El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Here, you can observe in the video clip an active arterial bleeding. We recommend seeing it in full screen mode. A 79-year-old female patient which had a bifemoral-aortic surgery (prosthesis) 25 days ago; a week before this procedure, she initiates with upper intestinal bleeding, with hematemesis, melenic stools, paleness and hypotension. She was hospitalized and a emergency endoscopy practiced by another college was performed after a series of ice cold gastric lavage. Due to the active bleeding, it was impossible to diagnose during this Endoscopy. 5 days later, after, the bleeding re-started and she received 4 blood transfusions. We then performed a new Endoscopy a day later and being more aggressive, we used the Therapeutic endoscope, with double channel and a more suction power. After a successful aspiration of the blood and good maneuvering, we were able to see the source of the bleeding.

Video Endoscopic Sequence 1 of 6.

         Dieulafoy´s Lesion (Exulceratio Simplex).

            You must see the video clip.

 Here, you can observe in the video clip an active arterial
 bleeding. We recommend seeing it in full screen mode.

 A 79-year-old female patient which had a bifemoral-aortic
 surgery (prosthesis) 25 days previously; a week before this
 procedure, she initiates with upper gastrointestinal
 bleeding, with hematemesis, melenic stools, paleness and
 hypotension.
 She was hospitalized and a emergency endoscopy practiced
 by another college was performed after a series of ice cold
 gastric lavage. Due to the active bleeding, it was impossible
 to diagnose during this endoscopy. 5 days later, after, the
 bleeding re-started, she received 4 blood transfusions.
 We then performed a new endoscopy a day later being
 more aggressive, we used the Therapeutic endoscope, with
 double channel with a more suction power. After a
 successful aspiration of the blood and good maneuvering,
 then we were able to see the source of the bleeding. 

 For more endoscopic details, download the video clips
 by clicking on the endoscopic images. 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.           

Dieulafoy´s Lesion (Exulceratio Simplex) In order to make hemostasis, we used the Argon Plasma Coagulator (APC). It is important to notice that we experienced technical difficulties with the APC which gave us electrical interference with the video. The are several options to treat this ulcer, such as endoclips, band ligation as use in esophageal varices, alcohol injection, etc.

Video Endoscopic Sequence 2 of 6.

Dieulafoy´s Lesion (Exulceratio Simplex)

 In order to make hemostasis, we used the Argon Plasma
 Coagulator (APC). It is important to notice that we
 experienced technical difficulties with the APC which gave
 us electrical interference with the video. The are several
 options to treat this ulcer, such as endoclips, band ligation
 as use in esophageal varices, alcohol injection, etc.
 For more information you can look for a similar case of
 Dieulafoy at the end of this chapter.
In this image and video you can observe the blood contents of the lesion. Dieulafoy, a French surgeon, described three cases in 1898, Dieulafoy called the lesion "exulceration simplex", because of its small size, and because of the large underlying artery which was normal on histological examination. The lesion has also been given other names: caliber-persistent artery, gastric arteriosclerosis, cirsoid aneurysm, and sub mucosal arterial malformation. Dieulafoy's lesion is inherently a difficult lesion to recognize, especially when bleeding is inactive. Nevertheless, it should be considered during the evaluation of any unexplained acute and recurrent major gastrointestinal bleeding.

Video Endoscopic Sequence 3 of 6.

 You can observe another image and video of the
 hemostasis performed by the Argon Plasma Coagulator
 (APC).

 Dieulafoy, a French surgeon, described three cases in
 1898, but the first case was in fact described by Gallard in
 1884. Dieulafoy called the lesion “exulceratio simplex”,
 because of its small size, and because of the large
 underlying artery which was normal on histological
 examination. The lesion has also been given other names:
 calibre-persistent artery, gastric arteriosclerosis, cirsoid
 aneurysm, and submucosal arterial malformation.
 Dieulafoy’s lesion is inherently a difficult lesion to
 recognise, especially when bleeding is inactive.
 Nevertheless, it should be considered during the evaluation
 of any unexplained acute and recurrent major
 gastrointestinal bleeding.
In this image and video you can observe the blood contents of the lesion.

Video Endoscopic Sequence 4 of 6.

 In this image and video you can observe the blood contents
 of the lesion.

 .
Final status of the exulceratio simplextreated with APC.

Video Endoscopic Sequence 5 of 6.

 Final status of the exulceratio simplextreated with APC.

 

 

 
Here you can observe part of the previous endoscopy practiced one day before where we almost discovered this lesion hidden beneath the blood clot.

Video Endoscopic Sequence 6 of 6.

 Here you can observe part of the previous endoscopy
 practiced one day before where we almost discovered this
 lesion hidden beneath the blood clot.

Dieulafoy´s Lesion (Exulceratio Simplex). A 70 year-old female, who was hospitalized due to gastrointestinal hemorrhage. The image and video displaying here is a small ulceration in a gastric fold at the anterior wall of the proximal corpus.

Video Endoscopic Sequence 1 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex).

 A 70 year-old female, who was hospitalized due to
 gastrointestinal hemorrhage. 
 The image and video displaying here is a small ulceration
 in a gastric fold at the anterior wall of the proximal corpus.   
       
Dieulafoy´s Lesion (Exulceratio Simplex). Dieulafoy´s Lesion is a vascular abnormality found almost exclusively in the proximal stomach that presents dramatically as acute and rapidly recurrent massive upper gastrointestinal hemorrhage when a small sub mucosal artery ruptures into the gastric lumen. Hemorrhage is caused by thrombosis and perforation of an abnormally large, tortuous sub mucosal artery in the center of a solitary 2- to 5-mm gastric mucosal erosion, surrounded by normal-appearing mucosa.

Video Endoscopic Sequence 2 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex).

 Dieulafoy´s Lesion is a vascular abnormality found
 almost exclusively in the proximal stomach that presents
 dramatically as acute and rapidly recurrent massive
 upper gastrointestinal hemorrhage when a small
 sub mucosal artery ruptures into the gastric lumen.
 Hemorrhage is caused by thrombosis and perforation of
 an abnormally large, tortuous sub mucosal artery in the
 center of a solitary 2- to 5-mm gastric mucosal erosion,
 surrounded by normal-appearing mucosa.
   
Dieulafoy´s Lesion (Exulceratio Simplex) A biopsy was taken, abnormal bleeding was noted. Dieulafoy´s varied endoscopic appearance includes active bleeding from a pinpoint mucosal defect, or a visible vessel containing adherent clot. Frequently, no endoscopic abnormalities are identified because of the small size of the lesion, the intermittent nature of its bleeding and the inability to visualize the bleeding point because of profuse hemorrhage. The diagnosis is often made only after repeated endoscopy or at the time of surgery or autopsy.

Video Endoscopic Sequence 3 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex)

 A biopsy was taken, abnormal bleeding was noted.
 Dieulafoy´s varied endoscopic appearance includes active
 bleeding from a pinpoint mucosal defect, or a visible vessel
 containing adherent clot.
 Frequently, no endoscopic abnormalities are identified
 because of the small size of the lesion, the intermittent
 nature of its bleeding and the inability to visualize the
 bleeding point because of profuse hemorrhage.
 The diagnosis is often made only after repeated endoscopy
 or at the time of surgery or autopsy.
  

Dieulafoy´s Lesion (Exulceratio Simplex). The image and the video clip displays bleeding which should be cleaned. Although reports from the pre-endoscopic era suggested a mortality rate of up to 80% more recent series report mortality in less than 30% of cases.

Video Endoscopic Sequence 4 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex).

 The image and the video clip displays bleeding
 which should be cleaned.
 Although reports from the pre-endoscopic era suggested a
 mortality rate of up to 80% more recent series report
 mortality in less than 30% of cases.

 
Dieulafoy´s Lesion (Exulceratio Simplex). Maneuvers of cleaner was made due to bleeding. Bleeding originates within 5 to 6 cm of the esophagogastric junction in 80% of cases.

Video Endoscopic Sequence 5 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex).

 Maneuvers of cleaner was made due to bleeding.
 Bleeding originates within 5 to 6 cm of the esophagogastric
 junction in 80% of cases.

Dieulafoy´s Lesion (Exulceratio Simplex). Therapeutical endoscopy using the argon plasma coagulator (APC). Therapeutic endoscopy has been used successfully, and is now the modality of choice for the initial treatment of Dieulafoy lesions Endoscopic modalities used include bipolar electrocoagulation, monopolar electrocoagulation, injection sclerotherapy, heater probe, laser photocoagulation, epinephrine injection, haemoclipping and banding. The injection of epinephrine has been used in combination with other modalities, as a means to slow or stop bleeding and allow better visualisation of the lesion and successful treat-ment. The specific therapeutic modality used seems to depend on the availability and personal experience with a particular technique. Endoscopic therapy is said to be successful in achieving permanent haemostasis in 85% of cases.

          Video Endoscopic Sequence 6 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex).

 Therapeutical endoscopy using the argon plasma
 coagulator (APC).
 Therapeutic endoscopy has been used successfully, and is
 now the modality of choice for the initial treatment of
 Dieulafoy lesions
 Endoscopic modalities used include bipolar
 electrocoagulation, monopolar electrocoagulation, injection
 sclerotherapy, heater probe, laser photocoagulation,
 epinephrine injection, haemoclipping and banding. The
 injection of epinephrine has been
 used in combination with other modalities, as a means to
 slow or stop bleeding and allow better visualisation of the
 lesion and successful treat-ment. The specific therapeutic
 modality used seems to depend on the availability and
 personal experience with a particular technique.
 Endoscopic therapy is said to be successful in achieving
 permanent haemostasis in 85% of cases.
. Of the remaining 15% in whom re-bleeding occurs, 10% can
 successfully be treated by repeat endoscopic therapy and 5%
 may ultimately require surgical intervention Other studies have
 reported a higher success rate with endoscopic treat-ment, and
 significant decline of the need for laparotomy for both diagnosis
 and treatment. It must be emphasised, however, that an
 experienced endoscopist and a reasonable selection of
 therapeutic instruments are essential to achieve a high success
 rate. A Dieulafoy lesion can easily be over-looked, as
 concomitant lesions such as ulcers or varices, may wrongly be
 considered responsible for the bleeding episode. Angiography
 may also be used therapeutically by gelfaom embolisation.This
 type of treatment is usually reserved for patients who are not
 amenable to endoscopic therapy and are poor surgical
 candidates, if bleeding is still active.

Dieulafoy´s Lesion (Exulceratio Simplex). Therapeutical endoscopy using the argon plasma coagulator (APC). The image and the video display the argon plasma coagulator beam inside of this lesion.

Video Endoscopic Sequence 7 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

 Therapeutical endoscopy using the argon plasma
 coagulator (APC).
 The image and the video display the argon plasma
 coagulator beam inside of this lesion.

Dieulafoy´s Lesion (Exulceratio Simplex). Therapeutical endoscopy using the argon plasma coagulator (APC).

Video Endoscopic Sequence 8 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

 More images and videos of therapeutical endoscopy using
 the argon plasma coagulator (APC).

Dieulafoy´s Lesion (Exulceratio Simplex). Therapeutical endoscopy using the argon plasma coagulator (APC). The image is observed blurred due to smoke.

Video Endoscopic Sequence 9 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

 Therapeutical endoscopy using the argon plasma
 coagulator (APC).
 The image is observed blurred due to smoke.
                                            
                                             
Dieulafoy´s Lesion (Exulceratio Simplex). Therapeutical endoscopy using the argon plasma coagulator (APC). Final status post argon plasma coagulation treatment.

Video Endoscopic Sequence 10 of 11.

        Dieulafoy´s Lesion (Exulceratio Simplex).
 
 Therapeutical endoscopy using the argon plasma
 coagulator (APC).
 Final status post argon plasma coagulation treatment.
 
 
Dieulafoy´s Lesion (Exulceratio Simplex). This picture and the video was taken 2 weeks after the procedure with argon plasma. Status post treatment is observed. The video displays a large submucosal vessel. The rupture of a submucosal persistent-caliber artery, named after the famous 19th century French surgeon as Dieulafoy?s lesion, is now a well-recognized cause of non-variceal upper gastrointestinal bleeding.

Video Endoscopic Sequence 11 of 11.

Dieulafoy´s Lesion (Exulceratio Simplex).

 This picture and the video was taken 2 weeks after the
 procedure with argon plasma. Status post treatment is
 observed. The video displays a large submucosal vessel.
 
 The rupture of a submucosal persistent-caliber artery,
 named after the famous 19th century French surgeon as
 Dieulafoy’s lesion, is now a well-recognized cause of
 non-variceal upper gastrointestinal bleeding.

 
Dieulafoy´s Lesion (Exulceratio Simplex). A 44 year-male, who was hospitalized in the emergency room of Rosale´s Hospital in the republic of El Salvador (Public Hospital) because of hematemesis and melenas. In that hospital an upper endoscopy was performed and two unit of blood was transfused, tree days after was discharged from the hospital and the same day visit our unit were a new endoscopy was performed here displayed.

Video Endoscopic Sequence 1 of 9.

Dieulafoy´s Lesion (Exulceratio Simplex).

 A 44 year-male, who was hospitalized in the emergency
 room of Rosale´s Hospital in the Republic of El Salvador
 (Public Hospital) because of hematemesis and melenas.
 In that hospital an upper endoscopy was performed and two
 unit of blood was transfused, three days after was
 discharged from the hospital, the same day visit our
 unit where a new endoscopy was performed here displayed.
 His hemoglobin was 8.0 gr/dl.  

We concluded that the bleeding became from this tiny ulceration in the proximal third of the gastric body. Similar lesions have also been described in the distal esophagus, small intestine, colon, and rectum. Awareness of the condition and experience in endoscopy are the mainstay of diagnosis. Therapeutic endoscopy is the first line of treatment. It is safe, effective and has very good long term results.

Video Endoscopic Sequence 2 of 9.

 We concluded that the bleeding became from this tiny
 ulceration in the proximal third of the gastric body.

 Similar lesions have also been described in the distal
 esophagus, small intestine, colon, and rectum. Awareness
 of the condition and experience in endoscopy are the
 mainstay of diagnosis. Therapeutic endoscopy is the first
 line of treatment. It is safe, effective and has very good
 long term results.

 
This tiny ulceración which this upholstered with a sanguineous clot. Dieulafoy?s lesion is an uncommon cause of gastrointestinal bleeding in which significant, and often recurrent, haemorrhage occurs from a pinpoint non-ulcerated arterial lesion

Video Endoscopic Sequence 3 of 9.

 This tiny ulceracion which this upholstered with a
 sanguineous clot.

 Dieulafoy’s lesion is an uncommon cause of gastrointestinal
 bleeding in which significant, and often recurrent,
 hemorrhage occurs from a pinpoint non-ulcerated arterial
 lesion.

 
This time we decided to treat this clinical entity with rubber bands. Three rubber bands were applied.

Video Endoscopic Sequence 4 of 9.

 This time we decided to treat this clinical entity with
 rubber bands.

Three rubber bands were applied.

 

 
Endoscopic injection therapy is another modality due to the ease of use, the safety profile, and effectiveness. The agents used include epinephrine, alcohol, ethanolamine, cyanoacrylate glue, polidocanol, thrombin, and hypertonic saline [13]. Hypertonic saline or a mixture of epinephrine and saline are the most commonly used agents and work by local tamponade or tamponade/local vasoconstriction, respectively.

Video Endoscopic Sequence 5 of 9.

 Endoscopic injection therapy is another modality due to the
 ease of use, the safety profile, and effectiveness. The
 agents used include epinephrine, alcohol, ethanolamine,
 cyanoacrylate glue, polidocanol, thrombin, and hypertonic
 saline. Hypertonic saline or a mixture of epinephrine and
 saline are the most commonly used agents and work by
 local tamponade or tamponade/local vasoconstriction,
 respectively.
The identification of high-risk stigmata of hemorrhage enables selective targeting of endoscopic therapy to lesions at high risk of rebleeding. Advances in technologies such as novel mechanical methods of hemostasis (eg, metallic clips), injection techniques (eg, cyanoacrylate injection), and the widening application of established endoscopic hemostatic techniques (eg, rubber-band ligation) to lesions offers the possibility of further improvements in the efficacy of endoscopic hemostasis.

Video Endoscopic Sequence 6 of 9.

 The identification of high-risk stigmata of hemorrhage
 enables selective targeting of endoscopic therapy to lesions
 at high risk of rebleeding. Advances in technologies such
 as novel mechanical methods of hemostasis (eg, metallic
 clips), injection techniques (eg, cyanoacrylate injection),
 and the widening application of established endoscopic
 hemostatic techniques (eg, rubber-band ligation) to lesions
 offers the possibility of further improvements in the
 efficacy of endoscopic hemostasis.
Multiple conventional methods for achieving hemostasis have been used effectively. These include thermal methods (such as monopolar/bipolar cautery), heater probe, injection therapy, combination injection/thermal therapy, and laser therapy (argon and neodymium-yttrium aluminum garnet [Nd:YAG]). Of these current methods, no one method or combination has been shown to be superior for hemostatic control.

Video Endoscopic Sequence 7 of 9.

 Multiple conventional methods for achieving hemostasis
 have been used effectively. These include thermal methods
 (such as monopolar/bipolar cautery), heater probe, injection
 therapy, combination injection/thermal therapy, and laser
 therapy (argon and neodymium-yttrium aluminum garnet
 [Nd:YAG]). Of these current methods, no one method or
 combination has been shown to be superior for hemostatic
 control.

Endoscopic thermal coagulation is most often administered with monopolar, bipolar, or multipolar heater probes and laser. Monopolar, bipolar, multipolar, and heater probes work by coagulating and coapting the blood vessels supplying the mucosa. Physical compression and tamponade of the vessel are essential to ensure optimal effectiveness of this modality.

Video Endoscopic Sequence 8 of 9.

 Endoscopic thermal coagulation is most often administered
 with monopolar, bipolar, or multipolar heater probes and
 laser. Monopolar, bipolar, multipolar, and heater probes
 work by coagulating and coapting the blood vessels
 supplying the mucosa. Physical compression and
 tamponade of the vessel are essential to ensure optimal
 effectiveness of this modality.

 
In this image as well as the video clip, the final status of ligation is displayed.

Video Endoscopic Sequence 9 of 9.

In this image as well as the video clip, the final status of
ligation is displayed.

 
DiulafoysXZ1

Video Endoscopic Sequence 1 of 8.

This 84 year-old lady who 3 week previously undergone a hip surgery due to a fracture, presented an upper gastrointestinal tract hemorrhage with hematemesis and melena.

The image and the video clips show a large blood clot in the lower third of the esophagus.

 
More images and video clips.

Video Endoscopic Sequence 2 of 8.

More images and video clips.
DiulafoysXZ3

Video Endoscopic Sequence 3 of 8.

 
Active bleeding due to Dieulafoy´s Lesion , The retroflexed image shows an ulcer with a large vessel in the proximal body. Approximately 75% to 95% of Dieulafoy lesions are found within 6 cm of the gastroesophageal junction, predominantly on the lesser curve. The blood supply to that portion of the stomach is from a large submucosal artery arising directly from the left gastric artery. Lesions of similar morphological and histological features have been found in the distal esophagus, the duodenal bulb the jejunum the colon and the rectum.

Video Endoscopic Sequence 4 of 8.

Active bleeding due to Dieulafoy´s Lesion 

 The retroflexed image shows an ulcer with a large vessel in
 the proximal body, Approximately 75% to 95% of
 Dieulafoy lesions are found within 6 cm of the
 gastroesophageal junction, predominantly on the lesser
 curve. The blood supply to that portion of the stomach is
 from a large submucosal artery arising directly from the
 left gastric artery. Lesions of similar morphological and
 histological features have been found in the distal
 esophagus, the duodenal bulb the jejunum the colon and the
 rectum.
The upper gastrointestinal bleeding by Dieulafoy?s lesion is a rare cause of bleeding, it is a massive hemorrhage and it is difficult to diagnose. Endoscopy is the diagnostic method of choice, in many cases are necessary repeated examinations. Therapeutic endoscopy is the first line of treatment. It is safe, effective and has very good long term results.

Video Endoscopic Sequence 5 of 8.

 The upper gastrointestinal bleeding by Dieulafoy’s lesion is
 a rare cause of bleeding, it is a massive hemorrhage and it
 is difficult to diagnose. Endoscopy is the diagnostic method
 of choice, in many cases are necessary repeated
 examinations.
 Therapeutic endoscopy is the first line of treatment. It is
 safe, effective and has very good long term results.

DiulafoysXZ6

Video Endoscopic Sequence 6 of 8.

Immediately a hemostasis was carry out with absolute alcohol injection. 
PATHOGENESIS , he consensus seems to be that it is caused by an abnormally large-calibre persistent tortuous submucosal artery. This has been demonstrated by histological examination of resected specimens and by postmortem examinations.

Video Endoscopic Sequence 7 of 8.

PATHOGENESIS

 The consensus seems to be that it is caused by an
 abnormally large-calibre persistent tortuous submucosal
 artery. This has been demonstrated by histological
 examination of resected specimens and by postmortem
 examinations.

 
Successful treatment of a gastric Dieulafoy's lesion with absolute alcohol. Endoscopic therapy is said to be successful in achieving permanent haemostasis in 85% of cases. Of the remaining 15% in whom re-bleeding occurs, 10% can successfully be treated by repeat endoscopic therapy and 5% may ultimately require surgical intervention.

Video Endoscopic Sequence 8 of 8.

Successful treatment of a gastric Dieulafoy's lesion with absolute alcohol.

 Endoscopic therapy is said to be successful in achieving
 permanent hemostasis in 85% of cases. Of the remaining
 15% in whom re-bleeding occurs, 10% can successfully be
 treated by repeat endoscopic therapy and 5% may
 ultimately require surgical intervention