bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.