bluuebunny/crossref_metadata_2025 huggingface dataset:
1736 Mega Esophageal Diverticulum Complicated by Post-Operative Esophageal Stricture
Authors: Then Eric O. , Aloreidi Khalil , Gayam Vijay , Paniagua-Morales Julian , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Esophageal diverticulae are rare outpouchings of the esophagus that occur secondary to underlying motility disorders. On average they measure approximately 7 cm. Here we present a case of mega diverticulum measuring 8.5 cm, complicated by post-operative esophageal stricture.

CASE DESCRIPTION/METHODS:

Patient is a 58-year old female with a medical history of gastroesophageal reflux disease who presented to our gastroenterology clinic complaining of progressively worsening reflux and weight loss. Given these symptoms, an esophagogastroduodenoscopy (EGD) was scheduled. This was done and showed a large esophageal diverticulum with luminal distortion and retained food in the lower third of the esophagus. Subsequently a barium swallow was ordered to better evaluate the esophagus. This was done and showed an 8.5 × 6.0 cm diverticulum from the right side of the distal esophagus with slight irregularity of the mucosa superior to the diverticulum (Figure 1). The patient was then referred the surgical clinic for possible intervention. After discussing the risks and benefits of treatment the patient agreed to undergo surgical repair consisting of a diverticulectomy. This was done successfully with no postoperative complications. Five days after the procedure a repeat barium swallow was done and showed resolution of the diverticulum with no leakage of barium, but did reveal lower esophageal narrowing with a dilated thoracic esophagus (Figure 2). Following these findings a repeat endoscopy was done which showed a lower esophageal stricture that was treated with balloon dilation (Figure 3). After the procedure the patient was able to tolerate oral intake and was safely discharge home.

DISCUSSION:

Management of esophageal diverticula depends on the severity of symptoms. In asymptomatic patients a conservative approach may be employed. In symptomatic patients who present with dysphagia, regurgitation, vomiting or chest pain, surgery is the mainstay of treatment. Surgical management consists of diverticulectomy with long myotomy and subsequent fundoplication. Postoperative complications include pulmonary edema, pneumonia, and leakage of barium swallow into the thoracic cavity. Rarely will esophageal narrowing resulting in persistent dysphagia occur. In these cases an endoscopic treatment with balloon dilation should be pursued. Our case highlights a rare presentation of a mega esophageal diverticulum complicated by a post-operative esophageal stricture that was successfully treated with balloon dilation.
1744 Not an Ordinary Ulcer: A Case of an Aorto-Esophageal Fistula
Authors: Poola Shiva , Jampala Nannaya , Naseer Maliha , Ali Eslam
Published: October 2019

INTRODUCTION:

Hematemesis is a common manifestation of variceal and non-variceal upper gastrointestinal (GI) bleed with a broad differential. Aortoesophageal fistula (AEF) is a life-threatening and catastrophic cause of gastrointestinal bleeding, which is caused by the abnormal communication between the aorta and the esophagus. We are presenting a rare case aorto-esophageal fistula in a young patient who was found to have a benign appearing esophageal ulcer on endocscopy that subsequently was found to be an (AEF).

CASE DESCRIPTION/METHODS:

A 33-year-old Caucasian male presented to the hospital for fatigue, non-blood emesis and progressively worsening leg swelling. His history is significant for hypertension, seizure disorder, chronic kidney disease (due to pauci-immune glomerulonephritis), heart failure and a descending aortic transection due to an accident 12 years ago which was repair endovascularly. The patient reported usage of NSAIDs prior to admission for pain control but otherwise denied alcohol or other substance abuse. The patient was admitted for his progressive renal failure and was started on hemodialysis complicated with a DVT for which was started on warfarin. During his hospitalization, the patient had an episode of hematemesis with hemodynamic instability which prompted cessation of anticoagulation. An EGD revealed a 2-3 cm non-bleeding ulcer in the proximal esophagus. The patient had stabilized hematocrit and hemodynamics and was restarted on anticoagulation. A week later, the patient had another episode of massive hematemesis with hypotension. A chest x-ray showed widening of the aortic knob, suggested change in location of the thoracic stent. CT angiogram showed aortoesophageal fistula with a leaking pseudoaneurysm at the proximal aspect of the thoracic aortic endovascular stent. Surgery proceeded with endovascular aortic repair of thoracic pseudoaneurysm. Patient had multi-disciplinary management strategy for staged repair.

DISCUSSION:

AEF are classified as primary i.e. spontaneous erosion of the aortic wall into the esophagus or secondary caused by either esophageal malignancy, surgeries or foreign body. Exact incidence of the AEF is unknown. Early recognition is important to decrease mortality. Chiari et al described the triad of midthoracic pain, herald hemorrhage, and fatal hematemesis as usual presenting features. Endoscopy plays a significant role in the evaluation however it has a poor rate of detection for AEFs prompting the need of CT imaging with high clinical suspicion.
1747 Rare Case of Esophagitis Dissecans Superficialis Mimicking Eosinophilic Esophagitis Treated With PPI
Authors: Qamar Khola , Tiwari Abhinav
Published: October 2019

INTRODUCTION:

Esophagitis dissecans superficialis (EDS) is a rare condition characterized classically by sloughing of the esophageal mucosa. EDS is a benign condition that usually resolves without lasting pathology. EDS can be associated with medications, chemical irritants, hot beverages, autoimmune diseases. Here we present a case of EDS which mimicked Eosinophilic esophagitis on endoscopy.

CASE DESCRIPTION/METHODS:

76 y old male with PMH of CAD on ASA presented with chief complain of dysphagia to solid food underwent EGD that revealed mucosal friability, non-obstructing Schatzki ring, faint mucosal rings. The esophagus was dilated with 18 Fr savory dilator. Biopsies from mid and distal esophagus showed nonspecific inflammation with no intramucosal eosinophils. EGD was repeated 3 months later while he was taking PPI BID. Repeat EGD showed esophagus with circumferential rings, congestions, friability and a thin white membrane lifting from the mucosa. Biopsies from mid and distal esophagus showed splitting of squamous mucosa, focal lymphocytic infiltration and diffuse parakeratosis consistent with EDS. He was continued with PPI BID with the improvement of symptoms.

DISCUSSION:

Classical EDS has been characterized by stripped, whitish mucosa with or without bleeding, vertical fissures and circumferential cracks. EDS is associated with medications such as bisphosphonates or NSAIDs, chemical irritants, celiac disease, hot beverages, autoimmune bullous dermatoses or idiopathy. Commonly presents as dysphagia, anemia, pain, and heartburn. It is unclear if 81 mg ASA taken by our patient is a culprit, as he did not have any other known risk factor. Treatment includes PPI and discontinuing precipitating factors and medications. In this case, endoscopic findings initially mimicked EoE, however, repeat EGD with biopsies revealed underlying EDS.
1749 Hematoma Involving the Inter-Arytenoid Fold: A Rare Mimic of Esophageal Foreign Body Impaction
Authors: Paul Navin
Published: October 2019

INTRODUCTION:

Approximately 120,000 cases of foreign body ingestion are reported annually in the United States. Although over 80% of ingested objects will pass spontaneously, approximately 10-20% may need endoscopic intervention and removal. Among US adults, food impaction is the most common cause of esophageal foreign body impaction. Typical presenting features include chest discomfort, inability to swallow food or secretions, foreign body sensation, and painful swallowing. This report details a rare cause for esophageal foreign body sensation raising suspicion for an impacted foreign body.

CASE DESCRIPTION/METHODS:

A 75 year old man presented to the emergency room with history of a sensation of something stuck in his throat. He had eaten a normal meal consisting of chicken before onset of symptoms. Abut 2 hours later, he became violently ill with stomach pain and dry heaves resulting in forceful vomiting, following which he developed a foreign body sensation in the throat. He was concerned that a piece of chicken was stuck in the upper esophagus or throat. He was able to swallow water and secretions, but reported pain on swallowing. He was not on any anticoagulant or antiplatelet agents. A trial of intravenous glucagon did not alleviate his pain, but viscous lidocaine resulted in temporary relief in his sensation. Given the history and reported foreign body sensation, he was scheduled for an endoscopy with conscious sedation. Endoscopy showed a hematoma involving the inter-arytenoid fold in the throat, with slight impingement of the tracheal opening. The esophagus was easily intubated alongside the hematoma, and appeared slightly tortuous but otherwise normal. Given lack of additional findings, it was felt that the hematoma was the cause for his foreign body sensation. Given slight impingement of the tracheal opening, an ENT consultation was obtained. The patient was conservatively managed as outpatient and reported improvement in symptoms within three days of hospital discharge.

DISCUSSION:

Inter-arytenoid hematoma is a rare entity. A review of literature showed only one previous report of symptomatic inter-arytenoid hematoma. This case is unique in that the cause for hematoma formation was forceful vomiting in the absence of any anticoagulant or antiplatelet use. In patients who present with suspected foreign body impaction, alternate causes for symptoms should be considered.
1752 Boerhaave's Syndrome Was Treated With Over-the-Scope Clip OTSC Closure (Bear Claw Closure): A Rare Case Report
Authors: Azawi Muaataz , Chun Soohwan , Bansal Raghav
Published: October 2019

INTRODUCTION:

Boerhaave's syndrome a rare yet frequently fatal diagnosis, is characterized by transmural rupture of the esophagus. The classic presentation of Boerhaave syndrome is characterized by Mackler's triad, consisting of chest pain, vomiting, and subcutaneous emphysema. Boerhaave syndrome can occur in patients with a normal underlying esophagus or pathological esophagus, such as eosinophilic esophagitis, Barrett's and malignancy. Rupture of the esophagus results in contamination of the mediastinal cavity with gastric contents, and subsequently bacterial infection and mediastinal necrosis. Surgical treatment is well established, but the development of interventional endoscopy has proposed new therapies.

CASE DESCRIPTION/METHODS:

57 year-old male presented with trauma in setting of alcohol intoxication. In the ED patient was found to have a left hemopneumothorax found in CT scan. The patient was admitted for lactatemia and chest tube management. Afterwards patient developed sepsis due to empyema which prompted him to undergo for VATs procedure. Patient remained septic and CT with contrast revealed an esophageal leak and Boerhaave’s syndrome was suspected. GI was consulted and patient underwent EGD. A 8 mm perforation was found in the left latero-posterior portion of the esophagus consistent with Boerhaave syndrome. To repair the defect, the tissue edges were approximated using suction and one 11 mm OTSC was successfully placed (Bear claw). Thereafter patient underwent g-tube and j-tube placement. Next, the patient was discharged home and was seen in the clinic, where the g-tube and j-tube was removed.

DISCUSSION:

The current management of BS includes conservative, endoscopic, and surgical treatments. The survival rates for each treatment are 75%, 100%, and 81%, respectively. The estimated mortality rate of patients with BS is 20%–40%. Endoscopy can be utilized to confirm the diagnosis of BS, particularly in equivocal cases. Endoscopic treatment with stenting can be effective and less invasive. In a systematic review that, endoscopic stenting had a success rate of 81% but endoscopic intervention was required in 17% and surgical reintervention in 10% patients. More recently, the use of OTSC has been reported in treatment of boerhaave’s alone or in combination with local therapies or esophageal stent. These endoscopic interventions are typically performed within several days of the perforation. Here we report successful closure of boerhaave with use of OTSC alone after 14 days from perforation.
1758 H-type Tracheoesophageal Fistula: A Rare Cause of Cough and Dysphagia in Adults
Authors: Voaklander Rebecca , Bank Jeffrey S. , Sossenheimer Michael , Iravani Aidin
Published: October 2019

INTRODUCTION:

Tracheoesophageal fistula (TEF) without associated esophageal atresia (H-type) is a rare congenital anomaly, accounting for ∼4% of esophageal malformations. It is defined as a connection between the posterior tracheal and anterior esophageal walls and is typically diagnosed before age 3. However, it can occasionally be seen in adults with chronic cough and respiratory infections. We present a 38-year-old female with a new diagnosis of H-type TEF.

CASE DESCRIPTION/METHODS:

A 38-year-old female (G16P12-0-3-12) with multiple prior admissions for hypoxia (presumed due to asthma and aspiration in the setting of achalasia) was admitted with HELLP syndrome. Prior pulmonary function tests showed severe airway obstruction and echocardiogram showed normal left and right ventricular systolic function. She reported coughing when supine and with meals, a history of congenital lung abnormality, severe infancy pneumonia, upper lobe resection, diagnosis of achalasia, and yearly admissions for pulmonary issues. After delivery, she was transferred to the pulmonary service for management of her hypoxia. A TEF without inflammation was noted on chest CT and confirmed by EGD and bronchoscopy. EGD showed a 3 mm proximal esophageal fistula. Bronchoscopy demonstrated a normal oropharynx and vocal cords (VC), erythematous larynx, inflamed arytenoids, a 4 mm proximal TEF without mucosal abnormalities, and right upper lobe (RUL) absence. A swallow study showed aspiration on the posterior side of the trachea presumed due to the TEF. Surgical repair rather than endoscopic clip or stent placement was determined to be the best treatment via cervical approach esophagoplasty, muscle flap reconstruction TEF repair, and laparoscopic Heller myotomy with Dor fundoplication.

DISCUSSION:

H-type TEF is rare and can mimic chronic lung disease due to aspiration, recurrent infection, and bronchiectasis. It must be considered in adults with recurrent respiratory infections, coughing with eating/drinking, and rarely, hemoptysis. A chest CT, bronchoscopy, esophagoscopy, and barium study are crucial to confirm the diagnosis. While endoscopic clip closure of fibrotic TEFs has been successful in 62%, it may obliterate surgical tissue planes. Surgery is the optimal treatment for H-type TEF and reported to be 75-94% successful. As H-type TEF disrupts myenteric plexus development with impaired esophageal peristalsis and lower sphincter dysfunction, a Heller myotomy and Dor fundoplication should be offered.
1763 Chronic Opioid Use and EGJ Outflow Obstruction: An Important Culprit to Address Before Expensive Management
Authors: Tran Victoria , Averbukh Leon D. , Tadros Micheal
Published: October 2019

INTRODUCTION:

With the opioid epidemic on the rise, a more thorough understanding of opioid’s side effects on esophageal motility is necessary. Esophageal motility disorders are an unrecognized association with opioid use.

CASE DESCRIPTION/METHODS:

Case 1: 58-year old female was referred to our clinic for second opinion. She presented with has intermittent solid and fluid dysphagia with sensations of food stuck in her esophagus and subsequent development of severe chest pain. She has a history of a cervical fracture and has been on oxycodone 15 mg TID. Extensive workup was performed, including endoscopy, EUS, CAT scan, cardiac stress test, all of which were negative. HRM showed EGJ outflow obstruction and features of jackhammer esophagus. Her esophagram showed delayed emptying of LES. Case 2: 65-year old female with history of skull fracture and was on hydromorphone 4 mg every 4 hours. She presents with weight loss, esophageal dysphagia, recurrent aspiration pneumonia, and refractory reflux. Upper endoscopy showed hypertonic LES with resistance passing the scope. Barium study showed delayed passage of tablet at the EGJ. HRM showed EGJ outflow obstruction. Symptoms improved with reduction of opioid dose.

DISCUSSION:

While opiates are known to cause gastrointestinal distress, their effect on esophageal motility is recently being investigated. As the opioid epidemic continues to grow and spread both in the US and abroad, it is vital for health care providers to recognize underreported symptoms caused by opioids. One of the symptoms recently identified in association with opioid use is dysphagia. It has been shown that the lower esophageal sphincter contains opioid receptors which when activated, elicit pathologic deglutition. EGJ outflow obstruction can be caused by chronic opioid use. Achalasia, jackhammer, and esophageal spasm have also been reported with opioid use, although this is less established. When encountering esophageal motility disorder in patients with chronic opioid use, providers should first attempt to reduce opioid dose, instead of using more invasive techniques such as myotomy and dilation. Babaei A, et al. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019 Ravi, K et al. Achalasia and chronic opiate use: innocent bystanders or associated conditions? Dis Esophagus. 2016;29:15‐21.
1768 Esophagitis Dissecans Superficialis Secondary to Ingestion of Hair Dye
Authors: Lopez Michell , Then Eric O. , Ofosu Andrew , Maddika Srikanth , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Esophagitis dissecans superficialis (EDS) is a rare and underdiagnosed esophageal lesion characterized by sloughing of the esophageal mucosa that has been associated with various autoimmune disorders and exposure to some chemical irritants. Our case highlights a 65-year-old woman diagnosed with EDS after incidental ingestion of hair dye containing resorcinol and paraphenylenediamine (PPD).

CASE DESCRIPTION/METHODS:

The patient is a 65 year-old female with a medical history of diabetes, hypertension, major depressive disorder, asthma, alcohol use disorder who presented to our emergency department complaining of nausea and vomiting after ingesting a colored hair dye. The patient stated she accidentally ingested 2 oz of hair dye believing it was cough syrup. Notable laboratory findings on admission included a complete blood count within normal limits; a venous blood gas showing a pH of 7.274; pCO2 of 39.2 mm Hg; HCO3 of 17.2 mEq/L and a lactic acid of 5.1. Notable imaging included a chest x-ray showing focal patchy opacities at both lung bases; and an X-ray of the neck showed no retropharyngeal soft tissue swelling. Physical exam was unremarkable. After initial evaluation esophagogastroduodenoscopy (EGD) was done and showed mild superficial mucosal desquamation in entire esophagus suggestive of esophagitis dissecans superficialis (Figure 1). After the procedure the patient was started on pantoprazole and admitted to the general medical floor for further monitoring. The following night the patients symptoms resolved and she was discharge with follow up appointments.

DISCUSSION:

PPD is an aromatic amine that is widely used in hair dye due to its favorable cosmetic outcomes. Adverse effects of PPD include cervicofacial edema, upper airway tract edema, oliguria, and shock. Resorcinol is a phenolic chemical that is also used in hair dye. Readily absorbed by the gastrointestinal tract, resorcinol is a corrosive acid that causes severe burns on direct contact. Its consumption may also result in pulmonary edema, hemolysis, and metabolic acidosis. Clinical manifestations of EDS are non-specific and include vomiting and dysphagia. Endoscopically it is characterized by sheets of sloughed squamous tissue which typically appear as multiple columns of strips, often described as "gift wrap paper" like distribution as was present in our case. Its prognosis is very favorable and long term complications are rare. To our knowledge this makes the first reported case of EDS occurring secondary to ingestion of hair dye.
1776 Bleach Gargling - An Effective yet Destructive Method to Beat a Drug Test: A Bizarre Case of Caustic Esophageal Injury
Authors: Turk Issam , Zakaria Ali , Piper Marc , Tesfay Alula
Published: October 2019

INTRODUCTION:

Caustic alkali ingestion can result in severe esophageal injury. Extensive luminal damage may result in esophageal necrosis and eventually perforation. Historically, caustic ingestion has been seen mostly accidentally in children and in individuals with psychiatric illness. Since the new regulations against opioids, certain individuals have been creative with methods of beating those drugs tests. We present to you a case in which bleach was the culprit in induction of severe mucosal injury.

CASE DESCRIPTION/METHODS:

A 35-year-old male on chronic Oxycodone therapy presented with chest pain, epigastric pain, odynophagia, dysphagia for several months. He denied any history of GERD, EOE, prior EGD or recent new meds. He denied any other GI symptoms such as diarrhea, melena or hematochezia. He reported hemoptysis 3 days prior. Vitals were stable on arrival. His WBC count was 16 and CRP at 100. CT scan revealed diffuse esophageal wall thickening greatest at the upper to mid esophagus. Upon further questioning, he admitted to gargling bleach regularly for several months to falsely pass his opioid drug salivary testing as he had been illegally taking hydrocodone in addition to his prescribed oxycodone. He wasn't aware that bleach may cause any harm as he was not ingesting it. EGD revealed findings consistent with LA grade C esophagitis characterized by esophageal edema, thickening and friability which was most severe at the upper esophagus. Biopsies were taken which came back positive for active esophagitis He was sent home the next day on Protonix 40 mg twice a day with outpatient follow up.

DISCUSSION:

Caustic ingestion in adults can cause severe gastro-esophageal injury. The severity and extent of the damage depends upon: the amount, concentration, form and corrosive property of the agent; along with the duration of contact. Patients will present with oropharyngeal, retrosternal or epigastric pain, dysphagia/odynophagia, or hyper-salivation with or without hemoptosis. In case of perforation the pain will be severe. Initial evaluation includes history, physical examination, lab work and CT scan to determine the depth of involvement. Symptomatic patients should be hospitalized for supportive care. The use of NG tube is contraindicated. Perforation is an indication for emergent surgery, however; In the absence of a perforation EGD should be performed early. Esophageal strictures, bleeding, fistula formation and esophageal squamous cell carcinoma are known complication of caustic ingestion.
1783 The Association of Sloughing Esophagitis With Eosinophilic Esophagitis: A Case Report and Review of the Literature
Authors: MacGregor Jenna , Maung Magdalene , Sapp Heidi , Epstein Ian
Published: October 2019

INTRODUCTION:

A review of current literature shows eosinophilic esophagitis and sloughing esophagitis as two distinct esophageal conditions that are diagnosed using clinical and pathological findings unique to each condition. Eosinophilic esophagitis is a known inflammatory condition associated with atopy, where high concentrations of eosinophils are found in the esophageal tissues resulting in esophageal dysfunction. Sloughing esophagitis however, is the necrosis and parakaratosis of longitudinal segments of surface esophageal squamous epithelium with intact underlying squamous epithelium underneath. This has been mainly associated with exposure to chemical esophageal irritants such as bisphosphonates and, on rare occasions, inflammatory conditions such as celiac disease.

CASE DESCRIPTION/METHODS:

We will describe a case of an otherwise healthy adult patient with eosinophilic esophagitis that presented to the emergency department repeatedly for food boluses. She was referred to gastroenterology and diagnosed with eosinophilic esophagitis. Unfortunately she was refractory to standard treatments to manage symptoms such as antiacid agents, inhaled corticosteriods, viscous budesonide, prednisone, and leukotriene receptor antagonists. She underwent a 6 food elimination diet to help identify a food trigger. Although improvement of her symptoms were seen with 6 food elimination, the reintroduction of wheat caused a return of her eosinophilic esophagitis symptoms, as well as findings on endoscopy consistent with sloughing esophagitis.

DISCUSSION:

An increasing incidence of both conditions presenting in the same patient may be suggestive of a similar underlying mechanism, and given the clinical context of this case, both conditions may be reflective of an immune-mediated response to a specific antigen trigger.
1787 Esophageal Stricture in Pregnancy Secondary to Stevens-Johnson Syndrome
Authors: Hudspath Caleb B. , Oroian Tudor , Manibusan Pedro
Published: October 2019

INTRODUCTION:

Stevens-Johnson syndrome (SJS) is a rare, potentially life-threatening, mucocutaneous reaction leading to extensive necrosis and detachment of the epidermis. SJS commonly follows a viral prodrome or drug hypersensitivity reaction with an incidence of 1 to 2 cases per million per year. The long-term sequelae include mucosal, pulmonary, cutaneous, vulvovaginal and rarely esophageal complications. We present a rare case involving a pregnant patient with multiple esophageal strictures due to SJS requiring repeat balloon dilations.

CASE DESCRIPTION/METHODS:

A 32 year old pregnant female with a history of drug induced SJS, complicated by multiple esophageal strictures and vaginal stenosis, presented with symptoms of recurrent, persistent solid food dysphagia and weight loss. Barium esophagram showed a mid-esophageal stricture measuring 5 mm in diameter and a distal stricture measuring 2 mm in diameter just proximal to the gastroesophageal junction. Due to the severity of symptoms, pregnancy, and the etiology of the stricture, the patient was started on a graded stepwise dilating approach by esophagogastroduodenoscopy (EGD). Repeat dilations were done by a “rule of 3” approach using a Savary dilator every two to three weeks. A maximal diameter of 10 to 11 mm was achieved and symptom relief improved throughout the patient’s pregnancy. The patient had no procedural complications and delivered a healthy baby at 39 weeks by cesarean section.

DISCUSSION:

Over 12,000 EGDs are performed annually on pregnant women and limited follow up data showed it as relatively safe for both the mother and fetus. SJS with esophageal involvement is exceptionally rare in adults with only a few reported cases and even fewer cases during pregnancy. Esophageal strictures secondary to SJS share many similarities to strictures caused by corrosive ingestion in both presentation and management. Corrosive ingestion strictures are treated by repeated dilation and one study showed a long term satisfaction of greater than 90%. In our case this was weighed against the higher incidence of iatrogenic injury to both the mother and fetus. Further research will need to be done to determine the long term complications in pregnant patients after repeat dilations.
1795 Jugular Venous Pulsations With Neoplastic Implications: A Case of Unilateral External Jugular Venous Pulsations in the Setting of a Mediastinal Mass
Authors: Malashanka Sofya , Quinones William , Obuch Joshua
Published: October 2019

INTRODUCTION:

Jugular venous pulsations (JVP) usually have associated cardiac or pulmonary pathology. In this case report we explore a patient with JVP due to an otherwise asymptomatic mediastinal mass.

CASE DESCRIPTION/METHODS:

A 44 year old male with no significant prior history presented to the ER after 5 months of intensifying unilateral pulsations (Figure 1), He denied neck pain, visual changes, dysphagia/odynophagia, palpitations, dyspnea, or weight loss. Lab evaluation revealed normal CBC, CMP, TSH, pro-BNP, and troponin level. Neck CT showed no vascular dilation or masses. Chest CT revealed a large lobulated mass in the posterior mediastinum arising from the gastroesophageal junction (GEJ) (Figure 2a–c). Follow up PET CT showed FDG avidity. EGD revealed a large diverticulum adjacent to the GEJ as well as diffuse gastritis with biopsies positive for H.Pylori. Endoscopic ultrasound (EUS) was performed (Figure 3a, 3b) for tissue acquisition with pathology showing a benign smooth muscle proliferation with immunophenotypic profile positive for desmin, smooth muscle actin and vimentin (SMA), and negative for S100, CD117 and DOG-1, consistent with leiomyoma. The patient underwent esophagectomy with gastric pull-through. Final pathology showed low-grade spindle cell neoplasm with similar immunohistochemical staining as EUS specimens consistent with a leiomyoma. Postoperative course was complicated by chylothorax requiring thoracic duct embolization as well as mild gastric outlet obstruction.

DISCUSSION:

This case of unilateral JVP in the setting of a posterior mediastinal mass illustrates the need for a low threshold for imaging in the setting of otherwise unexplained exam findings. Esophagogastric leiomyomas are rare and may have an association with H.Pylori infection as seen in this patient, which warrants exploration between the cause and effect of H. Pylori and leiomyomas (1). While hypermetabolic tumors on PET scan typically indicate malignancy, there are reports of leiomyomas appearing hypermetabolic on PET scan (2) as seen in this patient.
1796 Chronic Cough Leads to Unexpected Diagnosis: Sarcomatoid Squamous Cell Carcinoma of the Proximal Esophagus
Authors: Shah Natasha , Modilevsky Biana , Qazi Baseer , Chi Kenneth D.
Published: October 2019

INTRODUCTION:

Sarcomatoid squamous cell carcinoma (SSCC) of the esophagus is a rare malignancy with an incidence of 2.0%. This entity was previously thought to be associated with an overall good prognosis compared to squamous cell carcinoma, however, recent studies revealed the disease to be of higher malignant potential. We report a case of a patient who was diagnosed with SSCC of the esophagus presenting with atypical symptoms.

CASE DESCRIPTION/METHODS:

A 61 year old female with a 30 pack year smoking history presented with chronic cough and 30 pound weight loss over 3 months. She denied dysphagia. Vitals were significant for temperature of 39oC and respiratory rate of 22. Serology revealed leukocytosis, microcytic anemia, and low albumin. Chest X-ray revealed right lobe opacification and antibiotic therapy was initiated. A computed tomography (CT) of the chest revealed a large fungating central cavitary mass in the right lung apex that appeared to be arising from or invading the proximal esophagus (A). Esophagogastroduodenoscopy (EGD) visualized a non-bloody, fungating mass nearly obstructing the proximal esophagus (B). Endoscopic ultrasound (EUS) revealed a 6.5cm hypoechoic mass that extended beyond the esophageal wall (C). Multiple hyperechoic liver lesions greater than 1cm in diameter were found, raising suspicion for metastases. Forceps biopsy of the esophageal mass showed spindle shaped cells and cytokeratin positive epithelial cells consistent with SSCC. Positron emission tomography (PET/CT) scan revealed a right upper lobe necrotic lung mass and findings suggestive of metastases to bone and pancreas. Due to the extent of disease, she was neither a surgical candidate nor stable enough for chemotherapy and therefore, underwent palliative care. The patient expired shortly after her diagnosis.

DISCUSSION:

We highlight a rare pathology and its radiographic and endoscopic images in a patient who did not present with the typical symptom of dysphagia. Only 10% of these cases consist of asymptomatic patients. Therapy includes esophagectomy versus chemoradiotherapy depending on the extent of the disease. At this time, due to the rarity of the disease and the complexity of its diagnosis on biopsy, only a handful of case reports have identified patients with this etiology and very few large cohort studies have been done to further assess overall prognosis and survival rates.
1802 A Hard Truth to Swallow
Authors: Steele Joshua , Birris Thomas
Published: October 2019

INTRODUCTION:

Pseudoachalasia is a condition typically caused by lower esophageal sphincter (LES) obstruction in the setting of invasive neoplasm. In rare cases, a syndrome known as paraneoplastic achalasia can present similarly, but is not associated with tumor invasion into the esophageal mucosa.

CASE DESCRIPTION/METHODS:

76-year-old female with history of breast cancer status post mastectomy and radiation presented to her oncologist with one month of progressive dysphagia. She was referred to gastroenterology and scheduled for an outpatient EGD, but presented to the ED with weakness, fatigue and weight loss prior to completion of the EGD. CT scan in the ED showed two right lung masses, mediastinal adenopathy and esophageal wall thickening. Patient was admitted for further workup. Day 1 of admission, patient underwent EGD that was pertinent for severe Candida esophagitis, but was aborted after progressing only 1/3 of the way into the esophagus. Patient was started on fluconazole for esophagitis with improvement in dysphagia. On day 2, patient underwent bronchoscopy with biopsy and was discharged home with oncology follow up. Five days later, she was directly readmitted from the oncology office for worsened dysphagia and continued weight loss. Esophagram showed distal esophageal obstruction presumably secondary to post-inflammatory stricture. EGD the following day showed dilated and poorly contractile esophagus with a spastic LES concerning for achalasia. Manometry revealed absence of esophageal body contractility, but was unable to assess the LES due to intolerance of the procedure by the patient. Further workup including pathology showed that patient had metastatic non-small cell carcinoma (NSCC), lung primary. It was determined that patient had pseudoachalasia due to paraneoplastic syndrome in setting of non-small cell carcinoma of the lung without invasion of the tumor into the LES. Patient ultimately underwent palliative botox injection at the LES with improvement in symptoms.

DISCUSSION:

Paraneoplastic syndromes are considered rare disorders triggered by an altered immune response in the setting of malignancy. Paraneoplastic achalasia is a type of paraneoplastic syndrome that presents as a rapidly progressive dysphagia. Though it has been reported in the setting different malignancies, this is one of the very few case reports of paraneoplastic achalasia due to NSCC. This case also emphasizes the importance of considering other causes of achalasia when evaluating patients with abnormal presentations.
1803 Pseudoachalasia Following Nissen Fundoplication: A Progression Documented With High Resolution Manometry
Authors: Harbaugh Joshua W. , Clayton Steven
Published: October 2019

INTRODUCTION:

Pseudoachalasia, indistinct from achalasia in symptoms and high-resolution manometry (HRM) findings, varies by a secondary etiology. Over half of the occurrences arise from malignancy and seldom following surgeries involving the esophagus. This case presents a rare development of pseudoachalasia following Nissen fundoplication, further unique by documenting complete progression on HRM.

CASE DESCRIPTION/METHODS:

A 68-year-old male with continued dysphagia and gastroesophageal reflux disease underwent repeat EGD showing progression to LA grade B (from grade A) esophagitis and a 5cm (from 3cm) hiatal hernia. Initial HRM had normal findings (Figure 1A). Laparoscopic Nissen fundoplication was performed. Recurrence of symptoms led to two stricture dilations in one year. Repeat HRM showed intact peristalsis and normal LES relaxation, but six of ten swallows had decreased distal latency < 4.5 seconds consistent with esophageal spasm (Figure 1B). He was referred to an esophageal disease clinic and reported dysphagia, poor pill swallow and 15lb unintentional weight loss. Timed barium esophagram revealed a high-grade obstruction in the distal esophagus (Figure 2). EGD had significant resistance to gastric intubation of the scope concerning for an extrinsic compression or achalasia. A CT chest, abdomen and pelvis showed no extrinsic masses or alternative malignancy. HRM had 100% incomplete liquid bolus transit, elevated LES basal (56.7mmHg) and median integrated relaxation (22.4 mmHg) pressures with complete aperistalsis validating Type I Achalasia by Chicago Classifications (Figure 1C). Diagnosis was mechanical esophagogastric junction outflow obstruction with pseudoachalasia secondary to a tight Nissen fundoplication. After Nissen fundoplication takedown, dysphagia resolved and results were maintained at follow up.

DISCUSSION:

The etiology of pseudoachalasia in this case was theorized as myenteric plexus injury during wrap construction or degeneration from sustained distal obstruction. Intermediary esophageal spasms on HRM may forewarn of developing pseudoachalasia. One should understand the risk, albeit rare, of post-Nissen fundoplication dysmotility. Being cognizant of a possible HRM progression, as identified in this patient, may spur earlier clinical follow up, repeat testing or intervention. Finally, those with rapid onset of achalasia symptoms over age 50 should raise concern and be evaluated with barium esophagram, EGD with biopsies, CT scan and HRM to decipher a secondary etiology.
1806 When the Cure Is the Cause: Checkpoint Inhibitor-Induced Lymphocytic Esophagitis
Authors: Pizzuti Jessica , Wander Praneet , Lech Diana , Ashamalla Michael , Rishi Arvind , Lee Calvin
Published: October 2019

INTRODUCTION:

Immune checkpoint inhibitors are a group of novel treatment agents that are used for the treatment of multiple metastatic malignancies. Among these are programmed cell death 1 receptor (PD-1) antibodies that promote T cell proliferation, activating the immune response to tumor cells as well as non-tumor cells causing immune-related adverse events (irAEs). Diarrhea and colitis are common irAEs. Upper gastrointestinal involvement is rare with esophagitis limited to only case reports.

CASE DESCRIPTION/METHODS:

A 74-year-old female with metastatic renal cell carcinoma developed throat pain and dysphagia after 10 doses of Nivolumab. Proton pump inhibitor (PPI) and viscous lidocaine improved her symptoms. After 20 doses of therapy she developed odynophagia and dysphagia to both liquids and solids. She underwent an esophagogastroduodenoscopy which revealed esophagitis of 13 cm in length, manifest as circumferential erythema and exudate. Biopsy confirmed active esophagitis with dyskeratotic keratinocytes and lymphoplasmacytic infiltrate. Immunohistochemistry demonstrated markedly increased polyclonal plasma cells. This was consistent with nivolumab-induced esophagitis. Nivolumab was discontinued and she was started on methylprednisolone, with rapid improvement in symptoms and subsequent transition to prednisone. She was treated with a prolonged 3-month taper, but her dysphagia to solids recurred 2 months after completing the steroids. Repeat endoscopic biopsies were consistent with reflux esophagitis. She was treated with topical steroids for suspected residual Nivolumab-induced esophagitis as well as PPI with improvement in symptoms. Ten months later, the patient developed dyspepsia and early satiety. Repeat endoscopy showed discolored, linearly eroded, friable, sloughing mucosa. Biopsies taken revealed active and chronic esophagitis with lymphocytic infiltrate again consistent with Nivolumab-induced esophagitis. The patient symptomatically improved with sucralfate and PPI, and treatment was not further escalated.

DISCUSSION:

This is a rare case of Nivolumab-induced esophagitis demonstrating initial improvement with prolonged steroid taper followed by recurrent symptoms and persistent endoscopic disease treated with acid suppression, sucralfate and topical steroids. For refractory symptoms of esophagitis, immunosuppressants such as Infliximab could be considered. It is important to recognize the diversity and severity of immune-related adverse events to avoid incomplete treatment or a delay in therapy.
1811 Acute Esophageal Necrosis (Black Esophagus): A Rare Cause of Gastrointestinal Bleeding in Patients With Sepsis
Authors: Uy Pearl Princess , Coles Michael , Yap John Erikson , Vega Kenneth J.
Published: October 2019

INTRODUCTION:

Acute esophageal necrosis (AEN) is extremely rare with less than one hundred cases reported in the literature. AEN is due to an ischemic insult causing decreased esophageal perfusion. We present two cases of AEN associated with sepsis.

CASE DESCRIPTION/METHODS:

Case 1: A 78-year-old male with coronary artery and cerebrovascular disease as well as atrial fibrillation on apixaban, was admitted for sepsis from cholangitis. Endoscopic retrograde cholangiography (ERCP) with common bile duct (CBD) stent placement was performed on day 4 which revealed a normal esophagus. He developed hematemesis on day 7; EGD discovered circumferential proximal to distal black esophagus and hematin in the stomach. Treatment included intravenous proton pump inhibitors, antibiotics, and fluid resuscitation. Apixaban was held. The patient did well post EGD and the remainder of his hospitalization was unremarkable. Case 2: A 47-year-old male with fistulizing Crohn’s disease, resulting in subtotal colectomy and diverting colostomy, as well as deep vein thrombosis post IVC filter was admitted for septic shock from gram negative bacteremia. He had hematemesis on day 8; EGD showed black mucosa throughout the entire esophagus and a large duodenal ulcer with visible vessel requiring embolization. Unfortunately, the patient expired from disseminated intravascular coagulation.

DISCUSSION:

AEN, also termed black esophagus, is rare and lethal, especially among patients with hemodynamic compromise. The distal esophagus is often involved due to blood supply and gastric acid exposure. The etiology is likely multifactorial resulting from entities causing tissue hypoperfusion along with mucosal barrier impairment/injury. Sepsis was present in both cases, with predisposing factors of atherosclerosis and thrombosis. AEN often presents as hematemesis or melena, with diagnosis made endoscopically. Treatment includes hemodynamic support, gastric acid suppression, bowel rest, and management of underlying causes including intravenous antibiotics for septic patients. Complications include esophageal stricture and perforation. Although rare, it is important to have a high index of suspicion for AEN as an etiology for upper gastrointestinal bleeding especially in septic patients given its high morbidity and mortality.
1814 Esophageal Actinomycetoma Masquerading as Cancer in an Immunocompetent Patient
Authors: Baig Sher Nazir , Rehman Sadia , Daniel Mina , Deshpande Vrushak , Abdelsayed George , Gonzalez Manuel O.
Published: October 2019

INTRODUCTION:

All that looks like cancer is not always cancer. Esophageal Actinomycosis is a fine example that frequently mimics malignancy. Actinomyces is a bacteria acting like fungi which extremely rarely infects the esophagus in immunocompetent hosts. Risk factors are unknown due to paucity of data.

CASE DESCRIPTION/METHODS:

A 79-year-old African American woman was admitted with mild hematemesis. She had progressive, painless dysphagia for solids for 6 weeks and had lost 12 lb. She had curative lobectomy for lung cancer and quit smoking 10 years ago. She had COPD and GERD. Medications included Budesonide-Formoterol and Albuterol inhalers. She had no history of chemo/radiotherapy, tuberculosis, HIV, or diabetes. Physical exam was normal. CBC, renal function and LFTs were normal. CT chest with contrast showed air-fluid levels within the esophagus and wall thickening. EGD revealed a 1 cm friable mass in distal esophagus. Biopsy confirmed actinomycosis and candida esophagitis. She was discharged on Ceftriaxone 2 g/day for 4 weeks and oral Fluconazole 200 mg/day for 3 weeks. At 1-month follow up, dysphagia had improved and she was switched to oral Amoxicillin for 6 months.

DISCUSSION:

Actinomyces is an anaerobic, gram-positive, filamentous, branching rod. It grows as normal flora in the mouth and GI tract. Esophageal Actinomycosis is exceedingly rare in immunocompetent people with only 28 cases indexed in PubMed in English. 13 cases were reported in the US. 2/3 of patients were immunocompromised. It invades the esophagus following mucosal breach, and presents as a mass, esophagitis, ulcer, abscess, fistula, or stricture causing dysphagia/odynophagia. It is a great imitator, often misleading physicians, thereby triggering malignancy work-up. Diagnosis involves imaging and biopsy. Microscopy reveals yellow sulfur granules in 50% of cases. Actinomyces is difficult to isolate with culture yield as low as 24%. RNA sequencing can provide a quick, accurate diagnosis in future. Patient education and counseling is the cornerstone of successful prolonged antibiotic therapy. An initial course of IV penicillin G or Ceftriaxone for 4-6 weeks is followed by oral penicillin V or amoxicillin for 6-12 months. Necrotic ulcer, fistula, or abscess is managed surgically. We believe that inhaled corticosteroids may have created the milieu for the growth of Actinomyces and Candida in the esophagus by impairing local defenses. 43% of inhaled corticosteroid is deposited in the esophagus according to Gamma scintigraphic studies.