bluuebunny/crossref_metadata_2025 huggingface dataset:
1728 A Spastic Spiral: Paraneoplastic Pseudoachalasia in an Elderly Male With Multiple Malignancies
Authors: Dalsania Raj , Cassani Lisa S. , Raja Shreya M.
Published: October 2019

INTRODUCTION:

Pseudoachalasia is an uncommon condition that is difficult to distinguish from primary achalasia. Pseudoachalasia is usually caused by malignancy involving the gastroesophageal junction (GEJ); however, a paraneoplastic etiology has been reported in rare cases. Our aim is to describe the diagnosis and management of a case of paraneoplastic pseudoachalasia resulting from acetylcholine receptor (AchR) ganglionic (a3) antibodies.

CASE DESCRIPTION/METHODS:

A 72-year-old male with a history of lung adenocarcinoma, bladder transitional cell carcinoma and prostate adenocarcinoma presented with acute chest pain, regurgitation, and dysphagia. Positron emission tomography scan showed increased distal esophageal uptake prompting a referral for endoscopy. Endoscopy showed a tortuous, spiraling esophageal body, distal esophageal ulcer, and narrowed GEJ (Figure 1). Ulcer biopsies returned benign, and endoscopic ultrasound (EUS) was performed. EUS of the GEJ showed diffuse thickening of the muscularis mucosa with no discrete mass. Motility evaluation was performed. Barium esophagram demonstrated a corkscrew esophagus and persistently narrowed GEJ (Figure 2). Esophageal manometry was attempted, but the catheter was unable to traverse the lower esophageal sphincter. Tracings of the esophageal body revealed spastic contractions with occasional pan-esophageal pressurization suggestive of possible mixed Type II/III achalasia (Figure 3). A paraneoplastic serum autoantibody panel was obtained and returned positive with AChR a3 antibody level of 220 pmol/L (normal < 53). Evaluation for recurrent malignancy was negative. Trial of a cholinesterase inhibitor and calcium channel blocker were attempted without improvement. Intravenous immunoglobulin therapy was declined by the patient. Endoscopic botulinum toxin injection to the esophageal body and LES was performed and resulted in sustained symptom relief.

DISCUSSION:

Paraneoplastic pseudoachalasia is rare, and requires a high index of suspicion for diagnosis. It may be the initial clinical sign of malignancy, or as in our case, a finding concerning for recurrent malignancy prompting re-evaluation. Prior reports suggest AChR antibodies are associated with adenocarcinomas. In patients with known malignancy who present with achalasia-type symptoms, a paraneoplastic autoantibody panel can assist with diagnosis. Treatment of the malignancy is the primary therapy, while medications and endoscopic interventions remain anecdotal.
1729 An Unusual Case of Ventilatory Compromise and Mega-Esophagus
Authors: Pinto Jonathan , Asif Ammar , Thomas Kafi , Culpepper-Morgan Joan
Published: October 2019

INTRODUCTION:

Mega-esophagus, usually due to achalasia or pseudoachalasia, can cause bronchial compression when filled with phytobezoars. We present a case of mega-esophagus not due to achalasia but with profound ventilatory consequences.

CASE DESCRIPTION/METHODS:

A 67 year old alcoholic man presented with 24 hours of increasing dyspnea at rest. He denied fevers, chills, cough, chest pain, heartburn, dysphagia, abdominal pain or weight loss. On physical exam he was somnolent but arousable. He was able to speak in full sentences. Lungs revealed right sided rhonchi. He was afebrile, BP 211/100, pulse 68, respiratory rate 18, and O2 saturation 80-85% on room air which improved to 94% after 4L nasal O2. Urine toxicology was positive for opiates and cocaine. Chest CT showed a 6.8 cm esophagus filled with debris. It was herniated into the right upper thorax and terminated in a narrow taper at the aortic arch. The trachea deviated rightward and narrowed to 4 mm. The proximal left main-stem bronchus was narrowed to 2 mm. The right upper lobe showed scarring, cystic bronchiectasis, and pleural thickening. On day 2 the patient developed severe dyspnea and orthopnea. O2 saturation varied with position. After intubation and transfer to the ICU for treatment of acute ventilator failure, GI was consulted to decompress the mega-esophagus presumed due to end stage achalasia. EGD initially revealed a dilated esophagus with a phytobezoar. Upon partial clearing two lumens were noted: one containing more food and one which lead to a normal distal esophagus, stomach, and duodenum. The first opening was a large diverticulum located about 20 cm from the incisors and was filled with recently ingested food. Transfer to a tertiary care center was recommended to manage possible total airway collapse. There, repeat chest CT showed a distended esophagus to the level of the aortic arch with no compression of the airways. Esophagram was not consistent with achalasia but demonstrated a large bezoar filled diverticulum. Repeat EGD was done to complete bezoar removal. Patient’s respiratory status normalized. Elective esophagectomy was planned, but the patient was lost to follow up.

DISCUSSION:

Our patient likely had a traction diverticulum as he gave no antecedent history of heartburn or dysphagia and the food in the bezoar was not fermented. In addition, his distal esophagus appeared normal on barium swallow. This is may be the first reported case of airway compression due to mega-esophagus due to a traction diverticulum.
1730 Esophageal Actinomycosis in a Patient With Long-Standing Esophageal Stent
Authors: Kumar Vikas , Lam Steven , Deivert Duane , Obuch Joshua , Baidoo Cletus , Khara Harshit S. , Khan Yakub
Published: October 2019

INTRODUCTION:

Actinomyces is a commensal in aero-digestive tracts which rarely causes infection. The commonest site is cervicofacial region. Risk factors are low immunity and pre-existing tissue damage. Esophageal involvement is rare. We report a case of esophageal actinomycosis in an immunocompetent patient.

CASE DESCRIPTION/METHODS:

A 71-year-old male presented with recurrent dysphagia. The patient had multiple prior EGDs for management of refractory peptic stricture due to gastrin secreting pancreatic neuroendocrine tumor. He undewent multiple prior procedures with placement of fully-covered self-expanding metal stents (SEMS) for therapy of refractory stricture, as surgical esophagectomy was not possible due to co-morbidities and patient preference. On previous EGD, one of the stents could not be removed due to tissue ingrowth at the distal end, and another SEMS was placed overlapping the imbedded stent and extending to the gastric cardia. The patient was lost to follow up for 7 months until presenting with recurrence of dysphagia. EGD now showed proximal migration of the distal stent with severe stenosis, inflammation, and nodularity distal to the esophageal stents. The distal stent was imbedded in the abnormal mucosa and could not be removed. Following balloon dilation another SEMS was placed in the distal esophagus. Pathology revealed ulcerated acute esophagitis with actinomycetes colonies. The patient was placed on a long course of IV penicillin-G. At subsequent EGD a month later, the tissue ingrowth improved allowing removal of the esophageal stents. Repeat biopsies did not reveal actinomyces.

DISCUSSION:

Actinomyces, a gram positive anaerobic rod, is unable to penetrate healthy tissue. It requires mucosal compromise to invade tissue, leading to abscess and sinus formation across tissue planes. Our patient had multiple risk factors - mucosal damage, endoscopic dilations and stenting. Esophageal stent in situ for longer than 3 months increases the risk of embedment. Discovery of esophageal ulceration or tissue ingrowth in this setting should raise suspicion for possible actinomycosis (among other diagnoses) and biopsies should be obtained. Gram stain and histology would reveal necrosis with yellow sulfur granules and gram-positive filamentous pathogen. Early diagnosis is necessary to initiate treatment in a timely manner to prevent the potentially debilitating sequelae of chronic infection. Treatment includes penicillin G or amoxicillin for 3-12 months.
1732 Atypical Presentation of Herpes Simplex Virus Esophagitis in an Immunocompetent Patient
Authors: Patel Pooja R. , Wehbeh Antonios , Emerson Robert E. , Fatima Hala , Kim Hak Nam
Published: October 2019

INTRODUCTION:

Herpes Simplex Virus esophagitis (HSVE) is a well-documented opportunistic infection affecting immunocompromised patients. It can rarely manifest in the immunocompetent patient, with the most recent review in 2010 demonstrating 56 documented cases. Such patients commonly present with acute odynophagia, fever, and retrosternal pain. Here, we report a case of HSVE affecting an immunocompetent patient with a more subacute presentation.

CASE DESCRIPTION/METHODS:

A 37-year-old Nigerian female presented with generalized weakness, weight loss, and new onset dysphagia of two months duration. The dysphagia had progressed from solids to liquids with intermittent odynophagia. She denied fevers, chills, hematemesis, and melena. On exam, she was afebrile and exhibited no oropharyngeal lesions. Her abdomen was nontender to palpation and she demonstrated no hepatosplenomegaly or palpable masses. Labs showed severe iron deficiency anemia requiring transfusion, a normal white cell count, and a negative HIV screening test. An upper endoscopy (EGD) showed multiple small non-bleeding erosions throughout the middle and distal esophagus, as seen in Figures 1A and 1B respectively. Esophageal biopsy demonstrated squamous epithelium with viral inclusions and multinucleated cells. As demonstrated in Figure 2, immunohistochemical stain was focally positive for HSV supporting the diagnosis of herpes esophagitis. She was subsequently started on 7-day treatment of oral acyclovir 400 mg three times a day and had resolving symptoms one week later at her primary care visit.

DISCUSSION:

This case illustrates the importance of considering a diagnosis of HSVE in immunocompetent individuals, who can present with a subacute course of worsening dysphagia without systemic symptoms. Moreover, as HSVE endoscopic lesions can vary in appearance and location, gastroenterologists should have a low threshold for biopsying atypical lesions in the immunocompetent. In a recent study comparing endoscopic features of HSVE in immunocompromised and immunocompetent patients, endoscopists were more likely to mention the possibility of viral esophagitis on the endoscopy report in patients that were immunocompromised. Although HSVE in the immunocompetent is typically a self -limited disease, treatment with oral acyclovir can result in resolution of symptoms within 1-2 weeks. The etiology of HSVE in the immunocompetent may represent a primary infection of traumatized esophageal mucosa or reactivation after a previous infection.
1735 A Rare Case of Coexisting Achalasia and Pseudoachalasia
Authors: Dayah Rawan , Clark August , Reep Gabriel , Okereke Ikenna , Qiu Suimin , Nahmood Karen
Published: October 2019

INTRODUCTION:

Achalasia is an esophageal motility disorder in which the lower esophageal sphincter fails to relax and there is a loss of esophageal peristalsis. Pseudoachalasia closely mimics achalasia. We present a rare case of a patient who was initially diagnosed with pseudoachalasia but was later found to have achalasia after symptoms persisted following the resection of an esophageal leiomyoma.

CASE DESCRIPTION/METHODS:

A 39 year-old male was evaluated for weight loss and progressively worsening dysphagia to solids and eventually liquids with a 100 pound weight loss over 3 years. Esophageal manometry was consistent with achalasia with esophageal compression, subtype II (Figure 1). He underwent laparoscopic exploration and planned Heller myotomy and Dor fundoplication. During surgery, a very large submucosal mass was found in the distal esophagus extending to the gastroesophageal junction. The mass was enucleated and a Dor fundoplication was performed. Pathologic analysis showed the mass to be a leiomyoma measuring 6.7 centimeters in maximum diameter (Figure 2). Postoperatively, his symptoms of dysphagia persisted andrepeat esophageal manometry remained consistent with achalasia. He underwent Heller myotomy and redo Dor fundoplication 5 months after the initial surgery. His symptoms completely resolved after the second surgery and he has remained asymptomatic on follow-up.

DISCUSSION:

Patients with achalasia typically present with progressive dysphagia, initially to solids and then to liquids, due to the degeneration of ganglion cells within the myenteric plexus in the distal esophagus resulting in the loss of peristalsis. Pseudoachalasia closely mimics the presentation of idiopathic achalasia and is the diagnosis in approximately 4% of patients with achalasia-like symptoms. Intraluminal evaluation with endoscopic ultrasound may be a valuable tool to evaluate muscular wall thickness in motility disorders and could result in earlier diagnosis of pseudoachalasia. Intraoperative esophageal pressure monitoring is not used frequently but may have also been beneficial in this case. This case is unique since the patient was discovered to have an esophageal leiomyoma after he was diagnosed with primary achalasia. There are no documented cases of a patient with both primary achalasia and pseudoachalasia based on a literature review.
1737 Successful Endoscopic Repair of Boerhaave’s Syndrome: Changing the Narrative
Authors: Then Eric O. , Lopez Michell , Ofosu Andrew , Gayam Vijay , Are Vijay S. , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Boerhaave’s syndrome (BS) is a rare, life-threatening entity that is defined as spontaneous esophageal rupture occurring after forceful vomiting. Classically treatment of BS has consisted of a surgical approach. Here we present a rare case of BS that was successfully treated through endoscopic measures.

CASE DESCRIPTION/METHODS:

Patient is a 65 year old male with a medical history of chronic obstructive pulmonary disease who presented the emergency department with chest pain, shortness of breath and productive cough after an episode of retching 2 days prior. Notable workup in the emergency department included a chest x-ray which showed left lower lobe pneumonia, pneumothorax, and a left pleural effusion. A chest tube was then placed and a computed tomography angiography of the chest was also done. This showed pneumomediastinum with air around the mid to distal esophagus. A barium esophagram was subsequently done which showed contrast leak at the distal esophagus. An upper endoscopy was then performed and showed a large linear perforation near the gastroesophageal junction. This was closed with 2 over the scope clips in addition to placement of an overlapping partially covered stent. In order to ensure complete closure an esophagram was done with radioisotope. This showed complete closure of the perforation, with no evidence of leakage of the radiotracer. After the procedure the patient was able to tolerate oral feedings with no clinical sequelae. During his hospital stay the patient completed treatment with antibiotics, his chest tube was successfully removed and he was subsequently discharged home.

DISCUSSION:

Boerhaave’s syndrome is a lethal pathology that carries a high mortality rate. It mostly presents on the left posterolateral wall of the esophagus and occurs after forceful vomiting. Symptoms are non-specific and include vomiting, chest pain, dyspnea, and subcutaneous emphysema. Diagnosis of BS can be achieved through endoscopy, which allows direct visualization of the esophageal tear. Imaging studies such as barium swallow and CT scan may also be useful. These will show extravasation of contrast and pneumomediastinum respectively. Surgical repair is currently the treatment of choice in BS. Present day, endoscopic measures are challenging this consensus. More recently cases of BS have been successfully treated with the use of endoscopic suturing with esophageal stent placement. Our case was successfully treated by using 2 over the scope (OTS) clips and placement of an esophageal stent.
1738 Refractory Candida Esophagitis in an Immunocompetent Patient: A Rare Presentation
Authors: Then Eric O. , Hernandez Kimberly , Ofosu Andrew , Lopez Michell , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Candida esophagitis is an invasive fungal infection of the esophagus classically caused by Candida albicans. It is usually considered an opportunistic fungal infection affecting those who are immunocompromised. Recently however, there has been an increased incidence of the infection in immunocompetent patients. Here present a case of refractory candida esophagitis in an immunocompetent female.

CASE DESCRIPTION/METHODS:

The patient is an 83-year-old immunocompetent female with a past medical history of congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, venous insufficiency, obstructive sleep apnea, fibromyalgia, and degenerative joint who presented to the clinic with a 5-month history of dysphagia and odynophagia. She was recently diagnosed with candida esophagitis through esophagogastroduodenoscopy (EGD) and biopsy and was treated with fluconazole with temporary resolution of symptoms. We performed a repeat EGD which showed diffuse whitish mucosal patches consistent with severe candida esophagitis of the entire esophagus (Figure 1). Biopsies stained with GMS special stain confirmed the diagnosis. Due to the patient’s previous resistance to fluconazole, the patient was referred to an infectious disease specialist who placed the patient on a Nystatin swish and swallow for 14 days with a subsequent course of fluconazole. One-month post-treatment, a follow-up EGD was performed and showed significant improvement with few scattered specks of whitish mucosal exudates in the entire esophagus consistent with mild candidiasis (Figure 2). One month later at follow-up, the patient reported complete resolution of symptoms.

DISCUSSION:

Candida esophagitis was thought to be a disease of the immunocompromised (i.e. AIDS patients) but, has shown to be on the rise in immunocompetent patients. Several studies showed that diabetes, old age, corticosteroid use, and antibiotic therapy are all major risk factors for development of the infection in this population. It is usually an easily treatable condition through the use of fluconazole, an antifungal agent that is usually seen with great success. However, there have been reports of resistance to the drug and a possible explanation of this is its widespread use leading to growth of fluconazole-resistant strains such as non-albicans candida strains. Species identification and fluconazole susceptibility testing may aid in adjustment of treatment protocols for those with recurrence of candida esophagitis.
1740 Syphilitic Lichenoid Esophagitis: A Rare Finding
Authors: Khurana Shruti , Siddiqui Shaheer , Larson Scott
Published: October 2019

INTRODUCTION:

Extra-genital manifestations involving gastro-intestinal tract is extremely rare. We describe a case of biopsy-proven esophageal syphilis causing extremely rare pathological diagnosis of lichenoid esophagitis.

CASE DESCRIPTION/METHODS:

A 50 year-old woman with HIV-AIDS, HCV cirrhosis and recent anterior syphilitic uveitis presented with 4 days of melena. Esophagoduodenoscopy showed severe inflammation with LA grade D esophagitis. Mid esophagus had severe ulceration with crater formation and a stricture was noted at 35 cm (Figure 1). Histopathology of the biopsies showed marked intraepithelial lymphocytes, neutrophils, dyskeratotic keratinocytes (Civatte bodies) and dense band-like lymphoplasmocytic infiltrates in the lamina propria, consistent with lichenoid injury pattern (Figure 2), and visualization of spirochetes in the mucosa (Figure 3). No fungal elements or viral inclusion bodies were noted. Immunochemical staining was negative for CMV and HSV I/II. She was treated with a 14-day course of Penicillin G and reported complete resolution of symptoms on follow-up visit.

DISCUSSION:

Treponema pallidum rapidly spreads via the blood stream and lymphatics after the initial inoculation and can disseminate multiple foci to visceral organs including the gastrointestinal tract. Most common sites reported are oral cavity, stomach, rectum and rarely esophagus (1). T. pallidum incites an immune response with proliferative endarteritis affecting small vessels surrounded by T-lymphocytes, plasma cells and macrophages. This leads to extensive mucosal injury seen as diffuse esophagitis along with focal ulceration, which is prone to bleeding (2). The lichenoid pattern of injury with band-like infiltrate of lymphocytes in lamina propria and scattered degenerated keratinocytes (Civatte bodies) is atypical of syphilitic injury. This may cause fibrosis of the esophageal mucosa leading to stenosis and stricture (3). Salaria et. al. found that patients with lichenoid esophagitis were more likely to have concurrent HIV or viral hepatitis and were taking >3 medications (4).
1742 A Rare Case of Colorectal Cancer of the Neoesophagus
Authors: Shah Maulik , Truscello David , DeRosa Justin , Al-Annouf Nabil , Shmuts Robert
Published: October 2019

INTRODUCTION:

In the case that follows, we present a case and literature review of oligometastatic intestinal adenocarcinoma originating in a colonic interposition repair of esophageal atresia. Uniquely, the pathology of the tumor was consistent with colonic mucosa which only a few such instances have been reported in literature.

CASE DESCRIPTION/METHODS:

A 58-year-old female with a past medical history of tetralogy of Fallot (repaired at age 14), esophageal atresia status post esophageal colonic interposition, esophageal and pyloric stenosis, neo-esophageal polyp (found 2 years prior with biopsy showing reactive epithelial atypia), and atrial fibrillation on Coumadin presented to the hospital complaining of fatigue and dyspnea of one week duration. Her family history was significant for colon cancer in her father. Initial lab workup revealed a hemoglobin of 5. She was transfused 3 units of packed red blood cells. Due to severe symptomatic anemia, an upper endoscopy and colonoscopy were performed revealing an ulcerated mass, approximately 50% in circumference in the lower third of the esophagus, as well as moderate pyloric stenosis that prevented passage of the endoscope. The esophageal masswas not amenable to endoscopic excision due to undulations of the cardiac beat, however biopsy demonstrated invasive, moderately differentiated, intestinal-type adenocarcinoma (Figure 1). Given these findings a PET/CT scan was obtained which revealed a 2cm mass in the distal aspect of the interposed colonic segment and a 1.7 × 1.2cm hypodense mass in the medial segment of the left hepatic lobe, consistent with metastasis. She was referred to Cardiothoracic Surgery for tumor resection and Oncology for neoadjuvent chemotherapy.

DISCUSSION:

Oligiometastatic colorectal cancer or the esophagus is an extremely rare medical condition. Our patient had an initial polyp removed in 2016, that was read as reactive epithelial atypia. More diligent surveillance was likely warranted for her case. This was shown by Lindahl et al in long-term endoscopic follow-ups in patients with this condition. Of the 12 patients observed in the study, a variety of colonic pathology was foundranging from dysplasia, colonic polyp, and aneuploid cells. Given these findings, albeit rare, with one case report citing less than 15 instances, special considerations should be made for close surveillance of these patients. Although no specific treatment guidelines exist for this anomaly, there has been documented success with a curative resection.
1743 From Red to Black: A Deadly Case of Acute Esophageal Necrosis
Authors: Shah Maulik , DeRosa Justin , Suga Herman , Shivaprasad Punitha
Published: October 2019

INTRODUCTION:

Black Esophagus, or acute esophageal necrosis (AEN), is a rare but deadly clinical syndrome appearing as diffuse circumferential black necrotic mucosa on esophagogastroduodenoscopy (EGD). It is associated with comorbidities that cause hypoperfusion and ischemia to the esophageal mucosa. It has a reported incidence rate of about 0.001% to 0.2%. We report a case of black esophagus in a patient with fulminant hepatic failure related to nonalcoholic steatohepatitis (NASH) cirrhosis.

CASE DESCRIPTION/METHODS:

A 75-year-old female with a history of diabetes mellitus, hypertension, gastroesophageal reflux disease, NASH-related cirrhosis, and GI bleeding due to esophageal varices presented to the hospital with altered mental status and increased lethargy of 2 weeks’ duration. Her initial lab workup revealed a calculated MELD score of 36. She was diagnosed with an NSTEMI and hepatic encephalopathy in the setting of fulminant hepatic failure. During her hospital stay, she developed coffee ground emesis and melena with resultant drop in hemoglobin requiring transfusion with multiple units of blood. An EGD performed in order to find the source of her apparent upper GI bleeding revealed diffuse circumferential black discoloration of the mucosa at the middle and inferior third of the esophagus demarcated clearly from the normal-appearing mucosa of the cardia at the gastroesophageal junction (Figure 1). Unfortunately, she developed hepatorenal syndrome due to worsening liver function. Due to the poor prognosis, the patient’s family chose to request “do not resuscitate” (DNR) status. Severe hypoxia failing noninvasive positive-pressure ventilation ultimately led to cardiac arrest and death.

DISCUSSION:

This case emphasizes the need to include black esophagus on the differential of upper GI bleeding in a patient with a history of esophageal varices and NASH cirrhosis and highlights the high mortality rate, estimated at about 32%, associated with this condition. Documented cases exist of black esophagus in patients with alcohol-related cirrhosis, but we found no others reporting this condition in a patient with NASH-related cirrhosis. There is no direct treatment for black esophagus; recommendations are to treat comorbidities, suppress acid production, and optimize vascular perfusion. Complications include stricture, infection, perforation and death. This case clearly demonstrates that early detection through endoscopy and active management of its underlying cause is critical to improving patient outcomes.
1745 A Rare Case in a Rarer Place: A Severe Esophageal Stricture in a Patient With Both Bullous and Mucous Membrane Pemphigoid
Authors: Collins Kelsey , Hazan Ariela , Mitaka Hayato , Grabscheid Erica
Published: October 2019

INTRODUCTION:

Bullous pemphigoid (BP) and mucous membrane pemphigoid (MMP) are rare autoimmune conditions. The conditions affect the skin and mucosa respectively; immunoglobulins and complement proteins are deposited in the epidermal/ mucosal basement membranes, promoting subepithelial blister formation. 85% of patients with MMP have lesions in the oral cavity, but only 4% have esophageal involvement.

CASE DESCRIPTION/METHODS:

A 37-year-old man with a history of BP (diagnosed via skin biopsy), sickle cell trait, and smoking, presented with 5 months of progressive dysphagia, oral lesions, and weight loss. The dysphagia began with solid foods and progressed to liquids. His ability to initiate swallowing was intact, but he felt as though food was stuck mid-esophagus. Physical exam revealed a thin male with several active bullous lesions on the face and chest, with additional lesions on the hard palate, gingiva, and posterior oropharynx. An esophagram identified a severe serpiginous stricture in the cervical esophagus (C4-5) approximately 3 cm long. An EGD was then attempted with an XP/ stricture endoscope which showed multiple ulcerations and bullae in the upper esophagus; however, the stricture was too narrow for the endoscope to pass. IV steroids were initiated in order to reduce the inflammation contributing to the stricture. The EGD was re-attempted, however the stricture remained too narrow. The patient was discharged with a course of steroids and outpatient follow up. The patient returned 2 weeks later with recurrent dysphagia. He was restarted on the IV steroids and started on IV Diflucan for oral candidiasis. Dilatation of the esophagus was considered, however given the degree, size, and location of the stricture, dilatation was deemed too high risk. He was taken for surgical placement of a gastrostomy tube and tube feeds were ordered. The patient was discharged home with instructions to continue steroids and follow up with GI for a repeat EGD/ possible esophageal dilatation. The use of biologics and/ or immunosuppressants would be considered as future alternative treatments.

DISCUSSION:

Bullous pemphigoid and mucous membrane pemphigoid, typically seen in the elderly, are rare conditions. This case highlights a young adult with BP and MMP simultaneously, resulting in significant esophageal involvement; the resulting dysphagia/ severe esophageal stricture required artificial feeding assistance.
1748 Blood Bezoar: A Rare Complication of Achalasia
Authors: Martino Esteban Rodriguez , Martin-Ortiz Jose , Toro-Lugo Doris , Fernández Carlos
Published: October 2019

INTRODUCTION:

Bezoars are retained concretions of indigestible foreign material that accumulate and conglomerate in any part of the GI tract but rarely in the esophagus. Only a few patients with achalasia have been reported to develop esophageal bezoars.

CASE DESCRIPTION/METHODS:

76-year-old-man with history of atrial fibrillation on anticoagulation and achalasia s/p Heller myotomy in 1990, endoscopic dilation in 2007 and botox injection in 2015 who presented due to hematemesis after an episode of food binge. An upper endoscopy was performed with evidence of a severely dilated esophagus and presence of a bulky, cylindrical, foreign body composed of digested food and coagulated blood resembling a large blood sausage. The foreign body was removed through upper esophageal sphincter in piecemeal with a polypectomy snare and roth net using an overtube for airway protection. Two endoscopic procedures were necessary to completely remove the huge cylindrical esophageal bezoar.

DISCUSSION:

Bezoars are retained concretions of indigestible foreign material that accumulate and conglomerate in any part of the GI tract but rarely in the esophagus. They may occur due to ingestion of undigestible material or in patients with impairment in the grinding mechanism and the interdigestive migrating motor complex. Achalasia is an uncommon disorder resulting from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall, leading to failure of relaxation of the lower esophageal sphincter accompanied by a loss of peristalsis in the distal esophagus. Dysphagia for solids and liquids and regurgitation of undigested food are the most frequent symptoms, however patients may also present with chest pain, heartburn, and difficulty belching. Only a few patients with achalasia have been reported to develop esophageal bezoars. In such cases, patients may be asymptomatic for years, or present with symptoms like abdominal pain, nausea, vomiting or serious complications like outlet obstruction, perforation and hematemesis. Upper endoscopy is regarded as the mainstay modality for the diagnosis and treatment of esophageal bezoars. In difficult cases, step by step management with N-acetylcysteine and gastrografrin spraying has been reported. Surgery should be reserved for select patients with bezoars if chemical dissolution and endoscopic fragmentation cannot be performed or fail, as well as for patients with significant complications such as obstruction and severe bleeding.
1753 An “Eggstra-Ordinary” Cause of Esophageal Food Impaction: Esophageal Eggshell Food Impaction
Authors: Ratnasingam Denesh , Numan Laith , Zafar Yousaf , Elkafrawy Ahmed A. , El-Halawany Hani , Clarkston Wendell K.
Published: October 2019

INTRODUCTION:

Food bolus impactions are commonly encountered GI emergencies, often from impacted meat. We report two patients with esophageal eggshell impaction who presented predominantly with chest pain and odynophagia.

CASE DESCRIPTION/METHODS:

Case 1: An 88-year-old female with a history of gastroesophageal reflux disease, prior hiatal hernia repair, and intermittent dysphagia to solid food presented to the emergency department with intermittent severe, sharp chest and epigastric pain that occurred with swallowing 30 minutes after eating a hard-boiled egg. The patient could not handle secretions due to dysphagia and had several episodes of non-bloody emesis. Chest x-ray was unremarkable. Gastroenterology was consulted, and she underwent EGD. A rectangular piece of eggshell was found in the middle third of the esophagus. The eggshell was grasped with standard forceps and pushed into the stomach without difficulty. No esophageal lesions or erosions were noted in the esophagus. Case 2: A 26-year-old female with a history of chronic intermittent reflux symptoms presented to the emergency department with sharp midsternal chest pain upon swallowing that started after she drank egg whites. She was found to have an elevated D-dimer, and a CT Angiogram Chest was obtained in the emergency department which revealed a calcified foreign body within the mid-esophagus at the level of the carina. The patient denied any history of dysphagia. Her physical exam was unremarkable. Gastroenterology was consulted, and EGD was performed, showing a piece of eggshell, which was extracted using rat tooth foreign body forceps. The patient had a healthy mucosal appearance of the esophagus.

DISCUSSION:

Eggshell food impaction is rarely documented in the literature. In both cases, we describe, chest pain/odynophagia as a predominant symptom, although one patient did describe concomitant dysphagia. The eggshell foreign body was visible on a CT scan, perhaps due to the calcified nature of the shell. Thus, this calcified eggshell could potentially be mistaken for an impacted bone fragment in the esophagus on imaging studies. However, the eggshell was not seen on a routine chest x-ray in the other case. Endoscopic management was achieved by grasping the eggshell with standard forceps and pushing the eggshell into the stomach by extraction of the eggshell using foreign body forceps. Neither patients exhibited erosions caused by the impacted eggshell, despite the presence of sharp edges.
1755 A Case of Xylophagia
Authors: Yarze Joseph C. , Garber John J. , Shay Jessica E.
Published: October 2019

INTRODUCTION:

To describe a case of xylophagia with esophageal obstruction.

CASE DESCRIPTION/METHODS:

A 59-year-old female with prior medical history of hypertension, depression and PTSD presented with a sensation of mid retrosternal dysphagia and sialorrhea, which began during a meal consisting of eggs and toast. Prior surgical history was significant for prior sleeve gastrectomy. Upon her presentation, the patient noted that there was a several year history of chronic watery diarrhea for which she underwent extensive evaluation at an outside institution. The etiology of her diarrhea remained unclear and multiple empiric medication trials were unsuccessful. A friend of the patient suggested that she might try ingesting small amounts of toilet paper each day to solidify the stool. The patient began this practice several months prior to her presentation to the ED. The patient corroborated that by ingesting a small amount of toilet paper each day, her diarrhea had completely resolved. Aside from sialorrhea, her physical examination was unremarkable. The patient underwent urgent upper GI endoscopy under general anesthesia with endotracheal intubation. The mid and distal esophagus were found to be obstructed with a large amount of fluffy, soft toilet paper (Figure 1). The obstruction was painstakingly relieved by use of rat-tooth forceps and a polyp retrieval net. After nearly 2 hours of endoscopic manipulation, the esophageal obstruction was completely relieved and the duodenum was able to be intubated, with there being only scant amounts of residual toilet paper within the gastric sleeve and proximal duodenum. Post-procedure, the patient was able to ingest liquids and small amounts of solids without difficulty. After psychiatric consultation, the patient was discharged. It was strongly advocated by both the gastroenterology and psychiatric teams, that the patient curtail her habit of xylophagia.

DISCUSSION:

Xylophagia is a form of pica, involving the ingestion of items made of wood (such as paper, pencils, tree bark). Our patient endorsed commencing her habit of xylophagia in an effort to improve her chronic diarrheal disorder. It was suspected that her underlying psychiatric disease, prior bariatric surgery and willingness to accept another's ill–advised recommendation–all conspired to produce this unusual clinical presentation.
1756 Evolution of Esophageal Lichen Planus to Esophageal Leukoplakia
Authors: Yarze Joseph C.
Published: October 2019

INTRODUCTION:

To describe a case of esophageal lichen planus which appeared to evolve to leukoplakia (aka epidermoid metaplasia).

CASE DESCRIPTION/METHODS:

A 70 yo female with a prior history of lichen planus, presented from another institution for ongoing care related to proximal esophageal stricturing. The patient had well-documented lichen planus involving the oral and vaginal mucosae and axillary areas. Dysphagia had been ongoing for greater than a decade and prior endoscopic exams revealed the proximal esophagus to be of small caliber with proximal esophageal strictures/rings. Biopsies had shown nonspecific change. On some occasions an ultrathin gastroscope was required to traverse the proximal esophagus. The patient underwent numerous sessions of Savary dilation and given oral lichen planus, it was assumed that this process was also responsible for the proximal esophageal pathology. She was treated with periodic esophageal dilation and topical budesonide. Recently after the above therapy, dysphagia had resolved, and the patient was ingesting a normal diet. The esophagus was found to be of more normal caliber endoscopically (strictures were no longer evident) and prominent whitish proximal esophageal plaques were now noted (Figure 1). Proximal esophageal biopsies now revealed hyperorthokeratosis with hypergranulosis, but no inflammatory process or Civatte bodies (apoptotic keratinocytes). As such, recent endoscopic and pathologic findings were thought to be most consistent with esophageal leukoplakia/epidermoid metaplasia. Topical budesonide was continued for her oral lichen planus, but it was now recommended that it be administered in a "swish and spit" manner. Given the association of esophageal leukoplakia with squamous dysplasia and squamous cell carcinoma, the patient was placed in an endoscopic surveillance program. She has recently remained asymptomatic from the esophageal perspective.

DISCUSSION:

Lichen planus and leukoplakia (epidermoid metaplasia) involving the esophagus are distinct clinical, endoscopic and pathologic processes- both of which appear to have a female predominance, and potential association with squamous cell carcinoma. The esophageal disease in patient under discussion appeared to evolve from one of these processes to the other, raising the specter of an association between these disorders.
1767 Esophageal Synovial Sarcoma Diagnosed Using EUS-Guided Fine-Needle Biopsy
Authors: Garcia-Rodriguez Victor , Coronel Emmanuel
Published: October 2019

INTRODUCTION:

The GI tract is host to a variety of neoplasms of epithelium, neuroendocrine, mesenchymal and hematologic origin. Esophageal sarcomas are extremely rare representing only 0.1-0.5% of all esophageal neoplasms. In this case, we illustrate a case of esophageal synovial sarcoma (ESS) diagnosed by endoscopic ultrasound and fine needle biopsy (EUS-FNB).

CASE DESCRIPTION/METHODS:

A 54-year-old female with a past medical history of multiple myeloma presented with progressive dysphagia of 4-month duration. Physical exam was unremarkable. MRI of the chest showed a mass in the superior mediastinum originating from the esophagus measuring 78mm by 46mm (Figure 1). Upper endoscopy showed an area of extrinsic compression in the upper third of the esophagus (Figure 2). EUS revealed a hypoechoic mass with well-defined borders that appeared to arise from the adventitia layer of the esophagus. No lymph nodes were seen in the mediastinum (Figure 3). EUS-FNB for tissue acquisition was performed. Pathologic evaluation of the tissue revealed spindle cells positive for TLE1, negative for S100, STAT6, DOG1, and CD5 suggestive of ESS. FISH demonstrated the SS18-SSX translocation. Neoadjuvant chemotherapy with doxorubicin and ifosfamide was started prior to surgery.

DISCUSSION:

Synovial sarcomas are rare tumors driven by the translocation SS18-SSX. They have an incidence of 800-1000 cases per year in the US, adolescents and young adults are the most commonly affected age groups. The expected 5-year survival ranges from 50-60%. The GI tract can rarely be affected by this tumor and the stomach is the most frequent organ affected. When localized in the esophagus, ESS usually presents as a slow-growing mass causing dysphagia and compressive symptoms. Diagnostic imaging studies can help in identifying the size and location of this tumor. In this case, the tumor appeared as a subepithelial lesion on endoscopic evaluation. EUS revealed that the lesion originated from the outer most layer of the esophagus and FNB was critical in obtaining enough tissue for analysis of tissue architecture and immunohistochemistry. The SS18-SSX translocation can be identified by FISH or RT-PCR. Differentiation between other sarcomas is extremely important given the particular sensitivity of this tumor to alkylating agents. Surgery remains the mainstay of treatment. The role of chemotherapy remains controversial. Due to the size and location of the mass, neoadjuvant chemotherapy with ifosfamide and doxorubicin was started in our patient prior to surgery.
1773 Esophageal Obstruction From a “Cough Pill”: Case Report
Authors: Cobb Emaree , Gebreselassie Agazi
Published: October 2019

INTRODUCTION:

Foreign body obstruction in the elderly is usually due to an identifiable underlying cause such as psychiatric disease, substance-intoxification, secondary gain, or accidental food related event. Most esophageal obstructions are asymptomatic and usually result in the passage of the foreign body. However, some patients may present with acute onset dysphagia, choking, hypersalivation, blood-tinged saliva, regurgitation, and wheezing. Rarely, foreign body impaction occurs as a complication of pill ingestion. In the cases where a foreign body has been identified in the esophagus endoscopic intervention is indicated in only one out of five cases. This is a rare case of esophageal obstruction due to pill ingestion that resulted in endoscopic intervention.

CASE DESCRIPTION/METHODS:

Patient is an 80 year old male with a medical history of HTN, atrial fib/flutter, and history of throat cancer in 2003 s/p chemo and radiation who presented to the ED after he felt a "tablet stuck in his throat". He is unable to swallow saliva, with frequent spitting of blood. He had intermittent difficulty swallowing solid food prior to admission. Patient had an esophagram done previously in 2013 which showed slight narrowing of the esophagus at C7 (Figures 1.1 and 1.2). EGD was done which revealed a whitish foreign body in the upper esophagus which was subsequently removed (Figure 1.3), and patient was then able to swallow.

DISCUSSION:

Pill-induced esophageal obstruction is a rare but serious cause of obstruction. Patients presenting similarly to this case with dysphagia, hypersalivation, blood-tinged salvia, and regurgitation should have thorough history taken to elicit any previous pill ingestion. Prolonged time to diagnosis will lead to delayed intervention, and increased risk of pill-induced esophagitis. Women and elderly are at an increased risk due to higher medicine usage, and decreased saliva production and motility in the elderly. Additionally, radiation therapy to the head and neck greatly impacts swallowing, and is exacerbated by chemotherapy. In cases with elderly patients small pills and liquid formula should be considered to prevent pill impaction. The prolonged transit or stasis of a pill increases the interaction between the pill and the esophageal mucosa causing esophagitis. Pill induced esophagitis will produce ulcers, and presents with dysphagia, difficult swallowing, and odynophagia. sIncreased ability to recognize these patients will lead to more expedient intervention and reduce risks for complications.
1779 An Unexpected Cause of Iron Deficiency Anemia
Authors: Estremera-Marcial Rodolfo , Marzan-Loyola Adriana , Martin-Ortiz Jose
Published: October 2019

INTRODUCTION:

A 74-year-old Hispanic male with hypertension and depression was evaluated due to microcytic anemia associated with fatigue, generalized weakness and intermittent palpitations. Patient denied dysphagia, unintentional weight loss, abdominal pain or rectal bleeding. Laboratories were remarkable for Hgb 11 g/dL, MCV 79.8 fL, ferritin 20 ng/mL , iron level 36 μg/dL, TIBC of 293 μg/dL and a transferrin saturation of 12%. Patient underwent a colonoscopy for evaluation of iron deficiency anemia, which failed to reveal any pathology.

CASE DESCRIPTION/METHODS:

Esophagogastroduodenal endoscopy (EGD) was performed. EGD revealed, upon retrieval of the scope, a pedunculated polypoid lesion near the gastroesophageal junction. The lesion was removed using hot snare technique. Histologic examination revealed, “Erosive squamous mucosa with necro-inflammatory debris (consistent with an ulcer) associated with lobular mucosal vascular proliferation and capillary structures lined with endothelium with flat nuclei.” Infectious immunostaining for viral entities, including Cytomegalovirus and Herpes Simplex Virus were negative. Gomori Methenamine-Silver and Periodic Acid Schiff taining for fungi were also negative. The histological features and immunostaining profile were consistent with a lobular capillary hemangioma (pyogenic granuloma). Six months after the therapeutic endoscopy, the patient was asymptomatic and with adequate hemoglobin levels.

DISCUSSION:

Lobular capillary hemangiomas are benign vascular lesions that are commonly found in the skin or oral mucosa. The pathophysiology of lobular capillary hemangiomas remains a mystery. These lesions are rarely found in the gastrointestinal tract. Due to the propensity of these vascular lesions to bleed into the GI tract, severe anemia can develop, especially if not identified and/or treated correctly. In our patient there was no stigmata of recent bleeding, but here was evidence of iron deficiency anemia. Mucosal resection is curative and recurrence is rare. This case report describes a rare benign vascular condition, known as a lobular capillary hemangioma, which, by its location at the distal esophagus, was causing iron deficiency anemia through obscure GI bleeding. It demonstrates that it is imperative to evaluate the esophagus carefully during retrieval, since they may be missed.