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394 D.-M. Denk-Linnert and R. Scho¨fl
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Fig. 2 Hypopharynx carcinoma tumor mass in the left pyri-
form sinus (indirect rigid hypopharyngolaryngoscopy [From
Becker et al. (1983)]
Fig. 4 Leukoplakia of the left vocal fold (flexible hypophar-
yngolaryngoscopy)
Leukoplakia of the Vocal Folds (Fig. 4, left vocal
fold). The epithelium has a white coating, and dis-
tinction from malignancy can only be made histologically. Stroboscopy helps judge whether the
process is infiltrating or not, but cannot replace histology. If the vocal fold does not vibrate in stroboscopy, an infiltrating process is present, and urgent
microlaryngoscopy with biopsy for histological
examination is indicated.
Unilateral Vocal Fold Paralysis. The paralyzed
vocal fold is in fixed position (median, paramedian,
intermediate or lateral), and the arytenoid may be
Fig. 3 Reinke’s edema (rigid hypopharyngolaryngoscopy)
dislocated anteriorly. During phonation, depending on
the position of the vocal fold, glottic closure is
incomplete. Stroboscopy may be of some prognostic
Reflux Laryngitis. Gastroesophageal/pharyngeal
reflux disease can lead to a laryngitis that is not
always limited to the posterior larynx. Possible mor-
value: the presence of the mucosal wave is a good
prognostic sign. Figure 5 shows a left-sided vocal
fold paresis in paramedian position.
phological findings are reddening of the arytenoids,
hypertrophy in the posterior commissure, contact
granuloma of the vocal process, or glottic/subglottic
stenosis.
2.4 Flexible Endoscopic Evaluation
of Swallowing (with Sensory Testing)
Reinke’s Edema. This type of chronic laryngitis
frequently occurs in smokers, in patients with vocal
abuse or with endocrinological dysfunctions (e.g.,
menopause, hypothyroidism). It presents with edematous, thickened vocal folds and vasectasias (Fig. 3).
The voice typically sounds low and frequently hoarse.
The flexible endoscopic evaluation of swallowing
(FEES), also called videoendoscopic swallowing
study (VESS), was introduced by Langmore et al.
(1988) and Bastian (1991). This dynamic diagnostic
method allows an evaluation of the oropharyngeal
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Fig. 6 Aspirate in the trachea—flexible endoscopy via
tracheostoma
Fig. 5 Vocal fold paresis, left side (flexible hypophar-
yngolaryngoscopy)
Generally, no localanesthetic spray isused, in order not
swallow and has become a routine otorhinolaryngological/phoniatric procedure. It aims at defining the
individual swallowing profile of the patient, which
enables adequate treatment planning and recommendation for feeding. FEES is considered to be more
than a screening procedure and does not only identify
dysphagia and aspiration, but reveals the pathophysiology of the swallowing disorder.
Flexible endoscopic evaluation of swallowing with
sensory testing (FEESST) is the combination of FEES
with laryngopharyngeal sensory testing and was first
described by Aviv et al. (1998, 2002). The quantitative testing of sensory thresholds is performed by
endoscopically delivered standardized air puffs to the
mucosa, innervated by the superior laryngeal nerve to
elicit the laryngeal adductor reflex.
According to the modified barium swallow,
FEES(ST) is performed as a tailored examination (Bigenzahn and Denk 1999; Denk and Bigenzahn 2005;
Schröter-Morasch 1999; Schröter-Morasch et al. 1999;
Langmore 2001):colored food in various consistencies
is used, depending on the history and clinical findings.
Suction must be available in case of aspiration. Before
endoscopy, the patient has to be observed during the
clinical examination, and neurological symptoms or
disorders of speech, language orvoice have tobe noted.
The patient is in an upright position with the head
slightly down to facilitate swallowing function.
to impair pharyngolaryngeal sensibility. If needed,
only cotton balls with a local anesthetic and decongestant are positioned into the nose before endoscopy.
The flexible rhinopharyngolaryngoscope is introduced
transnasally into the oro- and hypopharynx and isleft in
place during deglutition. Digital recording allows an
analysis in slow motion and discussion of the findings
in the interdisciplinary management team.
The endoscopic examination consists of two parts:
non-swallowing and swallowing assessment. In the
‘‘non-swallowing assessment,’’ anatomy and function
are investigated. The mobility of the vocal folds, the
occurrence of hyperkinetic movements, pooling/aspiration of saliva, cough reflex (elicited by gently
touching the glottis with the tip of the endoscope) and
the possibility ofintentional(voluntary) throat-clearing
are tested.The velum, pharynx and larynx are observed
not only during respiration, but also during phonation,
breathhold maneuvers, throat-clearing, and coughing
to test intentional and reflexive mobility. The second
part of the procedure comprises the swallowing
assessment, i.e., ‘‘dry swallow’’ with saliva and ‘‘food
swallows’’ withmeasured quantities offoodand liquids
of differentconsistencies, dyed withbluefood coloring,
according to a standardized protocol. The endoscope is
positioned in the panoramic view above the tip of the
epiglottis. In tracheostomized patients, endoscopy via
the tracheostoma is also performed (Fig. 6).
396 D.-M. Denk-Linnert and R. Scho¨fl
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• Laryngeal closure (due to of epiglottic tilting) and
aspiration during the swallow cannot be examined
directly. The view during the swallow is obscured
because pharyngeal mucosa and the bolus touch the
tip of the endoscope.
• Larynx/hyoid elevation and upper esophageal
sphincter function are not shown. Diseases of the
pharyngoesophageal segment and esophagus can
only be indirectly presumed in the case of pharyngeal residue and/or pharyngeal regurgitation.
• Routinely, esophagoscopy is not part of the exami-
nation. Some authors propose using a longer flexible
endoscope toroutinely evaluate the esophagus during
FEES (Herrmann 1998), especially when transnasal
Fig. 7 Aspiration (flexible hypopharyngolaryngoscopy) [From
Bigenzahn and Denk (1999)]
esophagoscopy is performed (Tong et al. 2012).
The influence of the endoscope as a foreign body
during swallowing has not yet been evaluated exactly.
On the contrary,thereare many advantagesto FEES:
Swallowing function is evaluated with regard to
saliva pooling, triggering of the swallowing reflex,
leaking, penetration, retention, aspiration, cough
reflex, and regurgitation. Hypopharyngeal regurgitation leads to suspicion of a hypopharyngeal/esophageal
stenosis or Zenker’s diverticulum. Aspiration before
and after the swallow can be viewed, whereas aspiration during the swallow cannot be seen directly. Also,
• The direct visualization of the upper-aerodigestive
tract reveals even subtle morphological or functional findings.
• It is a non-invasive procedure without any radiation
exposure, repeatable as often as necessary, and
available also as a bedside examination, e.g., in the
intensive care unit (ICU).
• Regular food, not barium, is used.
the amount of aspiration cannot be judged securely
(only in patientswithoutcough reflex ortracheostomy).
The ability to effectively clear the throat of retention
and aspirated material is tested. Finally, compensatory
postures, swallowing techniques and various food
consistencies are evaluated in order to establish an
individually tailored treatment program. Moreover,
flexible endoscopyhas proved to be a treatment toolfor
visual biofeedback training in functional swallowing
therapy (Denk and Kaider 1997), and it’s combination
with other diagnostic procedures may be useful. In
addition, commercially available ‘‘workstations’’ will
eventually comprise sonography, electromyography or
other diagnostic methods. Figure 7 shows a static
image ofaspiration. Colored liquid is pouring down the
subglottic region into the trachea.
2.4.2 Comparison of FEES(ST)
and Videofluoroscopy
The only methods for visualization of aspiration are
videofluoroscopy (VFS) and FEES(ST). VFS enables
watching the bolus on its entire way from the oral
cavity to the stomach, and it was the first instrumental
procedure for the assessment of dysphagia (Logemann
1993, 1998; Jones and Donner 1991; Ekberg and
Olsson 1997). FEES(ST) shows the upper aerodigestive tract directly. Especially with regard to cost
effectiveness, the question arises as to which method is
best for the evaluation of dysphagia. The literature and
our own studies show that these dynamic methods are
not alternative, but rather complementary procedures
(Schima and Denk 1998). Both are valuable, and each
procedure has it’s place in the clinical setting. A study
2.4.1 Advantages and Limitations
The following limitations of FEES have to be taken
into account:
• There is no direct visualization of the bolus on it’s
entire path from mouth to stomach as offered by
videofluoroscopy.
by Aviv (2000) could show that the outcome of dysphagia management with regard to pneumonia incidence was the same using videofluoroscopy and
FEES(ST). Comparing the findings of FEES(ST) and
VFS, there is widespread agreement with regard to
aspiration and retention. Due to the limitations of
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Fig. 8 Laryngoscope according to Kleinsasser for direct
microlaryngoscopy
FEES(ST) mentioned above, VFS remains indispensable (‘‘gold standard’’) for the evaluation of the
complete upper digestive tract in a single examination.
FEES(ST) is the method of choice for the first-line
examination, follow-up examinations, for seriously ill
patients in the intensive care unit, and for the evaluation of compensatory maneuvers.
2.5 Direct Endoscopy of the Pharynx
and Larynx
Direct rigid endoscopy of the pharynx and larynx,
which was developed by Kleinsasser (1968) (‘‘laryngeal suspension microlaryngoscopy’’), does not
only allow microscopic evaluation of the pharynx and
larynx, but also surgical therapies (phonosurgery with
the aim of voice improvement, cold steel, and laser
surgery). The procedure is carried out under general
anesthesia. Various laryngoscopes are available in
different sizes and types, e.g. from Kleinsasser (1968)
(Fig. 8). The patient lies in the supine position, and
after protecting the teeth, the laryngoscope is inserted
to the level of the vocal folds while the hypopharynx
and supraglottis are being inspected. Then the laryngoscope is held by a laryngoscope holder that rests
either on a table over or directly on the patient’s chest.
The microscope is then positioned.
Recently developed ventilation techniques have
led to the possibility of tubeless jet ventilation to
avoid intubation (Aloy et al. 1991). This method
improves the operative conditions for the surgeon by
providing more space for manipulation and better
visibility (Fig. 9). Moreover, it is also suited for
Fig. 9 Granuloma of the left vocal process (direct micro-
laryngoscopic view, tubeless jet ventilation)
laryngeal laser surgery, thus avoiding flammable
tubes, and for endoscopic surgery of stenoses.
2.5.1 Examples of Typical Findings
Vocal Fold Granuloma. Figure 9 shows the micro-
laryngoscopical view ofatypical vocal fold granuloma,
which is locatedon the vocalprocess. It mayoccur after
intubation (intubation granuloma)or is often associated
with reflux disease (contact granuloma). Additional
risk factorsfor development of a contact granuloma are
functional voice disorders and psychogenic factors. For
therapy, conservative treatment with proton pump
inhibitors and logopaedic voice therapy can be tried. If
the pathology persists or if a histological diagnosis is
necessary, microlaryngoscopic surgery is performed.
Zenker’s Diverticulum. As an alternative to the
external approach with resection of a Zenker’s
diverticulum, endoscopic laser surgery may be performed. In Fig. 10, the party wall between the
esophagus and Zenker’s diverticulum is seen when
endoscopically exposed before laser surgery.
Laryngeal Carcinoma. An irregular mucosal surface or a tumor mass may be observed in the supraglottic (Fig. 11), glottic or subglottic area. Vocal fold
motility may be impaired. Depending on the tumor
size, the airway may be compromised.
Recurrent Respiratory Papillomatosis (Fig 12).
Papillomas are present both at the glottic level
(bilaterally), the left supraglottis region and the posterior commissure.
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Fig. 10 Zenker’s diverticulum (direct hypopharyngoscopic
view), intraoperative view on a party wall between the
esophagus and Zenker’s diverticulum. The laser marking for
the planned laser resection can be seen
Fig. 11 Carcinoma of the larynx (direct microlaryngoscopy).
The tumor mass is seen on the vocal folds
Fig. 12 Recurrent respiratory papillomatosis of the larynx
(direct microlaryngoscopy). Papillomas are seen at the glottis
level bilaterally and the left supraglottic region (ventricular
fold)
filtered blue light of a xenon short arc lamp and processed by a CCD camera system. During microlaryngoscopy, the use of autofluorescence can improve the
early detection of laryngeal cancer and its precursor
lesions (Malzahn et al. 2002).
Contact Endoscopy. Contact endoscopy tries to
improve the assessment of benign, pre-malignant and
malignant pathologies of the larynx during microlaryngoscopy. The aim is to make epithelial cells visible,
as in gynecology. After staining the tissue with
methylene blue, the magnifications obtained with
contact endoscopy (609 and 1509) enable observation of the epithelial cells and their characteristics
(Andrea et al. 1995). However, it does not replace
biopsy sampling (Warnecke et al. 2010).
3-D Endoscopy. For scientific purposes, 3-D endoscopic techniques were used in microlaryngeal surgery
using tubeless jet ventilation (Schragl et al. 1995). This
technique has not yet become clinically routine.
2.5.2 Recent Developments and Future
Aspects
Among the new technologies designed to enhance
information during endoscopy are:
Autofluorescence Endoscopy. The aim of this development is to enhance endoscopic information during
microlaryngoscopy. Autofluorescence is induced by the
3 Endoscopy of the Esophagus
Endoscopy of the esophagus as part of endoscopic
evaluation of the upper gastrointestinaltractis one of the
most frequent procedures performed in Western health
care systems (Owings and Kozak 1998). The aim of
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esophagoscopy is diagnosis, differential diagnosis and
follow-up of esophagealdiseases. Moreover, endoscopy
supports further diagnostic procedures, such as endosonography, and enables therapeutic interventions. Two
forms of esophagoscopy are in use: rigid and flexible
endoscopy. Gastroenterologists and surgeons are
accustomed to using flexible gastroscopes to perform
total esophagogastroduodenoscopy, whereas otorhinolaryngologists prefer rigid instruments.
3.1 Symptoms of Esophageal Diseases
As the esophagus provides transport of the bolus in the
esophageal phase of swallowing, diseases of the
esophagus bring aboutsymptoms related toswallowing
function. No single symptom is typical of a specific
disorder. The localization of symptomsby the patientis
unreliable. Patients who suffer from esophageal diseases (Table 1) may report the following symptoms
(see also ‘‘Saliva and the Control of Its Secretion’’):
• Dysphagia. In the case of esophageal stenosis
(e.g., esophageal carcinoma) or functional motility
disorders (e.g. achalasia of the lower esophageal
sphincter), the bolus transport is disturbed and
causes the feeling of a stopping of the bolus passage, especially for solid food. The dysphagia
symptom needs the analysis of all the four phases
of deglutition (oral preparatory, oral, pharyngeal,
and esophageal phase), since oropharyngeal and
esophageal dysphagia may influence each other or
occur in combination. Malignancy correlates with
rather fast progression of dysphagia, benign strictures with slowly progressive dysphagia, whereas
functional disorders such as achalasia like to vary
severity of symptoms over time. Grading of dysphagia can assist indication and quality measurement of treatment (see Table 2).
• Regurgitation. Reflux of swallowed bolus material
from the esophagus to the pharynx and mouth due
to retrograde esophageal motility, stenosing
esophageal diseases, or retained material (e.g. in
Zenker’s diverticulum).
• Odynophagia. Painful swallow.
• Globus sensation (globus pharyngeus) Globus
sensation often derives from gastro-esophageal
reflux disease. Other possible underlying causes
that have to be considered for differential diagnosis
are not only diverticula, webs, and rings, but also
Table 1 Esophageal diseases [modified from Seiden in Par-
parella et al. (1991)]
Motility disorders
Primary disorders
Achalasia
Diffuse esophageal spasm
Nutcracker esophagus
Non-specific dysfunction (hypertensive lower esophageal
sphincter, diminished amplitude of esophageal peristalsis)
Secondary disorders
Scleroderma and other connective tissue disorders
Diabetes mellitus
Alcoholism
Central nervous system disorders
Presbyesophagus
Chagas’ disease
Structural disorders
Extrinsic compression
Webs, rings
Diverticula
Stricture due to reflux esophagitis
Ingestion of caustic substances
Hiatal hernia
Varices
Foreign bodies
Benign tumors
Malign tumors
Congenital disorders
Atresias
Tracheoesophageal fistulas
Duplications
Dysphagia lusoria
Achalasia
Table 2 Grading of dysphagia
0 = able to eat normal diet/no dysphagia.
1 = able to swallow some solid foods
2 = able to swallow only semi-solid foods
3 = able to swallow liquids only
4 = unable to swallow anything/total dysphagia
(Knyrim et al. 1993 N Engl J Med)
thyroid gland diseases, cervical spine syndrome or
functional voice disorders.
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Fig. 13 a Rigid
esophagoscope. b, c Flexible
gastroscope; control part (b),
tip (c)
• Heartburn, retrocardiac chest pain. These symptoms
occuringastro-esophageal reflux disease,aswellasin
esophageal carcinoma, esophageal spasms or esophagitis of other etiologies. In approximately 40 % of
patients suffering from reflux disease, the typical
symptom of heartburn is lacking. Exclusion of
ischemic heart disease, pericarditis, aortic dilatation
and pleuritis is mandatory.
• Cough of unknown etiology. Cough may be due to
aspiration or occur in esophageal reflux disease.
• Gastrointestinal bleeding. Bleeding from the mouth
without source in the nose, mouth, pharynx or larynx or overt/occult blood in the stool necessitates
urgent esophagogastroduodenoscopy.
If one of these symptoms is present, endoscopy of
the esophagus is indicated.
Esophagoscopy is appropriate in (suspected) for-
eign body ingestion or as part of gastroduodenoscopy.
3.2 Rigid Esophagoscopy (Rigid
Hypopharyngoesophagoscopy)
Traditionally, rigid (open tube) esophagoscopy is the
method of choice for otorhinolaryngologists to remove
foreign bodies located in the pharyngoesophageal
segment or cervical esophagus and to perform tumor
staging (panendoscopy) in patients with primary
malignancies in the head and neck to exclude/diagnose
simultaneous additional malignancies (Dhooge et al.
1996). The incidence of simultaneous esophageal
malignancies is about 8.4 % (Dammer et al. 1999).
Rigid esophagoscopy is usually performed under
general anesthesia after informed consent. The patient
lies on his back, with the neck flexed and the head
extended. The open-tube esophagoscope (Fig. 13a) is
inserted after protection of the teeth. Behind the
arytenoids, the esophageal entrance is passed. The
esophagoscope has to be advanced gently to avoid
perforation. It is not possible to visualize the gastric
mucosa safely with an open esophagoscope in all
cases. If evaluation of the distal esophagus is needed,
an esophagoscope with air insufflation can be used.
Risks include tooth damage, luxation of the arytenoids, bleeding, and perforation of the hypopharynx or
esophagus with consecutive mediastinitis or peritonitis.
The complicationrate is under 1 % (Schmidtet al. 1998).
3.3 Flexible Esophagoscopy
Esophagoscopy is performed for the diagnosis of esophageal diseases, follow-up, additional diagnostic procedures, and for therapeutic measurements (hemostasis,
dilatation, stenting, argonplasmacoagulation,endoscopic
mucosal resection, endoscopic submucosal dissection).
Today, fiber endoscopes have been completely
replaced by video endoscopes with CCD cameras
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(charge coupled device) at the tip. This facilitates
additional techniques such as zooming, enhancement
of contrast and improvement of resolution (e.g. highdefinition technology, endomicroscopy). A channel in
these endoscopes allows other instruments (forceps,
brush, snare, injection needle, dilatation balloon) to
be passed through in order to take tissue samples,
remove polyps, inject varices, dilate strictures, etc.
The length of the esophagogastroscope (Fig. 13b, c)
is about 100–120 cm, with a diameter of about
5–14 mm, depending on it’s purpose (ultra-thin
stricture endoscope, therapeutic instruments with
extra-thick channels). It has become standard to
record the examination on a video/DVD recorder or
file images in an electronic processing system for
Fig. 14 Esophagogastric junction without pathology
documentation. Flexible endoscopy of the esophagus
is usually performed on an outpatient basis with local
anesthesia, using a spray containing benzocaine or
tetracaine hydrochloride. The patient, who has been
bleeding, cardiopulmonary complications, aspiration,
side effects of premedication, and infection.
fasting for 6–8 h prior to endoscopy, is offered intravenous sedation (e.g., with midazolam or propofol).
He is placed in the left lateral decubitus position. After
a hollow mouthpiece is introduced, the lubricated
endoscope is inserted under visual control. In the case
of pathological or unclear findings in the hypopharynx
or larynx, the patient is referred to the otorhinolaryngologist. The instrument is advanced until the tip of
the endoscope reaches the gastro-esophageal junction
(approximately 40 cm from the incisors). For examination of the stomach and duodenum (flexible esophagoduodenoscopy), the tip is further advanced
through the cardia, and the different portions of the
stomach (cardia, fundus, corpus with greater and lesser
curvature, antrum) are inspected. Afterwards, the tip is
passed through the pylorus, into the duodenal bulb and
the descending part of the duodenum.
The examination evaluates the lumen, wall, contents, peristalsis, and appearance of the mucosal surface and it looks at or excludes flat, protruded, or
excavated lesions. If indicated, biopsies and brushing
for histological, cytological and bacteriological
examinations are performed.
Large clinical studies report an incidence of
moderate or severe complications in 0.1–0.2 %, with
mortality between 1 in 100,000 and 1 in 5,000,
depending on the severity and urgency of underlying
diseases and the proportion of therapeutic procedures.
The complications that may occur are perforation,
3.3.1 Examples of Typical Findings
Normal esophagus. The esophageal mucosa (nonkeratinizing stratified squamous epithelium) appears
pale, whereas the gastric mucosa is reddish (columnar
epithelium). The transition between these two types of
epithelium (esophagogastric junction) should be very
visible. Because of it’s saw-toothed pattern, it is
called the Z line (Fig. 14).
Reflux esophagitis. Among the many patients with
reflux symptoms, endoscopy can define the subgroup
of those with reflux esophagitis characterized by
reddening, erosions, ulceration or stricture at and
above the Z line. A grading of reflux esophagitis can
be given with the Savary and Miller (1977), MUSE
(metaplasia, ulcer, stricture, erosions), or Los Angeles
Classification. According to the grading by Savary
and Miller (1977), four or five subgroups are
described:
Grade 1, singular erosions; Grade 2, confluent
erosions; Grade 3, esophagus covered by circular
erosions; Grade 4, complications with peptic stricture,
with or without signs of inflammation, or ulceration;
Grade 5, Barrett’s esophagus. Figure 15 shows a
reflux esophagitis Grade 2, Fig. 16 a peptic stricture
due to acid reflux.
Barrett’s Esophagus. Due to long-lasting peptic
reflux, the squamocolumnar junction in the distal
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Fig. 15 Reflux esophagitis (grade 2 according to Savary and
Miller)
Fig. 16 Peptic stenosis in the distal esophagus
esophagus moves upwards and the squamous epithelium is replaced by a specialized columnar epithelium
with intestinal metaplasia. It’s extent is described by
the Prague classification, with ‘‘C’’ for circumferential extent and ‘‘M’’ for the maximal longitudinal
extent of Barrett’s esophagus in centimeters. Barrett’s
metaplasia (Fig. 17) is a well-known risk factor for
the development of dysplasia and adenocarcinoma
(Fig. 18, early adenocarcinoma in Barrett’s esophagus). Endoscopically, metaplastic gastric mucosa is
recognized in the esophagus because of it’s salmonred appearance. Therefore, follow-up examinations
with biopsies are necessary. For improving the diagnostic yield, chromoendoscopy with acetic acid
(Fig. 19) or indigocarmine, optical filter technology
Fig. 17 Metaplasia due to chronic reflux (Barrett’s esophagus)
Fig. 18 Early adenocarcinoma in Barrett’s esophagus
(NBI) or digital image reprocessing should be added
to the routine procedure.
Esophageal carcinoma. Endoscopy shows early
cancer (Fig. 20) or a polypoid or ulcerated mass or
infiltration that can obstruct the esophageal lumen
(Fig. 21). Multiple biopsies are taken for histological
diagnosis. The incidence of adenocarcinomas derived
from Barrett’s esophagus has increased dramatically
in the USA and Europe, whereas the alcohol and
tobacco-associated squamous cell carcinoma has
become less frequent. High-grade dysplasia and early
cancer limited to the mucosa or superficial submucosa
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Fig. 19 Barrett’s esophagus with high-grade dysplasia, chro-
moendoscopy with acetic acid
Fig. 21 Advanced ulcerated squamous cell carcinoma of the
distal esophagus
Fig. 20 Early squamous cell carcinoma of the mid-esophagus
can now be removed endoscopically by endoscopic
mucosal resection (EMR- Fig. 22) or endoscopic
submucosal dissection (ESD). Photodynamic therapy
and radiofrequency ablation can assist in curative
treatment of these pre-malignant and early malignant
states. In the case of a symptomatic tumor stricture, a
balloon dilatation or bougienage can be performed
(Fig. 23) and a metal stent positioned as part of a
multimodal therapy or a palliative approach (Fig. 24).
Varices: In portal hypertension, collaterals are
found preferably in the distal esophagus. The blue,
more or less prominent strings can be ligated endoscopically with rubber bands or injected with glue to
treat or prevent bleeding (Fig. 25).
Fig. 22 Endoscopic mucosal resection
Schatzki Ring. Endoscopy reveals a stricturing
membrane in the distal esophagus. It may cause
dysphagia, especially concerning solid food, and
give rise to an impacted foreign body. For therapy,
dilatation or thermal ablation during endoscopy is
performed.
Soor esophagitis. A white cover or single white
spots (Fig. 26) are seen on the esophageal wall; they
can be removed with forceps, but not with rinsing.
Brush cytology easily depicts Candida during
microscopic examination.
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