus. (The esophagus is a long
 tube, known colloquially as the "gullet," through which food
 passes on its way to the stomach.) The procedure is normally
 performed by passing bougies, or dilators, through the constricted
 section of the esophagus, in order to break the constricting tissues
 or stretch the narrowed section.

 

The stenosis was overcome, the anastomosis of subtotal gastrectomy is appreciated, see the video clip.

Video Endoscopic Sequence 13 of 33.

 The stenosis was overcome, the anastomosis of subtotal
 gastrectomy is appreciated, see the video clip. 

A long segment of the jejunum is observed in the video clip.

Video Endoscopic Sequence 14 of 33.

 A long segment of the jejunum is observed in the video clip.
     
 

The patient needed several endoscopic dilations that was performed in several days. Therefore the surgeon decided to perform a surgery,  cutting the distal segment of the esophagus but in spite of  the surgery the evolution was not satisfactory and multiple  dilations of the esophagus were carried out.

Video Endoscopic Sequence 15 of 33.

 The patient needed several endoscopic dilations that was
 performed in several days.
 Therefore the surgeon decided to perform a surgery,
 cutting the distal segment of the esophagus
 (distal esophagectomy resection) but in spite of
 the surgery the evolution was not satisfactory and multiple
 dilations of the esophagus were carried out.
 

Balloon dilation of esophageal stricture under direct endoscopic visualization. The Balloon dilatation is one from the therapeutic procedures of stenosis of the esophagus and the balloon dilatation of the therapeutic procedures of the choice in stenosis of the esophagus.

Video Endoscopic Sequence 16 of 33.

 Balloon dilation of esophageal stricture under direct
 endoscopic visualization.

 The Balloon dilatation is one from the therapeutic procedures of
 stenosis of the esophagus and the balloon dilatation of the
 therapeutic procedures of the choice in stenosis of the esophagus.
                        

                        Esophageal Dilation, Medline.
 

The image and the video displays the dilator has overcome the Acid Peptic Stricture due to Zollinger Ellison syndrome.

Video Endoscopic Sequence 17 of 33.

 The image and the video displays the dilator has overcome
 the Acid Peptic Stricture due to Zollinger Ellison syndrome.

Status post esophageal dilatation. This image displays a long segment with necrosis and  rest of silk of the previous surgery of the distal segment  of the esophagus.

Video Endoscopic Sequence 18 of 33.

 Status post esophageal dilatation.

 This image displays a long segment with necrosis and
 rest of silk of the previous surgery of the distal segment
 of the esophagus.

Another image and video of this status post esophageal  dilation. Necrosis and rest of silk threads is observed.

Video Endoscopic Sequence 19 of 33.

 Extensive ulceration of the distal esophagus.

 Another image and video of this status post esophageal
 dilation. Necrosis and rest of silk threads is observed.

A self-expanding 10 cm. Z-Stent.  Due to the aggressiveness of this disease and the repetition of the stenosis, we decided to place an esophageal stent.

Video Endoscopic Sequence 20 of 33.

 A self-expanding 10 cm. Z-Stent.

 Due to the aggressiveness of this disease and the
 repetition of the stenosis, we decided to place an
 esophageal stent.

Three days after the placement of the stent an endoscopy was carried out.

Video Endoscopic Sequence 21 of 33.

 Three days after the placement of the stent an endoscopy
 was carried out.

 Finally, Patient undergone a total gastrectomy keeping the
 tumor of the head of the pancreas where was the exact site
 of the gastrinoma, patient gain weight after six year remain
 stable.

Six year after the total gastrectomy the patient has been stable with no symptoms, the cat scan displays a large mass in the head of the pancreas with no metastases.

Video Endoscopic Sequence 22 of 33.

Computerized Tomography Scan.

 Six year after the total gastrectomy the patient has been
 stable with no symptoms, the cat scan displays
 a large mass in the head of the pancreas with no
 metastases the gastrina level has been elevated to 32.250.  

Gastrinomas are an integral part of the Zollinger-Ellison syndrome (ZES). In fact, ZES is also known as gastrinoma. This syndrome consists of ulcer disease in the upper gastrointestinal tract, marked increases in the secretion of gastric acid in the stomach, and tumors of the islet cells in the pancreas. The tumors produce large amounts of gastrin that are responsible for the characteristics of Zollinger-Ellison syndrome, namely severe ulcer disease. Although usually located within the pancreas, they may occur in other organs.

Video Endoscopic Sequence 23 of 33.

 Gastrinomas are an integral part of the Zollinger-Ellison
 syndrome (ZES). In fact, ZES is also known as gastrinoma.
 This syndrome consists of ulcer disease in the upper
 gastrointestinal tract, marked increases in the secretion of
 gastric acid in the stomach, and tumors of the islet cells in
 the pancreas. The tumors produce large amounts of
 gastrin that are responsible for the characteristics of
 Zollinger-Ellison syndrome, namely severe ulcer disease.
 Although usually located within the pancreas, they may
 occur in other organs.

 

Surgically, gastrinomas are often difficult to locate, even with careful inspection. They may be missed in at least 10?20% of patients with ZES. Gastrinomas are sometimes found only because they have metastasized and produced symptoms related to the spread of malignancy. Such metastasis may be the most reliable indication of whether the gastrinoma is malignant or benign,  Approximately half of all gastrinomas do not show up on imaging studies. Therefore, exploratory surgery is often recommended to try to locate and remove the tumors.

Video Endoscopic Sequence 24 of 33.

 Surgically, gastrinomas are often difficult to locate, even
 with careful inspection. They may be missed in at least
 10–20% of patients with ZES. Gastrinomas are sometimes
 found only because they have metastasized and produced
 symptoms related to the spread of malignancy. Such
 metastasis may be the most reliable indication of whether
 the gastrinoma is malignant or benign,

 Approximately half of all gastrinomas do not show up on
 imaging studies. Therefore, exploratory surgery is often
 recommended to try to locate and remove the tumors.

Diagnostic imaging techniques help locate the gastrinomas. The most sophisticated is radionuclide octreotide scanning (also known as somatostatin receptor scintigraphy or 111In pentetreotide SPECT.

Video Endoscopic Sequence 25 of 33.

 Diagnostic imaging techniques help locate the gastrinomas.
 The most sophisticated is radionuclide octreotide scanning
 (also known as somatostatin receptor scintigraphy or 111In
 pentetreotide SPECT.

 

The radiological detection of endocrine tumors of the pancreas poses a difficult challenge to the radiologist because of the small size of most of these tumors and frequently requires the combined use of different imaging modalities. However, important progress in the detection of these tumors by noninvasive means has been achieved bythe introduction of  CT and fast MRI and with the combined use of ultrasound, CT and MRI a sensitivity of more than 90% can nowadays be achieved.

Video Endoscopic Sequence 26 of 33.

 The radiological detection of endocrine tumors of the
 pancreas poses a difficult challenge to the radiologist
 because of the small size of most of these tumors and
 frequently requires the combined use of different imaging
 modalities. However, important progress in the detection of
 these tumors by noninvasive means has been achieved
 bythe introduction of CT and fast MRI and with the
 combined use of ultrasound, CT and MRI a sensitivity of
 more than 90% can nowadays be achieved.

Over 90% of gastrinomas are found within an anatomic triangle referred to as the gastrinoma triangle. The 3 points that define this region are: (1) the confluence of the cystic and common bile duct, (2) the junction of the second and third portions of the duodenum, and (3) the junction of the neck and body of the pancreas. Recent evidence suggests that gastrinomas occur at least as frequently in the duodenal wall as in the head of the pancreas within this triangle. Gastrinomas vary in size, ranging from 0.1 cm to more than 20 cm in diameter. In at least 50% of cases, these tumors are multiple. Less commonly, gastrinomas may be found in the hilum of the spleen, in the stomach, liver, or parapancreatic and mesenteric lymph nodes. A small number of ovarian tumors have been shown to be gastrinomas. Although up to two thirds of gastrinomas are malignant, it is difficult to determine on histologic appearance alone. Even when malignant, these tumors are slow growing. However, a small number of patients with gastrinomas have tumors that grow and metastasize rapidly. Patients with gastrinomas limited to lymph nodes tend to survive for long periods, often over 20 years, without tumor progression. The presence of liver metastases reduces life expectancy to about 8 years.

 Video Endoscopic Sequence 27 of 33.

 Over 90% of gastrinomas are found within an anatomic
 triangle referred to as the gastrinoma triangle. The 3 points
 that define this region are: (1) the confluence of the cystic
 and common bile duct, (2) the junction of the second and
 third portions of the duodenum, and (3) the junction of the
 neck and body of the pancreas. Recent evidence suggests
 that gastrinomas occur at least as frequently in the
 duodenal wall as in the head of the pancreas within this
 triangle. Gastrinomas vary in size, ranging from 0.1 cm to
 more than 20 cm in diameter. In at least 50% of cases,
 these tumors are multiple. Less commonly, gastrinomas
 may be found in the hilum of the spleen, in the stomach,
 liver, or parapancreatic and mesenteric lymph nodes. A
 small number of ovarian tumors have been shown to be
 gastrinomas. Although up to two thirds of gastrinomas are
 malignant, it is difficult to determine on histologic
 appearance alone. Even when malignant, these tumors are
 slow growing. However, a small number of patients with
 gastrinomas have tumors that grow and metastasize rapidly.
 Patients with gastrinomas limited to lymph nodes tend to
 survive for long periods, often over 20 years, without tumor
 progression. The presence of liver metastases reduces life
 expectancy to about 8 years.

 

The mean age at presentation is 45-50 years, and men are affected more often than women. Because of the rarity of the disease, the average interval between onset of symptoms and diagnosis is about 6 years. Most gastrinomas are malignant; therefore, a high index of suspicion remains key to proper and prompt management of the disease. Management is aimed at cure. ZES may present in one of several ways:

Video Endoscopic Sequence 28 of 33.

Clinical Features of ZES

 The mean age at presentation is 45-50 years, and men are
 affected more often than women. Because of the rarity of
 the disease, the average interval between onset of
 symptoms and diagnosis is about 6 years. Most
 gastrinomas are malignant; therefore, a high index of
 suspicion remains key to proper and prompt management
 of the disease. Management is aimed at cure. ZES may
 present in one of several ways:

 

Peptic ulcer disease: This disease is present in 90%-95% of patients with gastrinomas. Patients who are Helicobacter pylori infection-negative and have no history of nonsteroidal anti-inflammatory drug use may have ZES. Peptic ulcers associated with ZES tend to be more persistent and less responsive to therapy than those not associated with ZES. Ulcers occurring in the second, third, or fourth portions of the duodenum or the jejunum should alert one to the possibility of ZES, although a single ulcer in the duodenal bulb is the most common presentation. Gastroesophageal reflux disease complicated by ulcerations and strictures of the esophagus also tends to be more prevalent and more severe in patients with ZES.

Video Endoscopic Sequence 29 of 33.

Clinical Features of ZES

 Peptic ulcer disease: This disease is present in 90%-95%
 of patients with gastrinomas. Patients who are Helicobacter
 pylori
infection-negative and have no history of
 nonsteroidal anti -inflammatory drug use may have ZES.
 Peptic ulcers associated with ZES tend to be more
 persistent and less responsive to therapy than those not
 associated with ZES. Ulcers occurring in the second, third,
 or fourth portions of the duodenum or the jejunum should
 alert one to the possibility of ZES, although a single ulcer in
 the duodenal bulb is the most common presentation.
 Gastroesophageal reflux disease complicated by
 ulcerations and strictures of the esophagus also tends to be
 more prevalent and more severe in patients with ZES.

Diarrhea: This symptom may precede ulcer symptoms and is seen in over 30% of patients with gastrinoma Diarrhea results not only from gastric acid hypersecretion and subsequent activation of pepsinogens by the acid (which causes mucosal injury of the small intestine), but also from acid inactivation of pancreatic enzymes and the acid damage to enterocytes.

Video Endoscopic Sequence 30 of 33.

Clinical Features of ZES

Diarrhea: This symptom may precede ulcer symptoms and is seen in over 30% of patients with gastrinoma Diarrhea results not only from gastric acid hypersecretion and subsequent activation of pepsinogens by the acid (which causes mucosal injury of the small intestine), but also from acid inactivation of pancreatic enzymes and the acid damage to enterocytes.

 Steatorrhea: This defect occurs in part because inactivation of
 pancreatic lipase by intraluminal acid in the upper small intestine
 and the low pH environment render some primary bile acids
 insoluble, and thereby reduce the formation of micelles
 (which are necessary for fatty acid and monoglyceride absorption
 ). In addition, patients often have blunted villi and, in rare cases,
 totally flat mucosa with resultant malabsorption.

Vitamin B12 malabsorption: This deficiency may develop  because low intraluminal intestinal pH interferes with intrinsic factor-facilitated active absorption of vitamin B12 by the distal ileum.

Video Endoscopic Sequence 31 of 33.

Clinical Features of ZES

 Less frequently, ZES may present as:

 Vitamin B12 malabsorption: This deficiency may develop
 because low intraluminal intestinal pH interferes with intrinsic
 factor-facilitated active absorption of vitamin B12 by the distal
 ileum.  

More images of the Computerized Tomography Scan.

Video Endoscopic Sequence 32 of 33.

More images of the Computerized Tomography Scan.

TacPostZeGastrctomy12

Video Endoscopic Sequence 33 of 33.

More images of the Computerized Tomography Scan.

 

MRMetastasisGastrinoma1

 8 years after the tumor has metastasized to the liver

 

 To download the video clips, press on the images of these
 Magnetic resonance imaging (MRI)

 

 

MRMetastasisGastrinoma2

 To download the video clips, press on the images of these
 Magnetic resonance imaging (MRI).

MRMetastasisGastrinoma3

 To download the video clips, press on the images of these
 Magnetic resonance imaging (MRI)

MRMetastasisGastrinoma4

 To download the video clips, press on the images of these
 Magnetic resonance imaging (MRI)

MRMetastasisGastrinoma5

 To download the video clips, press on the images of these
 Magnetic resonance imaging (MRI)