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Subepithelial Tumors of the Esophagus and Stomach

Introduction Neoplasms of nonepithelial origin, although uncommon, are lesions that a gastrointestinal (GI) endoscopist can expect to encounter with some regularity. Although the number of such pathologic entities is manageably small, the spectrum of clinical behavior manifested by these lesions spans from trivial to life-threatening. The difficulty in managing patients with such lesions is that the tumor originates from within the GI tract wall and often…

Gastric Polyps and Thickened Gastric Folds

Introduction Examination of the stomach by upper endoscopy often results in the incidental finding of gastric polyps or thickened gastric folds. Gastric polyps are estimated to be identified in 6% to 8% of all upper endoscopy exams. Most series report that the most common type of polyp encountered is the fundic gland polyp (FGP) (77% to 80%), followed by the hyperplastic polyp (17% to 19%), though…

Endoscopic Approaches for Gastroparesis

Introduction The word gastroparesis is derived from the Greek words gastro and pa'resis, and translates to partial paralysis of the stomach. The diagnosis of gastroparesis is defined as delayed gastric emptying in the absence of mechanical obstruction, associated with one or more of the following symptoms: postprandial fullness, early satiety, nausea, vomiting, and bloating. Whereas gastroparesis can be associated with diabetes mellitus, neuromuscular and connective tissue…

Palliation of Malignant Dysphagia and Esophageal Fistulas

Introduction The incidence of new cases of esophageal and gastroesophageal junction (GEJ) cancer is estimated to be 450,000 per year worldwide. Esophageal cancer is the eighth most frequent malignancy and has the sixth-highest cancer-specific mortality. The estimated 5-year survival rate in Western countries is less than 20% after the diagnosis. In the past, squamous cell carcinoma (SCC) was responsible for more than 90% of cases of…

Endoscopic Treatment of Early Esophageal Neoplasia

Introduction Esophageal cancer remains the eighth most common cancer and the sixth leading cause of cancer-related mortality worldwide. Two main subtypes exist: esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). EAC predominates in North America and Europe, and there has been a steep rise in its incidence over the last several decades. ESCC is most prevalent in Asia and Africa, and accounts for over 90%…

Screening for Esophageal Squamous Cell Carcinoma

Introduction and Epidemiology Esophageal cancer is the eighth most common cancer and the sixth leading cause of cancer death in the world. There are two major histologic subtypes of esophageal cancer: adenocarcinoma and squamous cell cancer. Globally, more than 400,000 deaths were estimated attributable to esophageal cancer in 2012. There is considerable geographic variability in the incidence of esophageal cancer, with the majority of cases (80%)…

Barrett’s Esophagus: Diagnosis, Surveillance, and Medical Management

Introduction Barrett's esophagus (BE) is an acquired condition resulting from severe esophageal mucosal injury. It is unclear why some patients with gastroesophageal reflux disease (GERD) develop BE whereas others do not. The diagnosis of BE is established if the squamocolumnar junction is displaced more than 1 cm proximal to the esophagogastric junction, and intestinal metaplasia is detected by biopsy. BE would be of little importance if not…

Gastroesophageal Reflux Disease

Introduction Gastroesophageal reflux (GER) occurs when there is retrograde movement of gastric contents into the esophagus. It occurs primarily after meals, and is part of a normal venting process to prevent excessive gastric distension and dyspepsia (the so-called “burp or belch” reflex). In contrast, gastroesophageal reflux disease (GERD) is defined as an abnormally elevated frequency of reflux and/or volume of refluxate, and typically presents as troublesome…

Eosinophilic Esophagitis

Introduction Eosinophilic esophagitis (EoE) is a chronic, immune-mediated clinicopathological disease characterized by esophageal symptoms, eosinophilic inflammation localized to the esophagus, and the absence of other causes of eosinophilia. This evolving definition, devised after multiple iterations by a consensus panel, excludes endoscopic findings as part of the diagnostic criteria. Nonetheless, such findings are often the first clue to the gastroenterologist that a patient may have EoE. Moreover,…

Ingested Foreign Objects and Food Bolus Impactions

Introduction Gastrointestinal foreign bodies (GIFBs) and food impactions are a common problem encountered by endoscopists, and, next to gastrointestinal bleeding, are the second most common endoscopic emergency encountered. Previous studies have suggested that between 1500 and 2750 deaths occurred in the United States secondary to GIFBs. More recently, mortality from GIFBs has been shown to be significantly lower, with no GIFB reported deaths reported in over…

Benign Esophageal Strictures

Introduction In this chapter, we describe the evaluation, treatment, and subsequent long-term management for patients with benign esophageal strictures. Patients with clinically significant esophageal strictures present with symptoms of dysphagia, typically first to solid foods. Symptoms may then progress in frequency and severity and some patients may develop dysphagia to liquids. Patients often modify their diets to avoid foods that lead to symptoms, and a thorough…

Endoscopic Diagnosis and Management of Zenker’s Diverticula

Introduction Zenker's diverticulum (ZD) is a posterior pharyngoesophageal mucosal outpouching that forms through Killian's triangle. Poor upper esophageal sphincter (UES) compliance is the acknowledged pathophysiologic mechanism of action, leading to creation of a high-pressure zone, ultimately resulting in diverticulum formation. This entity most commonly presents in the elderly, and can be associated with a plethora of potential symptoms, most commonly dysphagia. Cricopharyngeal myotomy is usually performed…

Esophageal Motility Disorders

Introduction Esophageal motility disorders are ubiquitous in gastroenterology practice today, and developments in technology have led to a revolution in both their diagnosis and treatment. This chapter focuses on clinically significant esophageal motility disorders relevant to gastrointestinal endoscopy practice, primarily achalasia, but also on other potentially related disorders, including esophagogastric junction (EGJ) outflow obstruction, distal esophageal spasm, hypercontractile esophagus, and ineffective esophageal motility (IEM). For each…

Occult and Unexplained Chronic Gastrointestinal Bleeding

Introduction Chronic gastrointestinal (GI) hemorrhage may be overt or occult. Overt bleeding is defined as chronic if it is persistent but not severe enough to cause circulatory compromise. It may be seen in the form of melena or red rectal bleeding. If bleeding is occult, patients may present with symptomatic anemia and evidence of occult bleeding with stool testing. In some patients, chronic hemorrhage may be…

Middle Gastrointestinal Bleeding

Introduction Traditionally, obscure gastrointestinal bleeding (OGIB) is reported to account for approximately 5% of all gastrointestinal (GI) bleeding and is defined as bleeding from an unknown source that persists or recurs after negative bidirectional endoscopic diagnostic evaluations. A negative bidirectional endoscopic diagnostic evaluation is defined as a negative upper endoscopy (esophagogastroduodenoscopy [EGD]) and negative colonoscopy with careful evaluation of the terminal ileum. However, with the introduction…

Lower Gastrointestinal Bleeding

Introduction Acute severe lower gastrointestinal (GI) bleeding is a common problem and frequent reason for hospitalization. Colonoscopy is often performed for diagnosis and potential therapeutic intervention. This chapter focuses on moderate to severe acute lower GI bleeding, defined as hematochezia, from a bleeding source distal to the ileocecal valve with an onset of less than 3 days of duration. This presentation usually prompts presentation to the…

Portal Hypertensive Bleeding

Introduction Portal hypertension is defined by a pathologic increase in portal pressure in which the pressure gradient between the portal vein and inferior vena cava (the portal pressure gradient, PPG) is increased above the upper normal limit of 5 mm Hg. Portal hypertension becomes clinically significant when the PPG increases above the threshold of 10 mm Hg (formation of varices) or 12 mm Hg (variceal bleeding, ascites). Acute variceal…

Nonvariceal Upper Gastrointestinal Bleeding

Introduction The annual incidence of upper gastrointestinal bleeding (UGIB) is 48 to 160 events per 100,000 adults in the United States, where it is the cause of approximately 300,000 hospital admissions per year. In Europe, the annual incidence of UGIB in the general population ranges from 19.4 to 57.0 events per 100,000 individuals. There is no formal explanation for the breadth of the range between countries,…

Endoscopic Simulators

Introduction Safe performance of gastrointestinal endoscopic procedures requires extensive and high-quality training. Endoscopy skills have traditionally been taught within the clinical setting, in the form of a mentor-apprenticeship model in which novice endoscopists learn skills under the supervision of experienced preceptors. Concerns with regard to patient safety and training efficiency have prompted the endoscopy community to reconsider this training model. It is becoming increasingly less acceptable…

Postsurgical Endoscopic Anatomy

Introduction Patients who have undergone surgical procedures that altered the upper gastrointestinal (GI) anatomy are often referred for endoscopic evaluation. It is essential for gastroenterologists to understand the postoperative anatomical alterations to select the appropriate endoscope and accessories and obtain meaningful and accurate diagnostic information. This chapter discusses the most common surgical procedures involving the upper GI tract. Technical details and common variations are described for…