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Fig. 12.14 Ileoanal pouch inflammation (pouchitis). Acute inflammatory changes similar to UC with somewhat patchy fi-brinous plaques and significant erythema. Fig. 12.15 Pouchitis (different segment). The changes here are more pronounced (simultaneous radiology of this region due to carcinoma in the anal transitional zone). Fig. 12.16 Pancolitis in UC, colitis carcinoma, hepatic flexure. Broad-based polyp with (tubulo)villous surface, appearing somewhat irregular, but not typical for a...

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G-i Large (about 7 mm) and very large diverticula (> 10 mm). Proximity to blood vessels is readily visible for most diverticula. Large diverticula (g-i) sometimes have bronchial-like branching at the base of the diverticulum, as can be clearly seen in i with a ca. 12 mm giant diverticulum in the sigmoid colon. Such large diverticula always pose the risk of being confused with colonic lumen when advancing the instrument. g-i Large (about 7 mm) and very large diverticula (> 10 mm). Proximity...

Safety of the Patient and Monitoring

Serious cardiopulmonary complications (occurring at a rate of 0.1-0.5 ) account for the overwhelming majority of complications related to endoscopy. Patients should be carefully monitored during and after colonoscopy, so that complications can be recognized and treated adequately, or, if possible prevented before they arise. Risk assessment. Every individual patient's cardiopulmonary risk should be evaluated prior to examination. A useful reference is the classification of risk groups by the...

Fjc

The ability to identify patients with longstanding bleeding or with a risk of rebleeding similar to patients with bleeding ulcers. Jensen et al. (30) and Grisolano et al. (24) have shown that, similar to acute upper gastrointestinal bleeding, evidence of active bleeding (Figs. 13.2-13.4), visible vessels (Figs. 13.5-13.8), and adherent clots (Figs. 13.9-13.11) are associated with severe course or high rate of rebleeding. According to the literature, colonoscopy is usually performed within 12-24...

Acute and Chronic Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding is defined as acute or chronic blood loss from a source distal to the ligament of Treitz. The following sections will focus on bleeding from sources in the colon and anal canal. Acute lower gastrointestinal bleeding. Acute lower gastrointestinal bleeding is defined (rather arbitrarily) as a bleeding situation in which blood loss has been occurring for less than three days and is causing hemodynamic instability, anemia, or the need...

Endoscopic Interventions

The spontaneous course of an anastomotic leakage is difficult to predict. According to the literature, 50-80 leakages ultimately heal spontaneously with sufficient drainage, systemic antibiotic therapy, parenteral nutrition, and local irrigation. Median length of time required is six weeks, after which the rate of spontaneous healing drops markedly. The aim of endoscopic treatment is to reduce follow-up treatment by ensuring more rapid closure of the fistula. Based on experience, some fistula...

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Flat Polyps Found During Colonoscopy

Fig. 10.1 a-c Carcinoma stenosis with irregular surface, swollen mucosa, vulnerable or spontaneously bleeding mucosa. Fig. 10.1 a-c Carcinoma stenosis with irregular surface, swollen mucosa, vulnerable or spontaneously bleeding mucosa. can be difficult. Malignant stenoses generally have an irregular surface, the mucosa is swollen and destroyed, vulnerable, or bleeding spontaneously (Fig. 10.1). Inflammatory stenoses have an edematous mucosa, a glassy, livid surface, and are without significant...

Advancing Further to the Hepatic Flexure

After passing the sigmoid colon, the junction with the descending colon is reached. Sharp angling of the lumen, due to the secondary retroperitoneal position of the descending colon, can make it difficult to pass the sig-moid-descending junction. Unlike the flexible sigmoid colon, which is located intraperitoneally, the descending colon is fixed on the posterior abdominal wall. Looping or excess air insufflation in the sigmoid colon during preceding advancement of...

Principles of endoscopic therapy

Bougienage entails a risk of eccentric and undesirable expansile force over longer bowel segments (Fig. 21.1). Balloon dilation placed either over a guidewire using radiographic control (limitations in the right colon) or through the endoscope using a balloon which is advanced through the working channel and placed under direct visualization (TTS through the scope balloon dilation). Balloon dilation has the advantage of direct visualization through the balloon (filled with a mixture of Fig....

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Radiation colitis traditionally occurs after brachytherapy for cervical carcinoma. However, in recent years, there has been a significant rise in frequency following adjuvant or neoadjuvant therapies of rectal carcinomas, affecting remaining or anastomosed intestinal segments. In isolated cases, it can also occur as proctitis after percutaneous radiation therapy of prostate carcinoma. Unlike acute radiation necrosis (Fig. 12.37), symptoms typically occur after the disease has been latent for a...

L Removal of Foreign Bodies in the Colon Method

The set of instruments for colonoscopic recovery of foreign bodies corresponds to these used in the upper gastrointestinal (GI) tract. Various polypectomy snares, special forceps with hooked jaws, multiple-pronged grasping forceps, and baskets are used. For mobilization, a balloon can also be used, inflated distal to the foreign body. The selection of instruments is based on shape, material, and size of the foreign body very often a range of instruments must be tried out (Figs. 23.1, 23.2)....

Laser therapy techniques NdYAG laser

The patient should be sedated with 0-10 mg of Midazolam during laser treatment. The Nd YAG laser (Medilas I or II, Dornier C., Munich, Germany) (Fig. 19.1) is operated at 70-100 W. The laser is aimed at the tumor through an optical fiber (cooled by carbon dioxide) in a noncontact procedure. A helium-neon laser emits a red pilot light. The optical fiber is easily guided through the working channel of the colonoscope, which is protected by a ceramic tip. Treatment proceeds from the upper tumor...

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- T 18.4 Procedure for polypectomy of broad-based polyps - T 18.4 Procedure for polypectomy of broad-based polyps a-d Procedure for removing a broad-based sessile polyp about 3 cm in size. The polyp is ensnared around the entire base. The snare is closed around the polyp and the polyp is slightly lifted. This polyp can be removed en bloc. a-d Procedure for removing a broad-based sessile polyp about 3 cm in size. The polyp is ensnared around the entire base. The snare is closed around the polyp...

Complications and Risks

Perforation, bleeding, and infection. Endoscopy of the colon entails risk of perforation, injury to blood vessels causing bleeding, and infection (Figs. 1.2, 1.3). The rate of complications can be minimized if the examiner takes precautions such as advancing the instrument only under conditions of high visibility. Sig-moidoscopy involves an average perforation rate of 1.8 per 100000 examinations bleeding severe enough to require a blood transfusion and perforations requiring surgical repair...

Triangle Lumen Transverse Colon

Proxinal Colon

Typical triangular shape. Fig. 6.16 Transverse colon. Typical triangular shape. Fig. 6.17 Transverse colon. Triangular lumen and strong haustrations. Fig. 6.18 Midtransverse colon with triangular lumen. Fig. 6.20 Transverse colon. Funnel-like transverse colon, angled dorsally just before the hepatic flexure. After passing this point, the instrument is angled caudally toward the ascending colon. Fig. 6.19 Transverse colon. Typical normal appearance, shown here with...

APC Argon Plasma Coagulation APC techniques

The argon beam coagulator has a high frequency generator (ERBE, T bingen, Germany) with an output of 50-100 W and an argon gas flow of 0.5-2 L minute. Energy is emitted though a 2-mm-thick Teflon tube in which argon gas flows around an electrode. The ionized argon gas is aimed from the probe tip at the targeted tissue without contact between the probe and the tissue. Because the argon gas is illuminated, it is possible to guide it over the coagulation surface. Energy delivery can be axial,...

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Polyps related to juvenile polyposis can occur in the entire digestive tract, or only in the colon where they mainly appear in the rectum. Their diameter measures 3-30 mm and they resemble solitary juvenile polyps. Given their smooth surface, juvenile polyps cannot be distinguished from adenomas macroscopically (0 9.13a-c) they also appear as diminutive polyps (H 9.13 d). Adenomas appearing at the same time as juvenile polyposis are considered precancerous and must be removed. Subtotal...

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Hyperplastic polyps are sessile polyps with a diameter of 5-10 mm. Special endoscopic techniques (chro-moendoscopy and pit pattern classification) must be used to distinguish hyperplastic polyps from adenomas macroscopi-cally. Hyperplastic polyps, often called metaplastic polyps, are pale or the same color as the surrounding mucosa (09.10 a-d). They usually appear as solitary polyps, but in 5-10 of patients several polyps appear in one colon segment. Larger hyperplastic...

Normal Transverse Colon

The transverse colon runs across the upper abdomen, connecting the descending colon and the ascending colon the splenic and hepatic flexures at either end of this colon segment demarcate the anatomical borders. The transverse colon is entirely intraperitoneal and is supplied by its own mesocolon. On the ventral side, the greater omentum is fixed to the transverse colon. Because both flexures are fixed to the posterior wall of the abdominal cavity, while the transverse colon lies in front of...

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Endo Vac Anastomosis

Fig. 22.19 Principle of EndoVAC system (R. Weidenhagen) Advance of a thin-caliber flexible endoscope into the wound cavity. The insertion tube of the EndoVAC system is guided under endoscopic visualization to the end of the cavity. The insertion tube is left there and the endoscope is withdrawn. The compressed sponge system is then introduced into the insertion tube. Deployment of the sponge system over the placement tube occurs on withdrawal of the insertion tube. Positioning is controlled...

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Clear triangular configuration, running mostly straight. Fig. 6.12 Descending colon. Normal oval or slightly triangular-shaped lumen. Fig. 6.13 Descending colon. More pronounced triangular shape. Fig. 6.14 Descending colon. Clear triangular configuration, running mostly straight. Fig. 6.12 Descending colon. Normal oval or slightly triangular-shaped lumen.

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Portal Hypertension Nursing

Angiodysplasias (a 13.1) are cited as the source of lower gastrointestinal bleeding in up to 30 of patients, though a rate of 3-12 is probably more realistic (64). The majority of angiodysplasias (62 ) are located in the right hemicolon, often occurring several at a time. The vast majority of affected individuals do not bleed (22, 42) and therapy is not always indicated for every angiodysplasia detected by colonoscopy. In addition, an angiody-splasia detected during urgent...

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Fig. 12.35 Crohn disease, current superinfection with Chlamydia trachomatis. This organism could be responsible for the small pitlike ulcerations in the ascending colon, which the patient had in addition to his Crohn-related lesions no longer detectable six weeks later at surveillance. Fig. 12.35 Crohn disease, current superinfection with Chlamydia trachomatis. This organism could be responsible for the small pitlike ulcerations in the ascending colon, which the patient had in addition to his...

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T 18.2 Polypectomy procedure using an Endoloop on a stalked polyp - T 18.2 Polypectomy procedure using an Endoloop on a stalked polyp - a-e Polypectomy procedure for use of an Endoloop on a large stalked polyp. The En-doloop (detachable snare) is positioned around the thick stalk, ligating it. The polypectomy snare is placed above the detachable snare at a sufficient distance to the polyp head for safe and complete resection. After polypectomy, the stalk retracts and becomes necrotic. The...

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C Mucosal tear proximal to the upper end of the stent (Wallstent Enteral). d Tumor ingrowth, not yet occlusive. Distal migration of Wallstent Enteral passage with a therapeutic gastro-scope impossible. Deployment of a 9-cm long Wallstent Enteral to traverse 5-cm long sigmoid carcinoma. The proximal end of the stent (22 mm) does not have complete contact with the dilated intestine. c Mucosal tear proximal to the upper end of the stent (Wallstent Enteral). d Tumor ingrowth, not yet occlusive. 1....

List of Contributors

III Medical Clinic Augsburg Clinic Augsburg, Germany Max Bittinger, M.D. III Medical Clinic Augsburg Clinic Augsburg, Germany Thomas Eberl, M.D. III Medical Clinic Augsburg Clinic Augsburg, Germany Reinhard Fleischmann, M.D. Assistant Professor III Medical Clinic Augsburg Clinic Augsburg, Germany Gertrud Jechart, M.D. III Medical Clinic Augsburg Clinic Augsburg, Germany Helmut Messmann, M.D. Professor III Medical Clinic Augsburg Clinic Augsburg, Germany Andreas Probst, M.D....

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Percent of the smaller flat adenomas (< 10 mm diameter) and 29 of the large flat adenomas (> 10mm diameter) were found to contain severe dysplasia or an adenocarcinoma (3). The fact that flat adenomas also have a lower incidence than polypoid lesions of K-ras mutations supports the hypothesis that malignant progression of flat adenomas to carcinoma does not necessarily have to include a polypoid phase. Flat adenomas perhaps are an early phase in the development of a de-novo colon carcinoma...

What Is Sigmoid Pale Mucosa

Ulceration The Sigmoid

A Clear chronic reaction to radiation therapy, telangiectasia, small ulcer, and bleeding tendency (upper rectum). b Moderate delayed reaction of mucosa with spidery angiectasia (lower rectum). c Pronounced radiation colitis following cervical carcinoma typical vessel garlands. a Clear chronic reaction to radiation therapy, telangiectasia, small ulcer, and bleeding tendency (upper rectum). b Moderate delayed reaction of mucosa with spidery angiectasia (lower rectum). c Pronounced radiation...

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Rectal Resection

Fig. 21.2 Anastomotic stenosis in middle rectum, light bleeding, considered normal, at the stenosis ends following balloon dilation. Fig. 21.2 Anastomotic stenosis in middle rectum, light bleeding, considered normal, at the stenosis ends following balloon dilation. Fig. 21.3 Anastomotic stenosis in middle rectum, moderate bleeding immediately after dilation. The patient comes every two to three years for balloon dilation and is without complaints. Fig. 21.4 Discrete laceration of the stenosis...

Descending Colon

Splenic Flexure Transverse Colon

Fig. 5.13 Variations of the splenic flexure with different angles between the descending colon and transverse colon. a A high flexure, ca. 180 . b Drooping flexure. Fig. 5.13 Variations of the splenic flexure with different angles between the descending colon and transverse colon. a A high flexure, ca. 180 . b Drooping flexure. creating an angle of 180 Fig. 5.13 . Passage can be especially difficult if the splenic flexure is displaced vertically. In such cases, pushing up the endoscope in the...

Therapy

The first step in therapy of acute pseudoobstruction is the correction of factors supporting it. This includes correcting electrolyte imbalance and other metabolic imbalances. A nasogastric tube should be attached to relieve the upper gastrointestinal tract and the patient should remain on a liquid diet. Forced mobilization and body positioning frequent changing of patient position, lying on the abdomen with raised pelvis can help empty the large bowel of gas. The only...

Anastomotic Leakage

An anastomotic leakage is any ex-traluminal extravasation from the region near the anastomosis. It is defined as a complete defect in the bowel wall near the sur gical line resulting in communication between intraluminal and extraluminal spaces 7 0 2.1, 22.2, Figs. 22.8, 22.9 . Prevalence figures on anastomotic leakage vary according to localization of the anastomosis and reporting author. According to the literature, leakage rates have decreased considerably in - F...

Normal Sigmoid Colon

Sigmoid Colon Pictures

The sigmoid colon is located in the lower left abdomen between the rectum and the descending colon. Its name is derived from its S shape sigma the Greek letter S . The sigmoid colon is completely intraperitoneal, attached and supplied by its own mesentery mesosigmoid to the posterior abdominal wall. Due to its intraperitoneal position, the sigmoid colon is usually highly mobile. However, previous lower abdominal surgery, especially gynecological operations and inflammation e.g., diverticular...

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Bizarre ulcer in the cecum with blood-covered borders. d Flat ulcer on a haustrum in the ascending colon the surrounding area shows no reaction. The patient was using Diclo-fenac. e Bizarre ulceration on the Bauhin valve. Bizarre ulcer in the cecum with blood-covered borders. g Depressed linear ulceration with swollen margins. h Larger, flat ulcer on the Bauhin valve, with a visible vessel on its margin. Large ulcer with swollen borders in the descending colon. g Depressed linear ulceration...

Acute Segmental Hemorrhagic Colitis

Acute segmental hemorrhagic colitis presents clinically with acute lower and middle abdominal pain usually rightsided and hematochezia. Onset is sudden and occurs about four to five days after oral use of penicillin or amoxicillin. Typical signs include spontaneous pain and considerable local tenderness in the right abdomen. Lab tests show increased levels of CRP C-reactive protein and leukocytes. Fever is not present or is only mild diarrhea is not typical. Sonography reveals lacking layering...

Colon Varices and Portal Colopathy

Formation Varices

Sharp increases in portal hypertension related to liver cirrhosis or portal vein thrombosis can cause formation of varices throughout the entire colon Fig. 17.12 . Lymphedema is not present. Bleeding is acute and can be controlled with fibrin glue and hemoclips. Long-term prophylactic measures such as lowering a Thick strands of varices throughout the entire colon. b Varix on the Bauhin valve in the same patient. a Thick strands of varices throughout the entire colon. b Varix on the Bauhin...

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Skin Tags Rectum

Fig. 18.7 Retroflexed instrument in the rectum. Retroflexion allows better evaluation of a flat adenoma located in the distal rectum. Fig. 18.7 Retroflexed instrument in the rectum. Retroflexion allows better evaluation of a flat adenoma located in the distal rectum. Fig. 18.8 Submucosal injection of saline with diluted epinephrine prior to polypectomy of a broad-based polyp. Mucosa is white from vasoconstriction effect. Fig. 18.9 Creating a fluid cushion in the submucosa. Increasing the...

Cqg

Laser is the acronym for Light Amplification by Stimulated Emission of Radiation. A crystal active medium is excited by outside energy to emit particularly intense light waves. One side of the crystal is completely reflective while the other is only partially reflective. The reflectivity of the crystal causes a type of chain reaction amplifying the light beam optical pumping . Only the photons traveling perpendicular to the mirrors are amplified all others escape to the side. When the beam has...

Procedure

The rectum is generally empty at endoscopy and should be carefully insufflated with air. At the rectosigmoid junction or just beyond it there is a point where the lumen is obstructed by torsion of the sigmoid colon Figs. 24.12, 24.13 . The endoscopic aspect is one of a spiraling mucosa. The en-doscopist should attempt to carefully pass this point, though this often means passing along the mucosa without direct vision. If the mucosa is ischemic, the scope should never be advanced without...

Withdrawing the Endoscope and Blind Spots

Distal Sigmoid Polyp

Compared with advancing the scope, withdrawal after reaching the terminal ileum does not pose any technical difficulties. Close inspection of the colon is made on withdrawal, as is the collection of pathological samples and the performance of any necessary diagnostic or therapeutic interventions biopsy, poly-pectomy, etc. . Slowly withdrawing the instrument and per- Fig. 5.32 Polyp in the proximal rectum. a After endoscopic resection, a small remaining polyp piece was visible from distal next...

Differential Therapy Using Fibrin Sealant Clips

Clip application and fibrin glue therapy are two procedures that can certainly complement each other and can even be used simultaneously Fig. 22.16, 0 22.4d-i .The decision on one procedure vs. the other is highly individual and can hardly be regulated. The following considerations are thus intended to be merely suggestions. Clips are more appropriate for fresh wound edges that are not subject to very high tissue tension. Too much tension on the wound edges prevents primary closure or leads to...

Metal stent insertion and positioning technique

There are now a number of manufacturers of self-expanding metal stents for traversing colon stenoses caused by tumor growth. The most common are the Wallstent Enteral and the Ultraflex Precision Boston Scientific , as well as the Z-stent Wilson-Cook , the latter of which is also available as a covered stent especially designed for traversing fistulas. There are two techniques for applying colorectal stents The advantage of endoscopic positioning is better fixation of the rectosigmoid colon with...

Endometriosis

Endometriosis is caused by metaplasia of endometrial tissue. In only 3 of patients does it occur in the intestine small intestine, appendix, colon, rectum , most often in the rectosigmoid. Endometriosis is frequently in the subserosa and is rarely submucosal. If localized in the rectum, there may be narrowing of the lumen with normal mucosa or there may be a polypoid tumor. In extremely rare cases, endometriosis may penetrate the bowel wall intramural to the mucosa, causing menstruation-related...

Fistula Closure and Management of Dehiscence Using Fibrin Sealant

Management Wound Dehiscence

If closure is the aim of therapy, the fistulous tract or wound dehiscence must first be cleaned to ensure longer-lasting closure. Depending on size and extent, endoscopic debridement can be performed with an irrigation probe under radiographic control if possible or even mechanically for larger necrotic cavities, using various instruments e.g., dormia basket . Therapy should be repeated in frequent intervals e.g., every three days until its efficacy is clearly seen. Only...

Preface

Prof Messmann Augsburg

Flexible colonoscopy is now nearly fifty years old. In 1957, the first attempts at constructing a flexible colonoscope were made in Japan by Matsunaga and Hirosaki. Now, almost half a century later, colonoscopy has become a vital part of gastroenterology. Advancements in recent years especially in chip technology have led to previously unseen standards in image quality, which continues to gain in importance, especially in combination with new staining techniques. In addition to the enormous...

Solitary Rectal Ulcer Syndrome

Sigmoid Colon

- F 12.9 Recurrent CD near anastomosis following ileal resection Stenosed ileocolonic anastomosis of ileum and ascending colon, not passable with instrument. Inflammatory changes aphthae, mini-ulcers visible in and around the stenosis. This is a frequent occurrence changes are not usually limited to scarring in this region, and are most likely after intense immunosuppression. b, c Typical attack in the neoterminal ileum. b Stenosed ileocolonic anastomosis of ileum and ascending colon. Here it...

Band Ligation

Endoscopic Hemoclip

Ligation of hemorrhoids is a proved, simple, and inexpensive treatment method Fig. 20.29 . Fig. 20.24 Loading and deploying a hemo-clip Olympus . a The clip is hung on the applicator's extended hook. b Next the clip is drawn into the applicator sheath, thereby closing the clip. The applicator is then advanced through the working channel of the endoscope. c When the tip of the applicator is protruding from the endoscope the clip is advanced. The clip opens on leaving the applicator sheath. d The...

Endoscopic therapy of postpolypectomy bleeding

Spontaneous bleeding from a polyp stalk can be controlled by again positioning the snare around the stalk, closing it, and holding it closed for ca. five minutes. If bleeding does not cease, a second attempt can be made with the snare for five more minutes. Alternative methods of hemostasis include injection therapy, application of hemoclips, and thermal methods such as argon plasma coagulation and the use of BICAP electrodes. For injection therapy, several milliliters of 1 10000 diluted...

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Clostridium Difficile Sigmoid

- T 12.15 Pseudomembranous colitis - - T 12.15 Pseudomembranous colitis - a Initial plaque formation, shown here with reddish halo, evidence of underlying inflammation. a Initial plaque formation, shown here with reddish halo, evidence of underlying inflammation. c Smaller plaques, but already confluent. Yellowish plaques, medium grade sigmoid colon . e Massive confluent plaque formation, chronic course. f Massive confluent pseudomembranes that were so thick that stenosis was suspected in the...

Iatrogenic Foreign Bodies

Plastic Biliary Prosthesis

The second most common category of foreign bodies comprises those of iatrogenic origin, such as probes, balloons or metal plastic prostheses. Biliary prostheses. Plastic biliary prostheses usually pass the bowel spontaneously. However, they can also result in GI tract obstruction. If the prosthesis can be reached, it can be extracted with a forceps or polypectomy snare. Metal stents. Dislodged metal stents such as duodenal enteral stents or colonic stents are problematic because of their size...

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Valvule Bauhin Anatomie

Fig. 22.6 Fistulizing Crohn disease. a Severe initial episode of Crohn disease. Fistulas were first discovered in the duodenum. b The other end of the fistulous tract with several openings in the colon widespread inflammation and ulcers next to the tract. Fig. 22.7 Tiny fistula opening in an indentation next to the Bauhin valve. The fistula ended after a few centimeters in the terminal ileum, which had massive inflammatory changes. T 22.1 Varying aspects of anastomotic leakage - T 22.1 Varying...

Indications and Contraindications

An assessment of the condition of the colonic mucosa is important where there are clinical indications of colitis, i. e., abdominal pain, diarrhea, malabsorption, perianal bleeding as a result of possible intestinal ischemia, inflammation, erosions and ulcers of various geneses, polyps and tumors, diverticula, or vascular malformations. Changes in bowel habits and an increasing tendency toward constipation are cause for performing an endoscopic search for a stricture in the...

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Infectious Colitis

T 12.11 Infectious colitis Campylobacter jejuni colitis T 12.11 Infectious colitis Campylobacter jejuni colitis a-c Terminal ileum and ileocecal valve involvement. a Vascular changes and mild edema in terminal ileum. b Circular ulceration on the ileocecal valve toward small intestine c Ulceration spreading in half-moon shape on the outer side of the ileocecal valve. The infection was already present for almost three months and thus had a tendency toward chronicity. d, e Characteristic...

Lumen Dilation and Pseudoobstruction

Colonic Pseudoobstruction Tube

The term megacolon describes both congenital and acquired forms of colon dilation. In all younger patients with megacolon, the possibility of Hirschsprung disease should be excluded. Hirschsprung disease manifests in the first years of life caused by absence of parasympathetic ganglion cells in myenteric Auerbach and submucosal Meissner plexuses in the rectum. The absence of ganglion cells results in constipation and bowel obstruction. Congenital megacolon Hirschsprung disease ....

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Peutz Jeghers Syndrome

A-c Multiple diminutive polyps, Gardner syndrome. a-c Multiple diminutive polyps, Gardner syndrome. d Improved detection of diminutive polyps using chromoendoscopy, Gardner syndrome. Fig. 9.7 Stalked polyp, Peutz-Jeghers syndrome, Fig. 9.7 Stalked polyp, Peutz-Jeghers syndrome, Given the risk of malignant transformation, treatment consists of a colectomy-proctomucosectomy with ileoanal anastomosis and pouch. Genetic counseling and evaluation, and, if indicated, screening tests, should be...

Magnifying or Zoom Endoscopy

Magnifying or zoom endoscopes enable image enlargement to a point nearly comparable to intravital microscopic examination of the mucosa. Automatic and electronic magnification systems. Enlargement can be achieved using a built-in powered lens system, computer-supported electronic magnification to produce a digitally enlarged image, or a combination of the two. Electronic magnification is technically simpler from an instrument standpoint and does not require moveable parts, but the enlarged...

Positioning the Patient

Positioning For Colonoscopy

Prior to colonoscopy, the patient should be supine for examination of the abdomen. In addition to general clinical examination procedures, special attention must be paid to any surgical scars and hernias inguinal, umbilical, or incisional hernias . At the beginning of the actual colonoscopy, the patient should be in the left lateral position, with his knees bent and pulled up. In this position, perianal inspection is possible, as is digital palpation and the insertion of the endoscope tip into...

Ingested Foreign Bodies

Ingested foreign bodies that pass the pylorus are often harmless, especially in adults, and usually manage to pass the colon, embedded in stool, without causing any problems. Exceptions are bizarre objects with sharp edges, such as chicken bones, which can become wedged transversely in the colon and impact the wall 3 , perforating the bowel. Batteries. Batteries are problematic because they contain toxic and or caustic metallic salts silver oxide, zinc oxide, mercury oxide, or lithium oxide or...

Fistula Closure and Management of Dehiscence IVUsing Clips

The application of an endoclip follows several relatively simple steps. First, the stainless steel clip is loaded onto the clipping device and retracted into the protective Teflon sheath. The loaded application device is then advanced through the working channel of a standard endoscope. As soon as the Teflon sheath comes into view, the clip can be advanced from the sheath. Using traction on the clip applicator, the prongs of the clip can be opened gradually. As the clip opens, the prongs click...

Monopolar and Biopolar Electrocoagulation

In biopolar coagulation an electrical current passes through the tissue between the two electrodes contained in the probe tip Fig. 20.2 . This requires that the tissue not be desiccated dried out as this results in loss of conductivity. Unlike monopolar probe use, the current does not pass through the patient's body, but is limited locally to the targeted tissue area. Loss of conduc- Fig. 20.1 Endoscopic irrigation device Endowasher, MTW . a Irrigation from the working channel of the...

Retroflexed View Rectum

Endoscopie Rectite Radique Apr Plasma

Fig. 13.37 Bleeding from a visible vessel of a resected polyp. b a Visible vessel, protruding from the remaining stalk of a resected c polyp in the sigmoid colon, causing massive rebleeding. Fig. 13.37 Bleeding from a visible vessel of a resected polyp. b a Visible vessel, protruding from the remaining stalk of a resected c polyp in the sigmoid colon, causing massive rebleeding. Epinephrine injection 1 10000 at the resection site. Afterward the visible vessel is clipped and closed with two...

Polyps and Polyposis Syndromes

Colonoscopy Polyps

The term polyp describes a mass of tissue protruding into the lumen of the bowel, without implying pathological relevance. Polyps can be stalked, round, or sessile and can vary in size. They can occur as solitary or multiple polyps. Polypoid lesions are the most common pathological finding of colonoscopy. Polyps can only be classified by histological evaluation. Pathologically and anatomically, polyps of epithelial tissue are distinguished from those of mesodermal tissue and there are also a...

Anatomy of the Colon

Sigmoid Colon Tenia

The endoscopist views the colon from a perspective unlike that of any other visualizing technique, viewing the inner relief of the intestinal skeleton, which is made up of three straplike bands of longitudinal muscles tenia coli and numerous half-moon-shaped cross-folds semilunar folds which give rise to the pouchlike haustra between them Fig. 1.6 . Structure of the intestinal wall. The intestinal wall can be divided microscopically into four layers, the structure of which does not vary...

Learning Examination Technique

Forceps Channel Video Colonoscope

Learning colonoscopy technique requires motivation, manual dexterity, concentration, and patience on the part of the trainee. Already practiced in the technique of endoscopically examining the upper digestive tract, the beginner will learn about similarities and differences related to using a gastroscope vs. using a colonoscope. All endoscopes can be divided into three sections the insertion tube, which is advanced in the patient, the instrument control head, where the physician can maneuver...

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Analkanaltumore

Fig. 11.8 Sessile carcinoid, pale yellow hue, and vascularized surface. Fig. 11.8 Sessile carcinoid, pale yellow hue, and vascularized surface. Treatment of submucosal tumors generally includes complete removal of the lesion, whereby the method depends on size and localization. For larger lesions, only surgical resection can ensure excisional biopsy. Smaller submucosal tumors can be removed endoscopically with a snare. Lipomas and leiomyomas. Lipomas, if asymptomatic, do not have malignant...

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Colonic Lipoma Translucent

A-e Sessile lipomas presenting as submucosal, rounded elevated forms 1-3 cm in size, yellowish color. Their surface s smooth and translucent, soft consistency. a-e Sessile lipomas presenting as submucosal, rounded elevated forms 1-3 cm in size, yellowish color. Their surface s smooth and translucent, soft consistency. f, g Stalked lipomas, round with smooth margins, yellowish color. f, g Stalked lipomas, round with smooth margins, yellowish color. Fig. 11.3 a, b Buttonhole biopsy at same...

Polypectomy and Mucosectomy

Mucosectomy Cap

Indications and Contraindications Endoscopic polypectomy of colorectal polyps is indicated by clinical symptoms to the extent that they are present such as bleeding or occlusion and or early detection or prevention of cancer. Table 18.1 lists indications and contraindications for endoscopic polypectomy. If the patient has any contraindications, the potential risks of polypectomy must be weighed against expected diagnostic or therapeutic benefit 3 . In such cases, procedures must be performed...

Malignant Tumors

Sigmoid Colon

Most colorectal carcinomas are adenocarcinomas, which developed from colorectal adenomas adenoma-carcinoma sequence . Less than 2 of malignancies are nonepithelial malignancies lymphomas or colon metastases of another primary tumor. Adenocarcinomas account for the vast majority of carcinomas in the colon 85 and rectum 90 mucinous adenocarcinomas account for only ca. 13 of carcinomas in the colon and ca. 8 of carcinomas in the rectum. Table 10.1 gives an overview of the histological...

Yid

Fig. 8.25 Substantial purulent secretion from a sigmoid diverticulum, severe diverticulitis. The diverticular neck is eroded and bloody, erosive changes extending from the diverticular neck toward the right and into the haustra. Fig. 8.26 Incidental finding localized diverticulitis in an asymptomatic patient. Stool particles visible in the diverticulum. The diverticular neck is reddened and edematous. The area surrounding the diverticulum does not exhibit any significant inflammatory changes....

Recovering Resected Polyps

Complete retrieval of resected polyps and all resected polyp pieces is essential for ensuring thorough histological diagnosis. Smaller polyp pieces can be either suctioned with the instrument or they may be suctioned and then collected in a trap device attached to the working channel S 18.1e . The disadvantage of suction technique is that, upon withdrawing the instrument, visualization is less than optimal and polyp fragments can be lost, especially in passing the sigmoid colon. Larger polyp...

Argon Plasma Coagulation APC

Argon Plasma Coagulation

Argon plasma coagulation APC transmits energy from ionized argon gas to the tissue without contact between the probe and tissue. Equipment includes a unit for controlling and regulating the supply of argon gas, a high frequency electrosurgical generator, and a flexible application probe Fig. 20.4 . The probe is a 2-mm-thick Teflon tube Fig. 20.5 , which is inserted into the en-doscope's working channel. Energy delivery from the probe tip can go around a corner and there are also probes that...

Thyroid Ticulitis

Thyroid Ticulitis

Fig. 8.14 Differentiating between diverticula and intestinal lumen. a Diverticular openings are round or oval, while intestinal lumen appears slitlike or half-moon shaped. Diverticula are located between haustral folds left half of image the folds converge in the luminal direction right half of image . Diverticular openings are perpendicular to the longitudinal axis of the colon. Fig. 8.14 Differentiating between diverticula and intestinal lumen. a Diverticular openings are round or oval, while...

Ytb

Indigo Carmin Colon

T 9.5 Polyps before and after staining T 9.5 Polyps before and after staining a-f The exact extent of flat adenomas can be better ascertained using staining chromoendoscopy . a-f The exact extent of flat adenomas can be better ascertained using staining chromoendoscopy . Table 9.4 Endoscopic characteristics of histologically different adenomas 9 Table 9.4 Endoscopic characteristics of histologically different adenomas 9 Sessile or stalked thicker stalk than tubular adenoma , medium sized...

Tumour With Ulceration Colon

Karzinom Sigmoid

Generalized lymphoma tends to occur in the left side of the colon and in the rectum. Viewed endoscopically, the affected mucosa appears friable, indurated, and erythema-tous exophytic tumor growth is very rare. Another endo-scopic appearance is characterized by multiple small, slightly raised, or flat elevated, polypoid lesions 0 10.6 . Gastrointestinal Stromal Tumors GIST tumors . In most cases, these are malignant leiomyomas, often accompanied by tumor bleeding. Fig. 10.7 Malignant...

Consistent Tubular Adenoma

Tubulovillous Adenoma

G Better visualization of this villous adenoma on the cecal pole f using chromoendoscopy. h, i Two villous adenomas with nodular contours, fingerlike processes, and tubular growth. Stained with indigo carmine dye. Cancerous tubulovillous adenoma with deformed surface and ulceration at the polyp base lower left edge of image . Villous adenoma with friable surface, some spontaneous bleeding. Malignant transformation on surface. c Wide tubulovillous adenoma, malignant transformation with surface...

Pathology of Malignant Colon Tumors

The vast majority of malignant colon tumors are epithelial adenocarcinomas ca. 80 , while the remainder ca. 20 are mucinous adenocarcinomas. Signet-ring cell carcinomas and undifferentiated carcinomas are very uncommon as are non-epithelial malignant colon tumors e.g., malignant lymphomas and fibrosarcomas , the latter comprising less than 1 of all colon tumors. Malignant lymphoma is primarily localized in the cecum and is infiltrative or polypoid, growing rapidly, and metastasizing early...

Hemoclips

There are a number of reasons which make metal clips an attractive alternative to the more common methods of hemostasis. First, clips allow definitive and secure closure of bleeding vessels 3 and the endoscopist can immediately recognize whether a vessel has been occluded. Another important aspect is that no complications have been reported so far. In a comparative study by Chung et al. 5 on patients with Dieulafoy lesions, some of which were in the colon, the initial hemostasis effect of...

Gsx

Fig. 13.7 Visible vessel on the base of a diverticulum. Fig. 13.7 Visible vessel on the base of a diverticulum. a Visible vessel, protruding near the edge of a small diverticulum. b Closed with a hemoclip Olympus . a Visible vessel, protruding near the edge of a small diverticulum. b Closed with a hemoclip Olympus . Fig. 13.9 Adherent clot on a diverticular orifice. An open diverticular orifice is visible next to this Fig. 13.9 Adherent clot on a diverticular orifice. An open diverticular...

Inspection and Palpation

The examination begins with an inspection of the perianal region. The patient should be in the left lateral position with his knees bent and pulled up. A simple inspection can detect skin changes, scars, anal skin tags, hemorrhoids, anal fissures, anal venous thromboses, fistula, injuries, or prolapse anal or rectal prolapse . Any findings must be noted later in the examination report. Figures 5.1, 5.2 show examples of pathologies detected during inspection. The diagnostic report...

Svl

Fig. 17.14 Venous thrombosis submu-cosa following polypectomy not clinically relevant . Fig. 17.17 Carcinoid tumor in the cecum. a Domeshaped growth behind the Bauhin valve, confirmed with biopsy as a highly differentiated carcinoid tumor. b A carcinoid tumor behind the Bauhin valve. The tumor, which is located in the cecum cannot be identified from this instrument position. pit pattern. For the experienced examiner, certain diagnosis of a lipoma is possible based on endoscopic appearances...

Rdp

Residual Polyp

- T 18.5 Procedure for polypectomy of a broad-based polyp using piecemeal resection technique a-f Polypectomy of a polyp with a very broad base around 5 cm in size, encircling half of the circumference. After creating a fluid cushion by submucosal injection, the polyp is resected in several portions piecemeal polypectomy . a-f Polypectomy of a polyp with a very broad base around 5 cm in size, encircling half of the circumference. After creating a fluid cushion by submucosal injection, the polyp...

Stents

Fibrin Glue For Fistula

In the upper gastrointestinal GI tract, covered wire mesh stents are well suited to traversing fistulas and dehiscences. In the colon, however, this type of stenting is still uncommon, and is reserved for special cases, e.g., traversing complex fistulas caused by malignancy 2 Fig.22.17 . It should also be noted that enteral stents that can be placed endoscopically cannot be used because they are noncovered. Ultimately, an esophageal stent e.g., Ultraflex was used, though it is not officially...

Postoperative Strictures and Suture Granulomas

Postoperative strictures are commonly observed in the anastomosed region of the lower rectum after rectal resection. They are occasionally the result of dehiscence after resection of very low rectal carcinomas. Therapy with balloon dilation can help dilate the stricture. Dilation should be performed step-by-step in intervals of three to four days balloon diameter 15-25 mm . Intestinal resection in Crohn disease can also lead to inflammatory stenosis or scarring Fig....

Introduction Of The Sigmoid Colon

In the thirty years since 1971 when total colonoscopy was first described 16 , significant technical advancements have been made in terms of instrument handling and imaging capability. Nevertheless, colonoscopy remains a procedure requiring manual dexterity and concentration. The experienced examiner can now successfully reach the cecum in 98 of patients and in most cases can also reach the terminal ileum. Difficulties can be posed by a mobile and elongated sigmoid colon or transverse colon as...

Diverticulosis and Diverticulitis

Colonic Diverticulosis

Colonic diverticula are fingerlike outpouchings protruding outward from the intestinal lumen. True and pseudodiverticula. A distinction is made between true diverticula and pseudodiverticula. The seldom-occurring true diverticula are present at birth and usually only appear in the right hemicolon. Pseudodiverticula, which occur much more frequently, are acquired. They can be found anywhere in the colon, though they tend to appear in the left hemicolon. True diverticula are characterized by...

Complications following Polypectomy or Mucosectomy

Possible complications related to polypectomy or mucosectomy include bleeding, perforation, and postpolypectomy syndrome. Bleeding. Bleeding is the most common complication following polypectomy risk of bleeding is 1.7 3, 8 . Bleeding can be spontaneous 0 18.8 a or it may appear with a delay of 7-12 days 0 18.8b . Depending on vessel supply to the resected polyp, bleeding intensity ranges from minimal oozing to arterial, pulsating spurting. Spontaneous bleeding occurs immediately after...

Kaposi Sarcoma

Kaposi sarcoma KS is a neoplastic proliferation of endo-thelium-like cells containing modified smooth muscle cells, which occurs in four forms KS in patients using immunosuppressants, Kaposi sarcoma related to HIV occurs primarily among homosexual men. KS is localized in the skin, mucous membranes, lungs, lymph nodes, gastrointestinal tract, and liver. Diagnosis of KS in the gastrointestinal tract can only be made with the assistance of endoscopy and biopsy. KS presents endoscopically as...

Fistulas and Postoperative Leakages

Perianale Fistel

The formation of fistulas or anastomotic leakages can be associated with inflammatory diseases especially Crohn disease or therapeutic interventions, which lead to disruption in the continuity of the walls of hollow organs Tab. 22.1 . This chapter addresses relevant aspects of these diseases for the colonoscopist. Enterocutaneous fistulas like the perianal fistula in Fig. 22.1 will not be specifically discussed as they are often complex proctological or surgical problems that would be beyond...

How Large Is 5 Mm Polyp

Polyp Specimen Retrieval Traps

D Instruments left to right for polyp retrieval normal polypectomy snare, grasping forceps, four-pronged grasping forceps, dormia basket. e Polyp trap device. The specimen bag is placed in the trap so that suctioned polyp fragments or small polyps remain hanging in the bag. The bag is cut open with scissors to retrieve the polyp fragments. f Polyp retrieval net. The net is placed over the working channel of the instrument and the polyp or polyp pieces are caught in the net. The polyps are...

Sigmoid Volvulus

Sigmoid Volvulus

Fig. 24.5 Endoscopic placement of a decompression tube in the colon based on Seldinger technique from 21 . a Commercially available coaxial decompression tube from WilsonCook with guidewire. b Decompression tube with inner pilot wire to stiffen the tube. c Endoscopic intubation of the colon to the cecum. d Advancing the wire through the endoscope. Careful withdrawal of the instrument under radiographic control , leaving the tip of the wire in the cecum. The decompression tube with the inner...

Looping and Using External Compression Techniques

Normal Sigmoid Colon

Using external compression or splinting techniques can often make the examination much easier for both the patient and examiner and in some cases, it may be the only means of completing ileocolonoscopy. Proper use of compression technique requires close cooperation between the examiner and assistant compression should be performed with targeted, steady pressure without using force. The localization of optimal pressure points is for the most part based on the experience of the examiner and...

Removal of Foreign Bodies in the Rectum

Rectal Foreign Object

The spectrum of objects inserted transanally is extremely varied and a list of possible objects is provided in Tab. 23.3. Motives are mostly sexual or criminal in nature and the type and size of the objects often exceeds the bounds of anatomical and physiological imagination. Transanally inserted foreign bodies often involve the added complication of serious injury to the rectosig-moid and also the sphincter muscles, which often require complex proctological surgical reconstruction. The...

Sigmoid Volvulus Omega Sign

Omega Sign Sigmoid Volvulus

Fig. 24.11 Volvulus in the sigmoid colon. a Radiographic image without contrast agent overdistended sigmoid colon demonstrating typical coffee bean appearance. b Radiographic image after rectal administration of a contrast dye for better visualization of the torsioned sigmoid images provided courtesy of Dr. V. Remplik, Institute for Diagnostic Radiology and Neuroradiology, Augsburg Clinic . a Endoscopic appearance of torsion with spiraling mucosa. b Dilated sigmoid lumen near the volvulus....

Normal Ascending Colon

Sigmoid Colon

The ascending colon runs near the right flank between the hepatic flexure and the ileocecal valve. Similar to the descending colon, the ascending colon is fixed to the dorsal abdominal wall and thus only slightly mobile, running relatively straight. The length of the ascending colon is variable, on average around 15-20 cm. However, it is occasionally very short, so that immediately after passing the hepatic flexure the ileocecal valve is reached. At the other extreme is a very long ascending...

Proximal Colon

Transillumination Caecum

After passing the hepatic flexure, the view opens up to the proximal segments of the large intestine. In addition to the capacious ascending colon, the cecal pole and ileocecal valve are often visible at the end of the field of vision Fig. 5.17 . Often after passing the hepatic flexure, there can be a certain unnecessary advancement of the endoscope in the more distal colon segments. Thus, after positioning the endoscope tip securely in the ascending colon, it is recommended that the endoscope...

Advancing the Endoscope in the Sigmoid Colon Sigmoidoscopy

Doublebarrel Colostomy

After reaching the rectosigmoid junction about ca. 16 cm proximal to the anocutaneous line, the endos-copy of the sigmoid colon begins. The sigmoid colon is situated intraperitoneally and is highly variable in length. The junction between rectum and sigmoid colon often appears as an acute bend in the lumen. The sigmoid colon can also be recognized by its prominent, circular folds. Passing the sigmoid colon with the patient lying in the left lateral position is unproblematic in...

Sigmoid Colon Infection

Cytomegarovirus Colitis Pathology

D, e Acute ulcerative colitis of uncertain genesis presumed cytomegalovirus infection was ruled out. Colon ulcer with adherent clot d . Visible vessel was seen after irrigation and removal of the clot and was closed with a hemoclip Olympus e . f Mild, acute hemorrhagic colitis in left hemicolon. No pathogen isolated. g, h Acute colitis with hemorrhagic erosions g and submucosal hemorrhages h . No pathogen detected. Acute colitis with massive mucosal edema, isolated hemorrhaging, and small,...

The Colonoscopy Workstation

Pump Disinfection Endoscope

Layout and instrumentation in modern endoscopy units, where colonoscopy is performed under quality control, are designed according to normative standards, and also conduct regular hygiene checks. The design of the colonoscopy workstation should meet not only the requirements of an ergonomic examination procedure and a patient-friendly atmosphere, but also must comply with regulations concerning ventilation and installation of electrical equipment. Keeping dust, micro-organisms and odors to a...

Melanosis Coli

Pseudomelanosis Coli

Melanosis coli presents as dark brown pigmentation of the mucosa that may have a zebra-striped or reticulated appearance. The pigment, which is actually not melanin, but rather lipo-fuscin, is deposited extracellularly in macrophages. Because the pigment is not melanin, this phenomenon is also correctly called pseudomelanosis coli. Mosaiclike brown mucosal coloration. Tiny polyps usually remain lighter in color. Mosaiclike brown mucosal coloration. Tiny polyps usually remain lighter in color....

Submucosal Tumors

As the term indicates, submucosal tumors are characterized by growth exclusively in the submucosa. Submucosal tumors occur much less frequently in the colon than in the upper gastrointestinal tract. Submucosal tumors are primarily carcinoid and non-epithelial tumors. Based on the WHO classification and nomenclature of colorectal tumors, submucosal tumors can be classified as nonepithelial tumors and carcinoid tumors Tab. 11.1 . Table 11.1 Classification of submucosal tumors Nonepithelial tumors...