Table Of ContentCLINICAL GASTROINTESTINAL
ATLAS OF
ENDOSCOPY
CLINICAL GASTROINTESTINAL
ATLAS OF
ENDOSCOPY
Third Edition
C. Mel Wilcox, MD, MSPH
Professor of Medicine
Divisionof Gastroenterologyand Hepatology
University ofAlabamaat Birmingham
Birmingham,Alabama
USA
Miguel Mun˜oz-Navas, MD, PhD
Professor of Medicine
Director of Gastroenterology Division and Endoscopy Unit
Division of Gastroenterology
University Hospital ofNavarra
University of Navarra
Pamplona
Spain
Joseph Sung, MD, PhD
MokHing YiuProfessor ofMedicine
Vice Chancellor and President
The Chinese University of HongKong
Shatin,Hong Kong
China
1600JohnF.KennedyBlvd.
Ste1800
Philadelphia,PA19103-2899
ATLASOFCLINICALGASTROINTESTINALENDOSCOPY,THIRDEDITION ISBN:978-1-4377-1909-3
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LibraryofCongressCataloging-in-PublicationData
Wilcox,C.Mel.
Atlasofclinicalgastrointestinalendoscopy/CharlesWilcox,MiguelMun˜oz-Navas,JosephJ.Y.Sung.
–3rded.
p.;cm.
Includesindex.
ISBN978-1-4377-1909-3(hardcover:alk.paper)
I.Mun˜oz-Navas,Miguel.II.Sung,JosephJ.Y.(JosephJaoYiu),1959-III.Title.
[DNLM:1.Endoscopy,Gastrointestinal–Atlases.2.GastrointestinalDiseases–pathology–Atlases.WI17]
616.33075450022’3–dc23
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To all those whohelped mecollectthese images aswellas tomy wonderfulfamily
for providingme the timeto compile thislabor oflove.
C.Mel Wilcox, MD,MSPH
This book is dedicated to my wife, Lucia,my children,Miguel, Javier, and Ina, for
theirlove, 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
inpeace),towhomIowewhatIam,andmylatefather-inlaw,Antonio,whowouldbe
veryproud ofthis publication.
Miguel Mun˜oz-Navas,MD,PhD
Tomy wife, Rebecca Wong.
Joseph Sung, MD,PhD
A C K N O W L E D G M E N T S
IwouldliketothankmycolleaguesoftheEndoscopyUnitoftheUniversityofNavarra
Clinic—Dr.JoseCarlosSubtil,Dr.CristinaCarretero,Dr.MaiteBetes,Dr.MaiteHerraiz,
Dr.SusanadelaRiva,Dr.CesarPrieto,andDr.RamonAngos—fortheirinvaluable
collaborationandsupport.Ialsowishtoexpressmygratitudetomycolleaguesandfriends
whogaveussomeexcellentpictures:Dr.OnofreAlarcon,Dr.FernandoAlberca,
Dr.BartolomeGarcia-Perez,Dr.IgnacioFernandez-Urie´n,Dr.CristianGheorghe,
Dr.PedroGonzalez-Carro,Dr.JuanManuelHerrerias,Dr.JavierJimenez-Perez,Dr.Sacha
Loiseau,Dr.AkikoOno,Dr.JavierPardo-Mindan,Dr.FranciscoPerez-Roldan,Dr.Pedro
Redondo,Dr.JesusJavierSola,Dr.AlbertoTomas,Dr.JoseLuisVazquez-Iglesias,
Dr.FranciscoVida,Dr.MichaelWallace,andDr.JoseLuisZubieta.
Miguel Mun˜oz-Navas,MD,PhD
Myheartfelt gratitude tomy colleaguesat the Institute ofDigestive Diseases who
contributedtothepicturesinthisproject:Dr.JamesLau,Dr.Y.T.Lee,Dr.JustinWu,and
Dr. Larry Lai.I would also like to thank Mr.Alan Fokand Ms. Ashur Lam for their
assistance indigitizing these pictures.
Joseph Sung, MD,PhD
ix
1
CHAPTER
Oropharynx and
Hypopharynx
INTRODUCTION
Theoropharynxisthegatewaytotheproximalgastrointestinaltract.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-
pharyngealabnormalitiescansuggestunderlyingesophagealdiseasein
thesepatients,andoropharyngeallesionsmaybethefirstmanifestation
of an underlying systemic disorder. Asymptomatic malignant disease
mayalsobedetected.Withincreasingappreciationoftheextraesopha-
gealmanifestationsofgastroesophagealrefluxdisease,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 FIGURE1.1 OROPHARYNX
soft palate Normalpharynxasviewedwithanendoscope,demonstratingthe
junctionofthehardandsoftpalate,uvula,andposteriorpharynx.
Palatopharyngeal
arch Hard palate
Palatoglossal
arch
Palatine
tonsil
Epiglottis
Vocal cords
Aryepiglottic fold
Piriform sinus
FIGURE1.2 LANDMARKSOFTHEOROPHARYNXANDHYPOPHARYNX
Withtheendoscopeadvancedunderdirectvision,theinferiorportionoftheuvulaisseenatthebaseofthetongue.Noticethatthe
imageisinverted(topleft).Withfurtheradvancement,thesuperiorportionoftheepiglottisisidentified(topright).Advancement
anteriorlyendsattheattachmentoftheepiglottis,termedthevalleculae(bottomleft).Toenterthehypopharynx,theendoscopeis
advancedposteriorlybehindtheepiglottisintothehypopharynx(bottomright).Theepiglottisappearstoformaroofoverthe
hypopharynx.Thevocalcordsaresurroundedbythearyepiglotticfoldsanteriorly.Inthisposition,thepiriformrecessesorsinusesare
onthelateralsideofthearyepiglotticfolds.Thecricopharyngeusandentrancetotheesophagusareinthemidlineposteriorly.
Atlas of Clinical Gastrointestinal Endoscopy 3
FIGURE1.3 DIRECTIONTO
CRICOPHARYNGEUS
Theendoscopeispassedoverthetongue
anduvula(upperleft).Oncepasttheuvula,
theepiglottisandhypopharynxareseen
inthedistance.Anasogastricfeedingtube
isnowpresent(upperright).The
arytenoidsarenowvisiblewiththe
feedingtubeseenposteriorinthemidline
(bottomleft).Thearytenoidsareopenand
thevocalcordsvisible.Again,thefeeding
tubeisposteriorinthemidlineshowing
thelocationofthecricopharyngeus
(bottomright).
FIGURE1.4 VOCALCORDS
Normalvocalcordsandsurroundingstructuresasseenfromthe
arytenoids.
4 Atlas of Clinical Gastrointestinal Endoscopy
A B
FIGURE1.5 HYPOPHARYNX
A,Normal-appearinghypopharynxasseenonhigh-definitionendoscopy.B,Narrow
bandimagingofthehypopharynx.
FIGURE1.6 HYPOPHARYNXWITH
ENDOTRACHEALTUBE
Notetheanatomyofthehypopharynx
withendotrachealintubation.
FIGURE1.7 PATENTUPPERESOPHAGEAL
SPHINCTER
Afterendoscoperemoval,theupper
esophagealsphincterremainedpatulous.
Noteitslocationrelativetothe
cricopharyngeus,confirmingtheposterior
locationoftheupperesophagealsphincter.
Alsonotetheerythemaofthehypopharynx
andarytenoids.
Upper
esophageal
sphincter
FIGURE1.8 TRACHEAANDCARINA
Viewofthe(A)tracheaand(B)carinaat
endoscopy.Notetheringlikearchitecture
ofthetrachea.
A B
