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Case Study

Male 60 yo, presented with dull aching intermittent pain in RUQ for 6 weeks. No fever or diarrhoea. Liver blood test showed ALT of 70 U/L, ALP 150 U/L, rest normal.  FBC showed neutrophilia.

Patient is retired for the last 5 years but used to own a dog rescue shelter. Drinks in excess about 25 units a week since retired. AFP and Ca 19,9 were normal. Serology for Entamoeba histolytica and Echinococcus were equivocal.

What next?

Click the image to see the answer >

Hydatid cyst type II: central cyst with daughter cyst(s). 10% can be seronegative. Key is contact with possible animal hosts (Dog or sheep), incubation period is often years.Amebiasis usually has a preceding history of diarrhoea and fecal-oral transmission. Albendazole 400 mg BD 4 weeks and given cyst is >5cm, consider PAIR therapy. Repeat serology (fluid aspiration has risk of rupture/ anaphylaxis (too risky just for diagnosis)
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GI QUIZ

Test your knowledge and challenge yourself with our interactive gastroenterology quiz!

10 random questions from our question bank, different everytime

Are you up for the challenge? Click below to start the quiz now!

1 / 10

For each 1% increase in adenoma detection rate (ADR) , there is a 3% reduction in CRC (colorectal cancer) incidence and a 5% reduction in cancer mortality

2 / 10

What is the minimum inspection time recommended by ESGE per cm of Barrett esophagus (BE) length during a surveillance endoscopy?

The incidence is variable and  depends on particular risk (the higher the fibrosis, the older the patient, persisting liver insult such as active alcohol or uncontrolled viral infection, and obesity)

Overall the risk is 1-8% , it is thought to be 2-3% per year in the US. Recent series report around 5% within1-2 years. See post

3 / 10

What is the overall yearly incidence of HCC (hepatocelullar carcinoma) in advanced chronic liver disease (ACLD)

4 / 10

We should biopsy Grade D reflux oesophagitis and repeat endoscopy in 3 months.

5 / 10

What is the percentage of variceal haemorrhage  that is not controlled or has early rebleeding despite treatment with vasoactive drugs plus variceal ligation?

6 / 10

Which one is the most common esophageal cancer worldwide?

7 / 10

84 yo female patient ,nursing home resident, admitted with diarrhoea 4-5 liquid stools a day over the last 6 days. White cells are 14000, CRP is 120mg/l  (normal <10), vitals and kidney function are stable. CT scan not performed. Colonoscopy done showed in the picture. What would be treatment recommended?

pseudomembranous colitis

8 / 10

Which Kudo pit pattern does this lesion present?

Your paragraph text 11

9 / 10

What is the abnormal cutoff of Fib 4 score in patients >65 yo?

10 / 10

We should offer ERCP and stone extraction to all fit patients with common bile duct stones, symptomatic or not

Your score is

The average score is 59%

0%

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Gallery

Mostly endoscopy, but without missing radiology or histology.  Images that capture the real-world experience in our GI day to day

Ampulla of Vater with previous sphincterotomy. The aim of cannulation should be at the apex (superior bit) of the ampulla.
Ampulla of Vater with previous sphincterotomy. The aim of cannulation should be at the apex (superior bit) of the ampulla.
Colon: Severe erythema, spontaneous oozing, purulent exudate and deep ulcerations, in keeping with Ulcerative Colitis Mayo score 3
Colon: Severe erythema, spontaneous oozing, purulent exudate and deep ulcerations, in keeping with Ulcerative Colitis Mayo score 3
Steatorrhea (Steato – fat , rrhea- flow) refers to the increase in fat excretion in faeces. This is usually a reflection of fat malabsorption that can happen in many conditions such as exocrine pancreatic insufficiency (EPI), celiac disease, and tropical sprue. Bile acid deficiency or malabsorption can also lead to low fat absorption. Here we can see fat droplets in a colonic remains. This usually floats and sticks in the pan when the patient open bowels and can be hard to flush.
Steatorrhea (Steato – fat , rrhea- flow) refers to the increase in fat excretion in faeces. This is usually a reflection of fat malabsorption that can happen in many conditions such as exocrine pancreatic insufficiency (EPI), celiac disease, and tropical sprue. Bile acid deficiency or malabsorption can also lead to low fat absorption. Here we can see fat droplets in a colonic remains. This usually floats and sticks in the pan when the patient open bowels and can be hard to flush.
Sometimes colonic polyps have different pit pattern in the same lesion. Here we can see KUDO II (green circle), IIIL (tubular but larger than normal pits, red circle) and IV (branch like gyrus, blue circle). When using NBI and near focus, we can see that despite some heterogeneity, there is no areas of irregularity, pits and vascularity are all well defined and the vessels are present and not blurring. Therefore there is no area suggestive of deep invasion or malignancy.
Sometimes colonic polyps have different pit pattern in the same lesion. Here we can see KUDO II (green circle), IIIL (tubular but larger than normal pits, red circle) and IV (branch like gyrus, blue circle). When using NBI and near focus, we can see that despite some heterogeneity, there is no areas of irregularity, pits and vascularity are all well defined and the vessels are present and not blurring. Therefore there is no area suggestive of deep invasion or malignancy.
Denuded oesophageal mucosa in lower oesophagus. This shows involvement of >75% of circumference therefore it is Grade D oesophagitis.
Denuded oesophageal mucosa in lower oesophagus. This shows involvement of >75% of circumference therefore it is Grade D oesophagitis.
Lower GI haemorrhage accounts for about 20% of the GI bleeds admitted to hospital. Even though rectorrhagia usually refers to bright red blood and haematochezia to dark blood, in fact both terms should be interchangeable. When the bloods is coming from rectum, tends to be very bright as it is expelled as it bleeds. In cases where the bloods is coming from proximal areas it appears darker, like a red wine colour(This case). Occasionally if coming from more proximal like caecum, it can appear really dark or even black stool (melaena)> This all depends on how long the blood is exposed to the intestinal enzymes and bacteria that produce the breaking down and change in colour and odour.
Lower GI haemorrhage accounts for about 20% of the GI bleeds admitted to hospital. Even though rectorrhagia usually refers to bright red blood and haematochezia to dark blood, in fact both terms should be interchangeable. When the bloods is coming from rectum, tends to be very bright as it is expelled as it bleeds. In cases where the bloods is coming from proximal areas it appears darker, like a red wine colour(This case). Occasionally if coming from more proximal like caecum, it can appear really dark or even black stool (melaena)> This all depends on how long the blood is exposed to the intestinal enzymes and bacteria that produce the breaking down and change in colour and odour.
Stomach with specks of digested blood (when hemoglobin is oxidized and blood becomes darker). This is suggestive of a recent or ongoing upper GI bleed
Stomach with specks of digested blood (when hemoglobin is oxidized and blood becomes darker). This is suggestive of a recent or ongoing upper GI bleed
Scalloping of duodenal folds was first described in 1988 by Jabbari et al. It refers to the rigged shape of a mucosal folds that resembles the scallop shell. It has high sensitivity for villous atrophy, but not only coealic can cause this, but other conditions such as eosinophilic gastroenteritis, H.Pylori infection, B12 deficiency or SIBO.
Scalloping of duodenal folds was first described in 1988 by Jabbari et al. It refers to the rigged shape of a mucosal folds that resembles the scallop shell. It has high sensitivity for villous atrophy, but not only coealic can cause this, but other conditions such as eosinophilic gastroenteritis, H.Pylori infection, B12 deficiency or SIBO.
45 yo male patient with colorectal adenocarcinoma T3N2M1 with liver metastasis that presents with sudden jaundice. MRCP showing florid hepatic metastasis that are pressing against the distal biliary duct. (Blue arrows point the obstructing metastasis)
45 yo male patient with colorectal adenocarcinoma T3N2M1 with liver metastasis that presents with sudden jaundice. MRCP showing florid hepatic metastasis that are pressing against the distal biliary duct. (Blue arrows point the obstructing metastasis)
For best assesing a colonic polyp we need to use NBI (Narrow band imaging- ©OLYMPUS) which are filters to separate wavelengths of white light and select out red, green, and blue bands. This enhances blood vessels and helps differenciating surface structure and pit pattern. Other similar system are i-SCAN (©PENTAX) and flexible spectral imaging color enhancement -FICE- (©FUJI).
For best assesing a colonic polyp we need to use NBI (Narrow band imaging- ©OLYMPUS) which are filters to separate wavelengths of white light and select out red, green, and blue bands. This enhances blood vessels and helps differenciating surface structure and pit pattern. Other similar system are i-SCAN (©PENTAX) and flexible spectral imaging color enhancement -FICE- (©FUJI).
Haemorrhoids are swollen and prolapsed veins that can affect and cause symptoms up to 50% in the adults during their lifetime. Here we can see the dentate line (transition between the pale squamous mucosa and the pink rectal mucosa) With has some areas of erythema on the surface of a ingurgitated internal haemorrhoid
Haemorrhoids are swollen and prolapsed veins that can affect and cause symptoms up to 50% in the adults during their lifetime. Here we can see the dentate line (transition between the pale squamous mucosa and the pink rectal mucosa) With has some areas of erythema on the surface of a ingurgitated internal haemorrhoid
Steps during ERCP (Endoscopic retrograde cholangiopancreatography) First, cannulation of the ampulla of Vater. Papilla is best approached from below, aiming at aligning the axis of the catheter/sphincterotome. Once cannulated and cholangiogram done, proceed to cut the sphincter (sphincterotomy) to be able to extract the calculi. Image 3 and 4 show the endoscopic view of extraction of biliary lithiasis.
Steps during ERCP (Endoscopic retrograde cholangiopancreatography) First, cannulation of the ampulla of Vater. Papilla is best approached from below, aiming at aligning the axis of the catheter/sphincterotome. Once cannulated and cholangiogram done, proceed to cut the sphincter (sphincterotomy) to be able to extract the calculi. Image 3 and 4 show the endoscopic view of extraction of biliary lithiasis.
Microscopic findings of steatohepatitis. Some macrovesicular steatosis with occasional infiltraton of inflammatory cells mostly neutrophils and lymphocytes (red arrows) in the hepatic lobule is seen (H-E, ×100). There are lobular inflammatory activity with ballooning degeneration (increased size, rounded shape instead of hexagonal, Mallory bodies in the rarefied cytoplasm (Balloon hepatocytes in blue circles)
Microscopic findings of steatohepatitis. Some macrovesicular steatosis with occasional infiltraton of inflammatory cells mostly neutrophils and lymphocytes (red arrows) in the hepatic lobule is seen (H-E, ×100). There are lobular inflammatory activity with ballooning degeneration (increased size, rounded shape instead of hexagonal, Mallory bodies in the rarefied cytoplasm (Balloon hepatocytes in blue circles)
Scar of previous haemorrhoidal banding seen in rectum
Scar of previous haemorrhoidal banding seen in rectum
Large confluent mucosal breaks in oesophagus are a clear sign of oesophagitis, in this case the breaks show white fibrinous interior and are confluent in >75% of the cirfumference, therefore this is Grade D (Severe) oesophagitis
Large confluent mucosal breaks in oesophagus are a clear sign of oesophagitis, in this case the breaks show white fibrinous interior and are confluent in >75% of the cirfumference, therefore this is Grade D (Severe) oesophagitis
Kudo IV pattern (dendritic or gyrus like pits) of a 0-Is colonic adenoma
Kudo IV pattern (dendritic or gyrus like pits) of a 0-Is colonic adenoma
Caroli's Disease is a rare congenital disorder that primarily affects the intrahepatic bile ducts, with saccular dilatation that appear as cysts on imaging . This can lead to bile stasis,cholangitis or duct stones. The overall risk of cholangiocarcinoma is increased (2.7% - 37.5%)
Caroli's Disease is a rare congenital disorder that primarily affects the intrahepatic bile ducts, with saccular dilatation that appear as cysts on imaging . This can lead to bile stasis,cholangitis or duct stones. The overall risk of cholangiocarcinoma is increased (2.7% - 37.5%)
Duodenal diverticula are noted in up to 20% of the population, with an increasing frequency with age. They tend to appear near the ampulla and most are incidental and do not need treatment (Image on the right show the interior of a big one)
Duodenal diverticula are noted in up to 20% of the population, with an increasing frequency with age. They tend to appear near the ampulla and most are incidental and do not need treatment (Image on the right show the interior of a big one)
Gastric polyps are found in 6% of all OGDs. Up to 75% of those are fundic gland polyps in western environment. They are sessile, pale, glassy, multiple and located in body and fundus.
Gastric polyps are found in 6% of all OGDs. Up to 75% of those are fundic gland polyps in western environment. They are sessile, pale, glassy, multiple and located in body and fundus.
72 yo, 3 weeks of dysphagia and weight loss. CT shows marked oesophageal dilatation up to just below the level of the carina, where there is evidence of a stricture, and localised perforation of the oesophagus,which appears continuous with a surrounding walled off fluid collection measuring approximately 43 mm x 36 mm (Purple arrow) These findings were due to esophageal malignancy, complicated by localised perforation and abscess formation. On axial imaging, the collection extends towards the right hilum, and partially encases the right main bronchus (blue star)
72 yo, 3 weeks of dysphagia and weight loss. CT shows marked oesophageal dilatation up to just below the level of the carina, where there is evidence of a stricture, and localised perforation of the oesophagus,which appears continuous with a surrounding walled off fluid collection measuring approximately 43 mm x 36 mm (Purple arrow) These findings were due to esophageal malignancy, complicated by localised perforation and abscess formation. On axial imaging, the collection extends towards the right hilum, and partially encases the right main bronchus (blue star)
Gastroduodenal angiodysplasia can cause melanea or coffee ground vomit. Sometimes they are so small and subtle that the only finding is a vascular serpinginous shape with persisting bleeding despite washing.
Gastroduodenal angiodysplasia can cause melanea or coffee ground vomit. Sometimes they are so small and subtle that the only finding is a vascular serpinginous shape with persisting bleeding despite washing.
Gastric angiodysplasia on the greter curve of corpus, causing upper GI bleed. Treated with APC (Argon Plasma Coagulation) at 30W with good result.
Gastric angiodysplasia on the greter curve of corpus, causing upper GI bleed. Treated with APC (Argon Plasma Coagulation) at 30W with good result.
This is part of the stomach protruding upwards into the esophagus when patient retches during a gastroscopy. This was due to a hiatal hernia and lax LES (Lower esophageal sphincter)
This is part of the stomach protruding upwards into the esophagus when patient retches during a gastroscopy. This was due to a hiatal hernia and lax LES (Lower esophageal sphincter)
Post ERCP perforation. (Stapfer type II, peri ampullary which is the most common) : Perf occur around 0.6% and can lead to 8%- 23% mortality rate. Massive pneumoperitoneum (arrows) Dilated bile duct (star) White contrast extravasation (cross)
Post ERCP perforation. (Stapfer type II, peri ampullary which is the most common) : Perf occur around 0.6% and can lead to 8%- 23% mortality rate. Massive pneumoperitoneum (arrows) Dilated bile duct (star) White contrast extravasation (cross)
Esophageal varices and GOV1 are supplied by the left gastric vein (LGV) and drain through the azygous vein (AV) into the superior vena cava (SVC). Gastrofundal varices can drain into the left renal vein (LRV) through a gastrorenal shunt (GRS). Rectal varices are supplied by the superior rectal vein (SRV) and drain into the middle rectal vein (MRVs) and inferior rectal veins (IRV).
Esophageal varices and GOV1 are supplied by the left gastric vein (LGV) and drain through the azygous vein (AV) into the superior vena cava (SVC). Gastrofundal varices can drain into the left renal vein (LRV) through a gastrorenal shunt (GRS). Rectal varices are supplied by the superior rectal vein (SRV) and drain into the middle rectal vein (MRVs) and inferior rectal veins (IRV).
Gastrointestinal stromal tumors (GISTs) Are the most common mesenchymal GI neoplasm, typically benign tumors, (70%) and located in the stomach-> mutation of tyrosine kinase expression c-kit proto-oncogen (CD 117)-->neoplastic growth involving interstitial cells of Cajal. The most common findings of GIST include subendothelial lesions seen on an endoscopy or contrast-enhancing mass with a smooth margin on CT. In some cases like this, the lesion can become ulcerated and cause GI bleed- likely needing surgical resection.
Gastrointestinal stromal tumors (GISTs) Are the most common mesenchymal GI neoplasm, typically benign tumors, (70%) and located in the stomach-> mutation of tyrosine kinase expression c-kit proto-oncogen (CD 117)-->neoplastic growth involving interstitial cells of Cajal. The most common findings of GIST include subendothelial lesions seen on an endoscopy or contrast-enhancing mass with a smooth margin on CT. In some cases like this, the lesion can become ulcerated and cause GI bleed- likely needing surgical resection.
This rectal scar is surprisingly a cicatrize from previous haemorrhoidal banding. Being too far (proximal) from dentate line, this could be due to a misplacement of one of the band in the technique which did not cause any complication at the time.
This rectal scar is surprisingly a cicatrize from previous haemorrhoidal banding. Being too far (proximal) from dentate line, this could be due to a misplacement of one of the band in the technique which did not cause any complication at the time.
Dilated extrahepatic bile duct with tapering caused by stricture (Arrow). In this case this was benign due to chronic pancreatitis.
Dilated extrahepatic bile duct with tapering caused by stricture (Arrow). In this case this was benign due to chronic pancreatitis.
Distal sigmoid polyp. Despite appearing hyperplastic on white light (Kudo II) ,when looked closer with NBI we saw pits smaller than the normal mucosa (Kudo IIIs) and in the perifery of the polyp we see tubular pits, near dendritic (kudo IIIL or IV)- Therefore this is a colonic adenoma and needs resection.
Distal sigmoid polyp. Despite appearing hyperplastic on white light (Kudo II) ,when looked closer with NBI we saw pits smaller than the normal mucosa (Kudo IIIs) and in the perifery of the polyp we see tubular pits, near dendritic (kudo IIIL or IV)- Therefore this is a colonic adenoma and needs resection.
Patient with Ulcerative colitis, now in remission. Colon showing longitudinal bands of scarring due to fibrosis of the submucosa (product of previous episodes of severe acute colitis in the past) Chromoendoscopy with blue dye.
Patient with Ulcerative colitis, now in remission. Colon showing longitudinal bands of scarring due to fibrosis of the submucosa (product of previous episodes of severe acute colitis in the past) Chromoendoscopy with blue dye.
Barrett's oesophagus uses the Prague Classification. This explample would be C2M4, being C the lenght in cm of the circunferencial portion and M the maximum lenght length of the Barrett’s including any tongues.
Barrett's oesophagus uses the Prague Classification. This explample would be C2M4, being C the lenght in cm of the circunferencial portion and M the maximum lenght length of the Barrett’s including any tongues.
Aerobilia or pneumobilia (air in any part of the biliary tract) is a sign of instrumentation (recent ERCP, previous sphincterotomy) fistula between the bowel and biliary tree or recent spontaneous passage of a stone. Less commonly, cholangitis can also be a cause.
Aerobilia or pneumobilia (air in any part of the biliary tract) is a sign of instrumentation (recent ERCP, previous sphincterotomy) fistula between the bowel and biliary tree or recent spontaneous passage of a stone. Less commonly, cholangitis can also be a cause.
Splenic flexure Colon Adenocarcinoma. : Big sized tumour, occupying nearly 3/4 of the circumference, very irregular, unclear lobulation, depresed and eroded, with complete loss of pit pattern or capillaries. A minimum of 6 biopsies should be taken and tattoo distally x3 in case of potential surgery
Splenic flexure Colon Adenocarcinoma. : Big sized tumour, occupying nearly 3/4 of the circumference, very irregular, unclear lobulation, depresed and eroded, with complete loss of pit pattern or capillaries. A minimum of 6 biopsies should be taken and tattoo distally x3 in case of potential surgery
When Ileocaecal valve (ICV) opening is facing inwards, the intubation of terminal ileum can be done in retroflexion (See the ICV opening very clearly in retroflexion). This view also increase the adenoma detection rate up to 6% compare to forward view alone.
When Ileocaecal valve (ICV) opening is facing inwards, the intubation of terminal ileum can be done in retroflexion (See the ICV opening very clearly in retroflexion). This view also increase the adenoma detection rate up to 6% compare to forward view alone.
ERCP: Impacted stone due to stone: duct ratio >1 (Stone size ÷ bile duct size one cm below the stone) - This stone could not be removed conventionally and needed cholangioscopy- EHL (electrohydraulic lithotripsy: high-energy shock waves to break up hard or large stones)
ERCP: Impacted stone due to stone: duct ratio >1 (Stone size ÷ bile duct size one cm below the stone) - This stone could not be removed conventionally and needed cholangioscopy- EHL (electrohydraulic lithotripsy: high-energy shock waves to break up hard or large stones)
Sliding hiatus hernia. We measure the distance between the diaphragmatic pinch (distally) and the OGJ ( area where the red columnar mucosa meets the pale squamous epithelia) We can see projected gastric folds up the level, therefore we know this is not Barrett's esophagus.
Sliding hiatus hernia. We measure the distance between the diaphragmatic pinch (distally) and the OGJ ( area where the red columnar mucosa meets the pale squamous epithelia) We can see projected gastric folds up the level, therefore we know this is not Barrett's esophagus.
Kodsi classification for oesophageal candidiasisr this is grade I ( a few raised white plaques up to 2 mm in size without edema or ulceration) . Those cannot be washed off with water irrigation. Risk factors include immunosupression, dismotility, PPI , local steroids, antibiotic therapy, poorly controlled diabetes or malnutrition. Treatment is with Oral Fluconazole for at least 14 days.
Kodsi classification for oesophageal candidiasisr this is grade I ( a few raised white plaques up to 2 mm in size without edema or ulceration) . Those cannot be washed off with water irrigation. Risk factors include immunosupression, dismotility, PPI , local steroids, antibiotic therapy, poorly controlled diabetes or malnutrition. Treatment is with Oral Fluconazole for at least 14 days.
Serrated lesions (SSL) are often subtle, pale in appearance and up to 50% masked by mucous cap. Features suggestive of SSL rather than hyperplastic polyp include dark spots within pits, indistinct boarder, a cloud-like or bosselated surface and irregular shape (See Workgroup Serrated Polyps and Polyposis -WASP- classification)
Serrated lesions (SSL) are often subtle, pale in appearance and up to 50% masked by mucous cap. Features suggestive of SSL rather than hyperplastic polyp include dark spots within pits, indistinct boarder, a cloud-like or bosselated surface and irregular shape (See Workgroup Serrated Polyps and Polyposis -WASP- classification)
a) Esophaegal SCC (Squamous cell carcinoma) at 30cm from inicisors. b) 3 months after radiotherapy patient presents dysphagia- Gastroscopy showed carcinoma response however late severe radiation esophagitis. Tx is usually symptomatic with PPI and aluminum hydroxide–magnesium carbonate. CMV should be ruled out as these patients are usually immunocompromised.
a) Esophaegal SCC (Squamous cell carcinoma) at 30cm from inicisors. b) 3 months after radiotherapy patient presents dysphagia- Gastroscopy showed carcinoma response however late severe radiation esophagitis. Tx is usually symptomatic with PPI and aluminum hydroxide–magnesium carbonate. CMV should be ruled out as these patients are usually immunocompromised.
ERCP with difficult intradiverticular papilla ,suboptimal endoscopic vision. In the 2 superior images, a first endoscopist stopped the procedure after attempting cannulation and being unsure if constrast was actually in bile duct. Two Inferior pictures- a second operator decided to persevere in the same position, eventually causing perforation- extravasation of the contrast as elongated diverticulum was perforated. Lesson: If unsure, a timely retreat is a victory.
ERCP with difficult intradiverticular papilla ,suboptimal endoscopic vision. In the 2 superior images, a first endoscopist stopped the procedure after attempting cannulation and being unsure if constrast was actually in bile duct. Two Inferior pictures- a second operator decided to persevere in the same position, eventually causing perforation- extravasation of the contrast as elongated diverticulum was perforated. Lesson: If unsure, a timely retreat is a victory.
Small Oesophageal varices. Generally are classified in small (5mm) as Baveno criteria . Other classifications such Modified Paquet or JSPH include moderate (1/3 of the circumference, or beady) and large (50% of circumference or tumour-shaped).
Small Oesophageal varices. Generally are classified in small (5mm) as Baveno criteria . Other classifications such Modified Paquet or JSPH include moderate (1/3 of the circumference, or beady) and large (50% of circumference or tumour-shaped).
Orange-Chronic pancreatitis (Lobularity, marked cystic changes, dilated main panc duct at the tail) causing extrinsic compression of the upper CBD (in blue) and upstream dilation of the CHD and main intrahepatic ducts. Still this compression is not an abrupt cutoff and we can follow down the narrow CBD (blue dots)
Orange-Chronic pancreatitis (Lobularity, marked cystic changes, dilated main panc duct at the tail) causing extrinsic compression of the upper CBD (in blue) and upstream dilation of the CHD and main intrahepatic ducts. Still this compression is not an abrupt cutoff and we can follow down the narrow CBD (blue dots)
Duodenal ulcer- Forrest IIa (non bleeding visible vessel, slightly protruding, red circle). This type has around 40% risk of rebleeding without treatment, therefore needs mechanical/ thermal/ sclerosing agent) In monotherapy or in combination with epinephrine. The blue arrows represent hematin (dark spots), unlike the raised vessel, they are flat.
Duodenal ulcer- Forrest IIa (non bleeding visible vessel, slightly protruding, red circle). This type has around 40% risk of rebleeding without treatment, therefore needs mechanical/ thermal/ sclerosing agent) In monotherapy or in combination with epinephrine. The blue arrows represent hematin (dark spots), unlike the raised vessel, they are flat.
Esophageal food bolus has underlying pathology in 75% such as peptic strictures (50%) eosinophilic esophagitis (EoE, 40%) or less frequently cancer or motility disorders. We should always take bx in food bolus to rule out EoE.
Esophageal food bolus has underlying pathology in 75% such as peptic strictures (50%) eosinophilic esophagitis (EoE, 40%) or less frequently cancer or motility disorders. We should always take bx in food bolus to rule out EoE.
Crohn's disease in TI (Terminal Ileum). Montreal classification A2L1B1, SES-CD score 9 (Moderate) with large ulcerations and patchy distribution. Colon was not involved in this case.
Crohn's disease in TI (Terminal Ileum). Montreal classification A2L1B1, SES-CD score 9 (Moderate) with large ulcerations and patchy distribution. Colon was not involved in this case.
Dilated intra and extrahepatic biliary system with abrupt cutoff of the distal CBD (arrows) due to malignant compression ,in this case, head of pancreas adenocarcinoma.
Dilated intra and extrahepatic biliary system with abrupt cutoff of the distal CBD (arrows) due to malignant compression ,in this case, head of pancreas adenocarcinoma.
Simethicone is used to clear the bubbles/foam residues during endoscopy. We can flush it through the scope channel. Also, orally (1 mL - 100 mg-in 5 mL of water) 30 min before gastroscopy has been proved to reduce the foam and the scope time by improving visibillity.
Simethicone is used to clear the bubbles/foam residues during endoscopy. We can flush it through the scope channel. Also, orally (1 mL - 100 mg-in 5 mL of water) 30 min before gastroscopy has been proved to reduce the foam and the scope time by improving visibillity.
Biliary plastic stents can be seen rarely on MRI, compared to xray or CT scan. This is an example of 2 plastic stents subtlely guessed.
Biliary plastic stents can be seen rarely on MRI, compared to xray or CT scan. This is an example of 2 plastic stents subtlely guessed.
Right colon: Crohn's disease causes deep longitudinal and tranmsural inflammation (deep ulcers with intervening mucosal edema, causing the typical cobblestone appearance)
Right colon: Crohn's disease causes deep longitudinal and tranmsural inflammation (deep ulcers with intervening mucosal edema, causing the typical cobblestone appearance)
Secondary phrophylaxis for oesophageal variceal haemorrhage. Carvedilol daily + Endoscopic banding every 2-4 weeks until varices eradicated; (no varices, only post-banding scars) From here, we keep re-scope yearly as long as persising liver insult (alcohol, virus, metabolic syndrome...) within Baveno criteria.
Secondary phrophylaxis for oesophageal variceal haemorrhage. Carvedilol daily + Endoscopic banding every 2-4 weeks until varices eradicated; (no varices, only post-banding scars) From here, we keep re-scope yearly as long as persising liver insult (alcohol, virus, metabolic syndrome...) within Baveno criteria.
Antral rounded/oval subepithelial lesion with a central depression or umbilication, this is an ectopic pancreas or pancreatic rest. This congenital anomaly affects ~1-2% of people and is completely benign and nearly always incidental.
Antral rounded/oval subepithelial lesion with a central depression or umbilication, this is an ectopic pancreas or pancreatic rest. This congenital anomaly affects ~1-2% of people and is completely benign and nearly always incidental.
Occasionally diverticula can associate local inflammatory signs (ulceration, erythema or exudate)
Occasionally diverticula can associate local inflammatory signs (ulceration, erythema or exudate)
Gastric antral xhantoma- often seen as white-yellowish plaques: Biopsies show foamy macrophages
Gastric antral xhantoma- often seen as white-yellowish plaques: Biopsies show foamy macrophages
Gangrenous cholecystitis- causing a pseudoaneurysm arising from the cystic artery. Coil embolisation with micro tornado coils with isolation of the pseudoaneurysm.
Gangrenous cholecystitis- causing a pseudoaneurysm arising from the cystic artery. Coil embolisation with micro tornado coils with isolation of the pseudoaneurysm.
Coledocoduodenal fistula: Large necrotic right upper quadrant mass involving the liver, duodenum, hepatic flexure and pancreatic head. The differentiasl were a large perforated hepatic flexure tumour (red arrow) although it is possible that the primary originates from the gallbladder or duodenum (Orange arrow)
Coledocoduodenal fistula: Large necrotic right upper quadrant mass involving the liver, duodenum, hepatic flexure and pancreatic head. The differentiasl were a large perforated hepatic flexure tumour (red arrow) although it is possible that the primary originates from the gallbladder or duodenum (Orange arrow)

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Check out our video library for easy-to-follow explanations and real-life examples in gastroenterology. Whether it’s learning procedures or understanding common conditions, these videos will help make the complex stuff simple- 

 

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