GIT J Club: OGD mistakes

1. Mistakes in UGI endoscopy & how to
avoid them:
From UEG education 2016.
Kurdistan Board GEH/GIT Surgery weekly J
Club:
Supervised by:
Professor Dr.Mohamed Alshekhani
MBChB-CABM,FRCP,EBGH.

2. 1: Missing Cameron ulcers1: Missing Cameron ulcers
 First described in 1986 by Cameron / Higgins.
 These erosions, or ulcerations, in the gastric mucosa are located at the
diaphragmatic hiatus & consist in multiple linear lesions on the crests of
gastric folds.
 They are associated with UGIB or obscure bleeding.
 Identifying them requires antegrade & retrograde observation of the
neck of the hiatal hernia &often go unrecognized during upper
endoscopy.
 The overall mean No of hospitalizations for UGIB without any
identified bleeding source preceding a final diagnosis of CU was 3.4.
 The incidence as the source of severe upper GI bleeding is low (0.2%),
but was higher as the source of obscure GI bleeding (3.8%).
 All patients had a large HH(>5cm) &their mean age was 70 years old.
 For patients with large HH& unexplained anaemia or upper GIB, we
recommend paying close attention to cardia in both ante& retrograde.

3. Antegrade endoscopic view of the neck of a HH in a 53-year-old manAntegrade endoscopic view of the neck of a HH in a 53-year-old man
with IDAof unknown origin diagnosed 6 years previously.with IDAof unknown origin diagnosed 6 years previously.
The white arrows indicate the presence of Cameron ulcersThe white arrows indicate the presence of Cameron ulcers..

4. 2: Missing dielafoy2: Missing dielafoy
 Described by Gallarden in 1884 and Georges Dieulafoy in 1898.Described by Gallarden in 1884 and Georges Dieulafoy in 1898.
 It is an abnormal vessel of the mucosa.It is an abnormal vessel of the mucosa.
 Normally, vessels become smaller as they penetrate the mucosa,Normally, vessels become smaller as they penetrate the mucosa,
but the Dieulafoy lesion is a calibre-persistent arteriole thatbut the Dieulafoy lesion is a calibre-persistent arteriole that
remains abnormally large &protrudes through the normal mucosaremains abnormally large &protrudes through the normal mucosa
into the lumen.into the lumen.
 A small mucosal defect with the eruption of the vessel can causeA small mucosal defect with the eruption of the vessel can cause
bleeding.bleeding.
 Although located elsewhere in GIT, the most frequent location of aAlthough located elsewhere in GIT, the most frequent location of a
is the proximal stomach along the lesser curve.is the proximal stomach along the lesser curve.
 Represent only 1–5% of UGIB, often unrecognized & multipleRepresent only 1–5% of UGIB, often unrecognized & multiple
gastroscopies may be needed for it to be identified.gastroscopies may be needed for it to be identified.
 The most frequent presentation of is acute overt bleeding withThe most frequent presentation of is acute overt bleeding with
haematemesis/or melena.haematemesis/or melena.

5. 2: Missing dielafoy2: Missing dielafoy
 The success of endoscopic haemostasis done by a combinedThe success of endoscopic haemostasis done by a combined
method (adrenaline injection & thermal electrocoagulation) ormethod (adrenaline injection & thermal electrocoagulation) or
mechanical methods has been reported to reach 90%, with amechanical methods has been reported to reach 90%, with a
higher endoscopic diagnostic a&therapeutic yield whenhigher endoscopic diagnostic a&therapeutic yield when
endoscopy is performed sooner.endoscopy is performed sooner.
 The rebleeding rate has been reported to be as high as 9–40%.The rebleeding rate has been reported to be as high as 9–40%.
 It is suspected in patients who experience multiples episodes ofIt is suspected in patients who experience multiples episodes of
UGIB without any origin visualized during multiples OGDs.UGIB without any origin visualized during multiples OGDs.
 There are tips & tricks that can be followed to help it:There are tips & tricks that can be followed to help it:
 Opt for an urgent upper endoscopy in the case of a new episode ofOpt for an urgent upper endoscopy in the case of a new episode of
bleeding or dizziness (before blood exteriorization).bleeding or dizziness (before blood exteriorization).
 2.Ask the patient to cough when the endoscope is inside the2.Ask the patient to cough when the endoscope is inside the
stomach & no visible lesion is seen—this could increase thestomach & no visible lesion is seen—this could increase the
vascular pressure & trigger bleeding, leading to adequatevascular pressure & trigger bleeding, leading to adequate
endoscopic treatment.endoscopic treatment.

6. Active bleeding from a Dieulafoy in the proximal stomach of a 69-Active bleeding from a Dieulafoy in the proximal stomach of a 69-
year-old patient. The patient presented with recurrent severe UGIB,year-old patient. The patient presented with recurrent severe UGIB,
underwent >3 gastroscopies &transfused with >8 (RBC) units beforeunderwent >3 gastroscopies &transfused with >8 (RBC) units before
the bleeding source was identified. The lesion was successfullythe bleeding source was identified. The lesion was successfully
clipped with no further bleeding recurrence.clipped with no further bleeding recurrence.

7. 3: Missing IEE3: Missing IEE
 Described for more than 15 years, (EoE) has become increasinglyDescribed for more than 15 years, (EoE) has become increasingly
recognized.recognized.
 Many patients with EoE have already undergone multiplesMany patients with EoE have already undergone multiples
endoscopies before the diagnosis is established.endoscopies before the diagnosis is established.
 The major symptoms in adults are dysphagia & food impaction,The major symptoms in adults are dysphagia & food impaction,
but secondary symptoms of heartburn & atypical noncardiac chestbut secondary symptoms of heartburn & atypical noncardiac chest
pain also reported.pain also reported.
 About 70% of patients have asthma, allergic rhinitis /or atopicAbout 70% of patients have asthma, allergic rhinitis /or atopic
dermatitis, underlining the association with atopy.dermatitis, underlining the association with atopy.
 Endoscopic signs suggestive : the presence of ringsEndoscopic signs suggestive : the presence of rings
(trachealization), oedema (loss of vascular marking), exudates(trachealization), oedema (loss of vascular marking), exudates
(white plates), furrows (vertical lines) &strictures.(white plates), furrows (vertical lines) &strictures.
 The diagnosis is made by obtaining multiple biopsies (2–4) of theThe diagnosis is made by obtaining multiple biopsies (2–4) of the
distal & proximal oesophagus, showing mucosal eosinophilia.distal & proximal oesophagus, showing mucosal eosinophilia.

8. 3: Missing IEE3: Missing IEE
 Pathophysiologic explanations include disease (GERD) & foodPathophysiologic explanations include disease (GERD) & food
antigen sensitization or allergy.antigen sensitization or allergy.
 Proton pump inhibitor (PPI) therapy is the cornerstone ofProton pump inhibitor (PPI) therapy is the cornerstone of
treatment &its role has been attributed to the direct anti-treatment &its role has been attributed to the direct anti-
inflammatory properties of PPIs &repair of mucosal permeabilityinflammatory properties of PPIs &repair of mucosal permeability
defects.defects.
 If needed, further treatment is based on topical steroid treatmentIf needed, further treatment is based on topical steroid treatment
& the six food (milk, wheat, soy, egg, nuts and seafood)& the six food (milk, wheat, soy, egg, nuts and seafood)
elimination diet.elimination diet.

9. EoE in a 53-year-old man who presented with atypical recurrentEoE in a 53-year-old man who presented with atypical recurrent
acute episodes of retrosternal chest pain, atopy&peripheralacute episodes of retrosternal chest pain, atopy&peripheral
hypereosinophilia. OGD revealed typical features of EoE—multipleshypereosinophilia. OGD revealed typical features of EoE—multiples
exudates &furrows. PPIs & the six food elimination diet wereexudates &furrows. PPIs & the six food elimination diet were
achieved a good clinical response.achieved a good clinical response.

10. 4: Missing long-segment Barrets4: Missing long-segment Barrets
 Barrett oesophagus is the replacement of squamous epithelium byBarrett oesophagus is the replacement of squamous epithelium by
columnar epithelium, with intestinal metaplasia identifiable incolumnar epithelium, with intestinal metaplasia identifiable in
biopsy samples taken from the distal oesophagus.biopsy samples taken from the distal oesophagus.
 On endoscopy, Barrett oesophagus appears as a salmon-pinkOn endoscopy, Barrett oesophagus appears as a salmon-pink
tongue of mucosa extending into the oesophagus from GEJtongue of mucosa extending into the oesophagus from GEJ
 LSBE is associated with an increased risk of malignancy.LSBE is associated with an increased risk of malignancy.
 Classically, BE extension is defined by the Prague C & M criteria,Classically, BE extension is defined by the Prague C & M criteria,
providing the maximal circumferential (C) & maximal tongue (M)providing the maximal circumferential (C) & maximal tongue (M)
extension in cm.extension in cm.
 The length of BE is associated with malignancy risk &number ofThe length of BE is associated with malignancy risk &number of
biopsies needed to be taken for detection of dysplasia.biopsies needed to be taken for detection of dysplasia.
 In very LSBE , in some patients Z line is so high in the proximalIn very LSBE , in some patients Z line is so high in the proximal
oesophagus that some endoscopists do not notice the presence ofoesophagus that some endoscopists do not notice the presence of
Barrett oesophagus,if no active search is done to locate it whenBarrett oesophagus,if no active search is done to locate it when
handling the scope.handling the scope.

11. LSB. a & b | A C12M17 long BE in a 73-year-old man. A the Z line is difficult toLSB. a & b | A C12M17 long BE in a 73-year-old man. A the Z line is difficult to
identify from 11h to 2h in this photo taken at 28cm from the incisors. If no activeidentify from 11h to 2h in this photo taken at 28cm from the incisors. If no active
search for the the Z line is done, the diagnosis might be missed. B the scope issearch for the the Z line is done, the diagnosis might be missed. B the scope is
retrieved to 23cm to see the upper part of the Z line. c & d | a 72-year-old manretrieved to 23cm to see the upper part of the Z line. c & d | a 72-year-old man
presented with a C9M10 BE. c | No Z line can be identified in the endoscopicpresented with a C9M10 BE. c | No Z line can be identified in the endoscopic
view at 33cm from incisors & the diagnosis of BE could be missed. D At 30cm, theview at 33cm from incisors & the diagnosis of BE could be missed. D At 30cm, the
irregular Z line can clearly be identified.irregular Z line can clearly be identified.

12. 5: Missing GAVE,PHG&PHPs5: Missing GAVE,PHG&PHPs
 Confusion can occur in the diagnosis of gastric lesions associatedConfusion can occur in the diagnosis of gastric lesions associated
with portal hypertension.with portal hypertension.
 In portal hypertension, various gastric lesions may occur that areIn portal hypertension, various gastric lesions may occur that are
known to present in different forms&require differentknown to present in different forms&require different
management.management.
 Confusion between (PHG) & (GAVE) frequently occurs.Confusion between (PHG) & (GAVE) frequently occurs.
 Sometimes, gastric polyps may also be associated with portalSometimes, gastric polyps may also be associated with portal
hypertension.hypertension.
 PHG classically starts from the fundus & corpus & extends intoPHG classically starts from the fundus & corpus & extends into
the antrum.the antrum.
 By contrast, GAVE starts in the antrum &extends to the corpus.By contrast, GAVE starts in the antrum &extends to the corpus.
 PHG has a snakeskin or mosaic background mucosa &whenPHG has a snakeskin or mosaic background mucosa &when
severe, is associated with flat or bulging red or brown spots thatsevere, is associated with flat or bulging red or brown spots that
may be friable or frank bleeding in severe cases.may be friable or frank bleeding in severe cases.

13. 5: Missing GAVE,PHG&PHPs5: Missing GAVE,PHG&PHPs
 GAVE lesions are characterized by convoluted tortuous columnsGAVE lesions are characterized by convoluted tortuous columns
of ectatic vessels along each longitudinal fold of the antrum,of ectatic vessels along each longitudinal fold of the antrum,
converging at the pylorus, which look like the stripes ofconverging at the pylorus, which look like the stripes of
watermelon.watermelon.
 Biopsy samples, can help the diagnosis (PHG is associated withBiopsy samples, can help the diagnosis (PHG is associated with
dilated mucosal & submucosal veins; GAVE is associated withdilated mucosal & submucosal veins; GAVE is associated with
dilated mucosal capillaries with fibrin thrombi& fibromusculardilated mucosal capillaries with fibrin thrombi& fibromuscular
hyperplasia of the lamina propria&spindle cell proliferation).hyperplasia of the lamina propria&spindle cell proliferation).
 Recognizing both types of lesion is important because of theirRecognizing both types of lesion is important because of their
specific management.specific management.
 PHG is reputed to respond to NSBB or (TIPS) if needed.PHG is reputed to respond to NSBB or (TIPS) if needed.
 GAVE do not respond to NSBB, but can be endoscopicallyGAVE do not respond to NSBB, but can be endoscopically
eradicated by APC, banding or RFA.eradicated by APC, banding or RFA.
 mixed cases exist & need either haemodynamic/or endoscopicmixed cases exist & need either haemodynamic/or endoscopic
therapies.therapies.

14. 5: Missing GAVE,PHG&PHPs5: Missing GAVE,PHG&PHPs
 In some cases, portal hypertension is associated with gastricIn some cases, portal hypertension is associated with gastric
polyps.polyps.
 Most of the time, these polyps are reddish with exudates on theirMost of the time, these polyps are reddish with exudates on their
top.top.
 Pathological analysis reveals vascular dilations in the laminaPathological analysis reveals vascular dilations in the lamina
propria with a small amount of lymphoplasmatocyticpropria with a small amount of lymphoplasmatocytic
inflammation.inflammation.
 These polyps can be associated with bleeding or anaemia, mightThese polyps can be associated with bleeding or anaemia, might
also respond to treatment with NSBB, or can be removed ifalso respond to treatment with NSBB, or can be removed if
symptomatic,but care needed because they are vascular &symptomatic,but care needed because they are vascular &
cirrhotic have coagulations & repair defects.cirrhotic have coagulations & repair defects.

15. Portal hypertensive gastric lesions. A , A subcardial vision of a patientPortal hypertensive gastric lesions. A , A subcardial vision of a patient
with cirrhosis and portal hypertension showing the typical mosaic-with cirrhosis and portal hypertension showing the typical mosaic-
like pattern of portal hypertensive gastropathy with red signs oflike pattern of portal hypertensive gastropathy with red signs of
diffuse tiny bleeding. B Typical aspect of a GAVE in the antrum of adiffuse tiny bleeding. B Typical aspect of a GAVE in the antrum of a
patient with cirrhosis with recurrent anaemia who was successfullypatient with cirrhosis with recurrent anaemia who was successfully
treated by TIPS for refractory ascites & by APC. C A pyloric polyptreated by TIPS for refractory ascites & by APC. C A pyloric polyp
with the typical appearance of a portal hypertensive gastric polypwith the typical appearance of a portal hypertensive gastric polyp
(reddish with exudate) in a patient with cirrhosis. The polyp was(reddish with exudate) in a patient with cirrhosis. The polyp was
resected for pathological analysis, showing dilated vessels. Theresected for pathological analysis, showing dilated vessels. The
patient had no recurrence of the gastric polyp at the follow-up.patient had no recurrence of the gastric polyp at the follow-up.

16. 6: EGC missing &mismanagement6: EGC missing &mismanagement
 Nowadays, the optimal scenario for accurate diagnosis is:
 Good cleaning of the lumen of the GI tract segment.
 Good characterization with an adequate endoscope.
 Addition of a virtual enhancement technique and/or chromoendoscopy
(if needed).
 Depending on the pit pattern and size
 Choice of adequate resection techniques.

17. 6: EGC missing &mismanagement6: EGC missing &mismanagement
 In referral centres, we still take patients who were sent for surgery
for benign or superficial neoplastic lesions that can be resected in
a curative manner endoscopically,.
 We still see some patients with recurrence of partially resected
lesions that were not treated adequately the first time&many
European endoscopists feel uncomfortable with pit pattern
characterization.
 European guidelines on (ESD) & (EMR) exists
 For esophageal squamous cell carcinoma, EMR is reserved for
 Lesions <10 mm if en-bloc resection can be foreseen.
 For larger lesions with a pit pattern and shape that favour a
superficial lesion, en-bloc resection by ESD must be proposed.
 For the majority of visible lesions in BE, EMR must be proposed
as a staging, sampling resection method.

18. 6: EGC missing &mismanagement6: EGC missing &mismanagement
 ESD is reserved for lesions >15mm, with poor lifting signs &
lesions at risk of submucosal invasion.
 For gastric lesions, ESD is encouraged because of its better
control of resection margins for lesions at low risk of lymph-node
metastasis.
 For colorectal lesions, endoscopic resection by EMR is safe &
most the time allows effective removal of the lesion.
 En-bloc resection by EMR or ESD (depending on the size) can be
considered to remove lesions with high suspicion of limited
submucosal invasion.

20. Examples of typical early neoplastic gastrointestinal lesions, theirExamples of typical early neoplastic gastrointestinal lesions, their
characterization & treatment modality. a & b | A 50-year-old malecharacterization & treatment modality. a & b | A 50-year-old male
with an extensive flat Paris O-Iibwith an extensive flat Paris O-Iib sccscc
was treated by ESD. Pathologicalwas treated by ESD. Pathological
analysis disclosed a pT1a well differentiated squamous cell carcinomaanalysis disclosed a pT1a well differentiated squamous cell carcinoma
without any lymphovascular infiltration. Resection was R0 (clearwithout any lymphovascular infiltration. Resection was R0 (clear
vertical and horizontal margins). Endoscopic surveillance wasvertical and horizontal margins). Endoscopic surveillance was
proposed to the patient. c–f | A 73-year-old inoperable man withproposed to the patient. c–f | A 73-year-old inoperable man with
C12M17 Barrett oesophagus with a visible Paris 0-IIa malignantC12M17 Barrett oesophagus with a visible Paris 0-IIa malignant
lesion of more than 3 cm was treated by ESD. The patient waslesion of more than 3 cm was treated by ESD. The patient was
asymptomatic after resection. Pathological analysis disclosed a well-asymptomatic after resection. Pathological analysis disclosed a well-
differentiated adenocarcinoma infiltrating the submucosal layerdifferentiated adenocarcinoma infiltrating the submucosal layer
(pT1b) with clear margins and no lymphovascular infiltration. In a(pT1b) with clear margins and no lymphovascular infiltration. In a
patient not fit for surgery, this treatment benefitted his prognosis. g–patient not fit for surgery, this treatment benefitted his prognosis. g–
j | Diagnosis of early gastric cancer is rare in Europe for manyj | Diagnosis of early gastric cancer is rare in Europe for many
reasons, including low incidence and lack of awareness of how toreasons, including low incidence and lack of awareness of how to
recognize the lesions. The main issue is to clean the stomach torecognize the lesions. The main issue is to clean the stomach to
remove all the saliva, bubbles & a part of the mucus to be able toremove all the saliva, bubbles & a part of the mucus to be able to

21. Here is the case of a 73-year-old man known to have advanced OLGAHere is the case of a 73-year-old man known to have advanced OLGA
stage IV metaplastic gastritis ,g | shows the aspect of the gastricstage IV metaplastic gastritis ,g | shows the aspect of the gastric
mucosa after cleaning. A suspicious early lesion is seen as a littlemucosa after cleaning. A suspicious early lesion is seen as a little
depressed reddish area in the angular incisure. h| Narrow-banddepressed reddish area in the angular incisure. h| Narrow-band
imaging (NBI) illustrates the presence of a clear demarcation lineimaging (NBI) illustrates the presence of a clear demarcation line
with altered pit pattern in the middle part, surrounded by metaplasticwith altered pit pattern in the middle part, surrounded by metaplastic
tissue presenting the "light blue crest" sign.tissue presenting the "light blue crest" sign.1818
i and j | i and j |
Chromoendoscopy with acetic acid and indigo carmine increases theChromoendoscopy with acetic acid and indigo carmine increases the
enhancement of the lesion to delineate it. A biopsy sample was taken,enhancement of the lesion to delineate it. A biopsy sample was taken,
disclosing early gastric neoplasia with high-grade dysplasia, which isdisclosing early gastric neoplasia with high-grade dysplasia, which is
an indication for resection by ESD. k–n | A 83-year-old Portuguesean indication for resection by ESD. k–n | A 83-year-old Portuguese
patient presented with a severe diffuse metaplastic gastritis. A Parispatient presented with a severe diffuse metaplastic gastritis. A Paris
O-IIa prepyloric lesion was discovered on chromoendoscopy withO-IIa prepyloric lesion was discovered on chromoendoscopy with
acetic acid (k) and characterized by NBI (l), showing a clearacetic acid (k) and characterized by NBI (l), showing a clear
demarcation line with altered pit pattern in the central part of thedemarcation line with altered pit pattern in the central part of the
lesion, suggestive of early gastric cancerlesion, suggestive of early gastric cancer

22. A staging resection was performed by ESD (m and n). TheA staging resection was performed by ESD (m and n). The
pathological specimen disclosed a poorly differentiatedpathological specimen disclosed a poorly differentiated
adenocarcinoma invading the submucosa with lymphovascularadenocarcinoma invading the submucosa with lymphovascular
infiltration (pT1b). Despite that the resection was R0, ainfiltration (pT1b). Despite that the resection was R0, a
complementary surgery was proposed to the patient, revealing 3complementary surgery was proposed to the patient, revealing 3
positive lymph nodes out of the 22 resected (pT1bN2). o–r | A 79-positive lymph nodes out of the 22 resected (pT1bN2). o–r | A 79-
year-old woman was discovered to have a 15mm polypoid Paris O-Isyear-old woman was discovered to have a 15mm polypoid Paris O-Is
lesion in the right colon located on a fold (o). The lesion has a NICElesion in the right colon located on a fold (o). The lesion has a NICE
III aspect on NBI suggestive of adenocarcinoma.III aspect on NBI suggestive of adenocarcinoma.1919
p | A good lifting p | A good lifting
was obtained with a 20% glycerol submucosal injection and en-blocwas obtained with a 20% glycerol submucosal injection and en-bloc
resection, which was mandatory in this case, was obtained by EMR.resection, which was mandatory in this case, was obtained by EMR.
Pathological analysis disclosed a moderately differentiatedPathological analysis disclosed a moderately differentiated
adenocarcinoma infiltrating the submucosa and the superficialadenocarcinoma infiltrating the submucosa and the superficial
muscle layer (pT2Nx) with clear margins. A complementary surgerymuscle layer (pT2Nx) with clear margins. A complementary surgery
was discussed by multidisciplinary oncologic staff. s–u | A 56-year-was discussed by multidisciplinary oncologic staff. s–u | A 56-year-
old man was referred for rectal polyp resection. On EUS, the lesionold man was referred for rectal polyp resection. On EUS, the lesion
was scored as uT1N0. On white light imaging, a Paris Is-IIa largewas scored as uT1N0. On white light imaging, a Paris Is-IIa large
adenoma infiltrating nearly half the circumference of the loweradenoma infiltrating nearly half the circumference of the lower

23. 7: Inadequate biliary stent for strictures7: Inadequate biliary stent for strictures
 ERCP has evolved over the past 20 years towards being a purelyERCP has evolved over the past 20 years towards being a purely
therapeutic procedure.therapeutic procedure.
 Stenting has also evolved with the successive availability of plasticStenting has also evolved with the successive availability of plastic
stents, noncovered, partially covered & fully covered self-stents, noncovered, partially covered & fully covered self-
expandable metallic stents (SEMS).expandable metallic stents (SEMS).
 One major concern when performing stenting should be to notOne major concern when performing stenting should be to not
compromise any aspect of the patient’s future outcome bycompromise any aspect of the patient’s future outcome by
implanting nonremovable stents.implanting nonremovable stents.
 More & more pretherapeutic diagnostic tools, (MRCP) &(EUS)/More & more pretherapeutic diagnostic tools, (MRCP) &(EUS)/
(FNA), are available to investigate the aetiology of a biliary(FNA), are available to investigate the aetiology of a biliary
stricture.stricture.
 But, the definitive diagnosis still relies on pathology toBut, the definitive diagnosis still relies on pathology to
demonstrate neoplasia.demonstrate neoplasia.

24. 7: Inadequate biliary stent for strictures7: Inadequate biliary stent for strictures
 Even in case of diagnostic presumption, it must be kept in mindEven in case of diagnostic presumption, it must be kept in mind
that placement of a noncovered SEMS in the biliary tree is athat placement of a noncovered SEMS in the biliary tree is a
nonreversible treatment that has potential long-term complicationsnonreversible treatment that has potential long-term complications
in the case of incorrect diagnosis.in the case of incorrect diagnosis.
 Along the same line, uncovered SEMS are the palliative treatmentAlong the same line, uncovered SEMS are the palliative treatment
of choice for nonresectable hilum tumours, but they should neverof choice for nonresectable hilum tumours, but they should never
be implanted if nonresecability has not been confirmed.be implanted if nonresecability has not been confirmed.
 Indeed, multiple metallic stents at the hilum may renderIndeed, multiple metallic stents at the hilum may render
impossible extended right or left hepatectomy for curativeimpossible extended right or left hepatectomy for curative
resection of a hilar cholangiocarcinom.resection of a hilar cholangiocarcinom.

25. Cholangiogram of a 74-year-old patient in whom a SEMS was placed for theCholangiogram of a 74-year-old patient in whom a SEMS was placed for the
treatment of a biliary stricture without an established malignant aetiology. At thetreatment of a biliary stricture without an established malignant aetiology. At the
patient’s follow-up, a primary sclerosing cholangitis associated with quiescentpatient’s follow-up, a primary sclerosing cholangitis associated with quiescent
inflammatory bowel disease (IBD) was diagnosed. The patient presented withinflammatory bowel disease (IBD) was diagnosed. The patient presented with
recurrent suppurative cholangitis episodes due to obstruction at the hilum byrecurrent suppurative cholangitis episodes due to obstruction at the hilum by
hyperplasia and required more than 20 ERCP procedures in 5 years. In this casehyperplasia and required more than 20 ERCP procedures in 5 years. In this case
both the choice of stent (uncovered, which means nonremovable) and its lengthboth the choice of stent (uncovered, which means nonremovable) and its length
(extending to the hilum, thus compromising resectability in case of a tumour and(extending to the hilum, thus compromising resectability in case of a tumour and
even rendering a surgical anastomosis difficult) were inadequate.even rendering a surgical anastomosis difficult) were inadequate.

26. 8: Missing altered biliary anatomy8: Missing altered biliary anatomy
 Knowledge of anatomical variants of bile duct anatomy is essentialKnowledge of anatomical variants of bile duct anatomy is essential
for the practice of ERCP.for the practice of ERCP.
 The classical anatomy only represents 63% of the cases.The classical anatomy only represents 63% of the cases.11
 Most frequently, there is a bifurcation with the posterior segmentsMost frequently, there is a bifurcation with the posterior segments
implanted on the right hepatic duct.implanted on the right hepatic duct.
 They are implanted at the hilum (trifurcation) in 10% of cases orThey are implanted at the hilum (trifurcation) in 10% of cases or
on the left hepatic duct in 11% of the cases.on the left hepatic duct in 11% of the cases.
 In 4% of cases, the posterior segments are implanted lower on theIn 4% of cases, the posterior segments are implanted lower on the
common bile duct—below the hilum (2%) or directly on the cysticcommon bile duct—below the hilum (2%) or directly on the cystic
duct (2%).duct (2%).
 These situations are important to recognize in order to drain theThese situations are important to recognize in order to drain the
liver adequately, to describe the anatomy for hepatobiliary surgery,liver adequately, to describe the anatomy for hepatobiliary surgery,
&avoid potential complications.&avoid potential complications.
 Pre-therapeutic assessment of the biliary anatomy by MRCP helpsPre-therapeutic assessment of the biliary anatomy by MRCP helps
when choosing the correct segment to catheterize &drain.when choosing the correct segment to catheterize &drain.

27. Cholangiograms by ERCP. A accessory duct for segment VIICholangiograms by ERCP. A accessory duct for segment VII
implanted on CBD. B Posterior segments implanted on the leftimplanted on CBD. B Posterior segments implanted on the left
HD. C MRCP showing a hilar trifurcation (posterior segmentsHD. C MRCP showing a hilar trifurcation (posterior segments
implanted on the hilum). implanted on the hilum).

28. d–g | A 46-year-old patient developed RUQ pain&cholestasis afterd–g | A 46-year-old patient developed RUQ pain&cholestasis after
cholecystectomy. D An initial ERCP showed an apparently normalcholecystectomy. D An initial ERCP showed an apparently normal
hepatography, but, if you look carefully, posterolateral segments arehepatography, but, if you look carefully, posterolateral segments are
missing on the cholangiogram. Either knowledge of the anatomy ormissing on the cholangiogram. Either knowledge of the anatomy or
MRCPMRCP

29. (e, f) showed dilation of the posterolateral segments, implanted on(e, f) showed dilation of the posterolateral segments, implanted on
the cystic duct. Then selective cystic duct cannulation and, bythe cystic duct. Then selective cystic duct cannulation and, by
chance, endoscopic drainage are possible (g). A combined ERCPchance, endoscopic drainage are possible (g). A combined ERCP
and percutaneous bile-duct access (using a transjugular intrahepaticand percutaneous bile-duct access (using a transjugular intrahepatic
portosystemic shunt (TIPS) set) to reconnect the excluded, dilatedportosystemic shunt (TIPS) set) to reconnect the excluded, dilated
bile-duct segment to the common bile duct would have been anbile-duct segment to the common bile duct would have been an
alternative treatment optionalternative treatment option

30. 9. Failure to take D2 Biopsies9. Failure to take D2 Biopsies
when celiac is suspected.when celiac is suspected.

31. 10. Failure to take the gastric10. Failure to take the gastric
atrophy seriously.atrophy seriously.