bluuebunny/crossref_metadata_2025_split huggingface dataset:
1777 Esophageal Perforation From Blakemore Tube Use Resulting in Mediastinitis: Important Clinical Pearls to Reduce Mortality
Authors: Saeed Naba , Khan Zarak H. , Muzaffar Mohammad , Gjeorgjievski Mihajlo , Hammad Sahla , Khan Humza , Tasleem Syed 
Published: October 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DISCUSSION:
The pathogenesis is hypothesized to be due to the distal portion of the esophagus being a watershed area due to lower levels of vascularization compared to the upper and middle portions. In one case series, 4 out of 16 cases (25%) of AEN occurred in the setting of diabetic ketoacidosis (DKA), and 14% of cases of DKA involved AEN. AEN is more likely to occur in men than women with a 4:1 ratio, and the ages of presentation ranged from 19-91 with a mean of 68 years. It is diagnosed by upper endoscopy which shows circumferential black necrosis in the distal third of the esophagus that may extend along the length of the esophagus into the upper third but will not extend into the gastric mucosa. Mortality is as high as 32% and the mortality specific to AEN is closer to 6%. Complications can include esophageal perforation, mediastinitis, and abscess formation in up to 6%. Late complications include esophageal strictures and stenoses which are seen in 10.2% of cases and appear as early as 7-12 days. AEN is typically managed with high dose PPI and sucralfate.
1804 An Unusual Presentation of Mallory-Weiss Syndrome (MWS)
Authors: Pacha Faris , Skrove Jamie L. , Mohan Karthik , Sobrado Javier , Rana Zaid 
Published: October 2019

INTRODUCTION:
Mallory-Weiss syndrome (MWS) is characterized as longitudinal mucosal tears of the esophagus, most often located in the gastro-esophageal junction that may extendproximally into the distal and even mid- esophagus or distally into the stomach. Risk factors for bleeding as a result of a tear include alcohol abuse and concomitant portal hypertension. Incidence is highest among the male gender and between the ages of 40-60. The proposed mechanism of the tearing is an increase in intra-abdominal pressure leading to a tear through the mucosa and underlying esophageal venous and/or arterial plexus. We present a unique case of MWS that originated in the mid-esophagus with no extended involvement of the distal esophagus.

CASE DESCRIPTION/METHODS:
A 51-year-old male with a past medical history of alcohol dependence presented to the ER for hematemesis. In the ER, the patient’s respiratory status rapidly declined and the patient was intubated. The lab values and chest xrays were all normal. After intubation, the patient continued with heavy retching that contained frank blood and clots. Emergent endoscopy was performed and a large mid-esophageal Mallory Wiess tear was identified and treated with epinephrine injections. There was also an ulceration of the GE junction that was treated with epinephrine and hemoclip placement. The patient recovered without further incident and was discharged several days later.

DISCUSSION:
Initial management of MWS with concomitant upper GI bleed includes: airway management, IV PPI, IV antiemetic, and upper endoscopy for evaluation of the tear with therapeutic interventions that may involve thermal coagulation, hemoclips, epinephrine injection, and/or band ligation. Complications often occur if bleeding cannot be controlled, and surgery may ultimately be necessary. As mentioned, MWS usually involves the gastro-esophageal junction. In a literature review, no previous cases involving a tear limited solely to the mid-esophagus were described until now. It is unclear as to what the pathophysiology behind this particular presentation is or if the location of the tear changes the prognosis and/or complication rate of the case. With no previous cases to review, recommendations are limited; however prompt management remains vital for all MWS cases.
1812 Upper Esophageal Stenosis Secondary to Multiple Foreign Body Ingestions
Authors: Hitawala Asif , Alomari Mohammad , Al Momani Laith , El Kurdi Bara , Sanaka Madhusudhan R. 
Published: October 2019

INTRODUCTION:
Multiple episodes of foreign bodies ingestion and subsequent esophagogastroduodenoscopies (EGDs) can lead to an uncommon and disabling complication- esophageal stenosis. We present an interesting case of recurrent foreign body ingestions complicated by upper esophageal stenosis making further foreign body retrieval difficult.

CASE DESCRIPTION/METHODS:
A 33-year-old female with a past medical history of borderline personality disorder, impulse control disorder and recurrent non-suicidal foreign body ingestions requiring multiple EGDs and surgeries presents to the emergency department after ingesting a battery. On arrival, she complained of trouble swallowing, chest pain and abdominal pain. Physical examination was remarkable for abdominal tenderness and guarding. Laboratory results showed hemoglobin of 8.4 gm/dl and hematocrit of 27.8%. Plain radiography of the chest and abdomen revealed a radiopaque tubular device overlying the stomach (Figure 1a) and a cylindrical radiopaque foreign body overlying the left upper quadrant over the stomach (Figure 1b), respectively. Patient was intubated and scheduled for an EGD. During the procedure, the patient was noted to have scarring and granulation polyp in the mid esophagus. (Figure 2) A battery was found in the gastric body and removed via a snare. During retrieval, the cricopharyngeus muscles were found to be tight and did not enable the passage of the battery. That required the use of Miller blade to open up the pharynx to enable safe passage. Battery was intact on removal. (Figure 3) The patient tolerated the procedure well and was discharged home after a period of observation.

DISCUSSION:
Foreign body ingestion and subsequent endoscopic procedures are associated with a variety of complications, including perforation, bleeding and infection. Those complications may result from the sedation as well as the diagnostic and therapeutic maneuvers performed. Our patient had a history of multiple foreign body ingestions, including knives and razor blades, requiring multiple EGDs for their removal. These together led to scarring of her esophagus with subsequent healing and contraction, resulting in esophageal stenosis. This warranted additional intervention and multidisciplinary approach for safe removal of the foreign body. Given the risk of esophageal stenosis in patient with recurrent foreign body ingestions, endoscopists should keep this complication in mind and be prepared with the needed equipment.
1816 Achalasia in the Setting of Esophageal Varices Achalasia in the Setting of Achalasia in the Setting of Esophageal Varices
Authors: DuBroff Jason , Bank Jeffrey S. , Fang John C. , Gawron Andrew J. , Byrne Kathryn R. 
Published: October 2019

INTRODUCTION:
Primary achalasia is an esophageal motility disorder characterized by inadequate or absent lower esophageal sphincter (LES) relaxation and loss of normal esophageal peristalsis of the esophageal body. We present an unusual case of achalasia in the context of esophageal varices, creating a challenging therapeutic dilemma.

CASE DESCRIPTION/METHODS:
A 63-year-old male with a history of hypertension, type II diabetes, decompensated HCV cirrhosis (status post sofosbuvir/velpatasvir and ribavirin without sustained virologic response) with hepatic encephalopathy, initially presented with a five month history of progressively worsening dysphagia, unintentional 40 lb. weight loss, and epigastric abdominal pain. He underwent an EGD with findings highly suspicious of achalasia with dilated esophagus, a large amount of retained food with associated stasis esophagitis, hypertonic LES, and no obvious esophageal varices. Esophageal manometry confirmed absence of normal contractility and elevated integrated relaxation pressure (29 mm Hg) consistent with Type I achalasia. On subsequent EGD, he was noted to have grade II esophageal varices. Treatment of achalasia was performed with botulinum toxin injections of the LES, carefully avoiding the esophageal varices. In the next 48 hours, he had significant improvement in symptoms of dysphagia, tolerated a full liquid diet, and then underwent a repeat EGD with successful decompression of his varices with placement of two bands. He was discharged from the hospital tolerating a regular diet.

DISCUSSION:
Achalasia is uncommon, with an annual incidence of approximately 1 in 100,000 individuals. Achalasia in combination with esophageal varices is a very rare occurrence with only 12 case reports and one retrospective study of 14 patients in the current published literature. This particular disease combination presents a therapeutic challenge as our patient was a poor candidate for surgical myotomy given his cirrhosis and bleeding risk. Our case is consistent with previously documented reports showing short-term clinical improvement with botulinum toxin injections as a well-tolerated first line therapy.
1820 Dysphagia Lusoria: When Surgery Is the Bitter Pill to Swallow
Authors: Werlang Monia Elisa , Paniz Graziella Rangel , Brahmbhatt Bhaumik 
Published: October 2019

INTRODUCTION:
Aberrant subclavian artery (ASA) is a rare anatomic variant and frequently asymptomaticcondition. We present a case of a young patient with progressive dysphagia who underwent extensive workup and repetitive endoscopic procedures until diagnosed.

CASE DESCRIPTION/METHODS:
35-year-old female with history of systemic lupus erythematous, presented with progressive dysphagia for several weeks. No preceding trauma, procedures or infections. She had anunremarkable upper endoscopy, but an empiric esophageal dilation was performed. However, in few months her symptoms recurred; another dilation was pursued along with proton pump inhibitor therapy and dietary changes.
Three years later, she had worsening dysphagia, leading to an 8-pound weight loss. An esophagram raised suspicion for an extrinsic esophageal compression (Figure 1). A computed tomography (CT) angiogram confirmed the presence of a right ASA (Figure 2).
Patient was referred to thoracic surgery and underwent operative repair of right ASA (Figure 3). A repeated esophagram on the 5th day after surgery, showing no delay in the passage of the barium pill. Upon discharge, she was tolerating soft diet and in one month she was able to eat normally.

DISCUSSION:
ASA is characterized by a vascular ring structure due to aberrant arising of one of the subclavian arteries (arteria lusoria) from the aortic arch. Although ASA is the most common congenital aortic arch anomaly, it occurs in less than 2.5% of overall population. Its management depends on symptoms: if mild and intermittent, dietary and behavioral modifications are appropriate; if severe dysphagia, surgery should be considered. During adulthood, 30% of patients are symptomatic with intermittent dysphagia being the most prominent symptom. Late presentation is probably related with atherosclerosis and aneurismal formation due to advancing age. Even though ASA is found mostly in women and its possible relation with atherosclerosis, we could not find any data in literature linking ASA to SLE. Dysphagia lusoria can be easily diagnosed by barium esophagogram, an inexpensive test which would typically show an impression defect at the level of the third or fourth vertebra. Esophageal manometry and upper endoscopy usually are unrevealing but a CT angiogram can confirm the diagnosis. Because of its rarity, ASA is not commonly suspected upon evaluation of dysphagia in adults, often times causing recurrent endoscopies and other non-revealing tests to be repeated.