Atlas of Clinical GI Endoscopy 2012 PDF

ATLAS OF CLINICAL GASTROINTESTINAL
ENDOSCOPY
ATLAS OF CLINICAL GASTROINTESTINAL
ENDOSCOPY Third Edition
C. Mel Wilcox, MD, MSPH

Professor of Medicine
Division of Gastroenterology and Hepatology
University of Alabama at Birmingham
Birmingham, Alabama
USA
Miguel Muñoz-Navas, MD, PhD

Professor of Medicine
Director of Gastroenterology Division and Endoscopy Unit
Division of Gastroenterology
University Hospital of Navarra
University of Navarra
Pamplona
Spain
Joseph Sung, MD, PhD

Mok Hing Yiu Professor of Medicine
Vice Chancellor and President
The Chinese University of Hong Kong
Shatin, Hong Kong
China
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF CLINICAL GASTROINTESTINAL ENDOSCOPY, THIRD EDITION ISBN: 978-1-4377-1909-3
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Library of Congress Cataloging-in-Publication Data

Wilcox, C. Mel.
Atlas of clinical gastrointestinal endoscopy / Charles Wilcox, Miguel Muñoz-Navas, Joseph J.Y. Sung.
– 3rd ed.
p. ; cm.
Includes index.
ISBN 978-1-4377-1909-3 (hardcover : alk. paper)
I. Muñoz-Navas, Miguel. II. Sung, Joseph J. Y. (Joseph Jao Yiu), 1959- III. Title.
[DNLM: 1. Endoscopy, Gastrointestinal–Atlases. 2. Gastrointestinal Diseases–pathology–Atlases. WI 17]
616.33075450022’3–dc23
2011040113
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Printed in China
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To all those who helped me collect these images as well as to my wonderful family
for providing me the time to compile this labor of love.
C. Mel Wilcox, MD, MSPH
This book is dedicated to my wife, Lucia, my children, Miguel, Javier, and Ina, for
their love, patience, and support, and my granddaughter, Ema, who has given me
so much joy. I must especially thank my parents, Calixto and Maria (may they rest
in peace), to whom I owe what I am, and my late father-in law, Antonio, who would be
very proud of this publication.
To my wife, Rebecca Wong.

ACKNOWLEDGMENTS
I would like to thank my colleagues of the Endoscopy Unit of the University of Navarra
Clinic—Dr. Jose Carlos Subtil, Dr. Cristina Carretero, Dr. Maite Betes, Dr. Maite Herraiz,
Dr. Susana de la Riva, Dr. Cesar Prieto, and Dr. Ramon Angos—for their invaluable
collaboration and support. I also wish to express my gratitude to my colleagues and friends
who gave us some excellent pictures: Dr. Onofre Alarcon, Dr. Fernando Alberca,
Dr. Bartolome Garcia-Perez, Dr. Ignacio Fernandez-Urién, Dr. Cristian Gheorghe,
Dr. Pedro Gonzalez-Carro, Dr. Juan Manuel Herrerias, Dr. Javier Jimenez-Perez, Dr. Sacha
Loiseau, Dr. Akiko Ono, Dr. Javier Pardo-Mindan, Dr. Francisco Perez-Roldan, Dr. Pedro
Redondo, Dr. Jesus Javier Sola, Dr. Alberto Tomas, Dr. Jose Luis Vazquez-Iglesias,
Dr. Francisco Vida, Dr. Michael Wallace, and Dr. Jose Luis Zubieta.
My heartfelt gratitude to my colleagues at the Institute of Digestive Diseases who

contributed to the pictures in this project: Dr. James Lau, Dr. Y. T. Lee, Dr. Justin Wu, and
Dr. Larry Lai. I would also like to thank Mr. Alan Fok and Ms. Ashur Lam for their
assistance in digitizing these pictures.
ix
CHAPTER
1
Oropharynx and
Hypopharynx
INTRODUCTION
The oropharynx is the gateway to the proximal gastrointestinal tract. Al-
though visualized daily by endoscopists, a thorough examination may
not be routine. With the expanding patient base of immunocompro-
mised patients, inspection of the oropharynx, particularly in patients
with esophageal symptoms, should be part of every examination. Oro-
pharyngeal abnormalities can suggest underlying esophageal disease in
these patients, and oropharyngeal lesions may be the first manifestation
of an underlying systemic disorder. Asymptomatic malignant disease
may also be detected. With increasing appreciation of the extraesopha-
geal manifestations of gastroesophageal reflux disease, hypopharyngeal
examination assumes an even greater role. A thorough knowledge of
hypopharyngeal anatomy is thus essential for all endoscopists.
2 Atlas of Clinical Gastrointestinal Endoscopy
Uvula and FIGURE 1.1 OROPHARYNX

soft palate Normal pharynx as viewed with an endoscope, demonstrating the
junction of the hard and soft palate, uvula, and posterior pharynx.
Palatopharyngeal
arch Hard palate
Palatoglossal
arch
Palatine
tonsil
Epiglottis
Vocal cords
Aryepiglottic fold
Piriform sinus
FIGURE 1.2 LANDMARKS OF THE OROPHARYNX AND HYPOPHARYNX

With the endoscope advanced under direct vision, the inferior portion of the uvula is seen at the base of the tongue. Notice that the
image is inverted (top left). With further advancement, the superior portion of the epiglottis is identified (top right). Advancement
anteriorly ends at the attachment of the epiglottis, termed the valleculae (bottom left). To enter the hypopharynx, the endoscope is
advanced posteriorly behind the epiglottis into the hypopharynx (bottom right). The epiglottis appears to form a roof over the
hypopharynx. The vocal cords are surrounded by the aryepiglottic folds anteriorly. In this position, the piriform recesses or sinuses are
on the lateral side of the aryepiglottic folds. The cricopharyngeus and entrance to the esophagus are in the midline posteriorly.
Atlas of Clinical Gastrointestinal Endoscopy 3
FIGURE 1.3 DIRECTION TO

CRICOPHARYNGEUS
The endoscope is passed over the tongue
and uvula (upper left). Once past the uvula,
the epiglottis and hypopharynx are seen
in the distance. A nasogastric feeding tube
is now present (upper right). The
arytenoids are now visible with the
feeding tube seen posterior in the midline
(bottom left). The arytenoids are open and
the vocal cords visible. Again, the feeding
tube is posterior in the midline showing
the location of the cricopharyngeus
(bottom right).
FIGURE 1.4 VOCAL CORDS

Normal vocal cords and surrounding structures as seen from the
arytenoids.
A B
FIGURE 1.5 HYPOPHARYNX

A, Normal-appearing hypopharynx as seen on high-definition endoscopy. B, Narrow
band imaging of the hypopharynx.
FIGURE 1.6 HYPOPHARYNX WITH
ENDOTRACHEAL TUBE
Note the anatomy of the hypopharynx
with endotracheal intubation.
FIGURE 1.7 PATENT UPPER ESOPHAGEAL

SPHINCTER
After endoscope removal, the upper
esophageal sphincter remained patulous.
Note its location relative to the
cricopharyngeus, confirming the posterior
location of the upper esophageal sphincter.
Also note the erythema of the hypopharynx
and arytenoids.
Upper
esophageal
sphincter
FIGURE 1.8 TRACHEA AND CARINA

View of the (A) trachea and (B) carina at
endoscopy. Note the ringlike architecture
of the trachea.
A B
Base of tongue
Ridge at base
of epiglottis
Valleculae
Piriform sinus
Epiglottis
Valleculae
Cricopharyngeus
Hyoid bone
Vocal cord
Esophagus
FIGURE 1.9 BARIUM STUDY OF HYPOPHARYNX AND ESOPHAGUS

A, Anteroposterior view demonstrates the base of the tongue, valleculae, piriform sinuses, and ridge at the base of the epiglottis.
B, Lateral view demonstrates the valleculae; hypopharynx; piriform sinus; cricopharyngeus, with some contrast seen in the esophagus;
and hyoid bone.
A B
FIGURE 1.10 TORUS PALATINUS

A, This large, masslike abnormality on the hard palate is an exaggeration of a normal structure, resulting from a bony exostosis of the
midline palatal suture. B, Nodular structure on the distal hard palate.
Differential Diagnosis
Aphthous Ulcer (Figure 1.11)
Infectious causes
Herpes simplex virus
Syphilis
Zoster
Histoplasmosis
Noninfectious causes
Systemic lupus erythematosus
T-cell disorders
Human immunodeficiency virus infection
FIGURE 1.11 APHTHOUS ULCER

Shallow, well-circumscribed ulceration on
the hard palate. This patient had active
inflammatory bowel disease (see
Figure 5.36).
A B
C D
FIGURE 1.12 HUMAN IMMUNODEFICIENCY VIRUS (HIV)-ASSOCIATED APHTHOUS ULCER

A, This large ulcer extends from the uvula to the soft palate. These lesions are frequent in patients with acquired immunodeficiency
syndrome (AIDS) and may occur on the tongue or buccal mucosa or in the hypopharynx. They may become large, simulating an
infectious or neoplastic process. B, Deep ulcer on the lateral aspect of the tongue. Note in the distance a well-circumscribed, similar-
appearing ulcer is present on the hard palate. C, Well-circumscribed, clean-based ulcer on the tongue. D, Multiple ulcerations on the
lower lip. This patient with severe odynophagia also had a large idiopathic esophageal ulceration.
FIGURE 1.13 HAIRY TONGUE

A, Yellowish coating of the tongue. B,
Close-up shows a furry appearance
resembling hair. This disorder, of
unknown etiology, is characterized by
hypertrophy of the filiform papillae.
A B
A B C
FIGURE 1.14 PEUTZ-JEGHERS SYNDROME

Multiple black hyperpigmented lesions of the (A) lips, (B) buccal mucosa, and (C) hard palate.
FIGURE 1.15 OSLER-WEBER-RENDU SYNDROME

Multiple ectasias of the (A) lips and tongue, (B) tongue, (C) palate, and (D) hypopharynx.
B C D
FIGURE 1.16 HERPES SIMPLEX VIRUS

STOMATITIS
A, Characteristic lesions of herpes simplex
virus stomatitis include diffuse ulceration
of the lips (top left, top right), tongue (top
right), hard and soft palate (bottom left),
and posterior pharynx (bottom right).
These lesions may also extend into the
hypopharynx or to the squamous mucosa
surrounding the lips or nares. B, Shallow
ulceration on the lower lip, tongue, and
the angle of the lips on the right (C).
B C
FIGURE 1.17 HERPES SIMPLEX VIRUS

STOMATITIS
A, Shallow ulceration on the hard
palate associated with several small
ulcerations. B, The ulceration extends
to the epiglottis toward the vocal cords
and aryepiglottic folds.
A B
FIGURE 1.18 HERPES SIMPLEX VIRUS STOMATITIS

Shallow ulceration on the lower lip, tongue, and face extending
to the nares.
FIGURE 1.19 VARICELLA

Nodularity and shallow ulceration of the hypopharynx involving the arytenoid region of
the larynx. Note the friability of the mucosa.
B C
FIGURE 1.20 OROPHARYNGEAL CANDIDIASIS

A, Multiple white and yellow plaques on the hard and soft palate and buccal mucosa. In this patient, the tongue appears to be spared.
Occasionally, the lesions will be identified in the hypopharynx when the endoscope is passed under direct vision. B, Normal-appearing
oropharynx in a patient with Candida esophagitis (top left). This patient was not receiving antifungal therapy, highlighting the fact that
thrush may be absent in patients with esophageal candidiasis. C, Erythematous type of oropharyngeal candidiasis. Note the
erythematous areas on the hard palate with minimal plaque material seen.
FIGURE 1.21 MUCORMYCOSIS

Necrotic-appearing hard and soft palate in this
immunocompromised patient. There was also pronounced
periorbital and facial swelling.
FIGURE 1.22 EPIGLOTTITIS

A, An ulcer is identified on the superior
portion of a markedly edematous
epiglottis. B, The distal portion of the
epiglottis and the arytenoids are also
edematous. Endoscopy was performed
for dysphagia and hoarseness. After
antibiotic therapy, all symptoms resolved.
A B
FIGURE 1.23 EPIGLOTTITIS

A, The epiglottis is markedly edematous
with overlying erosions. B, The arytenoids
are also edematous with erosive lesions.
A B
FIGURE 1.24 CAUSTIC INGESTION

Severe edema and hemorrhage in the hypopharynx. The vocal
cords are seen in the distance. The patient had no lesions in the
pharynx after ingestion of acetic acid. Further mucosal injury was
seen in the esophagus and stomach (see Figure 2.157).
A B C

Diffuse ulceration of the lips (A) and hypopharynx (B) 24 hours after caustic ingestion. The patient is intubated. C, Diffuse edema and
ulceration of the hypopharynx 4 days later.
FIGURE 1.26 RADIATION INJURY

Diffuse erythema of the hypopharynx,
epiglottis, and aryepiglottic folds. Note
the pronounced neovascularization and
pinpoint ectasias similar to what occurs in
other areas of the gastrointestinal tract
after radiation therapy (A, B).
A B
FIGURE 1.27 ARYTENOID CYST

Cystic structure with overlying normal vascular pattern in the
hypopharynx.
FIGURE 1.28 CONDYLOMA

Small, whitish, verrucous-appearing lesion on the hard palate.
A B
C1 C2
FIGURE 1.29 SQUAMOUS PAPILLOMA

A, B, Nodular mass lesion just proximal to the left piriform sinus with overlying verrucous appearance typical for a papilloma. C1, C2,
Inflamed squamous epithelium with an edematous fibrovascular core consistent with squamous papilloma.
FIGURE 1.30 EXTRINSIC COMPRESSION

Submucosal masslike lesion causing extrinsic compression of the
left hypopharynx.
FIGURE 1.31 LICHEN PLANUS

Plaquelike white lesions of the buccal mucosa (A–C).
B C
FIGURE 1.32 FIBROSARCOMA

Small, masslike lesion occupying the space just proximal to the
vocal cords. The lesion was seen to move with respirations.
A B
C D
FIGURE 1.33 KAPOSI’S SARCOMA

A, Reddish plaquelike lesions of the hard and soft palate. B, Verrucous-appearing purple lesion on the hard palate. C, Diffuse, flat
purple lesion on both the soft and hard palate. Accompanying gastric lesions are typical (see Figure 3.156). D, Kaposi’s sarcoma lesion
on the superior portion of the epiglottis. Note the associated edema, with loss of vascularity of the epiglottis. E, Characteristic skin
lesions.
FIGURE 1.34 SQUAMOUS CELL CARCINOMA

A, Ulcerative lesion in the right piriform sinus associated with edema and distortion of
the aryepiglottic folds. A nasogastric tube can be seen entering the esophagus,
demarcating the normal landmarks. B, The arytenoids and aryepiglottic folds are
distorted, with fresh blood present (B1). A necrotic ulcerated lesion is apparent in the
left piriform sinus (B2). This patient underwent endoscopy for dysphagia, during which
a squamous cell carcinoma of the distal esophagus was also found. C, Ulcerated
nodular lesion just proximal to the left piriform sinus involving the arytenoids.
B1 B2 C

Submucosal masslike lesion arising from the piriform sinus at
the upper esophageal sphincter. Note the compression on the
aryepiglottic folds.
FIGURE 1.36 MELANOMA

Submucosal mass-like lesion just proximal to
the aryepiglottic folds (A, B).
A B
FIGURE 1.37 LEUKEMIA

Diffuse edema and exudate of epiglottis
(A) and hypopharynx with erosion on the
left aryepiglottic fold (B). This patient
had leukemic infiltrates throughout the
gastrointestinal tract (see Figures 2.74
and 5.207).
A B
Vocal Cord Granuloma (Figure 1.38)
Differential diagnosis of vocal cord nodules
Nodules typically are bilateral
Polyps
Gastroesophageal reflux disease
Allergies
Neoplasm
FIGURE 1.38 VOCAL CORD GRANULOMA

A small, benign-appearing lesion on the left true vocal cord
diagnostic for a granuloma. There is no overlying epithelium
on the lesion.
FIGURE 1.39 VOCAL CORD INJURY WITH INTUBATION

The vocal cords are edematous with a dark area representing
trauma. Note the flame hemorrhages emanating from the cords
typical for reflux of acid associated with intubation.
FIGURE 1.40 VOCAL CORD LEUKOPLAKIA

White, plaquelike lesion involving the true vocal cords.
FIGURE 1.41 HYPOPHARYNGEAL RECONSTRUCTION

Note the color of the mucosa and associated hair. This patient had
hypopharyngeal surgery with a skin flap. This was the area of the
upper esophageal sphincter.
FIGURE 1.42 LATERAL

PHARYNGOTOMY WITH FLAP
In the left pharynx, suture material is seen
(A). More distally, note the distinction in
color between the right and left pharynx
(B). Resection was performed and a
forearm flap used in this dark skinned
individual.
A B
FIGURE 1.43
PEMPHIGUS VULGARIS
A, Marked erythema,
exudates, and whitish
mucosal changes of
the hypopharynx
involving the
arytenoids. B, Shallow
ulcer of the lip.
(B courtesy
P. Redondo, MD,
Pamplona, Spain.)
A B
FIGURE 1.44 BULLOUS PEMPHIGOID

A, Erosive lesion at the junction of hard and
soft palate. B, The erosive lesion extends to
the right hypopharynx involving the
epiglottis. Bullous lesions of the (C) hands
and (D) feet. (C, D courtesy P. Redondo,
MD, Pamplona, Spain.)
A B
C D
A B C
FIGURE 1.45 TRACHEAL BLEEDING

A, B, Fresh blood is seen to emanate from the vocal cords. C, Active bleeding from the tracheostomy site.
CHAPTER
2
Esophagus
INTRODUCTION
The esophagus is a muscular tube 20 to 23 cm in length, functioning as a
conduit from the oropharynx to the stomach. It begins at the level of the
sixth cervical vertebra and at approximately 15 to 17 cm on the standard
endoscope. Endoscopically, it is characterized by a whitish color typical
for squamous mucosa. Along the course of the esophagus, impressions
from the trachea and aortic arch may be identified. Mediastinal abnor-
malities may also manifest in the esophagus. The gastroesophageal (GE)
junction is located 38 to 40 cm from the incisors and is easily recognized.
A more proximal location of the junction suggests a hiatal hernia or
Barrett’s esophagus. The most common esophageal abnormalities
encountered by endoscopists relate to reflux disease and its complica-
tions, primary neoplasms, and opportunistic infections.
FIGURE 2.1 UPPER ESOPHAGEAL SPHINCTER

The cricopharyngeus muscle is contracting. The proximal
esophagus is in the distance.
FIGURE 2.2 MIDESOPHAGUS

The esophageal mucosa has a whitish
appearance with a delicate vascular pattern
(A) highlighted by narrow band imaging (B).
A B
FIGURE 2.3 VASCULAR PATTERN AT THE GASTROESOPHAGEAL

JUNCTION
Multiple linearly arranged blood vessels are present proximal to
the gastroesophageal junction.
FIGURE 2.4 GASTROESOPHAGEAL

JUNCTION
A, The squamous mucosa and blood vessels
end abruptly with a well-demarcated
margin. The orange mucosa of the stomach
is opposite the esophageal mucosa. B, Note
the crisp distinction between the squamous
mucosa and the orange appearance of the
gastric mucosa. In this case, a paucity of
blood vessels appears in the distal
esophageal mucosa. C1, C2, The
gastroesophageal junction is well delineated
by narrow band imaging.
A B
C1 C2
FIGURE 2.5 GASTROESOPHAGEAL JUNCTION WITH OPENING FIGURE 2.6 RETROFLEX VIEW OF THE GASTROESOPHAGEAL
OF THE LOWER ESOPHAGEAL SPHINCTER JUNCTION
The normal demarcation between the white squamous mucosa Retroflexion demonstrates demarcation of the gastroesophageal
and pinkish orange gastric mucosa. junction, where squamous mucosa can be seen encircling the
endoscope.
A B
FIGURE 2.7 BARIUM ESOPHAGRAM

A, Barium esophagram shows normal esophageal contour and luminal diameter. The esophageal mucosa is proximal to the barium
column. The esophageal walls are smooth and symmetric. Air bubbles are present at the proximal column of barium. The esophagus can
be seen entering the stomach at the gastric air bubble. B, With the esophagus collapsed, the esophageal folds are delicate and smooth.
FIGURE 2.8 NORMAL STRATIFIED SQUAMOUS EPITHELIUM

Vascular channels are seen in the epithelium. Portions of the
basal epithelium are present.
FIGURE 2.9 TRACHEAL IMPRESSION

Tracheal impression on the proximal esophagus.
A C
Splaying
of trachea
Enlarged
D1 D2 aortic arch
FIGURE 2.10 AORTIC IMPRESSION

A, Indentation on the midesophagus from an ectatic aorta. The indentation is smooth and unilateral. B, The normal diameter of
the esophageal mucosa is diminished by extrinsic compression; the overlying mucosa is normal. C, With systole, the esophageal lumen
is further compressed. D1, Extrinsic compression in the proximal midesophagus. D2, Chest x-ray film demonstrates splaying
of the trachea with an enlarged aortic arch. L indicates the left side.
Continued
Slight extrinsic
compression
related to
aortic arch
D3

D3, Barium swallow shows slight extrinsic compression related to the aortic arch.
A B

A, Extrinsic compression posteriorly in the midesophagus. Erosions are present on the lesion. B, The contrast-filled esophagus is
compressed posteriorly by an ectatic aorta.
FIGURE 2.12 TERTIARY ESOPHAGEAL CONTRACTIONS

A, Multiple tertiary contractions observed in a patient with dysphagia. B, Tertiary
contractions occur during endoscopy as well. C, Simultaneous contractions on
esophageal manometry.
A B C
A B
FIGURE 2.13 CORKSCREW ESOPHAGUS

A, Endoscopic images show circular folds resembling a corkscrew. B, Corresponding barium esophagram.
FIGURE 2.14 FELINE ESOPHAGUS

Multiple simultaneous smooth muscle contractions result in this
ringlike appearance.

REFLUX DISEASE (GERD)
A1, Typical appearance of erosive
esophagitis, with linear erythematous
streaks and central ulceration emanating
from the gastroesophageal junction.
Between the lesions, the squamous
epithelium is normal. A2, With the lumen
collapsed, the ulcerations reside primarily on
the surface of the normal esophageal folds.
B1, B2, Typical linear ulcerations emanating
from the gastroesophageal junction.
C, Multiple linear ulcerations in the typical
A1 A2 pattern.
B1 B2
C
A B C
D1 D2 E1
E2 F G
FIGURE 2.16 GASTROESOPHAGEAL REFLUX DISEASE

A, Single linear erosion in the distal esophagus. B, Erythematous erosions at the GE junction. Note the patulous sphincter. C, Streaks of
exudate in the distal esophagus. D1, Exudate at the GE junction, which is almost confluent. D2, More proximally, the exudate takes on
a linear migration typical for GERD. E1, Circumferential ulceration at the GE junction above a patulous sphincter. E2, More proximally,
the mucosa takes on the appearance of multiple, well-circumscribed, squamous “islands” caused by edema with intervening mucosal
erosion. F, Circumferential ulcer with fresh bleeding and luminal narrowing above a patulous GE junction. G, Patulous GE junction
above a hiatal hernia associated with multiple scars from prior disease. Note the linear erosions.
Continued
H I J
FIGURE 2.16 GASTROESOPHAGEAL REFLUX DISEASE

H, Note that some of the exudate has a plaquelike appearance in this patient with a patulous GE junction and hiatal hernia. I, The
exudate and ulceration have coalesced. The mucosa has a nodular appearance. J, Note the circumferential ulceration ends abruptly at
the GE junction.
Gastroesophageal Reflux Disease (Figure 2.16)
Infection
Cytomegalovirus
Herpes simplex virus
Other infections
Pill-induced esophagitis
Caustic ingestion

REFLUX DISEASE
A, The linear ulcers are becoming
circumferential and deep. The
gastroesophageal junction seen in the
distance is patulous, and the proximal
portion of a hiatal hernia is present.
B, Severe disease with circumferential
ulceration, overlying exudate, and loss of
the normal mucosal pattern. The diffuse
abnormality extends proximally from the
normal-appearing gastroesophageal
junction.
A B
E1
A C
B D
E2
FIGURE 2.18 SEVERE GASTROESOPHAGEAL REFLUX DISEASE

A, Narrowing in the distal esophagus associated with circumferential ulceration. B, More proximally the ulceration is
hemicircumferential. C, In the midesophagus, the ulceration takes on the typical linear ulceration. D, Near the upper esophageal
sphincter, no exudate is present, but erythema and evidence of scarring exist. E1, E2, Esophageal wall thickening on CT scan.
A1 A2
B1 B2 B3
FIGURE 2.19 SEVERE ESOPHAGITIS ASSOCIATED WITH GASTRIC OUTLET OBSTRUCTION

A1, Gastric bile stained fluid present in the distal esophagus. A2, After aspiration, the diffuse nodularity and ulceration are evident.
B1, Bilious fluid is present in the distal esophagus associated with erosions. B2, The stomach is full of bilious fluid because of pyloric
obstruction. B3, After aspiration of the fluid, severe erosive esophagitis is evident.
A B C
FIGURE 2.20 BLEEDING GASTROESOPHAGEAL REFLUX DISEASE

A, Arterial bleeding in the distal esophagus. B, Thermal probe applied to the area of bleeding. Note the circumferential erosive
esophagitis. C, Hemostasis achieved with a coagulation “footprint” remaining.
A B C
FIGURE 2.21 IRREGULAR Z LINE

A, Irregular squamocolumnar junction associated with a
hiatal hernia. B, Irregular squamocolumnar junction associated
with a hiatal hernia. C, Mild narrowing at the GE junction
suggestive of a ring above a hiatal hernia. Note the patches of
gastric mucosa above the ringlike structure. This may suggest
patches of Barrett’s mucosa. D, Biopsy confirms gastric
D
cardia mucosa without specialized intestinal epithelium.
A B C
FIGURE 2.22 BARRETT’S ESOPHAGUS

A, Typical-appearing Barrett’s mucosa emanating from the GE
junction. B, Tongue of Barrett’s mucosa with a small squamous
island. C, Two tongues of Barrett’s mucosa extending from the
GE junction. D, Normal squamous mucosa (left) with gastric
epithelium. Goblet cells are present in the gastric epithelium,
indicating intestinal metaplasia. E, The goblet cells are
highlighted with Alcian blue staining. The large vacuoles are
D
purple blue.
A1 A2 A3
A4 A5 B1
B2 B3 B4
B5
FIGURE 2.23 BARRETT’S

MUCOSA
A1-A5, Typical tongues of
Barrett’s mucosa of variable
lengths emanating from the
gastroesophageal junction.
B1-B5, The Barrett’s mucosa is
well delineated by narrow band
imaging. C, Biopsy of the
squamocolumnar junction shows
squamous tissue, as well as
columnar-lined intestinal mucosa
with plentiful goblet cells.
C
A B
C1 C2
Squamous
D1 mucosa D2
FIGURE 2.24 BARRETT’S MUCOSA WITH SQUAMOUS ISLAND

A, Long-segment Barrett’s mucosa with island of squamous mucosa. B, Barrett’s segment between squamous mucosa. The Barrett’s
mucosa shows dysplasia. C1, C2, Postoperative specimen shows the long-segment Barrett’s mucosa. D1, D2, Several areas of
squamous mucosa are identified in the Barrett’s mucosa.
FIGURE 2.25 LONG-SEGMENT BARRETT’S

ESOPHAGUS
A, Long segment of Barrett’s esophagus
extending from the GE junction. B, Note the
mucosa has a pale appearance with visible
blood vessels.
A B
A B C
D E F
G H
FIGURE 2.26 SHORT-SEGMENT BARRETT’S ESOPHAGUS

A, Short tongue of Barrett’s mucosa at the GE junction. B, Short-segment Barrett’s mucosa extending just proximal to the GE junction.
Note the two associated small Barrett’s patches. C, Small patch of Barrett’s mucosa that appears distinct from the GE junction. D,
Circumferential short-segment Barrett’s mucosa with an additional associated patch. E, Areas of short-segment Barrett’s mucosa
above a hiatal hernia. F, Short-segment Barrett’s mucosa as seen by high-definition endoscopy. G, Narrow band imaging also shows a
short segment of Barrett’s mucosa. H, Several areas of Barrett’s mucosa above a hiatal hernia proximal to the most proximal portion of
the gastric folds.
FIGURE 2.27 BARRETT’S ULCER

A, Ulceration with heaped-up margins in
the distal esophagus. B, The ulceration
becomes circumferential distally and has a
black base, indicating necrosis. The
gastroesophageal junction appears in the
distance. C1, Occasional goblet cells
indicate Barrett’s metaplasia of the
intestinal type. C2, Ulcerative esophagitis
with granulation tissue and gastric
epithelium.
A B
C1 C2
A B C
FIGURE 2.28 BARRETT’S ULCER

A, Proximal extent of long-segment Barrett’s mucosa to the midesophagus. B, Long midesophageal ulcer on a background of Barrett’s
mucosa. C, The ulcer extends to but does not involve the GE junction. Note the surrounding Barrett’s mucosa.
FIGURE 2.29 CONFOCAL
ENDOMICROSCOPY OF NORMAL AND
ABNORMAL ESOPHAGEAL LESIONS
A, Normal squamous tissue. B, Intestinal
metaplasia. Note the presence of goblet
cells. C, High-grade dysplasia. D,
Adenocarcinoma (note the disruption of the
normal architecture). (D courtesy Don’t
Biopsy Study.)
A B
C D
A B
C1 C2 D
FIGURE 2.30 BARRETT’S MUCOSA WITH DYSPLASIA

A, Flat hyperemic area in the midesophagus. B, The biopsy specimen shows high-grade dysplasia. C1, C2, Narrow band imaging shows
the abnormal tissue with a distinct demarcation. Note the intraepithelial papillary capillary loops. D, Mucosal resection was
performed. (C courtesy Dr. Cristian Gheorghe.)
A B C
D E F
FIGURE 2.31 BARRETT’S MUCOSA WITH HIGH-GRADE DYSPLASIA: ENDOSCOPIC MUCOSAL RESECTION
A, Nodular well-circumscribed area in the distal esophagus. B, Dilute saline and epinephrine are injected underneath the lesion.
C, The cap device is placed on the endoscope and positioned over the lesion for resection. D, After endoscopic mucosal resection
(EMR), a mucosal defect is produced. E, The argon laser is used to ablate any suspicious surrounding mucosa that was not removed
with the resection specimen. F, High-grade dysplasia in Barrett’s mucosa.
A B C
FIGURE 2.32 NODULAR LESION IN BARRETT’S ESOPHAGUS: HIGH-GRADE DYSPLASIA

A, Well-circumscribed nodule in the distal esophagus. B, A cap device is used for resection. C, Mucosal defect after resection.
A B C
FIGURE 2.33 BARRETT’S MUCOSA UNDERGOING RADIOFREQUENCY ABLATION

A, Typical Barrett’s esophagus. This patient had high-grade dysplasia on biopsy. B, After therapy, superficial ulceration is seen. C, Use of
the halo device to ablate additional areas of Barrett’s esophagus.
FIGURE 2.34 BARRETT’S ESOPHAGUS

WITH ENDOMICROSCOPY
A, Typical Barrett’s esophagus as seen on
narrow band imaging. Numbers represent the
area where endomicroscopy was performed.
B, Esophageal glands with normal
architecture and the presence of goblet cells.
No dysplasia is present. (Courtesy F. Alberca,
MD, Murcia, Spain.)
A B
A B C
D E
FIGURE 2.35 GASTROESOPHAGEAL REFLUX DISEASE-ASSOCIATED STRICTURE

A, Tight stricture of the distal esophagus associated with proximal ulceration. Note the collection of pills proximal to the stricture.
B, C, Severe esophagitis with circumferential exudate and an associated tight stricture. D, The stricture was dilated and endoscopy
performed. Note the luminal caliber is improved and there is underlying ulceration of the dilated area. E, After dilation, a large tear
is proximal to the stricture.
Normal Fibrotic
FIGURE 2.36 HEALED SEVERE GASTROESOPHAGEAL REFLUX

DISEASE
A, The esophageal mucosa appears thickened, with loss of
vascular pattern from fibrosis. A portion of normal mucosa is
still present. B, Retroflex view in the hiatal hernia shows evidence
of prior ulcers, with four well-circumscribed, reepithelialized
B
depressions.
A B C
FIGURE 2.37 MILD CANDIDA ESOPHAGITIS

A, Small white plaques throughout the midesophagus and distal esophagus. B, Multiple white plaques stud the distal esophagus.
C, Linear confluent plaques in the midesophagus. The surrounding mucosa is normal.
A
B C
D E F
G H
FIGURE 2.38 CANDIDA ESOPHAGITIS

A, Diffuse irregularity of the wall, with multiple filling defects. These abnormalities result from barium intercalating between the confluent
candidal plaques. In most cases, these irregularities do not represent ulceration. B, Typical-appearing raised, confluent yellow plaques. The
yellow plaque assumes a linear pattern in some areas, with normal intervening mucosa. C, Severe Candida esophagitis, with confluent
circumferential yellow plaque and encroachment on the esophageal lumen. D, If the candidal plaque is vigorously removed, the underlying
mucosa appears relatively intact. Denudation of the surface epithelium is seen in a few areas, with associated hemorrhage resulting from the
endoscopic trauma. No frank ulceration is present. E, Thick yellow exudate coats the esophagus and results in mild luminal narrowing. F, A
portion of the exudate is removed showing inflamed underlying mucosa. G, Full-thickness squamous epithelium with overlying candidal
plaque. The plaque is adherent to the surface epithelium. The plaque is composed of mature squamous epithelial cells, fungal
pseudohyphae, and yeast. The Candida does not extend into the deep layers of the epithelium. H, Gomori methenamine silver (GMS) stain of
the candidal plaque demonstrates branching fungal mycelia, including pseudohyphae and true hyphae, characteristic of C. albicans.
Squamous tissue
Squamous
tissue
A B Diffuse ulceration
C D E
F1 F2 G
FIGURE 2.39 HERPES SIMPLEX VIRUS ESOPHAGITIS

A, Herpes simplex virus esophagitis manifested by multiple whitish plaques. Diffuse erythema surrounds the plaque, representing
shallow ulceration. Islands of normal-appearing esophageal mucosa are still present. B, Diffuse shallow ulceration of the entire
esophagus, with two areas of normal-appearing squamous tissue present. C, Confluent exudate in the distal esophagus. D, Vesicular
lesions in the midesophagus. E, Volcano-like lesions in the midesophagus. F1, Large, plaquelike, exudative lesions that become
confluent more distally (F2). G, Ulceration with narrowing at the GE junction. The ulcer has thick exudate resembling GE reflux disease.
Continued
H I
FIGURE 2.39 HERPES SIMPLEX VIRUS ESOPHAGITIS

H, Herpes simplex virus infection of the esophagus, producing characteristic multinucleated inclusions in squamous epithelial cells.
I, Confirmation of herpes simplex virus by in situ DNA hybridization. The intranuclear viral inclusions are stained brown.
Herpes Simplex Virus Esophagitis (Figure 2.39)
Gastroesophageal reflux disease
Other infections
Cytomegalovirus
Varicella
FIGURE 2.40 VARICELLA ESOPHAGITIS

Diffuse nodularity and pinpoint exudates in the esophagus with
fresh bleeding.
Ulcer
B C
FIGURE 2.41 CYTOMEGALOVIRUS ESOPHAGITIS

A, Three esophageal ulcerations. Two of the lesions are on
opposite walls. There is no extravasation of barium to contiguous
structures or to the mediastinum. The surrounding mucosa is
normal, giving the ulcerations a well-circumscribed appearance.
B, Multiple large ulcerations. The ulcer on the left represents the
deep ulcer on the esophagrams. The distal ulcer is not visible at
this level. The ulcers are well-circumscribed, having a “punched-
out” appearance. The intervening esophageal mucosa is normal.
C, Multiple viral inclusions in endothelial cells and stromal cells in
the ulcer base. Cytomegalovirus inclusions typically consist of
enlarged cells with characteristic “owl eye” intranuclear inclusions
and granular eosinophilic cytoplasmic inclusions. In the
D gastrointestinal tract, atypical viral inclusions (some shown here)
are often present. Cells with atypical inclusions may appear
smudged or can be similar in appearance to ganglion cells.
D, Immunostain confirms the viral cytopathic effect to be
cytomegalovirus.
A B C
D1 D2 E
G2
F G1
G3 G4
FIGURE 2.42 CYTOMEGALOVIRUS ESOPHAGITIS

A, Long, linear ulcer. B, Multiple large, well-circumscribed ulcerations in the midesophagus. C, Shallow ulceration in the distal
esophagus. D1, Diffuse exudate in the midesophagus with areas of depression. D2, Markedly thickened distal esophagus.
E, Circumferential ulceration involving the distal esophagus. F, Deep ulceration extending outward from the lumen in the distal
esophagus. G1, Midesophageal ulcer with mild luminal narrowing. G2, After therapy, a stricture has resulted. G3, Balloon dilation
performed. G4, The stricture has torn appropriately, now exposing the submucosa. No perforation resulted.
A B
C D
FIGURE 2.43 CYTOMEGALOVIRUS ESOPHAGITIS WITH STRICTURE

A, Large, irregular ulceration at the gastroesophageal junction. There appears to be a mass effect just proximal to the
gastroesophageal junction. B, The distal esophagus is markedly thickened. C, Circumferential ulceration in the distal esophagus,
extending into the stomach anteriorly and forming a shelf. The gastric tissue is edematous. D, After therapy, the patient reported
dysphagia. A circumferential stricture is now present, with persistent active ulceration.
FIGURE 2.44 HEALED ULCER SCAR

Large scar in the midesophagus representing healing of a large ulcer. Note the
characteristic whitish color.
A B
FIGURE 2.45 TUBERCULOUS ESOPHAGITIS WITH FISTULA

Ulcer in the midesophagus representing a fistula to the mediastinum (A), well shown on barium esophagram (B).
Tuberculous Esophagitis with Fistula
(Figure 2.45)
Infection
Trauma
Neoplasia
FIGURE 2.46 ASCARIS LUMBRICOIDES

Large ascarid in the midesophagus. (Courtesy F. Vida, MD, and A. Tomas, MD, Manresa,
Spain.)
A B
FIGURE 2.47 EOSINOPHILIC ESOPHAGITIS

A, Multiple mild ringlike lesions of the midesophagus are characteristic. B, Biopsies show numerous eosinophils in the squamous
epithelium.
A B C1
C2 C3
FIGURE 2.48 EOSINOPHILIC ESOPHAGITIS

A, Multiple ringlike structures in the distal esophagus above a mild narrowing. B, More proximally, the mucosa has a feline appearance.
C1-C3, After biopsy, the blood essentially performs chromoendoscopy, and multiple fissures are also now very evident.
A B
FIGURE 2.49 DILATION OF EOSINOPHILIC ESOPHAGITIS

A, Typical-appearing rings. B, Long tear after dilation. C, Biopsy shows marked eosinophilia. D, Dense fibrosis is also present in the
submucosa.
A B C
FIGURE 2.50 ACUTE NECROTIZING ESOPHAGITIS

Diffuse black exudates coat the esophagus (A, B). C, Note the abnormalities stop at the GE junction.
A B C
FIGURE 2.51 PEMPHIGUS

A, Submucosal hemorrhage in the midesophagus. B, The biopsy forceps are used to
grasp the overlying mucosa showing that it can be “peeled away.” C, D, More extensive
esophageal involvement with sloughing of a large portion of the mucosa. The thin film of
D detached mucosa is visible.
FIGURE 2.52 PARANEOPLASTIC PEMPHIGUS

Diffuse edema and subepithelial hemorrhage.
Carcinoma
Air bubbles
B1 B2
FIGURE 2.53 EARLY SQUAMOUS CELL

CARCINOMA
A, Focal area of nodularity. Air bubbles can also be
seen on the barium-coated esophagus. B1, B2,
Verrucous-appearing lesion in the center of a well-
demarcated area of erythema. B3, After washing of
the lesion, it is found not to be fixed to the wall. B4,
A distal border of erythema is present. Biopsy of the
B3 B4
erythematous mucosa demonstrated carcinoma.
FIGURE 2.54 SQUAMOUS CELL CANCER

OF THE ESOPHAGUS WITH RECENT
BLEEDING
Raised ulcerative lesion of the
midesophagus with overlying blood clot
indicating recent bleeding (A, B).
A B
Piriform sinus
Proximal lip
of the tumor

A, Anteroposterior view shows a long segmental lesion, with nodular mucosa and luminal narrowing.
Continued
Trachea
Soft tissue
mass
Carcinoma
B
Manubrium Sternal notch
Clavicular head
Trachea
Adenopathy
Lumen
Mass

B, A soft-tissue mass anteriorly causes a mass effect, with posterior effacement of the trachea. C, Mass lesion of the cervical esophagus
at the level of the manubrium. The esophageal lumen is severely compromised. Adenopathy is present.
Continued
D E
F1 F2
FIGURE 2.55 SQUAMOUS CELL

CARCINOMA
D, Proximal lip of the tumor. A guidewire
is present. E, Hemicircumferential
ulceration. F1, Appearance of the lesion
after dilation. F2-F4. An ulcer with
irregular margins in the distal esophagus
was also a squamous cell carcinoma. The
lesion was found after dilating the
stricture. This could be a second primary
carcinoma, which is unusual, or a
F3 F4
metastatic lesion.
A B

A, The cancer has a volcano appearance, with a central area of necrosis surrounded by normal-appearing squamous mucosa.
B, Surgical specimen demonstrates a mass lesion protruding from normal-appearing squamous mucosa. C, Well-differentiated
squamous cell carcinoma.
B
Trachea
Dilated esophagus
Filling defect represents
carcinoma
C D

A, Irregular, masslike lesion producing high-grade partial obstruction of the esophageal lumen. The proximal esophagus is dilated, and
a round nodular intraluminal mass is seen in the barium column, representing proximal luminal tumor extension. A round structure is
present at the proximal portion of the carcinoma, suggesting a pill. Note the difference in caliber between the proximal and distal
esophagus. B, The esophagus is dilated with residual barium. A filling defect is also present in the barium column. The posterior and
left posterolateral walls of the trachea are deformed by the lesion. Adenopathy is present anteriorly. C, Luminal narrowing of the
esophagus outlined by the barium column, with surrounding mass lesion. D, Proximal portion of the tumor is hemicircumferential and
has a fleshy appearance. A pill is embedded in the tumor. E, The resection specimen demonstrates the bulkiness of the tumor and
luminal impingement.

A, Ulcerated lesion of the midesophagus with heaped-up
margins. B, Endoscopic ultrasonography confirms the tumor
extent and adjacent lymph nodes.
B
FIGURE 2.59 SQUAMOUS CELL CARCINOMA WITH

TRACHEAL ESOPHAGEAL FISTULA
An irregular nodular stricture with proximal shelving and a
fistulous communication to the right lower lobe bronchus. Other
areas of apparent fistula formation represent sinus tracts in the
tumor mass.
FIGURE 2.60 SQUAMOUS CELL

CARCINOMA WITH
TRACHEAL ESOPHAGEAL FISTULA
Dilated esophagus with multiple white
plaques, characteristic of Candida
esophagitis. Candida esophagitis
commonly occurs in areas of stasis
resulting from obstruction. The proximal
portion of the tumor is evident by the
hemicircumferential rim of nodularity. The
distal lumen is narrowed (top left). Two
lumina are seen distal to the proximal
portion of the tumor (top right). On the
left, the esophageal lumen with
circumferential carcinoma is shown; the
lumen on the right is the large fistula. The
fistula has an ulcerated appearance
(bottom left). The circumferential
ulcerated tumor is present distally in the
esophagus (bottom right).
A1 A2
A3 A4
Stomach
B
Tumor mass Barium collection

A1, A2, A raised, masslike lesion with central ulceration. A submucosal nodule is adjacent
to the tumor. A3, A4, Distal to the tumor are several submucosal nodules. B, A mass
lesion in the gastric cardia. A well-circumscribed pooling of barium can be seen in the
middle of the lesion. C, Retroflex view of the gastric fundus reveals a large mass lesion
with central ulceration. The lesion has the appearance of an extrinsic lesion that has
ulcerated in its central portion. Biopsy of the lesion demonstrated squamous cell
C carcinoma.
B1 B2
A B3 B4
C D

A, Long, irregular stricture characteristic of a neoplasm. The proximal portion of the tumor has shelving and is dilated. B1, The shelflike
lesion is evident. B2, The center of the tumor has a necrotic appearance. B3, B4, The midportion of the tumor becomes circumferential
and friable, with significant luminal narrowing. C, Gianturco metal stent placed into the esophageal cancer, resulting in luminal
patency. Tumor is growing into the mesh stent. D, The stent is in a good position through the tumor mass. Barium is outlining the wire
mesh of the stent.
A B
FIGURE 2.63 POLYURETHANE-COATED ESOPHAGEAL STENT

A, Proximal portion of the stent. B, The polyurethane coating of the metal stent avoids ingrowth of tumor. The metal flanges are
beneath the polyurethane.
A B C
D E F
G H I
FIGURE 2.64 STENTING OF SQUAMOUS CELL CANCER

A, Large mediastinal lesion with luminal compromise. B, Luminal compromise of the midesophagus with mediastinal extension of the
tumor. C, Ulceration extending to the mediastinum. D, A wire has been placed through the tumor into the stomach and the most
proximal margin of the tumor is marked with an arrow. E, The stent is passed fluoroscopically to the GE junction and deployed. Note
the proximal opening of the stent and the distal markings with the arrow. F, Stent has been fully deployed. G, The endoscope is passed
through the stent to the level of the fistula noting adequate deployment. H, Appearance of the stent after deployment. I, Proximal
extent of the prosthesis.
A B
FIGURE 2.65 ADENOCARCINOMA

A, Irregular stricture at the gastroesophageal junction. In the proximal portion of the stricture, a mass lesion is present in the barium
column. The proximal esophagus is dilated. The lesion can be seen extending into the gastric fundus. B, An irregular, masslike lesion is
outlined by the residual barium. C, The circumferential masslike lesion is adjacent to the liver and impinging on the gastric fundus. The
lumen is significantly narrowed. D, The proximal tumor appears as a round, nodular, masslike lesion. Part of the tumor appears to have
normal overlying squamous mucosa. E, Retroflex view of the proximal stomach demonstrates hemicircumferential ulceration with a
mass lesion, typical of adenocarcinoma of the gastroesophageal junction.
Continued
F G

F, The overlying squamous epithelium is compressed by poorly differentiated tumor occupying the submucosa. G, The mucicarmine
stain is useful in identifying mucin-producing adenocarcinoma.
A C
FIGURE 2.66 ADENOCARCINOMA WITH PROXIMAL SUBMUCOSAL EXTENSION

A, Dilated esophagus with a short, ulcerated stricture at the gastroesophageal junction. The distal esophageal mucosa is irregular. The
proximal stomach appears to be involved, with an ulcerated masslike lesion. B, Nodularity of the distal esophagus with overlying areas
of necrosis, resulting from proximal submucosal extension of adenocarcinoma at the gastroesophageal junction. Candidal plaques are
also present as a result of the distal obstruction, with secondary stasis. C, Retroflex view of the cardia shows a hemicircumferential
ulcerated mass.
A B C
FIGURE 2.67 BARRETT’S-ASSOCIATED ADENOCARCINOMA

A, Focal area of nodularity at the proximal margin of a hiatal hernia at the site of
Barrett’s mucosa. B, Focal area of nodularity at the proximal extent of a long segment of
Barrett’s esophagus. C, Circumferential narrowing of the distal esophagus. Note the
tumor involves the Barrett’s mucosa. D, PET scan shows focal positivity in the distal
D esophagus.
A B C
FIGURE 2.68 BARRETT’S ASSOCIATED ADENOCARCINOMA

A, Proximal extent of the long-segment Barrett’s-associated adenocarcinoma. Note the
lesion in the distance. B, Raised ulcerated lesion. C, Endoscopic ultrasonography shows
the mass lesion to be invading the adventitia. D, Fine needle aspiration of a celiac
D lymph node confirms metastatic disease.
B C
D E

A, Stricture of the distal esophagus. B, Circumferential thickening of the distal esophagus. C, Hemicircumferential ulceration at the
point of luminal narrowing in the distal esophagus. D, The area of neoplastic obstruction is now open after dilation. E, Note the distal
extent of the tumor and the Barrett’s mucosa in the distance. F, Endoscopic ultrasonography (EUS) shows invasion of muscularis and
adventitia (T3 stage). G, PET scan demonstrates the tumor.
A B
C D

A, Nodular mass lesion at the GE junction in the setting of
Barrett’s esophagus. B, Endoscopic ultrasonography confirms a
T3 tumor that involves the muscularis. C, Surgical resection
specimen. D, Adenocarcinoma on hematoxylin and eosin
E
staining. E, Note the tumor invasion of the submucosa.
FIGURE 2.71 NON-HODGKIN’S LYMPHOMA

Well-circumscribed ulcerated “donut” lesion in the proximal esophagus.
Non-Hodgkin’s Lymphoma (Figure 2.71)
Squamous cell carcinoma
Metastatic tumors
Melanoma
Lung carcinoma
Breast carcinoma
Lymphoma
A1 A2 A3
B C1 C2
FIGURE 2.72 BURKITT’S LYMPHOMA

A1, A2, Multiple well-circumscribed, raised, ulcerated dark lesions of the esophagus. There is central ulceration (A3). Note the
resemblance to the gastric lesion (B) and to the nodular skin lesions (C1, C2).
A B C
D F
FIGURE 2.73 POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER

A, Distal esophagitis with a large necrotic ulcerative lesion. B, Close-up shows the diffuse exudate. C, With washing, a large ulcerative
lesion is identified. Note the luminal narrowing distally. D, Upper GI shows the large ulcer proximal to the GE junction with distal
narrowing. E, CT shows the extent of the GE junction lesion. F, Hematoxylin and eosin stain shows infiltration with lymphocytes.
Continued
G H
FIGURE 2.73 POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER

G, CD20 immunostain is positive, indicating a population of B cells. H, Staining for Epstein-Barr virus is positive, typical for a
lymphoproliferative disorder after transplant.

A, B, Diffuse esophagitis with focal
ulceration. C1, C2, The submucosa is
infiltrated by lymphocytes. (See also
Figures 1.37, 5.145, and 5.207.)
A B
C1 C2
FIGURE 2.75 SMALL CELL CARCINOMA

A, Ulcerated heaped-up lesion in the distal
esophagus. B, Close-up shows the
hemicircumferential excavated lesion.
A B
A B

A, Multiple flat, red plaques throughout the esophagus. B, Characteristic spindle cell
stroma and slitlike vascular channels occupying the submucosa form a plaquelike lesion.
C
C, Smooth nodular lesion bulging into the esophageal lumen.
A B
C1 C2
C3 C4 D
FIGURE 2.77 GASTROINTESTINAL STROMAL TUMOR (GIST)

A, Large, masslike lesion, with obliteration of the esophageal lumen. B, Large mass lesion in the midesophagus with hypodense areas,
suggesting tumor necrosis or debris in the esophagus. The esophageal lumen is narrowed. C1, Polypoid mass in the distal esophagus.
Ulcer is present on the mass. C2, The distal esophageal lumen is obliterated by extrinsic compression. C3, The extrinsic compression is
ulcerated. C4, Retroflex view of the proximal stomach confirms the mass lesion. D, The resection specimen shows a bulky, necrotic
polypoid lesion.
A B1 B2
C D
FIGURE 2.78 GRANULAR CELL TUMOR

A, Small, submucosal, yellowish nodule. Patient has associated reflux esophagitis. B1, B2, Raised submucosal lesion with yellowish
discoloration at the mucosal surface. C, Amorphous pink material fills these large cells typical for granular cell tumors. D, Postoperative
specimen shows a giant granular cell lesion. Note the yellow appearance of the tumor.
B
C1 C2
C3 C4
FIGURE 2.79 LEIOMYOMA

A, Large, submucosal, masslike lesion of the midesophagus. B, Endoscopic ultrasonography shows the lesion arises from the
muscularis propria. C1, Submucosal lesion in the proximal esophagus. C2, Endoscopic ultrasonography with a probe demonstrates
the lesion arises from the muscle layer diagnostic of leiomyoma. C3, A cap device is used for endoscopic mucosal resection.
C4, Appearance of the mucosal defect after endoscopic mucosal resection.
FIGURE 2.80 FIBROVASCULAR POLYP

A, Submucosal lesion in the midesophagus.
The lesion extended to the GE junction
where the polypoid nature of the lesions
is appreciated on retroflexion
(B). (Courtesy B. Garcia-Perez, MD,
Cartagena, Spain.)
A B
FIGURE 2.81 METASTATIC GASTRIC CANCER

Multiple submucosal nodules in the distal esophagus in a patient
with signet ring carcinoma of the stomach.
FIGURE 2.82 EARLY PORTAL

HYPERTENSION
A, The vessels at the gastroesophageal
junction are dilated and tortuous. B, With
progression of portal hypertension, the
varices become more apparent. The
gastroesophageal junction is well
demarcated, and the veins appear to
originate from the gastroesophageal
junction. Veins are not present in the gastric
mucosa.
A B
FIGURE 2.83 ESOPHAGEAL VARICES ON BARIUM ESOPHAGRAM

Tubular filling defects in the distal esophagus.
A1 A2 B
FIGURE 2.84 PROXIMAL VARICES

A, Small serpiginous veins in the proximal esophagus. Note the normal distal esophagus (A2). This patient had superior venacaval
syndrome with marked varices on the neck and upper chest (B).
FIGURE 2.85 PROXIMAL ESOPHAGEAL

VARICES
A, Dilated veins in the proximal esophagus.
Small subepithelial vessels are also dilated
and ectatic. B, With further insufflation, the
esophageal veins flatten, but not
completely.
A B
A B C
FIGURE 2.86 RED COLOR SIGNS

High-risk bleeding stigmata on varices include red whale signs (A, B) and hematocystic spots (C).
FIGURE 2.87 BLEEDING VARIX AT THE GASTROESOPHAGEAL

JUNCTION
Active bleeding from this varix at the GE junction.
Varix
Active bleeding
B C
FIGURE 2.88 BLEEDING ESOPHAGEAL VARIX

A, Actively bleeding esophageal varix. B, Injection of sclerosant causes bleb formation, suggesting a submucosal rather than
intravariceal injection. C, With further sclerotherapy, the bleeding stops; a white nipple appears at the bleeding point.
A B C1
FIGURE 2.89 SCLEROTHERAPY-ASSOCIATED ULCERATION

A, Flat esophageal varices demonstrated by the two blue areas.
One area has a yellowish plaque, representing ulceration from
prior injection sclerotherapy. B, Large, irregular ulcerations in the
distal esophagus. Normal-appearing mucosa is seen between the
ulcers. With healing, the normal areas assume a polypoid
appearance from undermining of the ulcerations. C1, Deep
solitary ulcer with a central bleeding point. C2, Large right pleural
effusion was present in this patient as a complication of
C2
sclerotherapy.
FIGURE 2.90 VARICEAL

SCLEROTHERAPY
Varices with red color signs in the distal
esophagus (A1). The sclerotherapy needle
is placed into the lumen (A2) and directed
toward a varix. The needle is then
advanced into the varix and sclerosant is
injected (A3). A small amount of oozing
occurs after injection, marking the injection
site (A4). B, After sclerotherapy, the varix
appears to have a dark blue color.
A1 A2
A3 A4 B
FIGURE 2.91 VARICEAL SCLEROTHERAPY FIGURE 2.92 ESOPHAGEAL VARICEAL BANDING

After sclerotherapy, a deep bluish discoloration outlines the View of an esophageal varix through an early banding device.
sclerosed varix. This color change probably represents either The varix appears round, with the band encircling it. Two varices
variceal thrombosis or stasis of blood. A small amount of blood is that have not been banded are on the contralateral wall.
oozing from the injection site.
A B C
FIGURE 2.93 ESOPHAGEAL VARICEAL

BANDING
A, White nipple on the varix represents a
fibrin clot at the site of recent bleeding.
B, The banding device is placed just
proximal to the varix. The varix is
aspirated into the ligating device (C) and
the band deployed (D). Multiple varices
were ligated. Note the ischemic color of
D E
one varix after banding (E).
A B C
FIGURE 2.94 RECENT BANDING

A, Areas with the bands have spontaneously fallen off, leaving ulceration alongside persistent bands. B, More extensive ulceration at
the GE junction at the site of band placement. C, Ulceration just distal to the GE junction at the site of band placement.
FIGURE 2.95 POST-BANDING ULCER WITH RECENT BLEEDING

Large ulceration in the distal esophagus with two flat clots at the site of bleeding from a
banding-associated ulcer.
FIGURE 2.96 POST-BANDING SCAR

White stellate area in the distal esophagus representing a site of prior banding.
FIGURE 2.97 GASTRIC PROLAPSE

INDUCING A MALLORY-WEISS TEAR
A, With retching, prolapse of gastric mucosa
comes from the gastroesophageal junction.
B, After retraction of the stomach, two areas
of subepithelial hemorrhage with one small
tear are seen at the gastroesophageal
junction.
A B
Mallory-Weiss tear
Prolapsed stomach
A B
FIGURE 2.98 GASTRIC LESION ASSOCIATED WITH RETCHING

A, With repetitive emesis, gastric subepithelial hemorrhage
occurs. This hemorrhagic prolapsed mucosa mimics some unusual
mass lesions. A small Mallory-Weiss tear is also present on the
lesser curve portion of the distal esophagus. B, With retraction of
the stomach, the hemorrhagic area is well circumscribed, with
accentuation of the areae gastricae. C, Diffuse subepithelial
C
hemorrhage of otherwise normal gastric mucosa.
FIGURE 2.99 ESOPHAGEAL MALLORY-WEISS TEAR

Tear at the gastroesophageal junction extending proximally,
without involvement of the gastric mucosa. The base of the lesion
is hemorrhagic from recent bleeding. The most common location
for a Mallory-Weiss tear is on the lesser curvature side of the
FIGURE 2.100 ESOPHAGOGASTRIC

MALLORY-WEISS TEAR
Long, linear tear involving both the
esophageal and gastric mucosae. The
surrounding area is nodular, and the base of
the tear is hemorrhagic. A, Linear tear along
the lesser curve in the distal esophagus with
heaped-up margins. B, The tear extends
into a small hiatal hernia.
A B
A B C
FIGURE 2.101 MALLORY-WEISS TEAR WITH FIBRIN CLOT

A, Small tear at the GE junction. B, The tear extends along the lesser curve into the cardia. Note the adherent clot. C, On close-up, a
fibrin clot with active oozing is apparent.
Esophagogastric
tear
Blood clot
Oozing of blood
Esophageal tear
Blood clot
Squamocolumnar
junction
Blood clot
Esophagogastric tear
FIGURE 2.102 MULTIPLE MALLORY-WEISS TEARS

Two large, deep tears involve the esophagus and stomach, with overlying blood clots. One area of active oozing is present. One smaller
tear involves only the squamous mucosa.
FIGURE 2.103 MALLORY-WEISS TEAR

AND ESOPHAGEAL HEMATOMA
A, Multiple hematomas just proximal to the
GE junction on the lesser curve. B, The tear
extends into the cardia along the lesser
curvature. A visible vessel is present.
A B
FIGURE 2.104 BLEEDING MALLORY-WEISS TEAR

Retroflex view demonstrates an irregular tear, with blood oozing
from one of the margins.
A B C
FIGURE 2.105 MALLORY-WEISS TEAR: THERMAL PROBE THERAPY

A, Fresh blood clot and active oozing at the GE junction. B, The heater probe is used to wash the clot demonstrating active bleeding.
C, The thermal probe is applied to the area, resulting in eschar and hemostasis.
FIGURE 2.106 HEALING MALLORY-WEISS TEAR

Retroflex view shows shallow exudate with surrounding
subepithelial hemorrhage, characteristic of a healing Mallory-
Weiss tear. The endoscopic photograph was taken 6 days after
the clinical event.
FIGURE 2.107 ESOPHAGEAL TEAR

The proximal margin of the lesion has an
overlying blood clot (A1). The lesion is
linear with a hemorrhagic base (A2) and
an active bleeding point (A3). The lesion
does not extend to the gastroesophageal
junction (A4). Epinephrine and sodium
morrhuate were injected into the lesion
for hemostasis. After injection, a well-
demarcated area with a bluish hue
appeared (B1), resulting from ischemia.
Note that the base of the tear is now
bland (B2).
Continued
A1 A2
A3 A4
Tear
Ischemic
B1
B2

C, Four days later, the esophageal mucosa
appears abnormal. The tear is well shown
(C1-C3), Biopsy of the
mucosa demonstrated severe acute
inflammation, probably resulting from
ischemia secondary to the injection
therapy (C4).
C1 C2
C3 C4
A B

A, Large tear extending proximally from the GE junction. B, The lesion is shallow with well-circumscribed margins.
Contraction
Web
Web
B C
FIGURE 2.109 ESOPHAGEAL WEB

A, Lateral view demonstrates a short stricture with outpouching of mucosa in the middle of the stricture. An esophageal contraction is
shown proximally. Two webs are present, with the distal web well visualized. Between the two webs is normal esophagus. The distal
web is characterized by symmetric, circumferential narrowing of normal-appearing mucosa. B, Web just distal to the upper esophageal
sphincter. C, After dilatation, a tear is evident.
A B C
FIGURE 2.110 ESOPHAGEAL WEB IN PLUMMER-VINSON SYNDROME

A, Anteroposterior view shows the compromised luminal diameter. B, Lateral projection demonstrates a thick web just distal to the
cricopharyngeus. C, Tight stricture with Candida esophagitis resulting from stasis.
A B C
FIGURE 2.111 PROXIMAL ESOPHAGEAL STRICTURE

A, Tight ringlike stricture in the proximal esophagus. B, A Savary guidewire is passed through the stricture. C, Tearing of the stricture
after dilatation.
A B
FIGURE 2.112 ESOPHAGEAL RINGS

A, Multiple rings in the midesophagus. B, Endoscopically, the rings have a semilunar appearance.
A B C
FIGURE 2.113 CHRONIC GRAFT-VERSUS-HOST DISEASE

A, Ring in the midesophagus. B, When passing the endoscope through the area, the mucosa peels away. C, Multiple rings with a
thickened textured appearance.
FIGURE 2.114 SCHATZKI’S RING

A, Circumferential, smooth narrowing proximal to a hiatal hernia.
B, Close-up view demonstrates the hiatal hernia with gastric folds
radiating toward the stricture. C, A 12.5-mm tablet is delayed at
C
the level of the stricture.
Continued

Circumferential, smooth stricture at the
gastroesophageal junction, characteristic
of a Schatzki’s ring. The surrounding
esophageal mucosa is normal (D1).
The hiatal hernia is distal to the stricture
(D2) and by retroflexion (D3, D4).
Retroflex view in the hiatal hernia
demonstrates squamous mucosa tightly
encircling the endoscope (D4). E, After
passage of a 60 French Maloney dilator,
a tear can be seen in the stricture.
D1 D2
D3 D4 E
A B C

A, Typical-appearing ring as shown on standard endoscopy. B, High-definition and (C) narrow band imaging.
A1 A2 B1
B2 C
FIGURE 2.116 TEARING OF A SCHATZKI’S RING

A1, A2, Tight ring at the gastroesophageal junction on antegrade and retrograde views. B1, B2, After Maloney dilation, a large tear
with a flap of squamous tissue is shown. C, Linear ulceration and hematoma are shown more proximally.
A B C
FIGURE 2.117 RADIATION ESOPHAGITIS

A, Diffuse exudate of the midesophagus. B, With passage of the endoscope, the mucosa peels away. C, Diffuse exudate with ulceration
representing the site of prior tumor.
FIGURE 2.118 RADIATION STRICTURE

A, A short, smooth narrowing in the proximal esophagus. The esophagus is dilated
proximal to the stricture. B, The short, smooth stricture is shown. The surrounding
mucosa has a tan appearance, suggestive of fibrosis.
A B
FIGURE 2.119 ANASTOMOTIC STRICTURE

A, A short, smooth stricture proximal to the
gastric pull-up, after resection for
carcinoma. Multiple surgical clips are
present. B, The stricture is smooth, without
ulceration or tumor. Surgical clips and
sutures are shown.
A B
A1 A2 A3
A4 A5
FIGURE 2.120 BARRETT’S STRICTURE

A1, Linear erosions are emanating from the stricture. The mucosa at the stricture has a textured orange color. These findings suggest
reflux-associated Barrett’s esophagus. A2, The tip of the guidewire is just proximal to the stricture. A3, The guidewire is then passed
blindly through the stricture. A4, After passage of Savary dilators, a tear is seen in the stricture. A5, The base of the stricture has a
fibrotic appearance.
Continued
B1
B2
B3

B1, Irregular stricture in the proximal esophagus. B2, The distal esophageal mucosa has a fine granular appearance. Free reflux is seen
to the level of the stricture. A hiatal hernia is also present. These radiographic findings are compatible with a Barrett’s stricture. The
mucosa of the distal esophagus is granular as the squamous mucosa is replaced by gastric mucosa. B3, There is nodularity at the level
of the stricture and active ulceration. The orange ulcerated mucosa extending proximally from the stricture contained gastric mucosa
on biopsy.
Continued
B4

B4, The stricture has been dilated (top left). The mucosa distal to the stricture has an orange color with a few erosions (top right, bottom
left), and a large hiatal hernia is present (bottom right). Biopsy of the mucosa distal to the esophageal stricture consisted of normal
gastric (body-type) tissue.
FIGURE 2.121 STRICTURE DILATATION

WITH CREATION OF FISTULA
A, Slitlike area alongside a Schatzki’s
ring. B, Retroflex view shows tearing
representing creation of a fistula alongside
the ring. Dilatation was performed with a
Maloney bougie.
A B
A B C
D E
FIGURE 2.122 FOOD BOLUS IMPACTION

A, Acute dysphagia resulted after the patient swallowed a large piece of meat at a steakhouse. Barium can be seen overlying a filling
defect at the gastroesophageal junction, with mild dilation proximally. B, Barium coats the food bolus. C, The large meat bolus is being
extracted with the forceps grabber up to an overtube. D, After extraction, multiple large pieces of meat are identified. E, A slight area of
narrowing is seen at the gastroesophageal junction, which, although nonobstructing, caused the impaction. Many patients with food
bolus esophageal impaction have an underlying esophageal stricture, although, as shown in this case, it can be very mild. A 60 French
Maloney dilator was then passed to treat the stricture.
A B
FIGURE 2.123 ACHALASIA

A, The mediastinum is widened, with a large air-fluid level. B, The massively dilated esophagus is filled with barium. Note the
thickening of the esophageal wall. C, The dilated esophagus is well visualized on the anteroposterior view of the chest. D, The
massively dilated esophagus tapers to a “bird’s beak,” suggestive of achalasia. During observation of the esophagus under fluoroscopy,
there were noted to be tertiary contractions but poor peristalsis.
Continued
E F G
H I
J K

E, On endoscopic examination, the esophagus is found to be dilated, with puddling of fluid. The thick white mucosa and yellow
plaques represent Candida esophagitis, resulting secondarily from stasis of esophageal contents. F, Retroflex view of the gastric cardia
demonstrates no mass lesion. G, Close-up view of the gastroesophageal junction shows mucosa tightly encircling the endoscope. The
mucosa appeared to bulge when the endoscope was advanced. H, Esophageal motility is poor, with reduced amplitude and absence
of peristaltic waves. I, The lower esophageal sphincter does not totally relax. J, The Microvasive 35-mm balloon is passed across
the stricture and inflated. A “waist” is shown, representing the gastroesophageal junction. K, With full insufflation of the balloon, the
“waist” is obliterated, indicating successful dilation.
Continued
Contrast in dilated
air-filled esophagus
Stomach

L, After dilation, oral contrast material is swallowed, filling the dilated distal esophagus; however, contrast now enters the stomach. No
evidence of extravasation is present.
FIGURE 2.124 ACHALASIA TEAR POSTDILATATION

Deep mucosal defect just proximal to the GE junction.
A B C
FIGURE 2.125 BOTOX INJECTION IN ACHALASIA

A, Dilated esophagus filled with fluid and debris. B, Tight GE junction. C, D, Injection is
made with a sclerotherapy needle in a circumferential fashion at the GE junction using an
D
antegrade approach.
FIGURE 2.126 ACHALASIA COMPLICATED BY SQUAMOUS CELL

CARCINOMA
Hemicircumferential raised ulcerative lesion in the distal
esophagus. Note the esophagus is dilated.
FIGURE 2.127 HYPERTENSIVE LOWER

ESOPHAGEAL SPHINCTER
A, Smooth narrowing at the
gastroesophageal junction, suggesting
achalasia. The esophagus is dilated.
B, Only a small amount of barium
passes into the stomach. C1, The lower
esophagus appears to be wrapped tightly
around a doughnut; the gastroesophageal
junction appears to have a smooth
narrowing, although the endoscope
passed with slight pressure (C2, C3).
Retroflex view of the gastroesophageal
junction is normal (C4). A motility study
demonstrated an increased lower
esophageal sphincter pressure, with
normal relaxation and esophageal
peristalsis.
A B
C1 C2
C3 C4
A B C
FIGURE 2.128 DRUG-INDUCED ESOPHAGITIS

A, Hemicircumferential exudate at the GE junction caused by alendronate. B, Several shallow ulcers in the midesophagus caused by
aspirin. C, Multiple lesions in the midesophagus caused by doxycycline.
A B C
FIGURE 2.129 DRUG-INDUCED ESOPHAGEAL ULCER

A, Well-circumscribed ulcer, with a distal fold radiating to the lesion. The surrounding mucosa appears normal. B, Large
hemicircumferential esophageal ulceration. The surrounding esophageal mucosa and distal esophagus appear normal. Odynophagia
resulted several weeks after beginning doxycycline therapy. C, Healing of the ulceration shows the demarcated area now
reepithelialized, with a normal vascular pattern.
Drug-Induced Esophageal Ulcer (Figure 2.129)
Cytomegalovirus esophagitis
Herpes simplex virus esophagitis
Human immunodeficiency virus-associated idiopathic esophageal ulcer
Other infections
FIGURE 2.130 HUMAN IMMUNODEFICIENCY VIRUS-

ASSOCIATED IDIOPATHIC ULCER
Multiple well-circumscribed ulcerations throughout the
esophagus. The ulcers have a punched-out appearance, with
normal-appearing intervening mucosa. The ulcers seem to be
raised above the normal level of the esophageal wall, resulting in
this heaped-up appearance.
Human Immunodeficiency Virus-Associated Idiopathic Ulcer (Figure 2.130)
Histoplasmosis
Drug-induced esophagitis
Other infections
A B
FIGURE 2.131 HUMAN IMMUNODEFICIENCY VIRUS-ASSOCIATED IDIOPATHIC ULCER

A, Marked abnormality of the gastroesophageal junction, suggestive of ulceration. B, Barium is refluxing into the more proximal
esophagus. The combination of these two radiographic findings suggests reflux disease.
Continued
C1 C2
C3 C4
D E

C, Large, deep ulceration extending from the distal esophagus to the gastroesophageal junction (C1-C3), where the ulcer becomes
hemicircumferential (C3-C4). The ulcer base has an irregular appearance. D, Retroflex view into the ulcer demonstrates the depth of
the lesion. E, After oral steroid therapy, the ulceration has completely reepithelialized.
A B
C1 C2 C3

A, Large, well-circumscribed, heaped-up ulcer in the midesophagus. B, Multiple deep ulcers in the esophagus. C1, C2, Deep ulcer at
the GE junction with creation of a fistula to the stomach. Note the slit in the cardia representing the fistula into the stomach (C3).
A B1 B2
FIGURE 2.133 NASOGASTRIC TUBE ULCER

A, Linear “kissing” ulcers in the midesophagus associated with long-standing nasogastric tube placement. B1, B2, Linear ulcer with
raised appearance of the midesophagus. The most distal portion has a raised appearance to the edges.
A B
FIGURE 2.134 CROHN’S DISEASE

A, Multiple shallow, well-circumscribed ulcers in the midesophagus. B, Healing of the ulcers after corticosteroid therapy.
Crohn’s Disease (Figure 2.134)
A B
FIGURE 2.135 ESOPHAGEAL SARCOIDOSIS

A, Multiple pinpoint raised whitish areas. B, Biopsy confirmed granulomatous esophagitis.
A B C
D E
FIGURE 2.136 INLET PATCH

A, Distal to the cricopharyngeus, a well-circumscribed area with an orange color is shown. The surrounding esophageal mucosa has
the typical pearly white appearance of squamous mucosa. B, Close-up view of the patch. C, Large area of involvement. D, The inlet
patch has a raised appearance. E, This area represents heterotopic gastric mucosa. Normal squamous epithelium is on the right, with
gastric mucosa and typical-appearing fundic glands on the left.
FIGURE 2.137 SLOUGHING ESOPHAGITIS

Normal-appearing squamous mucosa appears to be peeling away from the mucosal
surface. Note the underlying mucosa is normal.
A B C
FIGURE 2.138 LICHEN PLANUS

A, Narrowing at the GE junction. B-D, The mucosa is easily detached from the
D
underlying mucosa.
FIGURE 2.139
SQUAMOUS PAPILLOMA
Verrucous-appearing lesion in the midesophagus.
A B C
D E
FIGURE 2.140 SQUAMOUS PAPILLOMA

A, Large verrucous plaquelike lesion. B, Multiple smaller lesions were more distal. C, Solitary verrucous lesion in the midesophagus. The
lesion is grasped with a hot biopsy forcep and ablated (D), and the area coagulated (E).
FIGURE 2.141 GLYCOGENIC ACANTHOSIS

Multiple slightly raised, yellowish lesions are seen throughout the
esophagus.
A B
FIGURE 2.142 GLYCOGENIC ACANTHOSIS

A, Solitary white lesion in the distal esophagus. B, Large, flat, white lesion in the midesophagus. This patient had multiple lesions.
A1 A2
B1 B2
FIGURE 2.143 PARAKERATOSIS

A1, A2, Marked thickening and plaquelike appearance of the squamous mucosa in the distal esophagus. These lesions can result from
stasis such as in achalasia or obstruction from other causes. B1, B2, Increased thickness of the stratum corneum with spindle-shaped
cells and condensed nuclei.
A B
C D
FIGURE 2.144 HYPERKERATOSIS OF THE ESOPHAGUS

A, B, Multiple whitish plaques throughout the distal esophagus, some of which are confluent. C, D, Biopsy of the lesion shows
squamous mucosa with thickening of the superficial squamous mucosa, granular cell formation, parakeratosis, and focal
papillomatosis. E, Close-up shows the marked thickening of the superficial mucosa.
FIGURE 2.145 VASCULAR LESION

This well-circumscribed lesion bulges into the esophageal lumen.
The overlying mucosa is normal and has a red discoloration,
typical of a vascular anomaly.
FIGURE 2.146 VASCULAR LESION

A1, A2, Venous bleb in the midesophagus.
A1 A2
A B C
FIGURE 2.147 HEMANGIOMA

A, Submucosal vascular lesion. B, Endoscopic ultrasonography characterizes the lesion. C, Doppler probe of the lesion confirms
arterial flow.
FIGURE 2.148 FIGURE 2.149

BLUE RUBBER BLEB VASCULAR
NEVOUS SYNDROME ECTASIA
Focal venous bleb in Pinpoint ectasia at
the distal esophagus. the GE junction in
a patient with
Osler-
Weber-Rendu
syndrome.
A1
A3
A4 A5
FIGURE 2.150 ESOPHAGEAL DIVERTICULA

A, Zenker’s diverticulum. A1, A2, Barium swallow both on anteroposterior and lateral
view shows typical location of the diverticulum, which is filled with barium. A3, Debris-
filled cavity posterior to the trachea. A4, Debris-filled cavity. A5, A guidewire is in the
esophagus at the level of the cricopharyngeus, with the arytenoids visible. This lesion
results from outpouching of hypopharyngeal mucosa between the oblique fibers of the
inferior pharyngeal constrictor muscle and the transverse fibers of the cricopharyngeus.
A2
This area of thin muscular wall is termed Killian’s triangle.
Continued
B1 B2
C1
C2 C3

B, Cervical esophageal. B1, A large diverticulum is present, distal to the cricopharyngeus. B2, The diverticulum is filled with
Candida, food debris, and a pill. C, Midesophageal. C1, Diverticulum in the midesophagus, usually termed a traction diverticulum.
C2, The diverticulum projects laterally. C3, Midesophageal diverticulum with exudate at the base.
Continued
D1
D2

D, Epiphrenic. D1, Epiphrenic diverticulum and tertiary esophageal contractions. D2, A large diverticulum proximal to the
gastroesophageal junction is present on the right, with the normal esophageal lumen on the left. The size of the diverticulum is
appreciated (bottom left). Gastric tissue appears to enter the diverticulum (right). Fresh blood is seen across the gastroesophageal
junction resulting from a Mallory-Weiss tear (bottom right).
FIGURE 2.151 ESOPHAGEAL DIVERTICULUM

Outpouching in the distal esophagus.
A B
FIGURE 2.152 INTRAMURAL PSEUDODIVERTICULOSIS

A, Multiple small collections of barium immediately lateral to the esophageal wall. B, The barium collections represent these round
defects in the esophageal wall. The base of the lesions does not have a granular appearance suggestive of ulceration.
Squamocolumnar
junction
Diaphragmatic
A B impression
FIGURE 2.153 HIATAL HERNIA

A, The gastroesophageal junction is patulous, outlined by the borders of the
squamous and gastric mucosae. The diaphragmatic impression is shown. B, Retroflex
view demonstrates the diaphragmatic impression, with the gastric mucosa proximal.
There is no apposition of the esophageal mucosa around the endoscope. C, A portion
C of the stomach is in the chest.
A B
FIGURE 2.154 PARAESOPHAGEAL HERNIA

A, The mediastinum is widened by a large gastric air bubble. B, Upper gastrointestinal barium study demonstrates that the air bubble
represents a significant portion of the stomach in the chest cavity. C, On retroflex view, a large defect is next to the endoscope
extending proximally (top left). The defect is entered, and typical gastric mucosa is shown (top right). With further advancement of the
endoscope, an area of impingement is seen encircling the stomach. More gastric mucosa is in the distance (bottom left). With further
advancement, the antrum is shown, as evidenced by the loss of gastric rugae (bottom right).
FIGURE 2.155 NISSEN FUNDOPLICATION FIGURE 2.156 FAILED NISSEN FUNDOPLICATION

The gastric mucosa tightly encircles the endoscope as if it were Although the gastric mucosa has a twisted appearance, the
twisted. endoscope is now free, with loss of competence.
A1 A2 B

A1, After the ingestion of acid, the squamous mucosa sloughs in a linear pattern. The mucosa is edematous and has a bluish
discoloration. A2, The gastric mucosa is hemorrhagic and edematous. B, Diffuse shallow ulceration with exudate coating the
esophagus.
A B C
D E F
G H I

A, Diffuse ulceration of the hypopharynx. Note the presence of an endotracheal tube. B, Just distal to the upper esophageal sphincter
the mucosa is denuded and there is a peculiar vascular pattern. C, More distally, the vascular pattern apparently represents the
submucosa as there is a deep ulcer with sparing of the contralateral wall. D, Exudative esophagitis is present in the distal esophagus
but without deep ulceration. E, The stomach is spared. F, At 4 days, the hypopharynx is much improved with erosion, and edema is
seen at the arytenoids. Ulceration is more extensive at the upper esophageal sphincter (G). H, The area of hemicircumferential
ulceration (C) is now more clearly demarcated. I, At 7 days, ulceration and edema are still present in the hypopharynx. Note the
presence of a feeding tube. J, Severe ulceration is still present in the proximal esophagus.
A B C
FIGURE 2.159 CAUSTIC INGESTION IN COLONIC INTERPOSITION

A, Diffuse edema of the hypopharynx and arytenoids. B, Diffuse ulceration is present in the colon. C, There is sparing of the
colonic gastric anastomosis.
A B C
D E1 E2
FIGURE 2.160 FOREIGN BODIES

A variety of foreign bodies are present in the esophagus, including a watch (A), quarters (B), PEG tube bumper (C), and shrimp (D).
E1, Bottle cap. E2, After removal, extensive ulceration is evident.
FIGURE 2.161 BLOM-SINGER PROSTHESIS

The plastic prosthesis enters anteriorly and fits tightly into the
esophagus. This prosthesis enters the esophagus through the
trachea and is used for speech after tracheostomy.
FIGURE 2.162 CYSTIC ESOPHAGEAL LESION

A, Well-circumscribed, smooth filling defect in the distal
esophagus.
Continued
A
FIGURE 2.162 CYSTIC ESOPHAGEAL

LESION
B, The filling defect appears round and
smooth, with overlying normal-appearing
mucosa. This can be seen both antegrade
(B1) and retrograde (B2, B3). The lesion
is soft and collapses when probed with
the biopsy forceps (B4). C, Multiple
cystic-appearing lesions in the
midesophagus.
B1 B2
B3 B4
C
FIGURE 2.163 PARAESOPHAGEAL CYST

A, B, Cystic impression in the midesophagus.
C, Large cystic lesion in the mediastinum
impinging on the esophagus.
A B
Esophagus
Cyst Aorta
C
Trachea
Esophagus
Fistula
FIGURE 2.164 TRACHEAL ESOPHAGEAL FISTULA

A, A communication is present in the midesophagus, with outline of the trachea.
Continued
B1 B2
B3 B4

B1, B2, A stricture is present proximal to the fistula. Beyond the stricture, the large fistula is apparent (B3, B4), with tracheal rings at the
level of the carina (B4).
A B

A, Erosion of endotracheal tube into the esophagus. B, A tracheoesophageal fistula resulted from radiation therapy for lung cancer.
FIGURE 2.166 TRACHEAL–ESOPHAGEAL

FISTULA CAUSED BY LUNG CANCER
A, Small fistulous opening identified.
B, A fully covered esophageal stent has
been placed.
A B
FIGURE 2.167 FISTULA AFTER

RADIATION THERAPY
A, Fistula easily seen. B, A covered stent has
been deployed across the opening.
A B
FIGURE 2.168 STENTING OF

TRACHEOESOPHAGEAL FISTULA FROM
LUNG CANCER
A, Large fistula in the midesophagus from
lung cancer. B, Placement of coated
metallic stent.
A B
FIGURE 2.169 TRACHEOESOPHAGEAL FISTULA CAUSED BY

LUNG CANCER
A, Large, deep ulceration of the midesophagus. B, C, CT scans
shows the large mass lesion that involves the esophagus.
B C
FIGURE 2.170 ULCER INVOLVING

MEDIASTINUM
A, Large idiopathic esophageal ulcer of
AIDS in the distal esophagus. B, Close-up
shows the depth of the lesion. Biopsy
showed lung tissue.
A B
FIGURE 2.171 POSTSURGICAL FISTULA

A, Large opening in the midesophagus
connecting to the mediastinum. B, Metallic
suture is present with neovascularization.
A B
FIGURE 2.172 DOUBLE-BARREL ESOPHAGUS
Two distinct esophageal lumens are visible. Such a lesion is typically
caused by some type of trauma creating a false lumen. In this case,
the false lumen is in the superior location.
False lumen
True lumen
Heart
Aorta
Spine
B
FIGURE 2.173 EXTRINSIC LESION

A, Tubular extrinsic compression in the midesophagus in a patient after pneumonectomy. B, Endoscopic ultrasonography confirms
the extrinsic compression to be the aorta.
CHAPTER
3
Stomach
INTRODUCTION
The stomach functions to store food and begin the process of digestion. It
can be divided physiologically, anatomically, and endoscopically. Upon en-
tering the stomach, one looks directly toward the greater curvature and
encounters the gastric rugae. On close inspection, the mucosa has a subtle
mosaic pattern, representing the areae gastricae. Any process causing mu-
cosal edema will accentuate this pattern. Gastric folds should flatten with
full insufflation. The incisura angularis (gastric notch), located on the distal
lesser curvature, is an important landmark that helps to differentiate the
gastric body from the antrum and is a common location for benign gastric
ulceration. Not unexpectedly, given the histologic differences, the antral
mucosa appears endoscopically different from the gastric body.
Inflammatory disorders are the most common gastric disorders en-
countered by endoscopists. As with any endoscopic abnormality, gastric
ulcers should be thoroughly characterized, noting location, size, and
appearance, because these characteristics yield important information
about the likelihood of neoplasm. Similarly, improved resolution with
newer endoscope systems has increased the sensitivity for the endo-
scopic detection of histologic gastritis. Helicobacter pylori gastritis may
be suspected at the time of endoscopy, although definitive diagnosis
requires confirmation, given that “endoscopic abnormalities” may
represent normal findings, and conversely, a normal endoscopic
appearance may not represent normal histology.
FIGURE 3.1 NORMAL ANATOMY
A, The gastric fundus is well filled with barium, providing an air
contrast view of the body, antrum, and duodenal bulb. Normal-
appearing gastric rugae are seen in the proximal body. The antral and
duodenal mucosae are smooth. Barium is entering the second portion
of the duodenum. B, Barium is filling the gastric body and antrum,
showing normal contour. An air contrast view of the gastric fundus is
shown. The distal duodenum and proximal jejunum are inferior to the
gastric body. C, As the endoscopic tube enters the stomach, the
greater curvature is on the left and the lesser curvature on the right,
with the angularis (i.e., incisura angularis) in the distance. Gastric rugae
are more prominent on the greater than the lesser curvature (C1).
Normal-appearing rugae are seen in the distal body, extending to the
level of the angularis (C2). The antral mucosa is smooth, and the
pylorus is in the distance (C3). The endoscope tip is elevated, and the
A scope is rotated slightly to the left, identifying the pylorus and
angularis, with the endoscope seen above (C4).
Continued
Fundus
Duodenal bulb Body
Antrum
Greater curve Lesser curve

(anterior) (posterior)
Antrum Angularis
C1 C2
Anterior Posterior
C3 C4
FIGURE 3.1 NORMAL ANATOMY

D, The endoscope is withdrawn to the
level of the angularis. The lesser curvature
forms the right wall and the greater
curvature the left wall. The gastric rugae
are more prominent on the left wall
(D1). With further withdrawal of the
endoscope, small rugae are seen on the
lesser curvature (D2). More prominent
rugae are on the opposite wall (greater
curvature) with the endoscope rotated
to the left (D3). With still further
withdrawal of the endoscope, the
gastric fundus and cardia are shown.
D1 D2 The fundus has no rugae, and blood
vessels are present. A small rim of
gastric mucosa (gastric cardia) can be
seen encircling the endoscope (D4).
D3 D4
FIGURE 3.2 ANTERIORPOSTERIOR RELATIONSHIP

With the patient supine, indentation of the anterior wall
documents the anteriorposterior relationship of the angularis.
FIGURE 3.3 AREAE GASTRICAE

A, This pattern may be seen in healthy
individuals or can be associated with
gastritis. Endoscopically, the pattern may
not be as well appreciated as with a barium
study. B, The normal areae gastricae as seen
underwater. Clarity is enhanced when
structures are viewed underwater.
A B
A B
FIGURE 3.4 GASTRIC HISTOLOGY

A, The normal histology of the gastric body is demonstrated. The foveolar surface epithelium is shown. The deeper structures
represent the fundic glands. The vertical orientation of the glands is evident. B, The normal antral mucosa is composed of deep pits
lined by foveolar epithelium. Mucin-producing glands are present.
FIGURE 3.5 GASTRIC BODYANTRUM

DEMARCATION
A, B, The gastric mucosa often changes in
appearance near the angularis, in association
with the histopathologic change. This
change may be more striking in patients
with associated gastritis.
A B
FIGURE 3.6 HELICOBACTER PYLORI GASTRITIS FIGURE 3.7 FOCAL HELICOBACTER PYLORI GASTRITIS
Mild superficial gastritis results in erythema and prominence of Patchy areas of inflammation in the proximal gastric body are
the areae gastricae (as seen underwater). well demarcated by the surrounding atrophic mucosa.
A B
FIGURE 3.8 HELICOBACTER PYLORI GASTRITIS

A, Multiple nodular filling defects and prominence of the areae gastricae in the gastric body. This pattern may represent inflammation
or an infiltrating neoplasm. B, Diffuse nodularity, with overlying normal mucosa.
Helicobacter pylori Gastritis (Figure 3.8)
Lymphocytic gastritis
Sarcoidosis
Lymphoma

A, There is marked nodularity of the anterior wall of the gastric body
when viewed from this angle. This has been termed a “chicken skin”
appearance. B, Follicular lymphoid hyperplasia associated with
prominent chronic gastritis. An enlarged lymphoid follicle with
germinal center is present.
A B C

A, Severe gastritis in the gastric body, with edema, erythema,
scattered subepithelial hemorrhage, and overlying exudate.
D
B, C, Severe gastritis manifested by erythema and exudate.
Continued

D-F, Gastric body mucosa with severe acute and chronic
E
inflammation and crypt abscess formation.
FIGURE 3.11 HELICOBACTER PYLORI ANTRAL GASTRITIS

A, A mottled appearance of the gastric antrum. The area of bleeding represents extreme
friability. B, Prominent chronic active gastritis. The pyloric glands are infiltrated by
neutrophils, and increased numbers of chronic inflammatory cells are in the lamina
propria. C, Close-up view of a gastric gland reveals infiltration with neutrophils.
Organisms compatible with Helicobacter pylori are seen on the luminal surface of the
epithelial cells.
Continued
B C
FIGURE 3.11 HELICOBACTER PYLORI ANTRAL GASTRITIS

Special stains with Giemsa (D) and silver stain (E) better
highlight the organism.
D E
Helicobacter pylori Gastritis (Figure 3.12)
Ménétrier’s disease
Infiltrating neoplasms
Lymphoma
Zollinger-Ellison syndrome
Mastocytosis

Marked prominence of the gastric rugae.

HELICOBACTER HELICOBACTER
PYLORI GASTRITIS PYLORI GASTRITIS
The areae WITH SCARRING
gastricae are End-stage H. pylori
prominent and gastritis with atrophy
there is associated and evidence of prior
subepithelial scarring, with
hemorrhage. “ghosts” of prior
mucosal injury seen as
linear areas of scarring
with surrounding
subepithelial
hemorrhage and
edema.
FIGURE 3.15 LYMPHOCYTIC GASTRITIS

A, Multiple erosions of the gastric body.
B, Multiple small polypoid lesions principally
involving the gastric body. C, Diffuse
nodularity of the distal (C1) and proximal
(C2) stomach. D1, Preserved architecture
with an appearance of chronic gastritis.
D2, Close-up shows a diffuse infiltration of
lymphocytes in the mucosa.
A B
C1 C2
D1 D2
FIGURE 3.16 CHEMICAL GASTRITIS

Focal area of edema with exudate in the gastric body. Biopsies showed mild
inflammation with foveolar hyperplasia. Iron was also present in the specimen. These
findings suggest gastropathy induced by pills, in this case, iron.
A C
FIGURE 3.17 GASTRIC ATROPHY

A, The end result of long-standing Helicobacter pylori gastritis is atrophy. The gastric
rugae are completely absent, with blood vessels easily seen throughout the gastric body
and antrum. B, Narrow band imaging highlights the underlying vasculature. C, Gastric
B
atrophy and chronic gastritis.
FIGURE 3.18 INTESTINAL METAPLASIA

A, Focal white plaquelike lesion of the
antrum. B, Multiple white plaquelike lesions
of the antrum. C1, C2, Multiple white
plaquelike lesions with a verrucous
appearance in the gastric antrum. Note that
the surrounding gastric mucosa is relatively
atrophic. D, Numerous goblet cells are
present, confirming the diagnosis.
Continued
A B
C1 C2
D
FIGURE 3.18 INTESTINAL METAPLASIA

INTESTINAL METAPLASIA PATHOLOGY
E, Intestinal metaplasia as seen by optical
coherence tomography. F, The goblet cells
stain and brush border are visible (red arrows
indicate brush border; yellow arrows indicate
goblet cells). G, Periodic acid-Schiff stain
highlights the goblet cells. (F courtesy
Cristian Gheorge, MD.)
E F
G
A B
Small, raised
donut-like
lesions
C1 C2
D1 D2 E1
FIGURE 3.19 PERNICIOUS ANEMIA

A, Marked gastric atrophy with absent rugal folds and prominent vascular pattern.
B, Multiple small polyps in the proximal body and fundus, which on biopsy were
carcinoid tumors. C1, Small, raised, donutlike lesions in the gastric body.
C2, Appearance on narrow band imaging. D1, D2, Small polyp on a background
of gastric atrophy. E1, E2, Appearance on narrow band imaging. These lesions
E2
were small carcinoid tumors.
Continued
F G
H I

F, G, The mucosa is atrophic with decreased or absent parietal
and chief cells, as well as presence of intestinal metaplasia.
H, At low-power view, a microcarcinoid tumor is shown.
I, Enterochromaffin cells are seen in the mucosa.
J, K, Chromogranin staining highlights the neuroendocrine
J
tumor.
Continued
K L

L, Enterochromaffin cell hyperplasia/dysplasia at the base of the gland (blue arrow).
FIGURE 3.20 SYPHILIS

A, Large gastric ulceration, with prominent irregular rugae
radiating to the lesion. B, Irregularly shaped ulceration on the
angularis, with nodularity of the ulcer rim.
Ulcer
Ulcer
Ulcer
Pylorus
B
Continued
C D
E2
FIGURE 3.20 SYPHILIS

C, Severe chronic inflammation composed primarily of plasma
cells. A prominent plasmacytic infiltrate in a patient with positive
syphilis serology is suggestive of gastric infection. D, Silver stain
for spirochetes demonstrates multiple organisms.
E, Hyperpigmented lesions on the hands (E1) and feet (E2) are
E1
typical for secondary syphilis.
FIGURE 3.21 FOCAL CYTOMEGALOVIRUS GASTRITIS

Multiple round, erythematous, raised lesions in the gastric body
and antrum. The remainder of the antrum and body is normal.
FIGURE 3.22 CYTOMEGALOVIRUS (CMV)

GASTRITIS
A, Patchy subepithelial hemorrhage in the
peripyloric area. B, Multiple focal areas of
subepithelial hemorrhage in a “halo” pattern.
C1, Numerous inclusions typical for CMV.
C2, High-power view shows many
intranuclear inclusions.
A B
C1 C2
A B
C2
FIGURE 3.23 DIFFUSE SEVERE CYTOMEGALOVIRUS GASTRITIS

A, The stomach wall is markedly thickened, with hypodense areas suggesting necrosis.
B, Retroflex view demonstrates nodularity and subepithelial hemorrhage. Diffuse ulceration
is seen on the lesser curve. C1, Marked edema and hemorrhage are present in the lamina
propria. The pronounced edema produces the striking nodularity and areae gastricae pattern.
C1
C2, Multiple intranuclear inclusions characteristic of cytomegalovirus cytopathic effect.
Cytomegalovirus Ulcer (Figure 3.24)
Peptic ulcer
Nonsteroidal antiinflammatory drug
(NSAID)-induced ulcer
Ischemia caused by vasculitis
Malignancy
Other Infections
FIGURE 3.24 CYTOMEGALOVIRUS ULCER

Well-circumscribed, clean-based ulcer in the posterior antrum.
The surrounding mucosa is normal.
FIGURE 3.25 CYTOMEGALOVIRUS ANTRAL ULCER FIGURE 3.26 MYCOBACTERIUM AVIUM COMPLEX GASTRITIS
Large, deep ulcer. The pylorus is seen at the top left, indicating Diffuse gastritis with petechial hemorrhages and a well-
the depth of the lesion. circumscribed, small nodular lesion with central erosion.
FIGURE 3.27 GASTRIC MUCORMYCOSIS

A, Erosion and exudate of the gastric antrum with a dark hue to the mucosa. A feeding
tube is present. B1, B2, Multiple fungal forms in the submucosa.
B1 B2
FIGURE 3.28 ANISAKIASIS

Single larva entering the gastric mucosa with
focal area of old bleeding (A) or subepithelial
hemorrhage (B). C, The larva is being
removed with biopsy forceps (C1, C2).
A B
C1 C2
Stomach Thickened
gastric wall
Adenopathy
Pancreas
Liver
Kidneys
A
FIGURE 3.29 SARCOID GASTRITIS

A, Marked thickening of the gastric body and antrum. Multiple retroperitoneal nodes are present. Fullness along the lateral margin of
the pancreatic head and retrocaval portion of the retroperitoneum suggests adenopathy.
Continued

B, Multiple erosions, some having an
unusual stellate appearance, in the
gastric body (B1), angularis and
proximal lesser curve (B2), and antrum
(B3, B4). The antrum has a yellow-
orange discoloration and a mottled
appearance; the mucosa is friable.
C, Noncaseating granuloma in the
lamina propria. Special stains for other
causes of granulomatous gastritis,
including mycobacterial and fungal
organisms, were negative.
B1 B2
B3 B4
C
A B C

A, Nodular fold thickening of the gastric
antrum, duodenal bulb, and postbulbar
duodenum. B, Marked thickening of the
gastric wall. C, Marked nodularity and
thickening of the folds in the gastric body.
D, Nodular lesions in the gastric antrum.
E, The thickening of the gastric wall is limited
to the mucosal layer by endoscopic
D E ultrasonography.
Sarcoid Gastritis (Figure 3.30)
Gastric adenocarcinoma
Lymphoma
Metastatic tumor resulting in linitis plastica
A B
FIGURE 3.31 ALCOHOL-INDUCED GASTROPATHY

A, The gastric rugae are edematous, with fresh blood seen under the mucosal surface; the overlying mucosa is smooth. B, A prominent
band of extravasated erythrocytes is present, associated with edema of the lamina propria. No histologic evidence of gastritis is
present.
A B
FIGURE 3.32 ASPIRIN-INDUCED GASTROPATHY

A, Multiple scattered petechial hemorrhages, with normal-appearing intervening mucosa. B, Subepithelial hemorrhage is present
without an associated inflammatory process.
FIGURE 3.33 ASPIRIN-INDUCED GASTROPATHY

Multiple areas of fresh hemorrhage in the distal gastric body and
antrum.
Pylorus
Erosions
FIGURE 3.34 NONSTEROIDAL ANTIINFLAMMATORY DRUG (NSAID)-INDUCED EROSIVE GASTROPATHY

Multiple linear erosions surrounded by a halo of erythema in the antrum, with normal intervening mucosa. Antral disease is the typical
location for NSAID-induced injury.
A B
FIGURE 3.35 NONSTEROIDAL ANTIINFLAMMATORY DRUG (NSAID)-INDUCED GASTROPATHY

A, B, Multiple small antral erosions with erythematous halos.
A B C
FIGURE 3.36 PORTAL HYPERTENSIVE

GASTROPATHY
A, Mild disease is manifested by
prominence of the areae gastricae, with
areas of erythema and subepithelial
hemorrhage. This appearance is not
pathognomonic but may be noted with
other disorders inducing mucosal edema,
such as Helicobacter pylori gastritis.
B, Marked prominence of the areae
gastricae. C, Severe gastropathy with
diffuse subepithelial hemorrhage in a
snakeskin pattern. D, Prominent edema of
the lamina propria with multiple
congested blood vessels. No histologic
D
evidence of gastritis is seen.
FIGURE 3.37 THROMBOTIC THROMBOCYTOPENIC PURPURA

Multiple areas of subepithelial hemorrhage throughout the
gastric body.
FIGURE 3.38 NASOGASTRIC TUBE

TRAUMA
A, Multiple well-circumscribed, hemorrhagic
lesions extending down the gastric body to
the antrum. B, The reddish color resembles
ectasias. C, With progression, erosions may
result, and then ultimately ulcers (D).
A B
C D
A B C
FIGURE 3.39 GRAFT-VERSUS-HOST DISEASE

A, Normal-appearing gastric antrum. Biopsies confirmed mild graft-versus-host disease. The mucosa may appear normal in
mild disease, emphasizing the importance of mucosal biopsies. B, Marked erythema of the gastric body with multiple erosions.
C, Sloughing of the antral mucosa leaving a shiny erythematous appearance.
FIGURE 3.40 GASTRIC TEAR

This fresh tear occurred during endoscopy in a patient with
pronounced gastric atrophy. This could occur from the endoscope in
addition to air insufflation and retching.
FIGURE 3.41 GASTRIC MALLORY-WEISS TEAR

A, Tear begins distal to the gastroesophageal
(GE) junction. B, Note the extent of the lesion
down the lesser curvature.
A B
A B C
FIGURE 3.42 BLEEDING GASTRIC MALLORY-WEISS TEAR

A, Retroflex view shows active bleeding from a linear lesion just distal to the GE junction. B, Epinephrine injection results in blanching
of the mucosa. C, Blanching is apparent around the tear with resultant hemostasis.
Continued
D E F
FIGURE 3.42 BLEEDING GASTRIC MALLORY-WEISS TEAR
CLIPPING OF A GASTRIC MALLORY-WEISS TEAR
D, E, Tear just below a ring at the gastroesophageal junction. F, Clips applied to the lesion resulting in hemostasis.
A1 A2 B
Cameron
lesions
C D
FIGURE 3.43 CAMERON LESIONS

Multiple erosions straddle a large hiatal hernia as shown on antegrade (A1, A2) and
retrograde (B) views. C, Several lesions on the gastric folds, one of which has a linear black
eschar. Multiple linear areas of fresh hemorrhage on the diaphragmatic hiatus on
E
antegrade (D) and retrograde (E) views.
FIGURE 3.44 BENIGN GASTRIC ULCER

Linear ulceration of the gastric cardia. The surrounding mucosa is
erythematous, with subepithelial hemorrhages.

Ulcer in the fundus with an elevated appearance.
Ulcer

A, Elbow-shaped ulceration along the lesser curvature.
The proximal portion of the ulcer has air contrast, whereas the
distal portion has barium pooling. B, The shape of the large
ulceration on the angularis corresponds to the radiograph.
Additional ulcerations are present anteriorly. Multiple black
spots (stigmata of hemorrhage) are present in the ulcer base,
B despite the absence of clinical bleeding.
A B

A, Ulcer on the angularis projecting away from the gastric lumen, suggesting a benign lesion. B, Large benign-appearing ulcer on the
angularis. Exudate covers the base. The ulcer has a symmetrical punched-out appearance, and no abnormal-appearing rugal folds
appear around the lesion.
Ulcer collar
Ulcer
Stomach

A, Large ulcer projecting off the lesser curve
at the angularis. An ulcer collar is present,
suggesting a benign lesion. B, Large, well-
circumscribed ulcer on the angularis seen by
retroflexion. The size of the ulcer is evident
by comparison with the open biopsy forceps
(6 mm in width). C, Close-up shows the size
and depth of the lesion. The base has a
nodular appearance suggestive of
involvement of surrounding abdominal
B C
structures.
Benign Gastric Ulcer (Figure 3.48)
Adenocarcinoma
Lymphoma
Extragastric neoplasm

Well-circumscribed ulcer of moderate depth on the angularis. The borders are smooth
and the ulcer is relatively symmetrical, all of which are features suggestive of a benign as
compared with a malignant ulcer.
A B

A, Benign-appearing gastric ulcer as demonstrated by the well-circumscribed nature of the barium collection (ulcer), with multiple
smooth folds radiating to the ulcer. A smooth, round, homogeneous mound of edema surrounding the crater, with smooth radiating
folds extending all the way to the crater, suggests a benign ulcer. Other signs of a benign ulcer include Hampton’s line or an ulcer collar
and projection beyond the lumen. B, Large, well-circumscribed antral ulceration, with folds radiating to the ulcer base.
FIGURE 3.51
PERIPYLORIC ULCER
Circumferential ulceration surrounds the
pylorus.
FIGURE 3.52 FIGURE 3.53 BENIGN GASTRIC ULCER
BENIGN GASTRIC ULCER Bile-stained peripyloric ulcer.
Small prepyloric ulceration, with
surrounding erythema superior and
posterior to the pylorus. There is
cicatrization of the stomach toward the
ulceration.
FIGURE 3.54 ANTRAL ULCER

Well-circumscribed, benign-appearing
ulcer in the antrum anteriorly on high-
resolution (A) and narrow band
imaging (B).
A B

Large deep ulceration at the pylorus (A, B).
A B
Benign Gastric Ulcer (Figure 3.56)
Adenocarcinoma
Metastatic carcinoma
Melanoma
Breast carcinoma
Lung carcinoma

Large ulceration with a heaped-up appearance in the distal
gastric body. The raised appearance is unusual and suggests
primary or metastatic malignancy. Follow-up endoscopy after
therapy showed ulcer healing.

Deep, well-circumscribed, benign-
appearing ulcer on the angularis (A). One
month after standard ulcer therapy, the
ulceration has almost completely healed;
there is a small central erosion, deformity,
and diffuse erythema and friability (B).
After 2 months of therapy, complete
healing is seen; friability is still present (C).
One month after discontinuation of
therapy, the ulcer has recurred in the same
location and with endoscopic
characteristics similar to those of the initial
ulcer (D).
A B
C D
FIGURE 3.58 BENIGN ULCER IN GASTRIC POUCH

Hemicircumferential ulceration in a small gastric pouch after
gastric bypass.
FIGURE 3.59 HISTOLOGY OF AN ULCER BASE

Characteristic histopathologic changes of an ulcer base, including
acute and chronic inflammatory cells, fibroplasia, and
neovascularization. Careful examination must be performed to
differentiate reactive atypia from neoplasia in this area.
FIGURE 3.60 ULCER SCAR

Retraction of the mucosa with radiating folds and erythema typical for an area of prior
large ulceration.
FIGURE 3.61 NONSTEROIDAL

ANTIINFLAMMATORY DRUG (NSAID)-
INDUCED GASTRIC ULCERS
A, Numerous well-circumscribed ulcers
involving the gastric body and fundus seen
on retroflexion. B, Multiple well-
circumscribed ulcerations of the antrum and
pyloric canal. C, Solitary chronic-appearing
ulcer of moderate depth on the posterior
wall of the antrum. Note the xanthomatous
lesion at the pylorus. D, Large, triangular-
B shaped ulcer in the distal antrum.
C D
A B C
FIGURE 3.62 PYLORIC STENOSIS CAUSED BY ULCER

A, Exudate and edema at the pylorus. The opening is not visible. B, A balloon was inflated across the ulceration. C, The luminal caliber is
now much improved.
FIGURE 3.63 BLEEDING GASTRIC ULCER

A, Large gastric ulcer with a central arterial
defect. Blood is spurting in a pulsatile
Blood clot fashion, characteristic of an arterial bleeding
source. B, A heater probe is applied with firm
pressure to the defect, causing cessation of
bleeding. C, After multiple pulses of energy
Arterial
Ulcer defect and washing, the defect is coagulated, as
represented by the black areas. With
washing, the large size of the ulceration is
evident.
B C
A B

A, Arterial jet pulsating from an area in the proximal gastric body. The heater probe is alongside the lesion. B, Thermal therapy was
then applied to the area, resulting in a black eschar and hemostasis.
Bleeding
gastric ulcer
Spurting
A vessel
B C D

A, Large ulceration with fresh bleeding and an actively pulsating jet. B, Epinephrine was injected and the heater probe used to ablate
the area, resulting in a large eschar (C). Now that the bleeding has ceased, the extensiveness of the ulcer can be identified (D).
FIGURE 3.66 GASTRIC ULCER WITH VISIBLE

VESSEL
A, Large ulcer on the angularis with central
raised lesion. B, Fleshy visible vessel in the
center of the ulcer.
A B
A B C1
C2 D1 D2
F1 F2
FIGURE 3.67 GASTRIC ULCER WITH VISIBLE VESSEL

A, Nipple-like projection emanating from a small mucosal defect. B, Fleshy nipple-like projection from a superficial ulceration.
C1, Linear ulcer with raised area with reddish covering. C2, After thermal therapy, the vessel has been obliterated, leaving a black
eschar with depth. D1, Dark nipple-like projection of the gastric body. D2, Thermal therapy obliterated the lesion, resulting in a
deep black eschar. E, A small gastric ulcer displays a nipple-like projection, which has all the appearance of an artery. F1, F2, Large
visible vessel with associated ulcer at a narrowed gastrojejunal anastomosis in a patient with a Roux-en-Y gastric bypass.
FIGURE 3.68 BLEEDING ANTRAL ULCER

Large ulceration WITH VISIBLE VESSEL
with nipple-like A-C, Large ulceration in the posterior antrum
projection with a nipple-like projection emanating from
the base of the lesion. Because of recurrent
bleeding, surgery was performed
demonstrating that the visible vessel was a
middle colic artery, a branch of the superior
pancreaticoduodenal arcade.
B C
A B C
D E F
G H
FIGURE 3.69 PREPYLORIC ULCER WITH VISIBLE VESSEL

A-C, Large, deep ulceration in the pyloric ring. Black eschar is shown, as well as a nipple-like projection. D, Epinephrine is first injected,
(E, F) followed by multiple pulses of the 10-French heater probe precipitating some bleeding. G, H, The visible vessel has been ablated,
resulting in a black eschar.
FIGURE 3.70 MALIGNANT GASTRIC ULCER WITH VISIBLE VESSEL

Visible vessel at the inferior margin of a malignant gastric ulcer.
The gastric ulcer has large, heaped-up margins.

WITH VISIBLE VESSEL
Gastric ulcer is actively oozing (top left).
With washing, the bleeding area is
cleaned of blood (bottom left). A
transparent piece of fleshy tissue is seen,
representing a visible vessel. Such a
transparent visible vessel may have the
highest incidence of rebleeding.
FIGURE 3.72 HISTOPATHOLOGY OF A

VISIBLE VESSEL
The vessel wall is ruptured at the luminal
surface and is filled by thrombus. The
surrounding tissue shows extensive
ulceration.
Clot
Arterial defect
Ulcer base
Artery
FIGURE 3.73 BLEEDING GASTRIC ULCER FIGURE 3.74 GASTRIC ULCER WITH CLOTS
Large, well-circumscribed ulcer on the angularis, with blood clot Giant gastric ulcer on the angularis with multiple areas of
and area of active oozing. The open biopsy forceps (6 mm) adherent clot.
documents ulcer size.
FIGURE 3.75 GASTRIC ULCER WITH

BLOOD CLOT
A, Gastric ulcer with large blood clot
adherent to a focal point. B, Rebleeding
occurred 1 week later. The clot is now gone,
and the bleeding point is evident. Debris can
be seen adherent to the ulcer base. C1, A
blood clot is seen at the edge of a benign
gastric ulcer. C2, Appearance of the lesion
after epinephrine injection.
A B
C1 C2
FIGURE 3.76 SMALL GASTRIC ULCER WITH

FRESH BLOOD CLOT
A, Long blood clot emanating from a small
area at the site of a Billroth-I anastomosis.
Biopsies were recently taken from this site.
B, After washing, a small ulcer, created by
the mucosal biopsy, with an area of active
bleeding is apparent.
A B
A B1 B2
FIGURE 3.77 GASTRIC ULCER WITH BLOOD CLOT

A, Large gastric ulcer on the angularis with focal overlying clot. B1, B2, After clot removal by washing, a visible vessel is exposed.
A B1 B2
C D
FIGURE 3.78 GASTRIC ULCER WITH ADHERENT BLOOD CLOT

A, Large blood clot on an ulceration in the midgastric body posteriorly near the angularis. The blood clot could not be removed.
B, Large-volume epinephrine was injected (B1, B2). With washing, the lesion is now more visible. C, Forty-eight hours later, second
look endoscopy is performed showing that the blood clot is now gone with shallow ulceration, and at one of the lesions an area
suggestive of a visible vessel is present (D).
FIGURE 3.79 PERIPYLORIC ULCER WITH RED SPOT

Large ulcer with a central flat red spot. There is associated edema,
with a small erosion near the ulcer.
FIGURE 3.80 GASTRIC ULCER WITH BLACK

BASE
A, Raised gastric ulcer with a black base. The
surrounding mucosa has a prominent areae
gastricae pattern. B, Deep ulcer with black
base in the gastric body.
A B
A B C
FIGURE 3.81 GASTRIC ULCER WITH SPOTS

A, Small gastric ulcer with a linear red spot. B, Well-circumscribed, small gastric ulcer with both black and red spots. C, Large gastric
ulcer on the angularis with multiple black spots.
FIGURE 3.82 HENOCH-SCHÖNLEIN

PURPURA
A, Diffuse purpuric lesions of the skin.
B, Focal subepithelial hemorrhage in the
gastric antrum. (A courtesy P. Redondo,
A B
FIGURE 3.83 BLUE RUBBER BLEB NEVUS SYNDROME

Multiple subepithelial blebs in the proximal stomach. This patient
had concomitant esophageal (see Figure 2.148) and colonic
lesions.
FIGURE 3.84 DIEULAFOY LESION

A, Arterial bleeding (spurting) just distal to
the gastroesophageal junction. B, The
bleeding point was a small defect without
endoscopic evidence of ulceration.
A B

A, Active arterial bleeding from a pinpoint
area along the lesser curvature. B, Band
applied to lesion.
A B

A, Active bleeding from a small lesion
in the gastric fundus. B, Bleeding
spontaneously stopped, and with washing
a visible vessel and blood clot are
apparent. C, Histopathology of the lesion
shows a large tortuous artery at the
mucosal surface.
A B

STRESS GASTRIC
GASTROPATHY ISCHEMIA
Diffuse Diffuse ulceration
hemorrhage of of the gastric body
the gastric body caused by a
after a prolonged gastric volvulus.
episode of
hypotension.
A B C
FIGURE 3.89 ISCHEMIC GASTROPATHY

A, B, Well-demarcated giant ulcer in the antrum with erythema and fresh hemorrhage. Note the geographic distribution. This patient
had intraarterial chemotherapy for hepatic metastases. C, Nine months later, follow-up endoscopy shows a well-defined ulcer in the
ischemic area.
A1 A2 B
C D
FIGURE 3.90 VASCULAR ECTASIA

A1, A2, Large ectasia in the gastric body with a typical spider-web appearance. B, The lesion was ablated with argon plasma
coagulation. C, Well-circumscribed ectasia in the midgastric body as seen on standard and (D) narrow band imaging.
FIGURE 3.91 VASCULAR ECTASIA ASSOCIATED WITH

CIRRHOSIS
This ectasia has well-defined blood vessels emanating from the
center of the lesion.
A B
FIGURE 3.92 VASCULAR ECTASIAS OF

OSLER-WEBER-RENDU SYNDROME
A, Multiple telangiectasias on the nose and
lips. B, Pinpoint ectasia at the GE junction.
C, Large ectasia of the gastric body. D, Large
C D
ectasia in the duodenal bulb.
FIGURE 3.93 HEATER PROBE

COAGULATION OF BLEEDING VASCULAR
ECTASIAS
A, Active bleeding from the gastric body.
B, With washing, bleeding is seen to
emanate from a pinpoint area consistent
with a vascular ectasia. C, The thermal
probe is applied to the lesion, resulting in a
white eschar and hemostasis. D, Follow-up
endoscopy 3 days later shows the ectasia
is ablated and a small ulcer has been
iatrogenically created.
A B
C D
A1 A2 A3
B C1 C2
Liver Stomach
Feeding vessel
AVM
FIGURE 3.94 ARTERIAL VENOUS MALFORMATION

A1, Large, raised structure with central area of apparent fresh bleeding in the midgastric body. After washing, the raised lesion has a
typical vascular ectasia appearance on its surface with an ulcer (A2). A3, The lesion is also well shown on retroflexion. B, Several other
ectasias are also shown in the duodenum. C1, C2, The ERBE laser is used to ablate the lesion, resulting in eschar. D, Computed
tomography scanning with contrast shows a large arterial venous (AV) malformation (AVM) in the body of the stomach.
FIGURE 3.95 GASTRIC ANTRAL

VASCULAR ECTASIA (GAVE) SYNDROME
ASSOCIATED WITH PORTAL HYPERTENSION
A, Multiple ectasias in the antrum in a
patient with small esophageal varices (B).
C, Multiple similar-appearing lesions were
present in the second duodenum.
D, Cluster of ectasias surrounds the pylorus,
and scattered lesions are seen in the
antrum. This patient had small esophageal
varices.
A B
C D
FIGURE 3.96 GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) SYNDROME (WATERMELON

STOMACH)
A, Multiple red stripes with a nodular appearance emanate from the antrum. B, Multiple
dilated capillaries in the submucosa and epithelium. C, Fibroproliferation, highlighted by
trichrome stain, is characteristic of GAVE.
B C
A
FIGURE 3.97 GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) SYNDROME (WATERMELON STOMACH)
A, Multiple red hemorrhagic stripes emanating from the pylorus. B, Dilated capillaries (arrow) and a fibrin thrombus are present.
A1 A2 A3
B C D
FIGURE 3.98 GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) SYNDROME

(WATERMELON STOMACH)
A, Red stripes emanating from the pylorus. Some have a nodular appearance, whereas
others are flat. A2, A3, The vascular nature of the lesion is highlighted by narrow band
imaging. B, Appearance immediately after thermal ablation with argon plasma
coagulation. C, Two-month follow-up shows improvement of lesions, with whitish areas
representing scarring. D, Petechial lesions in the cardia are common in patients with
E
GAVE. E, Cardia lesions immediately after thermal ablation.
A B C
D1 D2
FIGURE 3.99 GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) SYNDROME (WATERMELON STOMACH)
A, More diffuse involvement of the antrum; although more proximally, the lesions do retain a watermelon appearance. Such an
appearance is often attributed inappropriately to gastritis. B, Laser ablation performed. C, Partial ablation. D1, D2, Complete ablation
of the antrum.
A B C
FIGURE 3.100 RADIATION-INDUCED VASCULAR ECTASIAS

A, Multiple ectasias in the proximal stomach. This patient had radiation therapy after resection for gastric adenocarcinoma of the
cardia. B, Marked edema with diffuse vascular ectasias of the gastric antrum after radiation therapy for pancreatic cancer. C, Multiple
delicate blood vessels posteriorly in the antrum.
A B
FIGURE 3.101 GASTRIC VARICES

A, Irregularly shaped, masslike lesion in the gastric fundus.
B, C, Retroflex view of the fundus demonstrates dilated veins
C
with a “sack of grapes,” representing a cluster of gastric varices.
A B C
FIGURE 3.102 GASTRIC VARIX

A, Large gastric varix with mucosal defect representing recent bleeding. B, Close-up of the mucosal defect shows ulceration with a
visible vessel. C, Variceal sclerotherapy was performed for spontaneous bleeding.
FIGURE 3.103 GASTRIC VARIX

A, Typical-appearing cluster of fundal
varices. B, Endoscopic ultrasonography
shows the small varices feeding into the
larger varix.
A B
FIGURE 3.104 BLEEDING GASTRIC VARIX

A, Bleeding varix just distal to the
gastroesophageal junction. B, After
injection sclerotherapy and cessation of
bleeding, the varix has a dark discoloration.
The bleeding point is clearly below the
A B
A B C
D1 D2
FIGURE 3.105 PRIOR GASTRIC VARICEAL EMBOLIZATION

A, B, The coil material is now emanating from the prior gastric ulcer in the proximal stomach. C, Forceps are used to grasp the material,
but it could not be removed. D1, Appearance of the embolized vessel at the time of the initial procedure 2 years earlier. Note the
presence of large gastric varices and a transjugular intrahepatic portosystemic shunt (TIPS). Multiple coils were placed (D2).
FIGURE 3.106 GASTRIC VARICES AND

SPLENIC VEIN THROMBOSIS
A, The distal esophagus is normal (A1).
The rugae of the gastric body are
prominent, as a result of dilated veins (A2).
The gastric antrum is normal (A3).
Retroflex view of the fundus
demonstrates clusters of dilated veins (A4).
B, Drawing of the venous phase of
the abdominal angiogram shows dilated
veins (varices), as well as collaterals in the
proximal stomach. Portal vein flow is
barely visible, given the collateral flow.
The splenic vein is not seen.
A1 A2
A3 A4
Portal
vein
Gastric
varices
Collaterals
B
A B
FIGURE 3.107 FUNDIC GLAND POLYP

A, Small polyp in the proximal stomach. B, Multiple irregular glands with dilated lumen, forming cystic structures.
A B C
D E
FIGURE 3.108 FUNDIC GLAND POLYPS IN FAMILIAL ADENOMATOUS POLYPOSIS SYNDROME

A, Multiple polyps produce filling defects. B, Multiple small polyps of similar appearance studding the proximal stomach. C, Close-up
shows the appearance of the polyps. D, Multiple well-circumscribed polyps typical for fundic gland lesions. Note the smooth
appearance and subtle vascular pattern (E).
A B C
FIGURE 3.109 FUNDIC GLAND POLYPS

A, Multiple polyps in the gastric body. B, Close-up of the polyps demonstrates a “fleshy” appearance. C, More numerous polyps with
similar appearance. D, Solitary polyp of modest size with subtle vascular pattern and smooth rather than fleshy overlying mucosa.
E, Complete resection shows the characteristic findings with the numerous areas of cystic dilation.
Hyperplastic Polyp (Figure 3.110)
Inflammatory polyp
Fundic gland polyp
Adenomatous polyp
FIGURE 3.110 HYPERPLASTIC POLYPS

Multiple small polyps of the gastric antrum. Note that a number
of the lesions have overlying exudate.
A B
C D
E F
FIGURE 3.111 MULTIPLE LARGE HYPERPLASTIC POLYPS

A, B, Multiple large red polyps in the gastric antrum. C, The polyp
is snared at the base and resected using standard techniques.
D, The size of the polyp is noted. E-G, Cystically dilated gastric
foveolar glands with varying amounts of inflammation and
overlying ulceration. Intervening lamina propria shows marked
G
edema.
A B
C2
C1
FIGURE 3.112 HYPERPLASTIC POLYP

A, Solitary pedunculated polyp in the peripyloric area. B, The polyp was seen to prolapse in and out of the pylorus. C1, C2, Marked
foveolar hyperplasia and edema.
FIGURE 3.113 HYPERPLASTIC POLYP

Solitary polyp in the distal gastric body anteriorly. Note the
reddish discoloration of the polyp with overlying exudate
typical for hyperplastic polyps.
FIGURE 3.114 INFLAMMATORY POLYPS

Multiple nodular lesions with a central
depression, resembling a volcano, in the
gastric body (A, B). The gastric antrum is
noted to be inflamed, with areas of
erosion (C, D).
A B
C D
Polyps

A, Nodular defects of varying size and shape in the gastric
antrum. A small fleck of barium is in the center of some of the
lesions. B, Small round defects with a central depression in a
B linear pattern (left).
FIGURE 3.116 INFLAMMATORY POLYP

Single filiform lesion in the distal gastric body.
Polyps
B1 B2
B3 B4

A, Two defects in the gastric body and antrum: on the right, a round “bowler hat” lesion; on the left, a nipple-like lesion projecting into
the lumen and surrounded by barium. B, The “bowler hat” lesion is seen to be a round polyp with overlying erosion (B1, B2). The distal
lesion is a finger-like projection of inflammatory tissue, also with an erosion (B3, B4).
A1 A2 B1
B2 C

A1, A2, Round polypoid lesion with overlying ulceration at the pylorus. B1, B2, The polyp was snared and removed, leaving an eschar
in the pyloric canal (C).
A1 A2 B
C D
F G
FIGURE 3.119 CRONKHITE-CANADA SYNDROME

This syndrome is characterized by the tetrad of cutaneous hyperpigmentation, alopecia,
onychodystrophy, and intestinal polyps. A1, A2, Multiple polyps throughout the
stomach, duodenum (B), and ileum (C). D, Candida esophagitis accompanies
the syndrome. E, Hyperpigmentation of the torso with an area of vitiligo. F, Alopecia.
H
G, Onycholysis of the nails. H, A neck brace is worn because of onychodystrophy.
A B C
D1 D2
D3 D4
FIGURE 3.120 GASTRIC CARCINOID TUMOR

A, Solitary polyp with central erosion in the proximal stomach as shown on retroflexion. Note the marked gastric atrophy. B, Multiple
small polyps throughout the gastric body, many with overlying exudate. C, Small lesion with erosion in a patient with Zollinger-Ellison
syndrome and multiple endocrine neoplasia syndrome type 1. D1, D2, Small cells that form nests typical for carcinoid tumors. D3, Both
chromogranin and neuron-specific enolase (NSE) (D4) often show positive staining in carcinoid tumors.
A1 A2 B
C D E
F G
Stomach
Liver
Tumor
Spleen
FIGURE 3.121 GASTRIC CARCINOID TUMOR

A1, Well-circumscribed donut-shaped lesion in the midgastric body posteriorly. Fresh heme is on the lesion. A2, The size of the
lesion is measured using open biopsy forceps. Note the absence of gastric atrophy. The lesion is also well shown on retroflex
view (B). C, The appearance of the lesion on narrow band imaging. The lesion is tattooed with India ink (D, E). F, Nests of small cells
infiltrate the gastric mucosa typical for carcinoid tumor. G, Positive chromogranin staining of the tumor confirms the neuroendocrine
origin. H, Well-circumscribed, hyperenhancing lesion in the gastric body corresponding with the tumor.
Gastric Carcinoid Tumor (Figure 3.121)
Metastatic lesion
Melanoma
Breast
Lung
Primary gastric lymphoma
A B C
FIGURE 3.122 GARDNER’S SYNDROME

Multiple gastric polyps throughout the gastric body (A) and fundus (B). Histologically, these polyps are fundic gland polyps. C, Note on
close-up the fleshy appearance of the polyps typical for fundic gland polyps. (See Figure 3.109.)
Differential Diagnoses
Gardner’s Syndrome (Figure 3.122)
Hamartomatous polyps
Inflammatory polyps
FIGURE 3.123 COWDEN SYNDROME

Multiple small, benign-appearing gastric polyps. In Cowden
syndrome, these polyps are histologically hamartomas.
FIGURE 3.124 PEUTZ–JEGHERS SYNDROME

Multiple small gastric polyps throughout the gastric body.
Histologically, these polyps are hamartomas.
FIGURE 3.125 LEIOMYOMA
A, Large submucosal mass lesion in the gastric body.
B, Endoscopic ultrasonography (EUS) shows the lesion arises
from the muscularis propria, confirming a leiomyoma.
FIGURE 3.126 LIPOMA

A, Submucosal lesion with central erosion in the proximal antrum.
B, EUS shows a well-circumscribed lesion that is hyperechoic.
A B
FIGURE 3.127 TUBULAR ADENOMA

A, Large polyp just proximal to the angularis
shown on retroflexion. The polyp has a
serpentine appearance, typical of an
adenoma. B1, Well-circumscribed small
polyp of the distal gastric body in the setting
of gastric atrophy and pernicious anemia,
which was resected (B2). C, Polypectomy
specimen shows typical adenomatous
glands.
A B1
B2 B3

A, Small polyp of the distal gastric body.
B, Note the whitish discoloration of the
lesion, representing intestinal metaplasia,
and the surrounding gastric atrophy.
A B
A B
FIGURE 3.129 TUBULAR ADENOMA WITH CARCINOMA

A, Large polypoid lesion of the gastric antrum. B, Note the central ulceration that suggests carcinoma.
A B
FIGURE 3.130 ADENOMATOUS POLYPS AND CARCINOMA

A, Multiple round filling defects in the proximal gastric body and a large lesion at the angularis. B, A large, masslike lesion is present
along the greater curvature and antrum.
Continued
FIGURE 3.130 ADENOMATOUS POLYPS

AND CARCINOMA
C, Multiple round polypoid lesions seen
in the proximal gastric body along the
lesser curvature (C1, C4). Associated with
the polyps is a large, masslike lesion in
the distal body and antrum, representing
cancer (C2, C3).
C1 C2
C3 C4
A B
FIGURE 3.131 CARCINOMATOUS POLYP

A, Two polypoid defects originating from the lesser curvature in the distal gastric body. B, Trilobed polyp at the angularis.
FIGURE 3.132 EARLY GASTRIC CANCER

Well-circumscribed, round, raised lesion of the distal gastric
antrum.
A B C
D E
FIGURE 3.133 LINITIS PLASTICA

A, The gastric body and antrum are nondistensible and have a spiculated appearance, primarily along the greater curvature.
B, The gastric rugae are thickened, and spontaneous bleeding is present in the distal body. Despite maximal insufflation, there was no
further distention. C, Circumferential ulceration in the distal body and antrum. D, Poorly differentiated gastric carcinoma. Malignant
signet ring cells are present, characterized by an intracytoplasmic mucin vacuole, which can compress the nucleus. E, Signet ring cells
are demonstrated by histochemical stains for mucin, including mucicarmine and, in this figure, periodic acid-Schiff (PAS) reagent.
Continued

F, Postmortem specimen demonstrates the marked
thickening of the entire stomach, as well as the
thickened rugae.
A B
C1 C2

A, The rugae are prominent, the mucosa is friable, and the stomach is poorly distensible. B, The gastric wall is diffusely thickened.
C, Oral contrast and air help to highlight the circumferential wall thickening (C1, C2).
A B C1
D1 D2
C2
FIGURE 3.135 LINITIS PLASTICA SECONDARY TO METASTATIC BREAST CANCER

A, B, Upper gastrointestinal (GI) series shows thickened folds with narrowing of the
antrum. C1, C2, Marked thickening of the gastric wall as shown on routine and coronal
CT images. D1, D2, Gastric folds are markedly thickened and the gastric lumen is
D3
narrowed. The antrum is relatively spared (D3).
Continued
E1 E2
F1 F2
FIGURE 3.135 LINITIS PLASTICA SECONDARY TO METASTATIC BREAST CANCER

E1, E2, Numerous malignant cells fill the submucosa. The cells are estrogen receptor positive on special staining, confirming
metastatic breast cancer (F1, F2).
Tumor
Stomach
Liver
B C
D E

A, Marked thickening of the gastric body and antrum. B, Ulcerated mass originating in the gastric body. The surrounding mucosa does
not appear to be involved. C, The ulcerated neoplasm extends toward the pylorus, with the lesser curvature uninvolved. D, The
stomach has been everted, showing the tumor. E, Well-differentiated adenocarcinoma.
A B
C D

A, The gastric body appears to be fixed toward the antrum. The areae gastricae are prominent. B, An irregularly shaped ulceration in
the center of the antrum. The gastric body is fixed toward this lesion. The antrum, in the distance, appears normal. C, The thickened
rugae and irregular shape of the ulcer are apparent. D, The gastric wall and rugal folds are markedly thickened at the level of the
ulceration.
Stomach
C D

A, Markedly dilated stomach with an abrupt cutoff in the antrum. B, Markedly dilated stomach is outlined by barium. An apple-core-
like lesion can be seen in the antrum. C, Circumferential masslike lesion involving the gastric body and collapsing the antrum. D, An
annular constricting neoplasm with a fibrotic appearance is demonstrated on this surgical specimen.
Ulcer
Rugae

A, Irregularly shaped ulceration on the angularis. There is
associated thickening of the gastric rugae, some of which are not
smooth in appearance. B, Close-up view of the ulcer
demonstrates the irregular appearance of the ulcer mound,
especially along the distal margin, with associated thick gastric
folds surrounding the crater. The nodular appearance of both the
B
distal ulcer mound and the folds suggests malignancy.
Continued

C, Marked thickening and erythema of
the gastric rugae (C1). A large gastric
ulcer with heaped-up margins extends
from the midbody to the angularis (C2, C3).
Retroflex view demonstrates
the irregularity of the surrounding margin
in relation to the ulcer base (C4). D, The
malignant ulcer is deep, and the
prominent rugal folds are identified in the
surgical specimen.
C1 C2
C3 C4
D

Round, masslike lesion of the gastric body.
Adenocarcinoma (Figure 3.140)
Neuroendocrine neoplasm
Metastatic tumor
Melanoma
Breast cancer
Lung cancer
Other
Primary gastric lymphoma
B C
D1 D2 D3
FIGURE 3.141 GASTRIC ADENOCARCINOMA

A, Well-circumscribed lesion in the posterior gastric body. B, Typical adenocarcinoma with signet ring cells shown on close-up.
Mucicarmine stain also highlights the type of tumor (C). D1, Elevated polypoid lesion in the proximal antrum. D2, Endomicroscopic
image with optical coherence tomography shows abnormal glands with clusters of dark neoplastic cells. D3, Intestinal metaplasia is in
the mucosa surrounding the tumor. (B courtesy Javier Pardo-Mindan, MD, Pamplona, Spain.)
A B
FIGURE 3.142 GASTRIC ADENOCARCINOMA AFTER BILLROTH-II ANASTOMOSIS (STUMP CARCINOMA)

A, Ulcerated mass lesion at the anastomosis. B, Retroflexion shows the extent of proximal progression.
FIGURE 3.143 MALIGNANT GASTRIC ULCER FIGURE 3.144 MALIGNANT GASTRIC ULCER
This gastric ulcer is linear but irregular and has heaped-up lips to Large, deep ulcer on the lesser curvature.
the margin. The lips do not form a circumferential pattern
around the ulcer base.
A1 A2 A3
B1 B2
Stomach
Proximal
gastric
cancer
Liver
Spleen
FIGURE 3.145 PROXIMAL GASTRIC CANCER

A1-A3, Large ulcerated lesion in the gastric cardia with thick exudate. Note the extension to the gastroesophageal junction (B1) and
distal upper with multiple submucosal nodular lesions (B2). C, Large mass lesion in the proximal stomach posteriorly.
FIGURE 3.146 EARLY GASTRIC CANCER

Multiple white verrucous-appearing plaques along the greater
curvature in the antrum.
FIGURE 3.147 RECURRENT GASTRIC

CANCER
A, Normal-appearing esophagogastric
anastomosis after proximal gastric
resection. B, Masslike lesion just distal to
the anastomosis.
A B
A B C
D E
FIGURE 3.148 ENTERAL STENT PLACEMENT FOR OBSTRUCTING ADENOCARCINOMA OF THE ANTRUM
A, Endoscopic view shows a pinpoint opening in the antrum. B, A floppy guidewire was passed through the lesion under fluoroscopic
guidance and exchanged for a stiffer wire. C, The catheter is seen for the wire exchange. D, Over this wire, the metal prosthesis is
advanced. E, The stent has been fully deployed.
Endoscope
Ulcer
FIGURE 3.149 GASTRIC LYMPHOMA

A, Multiple umbilicated lesions distal to
the gastroesophageal junction. One large
ulceration is just distal to the
squamocolumnar junction. B, Atypical
lymphoid infiltrate with large
B
immunoblastic-type cells.
A1 A2
B1 B2 C1
C2 D
Satellite
lesion
Hemicircumferential
E polypoid lesion
FIGURE 3.150 GASTRIC LYMPHOMA

A1, A2, Diffuse erythema, hemorrhage, and nodularity of the gastric body. B1, Small reddish raised lesion of the distal gastric body.
B2, Close-up shows a central defect. C1, Large, well-circumscribed, ulcerated, masslike lesion in a patient with acquired
immunodeficiency syndrome (AIDS). The lesion was soft on biopsy. C2, Atypical lymphoid infiltrate with large immunoblastic-type
cells. D, Ulcer with raised margin extending distally in a serpiginous fashion. E, Hemicircumferential polypoid lesion with
overlying exudate occupying the gastric antrum posteriorly. Note the satellite lesion anteriorly by the pylorus (drawing).
A B1
B2 C
D1 D2
FIGURE 3.151 B CELL GASTRIC LYMPHOMA

A, Well-circumscribed donut lesionwithcentral ulcerationand freshbleeding in the gastric body anteriorly. B1, B2, Ulcerated gastric mucosa
with malignant lymphomatous infiltrate (diffuse large B cell lymphoma). C, Special stain for MUM1 demonstrated activated B lymphocytes,
confirming the diagnosis and type of lymphoma. D1, D2, This B cell lymphoma resulted in diffuse thickening of the gastric folds.
B Cell Gastric Lymphoma (Figure 3.151)
Gastric adenocarcinoma
MALT lymphoma
Metastatic lesion
Melanoma
Lung cancer
Breast cancer
FIGURE 3.152 BURKITT’S LYMPHOMA

A, B, Multiple nodular lesions, some of which
resemble the esophageal lesions (see
Figure 2.72).
A B
FIGURE 3.153 MUCOSA-ASSOCIATED LYMPHOID TUMOR (MALT) LYMPHOMA

Thickened gastric folds with scattered ulceration.
FIGURE 3.154 MUCOSA-ASSOCIATED LYMPHOID TUMOR

(MALT) LYMPHOMA
Raised lesion of anterior gastric body. FIGURE 3.155 NEUROENDOCRINE CARCINOMA
Raised donut-like lesion with central ulceration.
A B
C D E

A, Large, confluent, plaquelike lesions. B, Multiple well-demarcated, violet-red lesions, some of which are flat and some elevated.
C, With progression, they may form large ulcerated lesions, with the margins maintaining this violaceous red appearance. The lesion is
well circumscribed, and the surrounding mucosa is normal. D, Multiple confluent polypoid lesions with a characteristic violaceous red
appearance. E, Solitary round nodular lesion, central raised area, and indentation in the proximal stomach.
A B

A, A masslike lesion resembling a thigh appears to be protruding from the gastric wall. An associated nodule is seen by the endoscope.
The middle of the lesion has two ulcerations with spontaneous bleeding (inset). B, Sheets of malignant spindle cells.

A, Large luminal mass. B, Large, masslike lesion of the proximal stomach with fresh
hemorrhage. C, Close-up shows a well-circumscribed ulcer in the center of the lesion, the
site of bleeding.
B C
A B
C1 C2

A, Large lesion with central ulceration in the fundus. B, Round submucosal lesion in the fundus. C1, Submucosal lesion hanging from
the GE junction. C2, EUS shows that the lesion arises from the muscle layer.
FIGURE 3.160 GASTROINTESTINAL

STROMAL TUMOR (GIST)
A1-A4, Gastrointestinal stromal tumor
arising from the muscularis propria.
The tumor is suspected to be malignant.
B1-B4, Gastrointestinal stromal tumor
arising from the muscularis mucosae.
A1 A2
A3 A4
B2
B1
B3
FIGURE 3.161 METASTATIC BREAST CANCER

Well-circumscribed raised lesion with central indentation in the gastric body.
A B C
FIGURE 3.162 METASTATIC RECTAL CANCER

A, Well-circumscribed ulcerated lesion in the midbody posteriorly. The tumor extends into the antrum with a polypoid
configuration (B). C, CT scan shows the large lesion invading the distal stomach.
Metastatic Lung Cancer (Figure 3.163)
Metastatic melanoma
Metastatic breast cancer
Gastrointestinal stromal tumor
Lymphoma
FIGURE 3.163 METASTATIC LUNG CANCER

Well-circumscribed elevated ulcerative lesion as seen on
retroflexion. Evidence of recent bleeding is present.
FIGURE 3.164
METASTATIC MELANOMA
A, B, Well-circumscribed Differential Diagnosis
raised (volcano)
ulcerated lesion.
Metastatic Melanoma (Figure 3.164)
Adenocarcinoma
Metastatic neoplasm, breast and lung
Gastric lymphoma
FIGURE 3.165 METASTATIC MELANOMA

A, Upper GI series shows raised lesion with
central ulceration. B, Multiple raised lesions
with central ulceration.
B

A, Large, ulcerated, masslike lesions of the
gastric antrum. B, Large ulcerated “kissing
lesions” of the gastric antrum.
A B
A B C
D E

A, Fundal mass. B, Nodular lesion with
overlying exudate extending from the
gastric fundus. C, Mass lesion representing
a nodal mass at the pancreatic head
impinging on the duodenum. D, The mass
is submucosal in nature. E, The bile duct
stricture correlates well with the
characteristics of the lesion. F1, F2, Small
F1 F2
black lesions typical for melanoma.
FIGURE 3.168 SQUAMOUS CELL CANCER

AT THE SITE OF A PERCUTANEOUS
ENDOSCOPIC GASTROSTOMY (PEG) TUBE
A, Ulceration is seen around the PEG tube.
B, When the PEG tube is advanced inward,
the large nodular lesion is seen. Biopsy
confirms squamous cell cancer presumably
seeding at the time of gastrostomy tube
placement for squamous cell cancer of the
esophagus.
A B
A B
C D
FIGURE 3.169 ZOLLINGER-ELLISON SYNDROME

A, Marked esophagitis. B, Markedly thickened gastric folds with a
large amount of clear gastric fluid. C, Multiple duodenal erosions.
D, “Healthy” mucosa with prominent vascular pattern on the thick
rugae. E, Surgical specimen shows the striking nature of the
gastric rugae. The presence of esophagitis and duodenal erosions
coupled with the gastric findings should strongly suggest the
E
diagnosis.
FIGURE 3.170 ZOLLINGER-ELLISON

SYNDROME
A, B, In this patient, the gastric folds were
more pronounced and nodular, and the
mucosa was hypervascular.
A B
A B C
D1 D2 D3
Tail of pancreas
Lesion
FIGURE 3.171 ZOLLINGER-ELLISON SYNDROME ASSOCIATED WITH MULTIPLE ENDOCRINE NEOPLASIA TYPE 1
A, CT scan performed for upper abdominal pain shows marked gastric fold thickening. B, Endoscopic ultrasonography (EUS) confirms
the strikingly thickened gastric folds. C, In addition, multiple pancreatic tumors are present. D1, D2, The gastric folds are markedly
thickened with numerous small overlying red polypoid lesions. D3, Some of the polyps are much larger and are ulcerated. Note even
the very tiny red lesions are carcinoid tumors. E, A hyperenhancing lesion is in the pancreatic tail corresponding to one of the lesions
(gastrinomas) shown on EUS in C.
Continued
F1 F2
G2
G1
G3
FIGURE 3.171 ZOLLINGER-ELLISON SYNDROME ASSOCIATED WITH MULTIPLE ENDOCRINE NEOPLASIA TYPE 1
F1, F2, Biopsy of one of the numerous small red circumscribed areas demonstrates nests of cells typical for a small carcinoid tumor
(microcarcinoid) corresponding to the endoscopic lesions. Also note the marked subepithelial hemorrhage, which corresponds to the
endoscopic appearance (D3). G1, The large gastric polyp has been removed showing a carcinoid tumor. G2, Shallow ulceration is
present on the mucosal surface, confirming the endoscopic impression. G3, The tumor is well differentiated and benign.
A B C
FIGURE 3.172 SYSTEMIC MASTOCYTOSIS

A, Marked thickening of the gastric rugae. B, Marked prominence of the area gastricae. C, Hyperpigmented skin lesions on the back
termed urticaria pigmentosa.
Duodenum
Pylorus
Web
Prepyloric antrum
Stomach
FIGURE 3.173 ANTRAL MUCOSAL DIAPHRAGM

A, A dilated stomach ends abruptly without evidence of ulceration or mass lesion. B, A portion of stomach, as well as normal-appearing
pylorus and duodenal bulb.
Continued
C1 C2
C3 C4
FIGURE 3.173 ANTRAL MUCOSAL DIAPHRAGM

C, A semicircular ring demarcates the abrupt end of the stomach (C1, C2). In the middle of this semicircular fold is a pinhole opening
(C3). The endoscope could not be advanced through this area. There is associated reflux esophagitis resulting from the gastric outlet
obstruction (C4).
Antral
A narrowing
B C
FIGURE 3.174 ANTRAL RING

A, Segmental area of nodular annular narrowing in the distal antrum. The proximal and distal portions of the antrum appear normal, as
does the duodenal bulb. B, Ringlike abnormality with apparent mucosal thickening surrounding the area. C, Close-up view of the ring
demonstrates normal-appearing mucosa, with the antrum and pylorus in the distance.
FIGURE 3.175 BILLROTH I

ANASTOMOSIS
The gastric remnant appears somewhat
atrophic (A, B). The anastomosis is
visible at the level of the angularis and
is widely patent, with suture material
present (C, D).
A B
C D
Surgical clips
Afferent
limb
Efferent
limb
FIGURE 3.176 BILLROTH II ANASTOMOSIS

Gastric remnant with both small-bowel limbs visible.
FIGURE 3.177 BILLROTH II

ANASTOMOSIS
A, Diffuse erythema is present in the distal
gastric remnant. Multiple yellow plaques
represent xanthelasma (A1, A2). Both
afferent and efferent limbs are at the
anastomosis (A3, A4). The afferent limb is
on the right and the efferent on the left.
B, At the end of the afferent limb, the
major and minor papillae are shown.
A1 A2
A3 A4
Major papillae
Minor papillae
B
A B C
D1 D2 D3
FIGURE 3.178 GASTROJEJUNOSTOMY

A, The jejunum is anastomosed to the posterior gastric body. Ulceration around the anastomosis is frequent in the immediate
perioperative period. B, Note the relationship of the anastomosis to the antrum seen to the right. C, Widely patent anastomosis. D1, In
a patient with prior Roux-en-Y gastric bypass, the gastric pouch is seen from the gastroesophageal junction. D2, The gastric pouch is
small and the small-bowel limbs are visible. D3, Both small-bowel limbs are shown.
A B C
F G
Pancreatic rest
Liver
FIGURE 3.179 PANCREATIC REST

Variable appearance of a pancreatic rest (A-E). F, G, Pancreatic tissue present in this submucosal lesion. H, CT scan shows a small lesion
corresponding to D.
A B

A, A multilobed nodular lesion is seen pushing into the gastric body anteriorly. The nodular lesion was manipulated with a closed
biopsy forceps and found to be hard. B, Multiple metastatic lesions in the liver. A large lesion in the left lobe is impinging on the
stomach, corresponding to the area of extrinsic compression.

Round, well-circumscribed lesion in the anterior gastric body. The
overlying mucosa is normal. When the lesion was probed with the
closed biopsy forceps, it moved freely and was firm. This lesion
might be a benign submucosal lesion, malignant submucosal
lesion, or extrinsic lesion such as a lymph node.
FIGURE 3.182 EXTRINSIC LESION: PANCREATIC PSEUDOCYST
A, Large pseudocyst in the tail of the pancreas, causing
compression on the posterior gastric wall. B1-B4, Extrinsic
compression occurring posteriorly in the proximal stomach.
C, Large pseudocyst and its relationship to the stomach.
B1 B2
B3 B4
Stomach
Pseudocyst
C
A B C
FIGURE 3.183 PSEUDOCYST CAVITY AFTER SURGICAL CYST GASTROSTOMY

A, Widely patent anastomosis to the cyst cavity. B, Marked nodularity and exudate representing the pseudocyst cavity. C, Cavity
entered from stomach.
A1 A2 B1
B2 C1 C2
FIGURE 3.184 PRIOR SURGICAL CYST GASTROSTOMY

A1, A2, Large adherent exudate on the posterior gastric wall. B1, B2, After removal of
some of the exudate, the endoscope was passed through an opening into a large cavity
C3
representing the pseudocyst (C1-C3).
A B
C D
FIGURE 3.185 ENDOSCOPIC CYST GASTROSTOMY

A, Large retrogastric fluid collection. Note the stomach is compressed. B, The cyst cavity is large and contains some internal echoes
suggestive of debris. C, A large bulge is along the posterior gastric wall. D, The needle knife is exposed.
Continued
E1 E2 F
G H1 H2
I J1 J2
FIGURE 3.185 ENDOSCOPIC CYST GASTROSTOMY

E1, E2, The cyst is punctured and deeply entered, as confirmed by aspiration of cyst contents. F, With the catheter removed, purulent
material is seen draining around a guidewire, which has been coiled in the cyst cavity (G). H1, H2, The cyst wall is dilated with a
balloon. I, A 10-French pigtail stent is being advanced into the cavity. J1, J2, The double pigtail stent has been deployed.
A1 A2
A3 A4

A, Round, masslike lesion in the proximal gastric body. An area of depression is at the apex (A1). Both antegrade (A1, A2) and
retroflex (A3, A4) views suggest an extrinsic lesion. The overlying mucosa is normal. B, The mass lesion appears in the lumen, making
differentiation between an extrinsic and an intrinsic lesion difficult. C, Endoscopic ultrasonography shows the mass lesion with all
layers of the mucosa intact and displaced, suggesting an extrinsic lesion.
Extrinsic Lesion (Figure 3.186)
Leiomyoma
A1 A2
FIGURE 3.187 EXTRINSIC LESION: DILATED GALLBLADDER

A1, A2, Extrinsic compression of the gastric antrum anteriorly.
B B, Large, fluid-filled stricture represents the gallbladder.
B1 B2
FIGURE 3.188 EXTRINSIC LESION: PANCREATIC CANCER

A, Mass lesion extending from the pancreas to the posterior wall of the stomach. B1, B2, Raised donut-like lesion with large central
ulceration.
FIGURE 3.189 EXTRINSIC LESION: COLONIC CARCINOMA

A, Masslike lesion in the left upper quadrant involving the
posterior wall of the stomach, as well as kidney. B, C, Focal area
of thickened gastric folds with recent bleeding as seen on both
antegrade (B) and retroflex (C) views.
B C
B C
FIGURE 3.190 EXTRINSIC LESION: METASTATIC LUNG CANCER

A, Large mass involving left kidney with involvement of the posterior gastric wall. B, Ulcer on top of the mass. C, Retroflex view shows
extrinsic compression.
B C
FIGURE 3.191 EXTRINSIC LESION: SPLENIC ARTERY PSEUDOANEURYSM

A, Extrinsic lesion in the proximal stomach. B, Close-up of the center of the lesion shows an ulceration with fresh blood clot. C, Vascular
lesion posterior to the stomach representing a pseudoaneurysm. Old blood is seen in the gastric wall.
A B
C D
FIGURE 3.192 EXTRINSIC LESION: SPLENIC ARTERY ANEURYSM

A, Extrinsic masslike lesions involving the posterior wall as shown
on retroflexion. B, Large hematoma involving the posterior wall
of the stomach, with fresh hemorrhage represented by contrast
extravasation. C, Doppler ultrasound shows flow in the lesion.
D, Angiography demonstrates an aneurysm of the splenic artery.
E, Embolization of the lesion was performed successfully. Coils
E
now present with no blood flow.
FIGURE 3.193 GASTRODUODENAL

FISTULA
Two openings are in the gastric antrum (A).
If the superior opening is entered, an
obstructed duodenal bulb is shown (B). If
the endoscope enters the inferior
opening, ulceration is shown, with an
entrance distally (C). With further
advancement, the second portion of the
duodenum is visualized (D).
A B
C D
A B C
FIGURE 3.194 PERCUTANEOUS

ENDOSCOPIC GASTROSTOMY (PEG)
PLACEMENT
A, The anterior wall is palpated with a finger
easily compressing the anterior gastric wall.
B, The needle is passed into the gastric wall
with injection of lidocaine. C, Through the
needle, a wire is passed and grasped with a
snare. D, The wire is removed. E, The
bumper of the PEG tube is visible along the
D E
anterior gastric wall.
A1 A2 B
FIGURE 3.195 BLEEDING GASTRIC ULCER CAUSED BY PERCUTANEOUS ENDOSCOPIC

GASTROSTOMY (PEG) TUBE
A1, A2, Ulcer on the contralateral (posterior) wall caused by repetitive PEG tube trauma.
B, Large deep ulcer on the posterior wall opposite a G-tube as seen on retroflexion.
C C, Black eschar with surrounding serpiginous ulceration.
FIGURE 3.196 BLEEDING FROM

PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY (PEG) TUBE
A, The G tube is covered with blood clot.
B, With advancement of the G-tube, active
bleeding can be seen from the abdominal
wall. C, A sclerotherapy needle is placed
into the anterior wall of the stomach with
injection of a large volume of dilute
epinephrine. D, Marked ischemia of the
gastric wall with hemostasis.
A B
C D
FIGURE 3.197 BURIED BUMPER

A, A round defect is present in the anterior
gastric wall. B, CT shows the PEG in the
anterior abdominal wall separate from the
gastric lumen.
A B
FIGURE 3.198 SURGICAL GASTROSTOMY TUBE SITE FIGURE 3.199 PRIOR GASTROSTOMY TUBE SITE
Two metallic sutures are present in the area of a prior surgical A, Well-healed area with retraction and central indentation.
gastrostomy tube placement. The gastric folds are pulled up to Continued
the areas of suturing.
FIGURE 3.199 PRIOR GASTROSTOMY

TUBE SITE
B, The gastrostomy tube was removed
1 week before endoscopy. An ulcer
is present at the center of the old site
(B1-B3). Extrinsic compression at the scar
on the abdominal wall indicates the old
site (B4). C1, C2, Ulcerated area of the
anterior gastric wall representing a
recently removed G-tube site. C3, A snare
has been placed through the site and out
through the skin. C4, The snare is then
used to grasp the guidewire, which is
then withdrawn through the stomach
B1 B2 and oropharynx for subsequent PEG
replacement.
B3 B4
C1 C2
C3 C4
FIGURE 3.200 GASTRIC XANTHELASMA

A, Yellow plaque in the distal gastric body.
B, Yellow, well-circumscribed polypoid
lesion on the anterior wall of the gastric
body. C, Foamy macrophages can be
identified.
A B
C
A B1 B2
B3 B4 C
FIGURE 3.201 MÉNÉTRIER’S DISEASE

A, Irregularly thickened gastric folds.
B1-B4, Multiple gastric polyps beginning
at the gastroesophageal junction and
extending to the antrum. Mucus was seen
to exude from the polyps, as well as frank
bleeding. Biopsy of the polyp showed
striking foveolar hyperplasia. This patient
had chronic iron-deficiency anemia and
hypoalbuminemia. C, Multiple polyps
of the proximal stomach. Foveolar
hyperplasia (D1) associated with dilated
D1 D2
cystic areas (D2).
A B C
D E
FIGURE 3.202 AMYLOID

A, Scattered petechial hemorrhage of the gastric antrum, which appears slightly yellow. B, Subepithelial hemorrhage with minimal
abnormalities of the surrounding mucosa. C, Markedly thickened nodular antral folds with fresh hemorrhage. D, Amorphous material
fills the submucosa. E, Congo red stain highlights the submucosal material, confirming the diagnosis.
FIGURE 3.203 PSEUDOMELANOSIS

A, Black pigmented lesions throughout the
gastric antrum. This patient also had
pseudomelanosis duodena (B). (See
Figure 4.102.)
A B
A B
C2
FIGURE 3.204 CALCINOSIS

A, B, The gastric folds have a whitish thickened appearance in this
patient with renal failure on dialysis. C1, C2, Benign gastric
mucosa with mild edema, inflammation, and multifocal areas of
amorphous calcifications present in vascular and extravascular
C1
spaces.
FIGURE 3.205 BAROTRAUMA

A, Multiple linear lesions throughout the
gastric body. B, Close-up shows a linear tear
and fresh bleeding.
A B
A B C
FIGURE 3.206 NONSPECIFIC ABNORMALITIES

A, Diffuse erythema, subepithelial hemorrhage, and fresh heme. B, Multiple red linear lesions. Biopsy in both cases disclosed no
specific cause. Such findings are often attributed to “gastritis.” C, Diffuse hemorrhage of the gastric mucosa of unclear cause.
A B
FIGURE 3.207 PRIOR EMBOLIZATION COIL

A, In the gastric antrum, a blue structure is emanating from an indentation. B, This is a prior coil from embolization of an artery in the
setting of a bleeding pseudocyst.
A B C1
C2 D1 D2
FIGURE 3.208 FOREIGN BODY

A, Battery. B, Plastic pill container. C1, C2, Collard greens. D1, D2, Whole pecan.
E
E, Black-eyed pea.
CHAPTER
4
Duodenum and
Small Bowel
INTRODUCTION
Routine endoscopy is primarily limited to examination of the duodenal
bulb and second portion of the duodenum, with an occasional glimpse
of the third portion. With the availability of small-bowel enteroscopes
and more recently of capsule technology, the entire small bowel can
be visualized. The duodenal bulb appears as a small, round cavity with
a finely granular appearance. At the superior duodenal angle, which
marks the junction of the first and second portions, Kerckring’s valves,
or the circular folds, become visible. In contrast with the bulb, the mu-
cosa assumes a more granular and frequently whitish appearance. The
ampulla occasionally may be identified on the medial wall, especially
when prominent. The intimacy of the pancreas and biliary system to
the duodenum may be reflected by endoscopic lesions resulting from
diseases of pancreaticobiliary tree.
Duodenal disease is generally limited to the bulb, where inflammatory
disorders, erosions, and ulcers are found. Neoplasms typically reside in
the distal duodenum, jejunum, or ileum, and thus remain endoscopically
hidden with routine endoscopy. If required, examination of the distal

duodenum can be accomplished with a pediatric colonoscope or
dedicated enteroscope. The anterior–posterior relationships in the
duodenal bulb are important to understand, particularly when cha-
racterizing ulcer disease in the setting of gastrointestinal hemorrhage.
The terminal ileum can be evaluated at the time of colonoscopy in
most cases. In some situations, intubation of the terminal ileum should
be routine; for example, when evaluating for Crohn’s disease or when
finding fresh blood in the cecum in a patient with gastrointestinal
bleeding. The identification of small-bowel lesions by capsule en-
doscopy may now be amenable to endoscopic therapy with the
double-balloon endoscope.
Pylorus
Antrum
Contraction
wave
FIGURE 4.1 NORMAL DUODENUM

A, Upper gastrointestinal barium series demonstrates a normal-
appearing duodenal bulb, with barium in the second duodenum
(C sweep) and distal duodenum. The pylorus is seen en face.
B, The distal duodenum and proximal jejunum have a
characteristic feathery appearance. The distal duodenum and
B
proximal jejunum are seen coursing behind the antrum.
FIGURE 4.2 NORMAL DUODENAL BULB

A, The mucosa is not smooth but has a
subtle textured appearance. The superior
duodenal angle marks the junction between
the distal duodenal bulb and the second
duodenum. Vascularity can usually be
appreciated. B, The vascular pattern is more
pronounced. No real angle exists between
the bulb and the second portion of the
duodenum in this patient. The circular folds
of the second duodenum are shown.
A B
FIGURE 4.3 SECOND DUODENUM

A, The second duodenum is characterized
by circular folds termed valvulae
conniventes or Kerckring’s valves.
The mucosa has a granular appearance.
The junction of the second and third
duodenum (inferior duodenal angle) is in
the distance. B, The mucosa may have a
frosty white appearance. C, The duodenal
mucosa is characterized by slender villi
composed of goblet cells. Appearance as
shown by magnification endoscopy (D)
and narrow band (E) imaging.
A B
D E
Minor papilla
Lateral
Major papilla wall
Medial
wall
B1 B2
Major papilla
B3 B3
FIGURE 4.4 MAJOR AND MINOR PAPILLAE

A, The major papilla is seen on the medial wall of the mid-second duodenum; the minor papilla is shown proximally and in a superior
position. B1, Small, polypoid-like lesion on the medial wall in the mid-second duodenum. B2, The papilla can be seen in a more en face
view. The ampullary orifice is visible, and just distal is the longitudinal fold. B3, The major papilla is small and well seen with the forward
viewing endoscope. (Drawing) Folds lead to the papilla.
FIGURE 4.5 JEJUNUM

The jejunum is characterized by thinner but more frequent
circular folds than in the duodenum, and the mucosa is smoother.
A B C
D1 D2
E
FIGURE 4.6 TERMINAL ILEUM

A, Reflux of barium on enema examination. B, Small-bowel follow-through. Barium also outlines the cecum. C, The mucosa has a finely
granular appearance, and lymphoid follicles are present. D1, The mucosa has a fine, granular appearance. As visualized underwater,
the villi can now be appreciated (D2). E, Prominent villi are noted in this patient.
A B
FIGURE 4.7 LYMPHOID HYPERPLASIA

A, Marked nodularity of the terminal ileum, as shown by reflux of barium during barium enema examination. B, Multiple
well-circumscribed nodules. Lymphoid hyperplasia in the distal terminal ileum is a normal finding, frequent in younger persons.
FIGURE 4.8 EROSIVE DUODENITIS

Multiple erosions in the duodenal bulb.
FIGURE 4.9 EROSIVE DUODENITIS
A, Marked nodularity of duodenal bulb. B, Severe edema,
subepithelial hemorrhage, and multiple erosions. A portion of an
active crater is present.
Ulcer
Erosion
FIGURE 4.10 HEMORRHAGIC DUODENITIS

Patchy subepithelial hemorrhage in the distal duodenal bulb.
Anterior Posterior
Ulcer
A B
Anterior Posterior
C D
Pylorus
Anterior
Posterior
FIGURE 4.11 DUODENAL ULCER

A duodenal ulcer is shown anteroinferiorly (A). Methylene blue has been placed in the bulb with the patient still in the left
lateral decubitus position (B). If the patient is moved to the supine position, fluid collects posteriorly, confirming the position in
the bulb (C). The posterior portion of the antrum is demarcated by methylene blue (D).

A, Anterior clean-based duodenal ulcer.
The duodenal folds are markedly
edematous at the superior duodenal
angle. A speckled pattern is on the gastric
body, suggesting gastritis (inset, top).
The antrum appears normal
endoscopically (inset, bottom).
Helicobacter pylori chronic active gastritis
was histologically identified in both the
body and the antral mucosa. B, Deep
anterior ulcer with multiple black spots in
the ulcer base, suggesting recent
bleeding. The ulcer margins are
edematous and hemorrhagic. The antrum
and peripyloric area show mild erythema
and subepithelial hemorrhage, especially
around the pylorus, suggesting gastritis
(inset). H. pylori chronic active gastritis was
found on antral biopsy.
A
B
Radiating folds
Ulcer

A, A persistent collection of barium with radiating folds in
the duodenal bulb, highly suggestive of an ulcer. B, Posterior
duodenal ulcer with a clean base. There is marked edema of
the bulb, with folds radiating from the ulcer. Subepithelial
hemorrhage is surrounding the ulcer, as well as in the remainder
of the bulb. A small ulcerative lesion is also shown anteriorly.
B
FIGURE 4.14 DUODENAL ULCER FIGURE 4.15 DUODENAL ULCER

Well-circumscribed ulcer with yellow exudate resembling a Large duodenal ulcer with surrounding edema projecting into
fried egg. the duodenal bulb. The second duodenum is normal.
FIGURE 4.16 DUODENAL ULCER FIGURE 4.17 DUODENAL ULCER WITH SCARRING
Small, clean-based ulcer surrounded by prominent folds and Duodenal ulcer with several lesions and marked retraction
diffuse subepithelial hemorrhage. resulting from prior disease.
FIGURE 4.18 ANTERIOR SUTURE WITH SMALL ULCER

Suture at the site of a prior oversew of duodenal ulcer hemorrhage.
Small ulceration is seen at the base of the suture material.
FIGURE 4.19 DUODENAL ULCER WITH

DEFORMITY
A, Markedly abnormal duodenal bulb with
active ulceration and pseudodiverticula.
B, Forceps were placed in the slitlike
opening demonstrating a mucosal bridge.
A B
A B C
FIGURE 4.20 MALIGNANT DUODENAL ULCER

A, Edematous fold posteriorly at the junction of the first and second duodenum. There is mild narrowing and associated ulceration
anteriorly. B, The ulceration is surrounded by edematous duodenal tissue. C, The depth of the lesion is evident. Biopsy results proved
adenocarcinoma, and this patient had a hilar mass (cholangiocarcinoma).
Duodenal Ulcer (Figure 4.20)
Benign duodenal ulcer
Extrinsic neoplasm (cholangiocarcinoma, pancreatic carcinoma)
Periduodenal inflammatory process (e.g., pancreatitis)
A B
FIGURE 4.21 DUODENAL DEFORMITY MIMICKING ULCER

A, Collection of barium in the duodenal bulb with radiating folds, suggestive of an active ulcer crater. There is marked edema of the
folds in the second duodenum, suggesting duodenitis. B, The collection of barium represents an old healed ulceration. The duodenal
bulb is markedly distorted, with multiple erosions and edema. In a patient with prior ulcer disease, healed craters, and secondary
pseudodiverticula, active ulcer craters may be difficult to distinguish radiographically from inactive healed disease.
Polyp
Pyloric canal
Antrum
B1 B2
FIGURE 4.22 DUODENAL DEFORMITY

MIMICKING POLYP
A, Filling defect in duodenal bulb
mimicking a polyp. B, The pylorus is
patulous (B1); the bulb is edematous,
with an active crater (B2, B3). Marked
deformity and edema are present at the
junction of the first and second portion of
B3 B4
the duodenum (B4).
A B C
FIGURE 4.23 DOUBLE PYLORUS

A, Two openings at the pylorus separated by a mucosal bridge. B, The anterior opening is now more apparent when cannulated with
a stiff wire. C, Upper gastrointestinal (UGI) series shows the two pathways to the duodenal bulb.
Superior duodenal
angle
Bulb
Posterior ulcer
Anterior ulcer
FIGURE 4.24 PYLORIC CHANNEL ULCER

A, The pylorus is seen with a clean-based ulcer posteriorly and a smaller ulcer anteriorly. There is associated subepithelial hemorrhage
in the channel. A normal-appearing duodenal bulb and superior duodenal angle are seen in the distance.
Continued
B C
FIGURE 4.24 PYLORIC CHANNEL ULCER

B, Mild narrowing of the pylorus with erythema and shallow posterior ulcer. C, Patulous pylorus with shallow ulcer both anteriorly and
posteriorly.
A B
FIGURE 4.25 DUODENAL ULCER CAUSING GASTRIC OUTLET OBSTRUCTION

A, Markedly dilated, fluid-filled stomach, with barium seen in the distal esophagus and puddling in the gastric body. The gastric air
bubble is pronounced. A succussion splash was present on physical examination. B, Deformity of the peripyloric area and bulb.
Continued
Deformed bulb Mass effect
Ulcer
D1 D2

CAUSING GASTRIC OUTLET
OBSTRUCTION
C, Deformity of bulb with active ulcer
and edema, causing a mass effect on
the proximal second duodenum.
D, The pylorus is absent. A large
pseudodiverticulum is shown anteriorly
(D1-D3). Edema and narrowing are
present with further advancement of the
D3 D4
endoscope (D4).
Continued

CAUSING GASTRIC OUTLET OBSTRUCTION
E, An ulcer is seen posteriorly (E1-E3).
The circumferential process ends abruptly
at the superior duodenal angle (E4).
E1 E2
E3 E4
FIGURE 4.26 ULCER IN DESCENDING DUODENUM

Large hemicircumferential bile-stained ulcer in the mid-second
duodenum. The lesion was caused by nonsteroidal
antiinflammatory drug use.
FIGURE 4.27 ZOLLINGER-ELLISON

SYNDROME
A, Edema and erythema at the junction of
first and second duodenum associated with
a small posterior ulcer. B, Giant ulcer in the
second duodenum. C, Multiple ulcers in
the mid-second duodenum. D, This patient
also had severe erosive esophagitis.
The association of esophagitis with ulcers in
the second duodenum should raise
suspicion for Zollinger-Ellison syndrome.
A B
C D
FIGURE 4.28 DUODENAL ULCER WITH FLAT RED SPOT FIGURE 4.29 GIANT DUODENAL ULCER WITH RAISED SPOT
Large ulcer with flat red spot. Note the depth of the lesion with the surrounding ulcer rim.
A raised black spot in the center of the ulcer indicates the point
of bleeding.
A B C
FIGURE 4.30 DUODENAL ULCER WITH BLACK BASE

A, Large posterior ulcer with heaped-up margins and adherent heme. B, Well-circumscribed posterior ulcer partially covered by old
blood. C, Anterior duodenal ulcer with black base. Note the nearby small, clean-based ulcer.
A1 A2 A3
A4 A5
FIGURE 4.31 DUODENAL ULCER WITH CLOT

A1, Anterior ulcer with protruding adherent clot. A2, Epinephrine is injected into the base of the clot with bleeding precipitated.
A3, The clot is removed with biopsy forceps. Note the ischemic appearance of the duodenum resulting from the epinephrine
injection. A4, Oozing was seen from fleshy material at the base of the clot representing a visible vessel. A5, Thermal therapy
was applied to the bleeding area, resulting in black eschar with depth and hemostasis achieved.
Continued
B1
C D1
B2
D2 D3
E1 E2 E3
FIGURE 4.31 DUODENAL ULCER WITH CLOT

B, Deep serpiginous ulcer with adherent clot proximally and flat black spot distally.
C, Adherent clot to a posterior ulcer. D1, Shallow anterior ulcer with small adherent clot.
D2, 7-French heater probe applied to the clot. D3, Depression with black eschar
after successful ablation of the area of clot. E1, Large ulcer with central adherent clot.
E2, The clot was manipulated with the thermal probe, resulting in dislodgement and
exposure of fleshy material, presumably visible vessel. E3, Dilute epinephrine is injected
into the base of the fleshy material. Note the dislodged clot in the distance.
E4 E4, After injection, there is marked ischemia of the anterior duodenum.
A B C
D E
FIGURE 4.32 MASS-LIKE DUODENAL ULCER WITH CLOT

A, Mass effect in the posterior duodenum with central ulceration. B, Close-up of the ulcerated area demonstrates an opening covered
with clot. C, With clot removed, a cavity is evident. D, More distally, circumferential ulcer is seen with normal duodenum in the
distance. E, Marked circumferential thickening of the duodenum resembling a mass lesion. Air is seen in the lumen and in the
thickened wall. Surgery confirmed a benign duodenal ulcer.
FIGURE 4.33 MALIGNANT DUODENAL

ULCER WITH BLEEDING VISIBLE VESSEL
A, Large ulcer in the anterior wall of the
duodenal bulb. Note the mass effect in the
duodenum and the lack of well-defined
edges to the ulcer. There is a central fresh
blood clot with active oozing from
underneath. B, Thermal therapy was applied
to the area, resulting in eschar and
depression. Subsequent biopsy results
showed adenocarcinoma.
A B
A B C1
C2 C3 C4
C5 D1 D2
FIGURE 4.34 DUODENAL ULCER WITH VISIBLE VESSEL

A, Large ulcer with central protrusion and fresh bleeding. The protrusion was seen to
pulsate (an artery), and no endoscopic therapy was thus performed. B, Small ulcer with
fleshy visible vessel at the proximal margin with a small adherent red clot. C1, Red nipple
extending from a small anterior duodenal ulcer. C2, Dilute epinephrine is injected just
inferior to the nipple. C3, Note the marked blanching after epinephrine injection. C4, A
thermal probe is approaching the vessel. C5, Black eschar and cavitation resulting from
thermal therapy. D1, Visible vessel in a small duodenal ulcer with active arterial bleeding.
D2, Thermal therapy is applied directly to the bleeding point. D3, Black eschar at the site
D3
of thermal therapy and resultant hemostasis.
A B C
FIGURE 4.35 DUODENAL ULCER WITH VISIBLE VESSEL AND ARTERIAL BLEEDING
A, Large anterior duodenal ulcer with fleshy nonbleeding visible vessel. B, With observation, active arterial bleeding began.
C, Appearance of the ulcer after thermal therapy.
Clot
Pseudo-
diverticulum
Ulcer with clear,

visible vessel
FIGURE 4.36 DUODENAL ULCERS WITH MULTIPLE STIGMATA

Two ulcers in the bulb with associated pseudodiverticulum. The anteroinferior ulcer has a white nipple-like projection, whereas the
superior ulcer has a large, flat black area.
A B C
D E
FIGURE 4.37 BLEEDING ULCER IN SECOND DUODENUM

A, Fresh blood and active bleeding from a clot in the second duodenum. Because of the position, a forward viewing endoscope could
not adequately visualize the area for endoscopic therapy. B, Bleeding area as seen with side viewing duodenoscope. An en face view
was now possible. C, With vigorous washing, a focal area of bleeding was seen and dilute epinephrine injected with a sclerotherapy
needle. D, After epinephrine therapy, a fleshy vessel was identified. The 10-French thermal probe is in position. Multiple pulses were
applied, resulting in hemostasis and a black eschar. E, Note bile flowing from the major papilla just superior to the lesion.
FIGURE 4.38 DUODENAL ULCER PERFORATION

Large duodenal ulcer with apparent opening. Surgery confirmed a
perforated anterior ulcer.
FIGURE 4.39 COILS IN DUODENAL WALL

FROM PRIOR EMBOLIZATION
A, B, Round coils at site of prior bleeding
ulcer.
A B
A1 A2 B1
B2 B3 B4
FIGURE 4.40 CROHN’S DISEASE

A1, Irregular ulceration at the junction of
first and second duodenum. A2, Close-up
shows the serpiginous nature of the ulcer.
B1, B2, Serpiginous ulceration with
nodularity in the third duodenum with
some narrowing. B3, More distally, a
stricture is shown. B4, Balloon dilatation of
the stricture. B5, B6, UGI series with a
B5
small-bowel follow-through shows
multiple strictures and distal ileal disease
confirming the diagnosis of Crohn’s
B6
disease.
Crohn’s Disease (Figure 4.40)
Infection
Cytomegalovirus
Nonsteroidal antiinflammatory drug injury
FIGURE 4.41 JEJUNAL CROHN’S

DISEASE
Ulcerated stricture in the proximal
jejunum found by push enteroscopy.
(Courtesy F. Perez-Roldan, MD, and
Dr. P. Gonzalez-Carro, MD, Alcazar
de San Juan, Spain.)
FIGURE 4.42 ISCHEMIA

Serpiginous ulceration throughout the second duodenum.
A B1 B2
FIGURE 4.43 INFARCTION

A, Thick exudate covers the duodenum. B1, B2, When the exudate is débrided, the underlying mucosa is black and necrotic.
A B1 B2

A, Air has been withdrawn from the duodenal bulb to bring the ectasia closer, documenting the lack of depth and the characteristic
frondlike appearance. B1, Solitary ectasia in the second duodenum. B2, The ectasia is well delineated on narrow band imaging.
A1 A2
A3 A4
FIGURE 4.45 MULTIPLE VASCULAR ECTASIAS

A, Multiple ectasias in the second duodenum. Ectasias were not seen in the stomach or colon. B, Close-up view demonstrates the
variable appearance of two ectasias.
FIGURE 4.46 BLEEDING ECTASIA
UNDERWATER
A, A large amount of fresh blood in the
mid-second duodenum without a pinpoint
site. B, With infusion of water, blood was
now seen to stream from a pinpoint site.
A B
A B C
D E F1
F2 G1 G2
FIGURE 4.47 BLEEDING ECTASIA

A, A fresh stream of blood is shown. B, The heater probe water jet is applied to the bleeding area exposing a bleeding site.
C, With observation, blood is seen to stream from a pinpoint ectasia. D, The 7-French heater probe is applied to the area, resulting in
a white eschar and hemostasis. E, Fresh blood coating the proximal second duodenum with the forward viewing endoscope.
No specific bleeding site is seen. F1, F2, Using the duodenoscope and with washing, an area of persistent oozing is seen. The area is
vigorously washed identifying a pinpoint area whereby the heater probe is used to coagulate the lesion, resulting in exudate,
white eschar, and hemostasis (G1, G2).
A B
FIGURE 4.48 PORTAL HYPERTENSIVE DUODENOPATHY

A, Diffuse petechial lesions in the second duodenum. This patient also had esophageal varices. B, Multiple dilated capillaries in the
submucosa.
A B C

A, Active stream of blood jetting from the posterior duodenal bulb. B, Large volume of dilute epinephrine was injected into the
bleeding site. C, After injection, the mucosa has a whitish appearance from ischemia. A pinpoint area representing the bleeding site is
apparent.
FIGURE 4.50 RADIATION ENTERITIS

Multiple small ectasias throughout the
duodenum after radiation therapy (A, B).
A B
FIGURE 4.51 DUODENAL VARICES

A, Small submucosal veins. B, Gastric varices
were also present. This patient had splenic
vein thrombosis.
A B
FIGURE 4.52 ANASTOMOTIC VARICES

A, Variceal trunk near the site of a
small-bowel anastomosis. B, Close-up of
the area shows subepithelial varices.
A B
FIGURE 4.53 POLYARTERITIS NODOSA

A, Typical skin lesion on the lower
extremities. B, Submucosal purpuric lesion
of the duodenum. (A courtesy P. Redondo,
A B
FIGURE 4.54 HENOCH-SCHÖNLEIN

PURPURA
A, B, Focal petechial lesions in the second
duodenum. The surrounding mucosa is
normal.
A B

Two small, raised, polypoid lesions in the anterior duodenal bulb.
FIGURE 4.55 THROMBOTIC THROMBOCYTOPENIC PURPURA Biopsy findings demonstrated acute and chronic inflammation
Multiple well-circumscribed erosions in the second duodenum. without evidence of neoplasia. The appearance is not
pathognomonic for any specific type of polypoid lesion.
A B C
D E
FIGURE 4.57 GASTRIC METAPLASIA

A, Multiple small nodules on the anterior wall of the duodenal bulb that have a typical appearance for gastric metaplasia. B, Larger
lesions seen in association with the more typical smaller lesions. C, Larger polypoid lesions. D, Linear polypoid lesions. E, Gastric-type
mucosa with foveolar epithelium. Gastric metaplasia may be seen in the duodenal bulb, associated with polyps.
FIGURE 4.58 BRUNNER’S GLAND HYPERPLASIA

A, Small polypoid lesion in the duodenal bulb. B, Giant Brunner gland polyp. C, Normal-appearing duodenal tissue with submucosal
Brunner’s glands.
A B C
FIGURE 4.59 DUODENAL BRUNNER’S GLAND HAMARTOMA

A, CT scan shows large duodenal mass lesion. B, Large, round
lesion in the proximal second duodenum that appears
submucosal. C, Endoscopic ultrasound shows the size of the
lesion. D, Histology demonstrates the Brunner’s
D
glands. (Courtesy J. Pardo-Mindan, MD, Pamplona, Spain.)
Duodenal Brunner’s Gland Hamartoma (Figure 4.59)
Extrinsic lesion
A B
FIGURE 4.60 CARCINOID POLYP

A, Well-circumscribed lesion with central collection of barium in the proximal duodenal
bulb. This lesion is more suggestive of an ulcer than a polyp. The duodenal bulb and
second duodenum are normal. B, Polypoid lesion projecting from the anterosuperior
duodenal bulb. A central area of indentation corresponding to the radiograph is not
identifiable from this angle. C, A monotonous population of small, round cells fills
C
the lamina propria, compressing the normal duodenal glands.
FIGURE 4.61 CARCINOID TUMOR

A1, A2, Round, donut-shaped lesion with
central ulceration in the duodenal bulb
typical for a neuroendocrine tumor. B, C, UGI
series shows a defect in the duodenal bulb
with persistent barium in the ulcer crater
resembling the donut appearance (right).
D, CT also shows the large filling defect
represented by the hypodense lesion in the
duodenum.
A1 A2
Carcinoid
tumor
Pylorus
C Carcinoid tumor
D
Continued
E F
G H

E, Carcinoid features are seen on routine hematoxylin and eosin staining. The neuroendocrine origin of the lesion is demonstrated by
confirmational staining with chromogranin (F), synaptophysin (G), and keratin (H).
Carcinoid Tumor (Figure 4.61)
Metastatic tumor
Adenocarcinoma
Primary duodenal lymphoma
FIGURE 4.62 PANCREATIC REST

Well-circumscribed, donut-like lesion in the anterior duodenal
bulb. This lesion resembles that seen in the stomach
(see Figure 3.179).
FIGURE 4.63 DUPLICATION CYST

Large polypoid mass occupying the normal location of the
ampulla. A small ulcer is on the inferior portion of the lesion.
Duplication Cyst (Figure 4.63)
Primary ampullary adenocarcinoma
Other ampullary neoplasm
Impacted bile duct stone
A1 A2 B
C D
E F
FIGURE 4.64 DUODENAL LIPOMA

A, Gastric mucosa appears to be pulled into the duodenum.
B, On endoscopic ultrasonography (EUS), a hyperechoic lesion is
demonstrated. C, Intussusception as shown on CT. D, A mass
occupies the duodenal lumen. The black color of the lesion
represents a fat density on CT. E, Intussusception as seen at
laparoscopy. F, The duodenum is open and the large lipoma
demonstrated. G, The resection specimen confirms a fatty
G tumor.
Continued
Stalk
Polyp
Ulceration
H1
H2 H3 H4
H5 H6
FIGURE 4.64 DUODENAL LIPOMA

H1, Polyp in duodenal bulb with a long stalk and with central ulceration. H2, H3, The polyp is snared and resected, and measured to be
1 cm (H4). H5, H6, Small-bowel mucosa with underlying well-circumscribed fibroadipose tissue mass.
FIGURE 4.65 FAMILIAL ADENOMATOUS

POLYPOSIS
A, Multiple sessile to slightly raised lesions
with central discoloration in the second
duodenum. B, Large mushroom-shaped
polyp on the lateral wall of the second
duodenum. Biopsy results demonstrated
adenoma. The patient had previously
undergone total colectomy for familial
adenomatous polyposis coli syndrome.
A B
FIGURE 4.66 ADENOMA

Large adenomatous polyp at the superior duodenal angle
posteriorly. The polypoid lesion is somewhat nodular and has a
superficial texture suggestive of adenoma.
A B C
FIGURE 4.67 ADENOMA

A, B, Sessile adenoma of the mid-second
duodenum. Note the whitish texture,
which is characteristic of adenomas in
the duodenum. C, Large
hemicircumferential lesion. D, Large
D1 D2
lesion inferior to ampulla.
A B C
FIGURE 4.68 ADENOMA

A, Well-circumscribed adenoma at the junction of first and second duodenum. B, Appearance with narrow band imaging.
C, Endoscopic resection of lesion.
A B C
D E F
FIGURE 4.69 ADENOMA WITH ENDOSCOPIC MUCOSAL RESECTION

A, Sessile adenoma in the second duodenum. B, Adenoma with shiny appearance
inferior to the ampulla. This is the appearance with the forward viewing endoscope.
C, Dilute epinephrine is injected underneath the lesion. D, Further submucosal
injection raises the polyp. E, The snare is placed around the lesion. F, The snare is closed.
G
G, Mucosal defect created after complete resection.
FIGURE 4.70 VILLOUS ADENOMA

A, The lesion appears to emanate from the
distal duodenum (A1, A2). The center of
the lesion is covered with bile and has a
frondlike appearance, suggestive of
adenomatous tissue (A3). The lesion
appears to be on the lateral
duodenum when the instrument is
advanced, documenting the center of
the lesion (A4). B, Surgical specimen has
been partially everted, demonstrating the
well-circumscribed nature of the lesion.
A1 A2
A3 A4
FIGURE 4.71 CARCINOID TUMORS ASSOCIATED WITH MULTIPLE ENDOCRINE

NEOPLASIA TYPE 1 AND ZOLLINGER-ELLISON SYNDROME
Multiple round nodular lesions in the second duodenum.

Multiple polyps in the periampullary area
(A) and mid- and second duodenum (B).
A B
FIGURE 4.73 COWDEN’S SYNDROME FIGURE 4.74 PEUTZ-JEGHERS POLYPS

Large polypoid lesion in the second duodenum. Multiple small polyps in the second duodenum.
Gallbladder
Stomach
Common
bile duct
Duodenum
A
B C

A, The duodenal sweep is dilated and markedly circumferentially thickened. The common bile duct is seen. This suggests a masslike
lesion of the proximal second duodenum. B, Extrinsic compression in the distal duodenal bulb. The overlying mucosa appears normal.
C, Hemicircumferential ulcerative lesion in the proximal second duodenum. The adenocarcinoma was believed to be of primary
duodenal origin. Pancreatic carcinoma may present with duodenal abnormalities.
A B C

A, Narrowing of the junction of first and second duodenum with nodularity and a large central ulceration. B, There is circumferential
ulceration with impending obstruction. C, Enteral stent was placed for palliation.

A, At the junction of the second and third
duodenum, a glimpse of abnormal tissue is
shown. B, A circumferential ulcerated mass
lesion is identified with further
advancement. C, D, CT images show the
extensiveness of the mass.
A B
Adenocarcinoma
Adenocarcinoma
D
A B C

A, Hemorrhagic polypoid lesion in the mid-second duodenum. B, A large lesion was also present near the pylorus.
C, Well-circumscribed, raised, dark polypoid lesion in the second duodenum.
FIGURE 4.79 GASTROINTESTINAL

STROMAL TUMOR
A, Large mass lesion occupying the
lumen of the distal duodenum.
B, Hemicircumferential nature of the
tumor is apparent. C, The appearance of the
stent and tumor in the surgical specimen.
A B
C
FIGURE 4.80 GASTROINTESTINAL STROMAL TUMOR

Large hemorrhagic mass lesion.
Duodenal bulb
Filling defect

Nodularity of the duodenal bulb and filling defect in the proximal third duodenum.
A

A, Fleshy mass lesions in the second duodenum. B, Malignant lymphoid cells distorting the duodenal glands.
A B

A, Large anterior wall duodenal ulcer. B, White plaquelike lesions in the second duodenum.
Giant benign duodenal ulcer
Adenocarcinoma
Extrinsic lesion
Neoplasm
Infection
A B
C D

A, Smooth fold thickening throughout the second duodenum. B, The duodenum is markedly thickened. C, D, Diffuse large cell
lymphoma.
A B
FIGURE 4.85 MANTLE CELL LYMPHOMA

A, Small-bowel series shows diffuse mucosal thickening. B, Marked duodenal and proximal jejunal thickening.
Continued
FIGURE 4.85 MANTLE CELL LYMPHOMA

C, Diffuse small-bowel thickening and thickening of the colon.
D, Fold thickening in the second duodenum, proximal jejunum
(E), and ileum (F). There was also colonic involvement with loss
of mucosal vascular pattern, patchy ulceration, and mucosal
thickening (G, H).
D E F
G H
A1 A2 B

A1, Large, masslike lesion impinging on the second duodenum. A2, Large mass in the peripancreatic area. B, Large, ulcerated, masslike
lesion in the second duodenum. No normal mucosa is present.
A B

A, Small dark lesion in the proximal second duodenum. B, Large darkly discolored lesion eroding into the second duodenum.
FIGURE 4.88 METASTATIC HYPERNEPHROMA
Submucosal mass with overlying erosions.
A B
FIGURE 4.89 METASTATIC LUNG CANCER

Multiple lesions in the second duodenum. One lesion has a small ulceration (A), whereas the other lesion has a raised volcano
appearance with a deep ulcer (B).
Metastatic Lung Cancer (Figure 4.89)
Inflammatory polyp
Adenomatous polyp
Metastatic neoplasm
A B
C D
FIGURE 4.90 COLON CANCER INVOLVING DUODENUM

A, Well-circumscribed mass lesion in the second duodenum. B, A fleshy visible vessel was seen in the center of the lesion presumably at
the site of recent bleeding. C, Angiography shows a large tumor blush. D, Post-embolization film demonstrates the placed coils and
markedly reduced blood flow.
FIGURE 4.91 METASTATIC RECTAL CANCER FIGURE 4.92 METASTATIC PSEUDOMYXOMA PERITONEI
Submucosal lesion in the mid-second duodenum. Fleshy lesion in the mid-second duodenum.
FIGURE 4.93 CYTOMEGALOVIRUS ULCERATION

Marked edema and subepithelial hemorrhage in the duodenal
bulb. A well-circumscribed, clean-based ulcer is present, with an
ulcer also present in the distance.

A, Well-circumscribed ulcer with a
punched-out appearance in the mid-
second duodenum. Red spots are present in
the ulcer base. This patient was status post–
renal transplantation and had no clinical
bleeding. B, Characteristic viral cytopathic
effect in the epithelial cells.
A B
A B
C D
FIGURE 4.95 MYCOBACTERIUM AVIUM COMPLEX
A, There appears to be thickening of the wall of the third and
fourth duodenum and proximal jejunum. There is marked
adenopathy of the retroperitoneum and small-bowel mesentery.
The lumen of the third duodenum and proximal jejunum
appears narrowed and nodular, with associated bowel wall
thickening. B, Multiple nodular lesions throughout the second
duodenum. The circular folds appear somewhat thickened.
The surrounding mucosa does not have an ulcerated or inflamed
appearance. C, The duodenal villi are bulbous and markedly
distorted. There is a monotonous infiltrate of benign granular
macrophages in the lamina propria. D, Fite stain of the
duodenum demonstrates macrophages stuffed with slender
acid-fast bacilli. E, Autopsy specimen demonstrates the marked
E
thickening of the duodenum from infection with Mycobacterium
avium complex.
A B
FIGURE 4.96 CRYPTOSPORIDIOSIS

A, Marked thickening of the duodenal folds. B, The mucosa has a very granular, whitish appearance, and the circular folds are
thickened. Marked inflammation was present on biopsy.
A1 A2
B C
FIGURE 4.97 CRYPTOSPORIDIOSIS

A1, Diffuse erythema and granularity with some loss of the duodenal folds (A2). B, Histology shows mild blunting of the villi with a
marked inflammatory process. C, Numerous small, round structures are seen on the surface epithelium representing the
cryptosporidial organisms.
A B
FIGURE 4.98 GIARDIASIS

A, Marked nodularity and loss of the normal mucosal pattern. B, Marked inflammation associated with numerous Giardia organisms
represented by the crescent-like structures at the epithelial surface.

Large worm filling the duodenum. (Courtesy F. Vida, MD, and
A. Tomas, MD, Manresa, Spain.)
A1 A2 B
C D
FIGURE 4.100 WHIPPLE’S DISEASE

A1, Multiple yellow nodular lesions in the second duodenum.
A2, Close-up shows engorgement of the villi. B, Multiple diffuse
white plaques. C, Erythema with thickened folds. D, Hematoxylin
and eosin staining shows effacement of the normal duodenal
architecture. E, Periodic acid-Schiff stain shows multiple
positively staining cells representing the bacteria in
E
macrophages.
A B
FIGURE 4.101 DUODENAL

SARCOIDOSIS
A, Thickened folds of the duodenal
bulb and second duodenum. B, Marked
fold thickening with scattered erosions.
C
C, Large, noncaseating granuloma.
A B C
FIGURE 4.102 PSEUDOMELANOSIS DUODENI

A, Black speckling of the second duodenum. B, More significant
pigmentation. C, Striking black discoloration of the mucosa.
D, More extensive involvement. E, Black pigment apparent in
D
the mucosa on low-power view.
Continued
FIGURE 4.102 PSEUDOMELANOSIS DUODENI

F, Iron stain highlights the pigment. G, Black pigment seen in the
F
duodenal submucosa on high-power image.
FIGURE 4.103 LYMPHANGIECTASIA

Duodenal lymphangiectasia as shown on
routine (A) and narrow band imaging (B).
C, D, Lymphatic channels readily apparent
at the mucosal surface.
A B
C D
FIGURE 4.104 LIPID PLAQUE

Well-circumscribed yellow plaque with a white speckled surface.
Biopsy results demonstrated a focal lipid collection. These lipid
collections can be seen throughout the gastrointestinal tract.
Duodenum and jejunum Thickened jejunum
B C
FIGURE 4.105 INTRAMURAL HEMORRHAGE

A, Marked edema of the second duodenum and proximal jejunum. The jejunum has a markedly thickened wall, with small collections
of barium in the center representing the lumen. B, Marked spiculation and nodularity of the duodenum, with luminal narrowing in the
second duodenum. There is separation between the duodenal loops in this area, resulting from wall thickening. C, Marked thickening
and subepithelial hemorrhage throughout the distal second duodenum. In some areas where there is no subepithelial hemorrhage,
the mucosa has a bluish hue.
Continued
FIGURE 4.105 INTRAMURAL HEMORRHAGE

D, There is focal hemorrhage in the lamina propria, and
blood diffusely infiltrates the fibroconnective tissue of the
submucosa. Bleeding in the lamina propria appears
endoscopically as bright red subepithelial hemorrhage.
The bluish discoloration represents the deeper, submucosal
areas of hemorrhage.
A B
FIGURE 4.106 AORTOENTERIC FISTULA

A, Large defect in the mid-second duodenum with central depression and overlying blood clot. B, With washing, a large defect is now
visible.
Fluid
around graft
C D
FIGURE 4.107 AORTOENTERIC FISTULA

A, Computed tomography (CT) shows fluid around the graft (right). B, CT with vascular image reconstruction shows the abnormality of
the right iliac artery. C, Round, raised polypoid lesion in the duodenum. D, As seen at the time of surgery, the fistulous opening is
obvious.
A B C
D E F
G H
FIGURE 4.108 CELIAC SPRUE

A, The duodenal folds appear slightly thickened. B, When viewed underwater, minimal villi are appreciated. C, Fissuring and mild
nodularity of the valvulae conniventes. D, The mucosal changes are highlighted with methylene blue. E, Nodularity of the mucosa with
absent folds. F, Subtle loss of the villi with some areas of epithelial loss.
Continued
I J
K L
FIGURE 4.108 CELIAC SPRUE

G, Smooth mucosa with some ridging to the folds. H, Completely flat smooth mucosa. I, Villous atrophy with chronic inflammation in
the lamina propria. J, Numerous CD3 positively staining cells in the submucosa. K, Marked nodularity of the duodenum can be seen on
barium study. L, Dilated duodenum with thickened folds.
A B1 B2
FIGURE 4.109 CELIAC SPRUE WITH

ADENOMA
A, Large adenoma of the duodenum with
its characteristic whitish mucosa. Note the
flat surrounding mucosa. B1, B2, More
proximally mucosal ridging and fissuring
were evident. C, The lesion was ablated with
argon plasma coagulation. D, Follow-up
shows a small amount of residual tissue
C D
with scar.
FIGURE 4.110 GRAFT-VERSUS-HOST

DISEASE
A1, Patchy erythema of the second
duodenum. A2, Mild changes were also
present in the gastric antrum. B1, Diffuse
hemorrhage and complete mucosal loss.
Similar changes were present in the
stomach (B2).
A1 A2
B1 B2
A B
C1 C2
C3 C4
FIGURE 4.111 PANCREATITIS

A, Narrowing of the second duodenum. B, The wall of the second duodenum is markedly thickened.
C, At the superior duodenal angle, the lumen is collapsed by edematous mucosa. There is no
overlying mass lesion or ulceration (C1). The lumen is significantly narrowed at the superior duodenal
angle (C2). In the second duodenum, bile is present; the masslike lesion can be seen anteriorly (C3).
In the mid-second duodenum, the masslike lesion can be seen on the medial superior wall (C4).
Annular
lesion
A
FIGURE 4.112 CHRONIC PANCREATITIS AND DUODENAL

OBSTRUCTION
A, Irregular constricting lesion of the distal second duodenum
compatible with a neoplasm. Barium is refluxing into the common
bile duct. B, A circumferential ulcerated area at the junction of the
first and second duodenum, suggestive of carcinoma. Surgical
B
exploration revealed only chronic pancreatitis.
Chronic Pancreatitis and Duodenal Obstruction (Figure 4.112)
Primary duodenal adenocarcinoma
Pancreatic carcinoma
Other extrinsic inflammatory or neoplastic process
A B
Stomach
Pancreatic duct
Common bile duct
Pseudocyst
C
FIGURE 4.113 PANCREATIC PSEUDOCYST CAUSING DUODENAL OBSTRUCTION

A, Markedly dilated stomach displacing the transverse colon. B, After nasogastric suction, the transverse colon returns to its normal
position. C, The stomach is dilated, with no contrast material seen in the second duodenum. The pancreatic head is enlarged, and a
pseudocyst is present.
Continued
FIGURE 4.113 PANCREATIC

PSEUDOCYST CAUSING DUODENAL
OBSTRUCTION
D, The stomach is filled with fluid
(D1); the duodenal bulb is inflamed,
and a circumferential narrowing is
present at the junction of the
first and second duodenum (D2-D4).
E, The endoscope is advanced through
the area of narrowing (E1-E3), which
represents edema finally entering the
second duodenum (E4).
D1 D2
D3 D4
E1 E2
E3 E4
FIGURE 4.114 SPONTANEOUS
PANCREATICODUODENAL FISTULA CAUSED
BY NECROTIZING PANCREATITIS
A1, A2, CT shows complete pancreatic
necrosis with air in the pancreatic bed.
B1, Ulceration and distortion in the proximal
second duodenum. B2, On entering the
necrotic area, an opening is seen into the
cavity of pancreatic necrosis.
A1 A2
B1 B2
A B C
D E
FIGURE 4.115 SPONTANEOUS DUODENAL-COLONIC FISTULA FROM NECROTIZING

PANCREATITIS
A, An opening in the second duodenum is identified. B, On entering the area a tubular
circumferential ulcerated area is shown. C, An apparent opening to another structure.
D, Methylene blue was placed into the cavity. E, Colonoscopy was performed
demonstrating the methylene blue, although the fistula is not identified. F, UGI series
shows the fistulous tract with communication to the colon (arrow). G, CT demonstrates
G
an irregular extraluminal collection in the right upper quadrant (arrow).
A B C
D E F
G H
FIGURE 4.116 ENDOSCOPIC CYST DUODENOSTOMY

A, The cyst is large and free of internal echoes. No overlying vascular strictures are present. B, Large bulge is visible in the proximal
duodenum. C, A needle is placed into the lesion. D, A guidewire exchange is performed with a large amount of cloudy material passing
spontaneously through the puncture site. E, A balloon is inflated across the duodenal wall. F, G, Once deflated, a large defect is created
and fluid again rapidly drains. H, A large double pigtail stent is placed into the cyst.
A B C
FIGURE 4.117 SPONTANEOUS FISTULA FROM PSEUDOCYST IN SECOND DUODENUM

A, Subtle mucosal defect in the second duodenum with overlying debris and subepithelial hemorrhage. B, The area was probed and a
fistula to the cyst cavity identified. C, The fistulous tract is dilated.
A B C
FIGURE 4.118 DUODENAL DIVERTICULUM

A, Large diverticulum on the medial wall of the mid-second duodenum. Diverticula in the second duodenum are most commonly seen
around the papilla. B, Multiple diverticula on the lateral wall of the second duodenum. C, Large diverticulum on the medial wall of
second duodenum. This is likely the location of the major papilla.
A B C1
Soft gallstone in
distal left common
hepatic duct
C2 C3
D1 D2 D3
FIGURE 4.119 CHOLEDOCHODUODENOSTOMY

A, An opening can be seen in the anterior duodenal bulb, representing anastomosis of the distal common bile duct to the duodenum.
Another small defect represents past erosion of a common bile duct stone into the duodenal wall. Anterior–posterior relationships in
the duodenal bulb are important when defining ulcerative disease in the setting of gastrointestinal hemorrhage. The duodenum may
be involved secondarily in the setting of disease of surrounding structures, most notably pancreatic disease with pancreatitis. B, Small
defect anteriorly at the junction of first and second duodenum. A small gallstone is resting over the opening. C1, Opening in the
proximal second duodenum represents the choledochoduodenal anastomosis. C2, On entering the anastomosis, the biliary tree
and ducts are identified. C3, The common bile duct can be entered visualizing the hilum with junction of right and left common
hepatic ducts. Note the presence of a soft gallstone in the distal left common hepatic duct. D1, Circumferential folds in the proximal
duodenum. D2, The folds were gently entered, revealing an opening. D3, The endoscope was passed into the biliary system with
radicals identified.
FIGURE 4.120 CHOLECYSTODUODENAL

FISTULA
A1, Dark ulcer in the duodenal bulb with
diffuse bulbar erythema. A2, Note the
striking edema with accentuation of the
duodenal mucosal pattern. B, Large
gallstone at the entrance to the defect.
C, Once you enter the defect, the
gallbladder can be seen with a pigtail
cholecystostomy tube.
A1 A2
B C
FIGURE 4.121 PYLORUS-PRESERVING

WHIPPLE
A, With the endoscope in the pylorus, two
limbs are identified. B, The superior limb is
entered and bile duct stents are found.
A B
FIGURE 4.122 POSTSURGICAL DUODENAL

PERFORATION
Large opening in the anterior wall of the duodenal
bulb. A biliary tube is exiting the large defect. Other FIGURE 4.123 POSTSURGICAL DEFECT
drains are in the opening. This patient recently had Large defect in the duodenal wall with the presence of gauze.
complicated biliary tract surgery. This patient recently had complicated abdominal surgery with
packing of infected tissue.
A B C
FIGURE 4.124 DIRECT PERCUTANEOUS

ENDOSCOPIC JEJUNOSTOMY
A, A suitable site is identified in the jejunum
by finger compression. B, A needle is placed
into the jejunal lumen and then grasped
with a snare (C). D, After removal of the
needle, a wire is advanced and grasped
with the snare. Then the percutaneous
endoscopic gastrostomy (PEG) tube is placed
over the wire, with the PEG bumper now
D E
secure in the jejunal wall (E).
A B
FIGURE 4.125 BLEEDING ULCER AT ROUX-EN-Y ANASTOMOSIS

A, Roux-en-Y anastomosis with fresh adherent blood clot. B, Ulceration at the anastomosis with clot.
FIGURE 4.126 CHOLEDOCHOJEJUNOSTOMY

Ulceration at the site of a choledochojejunostomy in a patient
recently status post-liver transplantation.
A1 A2 B1
B2 C D1
D2 E1 E2
FIGURE 4.127 ENTERAL STENT PLACEMENT FOR MALIGNANT OBSTRUCTION

A1, Duodenal narrowing caused by tumor and prior radiation therapy. A2, The duodenum is markedly dilated. A biliary tube is present.
B1, Under fluoroscopic guidance, a catheter is passed through the lesion and injection confirms adequate position in the duodenum.
B2, The patient has a percutaneous biliary pigtail catheter in distal duodenum. C, A guidewire is passed to the distal duodenum.
D1, D2, The metallic prosthesis is advanced over the wire. E1, E2, The stent has been deployed.
Continued
FIGURE 4.127 ENTERAL STENT PLACEMENT FOR MALIGNANT

OBSTRUCTION
FIGURE 4.128 JEJUNAL DIVERTICULA
F, Barium study shows flow through the prosthesis.
Multiple diverticula in the proximal jejunum.
A B
FIGURE 4.129 MULTIPLE ILEAL DIVERTICULA

A, Multiple diverticula in the distal ileum identified at colonoscopy. Note the presence of lymphoid follicles (B).
FIGURE 4.130 JEJUNAL GASTROINTESTINAL STROMAL TUMOR

Submucosal tumor with central ulceration.
A1 A2
B C

A1, A2, Ulcerated lesion in the proximal jejunum with surrounding thickened folds. B, Low-power view shows effacement of the
mucosa with infiltrating tumor. C, High-power view shows numerous mitoses, one feature of malignancy in gastrointestinal stromal
tumors.
Jejunal Gastrointestinal Stromal Tumor (Figure 4.131)
Metastatic lesion
Primary small intestinal adenocarcinoma

Mass lesion with central ulceration in the proximal jejunum.
A B1 B2

A, Submucosal mass lesion with fresh bleeding. B1, B2, View at the time of surgery demonstrates the extraluminal component.
Continued
C D

C, D, Bland stroma typical for a gastrointestinal stromal tumor.
E
E, The tumor stains positively for c-kit receptor.
A B
FIGURE 4.134 JEJUNAL LYMPHOMA

A, Ulcerated lesion with central necrosis. B, Circumferential nature of the lesion is apparent.
A B C
FIGURE 4.135 JEJUNAL METASTATIC LESIONS

A, Jejunal metastasis. Squamous cell metastasis from a head and neck cancer. B, Metastatic melanoma. Fleshy mass lesion in the
jejunum. C, Metastatic lung cancer. Necrotic circumferential mass lesion.
A1 A2
B1 B2
FIGURE 4.136 CAPSULE ENDOSCOPY

A, Large ectasia. B, Polypoid small-bowel neoplasm.
Continued
C1 C2 C3
C4 C5 D1
D2 E1
E2 F

C, Crohn’s disease. D, Crohn’s disease with stricture. There is a stricture in the small bowel ultimately requiring surgery where the
capsule was retained. E, Gastrointestinal stromal tumor. F, Radiation-induced ectasia.
Continued
H1 H2
H3 H4
H5 H6

G, Lymphangiectasia. H, Familial adenomatous polyposis. Numerous adenomas are apparent in the small bowel. H5, Tubular
adenoma in duodenum. H6, Tubular adenoma.
Continued
I J K
L M N
O P Q

I, Ancylostoma worm in jejunum. J, Ampulla of Vater. K, Celiac disease. L, Duodenal ulcer. M, Duodenal Brunner’s gland hamartoma.
N, Peutz-Jeghers polyp with intussusception. O, Tapeworm. P, Portal hypertensive gastropathy. Q, Endoscopic clip at the site of prior
vascular ectasia. (I courtesy O. Alarcón, MD, Tenerife, Spain.)
A B1 B2
B3 B4 C
D1 D2
FIGURE 4.137 DOUBLE BALLOON ENTEROSCOPY

A, Fistula. B1, B2, Jejunal polyp histologically confirmed to be a hamartoma in the setting of Peutz-Jeghers syndrome. B3, Typical
oropharyngeal lesions. C, Adenocarcinoma.
Continued
FIGURE 4.137 DOUBLE BALLOON

ENTEROSCOPY
D1, Retained capsule above a stricture.
D2, The obstruction is caused by an
adenocarcinoma. E, Removal of retained
capsule. F, Gastrointestinal stromal tumor.
G, Circumferential ulceration from
Crohn’s disease. H, Solitary vascular ectasia.
(A courtesy E. Pérez-Cuadrado, MD.)
F
G
H
CHAPTER
5
Colon
INTRODUCTION
The colon can be divided into six segments both anatomically and
endoscopically. Unlike in the stomach, the histology of the colon is rel-
atively uniform. These segments can be divided into the cecum, where
the ileocecal valve and appendiceal orifice serve as important land-
marks; ascending colon; transverse colon; descending colon; sigmoid
colon; and rectum. Appreciation of the endoscopic differences between
regions is important, particularly when dealing with colonic neoplasms,
where accurate localization is essential.
In contrast with the upper gastrointestinal tract, in the colon, diagno-
sis and therapy of neoplasms assume a prominent role. Although adeno-
matous polyps are the most frequent neoplastic lesions, a variety of other
polyps may masquerade endoscopically; subtle mucosal differences may
aid in distinguishing these impostors. Inflammatory disorders such as
Crohn’s disease and ulcerative colitis represent another important group
of diseases. Other inflammatory disorders, including ischemia and infec-
tions (bacterial and viral), assume greater importance in the colon than
in the upper gastrointestinal tract. Many of these inflammatory processes
appear endoscopically similar; however, differentiation can usually be
accomplished based on the characteristics of the patient, location of dis-
ease (pancolonic versus segmental), and characteristics of the disease in
the involved segment (e.g., circumferential versus patchy; ulcer versus
no ulcer).
Descending
Ascending
Transverse
Terminal ileum
Appendix Redundant
sigmoid
Rectum
FIGURE 5.1 BARIUM ENEMA

An air-contrast barium enema demonstrates the normal anatomy of the colon. The sigmoid colon is redundant. The transverse
colon dips inferiorly into the pelvis. The ascending and descending colon are retroperitoneal and fixed. The sigmoid and transverse
colon have suspending mesentery and are thus mobile. The appendix is filled and seen in the pelvis. Reflux of barium demonstrates the
distal terminal ileum.
A B1 B2
C1 C2 D1
FIGURE 5.2 NORMAL MUCOSAL PATTERN

A, The normal descending colon visualized underwater demonstrates a linear
appearance of the mucosa. B1, The normal colonic mucosal vascular pattern as seen
on high-definition endoscopy. B2, The mucosal vascularity is now green when
visualized by narrow band imaging. C1, C2, Close-up of the colonic mucosa
demonstrates a honeycomb-type pattern. D1, At the flexures, one can oftentimes
see the longitudinal colonic muscle, or teniae, which provides the direction
D2 of the lumen (D2).
FIGURE 5.3 HISTOLOGY

Normal colonic architecture. The crypts form the multiple round
structures seen in cross section.
FIGURE 5.4 SIGMOID COLON

A, Circular folds of modest thickness are
identified. B, The sigmoid colon
demonstrates thickened circular folds
corresponding to hypertrophied
musculature. Several diverticula are present.
A B
FIGURE 5.5 DESCENDING COLON

The descending colon forms a long tube and is relatively
featureless.
FIGURE 5.6 SPLENIC FLEXURE

A long, bluish indentation from the spleen.
Normal colonic vasculature is seen. A, Long
bluish indentation from the spleen, with
normal overlying colonic vasculature.
B, Dark area easily identified under a normal
colonic vascular pattern.
A B
A B C
FIGURE 5.7 TRANSVERSE COLON

A-C, The typical-appearing triangular folds of the transverse colon.
FIGURE 5.8 HEPATIC FLEXURE FIGURE 5.9 ASCENDING COLON

The hepatic flexure is noted by the darkish hue from the liver. The ascending colon may also have triangular folds. The ileocecal
Normal colonic vasculature is seen overlying the bluish hue of valve is in the distance.
the liver. Visualization of the adjacent liver will depend on the
position of the patient.
A1 A2 A3
A4 A5 A6
A7 A8 A9
FIGURE 5.10 ILEOCECAL VALVE

A, Appearance of a normal ileocecal (IC) valve (A1-A10). Note that fluid in the right
colon puddles by the IC valve when the patient is in the left lateral decubitus position
A10
regardless of the rotation of the endoscope and can be used as a landmark.
FIGURE 5.12 CECUM

FIGURE 5.11 CECAL POLE
The thickened yellow structure represents the ileocecal valve.
The slit of the appendiceal orifice resides at the base of the cecal
On the contralateral wall, the thickened tinea coli converge with
pole. Folds radiate from the base of the cecum to the transverse
several others forming the transverse cecal fold, “crow’s foot” or
cecal fold.
cecal strap.
FIGURE 5.13 LIPOMATOUS ILEOCECAL

VALVE
A, A smooth filling defect extending from
the medial wall at the level of the ileocecal
valve. B, The filling defect represents a
bulbous (fatty) ileocecal valve. The red area
on the fatty valve resulted from endoscopic
trauma.
A B
FIGURE 5.14 PROLAPSED ILEOCECAL VALVE

Masslike appearance from prolapse of the valve. Biopsy confirmed
ileal epithelium.
A1 A2 B1
B2 B3 B4
B5 B6
C D
FIGURE 5.15 APPENDICEAL ORIFICE

A1, A2, Slitlike semilunar structure at the base of the cecum. B1, B2, Slitlike opening at the base of the cecum. The “leopard skin”
pattern around the appendiceal orifice represents lymphoid follicles that are frequently identified in the cecal pole. B3, B4, Narrow
band imaging highlights the lymphoid follicles (B5, B6). C, Circular raised area at the base of the cecum. The appendiceal orifice
is at the base of this structure. D, Multiple circular folds surround the appendiceal orifice.
A1 A2 B
C D E
FIGURE 5.16 EVERTED APPENDIX

A1, Circular folds emanating from an indentation in the cecal pole. A2, With further
observation, the appendix was seen to spontaneously evert, simulating a polyp. B, Fleshy
tissue emanating from the base of the cecum. C, Round, submucosal-appearing lesion at
the base of the cecum with overlying exudate. This patient had a prior appendectomy.
D, Short finger-like projection from the base of the cecum resembling a pedunculated
polyp. E, Long finger-like projection from the base of the cecum resembling a
pedunculated polyp. F, Round polypoid lesion at the base of the cecum resembling
F
a sessile polyp.
FIGURE 5.17 COLONIC EDEMA

A, B, Mild colonic edema highlights the
normal mucosal pattern. C, Marked edema
of the colon with loss of vascular pattern.
D, Close-up shows the accentuated
architecture of the mucosal pattern.
A B
C D
A1 A2
B1 B2
C D
FIGURE 5.18 ACUTE CULTURE-NEGATIVE BACTERIAL COLITIS

A1, Edema, loss of vascular pattern, subepithelial hemorrhage, and exudate in the descending colon. A2, Stool and pus are in the
ascending colon. B1, Diffuse subepithelial hemorrhage with thick mucopus. B2, Striking subepithelial hemorrhage of the distal colon.
Note the subepithelial hemorrhage spares the lymphoid follicles, creating a honeycomb pattern. C, Pancolitis with circumferential wall
thickening in each segment. The bowel wall thickening is accentuated by the fluid-filled colon. Note the inflammatory process
(stranding) extends around the colon, most striking in the cecum and descending colon. D, The colonic mucosa has both an acute and
a chronic inflammatory infiltrate and mild cryptitis. The crypt architecture is preserved, suggesting acute rather than chronic colitis.
A B C1
C3
FIGURE 5.19 SALMONELLA COLITIS AND ILEITIS
A, Edema, granularity, and mucopus are in the sigmoid colon. B, Similar findings are
present in the ileum. C1, C2, The colon is mildly edematous. The colon wall enhances
C2
with intravenous contrast injection. There is mild thickening of the left colon (C3).
FIGURE 5.20 CAMPYLOBACTER COLITIS

A, Diffuse erythema with patchy
subepithelial hemorrhage in the distal
colon. Stool culture was positive for
Campylobacter jejuni. B, A small ulcer
surrounded by subepithelial hemorrhage is
shown more proximally.
A B
Campylobacter Colitis (Figure 5.20)
Inflammatory bowel disease, ulcerative colitis
Ischemia
Other infections (bacterial, viral)
FIGURE 5.21 ESCHERICHIA COLI 0157 H7
A, Thumbprinting and luminal narrowing of
the distal transverse colon. B, Pancolitis
with mucosal enhancement. Note the
stranding changes around the right colon.
C, Diffuse edema and subepithelial
hemorrhage of the distal colon. Stool
culture was positive.
A C
Stranding
changes
Right colon
B
A1 A2 B
FIGURE 5.22 CLOSTRIDIUM DIFFICILE COLITIS

A1, A2, Characteristic multiple circular, plaquelike lesions of the distal colon. Note the halo of erythema and the loss of vascular pattern
in the surrounding mucosa. B, Diffuse erythema and edema of the distal colon with overlying exudate.
Clostridium difficile Colitis (Figure 5.22)
Ischemic colitis
A B
C1 C2 D
E F
FIGURE 5.23 CLOSTRIDIUM DIFFICILE COLITIS

A, Patchy circular subepithelial hemorrhage in the distal colon. There is colonic edema with loss of the normal mucosal vascular
pattern. B, Multiple raised white plaquelike lesions. C1, Multiple nodules underneath a thin coating of stool. C2, Washing of the lesions
demonstrates pinpoint erosions. D, Multiple bullae of the distal colon. E, Severe edema with overlying exudate. The honeycomb
appearance of the mucosa is apparent and is caused by the marked edema. F, Thumbprinting is apparent.
A1 A2 B
C1 C2
Colonic wall
thickness
C3
FIGURE 5.24 CLOSTRIDIUM DIFFICILE

COLITIS
A1, Patchy, well-circumscribed areas of
Nodular mucosa erosion with surrounding hyperemia.
(thumbprinting) A2, More proximally, the colitis
becomes more severe and the typical
pseudomembranes are observed. B, Flat
pseudomembranes with areas of mucopus.
C1, Multiple pseudomembranes have a
nodular appearance. C2, No normal mucosa
can be appreciated. C3, Striking colonic wall
thickness is present. Note the nodular
mucosa can also be seen on kidneys, ureter,
C4
and bladder termed thumbprinting (C4).
FIGURE 5.25 CLOSTRIDIUM DIFFICILE

COLITIS
A, Diffuse thickening of the entire colon with
contrast enhancement of the mucosa.
B, Severe colitis with acute and chronic
inflammatory cells and edema. A mushroom-
shaped pseudomembrane is shown. The
colonic architecture is preserved.
B
A B
C D
FIGURE 5.26 SEVERE CLOSTRIDIUM DIFFICILE COLITIS

A, Abdominal radiograph shows subtle nodularity of the colon. B, Marked irregularity of the rectal wall. C, The more proximal colon
demonstrates marked nodularity (thumbprinting) of the wall. The mucosa in some areas is poorly coated by the barium. D, The colonic
wall is covered by a thick, tenacious membrane. The rectum had multiple well-circumscribed yellow plaques characteristic of C. difficile
colitis.
A B C
D1 D2 D3
FIGURE 5.27 CYTOMEGALOVIRUS COLITIS

A, Multiple small, well-circumscribed, ringlike lesions with surrounding subepithelial hemorrhage. There is a diffuse colitis. B, Edema
and erythema of the sigmoid colon. C, Prominent subepithelial hemorrhage of the descending colon. D1, Striking diffuse subepithelial
hemorrhage. D2, Diffuse colonic wall thickening from rectum to right colon (D3).
Continued
E F
G1 G2
H I J

E, Well-circumscribed small ulcer with a halo of erythema and subepithelial hemorrhage. F, Flat ulcer with normal surrounding
mucosa. G1, Serpiginous ulcers in the rectum with an appearance suggestive of Crohn’s disease. G2, Marked thickening of the left
colon. H, Large ulcer of the cecum involving the ileocecal valve. I, Large shallow ulcer with exudate. J, Hemicircumferential ulceration
at an ileocolonic anastomosis.
Continued
K L

K, Diffuse petechial lesions throughout the left colon. L, Enlarged endothelial cell containing cytomegalovirus inclusions. A moderate
amount of chronic inflammation is in the lamina propria.
Cytomegalovirus Colitis (Figure 5.27)
Inflammatory bowel disease
Other infections
Ischemia
FIGURE 5.28
CYTOMEGALOVIRUS
COLITIS
A, Barium enema
shows a focal defect
at the splenic flexure
suggestive of
neoplasm. B, Well-
circumscribed
ulceration with
surrounding edema.
A B
FIGURE 5.29 TUBERCULOUS COLITIS

A, Thickening of cecum. B, Marked
nodularity and fresh hemorrhage around
the ileocecal valve.
A B
FIGURE 5.30 TUBERCULOUS COLITIS

A, Focal ulceration of the sigmoid colon.
B, Serpiginous ulceration of the right colon.
C, Circumferential ulceration with formation
of a stricture. D, Marked stricturing of the
cecum.
A B
C D
FIGURE 5.31 PINWORM INFECTION

(ENTEROBIUS VERMICULARIS)
A, Solitary worm. B, Multiple small worms
in the cecum characteristic of pinworms.
C, D, Under the microscope, unique features
of the worm are better appreciated.
A B
C D
FIGURE 5.32 WHIPWORM INFECTION
(TRICHURIS TRICHIURA)
Solitary worms (A, B).
A B
FIGURE 5.33 TAPEWORMS (TAENIA SPECIES)

A, Barium study shows worm in the cecum and ascending colon, as well as transverse
colon. B, The worm appears as white object in the stool. C, The length of the worm is
apparent after removal.
A B C
FIGURE 5.34 STRONGYLOIDES COLITIS

A, Marked colonic edema with patchy shallow ulceration. B1, Low-power view shows
acute colitis with structures present in the crypts. B2, High-power view shows larvae in
the crypts.
B1 B2
A B C
FIGURE 5.35 AMEBIC COLITIS

A, Large ulcer involving the ileocecal valve. Ulceration is also present in the cecum. B, Patchy well-circumscribed ulcers. C, Close-up
shows the ulcers having a raised (volcano) appearance.
Amebic Colitis (Figure 5.35)
Other infections (viral, bacterial)
A B C
D E F
FIGURE 5.36 ULCERATIVE COLITIS

A, Mild ulcerative colitis demonstrated by edema, loss of the normal mucosal vascular pattern, and patchy subepithelial hemorrhage.
B, Moderate colitis with loss of vascular pattern, subepithelial hemorrhage, and patchy mucopus. C, Diffuse mucopus coating the
colon. D, Diffuse colitis with diffuse shallow ulceration. E, Diffuse colonic hemorrhage. F, Focal colitis with point of demarcation to
normal mucosa.
Continued
G1 G2 H
I1 I2
J K1

G1, Severe colitis with mucosal bridge. G2, Deep ulceration with a residual round area of
preserved but hemorrhagic mucosa. H, Severe colitis with deep serpiginous ulcerations
most suggestive of Crohn’s disease. I1, I2, Surgical specimen shows severe colitis with
sparing of cecum. J, Severe acute and chronic inflammatory process, with multiple crypt
K2 abscesses. K1, K2, Multiple filiform polyps in the setting of active colitis.
Continued
L1 L2
Ulceration
Pseudopolyp
Ulceration
L3 L4
L5 L6

SEVERE ULCERATIVE COLITIS
L1, Kidneys, ureter, and bladder x-ray film shows haziness in the right colon compatible with pneumatosis. Also note the barium at the
splenic flexure. L2, CT scan shows diffuse dilatation of the colon with air not only in the lumen but in the colonic wall. L3, Severe
ulceration with mucosal loss and formation of pseudopolyps. L4, Pseudopolyp formation with surrounding ulceration. L5, The
exudate is removed showing the underlying edema of the mucosa. L6, Formation of long pseudopolyps.
Continued
L7 L8
N O

L7, Surgical specimen shows diffuse colitis, a cecal ulcer, and the marked pseudopolyposis (L8). M, Severe ulceration with scarring and
luminal narrowing. N, Lesion on the right ankle typical for pyoderma gangrenosum. O, The colonic architecture is distorted, with a loss
of crypts and abnormal branching of the crypts. The disordered architecture is useful in differentiating acute from chronic colitis.

A, Surveillance colonoscopy in a patient
with chronic ulcerative colitis. The
ascending colon (A1), transverse colon
(A2), and descending colon (A3) are
normal, with active disease of the sigmoid
colon (A4). B, Biopsy samples of the
normal-appearing colon demonstrate
abnormal architecture consisting of
shortened crypts but no active colitis.
C1, C2, Surveillance endoscopy shows
mild granularity of the mucosa. The
granularity and mild edema are more
pronounced in the sigmoid colon (C3).
A1 A2
A3 A4
C1 C2 C3
A B C1
C2 C3 D1
D2 E F
FIGURE 5.38 COLONIC CROHN’S DISEASE

A, Diffuse deep ulceration with a nodular appearance. B, Focal area of ulceration with distortion, luminal narrowing, and an early
fistula. C1, Focal ulceration with an appearance of the ulcer burrowing underneath the mucosal fold. C2, More proximally a large deep
ulcer was present, again with the appearance of the ulcer burrowing underneath the mucosa. C3, Marked involvement of the
anorectum was present. D1, Focal area of severe colitis resembling a mass lesion in the right colon. D2, Proximally diffuse disease was
evident. E, Circumferential ulceration of the distal colon resembling ulcerative colitis. F, Multiple punched-out ulcers with colitis.
Continued
G H I
J K L

G, Serpiginous ulcer. H, Mucosal bridge representing healing of a submucosal ulcer. I, Multiple aphthous ulcers. J, Pinpoint area in the
distal colon representing a fistulous tract. K, Thickening with inflammatory changes (stranding) around the cecum. L, Thickened
terminal ileum. M, Multiple well-circumscribed, noncaseating granulomata. This finding supports the diagnosis of Crohn’s disease
when an infectious cause is excluded.
A B C
D E F
G1 G2 G3

A, Multiple punctate ulcers in the descending colon. B, Large serpiginous ulceration of the descending colon. C, Solitary ulcer in
transverse colon. D, Irregular ulceration involves the ileocecal valve. E, Deep ulceration with associated pseudopolyps. F, “Bear claw”-
type ulceration. G1-G3, Routine and coronal CT images shows thickened colon. Coronal image shows colonic dilatation and colonic
wall thickening.
A B C
Wall thickening
at the splenic
flexure
D E
FIGURE 5.40 ILEOCECAL CROHN’S DISEASE

A, The ileocecal valve is patulous from involvement with Crohn’s disease. The valve is diffusely ulcerated and hemorrhagic. B, The
terminal ileum is edematous and hemorrhagic, and has scattered ulcerations typical of Crohn’s ileitis. C, The terminal ileum appears
nodular and narrowed (“string sign”). D, CT shows thickening of the right colon and pronounced thickening of a long segment of
terminal ileum. E, There is also circumferential wall thickening at the splenic flexure.
A B
C D
FIGURE 5.41 COLONIC CROHN’S WITH PSEUDOPOLYPS

A, Diffuse edema, ulceration, and multiple pseudopolyps. B, The surgical specimen demonstrates a normal-appearing colon on the
right. The involved area shows ulceration and diffuse polyposis representing inflammatory polyps. C, The surgical specimen
demonstrates marked thickening of the colonic wall typical of Crohn’s disease. D, Recurrence at the anastomosis, with deep ulceration
surrounding the sutures.
FIGURE 5.42 RECURRENT CROHN’S

DISEASE WITH ANASTOMOTIC ULCER
A, Narrowing, edema, and ulceration at
the site of a prior ileocolonic anastomosis.
B, Typical serpiginous ulcer seen in the
distal ileum just proximal to the
anastomosis.
A B
A B C

A, Tight stricture at the site of a prior ileocolonic anastomosis. B, A balloon has been placed across the anastomosis and inflated.
C, Improved luminal caliber after dilation.
A B C
FIGURE 5.44 COLONIC CROHN’S WITH

ULCER-RELATED BLEEDING
A, Deep serpiginous ulceration in the
descending colon. B, The ulcer base is
viewed underwater showing pinpoint
mucosal oozing. C, Epinephrine is injected
into the lesion, resulting in blanching of the
D1 D2
mucosa and hemostasis (D1, D2).
A B C
FIGURE 5.45 ISCHEMIC COLITIS

A, Distinct demarcation manifested by focal
subepithelial hemorrhage. B, Proximally,
the hemorrhage becomes confluent with
ulceration. C, Marked edema of the mucosa
forming subepithelial blebs. D, More
marked ulceration, edema, and luminal
narrowing. E, Follow-up colonoscopy 2
D E
months later shows scarring and distortion.

A, Patchy exudate overlying ulceration in the
descending colon. B, More proximally, the
ulceration becomes confluent and a deep
ulceration with raised border is seen.
A B
A1 A2 B
FIGURE 5.47 ISCHEMIC COLITIS WITH BLEEDING

A1, A2, The ulceration becomes confluent and nodular with marked luminal narrowing. Mucosal biopsy of such a lesion is generally
firm with ischemic colitis. B, Large ulceration with fresh bleeding and an adherent blood clot.

A, Circumferential ulceration with a thick
membrane, resembling Clostridium difficile
colitis. B, Marked nodularity and ulceration.
A B
Ischemic Colitis (Figure 5.48)
Bacterial colitis
A B C1
Colitis
C2 D
FIGURE 5.49 RIGHT-SIDED ISCHEMIC COLITIS

A, B, Marked edema and subepithelial hemorrhage of the right colon. The cecum is markedly edematous with luminal narrowing.
C1, C2, CT shows edema of the right colon. D, Small-bowel follow-through shows a normal small bowel, but edema of the right colon.
A B C
FIGURE 5.50 ISCHEMIC PROCTITIS

A, Edema of the proximal rectum with
circumferential disease. B, Circumferential
disease with nodularity and luminal
narrowing. C, Note the ulceration stops
relatively abruptly, typical for ischemia.
D, E, Progression over time shows
D E marked edema.
A B
C D
E1 E2

A, Focal ulceration with surrounding erythema and subepithelial hemorrhage just distal to the splenic flexure. B, More proximally,
there is marked edema, ulceration, and subepithelial hemorrhage typical for ischemic colitis. The mucosa was firm on biopsy, also
characteristic of ischemic colitis. C, More proximally in the distal transverse colon, the ulceration again follows the tinea with
surrounding focal edema. D, Barium enema shows nodularity at the splenic flexure. E1, E2, Dropout of glands with fibrosis of lamina
propria.
A B C
D E

A, Patchy yellow exudate in the distal colon resembling Clostridium difficile colitis. B, Circumferential edema with a prominent mucosal
pattern. C, Abrupt termination of ischemic colitis is characteristic. D, Colonic thickening at the splenic flexure. E, Resection specimen
shows the marked thickening of the colonic wall.

A, Marked diffuse subepithelial hemorrhage
involving the cecum. B, Note the lymphoid
aggregates are spared.
A B
FIGURE 5.54 ISCHEMIC COLITIS STRICTURE

A, Focal smooth stricture at the splenic flexure. B, Narrowing of the colonic
lumen with ulceration at the site of a prior episode of ischemia.
A B
FIGURE 5.55 INFARCTED COLON

A, Stool coats a black colon. B, Close-up
shows the dark discoloration with the
absence of normal-appearing mucosa.
C1, Dusky appearance of the distal colon.
C2, Air in the right colon wall best
appreciated on bone windows (C3).
A B
C1 C2 C3
FIGURE 5.56 RADIATION PROCTOPATHY

Multiple ectatic blood vessels in the distal rectum. This patient
previously underwent radiation therapy for prostate cancer.
FIGURE 5.57 DIVERSION COLITIS
Hartmann’s pouch demonstrates loss of normal haustrations and
vasculature, with diffuse subepithelial hemorrhage. Biopsy findings
demonstrated normal architecture with edema, subepithelial
hemorrhage, and mild chronic inflammatory infiltrate.
FIGURE 5.58 COLLAGENOUS COLITIS

A, Subtle loss of vascular pattern and erythema of the sigmoid colon. Typically,
the colonic mucosa is normal. B, Hematoxylin and eosin stain suggests the diagnosis.
C, Trichrome stain highlights the collagen layer in the subepithelium.
B C
A B C
FIGURE 5.59 BEHÇET’S DISEASE

A, Edema with shallow ulcers in the distal colon. B, More extensive disease in the right colon with prominent subepithelial
hemorrhage. C, Ulcer of the skin.
FIGURE 5.60 HENOCH-SCHÖNLEIN PURPURA

Subepithelial hemorrhage and recent bleeding.
FIGURE 5.61 MUSCULATURE HYPERTROPHY ANTEDATING DIVERTICULOSIS

Circumferential thickening of musculature antedating diverticula formation.
A1 A2
FIGURE 5.62 DIVERTICULOSIS

A1, Large diverticula filled with stool. The haustra are thickened.
A2, Barium enema demonstrated sigmoid diverticulosis.
B, Multiple diverticula in the sigmoid colon with thickened
B
haustra.
Continued
C D1 D2
D3 E F
G1 G2 H1
FIGURE 5.62 DIVERTICULOSIS

C, Multiple sigmoid diverticula between thickened haustra. D1, D2, Multiple large
diverticula. Note the depth and large caliber of the diverticula (D3). E, Engorged
diverticulum filled with stool. F, Isolated diverticula filled with stool with surrounding
edema and exudate potentially portending subsequent diverticulitis. G1, Large
fecalith that spontaneously passed from a diverticulum. leaving the diverticulum with
a wide-mouth appearance (G2). H1, H2, Multiple diverticula make identification of the
H2 colonic lumen difficult. Which way do I go?
FIGURE 5.63 RIGHT-SIDED

DIVERTICULOSIS
A, B, Multiple typical-appearing
diverticula just proximal to the
ileocecal valve.
A B
FIGURE 5.64 WIDE-MOUTHED COLONIC

DIVERTICULA
A, A large diverticulum in the descending
colon, with a small diverticulum distally.
B, Large, hemicircumferential, wide-
mouthed diverticulum. Wide-mouthed
diverticula are most suggestive of
scleroderma.
A B
A B1 B2
FIGURE 5.65 EVERTED DIVERTICULUM

A, Everted colonic diverticulum suggestive of a polyp. B1, Observation of this diverticulum showed intermittent eversion of colonic
tissue (B2).
FIGURE 5.66 PERFORATED

DIVERTICULUM FROM COLONOSCOPY
A, B, Yellow shiny surface is seen through
the lateral colonic wall representing a
perforation. The perforation presumably
occurred at the site of a diverticulum.
A B
FIGURE 5.67 DIVERTICULAR COLITIS

A, B, Patchy subepithelial hemorrhage and
edema of the sigmoid colon resembling
mild idiopathic ulcerative colitis. Histologic
changes of colitis were present.
A B
Diverticular Colitis (Figure 5.67)
Bacterial colitis
Ischemia/vasculitis
A B
C D1 D2
FIGURE 5.68 DIVERTICULITIS

A, Thickened sigmoid colon with several circumscribed areas of air-filled diverticula and possibly extraluminal gas (abscess). The
surrounding fat has a “dirty” appearance, suggesting an inflammatory process. B, Edema, subepithelial hemorrhage, and mucopus
are surrounding a diverticulum. The mucosal pattern is accentuated by the edema, as occurs with the areae gastricae of the stomach.
C, Pus exuding from a diverticulum. The surrounding mucosa is edematous. D1, D2, After resolution of the diverticulitis, areas of
edema and subepithelial hemorrhage are identified.
A B C
D1 D1
FIGURE 5.69 CHRONIC DIVERTICULITIS
A, Marked edema, diverticula, luminal
narrowing, and associated stranding
suggestive of diverticulitis. B, Marked
colonic edema with patchy subepithelial
hemorrhage and presence of mucopus.
C, Diverticula are present. D1, Mucopus
covers the diverticulum, and with further
observation, a large amount of pus passed
spontaneously (D2). E1, E2, After
antibiotics, there is improvement in
appearance, although there is still luminal
E1 E1 narrowing and mucopus.
FIGURE 5.70 DIVERTICULAR

HEMORRHAGE
A, A large blood clot is just proximal to the
ileocecal valve. B, After the area is irrigated, a
small amount of residual blood is in the
diverticulum near a visible vessel at the
entrance to the diverticulum.
A B
A B C
FIGURE 5.71 DIVERTICULAR HEMORRHAGE

A, Fresh blood and clot in the sigmoid colon; multiple diverticula are present. B, One large diverticulum with several internal diverticula
with adherent clot. C, With further washing, a small, nipple-like projection is apparent, suggesting a visible vessel.
A B C
FIGURE 5.72 COLONIC BLEEDING AFTER BIOPSY

Mucosal biopsy of a small polypoid lesion (A) results in marked bleeding (B). C, A single clip is applied, resulting in hemostasis.
FIGURE 5.73 DIVERTICULAR HEMORRHAGE WITH VISIBLE

VESSEL
Fleshy projection on the lip of a diverticulum in the right colon. FIGURE 5.74 FLAT ADENOMA
This patient had significant lower gastrointestinal bleeding. Small, flat adenoma that blends into the surrounding mucosa.
FIGURE 5.75 FLAT ADENOMA

A portion of the colonic fold is asymmetric and appears thickened and erythematous,
with subepithelial hemorrhage. The texture of the mucosa appears different from that of
the normal-appearing surrounding colon. Biopsy demonstrated adenomatous change
with focal high-grade dysplasia. The high resolution of the endoscopic equipment allows
such a flat adenomatous lesion to be discerned.

A, Flat adenoma that is subtle. B, The
adenoma is highlighted by the use of
methylene blue and is now much easier to
recognize.
A B
A B1 B2

A, Raised lesion on the ileocecal valve as seen on standard and narrow band imaging (B1, B2).
A B
C1 C2
D1 D2

A, A typical-appearing colonic adenoma. The head of the polyp has a textured appearance compared with the surrounding mucosa.
A colonic fold is pulled to the side by the polyp. Just superior to the adenomatous polyp are two small hyperplastic polyps.
B, Adenomatous colonic mucosa demonstrating atypical cells, with an increased nuclear/cytoplasmic ratio and a “picket-fence”
appearance of the nuclei. C, Tubular adenoma as seen by high-definition endoscopy (C1) and narrow band imaging (C2).
D, Pedunculated adenoma as seen by high-definition endoscopy (D1) and narrow band imaging (D2).
A B C
D1 D2 E1
E2

A, Small white raised polyp with a subtle pattern distinct from normal surrounding mucosa. B, Small, well-circumscribed polyp. The
mucosal surface is smooth. C, Small erythematous-appearing polyp. Note the overlying mucosa is different from the surrounding
normal colonic mucosa. D1, Small polyp with abnormal mucosal pattern highlighted with narrow band imaging underwater for
magnification (D2). E1, Small redheaded polyp. Mucosal pattern also can be seen on narrow band imaging (E2).
Continued
E3 E4
F G

Histology shows features of a tubular adenoma on low and
high power. Note the submucosal hemorrhage that results in
the red appearance of the lesion (E3, E4). F, Typical-appearing
pedunculated adenoma. The polyp head is markedly
hemorrhagic, and the stalk is a dark brown color. These color
changes represent bleeding into the polyp with subsequent
deposition of hemosiderin. G, Pedunculated polyp with a “red
head.” H, The red color of the polyp head results from diffuse
H subepithelial hemorrhage.
A B1 B2
B3 C1 C2
D1 D2
E1 E2 E3
FIGURE 5.80 TUBULOVILLOUS ADENOMA

A, Small polyp with a whitish serpentine appearance. The polyp has a white granular mucosa distinct from the normal surrounding
mucosa. This polyp could be mistaken for a hyperplastic polyp. B1, B2, Small sessile polyp as seen by white light and (B3) narrow band
imaging with the mucosal pattern typical for villous adenoma better visualized. C1, Large pedunculated polyp with a typical-
appearing reddish serpentine mucosa best seen on close-up (C2). D1, Multilobed pedunculated polyp. D2, Area of fresh hemorrhage
is visible on the mucosal surface. This patient, on chronic anticoagulation, experienced mild rectal bleeding. E1-E3, Polypoid lesion as
seen by high-definition endoscopy (E1) and narrow band imaging (E2, E3).
A B

A, Adenomatous polyp with tubulovillous features and areas of low- and high-grade dysplasia. The S and I represent areas where
endomicroscopy was performed. B, Endomicroscopy of the lesion shows villous structure, irregular glands, and hyperchromatic nuclei
with increase of the stroma.
B C D

A, Polyp in the descending colon with a long stalk. B, The polyp head is hemorrhagic with spontaneous bleeding. The geographic
appearance is typical for adenoma. C, The large size of the stalk is evident. D, Well-circumscribed sessile lesion. Note the same
geographic appearance typical for adenoma.
Continued
E F

E, Typical appearance of a tubulovillous adenoma is noted. F, Transition zone from adenomatous to normal colonic mucosa is at the
base of the polyp stalk.
A1 A2 B

A1, Sessile polyp just opposite the ileocecal valve. A2, Close-up shows the sharp demarcation of normal colon with the diffuse nodular
appearance of the polyp. B, Both a snare and argon plasma coagulator were used to remove the polyp.

A, Cartoon of the different pit patterns. B1, B2, Pit pattern III as
shown on standard and narrow band imaging. C1, C2, Pit pattern
IV as shown on standard and narrow band imaging.
Pit Pattern I Pit Pattern II Pit Pattern IIIS
Pit Pattern IIIL Pit Pattern IV Pit Pattern V

A
B1 B2
C1 C2
FIGURE 5.85
TUBULOVILLOUS
ADENOMA
A, Pedunculated
polyp. The mucosal
pattern of the polyp
would be classified as
pit pattern IV. B, High-
grade dysplasia on
pathology. The
crowding of the cells is
more pronounced.
A B
A, Large sessile lesion of the sigmoid colon
as seen on standard and (B) narrow band
imaging. The lesion was hypermetabolic on
positron emission tomography computed
tomography scanning (C1, C2).
A B
C1 C2

A, Flat-appearing villous adenoma with
serpiginous borders in the sigmoid colon.
B, The base of the villous adenoma
has a whitish and serpentine appearance.
C, Well-circumscribed villous adenoma.
A B
C
FIGURE 5.88 SESSILE SERRATED

ADENOMA
A, Sessile polyp on standard and narrow
band imaging (B). C, Typical features of a
sessile serrated adenoma include flattening
of the angulated crypt base, some of which
have a T-shaped appearance, and serrations
extending into the deep portion of the gland
in focal areas showing an “invasive” growth
pattern where the lesion dips into the
A B muscularis mucosae.
A1 A2 B

A1, Sessile polyp with central area of retraction and hypervascularity. A2, Close-up shows the hypervascularity of the lesion. Biopsy
showed tubulovillous adenoma with carcinoma in situ. B, Small, typical-appearing adenomatous polyp. Biopsy results showed
carcinoma in situ.
A B

A, A flat, sessile polyp in the descending colon. The polyp size and appearance suggest a benign adenoma. B, Malignant glands invade
the muscularis mucosa at the edge of the polyp.
A B C
D E F
FIGURE 5.91 COLONIC POLYPECTOMY

A, Pedunculated polyp on a long stalk. B, A snare has been opened and positioned around the polyp to the midportion of the stalk.
C, The snare is closed. D, The snare is advanced so that the polyp does not touch the contralateral wall. E, The snare has been closed for
several seconds, ensuring ischemia to the polyp head. Note the now purplish discoloration.
Continued
G H1 H2
I J
K1 K2 K3
FIGURE 5.91 COLONIC POLYPECTOMY

F, Coagulation current is used with the polyp completely incised, which falls away from the stalk. Note the “smoking gun.” G, The snare
is now placed around the stalk, and if bleeding ensues, further coagulation may be performed. H1, The polyp is grasped and will
be removed with the endoscope. The polyp stalk is free of bleeding. H2, An ulcer is present on the polyp. I, Note the appearance of
the polyp on removal. There appears to be a central core with outer covering. J, Subsequent colonoscopy shows a scar at the site of
the polypectomy. K1-K3, Cold snare polypectomy. A sessile polyp is identified (K1); a snare is placed around the polyp and snaring
some normal colonic tissue (K2); mucosal defect seen after cold snare polypectomy (K3).
A B C
D E F
FIGURE 5.92 SALINE LIFT TECHNIQUE FOR POLYPECTOMY

A, Sessile adenomatous-appearing polyp. B, Sclerotherapy needle advanced to the base of the polyp with injection of dilute
epinephrine and saline. C, The polyp has been elevated off the colon wall. D, The polyp is snared. E, Defect from polypectomy.
The remaining polyp is removed. F, Follow-up colonoscopy shows scar at the site of polypectomy.
A B C
FIGURE 5.93 POLYPECTOMY

A, Sessile polyp. B, A snare was used without saline lift with removal in a piecemeal fashion. C, Note the large defect at the site of
polypectomy with the submucosa visible.
FIGURE 5.94 ULCER SCAR

A, B, White linear area of fibrosis in the
descending colon resulting from prior
polypectomy.
A B
FIGURE 5.95 POSTPOLYPECTOMY ULCER

WITH BLEEDING
A, Ulcer with adherent clot. B, Close-up
shows the deep ulcer with clot.
A B
FIGURE 5.96 POSTPOLYPECTOMY

BLEEDING
A, Deep ulcer with visible vessel at the site
of recent polypectomy. B, Clips applied to
the lesion. The patient experienced no
further bleeding.
A B
A B C
FIGURE 5.97 POSTPOLYPECTOMY BLEEDING

A, Small ulcer at the site of recent polypectomy. A small remnant of the polyp remains over the ulcer. B, Dilute epinephrine was
injected into the base of the ulcer. C, The ulcer is somewhat raised off the mucosa because of the injection, and there is blanching of
the surrounding mucosa.

BLEEDING
A, Deep ulcer with adherent blood clot.
B, Thermal therapy was applied to the lesion,
resulting in an eschar (C). D, Given the
apparent depth of the lesion, multiple clips
were applied.
A B
C D

BLEEDING
A1, A2, Area in the cecal pole with ulceration
and long adherent blood clot/visible vessel.
The lesion is well visualized underwater.
B, The first clip is applied. C, Two clips
applied to the lesion.
A1 A2
B C
FIGURE 5.100 HOT BIOPSY TECHNIQUE

A, A small adenomatous-appearing polyp.
B, The hot biopsy forceps is opened, and
the head of the polyp is grasped and lifted
away from the wall. C, With application of
coagulation current, the base of the polyp
assumes a white discoloration. Note the
immediate edema present at the base of
the polyp. D, A small amount of bleeding is
present after biopsy, and edema is now
more pronounced.
A B
C D
FIGURE 5.101 COLONIC TATTOOING

A, A sessile-appearing polyp in the
descending colon (A1). A sclerotherapy
needle filled with sterilized India ink is
injected into the colonic wall surrounding
the sessile lesion (A2-A4). After washing,
a black discoloration is in the colonic wall
at the point of injection (A3, A4).
Continued
A1 A2
A3 A4
B C

B, Postoperative specimen shows the polyp and submucosal
India ink better seen on close-up (C). D, A small, dark area
corresponding to the injection site is visible on the serosal
D
surface.
A B1 B2

A, Large sessile polyp in the right colon. B1, B2, India ink is applied submucosally around the lesion.
A B
FIGURE 5.103 MULTIPLE COLONIC POLYPS

A, Multiple filling defects in the left colon and cecum, misinterpreted as a poor preparation with stool. B, Multiple colonic polyps, some
on stalks and some sessile. Polyps were present throughout the colon. C, Resection specimens show the cluster of polyps. Arrows point
to the larger polyps, which were villous adenomas.
A B
Colonic wall
thickening
B1 B2 with polyps
C D1
FIGURE 5.104 MULTIPLE COLONIC POLYPS IN FAMILIAL

ADENOMATOUS POLYPOSIS
A, Multiple colonic polyps circumferentially coat the mucosa.
B, Close-up of the polypoid lesions. B1, CT shows marked
thickening of the rectum with multiple filling defects compatible
with polyps. B2, A similar appearance of colonic wall thickening
with polyps identified in the right and left colon. C, Surgical
specimen demonstrates numerous polyps throughout the colon.
D2 D1, D2, Close-up of the multiple polyps.
A1 A2 B1
B2
C D
E F1 F2
G1 G2

A1, A2, Solitary small white polyp in the distal rectum. Note the overlying mucosa is smooth. B, Multiple hyperplastic polyps in the
distal rectum. B1, B2, Solitary sessile polyp with smooth overlying mucosa in the descending colon on standard and narrow band
imaging. C, Reddish polyp in the distal rectum. D, Flat polyp at the ileocecal valve. The mucosa blends in with the normal colonic tissue.
E, Large sessile polyp resembling a villous adenoma. Note the nearby hyperplastic-appearing polyp. F, Hyperplastic polyp as shown on
high-definition endoscopy (F1) and narrow band imaging (F2).
Continued
H1 H2 I1
I2 J1 J2

G-J, Polyps of varying sizes. Note the difference in the mucosal pattern on narrow band imaging in comparison with the adenomatous
polyps. K, Typical mucosal changes of a hyperplastic polyp. The colonic crypts have an increased number of goblet cells, resulting in a
“starfish” appearance. There is no inflammatory infiltrate or alteration in the nuclear/cytoplasmic ratio to suggest adenoma. L, Colonic
mucosa with cells having increased cytoplasmic mucin content and arranged in a serrated configuration.
A B C
D E
F1 F2

A, B, A polypoid lesion is completely coated with exudate. With some of the exudates removed, the polyp is edematous with overlying
ulceration. C, The polyp is snared and removed, resulting in a mucosal defect (D). E, Small red polyp with overlying ulceration in the left
colon. F1, F2, Polypoid mucosa with acute and chronic inflammation and ulceration with abundant granulation tissue.

A, Small polyp with ulcerated surface.
B, Polyp with overlying exudate and ulcer.
C, Multiple small polyps in the descending
colon. This patient has a long-standing
history of ulcerative colitis. D, Large
inflammatory polyps with a reddish
discoloration in a patient with long-
standing ulcerative colitis.
A B
C D
FIGURE 5.108 COLONIC INFLAMMATORY

POLYP IN DIVERTICULUM
A, Small polyp in the base of a diverticulum.
B, The polyp is removed using standard
techniques.
A B
A B
C1 C2
FIGURE 5.109 FIBROVASCULAR POLYP

A, Solitary lesion with patchy vascular pattern as shown on standard and (B) narrow band imaging. C1, C2, Polypoid colonic mucosa
with focal surface erosion and prominent submucosa showing edema, fibrosis, focal adipose deposition, and vascular congestion/
dilatation.
A B
FIGURE 5.110 LEIOMYOMATOUS POLYP

A, The polyp has a short stalk and an unusual red demarcation of the head. The polyp head looks smooth and lacks the serpentine
appearance of an adenomatous or a villous lesion. B, Normal colonic mucosa with subepithelial hemorrhage overlying a mass of
smooth muscle bundles.
A B
FIGURE 5.111 INFLAMMATORY FIBROID POLYPS

A, Multiple small polyps at the hepatic flexure. The polyps themselves are nondiagnostic in appearance. B, A moderate amount of
inflammation is in the polyp. The striking finding in this polyp is the multiple eosinophils.
A B
FIGURE 5.112 ARTERIOVENOUS MALFORMATION

A, A snakelike polyp with a yellowish stalk and red color of the head of the lesion. The polyp has been snared. B, The polypectomy
specimen demonstrates an arterial malformation in which multiple, abnormally thick-walled arteries occupy the lamina propria.
FIGURE 5.113 NORMAL COLON

MIMICKING A POLYP
A, Well-demarcated sessile polyp in the
descending colon. The surrounding
mucosa has a normal vascular pattern.
B, Pedunculated polyp. Note the absence
of any adenomatous appearance of the
polyp head.
A B
A B
C D
FIGURE 5.114 JUVENILE POLYP

A, This pedunculated polyp resembles an adenoma. The polyp
was “rubbery” to palpation. B, C, Mushroom-shaped polyp as seen
on standard and narrow band imaging. D, Typical features of a
juvenile polyp include the large cystic structures. E, The red color
of the polyp resulted from subepithelial hemorrhage and vascular
E engorgement.
Juvenile Polyp (Figure 5.114)
Arterial venous malformation
Inflammatory polyp
Adenomatous polyp
Leiomyoma
FIGURE 5.115 LIPOMA

Yellow sessile polyp in the right colon. Forceps demonstrate a
pillow sign (inset).
A B C
FIGURE 5.116 LIPOMA

A, Large polyp on a stalk; the lesion has areas of hypervascularity. A closed polyp snare is indenting the polyp (“pillow” sign).
B, The lipoma measures about 2.5 cm. The lesion appears to be encapsulated. C, The lipoma is composed of mature adipocytes and
compresses the overlying colonic mucosa.
A B C1
C2 C3 D
Resected polyp
Lipomatous Resected
contents margin
E1 E2
FIGURE 5.117 LIPOMA

A, Large polyp with a hemorrhagic appearance. B, Note the large stalk. C1-C3, Hemorrhagic polyp. Note the overlying mucosa does
not resemble an adenoma. D, Because of persistent bleeding, the larger polyps were removed using standard snare techniques.
Coagulation current cuts very slowly through the lesion. E1, E2, After resection, note the mucosa surrounding the center of the polyp.
A1 A2
C D
FIGURE 5.118 GIANT LIPOMA

A1, Large mass lesion in the cecum. The surface appears ulcerated. A2, Close-up shows the exudate and nodularity of the lesion.
B, Colectomy specimen shows the well-circumscribed polyp with overlying ulcer. C, The fatty polyp after removal. D, Right-sided
colonic polyp has a dark center, the density of fat.
Giant Lipoma (Figure 5.118)
Adenocarcinoma or other neoplasia
A1 A2
B C
D1 D2
FIGURE 5.119 NEUROFIBROMA AND GANGLIONEUROMA

A1, A2, Hemorrhagic-appearing polyps in the right colon. This patient has Von Recklinghausen syndrome. B, The lamina propria is
hypercellular and composed of cytologically bland spindle-shaped cells. C, The cells are immunoreactive to the anti–S-100 protein
antibody. D1, D2, Small, nondescript polyp of the left colon.
Continued
E1 E2
E3 E4
FIGURE 5.119 NEUROFIBROMA AND GANGLIONEUROMA

E1-E3, Colonic mucosa with lamina propria showing mild fibrosis, occasional wavy neural fibers, and numerous scattered ganglion
cells consistent with ganglioneuroma seen on high power (E4). Usually, ganglion cells are located in the muscularis propria, not in the
lamina propria.
FIGURE 5.120 PSEUDOPOLYPS

A, B, Multiple filamentous polyps in the
descending colon in a patient with prior
active ulcerative colitis.
A B
A B C
D E F

A, Multiple polyps in the cecum. B, Large pedunculated polyps. C, Multiple small flat polyps in the right colon. D, Osteoma in the
ethmoid sinus. E, Multiple abdominal scars and deformity from desmoid tumors. F, Large desmoid tumor as shown on CT. (D courtesy
J. L. Zubieta, MD, Pamplona, Spain.)
A B C
FIGURE 5.122 COWDEN SYNDROME

Multiple small colonic polyps (A-C).
Histologically, these polyps are
hamartomas. D1, D2, Typical skin lesions on
the scalp (trichilemmomas) with
hyperkeratotic papules and verrucous
lesions. (Courtesy P. Redondo, MD,
D1 D2
Pamplona, Spain.)
FIGURE 5.123 LYMPHATIC CYST

Multilobe cystic structure in the transverse colon.
A B C
D1 D2 E
FIGURE 5.124 PNEUMATOSIS COLI

A-C, Multiple submucosal lesions throughout the colon. D1, The lesion biopsy results show typical appearance of submucosal air (D2).
E, Endoscopic ultrasonography demonstrates the submucosal lesions to be air represented by the hyperechoic areas with shadowing.
FIGURE 5.125 SENTINEL POLYP WITH CANCER

Adenomatous-appearing pedunculated polyp is just distal to a
large mass lesion.

Small, flat polyp with overlying erosion.
FIGURE 5.127 ADENOCARCINOMA OF THE RECTUM

A, A narrow stricture in proximal rectum. The margin of the stricture is nodular, and there is extrinsic compression proximal to the
stricture. B, Circumferential ulcerated mass lesion. The black area with exudate represents tumor necrosis and ulceration. C, Well-
differentiated adenocarcinoma with an increased nuclear/cytoplasmic ratio and atypical glands that appear “back to back.”
U-shaped
tumor
FIGURE 5.128 ADENOCARCINOMA OF SIGMOID

A, U-shaped mass lesion in the sigmoid colon.
B
B, Hemicircumferential mass typical of carcinoma.
C D
FIGURE 5.129 ADENOCARCINOMA OF SIGMOID

A, Annular lesion of the sigmoid colon is noted. B, “Apple-core” lesion demonstrated by computed tomography. C, Circumferential
lesion shown with spontaneous bleeding. A cavity is in the superior portion of the polypoid tumor. D, Surgical resection demonstrates
the circumferential polypoid nature of the sigmoid adenocarcinoma.
A B C
D
D1
D2
FIGURE 5.130 ADENOCARCINOMA OF TRANSVERSE COLON

A, Mass lesion covered with stool and exudate. B, C, With washing, a typical hemicircumferential tumor can be seen. D, The patient
previously underwent distal resection. Note the anastomotic scar and neovascularity. D1, Mass lesion of transverse colon as shown on
standard and coronal images (D2).
Continued
E1 E2
E3
FIGURE 5.130 ADENOCARCINOMA OF TRANSVERSE COLON

E1, E2, Invasive well-differentiated to moderately differentiated adenocarcinoma arising in a tubulovillous adenoma. Mucin is present
(E3), but the tumor has to consist of more than 50% mucin to be labeled a mucinous (colloid) carcinoma.
B C
D
E
FIGURE 5.131 ADENOCARCINOMA OF ASCENDING COLON

A, “Apple-core” lesion is shown. B, The mass lesion is easily identified. C, The distal portion of the neoplasm is demonstrated by the
edematous circumferential fold. An ulcer is present in the center of the tumor. D, Surgical specimen confirms the circumferential
neoplasm. E, Scirrhous nature of the colonic neoplasm is evident.
A B
FIGURE 5.132 ADENOCARCINOMA ARISING IN VILLOUS ADENOMA

A, Large polypoid lesion in the right colon. Note the venous congestion. B, Large sessile polyp.
A1 A2
B1 B2
FIGURE 5.133 HEMICIRCUMFERENTIAL ADENOCARCINOMA OF THE CECUM

A1, Mass lesion appears hemicircumferential; the lesion appears to have an inflammatory component outside the colonic wall.
A2, Hemicircumferential mass with central ulceration. B1, B2, The tumor is opposite the ileocecal valve and demonstrates a raised
ulcerated appearance.
A B
FIGURE 5.134 ULCERATED CECAL ADENOCARCINOMA

A, Large, ulcerated mass lesion occupying the cecum. B, Large cecal mass.
C C, Ulcerated cecal mass with stigmata of recent bleeding.
A B
FIGURE 5.135 PERFORATED CECAL ADENOCARCINOMA

A, Mass lesion of the cecum exuding pus. B, Large mass lesion with a central hypodense area representing abscess.
A B
FIGURE 5.136 ADENOCARCINOMA OF ILEOCECAL VALVE

A, Mass lesion in the cecal pole with extrinsic compression on
the terminal ileum, associated with nodularity and narrowing of
the distal ileum and proximal dilation. The cecum is contracted
and thick-walled. B, The mass lesion occupies the ileocecal
valve. The folds surrounding the valve are edematous. The center
of the lesion has a nodular appearance. C, Carcinoma of the
ileocecal valve with a nodular appearance. The terminal ileum
is on the right and is dilated. Normal colonic mucosa is present
C
on the left.
A1 A2 B
FIGURE 5.137 INFILTRATING COLON CANCER (LINITIS PLASTICA)

A1, A2, Diffuse nodularity of the right colon without mass lesion. This resembles a linitis plastica appearance. B, Hemorrhagic nodular
lesions infiltrating the colonic wall.
A B C
D E
FIGURE 5.138 ENTERAL STENTING OF OBSTRUCTING COLON CANCER

A, Obstructing mass lesion of proximal descending colon. B, The prosthesis is placed fluoroscopically through the lesion. C, The stent
has been deployed. D, The stent is widely patent. E, Position of stent in tumor at resection.
A B
FIGURE 5.139 ADENOCARCINOMA IN ULCERATIVE COLITIS

A, Raised lesion in distal colon. The surrounding mucosa has a bland appearance. B, Multiple colonic polyps and cancers are present
throughout colon.

Submucosal mass lesion with petechiae.
A B
C D

A, Large mass lesion in the proximal transverse colon. Hypodense areas in the tumor represent necrosis. The patient has acquired
immunodeficiency syndrome with fever and abdominal pain. B, Circumferential ulcerated mass lesion is shown. C, The circumferential
necrotic nature of the mass is shown. D, The lamina propria is expanded by infiltration of lymphoma cells. For optimal pathologic
diagnosis of lymphoma, a portion of the specimens should be placed in Bouin’s fixative or submitted on saline-dampened gauze
immediately.
Adenocarcinoma
Metastatic neoplasm
A B
FIGURE 5.142 NON-HODGKIN’S LYMPHOMA OF THE

ILEOCECAL VALVE
A, Bulbous ileocecal valve. The valve appears firm and fixed.
B, Mass lesion involving the ileocecal valve. Note the ileum is
dilated and a synchronous ileal lymphoma is present (right).
C C, Close-up shows the ileocecal valve mass.
A B
FIGURE 5.143 CECAL NON-HODGKIN’S LYMPHOMA IN ACQUIRED IMMUNODEFICIENCY SYNDROME

A, Mass lesion occupying the cecum. B, Mass lesion projecting from the base of the cecum.
Cecal Non-Hodgkin’s Lymphoma in Acquired Immunodeficiency
Syndrome (Figure 5.143)
Carcinoid tumor
Adenocarcinoma
A B
C1 C2 C3
D1 D2
FIGURE 5.144 MANTEL CELL LYMPHOMA

A, B, Solitary polypoid lesion in the distal colon with overlying ulceration. C1, C2, Multiple sigmoid lesions shown on high-definition
and narrow band imaging (C3). D1, Atypical lymphoid infiltrates are present. D2, CD20 immunostain highlights the malignant
B lymphocytes.
A B1 B2

A, Circumscribed red lesions throughout the colon. B1, B2, Close-
up shows the lesions to be well-circumscribed, round areas of
subepithelial hemorrhage suggestive of lymphoid aggregates.
C, The mucosa is infiltrated by leukemic cells. (See also
C Figures 1.37, 2.74, and 5.207.)
A B C

A, Multiple confluent hemorrhagic mass lesions in the cecum. B, Solitary raised lesion in the transverse colon. C, Solitary mass lesion in
the descending colon.
FIGURE 5.147 KAPOSI’S SARCOMA IN

ACQUIRED IMMUNODEFICIENCY
SYNDROME
A, B, Small submucosal hemorrhagic
lesion. C, Spindle cells in the submucosa.
A B
C
A1 A2 A3
B C1 C2
FIGURE 5.148 METASTATIC LESIONS TO THE COLON

A, Breast cancer. A1, Large mass lesions occupying the colonic lumen. A2, Solitary raised
lesion. A3, Raised white plaquelike lesion. B, Cervical cancer. Raised lesion with central
indentation. C, Metastatic neuroendocrine tumor of the pancreas. C1, Nodular lesion.
D
C2, Large nodular mass lesion. D, Metastatic melanoma. Raised dark lesion.
A B

A, Well-circumscribed mass is at the ileocecal valve. The surface of
the lesion is smooth and was hard when probed with the biopsy
forceps. These features are atypical for an adenoma. B, Surgical
specimen shows well-demarcated lesion at ileocecal valve.
C
C, Typical pathologic appearance of carcinoid tumor.
D E F
FIGURE 5.150 SIGMOID VOLVULUS

A, Typical kidney-bean shape of a sigmoid volvulus. B, The twist of the sigmoid colon is demonstrated. C, The colonic mucosa appears
twisted around a central opening at barium enema examination. D, Midportion of the twist is shown. No associated colitis or mass
lesion is present. E, Further advancement of the colonoscope demonstrates partial opening in the proximal end of the twist. F, Once
past the twist, the colon is markedly dilated. The mucosa appears normal, with no evidence of ischemia.
A B C1
C2 D1 D2
D3 E F1
FIGURE 5.151 MELANOSIS COLI

A, Mild disease with subtle pinpoint dark discoloration to the mucosa. B, More extensive
dark discoloration. C1, C2, The colon is black. D1, Lymphoid tissue does not take up
the pigment, and thus is easily identified, (D2) as shown on narrow band imaging.
D3, Multiple lesions in the cecal pole. E, Likewise, polyps do not take up the pigment and
are readily identified. F1, The mucosa overlying this polyp is stained. F2, The polyp is
resected demonstrating a lipoma. Because the overlying mucosa was normal, the
F2
pigment was taken up.
Continued
FIGURE 5.151 MELANOSIS COLI

G, Striking changes in this colectomy specimen.
H, Normal-appearing colonic mucosa, with multiple
pigment-containing macrophages.
FIGURE 5.152 VASCULAR ECTASIAS

A tuft of blood vessels resembles spider angioma in the cecum. A large draining vein is emanating from the ectasia. Several other
vascular ectasias are noted proximally.
FIGURE 5.153 VASCULAR ECTASIA FIGURE 5.154 VASCULAR ECTASIA

Large sessile ectasia in the cecal pole. Typical spider-web appearance of a vascular ectasia. Note the
draining vein.

Solitary ectasias in the right colon (A, B).
A B

A, Large ectasia in a patient with portal
hypertension. B, Note the draining vein on
close-up.
A B
FIGURE 5.157 VASCULAR ECTASIAS

A, Two well-circumscribed vascular ectasias
in a patient with chronic renal failure and
hematochezia. The tuft of blood vessels in
the ectasia does not have a spider
angiomatous appearance. B, The 7-French
heater probe is shown after coagulation of
the lesions. The ectasias now appear white
from the coagulation.
A B
A B C
FIGURE 5.158 ACTIVE BLEEDING FROM VASCULAR ECTASIA

A, B, A stream of blood is emanating from an ectasia. C, Appearance of the lesion after thermal ablation.
FIGURE 5.159 LASER ABLATION OF

VASCULAR ECTASIA
A1, A2, Ectasia in distal colon. Close-up
shows the draining vein. B, The argon laser
probe is visible. Spontaneous bleeding was
present from the lesion with inadvertent
trauma from the catheter. C, Lesion after
ablation.
A1 A2
B C
FIGURE 5.160 THERMAL TREATMENT OF

VASCULAR ECTASIAS
A, Large tuft of ectasias. B, Thermal therapy
being applied.
A B

A, Typical appearance of ectasia with draining veins. B1, Biopsy shows submucosal
blood vessels. B2, Red blood cells in a vascular channel.
B1 B2
FIGURE 5.162 ANASTOMOTIC VARICES

Neovascularization is apparent at the site of prior surgical
anastomosis.

A, Pinpoint area of active bleeding.
The thermal probe is alongside the lesion.
B, Hemostasis achieved after thermal
ablation.
A B
FIGURE 5.164 BLUE RUBBER BLEB NEVUS

SYNDROME
A, Large solitary cavernous hemangioma.
B, Two lesions. C, Three submucosal
cavernous hemangiomas in the left colon.
D, Vascular lesion on the buttocks.
A B
C D
FIGURE 5.165 KLIPPEL-TRENAUNAY-

WEBER SYNDROME
A, Large, flat submucosal venous structure
in the rectum sparing the lymphoid follicles.
B, Subtle rectal hemangioma. C, Large flat
hemangioma of the leg.
A B C
FIGURE 5.166 BAROTRAUMA

A-C, Multiple linear lesions in the right colon.
Cecal Ulcer (Figure 5.167)
Infection (cytomegalovirus)
Inflammatory bowel disease (Crohn’s disease)
Vasculitis
FIGURE 5.167 CECAL ULCERS

Large ulcerations in the cecum. The lesions were not secondary
to ischemia but were idiopathic. Similar lesions may be observed
in patients with Crohn’s disease or secondary to nonsteroidal
antiinflammatory drug treatment.
FIGURE 5.168 IDIOPATHIC COLONIC

ULCER
Large ulceration in the right colon (A) and
cecum (B) in a patient with acquired
immunodeficiency syndrome.
A B
A B C
FIGURE 5.169 NONSTEROIDAL ANTIINFLAMMATORY DRUG-INDUCED ULCER

A, Solitary ulcer at the ileocecal valve. B, Large ulcer straddling the ileocecal valve. C, Ulceration of the ileocolonic anastomosis.
FIGURE 5.170 NONSTEROIDAL

ANTIINFLAMMATORY DRUG-INDUCED
COLITIS
Normal-appearing ascending colon, with
the cecum in the distance (A). Withdrawal
of the colonoscope demonstrates focal
ulceration (B); further withdrawal
demonstrates circumferential edema and
ulceration, suggestive of ischemia (C, D).
Segmental circumferential disease also
occurs with ischemia, inflammatory bowel
disease (Crohn’s disease), and some
infections (cytomegalovirus colitis).
A B
C D
Nonsteroidal Antiinflammatory Drug-Induced Colitis (Figure 5.170)
Crohn’s disease
Ischemia
Ringlike stricture
Stricture
B C
FIGURE 5.171 NONSTEROIDAL ANTIINFLAMMATORY DRUG (NSAID)-INDUCED COLONIC STRICTURES

A, Segmental strictures in the right colon, with normal-appearing mucosa. B, The distal stricture has a ringlike appearance. The mucosa
appears normal. C, The proximal stricture is formed by a ring of fibrosis, and a small ulceration is present. The strictures and ulceration
were secondary to chronic NSAID use.
A B C
FIGURE 5.172 NONSTEROIDAL ANTIINFLAMMATORY DRUG-INDUCED COLONIC STRICTURE

A, Tight stricture with cicatrization of the surrounding mucosa in the transverse colon. B, Barium enema shows the caliber of the
transverse colon stricture. C, Thickening of the transverse colon in the area of the stricture. This patient also had gastric (see
Figure 3.61B) and duodenal ulcers.
A B C
FIGURE 5.173 BENIGN COLONIC STRICTURE

A, Tight anastomotic stricture in the descending colon. B, A balloon is passed across the stricture and inflated. C, The appearance after
dilatation.

DISEASE (GVHD)
A, Patchy subepithelial hemorrhage and
edema of the descending colon. B, Severe
disease with complete loss of the mucosa
associated with mucopus. C, Diffuse edema
with exudate covering the descending
colon. D, Diffuse erythema is typical for
GVHD of the skin.
A B
C D
A B1 B2
FIGURE 5.175 AMYLOID COLOPATHY

A, Patchy subepithelial hemorrhage in the distal colon. B1, B2, Diffuse edema and ulceration of the right colon resembling an
inflammatory bowel disease.
FIGURE 5.176 SYSTEMIC MASTOCYTOSIS

Two linear areas of edema with overlying subepithelial
hemorrhage are related to touching the mucosa with biopsy
forceps. Similar phenomenon have been described for the skin
termed Darier sign (urticaria pigmentosa).
FIGURE 5.177 XANTHOMA

A, B, Multiple well-circumscribed,
hyperpigmented lesions throughout the
colon.
A B
A B
FIGURE 5.178 APHTHOUS ULCERS

A, B, Diffuse aphthous ulcers in the distal colon.
A B C
FIGURE 5.179 LYMPHOID HYPERPLASIA

A, Barium enema shows numerous filling defects in the right colon (new x-ray scan). B, Multiple small nodular lesions surrounding the
appendiceal orifice are typical of lymphoid hyperplasia. Some of the lesions have a “red ring” appearance. The appendiceal orifice is in
the center. C, Melanosis accentuates the finding.
FIGURE 5.180 END-TO-END ANASTOMOSIS

Sutures are seen at the anastomosis. The polypoid-appearing
tissue at the suture site represents an inflammatory response
rather than residual tumor or adenoma.
A B C
FIGURE 5.181 END-TO-END ANASTOMOSIS

A, The anastomosis is on the right. B, The small-bowel mucosa prolapses, confirming the endoscopic impression. C, Widely patent end-
to-end distal colonic anastomosis.
A B1 B2
FIGURE 5.182 END-TO-SIDE ANASTOMOSIS

A, The blind colonic pouch is at the top right, with the ileum on the lower left. B1, B2, Large, circular fixed anastomosis with a small
amount of prolapsing small-bowel mucosa.

Extrinsic compression in the proximal rectum, with normal-
appearing overlying mucosa. The extrinsic compression resulted
from a tumor mass in the pelvis.
A1 A2 B1
B2 C
FIGURE 5.184 EXTRINSIC COMPRESSION

A1, A2, Multiple extrinsic lesions compressing the right colon in a patient with polycystic liver and kidney disease. B1, B2, Magnetic
resonance imaging (MRI) shows the multiple lesions of the liver and kidneys. C, Corresponding compression in right colon.
FIGURE 5.185 EXTRINSIC COMPRESSION IN THE RIGHT COLON
FROM CIRRHOSIS
Note the nodular appearance of the compressing liver.
FIGURE 5.186 SEROSAL LESION

A well-circumscribed, edematous lesion that appears to be
submucosal. A small ulceration is at the apex of the lesion.
The surrounding colonic mucosa appears normal.
This submucosal lesion represents a serosal metastasis from
a distal colonic carcinoma.
A B

A, Round, masslike lesion at the hepatic flexure that appears to
C be submucosal. B, Ulcerated lesion with a well-circumscribed
nodular border. C, Renal cell carcinoma eroding into the colon.
A B1 B2
C1 C2 D1
FIGURE 5.188 EROSION OF PANCREATIC

PSEUDOCYST INTO LEFT COLON
A, Fluid collection in the right and left colon.
B1, B2, Note large amount of air fills the
collection. C1, C2, Mucosal defect is seen
with fresh blood. D1, D2, The colonoscope
is passed through the defect, demonstrating
a large cavity representing the pseudocyst.
E, Large pseudocyst cavity where the scope
D2 E
has entered.
A B C
FIGURE 5.189 NONSPECIFIC ABNORMALITY

A, Focal area of edema and subepithelial hemorrhage of unclear significance. B, Narrow band imaging suggests the lesion is not
adenomatous. Biopsy showed nonspecific findings. C, Linear area of hypervascularity related to the colonoscope. This linear lesion is
commonly seen in the distal colon on colonoscopic withdrawal.
FIGURE 5.190 COLONIC FOREIGN BODIES

Fly. (Courtesy Leticia Luz, MD.)
A1 A2 A3
B1 B2 C
FIGURE 5.191 COLITIS CYSTIC PROFUNDA

A1-A3, Focal area of submucosal nodularity and cystic-appearing
lesions. B1, B2, The lesion is firm, and biopsy results show the
underlying mucosa has a cystic component. C, With the
endoscope advanced to the cystic area, a honeycomb-type
pattern represents the multiple cystic areas. D, Pathology shows
D
the submucosal cystically dilated spaces.
A B1 B2
FIGURE 5.192 PORTAL HYPERTENSIVE COLOPATHY

A, Focal area of erythema in a circular pattern that is composed of blood vessels.
C
B1, B2, Tortuous vascular pattern in the distal colon. C, Solitary vascular ectasia.
A B C
FIGURE 5.193 CONFOCAL

ENDOMICROSCOPY
Endoscopic images of normal and abnormal
colon. A, Normal colon. B, Hyperplasia.
C, Adenoma. D, Ulcerative colitis.
E, Adenocarcinoma. (A courtesy A. Meining,
MD, Klinikum Rechts Der Isar, Munich,
Germany; B courtesy E. Coron, MD,
CHU Nantes, France; C-E courtesy Michael
D E
Wallace, MD, Mayo Clinic, Jacksonville, FL.)
A B1 B2
C D1 D2
E F1 F2
FIGURE 5.194 PILLCAM COLON

A, Eosinophilic esophagitis. B1, Portal hypertensive gastropathy as shown on upper endoscopy and colon capsule (B2). C, Ampulla of
Vater. D1, D2, Colonic diverticula. E, Colonic ectasia. F1, F2, Blue rubber bleb nevus syndrome.
Continued
G H1 H2
I1 I2 J1
FIGURE 5.194 PILLCAM COLON

G, Ulcerative colitis.
COLONIC LESIONS ON STANDARD PILLCAM
H1, H2, Pedunculated colonic polyp. I1, I2, Sessile colonic polyp.
J2
J1, J2, Colonic carcinoma. (Courtesy I. Fernandez-Urién, MD, Pamplona, Spain.)
A1 A2 A3
B1 B2 C
FIGURE 5.195 NORMAL ILEUM

A1-A3, Normal-appearing ileum. Note the pronounced villi as
viewed underwater, which is accentuated with bile.
B1, B2, Normal ileum as shown with high-definition endoscopy
(B1) and narrow band imaging (B2). C, Marked nodularity of the
distal ileum representing normal lymphoid follicles. D, Lymphoid
follicle found on biopsy of the nodule. (Courtesy J. Pardo-Mindan,
D
FIGURE 5.196 APPENDICITIS

The appendiceal orifice appears masslike.
A B
FIGURE 5.197 APPENDICEAL TUMOR

A, Prolapsing lesion emanating from the base of the cecum. B, Large appendix with extension into the base of the cecum caused by a
neuroma.
FIGURE 5.198 ACUTE ILEITIS

A, Diffuse edema and shallow ulceration
of the distal ileum. B, Thickening of the
distal ileum resulting in a tubular
appearance on CT.
A B
FIGURE 5.199 CROHN’S ILEITIS

Shallow ulcer with surrounding edema
of the distal ileum as shown on high-
definition endoscopy (A) and narrow
band imaging (B).
A B
A1 A2 B
FIGURE 5.200 ILEAL CROHN’S DISEASE

Numerous ulcerations in the terminal ileum on high magnification (A1, A2) and narrow band imaging (B).
A B C
FIGURE 5.201 CYTOMEGALOVIRUS ILEITIS

A, Multiple well-circumscribed, punched-out ulcers of the ileum. B, Marked involvement of the ileocecal valve results in a stenotic
appearance. C, The bleeding represents the appearance after biopsy.
FIGURE 5.202 WHIPPLE’S DISEASE

The mucosa is thickened with white plaques.
A B
C D
FIGURE 5.203 ILEAL GRAFT-VERSUS-HOST DISEASE

A, Minimal abnormalities in the terminal ileum. B, Complete loss of the ileal mucosa with hemorrhage and exudate, as seen with severe
disease. (C) Low- and (D) high-power views show abundant apoptosis involving the crypts.
Ileal Graft-versus-Host Disease (Figure 5.203)
Bacterial ileitis
A B
FIGURE 5.204 ILEAL DIVERTICULAR HEMORRHAGE

A, Small clot covered diverticulum in the distal ileum. B, Diverticulum apparent in the surgical specimen.
A B
FIGURE 5.205 GARDNER SYNDROME

A, B, Multiple small polyps throughout the distal ileum.
A B

A, Ulcerated mass lesion just inside the ileocecal valve. B, Round mass lesion in the terminal ileum.
A B
C D

A, Subepithelial hemorrhage and edema of the ileocecal valve. B, Edema, granularity, and subepithelial hemorrhage of the terminal
ileum. (C) Low- and (D) high-power views show infiltration of the ileal mucosa by leukemic cells. (See also Figures 1.37, 2.74, and 5.145.)

Solitary donut-shaped lesion in the ileum.
CHAPTER
6
Anorectum
INTRODUCTION
Management of diseases of the anorectum has traditionally been
relegated to the proctologist, often a surgeon. The ease of sigmoidos-
copy and the advent of video technology have provided the tools for
endoscopists to assume a more active role in the evaluation and
treatment of these disorders. Visual inspection of the perianal area
coupled with digital examination should always precede endoscopic
examination because subtle clues to underlying pathology may be iden-
tified. Retroflexion best permits evaluation of distal lesions, particularly
those at or above the dentate line. A careful inspection of the anal canal
should also be performed, especially for patients reporting anorectal
pain and for patients with pain elicited on digital examination. Evalua-
tion of the anal canal can also be performed with a disposable plastic
anoscope.
FIGURE 6.1 RECTUM

The rectum is characterized by prominent vascularity, in contrast
with the sigmoid and proximal colon.
FIGURE 6.2 VALVES OF HOUSTON

A, The three valves of Houston are semilunar
structures, two on the right and one on the
left. In this patient in the left lateral decubitus
position, the two valves on the right are
anterior. B, Narrow band imaging
demonstrates the subtle vascular pattern of
the rectum.
A B
Dentate line
Endoscope
FIGURE 6.3 ANORECTAL JUNCTION ON RETROFLEXION

Retroflexion at the anorectal junction shows the dentate line demarcating the squamous mucosa from the colonic mucosa. In this case,
black pigment of the squamous mucosa is near the endoscope.
FIGURE 6.4 HYPERTROPHIED ANAL
PAPILLAE
A, Three white polypoid structures are distal
to the dentate line. These normal structures
are hypertrophied, simulating a polyp on
digital rectal examination. B, Solitary skin
tag associated with enlarged hemorrhoidal
tissue.
A B
A B C1
C2 D E
F G
FIGURE 6.5 HEMORRHOIDAL DISEASE

INTERNAL HEMORRHOIDS
A, Although vascular cushions at the anorectum (hemorrhoids) are normal, this structure is markedly enlarged in this particular patient.
The venous enlargement is proximal to the dentate line. B, Multiple internal hemorrhoids are at the dentate line. C1, Two reddish
vascular tufts with overlying vasculature at the dentate line as seen on antegrade withdrawal of the colonoscope. C2, Retroflexed view
confirms the location of the hemorrhoidal tissue proximal to the dentate line.
EXTERNAL HEMORRHOIDS
D, Thrombosed external hemorrhoid is shown. E, The enlarged vascular cushion is distal to the dentate line, thus representing
an external hemorrhoid. The dentate line is well visualized. F, Multiple dilated veins on hemorrhoidal tissue are similar to the red
signs on esophageal varices. G, External hemorrhoid prolapsed back in the rectum as shown on retroflexion.
FIGURE 6.7 EXTERNAL HEMORRHOID WITH BLEEDING

STIGMATA
Note the adherent blood clot on the external hemorrhoid as
shown on retroflexion.
FIGURE 6.6 EXTERNAL HEMORRHOIDS IN PORTAL
HYPERTENSION
Prominent external hemorrhoids in a patient with cirrhosis, portal
hypertension, and esophageal varices.
FIGURE 6.8 ULCERATIVE PROCTITIS

A, The colitis can be seen to begin just inside
the anal verge. B, Marked proctitis with all
the features of colitis including loss of the
mucosal vascular pattern, edema,
subepithelial hemorrhage, friability, and
mucopus.
A B
FIGURE 6.9 NONSPECIFIC HEMORRHAGE

Striking subepithelial hemorrhage in the rectum. Biopsies
disclosed no specific cause. Such nonspecific changes can
be seen in patients on anticoagulation, or who have
thrombocytopenia, or the changes lack specific explanation.
A B C
FIGURE 6.10 PERIANAL CROHN’S DISEASE

A, Multiple large skin tags at the anus simulate thrombosed external hemorrhoids. B, Further inspection reveals fistulae at the base of
the tags. Fistulae are also seen in areas of ulcerated mucosae. C, Retroflexion at the anorectal junction demonstrates multiple
serpiginous ulcerations, typical of Crohn’s disease.
FIGURE 6.11 MULTIPLE SKIN TAGS IN CROHN’S DISEASE

Multiple skin tags at the anal verge in a patient with long-
standing Crohn’s disease.
A B
FIGURE 6.12 MULTIPLE SKIN TAGS IN CROHN’S DISEASE

A, Multiple ulcerated skin tags. B, After surgical resection,
C
granulomas can be seen, as well as multinucleated giant cells (C).
A B
FIGURE 6.13 SKIN TAGS FROM PRIOR HEMORRHOIDAL DISEASE

A, Multiple skin tags and redundant tissue at the anal verge caused by prior hemorrhoidal disease. B, Solitary large skin tag at the
dentate line as shown on antegrade view.
FIGURE 6.14 BLEEDING SKIN TAG

A, Retroflexed view shows a large skin tag
with fresh bleeding. B, After washing,
ulceration can be seen at the base of the
large skin tag.
A B
A B C
FIGURE 6.15 J POUCH

A, Distal anastomosis in the foreground. B, Characteristic appearance of the pouch. C, Both limbs are now shown.
FIGURE 6.16 POUCHITIS

Patchy ulceration and edema in the pouch
extending to the limbs (A1, A2). B1, B2,
More diffuse disease with edema,
ulcerations, and mucopus.
A1 A2
B1 B2
FIGURE 6.17 RECTAL FISTULA

Retroflexion in the rectum demonstrates an opening near the
anorectal junction. This patient had a history of Crohn’s disease.
Note the absence of rectal inflammation. The fistula could also be
identified in the antegrade view of the anorectum.
FIGURE 6.18 RECTAL AND PERIANAL

FISTULAE
Fistulous opening proximal to the dentate
line on retroflexion view (A, B). Opening
is shown antegrade on withdrawal (C).
Perianal skin tags with erosions and a
fistulous opening are also noted (D).
A B
Fistula Ulceration
Anus
C D
A B C
FIGURE 6.19 RECTAL FISTULA IN CROHN’S DISEASE

A, Ulceration at the anal verge in a patient with Crohn’s disease. B, Fistula site identified. C, After medical therapy, the rectal mucosa is
now normal, although the fistula is still widely patent. This patient now reported passage of stool through the vagina.
FIGURE 6.20 RECTAL FISTULA

Area in the distal rectum as shown on retroflexion with nodularity
and where pus was seen to pass spontaneously.
A B C
FIGURE 6.21 FISTULA IN ANO

A, Opening in the anal canal. B, Close-up shows the fistula. C, Redundant tissue at the anal verge with an opening representing the
fistulous tract.
FIGURE 6.22 FISSURE

Linear tear in the anal canal with associated
sentinel pile (A, B).
A B
FIGURE 6.23 RECTAL VARICES

A, Cluster of varices in the distal rectum.
There is bleeding stigmata on one of the
variceal trunks. B, A vascular ectasia was
identified just proximal to the varices. These
can be seen in colonic disease related to
portal hypertension.
A B
FIGURE 6.24 RECTAL VARICES

A, Large cluster of veins in the midrectum
resembling a mass lesion. B, Contrast
examination shows a large variceal trunk in
the rectum.
A B
FIGURE 6.25 ADENOMATOUS POLYP

Large, adenomatous-appearing polyp at the anorectal junction
shown on retroflexion. A soft mass lesion was palpated on digital
rectal examination. The lesion could not be observed as the
endoscope was advanced into the rectum.
A1 A2 A3
B1 B2 B3
C1 C2 C1a
C2b

A1-A3, Typical-appearing small sessile polyp in the distal rectum on standard and narrow band imaging (B1-B3). The narrow band
image demonstrates a “brain” appearance suggesting an adenoma. C1, Small polyp with reddish overlying vascular pattern as shown
on standard and narrow band imaging (C2). Note the appearance is accentuated by examining the lesion underwater because of
magnification (C1a, C2b).
Continued
D1 D2

D1, Neoplastic epithelium with elongated cigar-shaped nuclei, increased nuclear/cytoplasmic ratio, and surrounding lamina propria
with focal fresh and remote hemorrhage (D2).
A1 A2 B

A, Solitary small polyp at the anal verge typical for an adenoma (A1). Polyp as shown on retroflexion (A2). B, The polyp has been
snared.
FIGURE 6.28 PROLAPSED ADENOMA

A, Hemorrhagic polyp at the anal verge. B,
With passage of the endoscope into the
rectum, the polyp was seen to be
pedunculated on a long stalk. C, The polyp
has been snared. D, The base of the polyp
was on the first valve of Houston.
A B
C D
A1 A2 B

A1, A2, Circumferential lesion of the
distal rectum. Note the large amount
of mucus. B, The center of the
circumferential lesion has a typical villous
appearance. C, Note the sharp
demarcation at the proximal border.
D, Surgical specimen shows a typical-
C D
appearing large villous adenoma.

A1, A2, Multiple small polyps in the distal
rectum. Close-up shows a smooth surface
and slight pink discoloration. B1, Small clear
polyp in the rectum. On narrow band
imaging, no pattern is appreciated on the
mucosal surface (B2). C, Colonic mucosa
with cells having increased cytoplasmic
mucin content and arranged in a serrated
configuration.
A1 A2
B1 B2
C
A1 A2
B1 B2 B3
B4 B5
FIGURE 6.31 CARCINOID POLYP

A, Small yellowish-appearing polyp in the distal colon (A1).
Close-up shows the submucosal nature of the polyp and typical
yellow color (A2). The lesion was firm on biopsy. B1, Yellow
smooth sessile polyp in the distal rectum. B2, The polyp has
been snared. Note the peculiar overlying vascular pattern as
shown on standard and (B3) narrow band imaging. B4-B6,
Typical features of a carcinoid lesion demonstrate a
predominantly ribbon-like architectural arrangement and
neuroendocrine cytologic features including relatively
plasmacytoid nuclear placement, “salt and pepper” chromatin,
B6
and mild amount of cytoplasm.
FIGURE 6.32 CARCINOID LESION

A1, Submucosal lesion. Endoscopic
ultrasonography (EUS) shows the
submucosal nature of the polyp (A2). A cap
device is used for endoscopic mucosal
resection (A3, A4). B, The lesion has been
snared and completely resected.
A1 A2
A3 A4
B1 B2
B3 B4
FIGURE 6.33 MULTIPLE RECTAL

NEOPLASMS
Hypervascular sessile lesion in the distal
rectum with a fresh blood clot represents
recent bleeding (right). The lesion was an
adenocarcinoma and was associated with
other colonic polyps. In the more proximal
rectum, a 3-mm polyp compatible with
either an adenoma or a hyperplastic polyp
was present (top left). This was a
tubulovillous adenoma. In the distal rectum,
two clear hyperplastic polyps were found
(bottom left).

This polypoid mass can be seen at the anorectal junction, with
active bleeding. Retroflexion in the rectum demonstrated that
the lesion arose from the colonic mucosa at the anorectal
junction, thus identifying this lesion as a primary colonic
carcinoma with prolapse into the anal canal rather than a primary
anal carcinoma.

Small, friable nodular lesion of the distal rectum. Note the
irregularity of the distal margin. This lesion was metastatic to the
liver at diagnosis.
A1 A2 B1

A1, Hemicircumferential necrotic
tumor just inside the anal verge.
A2, Retroflexion shows the nature of
the tumor in relation to the anal verge.
B1, Circumferential ulcerated mass at
the anal verge. B2, Just proximal to
the tumor, there is an additional sessile
ulcerated lesion, likely adenocarcinoma
as well. B3, Tumor on antegrade view in
B2 B3
the anal verge.
A B1 B2

A, Endoscopic ultrasonography stages the lesion to involve the serosa and a lymph node is present (stage T3N1). B1, Donut-shaped
lesion of the distal rectum. B2, The tumor involves the muscularis to the adventitia compatible with a stage 3 tumor.
A B1 B2

A, Hemicircumferential mass lesion in
the midrectum. B1, B2, The lesion was
limited to the mucosa without evidence
of nodal disease. C, Lesion easily seen on
CT scan using rectal contrast. D, Solitary
C D
midrectal cancer.
A1 A2 B
C D E
F G H
FIGURE 6.39 ENTERAL STENTING OF OBSTRUCTING RECTAL CANCER

A1, A2, Circumferential ulcerated tumor of the midrectum. B, A guidewire is passed more proximally under fluoroscopic guidance and
contrast injected. The stent is deployed (C-F). Stent as seen on follow-up CT scan (G, H).
FIGURE 6.40 PROSTATE BIOPSY SITE FIGURE 6.41 PROSTATE CANCER

Area of fresh hemorrhage from recent transrectal prostate biopsy. Diffuse ulceration anteriorly extending from the anal verge
proximally.
A B1 B2

A, Round, elevated, ulcerated mass lesion in the posterior rectum. B1, Edema and shallow ulceration of the midrectum with areas of
nodularity (B2).
FIGURE 6.43 CLOACOGENIC CARCINOMA

Large ulcerated mass at the anal verge resembling an
adenocarcinoma.
FIGURE 6.44 KAPOSI’S SARCOMA FIGURE 6.45 GASTROINTESTINAL STROMAL TUMOR

Hemorrhagic subepithelial lesions. Hemorrhagic raised lesion in the distal rectum shown on
retroflexion.
A B
FIGURE 6.46 SOLITARY RECTAL ULCER

A, Large, well-circumscribed ulceration with a clean base is associated with edema of the proximal margin. This elderly patient had no
evidence of infection, ischemia, or anorectal trauma. B, Typical histopathologic findings for the solitary rectal syndrome are present,
including superficial ulceration, hyperplastic mucosal changes, and obliteration of the lamina propria by fibroblasts and smooth
muscle cells.
Enema
tip
Folds
Folds
B C
FIGURE 6.47 SOLITARY RECTAL ULCER

A, Linear folds in distal rectum. The surrounding mucosa is normal. B, Lateral view. These findings are consistent with hemorrhoids.
C, Solitary ulceration in the distal rectum.
FIGURE 6.48 STERCORAL ULCER

Large, well-circumscribed, deep ulcer in the distal rectum is
shown by retroflexion. This patient is an elderly woman with
chronic constipation and fecal impaction.
FIGURE 6.49 RADIATION-INDUCED RECTAL ULCER

Large ulcer on the anterior wall of the rectum in a patient with a prior history of radiation
therapy for prostate cancer.
FIGURE 6.50 RECTAL ULCER SECONDARY

TO RECTAL TUBE
A, Shallow ulcer covered with exudate
just inside the anal verge.
B, Hemicircumferential ulceration
with fresh clot.
A B
FIGURE 6.51 RECTAL ULCER WITH VISIBLE VESSEL

Small ulcer just proximal to the dentate line with a visible vessel.
FIGURE 6.52 RECTAL ULCER WITH

RECENT BLEEDING
A, Ulcer in the distal rectum with visible
vessel. Note the proximity to the dentate
line. B, Large-volume epinephrine injection
was performed with the endoscope in the
anal canal.
A B
FIGURE 6.53 IDIOPATHIC ULCER IN

ACQUIRED IMMUNODEFICIENCY
SYNDROME
A, Ulceration in the distal rectum with an
apparent opening. B, The opening was
entered demonstrating a complex cystic
cavity. Biopsy forceps are visible.
A B

A, Circumferential ulceration extends from
the anal verge to the proximal rectum, with
sharp demarcation of the proximal border.
Biopsy specimens demonstrated necrosis
involving soft tissue, nerve, and fat,
suggestive of an abscess cavity. B, Repeat
examination 3 weeks later demonstrated
almost complete reepithelialization, with
areas of normal vascular pattern present.
A B
A B C

A, As viewed from the anal canal, the ulceration spares the anus and the disease begins just proximal to the anal verge. B,
Circumferential ulceration in the distal rectum that extends proximally. C, Note the disease becomes more severe proximally.
A1 A2 B1
B2 C1 C2
C3
FIGURE 6.56 LYMPHOID TISSUE

A, Lymphoid hyperplasia. A1, A2, Red ring sign in the proximal rectum observed in a patient with acquired immunodeficiency
syndrome (AIDS). The red rings are formed by blood vessels, with the central areas representing well-circumscribed lymphoid nodules.
The red ring sign may be seen in young adults or in patients with systemic diseases associated with immune system activation, such as
AIDS, inflammatory bowel disease, and neoplasms. B1, B2, With the lumen collapsed, the red ring signs disappear and small pits are
seen. C1, C2, Multiple nodular lesions in the rectum. C3, A lymphoid nodule is noted.
Continued
D1 D2
E1 E2 E3
FIGURE 6.56 LYMPHOID TISSUE

D1, Patchy subepithelial hemorrhage shown with central spared areas. The uninvolved rectum is normal. D2, Lymphoid follicular
aggregate is observed. Some subepithelial hemorrhage is apparent at this magnification. The mucosal architecture is normal. The
lymphoid tissue is apparent because of the surrounding mucosal hemorrhage, which does not involve the aggregate. E1, E2, Multiple
aphthous ulcer-appearing lesions in the rectum. E3, With the lumen slightly collapsed, these lesions are shown to be on a mound of
tissue representing a lymphoid follicle.
B C
FIGURE 6.57 CLOSTRIDIUM DIFFICILE PROCTITIS

A, Typical-appearing thick yellow plaques in the rectum. B, CT shows marked thickening of the rectum both on standard and coronal
views (C).

A, Active bleeding in the distal rectum.
B, Close-up shows a pinpoint arterial
bleeding source.
A B

A, Visible vessel in rectum as shown with a
cap device (A1). Epinephrine is injected
(A2). B, After injection, thermal therapy is
applied.
A1 A2
B1 B2

A, Pinpoint clot/visible vessel in the rectum
without associated ulceration. B, The
banding device has been placed over the
lesion. C1, The band has been successfully
deployed. C2, The banded tissue has a
whitish appearance caused by ischemia.
A B
C1 C2

A, Barium enema demonstrating a stricture
of the distal rectum. B, Tight stricture of the
distal rectum after low anterior colonic
resection. C, Balloon dilatation performed.
D, Widely patent anastomosis after
dilatation.
A B
C D
FIGURE 6.62 ACUTE RADIATION INJURY FIGURE 6.63 RADIATION-INDUCED STRICTURE

Marked edema and fresh hemorrhage in the distal rectum. Tight stricture with ulceration and edema related to prior
radiation therapy.
FIGURE 6.64 FOCAL RADIATION–

INDUCED ECTASIA
A, Focal area of ectasias anteriorly in the
distal rectum related to prior radiation
seeds placed for prostate cancer.
B, Appearance after argon plasma
coagulation.
A B
A1 A2 B1
B2 B3 B4
FIGURE 6.65 RADIATION-INDUCED ECTASIAS

MILD INJURY
A1, Multiple vascular ectasias in the rectum as shown from the anal verge. A2, Note the ectasias begin just inside the anal verge.
SEVERE INJURY
B1, Numerous large ectasias with active bleeding. The argon laser is being used to treat the lesions (B2, B3). Multiple areas of
coagulation are visible after thermal therapy. Hemostasis is achieved (B4).
Continued
C1 C2
C3 C4
FIGURE 6.65 RADIATION-INDUCED ECTASIAS

C1, C2, Standard and narrow band imaging.
C3, C4, Appearance of the lesions after ablation.
D, Blood vessels in the subepithelium are shown as
D
empty spaces.
Dentate line
Endoscope
Condyloma Papilla

Retroflexion demonstrates the dentate line and a hypertrophied papilla. In addition, a verrucous-appearing sessile lesion overlies the
dentate line, typical of condyloma.

A, Polypoid lesions at the anal verge shown
on retroflexion. These may mimic anal
papillae. B, Multiple small verrucous lesions
at the anal verge. C, Large condylomatous
mass at the anal verge in a transplant
patient.
A B
C
Ulceration

Large hemicircumferential ulcer of the anal canal in a patient with acquired immunodeficiency syndrome. Squamous mucosa is shown
posteriorly, documenting the lesion’s location. This lesion was associated with severe anorectal pain. Other lesions causing anorectal
pain, especially with defecation, include ulcerations, fistulae, fissures, and hemorrhoidal disease.
FIGURE 6.69 CYTOMEGALOVIRUS (CMV) PROCTITIS

A, Diffuse subepithelial hemorrhage of the rectum with loss of mucosal vascular pattern. B, Characteristic large eosinophilic
intranuclear inclusion of CMV. Note the colonic edema.
A B
FIGURE 6.70 PNEUMATOSIS CYSTOIDES

A, Multiple submucosal cystic projections. B, Ultrasound confirms the lesions to be cystic in nature.

DISEASE
Patchy subepithelial hemorrhage is present
in the rectum (A) and sigmoid (B).
A B
FIGURE 6.72 RECTOCOLONIC

ANASTOMOTIC DEHISCENCE
A1, A2, Large ulceration at the surgical
anastomosis.
A1 A2

Extrinsic lesion in the anterior rectum in a patient with ulcerative
proctitis, who was 22 weeks pregnant.
A B
FIGURE 6.74 EXTRINSIC LESION: OVARIAN CANCER

A, Ulcerated lesion in rectum. B, Extrinsic mass lesion.
FIGURE 6.75 DESMOID TUMOR

Whitish lesion representing infiltrating tumor from the gluteus.
A B
FIGURE 6.76 RECTAL PROLAPSE

A, Prolapsing rectal tissue visible at the anal verge. B, Retroflexion shows the reddish tissue is now reduced.
Rectocele
Anus
FIGURE 6.77 RECTOCELE

Prolapse of the rectum through the vagina. The anus is inferior to the rectocele.
CHAPTER
7
Hepatobiliary
Tract and
Pancreas
INTRODUCTION
Video endoscopic technology has simplified the mechanics of endo-
scopic retrograde cholangiopancreatography (ERCP). Identification of
anatomic landmarks such as the entrance into the stomach, the incisura
angularis (gastric notch), and pylorus, as well as the papilla itself, is now
simpler. The refined optics can also assist in identifying subtle abnormal-
ities of the papilla caused by inflammatory or neoplastic disorders. In
contrast with endoscopy in other organs, where the action is on the
screen, ERCP primarily identifies abnormalities in the ductal structures
radiographically. With continued advancements in the technology of
smaller endoscopes (mother–daughter scopes), endoscopic identifica-
tion of intraductal disease may become more widespread. The ability
to watch the procedure on a monitor is nowhere more advantageous
than during a therapeutic case in which all personnel have a firsthand
look. This teamwork undoubtedly improves success and safety.
FIGURE 7.1 LANDMARKS

Typical view of the mid and distal
stomach, with the duodenoscope tipped
down and the patient prone. The lesser
curvature is at the top (posterior) and the
greater curvature is at the bottom
(anterior; top left). With advancement of
the duodenoscope to the antrum, the
angularis is directly above, with the
pylorus in the 6 o’clock position in the
distance (top right). To advance the
endoscope into the duodenum, the
pylorus should be in the 6 o’clock position
(bottom left). On entering the duodenal
bulb, the endoscope is deflected to the
right, advanced, and then withdrawn,
revealing the normal position of the major
papilla. In this patient, the papilla cannot
be directly visualized, but its normal
position can be ascertained by the
presence of the longitudinal fold, which
leads proximally to the papilla, as well as
by the presence of bile. The papilla
appears to sit on a ledge (bottom right).
Longitudinal fold
FIGURE 7.2 HIDDEN AMPULLA

Bile can be seen draining from the middle of this longitudinal
structure, with no ampullary orifice identified (A). The hooded
fold is lifted by the diagnostic catheter, demonstrating the
pinkish color of the ampullary orifice (B). The longitudinal fold
B is a landmark to the papilla.
FIGURE 7.3 THE MANY FACES OF

THE MAJOR PAPILLA
A, Small papilla in a jaundiced patient.
B, The papilla is more bulbous with
exudate and erythema at the papilla.
This patient had gallstone pancreatitis.
C1, More pronounced major papilla.
When the hooded fold is moved
with the catheter, the intraduodenal
segment with protruding epithelium is
appreciated (C2). D1, The papilla is
situated under duodenal folds with
ampullary tissue visible. When viewed in
the appropriate position, the biliary
A B sphincter can be seen in the ampullary
orifice (D2).
C1 C2
Biliary
sphincter
D1 D2
Continued
Guidewire in
biliary sphincter
Septum
Opening to the
E pancreatic sphincter F1
F2 G1 G2
FIGURE 7.3 THE MANY FACES OF THE MAJOR PAPILLA

E, A guidewire is present in the biliary sphincter, and the opening to the pancreatic
sphincter is shown inferiorly. The septum between the two ducts is also apparent.
F, The major papilla is normal, and the biliary sphincter relaxes with flow of bile
(F1, F2). G, Variable length of the longitudinal fold leading to the ampulla (G1, G2).
H H, The minor papilla is often visible in a lateral superior orientation.
Continued
FIGURE 7.3 THE MANY FACES OF

THE MAJOR PAPILLA
I1, I2, Major papilla is in a small
diverticulum and is flat, but with
cannulation the papilla becomes more
pronounced. J1-J3, The papilla is
situated in a diverticulum but is seen
to prolapse out.
I1 I2
J1 J2 J3
A1 A2 A3
B1 B2 C
FIGURE 7.4 SEPARATE OPENINGS FOR THE BILE AND PANCREATIC DUCTS
A1, Major papilla alongside a diverticulum with fleshy tissue both above and below a fold. A2, The bile duct is selectively cannulated.
A3, The fleshy tissue inferiorly is cannulated confirming the pancreatic segment. B1, A structure resembling the ampulla is seen above
a longitudinal fold with ampullary tissue. Underneath the fold, typical ampullary epithelium is also shown. B2, A sphincterotome is
used to selectively cannulate the bile duct. C, Bile exits from an opening on the superior surface of the ampulla. A slitlike area in the
middle of the papilla represents the pancreatic segment. The patient has previously undergone biliary sphincterotomy.
Continued
D1 D2 D3
Biliary
sphincter
Pancreatic
stent
D4 E1
E2 E3 E4
D, A manometry catheter is in the pancreatic sphincter (D1). The manometry catheter is in the biliary sphincter (D2). D3, D4, A
pancreatic stent is deployed in the pancreatic duct. E1, The patient has previously undergone pancreatic sphincterotomy, and a
pancreatic stent is visible. The biliary sphincter is at the 11 o’clock position. E2, The bile duct is selectively accessed. E3, Biliary
sphincterotomy is performed. E4, A bile duct stent is now present.
Continued
Papillary
structures
F1
F2 F3
F1, Two distinct papillary structures. The bile duct has been cannulated (F2) and sphincterotomy performed. Note the opening to the
bile duct and the papillary structure inferiorly representing the pancreatic sphincter (F3).
FIGURE 7.5 INTRAAMPULLARY SEPTUM

Both biliary and pancreatic sphincterotomies were performed
with a pancreatic stent in place. Note the thick septum dividing
the two openings.
FIGURE 7.6 POSITION OF MAJOR PAPILLA WITH BILLROTH II

ANATOMY
Note the inverse relation of the longitudinal fold to the hooded
fold over the major papilla (A, B).
Longitudinal
fold
Major papilla
Hooded fold
B
FIGURE 7.7 INTRADUODENAL SEGMENT

OF COMMON BILE DUCT
A, Note the long intraduodenal segment.
The length of the intraduodenal segment
dictates the length of the sphincterotomy
incision. B, Catheter in bile duct.
C, Intraduodenal segment easy to
identify as it appears separate from the
duodenal wall. D, Very small segment.
A B
C D
A1 A2 B
FIGURE 7.8 POSITION OF AMPULLA ON DIVERTICULUM

A1, Ampulla residing on the diverticular ridge. A2, Close-up shows the small ampullary structure. B, Ampullary structure at the
5 o’clock position.
Continued
C D E1
E2 E3
FIGURE 7.8 POSITION OF AMPULLA

ON DIVERTICULUM
C, Ampullary structure at the 6 o’clock
Ampullary position. D, Large intraduodenal segment
orifice occupying the center of the diverticulum.
E1, Diverticulum with no ampullary
structure visible. E2, View of the
diverticulum from a distance shows a small
area compatible with the papilla on the
inside lip at the 5 o’clock position. E3, A
sphincterotome has been used to move the
ampullary tissue toward the lumen.
F, Bulbous ampulla occupying the inferior
lip of a diverticulum. Cannulation
F confirmed an impacted stone.
Continued
G1 G2 H1
H2 H3 H4
FIGURE 7.8 POSITION OF AMPULLA ON DIVERTICULUM

G1, The ampulla is located in a small diverticulum inferior to a larger diverticulum.
G2, After selective biliary cannulation, the ampulla appears to be withdrawn from the
diverticulum. H1, The ampullary orifice is on the 3 o’clock position deep inside a large
diverticulum. H2, The diverticulum had to be entered for selective cannulation.
H3, The diverticulum is gently entered and sphincterotome used for selective bile
H5
duct access. H4, Biliary sphincterotomy performed and a solitary stone removed (H5).
FIGURE 7.9 DIVERTICULUM WITH DEBRIS
A, Large duodenal diverticulum with amorphous debris and air.
This patient had a bile duct obstruction. B, Mass of debris
obscures the ampulla. C, The debris was ultimately removed,
exposing a large periampullary diverticulum. Bile duct
obstruction in this setting has been termed Lemmel syndrome.
In this patient, jaundice resolved after removal of the debris.
B C
FIGURE 7.10 BILIARY CANNULATION TECHNIQUES

A, The bile duct was selectively cannulated from a distance that takes advantage of the
curve in the catheter. Note the direction toward the 11 o’clock position. A tortuous
longitudinal fold leads to the ampulla. B1, The major papilla is bulbous, and overlying
duodenal mucosa hides the ampullary orifice. B2, A sphincterotome is used to push
away duodenal mucosa, exposing the ampullary structure. B3, Given the more en face
position and need for biliary cannulation, a bowed sphincterotome was used for
selective cannulation.
B1 B2 B3
Continued
FIGURE 7.10 BILIARY CANNULATION

TECHNIQUES
C1, Exudate covers the ampullary tissue
resulting from recent previously failed
cannulation. C2, A sphincterotome is
placed just inside the ampullary
structure toward the 11 o’clock
position. C3, C4, The sphincterotome is
slowly bowed, the elevator dropped,
and the sphincterotome slowly
advanced, which helps orient to the
11 o’clock position.
C1 C2
C3 C4
A B C
FIGURE 7.11 RENDEZVOUS FOR BILIARY CANNULATION

A, This patient has a T-tube in place. A wire is passed through the T-tube and out of the ampulla. B, A diagnostic catheter is placed
toward the wire. C, The wire is fed into the catheter, and the catheter is then advanced into the bile duct.
A B1 B2
FIGURE 7.12 INTRAMUCOSAL CONTRAST INJECTION

A, Purplish hue to the ampullary structure. B, After biliary sphincterotomy, the underlying mucosa is hemorrhagic. A biliary stent was
inserted.
A1 A2
FIGURE 7.13 BILIARY OPENING AFTER

WHIPPLE PROCEDURE
A1, Biliary anastomosis after Whipple
procedure. Note the small subtle opening to
the bile duct. A2, A biliary catheter has been
placed into the duct. B, Distinct orifice
draining bile. C, Large anastomosis with the
B C
bile duct easily visible.
FIGURE 7.14 TERMINATION OF AFFERENT

LIMB AFTER WHIPPLE PROCEDURE
A, Termination of the afferent limb. B, The
ECRP catheter is pointing to the entrance to
the pancreatic duct. The pancreatic duct is
anastomosed in variable positions (see
below). C1, In this patient, the pancreatic
duct was anastomosed more distally. A stent
is present. C2, The stent is grasped with
forceps. Note a small suture is present
superiorly.
A B
C1 C2
A1 A2 A3
B1 B2
FIGURE 7.15 POSITION OF PANCREATIC DUCT AFTER BILIARY SPHINCTEROTOMY

A1, Note the opening of the biliary duct in relation to the pancreatic sphincter. A2, The diagnostic catheter is placed in the biliary tree.
A3, The catheter is placed in the pancreatic duct. B1, Patulous biliary opening. Note the small defect immediately inferior representing
the pancreatic duct. B2, The catheter is entering the pancreatic duct.
A1 A2 B
FIGURE 7.16 PAPILLA AFTER PASSAGE OF A STONE

A, The periampullary area is hemorrhagic, and the ampulla itself appears open. B, Hemorrhagic edematous papilla from stone passage.
A B C
D1 D2 D3
E1 E2 F
FIGURE 7.17 IMPACTED STONE

A-E, In each case, a bilirubinate stone is impacted at the ampulla. D1, Stone impacted in
ampulla. D2, Endoscopic ultrasonography (EUS) image shows dilated bile duct with large
impacted stone. Note the shadowing. D3, E2, After cannulation, a large amount of pus
spontaneously passed. E1, Bilirubinate stone seen in ampullary orifice. F, Ulceration from
G impacted stone with impending fistula. G, Small stone in the ampullary orifice.
A B C
FIGURE 7.18 OBSTRUCTION FROM PUS

A, Yellow material obstructs the ampulla. B, With sphincterotomy, only pus passes from the obstructed duct. C, At laparoscopic
cholecystectomy, thick yellow pus exudes from the gallbladder.
FIGURE 7.19 PASSAGE OF SLUDGE

A, Bile filled with sludge was seen to
spontaneously pass. This patient had acute
pancreatitis. B1, Characteristic gallbladder
sludge by EUS. B2, Mildly dilated common
bile duct with scant debris that does not
shadow typical for common bile duct
sludge. B3, Large amount of sludge
removed with balloon catheter.
Continued
A B1
B2 B3
C1 C2 C3
FIGURE 7.19 PASSAGE OF SLUDGE

C1-C3, After biliary sphincterotomy, a large amount of sludge is
C4
seen to pass. C4, Bile aspirate shows debris.
FIGURE 7.20 SPONTANEOUS PASSAGE

OF LARGE IMPACTED STONE
A, Markedly enlarged ampulla. B, With
observation, a large stone was seen to
spontaneously pass, leaving a tear (C). Bile
and pus now spontaneously pass from this
large opening (D).
A B
C D
A1 A2 B
FIGURE 7.21 AMPULLARY STONE

A1, The ampulla is open, and on close-up (A2) a stone is visible. B, After sphincterotomy, a balloon is being withdrawn
delivering a calculus.
A B C
D E F
G H1 H2
FIGURE 7.22 BILIARY SPHINCTEROTOMY

A, The bile duct has been selectively cannulated with a sphincterotome. B, The wire is
slightly bowed. Note the length of the intraduodenal segment proximal to the large
duodenal fold. C, The incision is slowly made. D, The incision is extended close to the
overlying fold. E, The fold is now being incised again, noting the length of the
intraduodenal segment. F, The fold is being incised. G, A small incision is made just
proximal to the fold, which is the full extent of the intraduodenal segment. H1, Small
papilla and intraduodenal segment. H2, A sphincterotome is bowed in the papilla.
H3, Complete biliary sphincterotomy performed. Note the incision was made to
H3 the most proximal portion of the bulge in the duodenum. I1, Sphincterotome in
the ampulla with selective biliary cannulation.
Continued
I1 I2 I3
I4 I5 I6

I2, Note the incision was made over the duodenal fold and to the duodenal wall
(I3). I4, Dilated bile duct with multiple stones. Contrast fills a normal distal pancreatic
duct. I5, A balloon catheter is removing a large number of stones. I6, The bile duct is
easily seen through the wide sphincterotomy. I7, At fluoroscopy air was now seen to
I7 outline the biliary tree, suggesting complete incision.
Continued

J1, Normal major papilla. J2, Biliary
sphincterotomy is carried out to the
duodenal wall just distal to the overlying
fold. J3, The duodenal wall itself is now
visible overlying the exposed common
bile duct (CBD). K1, Long intraduodenal
bile duct segment. The sphincterotome is
in the bile duct. K2, Biliary sphincterotomy
performed. K3, A small portion of the
duodenal wall is shown.
J1 J2
Duodenal
wall
CBD
J3
K1 K2 K3
FIGURE 7.23 SUTURE ALONGSIDE BILIARY SPHINCTEROTOMY

Suture material is present at the site of prior sphincterotomy. This patient had duodenal
oversew after duodenal perforation at the time of biliary sphincterotomy and stone
removal.
A B C1
C2 D E
F G H
FIGURE 7.24 BILIARY SPHINCTEROTOMY WITH STONE

REMOVAL
A, Common bile duct stone with shadowing on EUS. B, Bulbous-
appearing ampulla. C1, Solitary stone on cholangiography.
C2, The more proximal biliary tree is normal. Note the large
number of filling defects representing gallbladder stones. D, The
biliary sphincter is incised. E, The incision is performed to the
duodenal wall. F, A balloon catheter is placed in the bile duct. Note
the pancreatic sphincter is easily seen inferiorly. G, The balloon
catheter is slowly removed, delivering a cholesterol mulberry-like
stone. H, The stone is now completely removed and resides in the
duodenum. I, The surgical specimen shows a large number of
I
similar-appearing stones with debris.
A1 A2 A3
A4 A5 A6
A7 A8 A9
FIGURE 7.25 IMPACTED STONE REMOVAL

A1, A2, The major papilla is bulbous and a stone is present. A3-A5, The needle knife is
used to incise the ampulla, resulting in a gush of bile and a stone. A6, The
sphincterotome is used to complete the sphincterotomy. A7, A8, Multiple stones
A10 delivered. A9, Multiple large bile duct stones as shown on retrograde cholangiogram.
A10, As shown on fluoroscopy, the stones are being removed with a balloon catheter.
Continued
B1 B2a B2b
B2c B3 B4
B5 B6 B7

B1, B2a, Markedly enlarged papilla with impacted cholesterol stone. B2b, CT shows large stone at ampulla (arrow). A similar stone
is present in the gallbladder (B2c). B3, A needle knife is used and an incision is made over the stone. B4, A large amount of dark bile
passes when the biliary segment is entered. B5, B6, A sphincterotome is used to complete the incision. B7, A solitary stone is
removed.
Continued
C1 C2a C2b
C3a C3b C4

C1, The major papilla is bulbous, suggesting an impacted stone. C2a, C2b, Pus
spontaneously passes from the papilla. C3a, C3b, A needle knife is used and an incision
is made in the ampulla revealing a stone. C4, A sphincterotome is used to complete
the incision and a balloon inserted to retrieve the stone. C5, A large cholesterol
C5
stone is present.
A B C

IN DUODENAL DIVERTICULUM
A, Large intraduodenal segment extending
through the diverticulum. B, The
sphincterotome is placed in the ampulla
and cutting begun. C, The incision is made
toward the top of the intraduodenal
portion. D, A stone is being removed using
a balloon catheter. E, The appearance of the
D E
papilla after stone removal.
A B C
FIGURE 7.27 STONE IN BILIARY OPENING

A, The ampullary tissue is shown, as well as a slitlike dark opening superiorly. B, The sphincterotome is placed in the superior opening,
and injection confirms the bile duct. This anatomy could be because of a separate opening of the biliary tree or a fistula from stone
disease. C, After sphincterotomy, a small bilirubinate fragment can be seen.
FIGURE 7.28 FISTULOUS OPENING ON
PAPILLA FROM STONE
A, Enlarged hemorrhagic papilla with an
opening on the superior portion covered
with exudate. B, Cannulation of the biliary
tree is performed through the fistulous
opening, confirming the bile duct with
multiple stones. C, After catheter removal,
dark bile passes. D, Sphincterotomy was
performed through the fistulous tract and
numerous pearl-like stones delivered.
A B
C D
FIGURE 7.29 BULBOUS MAJOR PAPILLA

SECONDARY TO GALLSTONE
A, The minor papilla is proximal and
superior to the major papilla. B, A gallstone
is impacted in the ampullary orifice. C, The
stone spontaneously passes. D, Bile now
exits freely. A sphincterotomy was then
performed, with removal of other stones.
A B
C D
A B C
D1 D2
FIGURE 7.30 BALLOON DILATATION OF AMPULLA FOR STONE EXTRACTION

A, After biliary sphincterotomy, a 12-mm balloon is used to dilate the ampulla. B, A 12-mm balloon is placed through the ampulla and
inflated, revealing a waist that was effaced. C, A large defect is shown. D1, D2, The stone is extracted.
A1 A2 A3
B1 B2 C1
C2 C3 C4
FIGURE 7.31 ENDOSCOPIC THERAPY IN BILLROTH II ANATOMY

A1, Note the reverse orientation of the ampulla and the duodenoscope (A2). A3, Exudate is present in the ampullary orifice. B1, B2,
Note the use of the sphincterotome and the downward orientation of the guidewire for biliary access. C1, C2, Over the wire, the needle
knife is used to incise the ampulla. C3, C4, The biliary opening is now shown. The balloon is used to remove several small stones.
Continued
Needle knife
incising the
biliary sphincter
D1 D2
E1 E2 F1
F2 F3
FIGURE 7.31 ENDOSCOPIC THERAPY IN BILLROTH II ANATOMY

D1, The major papilla is bulbous and is located alongside a diverticulum. D2, A needle knife is used to incise the biliary sphincter.
E1, E2, A large tube is in the ampulla. The tube itself is used as a guide for needle knife biliary sphincterotomy. F1, The bile duct is
selectively accessed. Note the orientation downward of the guidewire. F2, The introducer tube is placed. F3, A plastic stent is
deployed.
A B
FIGURE 7.32 IMMEDIATE POSTSPHINCTEROTOMY BLEEDING

A, Biliary sphincterotomy has been performed with subsequent continuous stream of bright red blood. B, Dilute epinephrine is
injected into the superior margin of the papilla beginning at the duodenal wall, resulting in enlargement of the papilla from the
submucosal injection and marked blanching caused by ischemia.
A B C
FIGURE 7.33 DELAYED

POSTSPHINCTEROTOMY BLEEDING
A, Note the reddish visible vessel at the site
of the prior sphincterotomy. B, The area
was touched with the injection catheter
provoking active bleeding. C, Epinephrine
injection results in edema and blanching of
the area with hemostasis. D1, Active oozing
from a clot at the site of prior
sphincterotomy. D2, After large-volume
epinephrine injection, bleeding stops and
there is edema and blanching of the
D1 D2 duodenal mucosa.
A B C
D E F
G H I
FIGURE 7.34 DELAYED POSTSPHINCTEROTOMY BLEEDING

A, A large, bulbous, visible vessel at the site of a prior sphincterotomy. B, Epinephrine is first injected using a standard injection needle.
C, The 10-French heater probe was used to ablate the vessel (coaptive coagulation), ultimately resulting in a black eschar and
hemostasis (D). E, Large blood clot occupying the ampulla. F, After clot removal, active oozing is seen. G, Epinephrine is used to inject
the area. H, The 7-French heater probe is used to ablate the vessel, resulting in hemostasis (I).
FIGURE 7.35 DELAYED

POSTSPHINCTEROTOMY BLEEDING
A, Papilla immediately after biliary
sphincterotomy. B, Patient presents with
melena 1 week later. Note the
postsphincterotomy appearance of the
papilla with active oozing from the
11 o’clock position. C, Epinephrine injected
into the area with a sclerotherapy needle.
D, Note the marked blanching of the
ampulla and the periampullary tissue with
permanent hemostasis achieved.
A B
C D
A B C
FIGURE 7.36 PRECUT BILIARY

FISTULOTOMY
A, Note the bulbous papilla with a left-to-
right orientation. A small amount of the
needle knife is exposed. B, The needle is
placed into the papilla and an incision
made superiorly. C, The biliary sphincter
has been exposed. Note the onion skin
appearance of the muscle fibers. D, Bile is
now shown to spontaneously flow from
this area. E, The diagnostic catheter is
placed into the duct and bile withdrawn,
D E
confirming selective cannulation.
A B C
FIGURE 7. 37 PRECUT BILIARY

FISTULOTOMY
A, After failed cannulation, the needle knife
is over a slightly bulbous papilla. B, The initial
incision is made. C, After an additional
incision, bulbous tissue is now present
representing the biliary sphincter.
D, E, The sphincterotome now easily
enters the bile duct over a wire, and
D E
sphincterotomy is performed.
FIGURE 7.38 EXPOSED BILIARY

SPHINCTER AFTER NEEDLE KNIFE
FISTULOTOMY
A, Note the bulbous tissue underneath the
duodenal mucosa after precut fistulotomy.
B, The needle knife incises the tissue,
resulting in drainage of bile indicative of the
biliary sphincter. C, Further incision is made.
D, Completion of sphincterotomy with a
standard sphincterotome.
A B
C D
A1 A2 B
C1 C2 C3
FIGURE 7.39 PRECUT SPHINCTEROTOMY EXPOSING AN OBSTRUCTING STONE

A1, Bulbous major papilla with long intraduodenal segment. A2, The needle knife
is in the appropriate orientation. B, After incision superiorly, a stone is identified.
C1, A small portion of the needle is exposed toward the major papilla in an appropriate
orientation for fistulotomy. C2, With initial small incision, yellow material is visible.
C3, With further incision, a stone is visible. C4, The stone spontaneously passed, and the
sphincterotomy is now extended toward the duodenal wall to remove the remaining
C4 fragments.
FIGURE 7.40 PRECUT FISTULOTOMY

WITH PANCREATIC DUCT STENT
A, 5-French stent was placed into the
pancreatic duct to assist in biliary
fistulotomy because the papilla was small.
Note the clear drainage of pancreatic juice
from the stent. B, A small incision is made
proximal to the stent in the location of the
bile duct. C, Exposure of biliary muscle
fibers. D, A diagnostic catheter is placed
through the fibers and aspiration confirms
selective cannulation of the biliary system.
A B
C D
FIGURE 7.41 PRECUT PERFORATION

A, Large opening created by precut
technique. B, Probing with a catheter
exposes a large defect representing
perforation.
A B
FIGURE 7.42 PRIOR FAILED PRECUT

FISTULOTOMY
A, Appearance of the papilla after prior
attempt at fistulotomy. B, Close-up shows
an area compatible with biliary muscle
fibers. C, The diagnostic catheter is placed
into the area and bile aspirated.
D, A sphincterotomy is now performed.
A B
C D
FIGURE 7.43 PRIOR PRECUT FISTULOTOMY

The biliary sphincter is superior to the pancreatic sphincter, where a wire is present in the
pancreatic duct.
A B C
FIGURE 7.44 PANCREATIC SPHINCTEROTOMY

A, After selective pancreatic duct cannulation, the sphincterotome is bowed. Note the orientation toward the 1 o’clock position.
B, The incision is extended to the top of the bulge in the duodenum representing the intraduodenal pancreatic duct segment.
C, Appearance after complete incision of the pancreatic sphincter.
A B C
D E F
FIGURE 7.45 PANCREATIC AND BILIARY SPHINCTEROTOMIES

A, A manometry catheter is in the pancreatic sphincter. High pressures were documented; pancreatic and biliary sphincterotomies
will be performed. B, Pancreatic sphincterotomy being performed with the pull-type sphincterotome. C, A 3-French stent is placed
in the pancreatic duct. D, Note the biliary sphincter is now exposed inferiorly on close-up. E, Biliary sphincterotomy being performed.
F, After biliary sphincterotomy, the intraampullary septum is now visible.
A B C
FIGURE 7.46 COMMON BILE DUCT

STRICTURE WITH STENT PLACEMENT
A, Cholangiogram demonstrates a dilated
common bile duct, which ends abruptly in
the intrapancreatic portion of the common
D1 D2 bile duct. Note the distance from the
contrast in the common bile duct to the
duodenal wall, demarcated by the air in the
duodenum. This patient had pancreatic
adenocarcinoma, resulting in a biliary
stricture. B, Appropriate position of the
stent in the common bile duct, with the end
of the stent in the duodenum. C, The stent
is observed in the prior sphincterotomy
orifice. Bile is now draining freely.
D, Jaundice recurred 2 months later.
The papilla appears enlarged (D1).
Tissue surrounding the stent has an
erythematous and villous appearance
(D2, D3). Biopsy results of these
abnormalities demonstrated pancreatic
D3 D4
carcinoma. The stent is occluded (D4).
FIGURE 7.47 MIGRATED BILE DUCT

STENT REMOVAL WITH PRECUT
FISTULOTOMY
A, Selective cannulation could not be
achieved as the stent was seen in the
ampulla fluoroscopically. The stent is not
visible in the duodenum. A needle knife was
used to create a fistulotomy. B, The biliary
sphincter is now visible, but no stent is
shown. C, With further incision, dark
material is visible, and with a complete
incision, the bile duct stent is now
visible (D).
A B
C D
FIGURE 7.48 MIGRATED BILE DUCT

STENT REMOVAL
A, The major papilla appears normal.
B, Fluoroscopy shows the stent inside the
papilla. C, A sphincterotome is used for
cannulation and sphincterotomy
performed exposing the stent. D, The stent
is grasped with forceps and removed.
A B
C D
FIGURE 7.49 BILIARY METALLIC STENT

PLACEMENT
A, Precut fistulotomy was required to access the
bile duct. A pancreatic duct stent is shown.
The 10-French metal stent is placed into the bile
duct. Note that a small portion of the metal
stent is at the level of the ampulla. B, The stent is
slowly deployed, and with full deployment
note that it is just at the level of the papilla.
C, Note the wide opening through the metallic
stent. D, Fluoroscopic image shows the location
of the stent and the intrapancreatic common
bile duct stricture.
A B
C D
FIGURE 7.50 ULCER RELATED TO BILIARY

METALLIC STENT
A, A significant amount of the metallic stent,
placed percutaneously, resides in the
duodenum. B, The distal end of the stent was
impacted into the duodenal wall. C, The stent
was moved from the wall with the endoscope
revealing a large ulcer on the contralateral wall.
D, 10-French plastic stent exiting the papilla.
A large amount of the stent resides in the
duodenum and is impacted in the duodenal
wall, causing an ulcer crater on the lateral wall.
The pancreatic stent has been removed.
A B
C D
A B C
FIGURE 7.51 ULCER RELATED TO MIGRATED COVERED METAL BILIARY STENT WITH STENT REMOVAL
A, The coated stent has slightly migrated, resulting in ulceration in the contralateral wall. B, The stent is grasped with a standard snare
and removed, resulting in a large mucosal defect (C).
A B C1
FIGURE 7.52 OCCLUDED PLASTIC BILIARY

STENT
A, Note the absence of bile in the duodenum
and the presence of debris in the stent.
B, The appearance of papilla after stent
removal. C1, A metallic stent has been
deployed. C2, C3, Note the large amount of
C2 C3 spontaneous passage of pus.
A B C
FIGURE 7.53 OCCLUDED METALLIC

STENT
A, Debris fills the metallic stent in a patient
with recurrent jaundice. B, The catheter is
placed through the metallic stent.
C, Injection shows tumor ingrowth with a
thin stream of contrast passing proximally.
D, A plastic stent is placed through the
metallic stent. E, A plastic stent is placed to
D E
the common hepatic duct.
A1 A2 B
FIGURE 7.54 AMPULLARY ADENOMA

A1, Small adenoma of the ampulla. A2, With the catheter in the bile duct, the demarcation between the adenomatous tissue and
normal ampulla is evident. B, Adenoma occupying the major papilla. Note the spontaneous passage of bile.
FIGURE 7.55 LARGE AMPULLARY

ADENOMA
A, Adenoma of the papilla on the 7 o’clock
position of a diverticulum. B1, Large
adenoma can be seen entering the second
duodenum. B2, En face view shows typical
adenomatous epithelium. B3, Demarcation
of the adenoma with normal duodenal
mucosa is visible inferiorly.
A B1
Ampulla
Adenomatous
B2 epithelium B3
FIGURE 7.56 PROMINENT PAPILLA FROM

ADENOMA
A, Prominent papilla. B, EUS shows an
intrapapillary structure with a filling defect.
A B
A B C1
C2 C3 C4
D E1 E2
FIGURE 7.57 AMPULLECTOMY FOR ADENOMA

A, Characteristic–appearing adenoma occupying the ampulla. The adenoma has a
typical whitish verrucous appearance. B, With probing of the lesion, the sphincter cannot
be localized. C1-C4, A snare is used, and the adenoma removed in a piecemeal fashion.
D, After removal of the adenoma, a round yellow structure is exposed representing the
pancreatic sphincter. E1, The yellowish structure representing the pancreatic sphincter is
now selectively cannulated, and a wire is placed (E2). F, A pancreatic duct stent is placed
F
to prevent pancreatitis.
A B C1
C2 C3 D
E1 E2
FIGURE 7.58 AMPULLECTOMY FOR ADENOMA

A, Adenoma occupying the major papilla. Ampullary tissue is visible. B, The pancreatic duct is selectively cannulated and pancreatic
duct sphincterotomy performed for later stent placement. C1-C3, The ampullary adenoma is removed using snare techniques.
D, A pancreatic duct stent is placed and additional polyp removed with a snare. E1-E2, Additional adenomatous tissue is ablated by
argon plasma coagulation.
FIGURE 7.59 AMPULLARY ADENOMA IN

FAMILIAL ADENOMATOUS POLYPOSIS
SYNDROME
A, Adenoma involving the ampulla.
Additional small adenomas are in the
descending duodenum. B, EUS shows a
lesion indistinguishable from the
surrounding structures. A Whipple
pancreaticoduodenectomy was performed.
A B
FIGURE 7.60 AMPULLARY CANCER

A, Enlarged ulcerated ampulla.
B, The tumor is locally advanced invading
the pancreas as shown by EUS.
A B
A1 A2 A3

A1, Prominent papilla resembling a thumb. A2, The ampullary tissue appears prominent. A3, A biliary brush was used to diagnose
malignancy.
Continued
B1 B2 B3

B1, The major papilla appears enlarged.
Note the location of the adjacent minor
papilla. B2, En face view shows the
ampulla to be ulcerated, which is
C1 C2 characteristic of carcinoma. B3, EUS shows
a dilated bile duct ending in a mass lesion.
C1, Ulceration at the ampulla. C2, The bile
duct was cannulated as shown by
aspiration of bile. An attempt should be
made to localize the bile duct because
multiple cannulation attempts will induce
bleeding. C3, Surgical specimen shows
the large ulcerated papilla. C4, Ampullary
tumor in cross sections shows the short
segment of tumor and the marked
dilatation of the more proximal biliary
C3 C4 tree.
Continued
D1 D2
E1 E2 F1
Area of
spontaneous
bleeding
F2 F3

D1, Markedly enlarged intraduodenal segment of the bile duct. D2, The ampullary orifice is prominent and friable, suggestive of
underlying tumor. E1, Polypoid mass of the ampulla. E2, Identifying the ampulla was challenging and found on the lateral margin.
F1, The ampulla is enlarged and ulcerated. F2, With observation, spontaneous bleeding was apparent. F3, The ampullary mass
occupies a majority of the duodenal lumen, as shown on CT scanning. Note the dilated gallbladder.
Continued
G1 G2 G3
H1 H2 H3

G1, Note the bulbous papilla. G2, The ampullary orifice itself is ulcerated. G3, A glidewire is used to access what appears to be
the biliary sphincter. H1, Large, bulbous, ulcerated ampulla. H2, Biliary orifice is identified and selective cannulation achieved.
H3, The ampullary cancer as shown on EUS.
Mass
B C
Dilated intrahepatic ducts
Stomach
Gall- Pancreatic duct

bladder Common bile duct
FIGURE 7.62 AMPULLARY CARCINOMA
A, Barium study demonstrates a mass lesion on the medial wall of
the second duodenum, extending into the lumen. B, Contrast in the
second duodenum is displaced by the mass. C, The pancreatic duct
and common bile duct are dilated, suggesting distal obstruction.
The gallbladder is also large, with dilation of the intrahepatic ducts. Duodenum
Continued
FIGURE 7.62 AMPULLARY CARCINOMA

D, With the duodenoscope in the standard position, a mass is
clearly seen compromising the duodenal lumen. E, A large cancer
is on the medial wall at the level of the normal papilla. F, A pigtail
catheter is placed percutaneously for drainage. The common bile
duct is dilated.
E1 E2
E3 E4 F
A B1 B2
C1 C2 D
FIGURE 7.63 ABNORMAL PAPILLA CAUSED BY PANCREATIC CANCER

A, Purplish hue with retraction on the superior portion of the ampulla. B1, Purplish hue superior to the ampulla. B2, On close-up, there
is villous-appearing tissue more superiorly with narrowing of the duodenum. This patient had jaundice and a pancreatic duct
stricture. Biopsy of the area showed adenocarcinoma. C1, Large bulging ampulla. C2, The diagnostic catheter is used to expose the
ampulla. D, Masslike appearance of the papilla. Note the ampulla distally with protruding tissue.
FIGURE 7.64 DUODENAL CANCER

INVOLVING THE AMPULLA
A, B, Hemicircumferential ulcerated mass
lesion involving the medial wall of the
duodenum. Note the villous appearance of
the tumor.
A B
Sphincteroplasty
Pancreatic duct
B1 B2
B3 B4
FIGURE 7.65 SURGICAL SPHINCTEROPLASTY AND PLACEMENT OF A PIGTAIL STENT

A, The opening to the common bile duct is to the left. The pancreatic sphincter is demarcated by the slitlike opening, with surrounding
villous-appearing tissue. B, The diagnostic catheter is removed over a guidewire (B1), and a 7-French pigtail stent is advanced over the
wire (B2). The guidewire is removed with the stent in place, assuming its pigtail shape (B3, B4).
FIGURE 7.66 AMPULLARY

GASTROINTESTINAL STROMAL TUMOR
A, B, Large bulging ampulla.
A B

A, A long filling defect in the bile duct on cholangiogram. B, C, Worm exposed after
sphincterotomy exiting the duct. D, Worm removed from the bile duct with a
snare. (Courtesy J. L. Vazquez-Iglesias, MD, La Coruña, Spain.)
B C D
A B
FIGURE 7.68 FASCIOLA HEPATICA (LIVER FLUKE)

A, Filling defect in common bile duct. B, The flat worm is on the ampulla after removal. (Courtesy J. Jimenez-Perez, MD, Pamplona,
Spain.)
A B
FIGURE 7.69 CLONORCHIS SINENSIS (LIVER FLUKE)

A, A small, flat worm is apparent after sphincterotomy. B, Multiple worms removed from the bile duct.
A B C1
C2 C3 C4
FIGURE 7.70 MINOR PAPILLA

A, On entering the second duodenum, the
major papilla can be seen on the medial
wall (left) with the minor papilla, superior
and lateral. B, The minor papilla is superior
and lateral to the papilla. The papilla is
captured open. C1, C2, The minor papilla is
prominent. The major papilla is shown
distally. C3, C4, Cannulation was achieved
using a standard catheter and guidewire.
D1, Bulbous dilatation of the minor papilla
as shown entering the second duodenum
D1 D2
and on close-up (D2).
FIGURE 7.71 SANTORINICELE

A, The minor papilla is slightly bulbous, with an area suggestive
of the orifice. B, After several failed attempts at cannulation,
secretin was given. The opening is now visible, with marked flow
of clear pancreatic juice. C1, Cystic dilation at the minor papilla
diagnostic of a santorinicele. C2, Contrast has drained from the
dorsal duct with residual contrast in the santorinicele.
Continued
C1 C2
D1 D2 D3
FIGURE 7.71 SANTORINICELE

D1, The minor papilla is exposed. D2, A small guidewire is used for cannulation followed by a standard sphincterotome. D3, Note the
size of the distal pancreatic duct after sphincterotomy.
A B C
D E F
FIGURE 7.72 MINOR PAPILLA SPHINCTEROTOMY

A, Both the major and minor papilla are visible. B, A metal-tipped catheter is used for
cannulation, and injection confirms the dorsal duct. C, After catheter removal, the
sphincter is seen to open with drainage of pancreatic juice. D, A stiff guidewire is placed
in the dorsal duct. E, A 5-French single pigtail stent has been placed. F, A needle knife is
G exposed. G, The knife is used to incise the minor papilla, now exposing the stent.
A1 A2 B
FIGURE 7.73 MINOR PAPILLA

SPHINCTEROTOMY WITH A STANDARD PULL
SPHINCTEROTOME
A, The minor papilla ampullary orifice is
identified. A2, After secretin injection,
pancreatic juice gushes from the orifice.
B, A sphincterotome is used to cannulate the
papilla. C, Sphincterotomy is performed.
D, After wire placement, a 5-French single
C D
pigtail stent is placed.
Needle knife
Wire
A B
FIGURE 7.74 INCISION OF MINOR PAPILLA OVER AN INSERTED WIRE

A, Neither the standard catheter nor the 5-4-3 catheter entered the strictured orifice
over a small wire. B, A needle knife was placed alongside the wire and incision
C
performed. C, The catheter now enters the duct, and a stent is deployed.
A1 A2 B1
B2 B3 C
FIGURE 7.75 MINOR PAPILLA PRECUT FISTULOTOMY

A1, A2, The minor papilla is bulbous and selective cannulation could not be achieved.
Because of its large size, the minor papilla resembles a major papilla. B1-B3, A needle
knife is used to incise the papilla, exposing the duct. C, Selective cannulation is achieved
and a stent ultimately deployed. D, The incision is completed with a needle knife incision
D
made over the stent.
A1 A2 B1
B2 C1 C2
FIGURE 7.76 HEMOBILIA

A1, A2, Fresh blood emanating from the major papilla. B1, Large blood clot emanating
from the papilla with fresh blood in the duodenum. B2, The periampullary area was
washed, revealing thick fresh clot on the papilla. C1. C2, The papilla is bulbous with clot
in the orifice. C3, A small sphincterotomy is performed and a large blood clot passes
C3
spontaneously.
A B1 B2
Spleen
Pseudocyst
in body of
pancreas.
Fluid with clot
B3
FIGURE 7.77 HEMOSUCCUS
PANCREATICUS
A, The minor papilla is gaping with mucus,
blood clot, and fresh bleeding. This patient
has IPMN (intra pancreatic mucinous
neoplasm), and fine needle aspiration biopsy
of a lesion was performed, which
precipitated the bleeding as shown 1 hour
later. B1, Clot overlying the ampulla. B2, Clot
fills the pancreatic duct. B3, A pseudocyst in
the pancreatic body with clot. Note there is
also fluid with clot surrounding the spleen.
B4, Arteriogram demonstrates the cystic
structure (pseudoaneurysm), which is
B4 B5
embolized (B5).
Displaced
Mucus from biliary sphincter
pancreatic duct
B1 B2
B3 C1
FIGURE 7.78 INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM

A, Fish mouth appearance of the major papilla with the presence of gelatinous mucus. B1, Papilla is bulbous with a large amount of
mucus and displacement of the biliary sphincter. B2, Spontaneous gush of a large quantity of mucus. B3, Note that mucus is also
passing from the minor papilla. C1, The pancreatic duct is easily cannulated with a sphincterotome.
Continued
C2.1 C2.2 C3
C4 D1 D2
E1 E2 F
FIGURE 7.78 INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM

The pancreatic duct is grossly dilated in the head (C2.1) and body (C2.2). C3, Dilated mucus-filled pancreatic duct. Note the biliary
stent. C4, Dilated pancreatic duct as shown on magnetic resonance cholangiopancreatography. D1, The bile duct sphincter, pushed
laterally from the mucus, is selectively cannulated with a wire. D2, Stricture of the intrapancreatic bile duct. E1, Pancreatoscopy
shows the frondlike projections representing the papillary tumor. E2, The small endoscope shown fluoroscopically in the duct.
F, Whipple resection shows dilated pancreatic duct with a mucosal nodule. Adenocarcinoma was found histologically.
A B C1
FIGURE 7.79 INTRADUCTAL NEOPLASM

A, A small amount of blood is alongside the wire in the bile duct. B, Sphincterotomy is
performed followed by a gush of bile mixed with blood. C1, C2, A balloon is used to
C2
remove a large fragment of tissue confirmed to be hepatocellular cancer.
A B1 B2
FIGURE 7.80 SURGICAL SPHINCTEROPLASTY

A, Recent sphincteroplasty performed showing edema around the biliary opening. B1, A large defect with an impacted stone.
B2, A balloon is used to remove a stone.
FIGURE 7.81
CHOLEDOCHODUODENOSTOMY
A1, Large defect in the duodenal wall just
lateral to the ampulla. A2, Close-up shows a
catheter in the bile duct. B1, Stent in the
duodenal wall at the site of side-to-side
choledochoduodenostomy. B2, Close-up of
the defect shows the top-most portion of
the bile duct stent with the stent exiting the
ampulla in the distance (B3).
A1 A2
B1 B2 B3
FIGURE 7.82
CHOLEDOCHODUODENOSTOMY WITH
STONES
A, Bulging defect in duodenum covered
with sludge. B, Cannulation with a balloon
catheter. C1, C2, A large stone is removed.
D, Large opening apparent after the stone
and sludge were removed.
A B
C1 C2 D
A B1 B2
B3a B3b B4
FIGURE 7.83 DUODENAL OBSTRUCTION FROM PANCREATIC CANCER

A, Large, hyperdense pancreatic mass with arterial encasement. Note the dilated stomach and duodenum to the level of the tumor,
as well as dilated gallbladder. B1, Dilated duodenum with marked amount of retained fluid from the distal duodenal obstruction.
B2, Biliary metal stent has been deployed. B3, Both metal prostheses are shown (B3a). The distal end of the duodenal stent has not yet
fully deployed (B3b). B4, Both metal stents are visible in duodenum.
Continued
C1 C2 C3
C4 C5 C6
C7a C7b C8

C1, Markedly dilated stomach with air in the biliary tree from prior percutaneous transhepatic cholangiogram. C2, The duodenum
is also markedly dilated to the level of the percutaneously placed stent. C3, Large pancreatic mass lesion encases the stent.
C4, The stomach is filled with fluid and debris. C5, In the proximal duodenum, a pinhole area is identified representing the point
of obstruction, C6, Scout image shows the stent at the level of obstruction and the percutaneous placed biliary pigtail catheter.
Note the markedly dilated stomach. C7a, C7b, After guidewire placement, the catheter is advanced to the level of obstruction.
C8, Injection confirms the level of obstruction, as well as a normal-appearing distal duodenum.
Continued
C9 C10a C10b
C11 C12 C13a
C13b C14 C15

C9, A guidewire is passed distally followed by the catheter, and again injection is performed to confirm a normal distal bowel.
C10a, C10b, The prosthesis is advanced over the wire fluoroscopically to the distal duodenum. The stent is then slowly deployed
(C11-C13b). C14, The stent has been fully deployed. C15, CT image following stent placement. The percutaneous catheter is still in place.
FIGURE 7.84 FISTULOUS OPENING INTO THE URETER

ERCP catheter in an opening inferior to the papilla that enters the ureter confirmed by
injection of contrast.
A B1 B2
C D1 D2
E F G1
FIGURE 7.85 ENDOSCOPIC FINDINGS AT ERCP

At the time of ERCP, the side viewing endoscope can be used to examine the
distal esophagus, stomach, and duodenum. The accuracy is quite high, and the
opportunity should be utilized for a complete examination. A, Barrett’s esophagus.
B1, B2, Nonobstructing Schatzki’s ring. C, Esophageal varices with red color signs.
D1, D2, Epiphrenic diverticulum. E, Cytomegalovirus (CMV) esophagitis. F, Squamous
G2
cell cancer of the esophagus. G1, G2, Gastric varices.
Continued
H I1 I2
J K L
M N O

H, Intact Nissen fundoplication. I1, I2, Proximal gastric tear on lesser curvature. J, Extrinsic
compression from a dilated gallbladder in the antrum anteriorly. K, Antral ulcer with a
black base. L, Duodenal ulcer (as shown from the pyloric canal). M, Extrinsic compression
posteriorly in the duodenal bulb from cholangiocarcinoma. N, CMV duodenitis.
P O, Lipoma just distal to ampulla. P, Second ampulla.
Continued
Q R S

Q, Scalloped duodenal folds in patient with celiac sprue. R, Ulcer underneath papilla caused by pancreatic cancer. S, Large, mass like
lesion of the second duodenum resulting in obstruction.

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ATLAS OF CLINICAL GASTROINTESTINAL

ENDOSCOPY Third Edition

C. Mel Wilcox, MD, MSPH

Miguel Muñoz-Navas, MD, PhD

Joseph Sung, MD, PhD

ATLAS OF CLINICAL GASTROINTESTINAL ENDOSCOPY, THIRD EDITION ISBN: 978-1-4377-1909-3

Copyright # 2012, 2007, 1995 by Saunders, an imprint of Elsevier Inc.

Library of Congress Cataloging-in-Publication Data

Senior Content Strategist: Kate Dimock

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my wife, Rebecca Wong.

My heartfelt gratitude to my colleagues at the Institute of Digestive Diseases who

Uvula and FIGURE 1.1 OROPHARYNX

FIGURE 1.2 LANDMARKS OF THE OROPHARYNX AND HYPOPHARYNX

FIGURE 1.3 DIRECTION TO

FIGURE 1.4 VOCAL CORDS

FIGURE 1.5 HYPOPHARYNX

FIGURE 1.7 PATENT UPPER ESOPHAGEAL

FIGURE 1.8 TRACHEA AND CARINA

FIGURE 1.9 BARIUM STUDY OF HYPOPHARYNX AND ESOPHAGUS

FIGURE 1.10 TORUS PALATINUS

FIGURE 1.11 APHTHOUS ULCER

FIGURE 1.12 HUMAN IMMUNODEFICIENCY VIRUS (HIV)-ASSOCIATED APHTHOUS ULCER

FIGURE 1.13 HAIRY TONGUE

FIGURE 1.14 PEUTZ-JEGHERS SYNDROME

FIGURE 1.15 OSLER-WEBER-RENDU SYNDROME

FIGURE 1.16 HERPES SIMPLEX VIRUS

FIGURE 1.17 HERPES SIMPLEX VIRUS

FIGURE 1.18 HERPES SIMPLEX VIRUS STOMATITIS

FIGURE 1.19 VARICELLA

FIGURE 1.20 OROPHARYNGEAL CANDIDIASIS

FIGURE 1.21 MUCORMYCOSIS

FIGURE 1.22 EPIGLOTTITIS

FIGURE 1.23 EPIGLOTTITIS

FIGURE 1.24 CAUSTIC INGESTION

FIGURE 1.25 CAUSTIC INGESTION

FIGURE 1.26 RADIATION INJURY

FIGURE 1.27 ARYTENOID CYST

FIGURE 1.28 CONDYLOMA

FIGURE 1.29 SQUAMOUS PAPILLOMA

FIGURE 1.30 EXTRINSIC COMPRESSION

FIGURE 1.31 LICHEN PLANUS

FIGURE 1.32 FIBROSARCOMA

FIGURE 1.33 KAPOSI’S SARCOMA

FIGURE 1.34 SQUAMOUS CELL CARCINOMA

FIGURE 1.35 SQUAMOUS CELL CARCINOMA

FIGURE 1.36 MELANOMA

FIGURE 1.37 LEUKEMIA

FIGURE 1.38 VOCAL CORD GRANULOMA

FIGURE 1.39 VOCAL CORD INJURY WITH INTUBATION

FIGURE 1.40 VOCAL CORD LEUKOPLAKIA

FIGURE 1.41 HYPOPHARYNGEAL RECONSTRUCTION

FIGURE 1.42 LATERAL

FIGURE 1.44 BULLOUS PEMPHIGOID

FIGURE 1.45 TRACHEAL BLEEDING

FIGURE 2.1 UPPER ESOPHAGEAL SPHINCTER

FIGURE 2.2 MIDESOPHAGUS

FIGURE 2.3 VASCULAR PATTERN AT THE GASTROESOPHAGEAL

FIGURE 2.4 GASTROESOPHAGEAL

FIGURE 2.7 BARIUM ESOPHAGRAM

FIGURE 2.8 NORMAL STRATIFIED SQUAMOUS EPITHELIUM

FIGURE 2.9 TRACHEAL IMPRESSION

FIGURE 2.10 AORTIC IMPRESSION