bluuebunny/crossref_metadata_2025 huggingface dataset:
1700  Low Back Pain: An Unusual Initial Presentation of Esophageal Adenocarcinoma
Authors: Hawa Fadi , Al Hillan Alsadiq , Al-Banaa Kadhim , Gunaratnam Naresh T. , Yazdani Ali
Published: October 2019

INTRODUCTION:

Esophageal cancer is the sixth most common cancer worldwide that is associated with a poor prognosis. Clinically, dysphagia and weight loss are the most common presentations. However, non-specific symptoms of distant metastatic disease might be the initial presentation which provides a diagnostic challenge and delay in management. We describe a case of an unusual presentation of esophageal cancer with acute low back pain secondary to vertebral compression fracture without gastrointestinal symptoms.

CASE DESCRIPTION/METHODS:

A 51-year-old male with tobacco use disorder but otherwise unremarkable medical history, presented to the clinic with acute onset non-traumatic right flank pain and low back pain. Patient had no gastrointestinal symptoms. Physical examination and baseline laboratory data yielded no pertinent findings. Computed Tomography scan of the abdomen showed L2 vertebral body compression deformity. Radiography and Magnetic Resonance Imaging of the lumbar spine were concerning for an acute L2 pathological compression fracture. Therefore, patient had a core biopsy of the L2 vertebral body which revealed metastatic adenocarcinoma favoring an upper gastrointestinal primary tumor. Accordingly, patient underwent an upper endoscopy which revealed a non-lumen occluding distal esophageal mass. Endoscopic Ultrasound revealed a 7 × 8 mm lymph node adjacent to the pancreatic body. Biopsy of the mass and fine needle aspiration of the lymph node were consistent with Stage IV esophageal adenocarcinoma. Patient is currently undergoing palliative chemotherapy and radiation therapy.

DISCUSSION:

Esophageal cancer is often asymptomatic in early stages and patients present with progressive dysphagia at advanced stages, when the esophageal lumen is less than 13 mm. Initial presentation of esophageal cancer with symptoms of distant metastatic disease without gastrointestinal symptoms have been rarely described in the literature. Our patient’s lack of supportive gastrointestinal symptoms and atypical presentation with low back pain, provided a diagnostic challenge. However, L2 vertebral body biopsy was the key in establishing the diagnosis of esophageal cancer. This case highlights the atypical initial presentation of esophageal cancer as a metastatic disease which can present with myriad of symptoms unrelated to the primary tumor. Therefore, when esophageal malignancy is suspected, histopathological examination of a possible metastasis might be the only window towards diagnosing the primary esophageal cancer.
1702 Acute Esophageal Necrosis: A Rare Complication of Long-Standing Alcohol Abuse With Severe Hypoperfusion
Authors: Serrano Alexis , Shah Reshma , Brizell Kimberly , Kudelko Marc , Halleman Christopher D.
Published: October 2019

INTRODUCTION:

Acute Esophageal Necrosis, the “black esophagus”, is dark pigmentation of the esophagus with histologic mucosal necrosis that presents with symptoms of bleeding from the upper GI tract. AEN itself is not a poor prognostic factor. AEN in combination with multiple comorbidities raises mortality up to 32%. Risk factors include alcohol abuse, advanced age, male gender, advanced malignancies, hypertension, coronary artery disease, renal disease, and diabetes mellitus.

CASE DESCRIPTION/METHODS:

A 71 yr old male with medical history of CKD4, CAD, HTN, HLD, Barrett’s esophagus, ulcerative esophagitis, and alcohol use presented with hematemesis, abdominal pain, and melena that began three days prior. Patient was hypotensive and tachycardic with a hemoglobin of 4.8g/dL. Pt was administered multiple unity's of pRBCs, IV PPI, IV Octreotide, and IV fluid resuscitation. Due to hemodynamic compromise, a left IJ CVC was placed and vasopressors started. The GI team was consulted. Emergent EGD revealed circumferential esophagitis with ulcerations, adherent clots, and large areas of black mucosal discoloration. Broad spectrum antimicrobials initiated. A gastrograffin study was obtained without extravasation noted. Patient was diagnosed with pyelonephritis and transitioned to culture sensitive antimicrobial therapy; still requiring vasopressors and blood products due to multifactorial shock. Given severity of illness and grim prognosis, the patient’s family elected for comfort care.

DISCUSSION:

AEN is a rare condition with an etiology thought to be multifactorial-to a low flow state from watershed distribution and corrosive injury from gastric contents due to esophagogastroparesis and gastric outlet obstruction resulting in decreased function of mucosal barrier systems and impairment of repairing mechanisms. Visualization via EGD of circumferential black mucosal necrosis with an abrupt stop at the GE junction is diagnostic. If circumferential necrosis is seen, immediate withdrawal of the scope should be performed. In patients with patchy necrosis, the clinician may be able to continue with endoscopy. Treatment is supportive with IVFR, IV PPIs, blood transfusions, carafate, and most importantly treatment of the underlying disease state. Complications include esophageal perforation, mediastinal infections with abscesses, esophageal strictures, esophageal stenosis, and death. General Surgery should be consulted for possible intervention. After the patient exhibits improvement, repeat endoscopy should be performed.
1707 Sorafenib-Induced Severe Candida Esophagitis
Authors: Tageldin Omar , Mansoor Muhammad Sohail , Parsa Nour
Published: October 2019

INTRODUCTION:

Candida species are a part of normal GI flora however some patients, especially during immunocompromised state can develop Candida esophagitis (CE). Sorafenib is a tyrosine kinase inhibitor commonly used for treatment of renal cell and hepatocellular carcinoma (HCC). We report one of the most severe cases of CE following Sorafenib.

CASE DESCRIPTION/METHODS:

An 84-year-old man was admitted for a 2-week history of solid food dysphagia with nausea, chocking and regurgitation following food intake. His medical history included type 2 diabetes mellitus and stage IV (T3N0M1) metastatic HCC. Patient had been taking Sorafenib 400mg twice daily for the last 6 months and recently received palliative radiotherapy (RT) for a pathologic pelvic fracture due to bone metastasis. Patient denied any vomiting, odynophagia, anorexia, fever, chills, abdominal pain, diarrhea or constipation. On clinical examination, he had normal vital signs, appeared thin and cachectic, had oral thrush underneath artificial dentures while the rest of the clinical examination was unremarkable. His lab-work showed borderline leukocytosis of 11.9 103/µL, mild anemia with Hb of 10.5 g/dl, and normal electrolytes, renal function and liver integrity enzymes. He underwent an esophagogastroduodenoscopy (EGD) which interestingly showed esophagus completely lined with thick whitish adherent plaques, diffuse atrophic gastropathy and normal duodenum. Despite the esophagus having no tortuosity, rings or strictures, it required considerable amount of force to advance the endoscope through the copious amount of exudate in the esophagus which would explain the patient’s dysphagia. We obtained biopsy and brushing from esophagus which revealed abundant inflammatory cells and fungal organisms consistent with Candida species. Patient was given a loading dose of 400 mg of Fluconazole followed by 200 mg daily for 21 days. After completion of therapy, patient’s symptoms had improved, and he was tolerating a regular diet.

DISCUSSION:

Upon literature review we found one case series of 2 patients mentioning CE as a side effect with the use of Sorafenib. Unlike above case series in which patients developed CE soon after initiation of Sorafenib, our patient developed symptoms after being on it for 6 months. Physicians should be aware when using Sorafenib that it can induce an immunosuppressive state with an increased risk of CE. Delayed diagnosis and subsequent treatment may affect the nutritional status and subsequently the overall survival in these patients.
1725 A Case of Latin American Female Diagnosed With Esophageal Adenocarcinoma on Brush Cytology Biopsies
Authors: Multani Monica , McDonald Emmanuel , Ponce Fernanda , Sharma Radhika , Sobrado Javier
Published: October 2019

INTRODUCTION:

In 1975, the incidence of esophageal adenocarcinoma (EAC) was 0.4 cases per 100,000. In 2009, the incidence had risen by 5 fold to 2.58 cases per 100,000, making it one of the fastest growing cancers at this time. Esophagoduodenoscopy (EGD) is the gold standard for diagnosing Barrett’s esophagus (BE), which is a precursor to EAC. With the advent of new techniques of brush cytology sampling, there is potential to broaden our technology and our screening criteria for prevention. We present a rare case of a Latin female who was diagnosed with EAC after goblet cells were incidentally found on brush cytology.

CASE DESCRIPTION/METHODS:

A 73 year old Latin female with history of hiatal hernia, and H. Pylori presented with heartburn and abdominal pain. The EGD showed foveolar dysplasia at the gastric-esophageal junction. Wide Area Transepithelial Sample Biopsy With 3-Dimensional Computer-Assisted Analysis (WATS3D) showed goblet cell metaplasia. Repeat WATS3D confirmed these results and repeat forceps biopsy showed high grade dysplastic glands consistent with a well differentiated EAC. She underwent endoscopic ultrasound with biopsy and it was staged as T3N2Mx. She had a mucosal resection performed which showed poorly differentiated EAC and was referred to oncology.

DISCUSSION:

It is predicted that between 2011 and 2030, deaths related to EAC will double the number of those that died between 1991 to 2010. Some studies have shown increased detection rates of EAC precursors including those of BE and esophageal dysplasia (ED). For example, a 2010 study concluded that WATS3d brush biopsy allowed for substantial increases in the detection rates of BE by 39.8% and ED by 87.5%. Another 2017 study revealed an increase of 83% for BE and 88.5% for ED. Thus, cytology brush biopsies can help to diagnose high grade dysplasia and/or cancer with greater than 80% sensitivity and 95% specificity. It is also important to note that for women, the future incidence and mortality rates are also expected to rise in 2030 by approximately 9 times. The population we screen for BE is in white males over 50 who are symptomatic and with risk factors for BE or EAC. However, this is a rare case of a latin female that would not have fallen under these screening guidelines. Because of the rising incidence with worsening mortality contributing to the overall rise in EAC cases, we believe that it is imperative to broaden our screening criteria and to implement new tools such as brush cytology biopsies to a broader population as well.
1727 Importance of DIETARY Modification in Successful Management of Eosinophilic Gastroenteritis
Authors: Kudaravalli Pujitha , Saleem Sheikh A. , Sapkota Bishnu
Published: October 2019

INTRODUCTION:

Eosinophilic gastroenteritis (EGE) is an extremely rare inflammatory disorder with an estimated prevalence of 22-28/100 000. We herein, present a case of EGE in an elderly patient which was successfully managed with dietary restriction. We would like to stress that food allergy is the main culprit in certain cases of EGE and dietary modification should always be the first step in the management of these cases.

CASE DESCRIPTION/METHODS:

A 70-year-old male with a history of GERD, atopic dermatitis and asthma presented with 2 weeks history of foul-smelling non-bloody diarrhea associated with nausea, vomiting and weight loss. Physical examination was significant for dry oral mucosa and loss of skin turgor. Lab findings were significant for a Hb/Hct (g/dl/%) of 13.2/38.5, MCV of 86.3%, WBC count of 24,200/mm3, albumin of 2.2 g/L, stool fat of 70g, stool osmolar gap of 115, CRP of 1.47. ESR, HIV test, infectious stool work-up were unremarkable. CT abdomen was unremarkable. The mucosa appeared mildly inflamed on upper endoscopy and colonoscopy, and biopsies showed eosinophilic infiltration of the mucosal and muscular layers. A diagnosis of EGE was made after other causes such as parasitic infection, drug use and malignancy were ruled out. The patient was suggested a six-food elimination diet which successfully resolved his diarrhea. The patient did not have any relapses with dietary modification on follow-up.

DISCUSSION:

The prevalence of EGE is underestimated as it is under diagnosed given the rarity of the condition especially when it presents outside of the age spectrum. The pathogenesis of EGE remains unclear and it is hypothesized to be a hypersensitive response to certain allergens. The recurrence rate of EGE is 50% and a dietary trial could be a long-term solution. A six-food elimination diet or an elemental diet is recommended. Steroids improve symptoms in 90% of cases but the recurrence rates are high. The type, dose and duration of steroid therapy is unclear. Sodium cromoglicate, ketotifen, and Montelukast are other proposed treatments, the results being inconclusive. Bowel resection is performed in intestinal obstruction, but medical therapy is needed as recurrence in other segments in common. The clinical guidelines for the diagnosis of EGE is sparse and the treatment offered is low-evidence based. Dietary modification, a therapy with no side-effects should be the first line of treatment and can result in resolution sparing the patient of steroid induced side effects.
1731 Leukemic Infiltration Leading to Esophagitis: A Rare Initial Presentation of AML
Authors: Chung Jae , Richter Seth , Wazir Ali , Rahman Haider , Naseer Usman , Fitzpatrick Michael , Arslan Mustafa Erdem
Published: October 2019

INTRODUCTION:

Acute Myeloid Leukemia (AML) is a group of blood cancers that arise from clonal proliferation of malignant hematopoietic precursor cells in bone marrow. We report a case of AML that presented as esophagitis secondary to leukemic infiltration of the esophagus.

CASE DESCRIPTION/METHODS:

A 60 year male who presented with 1 month history of worsening retrosternal pain, worsened with eating & drinking, leading to a 9 kg weight loss. Patient was taking increasing doses of NSAIDS to treat this pain unsuccessfully. Patient’s past medical history included hypertension, hyperlipidemia & Bell's palsy. Patient’s EKG & 3 troponins were normal. He had no melena, hematochezia but stool guaiac tested positive. Initial CBC showed a WBC 20.5 k/mm3, Hgb 7.7 g/dL, & Platelets 28 k/mm3 with peripheral smear revealing 86% blasts with rare Auer rods. Patient was diagnosed with AML with NSAID associated gastritis & was started on IV Proton pump inhibitor therapy. Patient underwent a bone marrow biopsy that showed 95% blasts and 5% erythroid. On flow cytometry 95% were myeloblasts. Fluorescence in-situ hybridizationtesting showed MLL mutation with 11q23 rearrangement. While awaiting induction 7 + 3 chemotherapy, patient underwent EGD due to continued odynophagia. It showed multiple discreet large non-bleeding ulcers in the proximal & middle third of the esophagus. CMV esophagitis was suspected & the patient received empiric ganciclovir for 3 days. The final biopsy showed no CMV and colonisation without invasion by Actinomycetes, but it also showed atypical mononucleated cells consistent with leukemic infiltrates in the ulcer bed. Patient received induction chemo 7 + 3 but had partial response based on day 14 bone marrow & was successfully reinducted. He is currently awaiting a bone marrow transplant on consolidation chemotherapy. He is symptom free of esophagitis.

DISCUSSION:

In AML, large numbers of immature myeloid cells are seen in the bone marrow & in peripheral blood resulting in a crowding out effect of other cell lines. Presentation is usually symptoms of anemia, bleeding from thrombocytopenia or immune deficiency. In previous autopsy series, gastrointestinal involvement of leukemia have been noted, with involvement of the esophagus being less common. There have been reports of leukemic infiltration of the esophagus developing during treatment for AML, but our case is a rare initial presentation with esophagitis from leukemic infiltration which led to the diagnosis and treatment of AML.
1741 Large Cell Neuroendocrine Carcinoma of the Esophagus Arising From Barrett’s Esophagus: A Rare Phenomenon
Authors: Shah Maulik , Truscello David , Lal Kailash , Kolnik John
Published: October 2019

INTRODUCTION:

In this case report, we present an anomalous case of poorly differentiated large cell neuroendocrine carcinoma (NEC) arising in Barrett’s esophagus (BE). BE typically predisposes a patient to an adenocarcinoma of the gastroesophageal junction, although the incidence is low. Proximally, squamous cell carcinomas are a more likely finding in the esophagus. Esophageal large-cell NECs are rare and aggressive tumors and lead to a poor prognosis.

CASE DESCRIPTION/METHODS:

56-year-old male presented to the outpatient gastroenterology office with a history of gastroesophageal reflux disease (GERD) and unintentional 22 lb weight loss. He endorsed acid reflux refractory to long-term PPI therapy. Initial upper endoscopy revealed short segment Barrett’s esophagus and gastritis. Follow-up surveillance endoscopy performed six months later demonstrated a cratered ulcer within the segment of Barrett’s esophagus (Figure 1). Biopsies revealed large-cell neuroendocrine carcinoma in the setting of Barrett’s esophagus (Figure 2). Repeat biopsies taken during endoscopic ultrasound confirmed this. The biopsy stained positive for CDX2, CK7, CK20, chromogranin and synaptophysin. Following diagnosis, he was seen by Thoracic Surgery and had Ivor Lewis esophagectomy (ILE) performed. Given its aggressive biology and risk of recurrence, he was evaluated by oncology and started on carboplatin and etoposide chemotherapy treatment.

DISCUSSION:

Our patient is a middle-aged Caucasian male with a history of GERD, which are known risk factors for development of BE. BE is a precursor for esophageal adenocarcinoma (EAC), with the annual risk of transformation being 0.1-0.5%. Considering BE increases the risk of developing esophageal cancer, this case reminds gastroenterologists of the importance of surveillance endoscopy and biopsy. Although there are a few cases of esophageal large-cell NEC noted in literature, we found no others reporting this subtype in the setting of BE. Neuroendocrine collision tumors in the setting of BE have only been reported in one other case. Esophageal large-cell NEC are extremely rare, accounting for only 0.04-1.4% of GI NECs reported. Given the rarity of esophageal large-cell NECs, there are no definitive guidelines for diagnosis, staging and treatment. Surgery and platinum-based adjuvant chemotherapy have been the only effective treatments. Aggressive biology and high risk of recurrence means it is imperative that an accurate diagnosis is made and prompt treatment is initiated.
1751 A Rare Complication of a Common Finding: A Case of Iron Deficiency Anemia Secondary to an Ulcerated Inlet Patch
Authors: Curtis Stephen , Tritsch Adam
Published: October 2019

INTRODUCTION:

Inlet patches are a congenital anomaly of the cervical esophagus which are comprised of heterotropic gastric mucosa and have been reported in 1-12% of patients on endoscopy. Typically, this finding is seen distal to the upper esophageal sphincter, and appears endoscopically as a salmon colored patch which contrasts against normal esophageal mucosa. Rarely, inlet patches become symptomatic due to mucosal changes leading to ulceration, neoplasia or stricturing. We present a case of an ulcerated inlet patch leading to iron deficiency anemia.

CASE DESCRIPTION/METHODS:

The patient was a 41 year old African American female, who was admitted with a cardioembolic stroke (CVA). On admission, hemoglobin was noted to be 5.8 g/dL with an MCV of 55 fl. Her iron panel was suggestive of iron deficiency anemia (TIBC 455 ug/dL, Ferritin 5 ng/ml, Iron Saturation 4.4%). She denied having gastrointestinal symptoms, overt bleeding and she endorsed only having light bleeding during menstruation. EGD and colonoscopy were performed to further evaluate her anemia. Colonoscopy with intubation of the terminal ileum was unremarkable however, EGD revealed an ulcerated gastric inlet patch with adherent clot at 20 cm from incisors. No other obvious bleeding source was identified on EGD. Given her recent initiation of anticoagulation for cardioembolic stroke and absence active bleeding, the decision was made to not perform any endoscopic interventions. She was started on a proton pump inhibitor and serology for Heliobacter pylori (HP) IgG obtained. When this returned was positive she was initiated on triple therapy.

DISCUSSION:

This represents a rare case of an ulcerated gastric inlet patch resulting in iron deficiency anemia. Literature suggests that there may be high concordance of Helicobacter pylori colonization of inlet patches in patients with colonization of the stomach. Potentially this could be a unifying diagnosis of her HP serology positivity and an ulcerated inlet patch. This case also highlights the importance of deliberate visualization of the esophagus during EGD where proximal esophageal lesions can be easily missed.
1760 A Tough to Swallow Diagnosis: Dysphagia as a Manifestation of Esophageal Pemphigus
Authors: Yang Grace H. , Apfel Tehilla , Peters Stephen , Jones Anja , Shulik Oleg
Published: October 2019

INTRODUCTION:

Pemphigus is a rare group of autoimmune blistering disorders that affect mucous membranes and skin via acantholysis triggered by binding of circulating IgG autoantibodies to intercellular adhesion molecules. Pemphigus vulgaris (PV) is the most common, although paraneoplastic pemphigus in association with lymphoproliferative disorders exists as well. The esophagus is an uncommon site of involvement, but if present, may cause dysphagia and odynophagia or rarely, hematemesis.

CASE DESCRIPTION/METHODS:

A 76-year old man with a history of stable PV maintained on chronic steroids presented with several months of dysphagia with new oral ulcerations and bullous lesions on his upper and lower extremities. Patient also had a history of stage IIB (T2N1) squamous cell carcinoma of the distal esophagus. He underwent neoadjuvant chemotherapy and radiation with subsequent esophagectomy 2 years ago. Surveillance CT Chest/Abdomen/Pelvis immediately prior to admission showed no evidence of metastatic disease. Given dysphagia and history of esophageal cancer, patient underwent EGD, which revealed desquamating areas of the esophagus. Two small nodules in the areas of desquamation were biopsied. The esophageal biopsies were notable for squamous esophageal mucosa showing “denuded upper epithelial layers leaving one to several layers of suprabasal keratinocytes at the surface. The remaining keratinocytes show loss of cohesion consistent with involvement by the patient’s pemphigus.” New skin lesions continued to appear, most notably on the patient’s right hand. Biopsy of the skin lesion on his right thumb revealed PV, but it was noted that paraneoplastic pemphigus could not be excluded.

DISCUSSION:

Esophageal involvement of pemphigus is a rare finding in an already rare disease. It may be misdiagnosed or missed altogether if not on the differential. The presentation of dysphagia with concomitant oral ulcerations in a patient with a history of pemphigus should be further explored with EGD. Biopsies, brushings, and immunofluorescence of esophageal tissue will aid in diagnosis. Prognosis is poor despite therapy in refractory pemphigus, with mortality as high as 70-80% in 2 years. Despite high dose steroids, the patient's PV continued to worsen requiring rituximab and IVIG combination therapy as well as plasmapheresis.
1764 It’s Not Always Reflux: The Role of High-Resolution Manometry in Management of Patients With Sleeve Gastrectomy
Authors: Tran Victoria , Kuna Michael , Averbukh Leon D. , Singh Tejinder Paul , Tadros Micheal
Published: October 2019

INTRODUCTION:

We present cases of esophageal motility disorders associated with sleeve gastrectomy and identify the role of high-resolution manometry (HRM) in perioperative diagnosis and management.

CASE DESCRIPTION/METHODS:

Case 1: A 44-year old female with history of morbid obesity and gastric reflux presented with persistent symptoms of regurgitation, vomiting, and refractory reflux after undergoing a sleeve gastrectomy two years prior. Upper endoscopy showed slight resistance to endoscope passage at the lower esophageal sphincter and HRM evaluation was consistent with Type II achalasia, a finding confirmed by barium esophagram. The patient underwent a Heller myotomy with conversion into gastric bypass. On follow-up, patient noted no further recurrence of her presenting symptoms. Case 2: 52-year old female with multiple comorbidities presented with refractory dysphagia. She had undergone sleeve gastrectomy 5 years prior and subsequently developed worsening postprandial chest pain and solid food dysphagia. Outside work up of her dysphagia including multiple endoscopies and an esophagram were negative. On present evaluation, a 13 mm Barium pill traversed the esophagus without delay, and HRM showed a hypercontractile esophagus with high normal integrated relaxation pressure. The patient was started on antispasmodic therapy with symptom improvement.

DISCUSSION:

Laparoscopic sleeve gastrectomy is a bariatric surgical procedure for rapid weight loss in those classified as morbidly obese. The procedure leaves patients with a narrow tubular stomach roughly the diameter of the esophagus. Post operatively, patients have been noted to experience dysphagia, odynophagia, and most commonly (19.7% of cases) reflux. In our cases, patients experienced severe esophageal dysmotility which may have been caused by post-operative alterations of gastric anatomy and pressures. The mechanism behind post-operative motility disorders is unclear, and some studies have suggested that the procedure may unmask previously latent or subclinical disorders rather than induce them. We believe that HRM should be used as part of high value care in evaluating gastric sleeve patients with esophageal symptoms, especially before surgical revisions. Braghetto, I., et al. OBES SURG (2010) 20: 357. https://doi-org.elibrary.amc.edu/10.1007/s11695-009-0040-3.
1766 Can We Avoid Esophagectomy in T1b Esophageal Adenocarcinoma?
Authors: Odah Tarek , Shafa Shervin
Published: October 2019

INTRODUCTION:

Current guidelines recommend esophagectomy for Esophageal Adenocarcinoma stage T1b. There are limited data regarding multimodality therapy for Esophageal Adenocarcinoma T1b using endoscopic therapy instead of a surgical option. We present a case of EAC stage T1b patient who was successfully treated by multimodality treatments.

CASE DESCRIPTION/METHODS:

An 84 years old female with a history of Barrett’s esophagus underwent an endoscopy and was found to have esophageal adenocarcinoma with deep submucosal invasion (T1b) with no surrounding lymphadenopathy on EUS. She was recommended to have an esophagectomy but refused and requested a less invasive approach. She was offered endoscopic mucosal resection (EMR) and cryoablative treatments. Over the course of one year, the patient underwent several sessions of endoscopic EMR followed by cryoablative therapy. The fourth EMR specimen revealed positive deep margins involving the submucosa with lymphovascular invasion (LVI). Further sessions of cryoablation and EMR were done and she was also referred to oncology for adjuvant therapy. Oncology recommended both chemotherapy (with paclitaxel and carboplatin) as well as radiotherapy. However, the patient couldn’t tolerate more than two sessions of chemotherapy so it was discontinued while radiotherapy was continued. Few months after the patient finished radiotherapy she underwent a follow-up EGD with multiple biopsies which showed no evidence of dysplasia or malignancy.

DISCUSSION:

Endoscopic eradication therapy is the treatment of choice for early esophageal cancer. Surgical management for T1b is recommended given higher rates of LVI. Our case represents a successful case of eradicated adenocarcinoma using a multidisciplinary approach involving gastroenterology, thoracic surgery, medical oncology, and radiation oncology. More data will be helpful in assessing the effectiveness of a multimodality approach in treating T1b esophageal adenocarcinoma with LVI without invasive surgery.
1770 The Utility of Congo Red Staining in Grossly and Histopathologically Silent Gastrointestinal Amyloidosis
Authors: Zilberstein Netanel F. , Singh Sanmeet , Zilberstein Ashley T. , Carroll Robert
Published: October 2019

INTRODUCTION:

Primary amyloidosis (AL) with gastrointestinal (GI) involvement is a rare disease with nonspecific clinic manifestations1. Patients with symptoms suggestive of GI amyloidosis undergo endoscopic evaluation with biopsy and up to 75% of patients with GI amyloidosis have non-specific gross findings on endoscopy2. H&E staining shows characteristic amyloid deposition, which is then followed up by confirmatory Congo red staining. If both endoscopic and histologic evaluations are unremarkable, it is not common practice for Congo red staining to be performed3. We present two cases of AL amyloidosis with gastrointestinal involvement diagnosed by Congo red staining despite normal endoscopic findings and non-specific histopathologic findings.

CASE DESCRIPTION/METHODS:

71-year-old female with history of smoldering myeloma and AL amyloidosis complicated by heart failure presented with several weeks of nausea, vomiting, abdominal pain and anorexia. Her symptoms were initially attributed to her chemotherapy regimen; however, they persisted despite reduction of her chemotherapy doses and addition of a protein pump inhibitor. She also developed new-onset dysphagia to solid foods. The patient was referred to gastroenterology for an esophagogastroduodenoscopy (EGD), which was grossly unremarkable. Biopsies showed only nonspecific chronic inflammation, yet Congo red staining was performed due to high clinical suspicion for amyloidosis and was positive. She was started on a dysphagia diet with eventual resolution of her symptoms. A similar case involved a 51-year-old female with history of AL amyloidosis complicated by gastroparesis with gastrostomy tube placement who presented for chronic diarrhea for 6 months. Workup including stool PCR studies, fecal fat, and stool alpha-1-antitrypsin were all negative. She was referred for EGD and colonoscopy which were grossly unremarkable. Histological evaluation of the biopsy was negative for significant pathologic changes (Figure 1A). However, she was found to have positive Congo red staining (Figure 1B). She underwent treatment with octreotide and psyllium with resolution of her symptoms.

DISCUSSION:

These two cases highlight the importance of performing Congo red staining in all cases in which there is high clinical suspicion for GI amyloidosis despite negative endoscopic and histopathologic evaluation. This method will allow for increased diagnosis and early treatment of the disease.
1774 Achalasia Presenting as a Complicated Lung Abscess
Authors: Vijayasekar Kavitha , Syed Umer , Ahmed Moiz , Walfish Aaron
Published: October 2019

INTRODUCTION:

Achalasia is a rare motor disorder of the esophagus resulting from inflammation and degeneration of neurons and the interstitial cells of Cajal in the esophageal wall. Patients typically present with slow progressive dysphagia for solids and liquids, regurgitation, chest pain, cough, aspiration, and pneumonia. If patients are undiagnosed for an extended period of time, complications can arise. We report a case of how a complication can arise from achalasia, particularly in the form of lung abscess. The purpose of this report is to bring awareness of the increasing incidence of respiratory complications in patients with achalasia warranting further study.

CASE DESCRIPTION/METHODS:

A 44-year-old male came to the hospital with chest pain for one week. Shortly after, he began to experience severe pleuritic chest pain. The pain worsened with deep inspiration and coughing, preventing him from eating. A CT scan in the emergency room demonstrated infectious/inflammatory changes of the right upper lobe, concerning for abscess. His CT chest also showed a dilated esophagus, suggestive of achalasia. Further questioning revealed a several year long history of regurgitation symptoms. It was determined that the abscess was likely a complication of his suspected achalasia. IR guided drainage of the abscess was performed, and cultures were obtained, which grew multiple organisms found in oral flora. He subsequently underwent a VATS procedure for washout, decortication, chest tube placement, and bronchoscopy. An EGD to rule out pseudoachalasia caused by any mass lesions was performed showing a dilated esophagus. His EGD with manometry showed dilation of entire esophagus, notable for achalasia. A POEM procedure was performed with intra-operative real-time assessment using ENDOflip showed adequate myotomy.

DISCUSSION:

This case represents a rare complication of achalasia - lung abscess. Respiratory complications are common in patients with achalasia. Patients with achalasia experience respiratory symptoms with much greater frequency than previously thought, as shown in one study of 110 patients with achalasia where fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%). Imaging obtained earlier in the hospital course may be beneficial to identify any respiratory processes that may be a result of the underlying achalasia. This case highlights the potentially severe complications of achalasia in patients with atypical clinical findings.
1777 Esophageal Perforation From Blakemore Tube Use Resulting in Mediastinitis: Important Clinical Pearls to Reduce Mortality
Authors: Saeed Naba , Khan Zarak H. , Muzaffar Mohammad , Gjeorgjievski Mihajlo , Hammad Sahla , Khan Humza , Tasleem Syed
Published: October 2019

INTRODUCTION:

Esophageal variceal bleeding is one of the leading causes of death in patients with cirrhosis, requiring rapid endoscopic intervention and vasoactive medication administration. When this fails, balloon tamponade using Sengstaken–Blakemore (SB) tube is an effective temporizing measure in up to 90% of patients. However, it can result in esophageal perforation, with potentially fatal septic mediastinitis. Mediastinitis from esophageal perforation carries mortality rates as high as 40-67%, with mortality rate increasing as time to perforation detection increases. Hence a high level of suspicion and rapid identification are key.

CASE DESCRIPTION/METHODS:

A 56 year old male with history of decompensated Hepatitis C related cirrhosis, recurrent variceal bleeds and portal vein thrombosis (on warfarin), presented with massive hematemesis due to variceal bleed. Despite endoscopy (EGD) with banding, re-bleeding occurred, with rapid drop in hemoglobin from 9 to 5 g/dl. Despite multiple attempts, SB tube was unsuccessful due to resistance. Therefore, the patient was emergently transferred to a tertiary care center for specialist management. Upon presentation, he was found to be in fluid/blood unresponsive shock, requiring high dose vasopressor support. An emergent EGD revealed a 1 cm esophageal perforation above the gastroesophageal junction. CT chest revealed pneumomediastinum. He underwent esophageal stent placement 24 hours later, and was concomitantly treated with antibiotics, antifungals, vasopressors and chest tube insertion for mediastinitis. He slowly stabilized following these interventions, and within 1 week was transferred out of the ICU.

DISCUSSION:

In patients with fluid/blood unresponsive shock following esophageal manipulation with an SB tube, a high level of suspicion for esophageal perforation and mediastinitis should be maintained. In the past, Xray and esophagogram were thought to be helpful in establishing the diagnosis, however, it is now recognized that going straight to contrast-enhanced CT thorax has the highest yield and will establish diagnosis expediently. This is a necessity, as studies have shown a dramatic reduction in mortality if the diagnosis is made within the first 24 hours, with subsequent initiation of antibiotics and antifungals. Lastly, early consideration for esophageal stenting has also shown to reduce mortality, by tamponading the bleeding varices as well as the perforation.
1778 Too Stubborn to Contract: A Case of End Stage Achalasia Presenting as a Sigmoid Esophagus
Authors: Abbas Syed , Nawaz Waqas , Guddati Harish , Hertan Hilary
Published: October 2019

INTRODUCTION:

Sigmoid esophagus is a form of end stage achalasia characterized by massive dilatation and tortuosity of the esophagus. It is associated with poor response to conventional treatment and poses a significant challenge in the management. We present a case of an elderly female with achalasia who presented with sigmoid esophagus and was not considered a surgical candidate due to comorbidities.

CASE DESCRIPTION/METHODS:

An 84-year-old female with medical history of achalasia, colon cancer, heart failure and end-stage renal disease, admitted for aspiration pneumonia and respiratory failure requiring mechanical ventilation. Her achalasia was diagnosed three years prior to the presentation and was treated with botulinum toxin injection multiple times. Physical exam showed copious secretions in the oral cavity. Laboratory data showed leukocytosis. Chest CT showed a markedly dilated and tortuous esophagus with 10.2 cm diameter in maximum dimension. Upper endoscopy revealed a dilated and patulous lower esophagus with a tight gastroesophageal junction without any obstructing mass. A large amount of food was noted in the entire esophagus which was removed by a Roth net. Achalasia was considered end stage and the patient was deemed not a candidate for surgical treatment of achalasia in view of the comorbidities. A percutaneous gastrostomy tube was placed.

DISCUSSION:

Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and failure of the lower esophageal sphincter to relax during deglutition. Sigmoid esophagus is a severe form of achalasia characterized by a tortuous and massively dilated esophagus more than 6 cm that resembles sigmoid colon. Despite the treatment by the conventional methods like surgical myotomy, pneumatic dilation or botulinum toxin, 5% of the patients may develop an end stage achalasia. Dysphagia, regurgitation and recurrent aspiration pneumonia are the main clinical features. Imaging and esophagogram show dilated esophagus. Endoscopy shows tortuous dilated lumen and friable mucosa with food debris. Manometry is usually not needed to diagnose sigmoid esophagus as the esophagogram and endoscopy are diagnostic. Whereas, Heller’s myotomy is the treatment of choice in achalasia, it is regarded inadequate for the treatment of sigmoid esophagus due to operative difficulty, and esophagectomy is considered as the most appropriate option. However, the esophagectomy is associated with 5-10 % mortality and is not an option for patients with multiple comorbidities.
1788 Colchicine Toxicity Presenting as Esophagitis
Authors: Steimle Cassandra , Kelts Andrew , Jeng Jennifer , Kochik Michael , Golikov Edwin , Ali Farhan , Raborn Eric , Masoud Firouzi
Published: October 2019

INTRODUCTION:

Colchicine, a commonly prescribed medication for numerous medical conditions, is notorious for causing harm in the stomach and small intestine. Less commonly, damage can occur in other organs, such as the esophagus.

CASE DESCRIPTION/METHODS:

A 72-year-old male with a history of gout presented to the gastroenterology clinic with a several month progression of pyrosis and dysphagia. Upper endoscopy was performed which revealed erosive esophagitis. Biopsies were obtained which revealed mitotic arrest of the cells in metaphase. On review of his medications, he had been on long-term colchicine therapy for management of his gout.

DISCUSSION:

Colchicine, an anti-inflammatory medication, acts at the cellular level by interrupting mitosis. This is achieved through disrupting neutrophil microtubules and ultimately preventing neutrophil migration and adhesion, thus, decreasing the inflammation associated with diseases, such as gout. Microscopically, mitotic arrest is commonly seen in metaphase with evidence of ringed mitoses, glandular cell apoptosis, and epithelial pseudostratification. Within the gastrointestinal tract, colchicine is most notable for causing side effects such as diarrhea and nausea. However, due to its prevention of cellular division, it can cause injury to rapidly proliferating cells within the gastrointestinal tract. Most commonly, this occurs in the small bowel and gastric antrum. We present a rare case in which evidence of colchicine toxicity is identified within the esophagus. In our patient, colchicine was discontinued and he was treated with proton pump inhibitor therapy with improvement of his symptoms.
1800 Tubular Adenoma With High Grade Dysplasia in the Esophagus: It Can Happen!
Authors: Crain Rebecca , Zaibaq Jenine , Bilal Mohammad , He Jing , Qiu Suimin , Parupudi Sreeram , Luthra Gurinder
Published: October 2019

INTRODUCTION:

Tubular adenoma is a common finding in the colon accounting for majority of the colonic adenomas. Consensus guidelines have outlined surveillance intervals for patients with tubular adenoma in the colon based on the number and size. We present a unique case of a tubular adenoma in the interpositioned colon. Colonic interposition is a common surgery in patients with esophageal atresia. We present a unique case of a TA with high-grade dysplasia in the interpositioned colon.

CASE DESCRIPTION/METHODS:

A 50-year-old female with a past history of esophageal atresia who underwent colonic interposition between the upper esophagus and stomach at the age of five presented with dysphagia. A barium swallow was performed which showed delayed emptying in the mid-esophagus. An esophagogastroduodenoscopy (EGD) was performed which showed food material stuck in the proximal interpositioned colon. There were no strictures at the site of the anastomosis. Incidentally a 10 mm polypoid lesion was seen in the interpositioned segment of the colon [Figure 1]. The polypoid lesion was biopsied and histological examination showed disorganized glands in the background of normal colonic mucosa along with hyperchromatic nuclei with increased mitosis in the cells, consistent with tubular adenoma. Repeat EGD showed three sessile polyps ranging from 10 mm to 20 mm in size. The polyps were successfully resected using hot snare polypectomy. Pathological examination showed two tubular adenomas, and the largest polyp had tubular adenoma with focal high grade dysplasia [Figure 2]. Resection margins were negative for dysplasia. A colonoscopy was also performed which found two sub-centimeter adenomatous polyps as well.

DISCUSSION:

Esophageal atresia is a congenital malformation of the upper gastrointestinal tract. The prevalence varies from 1 in 2500 to 1 in 4500 births. Currently, there is no ideal replacement for the esophagus. Primary anastomosis of the esophagus is performed in about 90% of cases, and a colonic interposition is performed when there is an extremely long gap. Common complications with colonic interposition include stenosis of the anastomosis, esophageal dysmotility, and gastroesophageal reflux. Development of adenomatous polyps in the interpositioned segment of the colon are exceedingly rare and usually an incidental finding. Our case and other similar reports highlight that surveillance strategies need to be developed in these patients to prevent carcinoma.
1801 A Rare Case of Acute Esophageal Necrosis
Authors: Joshi Tejas V. , Gioe Reed , Stibbe Jason R. , Evans Jerry , Raines Daniel
Published: October 2019

INTRODUCTION:

AEN is a rare disease with an incidence ranging from 0.01% to 0.28% of all upper GI endoscopies. AEN occurs in the setting of underlying critical illnesses. Upon review of the English literature, only 14 cases of AEN associated with DKA have been published over the past 50 years.

CASE DESCRIPTION/METHODS:

A 61 yo M with a PMH: HTN, HTN, GERD, ETOH abuse, and obesity presented to the hospital with severe SOB, worsening mid-back pain, and a 1.5 wk hx of GERD symptoms. T 97.8 F, BP 183/85, HR 141, RR 31/min. BG of 833 mg/dL, arterial blood gas (ABG) pH of 7.164, pCO2 of 11.1 mmHg, HCO3 of 4 mEq/L, and PO2 of 128 mmHg with an anion gap of 25, serum Beta-Hydroxybutyrate of 4.9 mmol/L, 2+ urine ketones. (WBC) of 30.2 K/uL, Hb 13.5 K+ 5.8, Cr: 2.7. Admitted for DKA on day 2 of his hospital stay he developed N/V and hematemesis. He denied melena. On day 3 he had hematemesis and complained of feeling that food was getting stuck in his mid-chest upon swallowing. On day 4 his Hb dropped from 12.8 to 10.7 g/dL and he began to complain of chest pain and discomfort. (EGD) showed severe necrotizing esophagitis along entire length of esophagus with normal stomach and duodenum. Patient was started on oral (PPI) therapy and oral sucralfate therapy. DKA resolved, anion gap closed, AKI resolved, WBC normalized, and he was weaned off the insulin infusion. He was discharged on hospital day 8 with 6 weeks of oral PPI and sucralfate therapy.

DISCUSSION:

The pathogenesis is hypothesized to be due to the distal portion of the esophagus being a watershed area due to lower levels of vascularization compared to the upper and middle portions. In one case series, 4 out of 16 cases (25%) of AEN occurred in the setting of diabetic ketoacidosis (DKA), and 14% of cases of DKA involved AEN. AEN is more likely to occur in men than women with a 4:1 ratio, and the ages of presentation ranged from 19-91 with a mean of 68 years. It is diagnosed by upper endoscopy which shows circumferential black necrosis in the distal third of the esophagus that may extend along the length of the esophagus into the upper third but will not extend into the gastric mucosa. Mortality is as high as 32% and the mortality specific to AEN is closer to 6%. Complications can include esophageal perforation, mediastinitis, and abscess formation in up to 6%. Late complications include esophageal strictures and stenoses which are seen in 10.2% of cases and appear as early as 7-12 days. AEN is typically managed with high dose PPI and sucralfate.