bluuebunny/crossref_metadata_2025_split huggingface dataset:
1743 From Red to Black: A Deadly Case of Acute Esophageal Necrosis
Authors: Shah Maulik , DeRosa Justin , Suga Herman , Shivaprasad Punitha 
Published: October 2019

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

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

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

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

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

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

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

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

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

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

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

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

INTRODUCTION:
To describe a case of xylophagia with esophageal obstruction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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