Differential Therapy Using Fibrin SealantClips
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
Endoscopic debridement. 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
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...
Iii Eng
- 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
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...
Iii Mrx
- 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
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...
Iv Ohh
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
Indications. 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...
Iii Axc
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
Megacolon. 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 ....
Iii Ekr
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
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...
Iii Mut
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...
Anatomy of the Colon
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
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...
Iii Xer
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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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 1
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
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...
Iii 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 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...
Iii 1
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...
Iii Ytb
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...
Iii Lpc
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...
Iii Rpl
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...
Solitary Rectal Ulcer Syndrome
Solitary rectal ulcer syndrome describes a solitary ulcer surrounded by normal appearing rectal mucosa. Patients present with tenesmus and a feeling of anal obstruction. Blood and mucus appear in stool. Using either a rigid rectoscope or a flexible sigmoidoscope the rectum should be inspected up to the rectosigmoid junction. An ulcer 0.5-2.0 cm in size can usually be found between 6 and 13 cm from the anus on the anterior rectal wall, surrounded by normal appearing mucosa. flat ulcer with...
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...
Iii 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
Inspection. 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...
Iii 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...
Iv Rdp
- 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
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. 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...
Polypectomy and Mucosectomy
Indications and Preparing for Polypectomy and Instrumentation Polypectomy Small Stalked Sessile Malignant Polyps Mucosectomy Recovering Resected Polyps or Follow-up Surveillance after
Diverticulosis and Diverticulitis 1
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 1
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...
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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...