Enteroscopy. Atlas of. L. Demling M. Classen P. Friihmorgen. Endoscopy of the Small and Large Bowel; Retrograde Cholangio-Pancreatography

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2 L. Demling M. Classen P. Friihmorgen Atlas of Enteroscopy Endoscopy of the Small and Large Bowel; Retrograde Cholangio-Pancreatography With the Collaboration of H. Koch and H. Bauerle Translated and Adapted by K. H. Soergel with the Assistance of H. Pease With 289 Illustrations, Most in Color Springer-Verlag Berlin Heidelberg New York 1975

3 Professor Dr. med. LUDWIG DEMLING, Director, University Hospital for Internal Medicine, Erlangen Dr. med. MEINHARD CLASSEN, Associate Professor, Physician-in Chief, Department of Medicine I, General Hospital Barmbek, Hamburg Dr. med. PETER FRUHMORGEN, Research Assistant, University Hospital for Internal Medicine, Erlangen Translator and Adaptor: KONRAD H. SOERGEL, M.D., Professor of Medicine and Chief, Department of Gastroenterology, The Medical College ofwisconsin, Milwaukee, Wisconsin HARRY PEASE, Science Writer, Milwaukee Journal ISBN-13: e-isbn-13: DOl: / Library of Congress Cataloging in Publication Data. DEMLlNG, LUDWIG, 1921~. Atlas of enteroscopy. Translation of Atlas der Enteroskopie. Bibliography: p. Includes index. 1. Digestive organs-exploration. 2. Intestines-Diseases-Diagnosis. 3. Endoscope and endoscopy. I. CLASSEN, MEINHARD, joint author. II. FRUHMORGEN, PETER, 1940~, joint author. III. Title. RC 804.E6D '07'54.75~11709 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under 54 of the German Copyright Law, where copies are made for other than private use, a fee is payable to the publisher, the amount of the fee to be determined by agreement with the publisher. by Springer-Verlag Berlin Heidelberg Softcover reprint of the hardcover 1st edition 1975 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Typesetting, printing, and bookbinding: StiirtzAG, Wiirzburg IV

4 Foreword It is my pleasure to introduce you to this new Atlas by Professor DEMLING and his colleagues on the very timely subjects colonoscopy, duodenoscopy and endoscopic cannulation of the bile and pancreatic ducts. Professor DEMLING, unlike many others who carry his teaching and administrative burdens, continues to be very personally involved in performing endoscopies. His clinic is one of the best organized and best equipped in the world. Professor DEM LING and his colleagues have been instrumental in introducing to the European continent these new techniques of duodenoscopy, colonoscopy and bile duct cannulation which were originally developed in Japan. They have added significant contributions of their own and now present to the reader a clear, concise, very well illustrated description of these methods. Dr. CLASSEN is one of the pioneers in endoscopic cannulation. He has been kind enough to come to the United States and share his expertise with us at several Post Graduate Education programs. The students in these courses have been most enthusiastic about his presentations. Through this text he makes his extensive experience available to all endoscopists. The beginner at cannulation will find the illustrations of the various shapes the papilla may assume most helpful. I had the pleasure this summer of teaching a course in Brazil with Dr. FRUHMORGEN. Very few physicians have concentrated on colonoscopy to the extent that he has. Though he has been involved with the method for a relatively few years, he writes from an experience of more than cases. He has gathered together the largest and clearest collection of colonoscopic photographs that I have ever seen. Even the experienced colonoscopist will learn from his well illustrated presentation on colonoscopic technique. This text compliments Professor DEMLING'S earlier Atlas on the Endoscopy of the Upper Gastrointestinal Tract. The English reader is indebted to Dr. KONRAD SOERGEL for his excellent translation of the text into English. Madison, 1975 JOHN F. MORRISSEY v

5 Preface to the German Edition The Atlas of Enteroscopy represents a venture into new territory by describing the advances of modern gastroenterologic endoscopy in the examination of the small intestine, from duodenum to ileum, and of the entire colon. Until three years ago, large areas of the intestinal tract were not accessible to direct inspection. Today, the entire organ system, from esophagus to anus, can be visualized and biopsied, either by a combination of enteroscopy and coloscopy, or by peroral enterocoloscopy. It is now possible to inspect inflammatory and peptic lesions, tumors, diverticula, and stenotic areas and to detect their histologic features. Another new development is the filling of the biliary and pancreatic duct systems with radiopaque contrast media by endoscopic intu bation of the papilla of Vater. The pancreatic ducts have now become accessible to preoperative radiologic evaluation; this examination can be combined with selective mesenteric arteriography. Retrograde endoscopic filling of the bile ducts represents a significant advance in the differential diagnosis of obstructive jaundice: it carries a lower risk than percutaneous and laparoscopic cholangiography. Operative endoscopy of the small and large intestine is yet another terra nova which has recently been entered. It includes the removal of foreign bodies, topical treatment of circumscribed lesions, coagulation of bleeding sites, and the removal of polyps with the diathermy snare. The primary purpose of this atlas is to demonstrate the future possibilities for new clinical procedures which are based on advances in endoscopy, alone or in combination with radiologic procedures. The number of instances where the impact of these new methods can already be demonstrated is large, but a systematic description of all diseases now accessible to diagnostic and therapeutic intervention is not yet possible. The atlas represents an attempt to illustrate the giant strides taken by gastroenterologic endoscopy during the years It is directed at gastroenterolo- VII

6 gists; internists, surgeons, pathologists and all those physicians who have maintained an active interest in the broadening scope of contemporary medicine. Erlangen, Spring 1974 L. DEMLING VIII

7 Contents 1. Instruments l.l Endoscopic Instruments Duodenoscopy Enteroscopes. Coloscopy. 1.2 Radiologic Equipment Duodenoscopy 2.1 Historical Development 2.2 Indications Technique, Including Patient Preparation 2.4 Endoscopic Orientation in the Duodenum 2.5 Endoscopy of the Duodenum Peptic Lesions and Sequelae.... Duodenal Ulcer. The Significance of Endoscopic Diagnosis Method. Scarring. Erosions Duodenitis Duodenal Stenoses Diverticula Duodenal Tumors and Heterotopias. Heterotopias... Benign Tumors Malignant Tumors Antral Mucosa in the Afferent Loop Following Billroth II-Resection Endoscopy of the Papilla of Vater (Major Papilla) Anatomy... Endoscopic Aspects IX

8 Minor Papilla The Ampulla of Vater The Abnormal Papilla of Vater 28 Stenosing Papillitis Concrements in the Papilla. 29 Prolapse of the Papilla of Vater 29 Carcinoma of the Papilla of Vater Retrograde Cholangiography. 30 Normal Cholangiogram Bile Duct Stones Inflammation of the Biliary Tract 31 Cholecystitis Cholangitis Tumors of Gall bladder and Bile Ducts Sequelae of Operations on the Biliary Tract 33 Postcholecystectomy Syndrome. 33 Biliary-Enteric Anastomoses Diseases of the Liver. 33 Hepatic Abscess 34 Hepatic Cysts 34 Hepatic Tumors Retrograde Pancreatography Anatomy and Topography of the Pancreas 35 Emptying of Contrast Media from the Pancreatic Ducts Congenital Abnormalities of the Pancreas Pancreatitis Indications and Findings Tumors of the Pancreas Complications Complications During Insertion of the Instrument Cholangiopancreatography (ERCP) X Jejuno-lleoscopy Indications Technique and Results Level of Intubation Diagnostic Yield Crohn's Disease Tumors Bleeding Sites Complications Summary

9 4. Coloscopy Historical Development Anatomy and Physiology Indications Contraindications Baseline Studies Patient Preparation Technique of Examination Coloscopy "Operative" Coloscopy. 53 Coloscopic Polypectomy. 53 Foreign Body Removal 55 Injections Electrocoagulation 55 Angiography Findings Developmental Abnormalities Tumors of the Colon 57 Benign Tumors.. 57 Malignant Tumors 59 Pseudotumors Inflammatory Diseases 61 Idiopathic Ulcerative Colitis 61 Crohn's Disease ofthe Colon (Granulomatous Colitis) Rare Diseases Diverticula Endometriosis Melanosis coli Megacolon Enteric Parasites Appendix Complications 69 Perforation 69 Bleeding.. 69 Gas Explosion Illustrations Endoscopic Orientation in the Duodenum (Figs. 1-4) Duodenal Peptic Lesions and Their Sequelae (Figs. 5-17) Duodenitis (Figs ) , 76 XI

10 Diverticula (Figs ). 78 Tumors and Heterotopic Lesions (Figs ) 80 Afferent Loop Following Gastric Resection with Billroth II Anastomosis (Figs ) 86 Endoscopy of the Papilla of Vater (Figs ) 86 Retrograde Cholangiography (Figs ) 100 Retrograde Pancreatography (Figs ) 118 Total Enteroscopy (Figs ) 152 Enteroscopy (Figs ) 154 Coloscopy Accessory Instruments (Figs ) Accessory Equipment (Figs. 150) Use of Accessory Instruments (Figs ) Anatomy (Figs ) Technique (Figs ) Sigmoid Colon (Figs ) Transverse Colon (Figs ) Inversion (Fig. 176) Ileoscopy (Figs ) Findings Ileocecal (Bauhin's) Valve (Figs ) Ileum (Figs ) Selective Coloscopic Visualization of the Appendix (Figs ) Findings after Appendectomy (Figs ) Inversion (Fig. 190) Operative Co1oscopy Mechanical Ablation (Fig. 191) Electrocoagulation (Fig. 192) High Frequency Currents (Fig. 193) Resection with the High Frequency Diathermy Snare (Figs ) Sessile Colonic Polyps (Figs ) Peutz-]eghers Polyps (Fig. 203) Follow-up Observations after Polypectomy (Figs ) Foreign Body Removal (Fig. 206) Injections (Fig. 207) Electrocoagulation (Fig. 208) Angiography (Fig. 209) Tumors of the Colon Benign Tumors (Figs ) 216 XII

11 9.2 Malignant Tumors (Figs ) Stenosis of the Sigmoid Colon (Figs ) Pseudo tumors (Figs ) Idiopathic Ulcerative Colitis (Figs ) Crohn's Disease of Colon and Terminal Ileum (Figs ) Radiation Colitis (Fig. 262) Melanosis Coli (Fig. 263) Diverticula (Figs ) Enteric Parasites (Fig. 266) 240 Subject Index 243 XIII

Postgastrectomy and Postvagotomy Syndromes

H. D. Becker W.F. Caspary Postgastrectomy and Postvagotomy Syndromes With 84 Figures (Mainly in Two Colors) Springer-Verlag Berlin Heidelberg New York 1980 Professor Dr. med. H. D. Becker KlInik und PolIklImk