Barium Esophagogram Research Articles

Muscular thickness of lower esophageal sphincter and therapeutic outcomes in achalasia: A prospective study using high-frequency endoscopic ultrasound.

Patients with achalasia typically have thicker lower esophageal sphincter muscles, which can affect the distensibility of the esophagogastric junction. We aimed to assess whether these muscular features, measured using high-frequency endoscopic ultrasound, affect treatment outcomes. Consecutive adult patients with suspected achalasia were enrolled prospectively. They underwent a comprehensive diagnostic workup, including endoscopic ultrasound. The thickness of the lower esophageal sphincter, including the internal circular and outer longitudinal muscles, was measured using a 12-MHz ultrasonic miniprobe. Follow-up was performed at 1month and then at 6-month intervals, after treatment. Treatment response was defined as a reduction in Eckardt score to ≤3 or an improvement in the height of the timed barium esophagogram of ≥50%. Of the 29 patients who received pneumatic dilatation, all but one (96.6%) exhibited a good short-term treatment response. At an average follow-up time of 18.5 (12-55.5)months, patients who had a mid-term recurrence after pneumatic dilatation had a significantly thicker outer longitudinal muscle (1.8 [1.5-1.8] vs 0.9 [0.8-1.7]mm, P=0.036), but not internal circular muscle (2.0 [1.9-2.5] vs 2.1 [1.2-2.7]mm, P=0.874) or total lower esophageal sphincter (3.7 [3.5-4.4] vs 3.6 [2.0-4.1] mm, P=0.362). Patients with an outer longitudinal muscle ≥1.3mm thick had a significantly lower mid-term remission rate than others (36.3% vs 100%, P=0.01). Thickening of the outer longitudinal muscle at the lower esophageal sphincter is associated with poor mid-term treatment outcomes for achalasia patients treated with pneumatic dilatation.

Endoscopic pneumatic dilatation and peroral endoscopic myotomy in dilated megaesophagus

Achalasia is a primary esophageal disorderth variable causes, with an incidence between 0.03 to 1/100,000 people, and prevalence of approximately 10/100,000, with no difference between gender. It is more frequent in South and Central America, where Chagas disease is endemic. There are several methods to treat achalasia including endoscopic and surgical procedures, however, all of these methods are palliative. This article discusses 2 different endoscopic methods to treat advanced megaesophagus in Chagas disease, pneumatic balloon dilatation (PBD), and peroral endoscopic myotomy (POEM). Although varying between studies, PBD has an average symptom relief in 93% of patients in 6 months and 44% in 6 years. Some risk factors for failure of PBD are: younger age, male gender, a wider esophagus, poor emptying on post-treatment barium esophagogram and Eckardt scale < 3 before the treatment. Despite relatively short-term follow-up of an average of 3 years, POEM has excellent results. The clinical success achieved in 98 % with the Eckardt score decreased from 6.9 preoperatively to 0.77. Regarding sigmoid-shaped esophagus, only a few papers have been published on POEM. The largest population was 32 patients with a follow-up of 2 years. There was an efficacy of 96%, with the Eckardt scale decreasing from 7.8 to 1.4. In conclusion, PBD, is still widely used mainly due to its availability, especially in patients with a higher surgical risk and in patients who already had a Heller myotomy who persist or develop dysphagia. POEM has already demonstrated excellent results, but it requires advanced technical skills and Long-term results and randomized clinical trials are needed to validate the use of POEM in routine clinical practice.

Dysphagia Lusoria in a Patient With Down Syndrome

Introduction: Dysphagia lusoria is a rare cause of dysphagia in which a vascular anomaly causes extrinsic compression of the esophagus. A number of vascular abnormalities can cause dysphagia lusoria, the most common is an aberrant right subclavian artery. Case Report: A 23-year-old man with Down's syndrome presented to clinic with cough, hoarseness and dysphagia. His symptoms were previously thought to be due to asthma with allergic rhinitis, postnasal drip and chronic sinusitis. Thusly he was treated with multiple courses of antibiotics with only partial symptoms relief. Otolaryngology then offered tonsillectomy with septoplasty for a deviated septum. This was declined by the patient's guardian and his symptoms progressed so he was referred to gastroenterology. Initial evaluation was done with barium esophagogram and upper endoscopy (EGD). Barium esophagogram showed normal emptying and a small filling defect near the gastroesophageal junction. The EGD revealed an esophageal ulcer at the gastroesophageal junction and a dilated esophagus (Fig 1). Biopsy of the ulcer showed acute and chronic inflammation. The patient was on doxycycline for acne vulgaris and folliculitis so the initial concern was for pill-induced esophagitis. A proton-pump inhibitor was initiated and recommendations were made to avoid tetracyclines. Despite these interventions his symptoms did not improve so esophageal manometry was undertaken. Manometry showed distal esophageal spasm and simultaneous swallows with poor bolus transit (Fig 2). Based on his manometric results and his history of Down's syndrome the diagnosis of dysphagia lusoria was considered. Computed tomography (CT) revealed an aberrant right subclavian artery exerting a mass effect on the posterior esophagus (Fig 3). Vascular surgery was consulted but the patient's guardian has deferred surgery at this time and plans to monitor his symptoms.FigureFigureFigureDiscussion: Dysphagia lusoria is a rare vascular anomaly resulting in extrinsic compression of the esophagus. Barium esophagogram classically shows an oblique filling defect coursing from the left inferior to right superior esophagus. Definitive diagnosis can be made by endoscopic ultrasonography or CT imaging. An aberrant subclavian artery is most often asymptomatic throughout life. For symptomatic patients the initial management should be through dietary and lifestyle modifications. For intractable symptoms surgical intervention should be considered.

C-reactive protein for the early prediction of anastomotic leak after esophagectomy in both neoadjuvant and non-neoadjuvant therapy case: a propensity score matching analysis.

Anastomotic leak is one of most significant causes of mortality after esophagectomy. Therefore, it is clinically valuable to detect anastomotic leak early after esophagectomy in esophageal cancer. The purpose of this study is to investigate the associations between routine postoperative laboratory findings and anastomotic leak and to analyze the laboratory findings to find out an independent predictive marker for anastomotic leak. In addition, this study compares cases treated with neoadjuvant therapy (NT) and those without (non-NT). We retrospectively assessed the medical records of 201 consecutive cases that met this study's criteria from January 2009 to December 2016. All patients underwent curative and complete esophagectomy for intra-thoracic esophageal cancer. We compiled and analyzed routine laboratory findings from the day before surgery to the eighth postoperative day on a daily basis. Routine laboratory tests consisted of 26 separate tests, including complete blood cell counts, blood chemistries, as well as erythrocyte sedimentation rate and C-reactive protein (CRP). Barium esophagogram with chest computed tomography (CT) was performed on the seventh postoperative day to evaluate the presence of an anastomotic leak. A total of 45 of 201 patients underwent NT. Anastomotic leaks were found in 23 (11.4%) of 201 patients (8 patients in NT and 15 patients in non-NT). White blood cell (WBC) from the second postoperative day (P=0.031, P=0.006, P=0.007, P=0.007, P=0.041, and P=0.003, respectively) and CRP from the third postoperative day (P=0.012, P<0.001, P=0.014, P<0.001, P=0.001, and P=0.006, respectively) were associated with anastomotic leak in non-NT; however, only CRP on the third, fifth, sixth, and seventh postoperative days (P=0.041, P=0.037, P=0.002, and P=0.003, respectively) was associated with anastomotic leak in NT. The CRP level on the third postoperative day was a significant independent predictive marker of anastomotic leak (P=0.041, odd ratio (OR) 1.056, 95% confidential interval (CI): 1.002-1.113) and had a significant diagnostic cutoff value for the development of anastomotic leak (non-NT: cutoff value 17.12 mg/dL, sensitivity 69.2%, specificity 78.1%, P<0.001, area 0.822; NT: cutoff value 16.42 mg/dL, sensitivity 80.0%, specificity 70.0%, P=0.042, area 0.7104). There were divergent laboratory findings reflective of anastomotic leak between patients who underwent NT and those who did not. The CRP level on the third postoperative day had a significant cutoff value for early detection of anastomotic leak after esophagectomy in both NT and non-NT groups.

When Esophagus Met Bronchus: And Itʼs not a Love Story

Esophagopulmonary fistula is a devastating complication of advanced esophageal cancer (EC). Embryonically, the trachea and esophagus are derived from the foregut. When these structures meet again, they impact oral feeding and quality of life. This connection during development likely causes future malignant invasion into the respiratory tract. The incidence of stage T4, in which the tumor invades adjacent structures, is reported to be 8-30% among thoracic esophageal carcinomas.WhileEC accounts for 1% of all newly diagnosed cancers in the US, it is the 7th leading cause of cancer deaths among men. The 5-year survival rate of EC is 18% at diagnosis drops to 5% with stage IV disease, likely due to complications. We present one such complication, esophagopulmonary fistula, diagnosed with esophagogastroduodenoscopy (EGD). A 60-year-old Caucasian male presented with back pain, 10 lb. weight loss, and progressive dysphagia for 2 weeks. He had history of hypertension and a hiatal hernia, but denied heartburn. He was a former smoker, 1 pack/day for 5 years, with an average BMI. Barium esophagogram revealed a lobulated soft tissue mass near the GEJ. Contrast CT demonstrated a large heterogeneous enhancing esophageal soft tissue mass, as well as bilateral pulmonary nodules. Endoscopy revealed an esophageal mass from 29cm to the GEJ at 37cm, encompassing 75% of the lumen. Our advanced endoscopist was able to pass the endoscope into the stomach. While maneuvering around the mass, a pulmonary fistula was observed on the right side of the esophagus at 30cm. Given the location and the two lumens, this fistula was believed to connect to the right middle lobe bronchus. Biopsies were consistent with esophageal adenocarcinoma. He was palliatively treated with a covered stent, allowing him to eventually eat solids. ECs are aggressive and often diagnosed at later stages when complications are increased, namely esophagopulmonary fistulas. Making screening in this population is of utmost concern. Our patient adamantly denied heartburn or acid regurgitation. However, his wife reported that he had daily reflux and chronic cough, but declined to seek medical evaluation. This case serves to highlight the importance of strong patient and primary care provider relationships, to hopefully discover more EC cases in earlier stages. This case also affirms that covered expandable metallic stents allow for feeding, safely prevent aspiration from the fistula, and improve quality of life.Figure: Anatomical Reference - Esophagus cm from Incisors.Figure: Proximal Portion of Esophagopulmonary Fistula.Figure: Communication between Esophagus and Right Middle Lobe Bronchus.

Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry

BackgroundLaparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate. AimThe aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores. MethodsA randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires. ResultsSeventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months. ConclusionThere were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia.

Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia. Of patients aged less than 40years who had undergone a laparoscopic Heller-Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes. This study included 100 men and 101 women with a median age of 31years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction. In patients aged less than 40years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.

Clinical and imaging differences between neonates and children with pyriform sinus fistula: which is preferred for diagnosis, computed tomography, or barium esophagography?

PurposePyriform sinus fistula (PSF) is very rare. It is difficult to make an accurate diagnosis preoperatively. The aim of this study is to summarize the characteristics of clinical and radiologic presentations in neonates and children with PSF and to assess which examination is more helpful for diagnosis. MethodsA retrospective review was performed in 29 patients with PSF at a single center from January 2013 to September 2016. The clinical presentation, computed tomography (CT) scan/magnetic resonance imaging (MRI), and barium esophagogram were evaluated between neonates and children. ResultsThis study comprised 14 neonates and 15 children. Neonatal patients presented with cervical cyst, dyspnea, and stridor. However, the most common presentations of children were recurrent neck abscess and thyroiditis. All the neonates and 12 the children underwent CT scan/MRI, which showed the characteristic air pocket in the cervical lesion of 11 (78.6%) neonates and 4 (33.3%) children. The positive rates of barium esophagography in the neonates and children were 27.3% and 86.7%, respectively, the difference of which was statistically significant. ConclusionTo obtain an accurate diagnosis of PSF, the differences in clinical and radiologic presentation suggest that CT scan/MRI is preferred for neonates, and barium esophagography is preferred for children. CT scans performed immediately after barium swallow improve the positive rate.

Clinical Characteristics of Patients with Untreated Achalasia.

Background/AimsPatients with untreated achalasia frequently complain of heartburn and regurgitation. The diagnosis of achalasia might be delayed because these symptoms are misinterpreted as gastroesophageal reflux. We aim to evaluate the clinical, radiologic, and manometric findings in patient with untreated achalasia.MethodsThe records of patients diagnosed with primary achalasia between July 2004 and January 2012 at Gangnam Severance Hospital, Seoul, Korea were evaluated. We reviewed their clinical history and the findings of barium esophagogram, upper gastrointestinal endoscopy, and esophageal transit scintigraphy. We also compared the clinical, radiologic, and manometric findings of patients according to heartburn symptoms and proton pump inhibitor use.ResultsOur study included a total of 64 patients with a median age of 44.5 (interquartile range, 31.5–54.0). The median duration of symptoms was 23.5 (interquartile range, 5.3–57.0) months. Sixty-four patients (100%) had dysphagia, 49 (76.6%) had regurgitation, 35 (54.7%) had chest pain, and 38 (59.4%) had heartburn. Typical clinical features of gastroesophageal reflux disease (GERD) such as regurgitation, heartburn, and chest pain were observed in more than 50% of achalasia patients. Proton pump inhibitors were prescribed for 16 patients (25%) on the assumption that they had GERD. Patients with heartburn were more likely to experience weight loss (P = 0.009), regurgitation (P = 0.001), or chest pain (P = 0.019).ConclusionsHeartburn, regurgitation, and chest pain were commonly observed in patients with untreated achalasia. Therefore, these findings suggest that achalasia should be suspected in patients with refractory GERD.

Health-Related Quality of Life and Physiological Outcomes of Peroral Endoscopic Myotomy for Achalasia.

Peroral endoscopic myotomy (POEM) has gained acceptance as a treatment for achalasia. The aim of this study was to assess symptomatic, quality of life (QoL), and physiological outcomes of POEM using standardized methods. Patients who were planned to undergo POEM were evaluated pre- and postoperatively with timed barium esophagogram (TBE), high-resolution manometry (HRM), the achalasia symptom questionnaire (ASQ) (best score 10, worst score 31), and the short form (SF)-36 (best score 100, worst score 0). Nine patients completed postoperative HRM, TBE, and 48 hours esophageal pH monitoring. A P-value of <.05 was considered statistically significant. A total of 34 of 37 patients completed the POEM procedure. There was improvement in the ASQ scores and in QoL. HRM integrated relaxation pressures (IRPs) improved from 31.4 ± 10.8 mmHg preoperatively to 12.3 ± 6.7 mmHg postoperatively, and lower esophageal sphincter pressure (LESP) improved from 49.1 ± 16.9 mmHg preoperatively to 23.1 ± 9.4 mmHg postoperatively. Of the 7 patients who were evaluated with 48-hour pH monitoring postoperatively, 5 patients (71%) demonstrated pathological reflux with an average Demeester score of 23.1 ± 19.1. There was a negative linear correlation between LESP change and Demeester scores (r = -0.7, P = .03). The POEM procedure significantly improves achalasia-related symptoms and improves social functioning. Physiologically, there is reduction in both IRP and LESP. Postoperative pathological reflux is correlated with LESP reduction.

Functional restoration of the esophagus after peroral endoscopic myotomy for achalasia.

PurposePeroral endoscopic myotomy (POEM) is a new efficacious treatment option for achalasia. We propose to define “esophageal remodeling” as the functional restoration of the esophagus that involves decreased lower esophageal sphincter (LES) pressure, recovery of esophageal body peristalsis, and reduction of luminal diameter. The aim of this study was to investigate “esophageal remodeling” after POEM for achalasia.Materials and methodsWe analyzed data from a prospectively collected database of POEM subjects, which included preoperative and 2-month postoperative Eckardt symptom scores, and results from esophageal high resolution manometry (HRM) and barium esophagogram (BE). We recruited 23 patients (13 male; mean age: 53.9 years) whose preoperative and postoperative HRM and BE results were available, from among 30 patients with achalasia who underwent POEM at two institutions between July 2013 and December 2015.ResultsAll patients achieved clinical treatment success (Eckardt score≤3). Partial recovery of esophageal body peristalsis was noted in 1/5 patients with type I (20%), 6/11 with type II (54.5%), and 7/7 with type III (100%) achalasia after POEM. Pan-esophageal pressurization disappeared after POEM in 10/11 type II achalasia patients. The average diameter of the esophageal body after POEM was significantly decreased in all types of achalasia.ConclusionPOEM provided excellent clinical symptomatic relief and esophageal remodeling in terms of restoration of peristalsis and reduction in diameter of the esophageal body, especially in patients with type III achalasia.

Tu1239 Timed Barium Esophagogram (Tbe) As a Predictor of Treatment Response After Poem in Patients With Achalasia. Initial Experience in Mexico

Tu1239 Timed Barium Esophagogram (Tbe) As a Predictor of Treatment Response After Poem in Patients With Achalasia. Initial Experience in Mexico

Impact of esophageal flexion level on the surgical outcome in patients with sigmoid esophageal achalasia.

Esophageal achalasia can be roughly divided into non-sigmoid and sigmoid types. Laparoscopic surgery has been reported to be less than optimally effective for sigmoid type. The aim of this study was to examine the impact of the esophageal flexion level on the clinical condition and surgical outcomes of patients with sigmoid esophageal achalasia. The subjects were 36 patients with sigmoid esophageal achalasia who had been observed for >1year after surgery. The subjects were divided into sigmoid type (Sg) and advanced sigmoid type (aSg) groups based on the flexion level of the lower esophagus to compare their clinical parameters and surgical outcomes. The Sg and aSg groups included 26 (72%) and 10 subjects, respectively. There were no marked differences in the clinical parameters or surgical outcomes between the two groups. However, the clearance rate calculated using the timed barium esophagogram was lower in the aSg group than in the Sg group. No differences were found in the postoperative symptom scores between the two groups, and both reported a high level of satisfaction. Although laparoscopic surgery for symptoms of sigmoid esophageal achalasia was highly successful regardless of the flexion level, the improvement in esophageal clearance was lower when the flexion level was higher.

Mo1514 - Esophageal Stasis on Barium Esophagogram in Achalasia Patients Without Symptoms after Treatment does not Predict Symptom Recurrence

Mo1514 - Esophageal Stasis on Barium Esophagogram in Achalasia Patients Without Symptoms after Treatment does not Predict Symptom Recurrence

Gigantinės stemplės lipomos komplikuotas chirurginis gydymas: klinikinis atvejis

Įžanga Lipoma – retas nepiktybinis stemplės navikas. Tiriant pacientus dėl nespecifinių viršutinio virškinamojo trakto ligos simptomų, reikėtų nepamiršti nepiktybinių stemplės navikų. Vaizdiniais tyrimais įtartas nepiktybinis stemplės navikas ir tiksliai nustatyta histologinė diagnozė priešoperaciniu laikotarpiu yra svarbūs veiksniai pasirenkant tinkamiausią gydymo metodą bei siekiant išvengti sudėtingesnių chirurginių procedūrų.Klinikinis atvejis Moteris, 59 metų amžiaus, buvo paguldyta į chirurgijos skyrių dėl disfagijos, trunkančios apie 1,5 mėnesio. Endoskopiškai įtartas stemplės pogleivio navikas. Atlikus krūtinės ląstos kompiuterinės tomografijos tyrimą rastas 13 cm ilgio ir 2 cm pločio, –67 Houn­sfieldo vienetų tankio intraluminalinis pogleivio darinys ant kojytės. Radiologiškai labiausiai tikėtina diagnozė buvo stemplės li­poma. Navikas pašalintas atlikus ezofagotomiją per dešinės pusės torakotominį pjūvį. Pooperaciniu laikotarpiu atlikta kontrastinė ezofagograma parodė stemplės nesandarumo požymius. Buvo atlikta retorakotomija ir stemplės defektas užsiūtas. Kartotinis ra­diologinis stemplės tyrimas parodė, kad stemplės nesandarumas išliko. Tuomet į stemplę buvo implantuotas biodegraduojantis SX-ELLA dengtas 10 cm ilgio, 31/25/31 mm išorinio skersmens stentas, kuriuo defektas stemplėje sėkmingai užgydytas.Išvados Stemplės lipoma yra retas nepiktybinis stemplės navikas, sukeliantis disfagiją. Atvira stemplės operacija yra geriausias gy­dymo būdas esant dideliems nepiktybiniams stemplės navikams. Tačiau tokios pooperacinės komplikacijos kaip stemplės nesandarumas nėra retos pacientams po atvirų stemplės operacijų, o jų gydymas sudėtingas. Biodegraduojantis stentas galėtų būti tinkamas įsisenėjusiam stemplės nesandarumui gydyti.

Esophageal stasis in achalasia patients without symptoms after treatment does not predict symptom recurrence.

After achalasia treatment, a subset of patients has poor esophageal emptying without having symptoms. There is no consensus on whether to pre-emptively treat these patients. We hypothesized that, if left untreated, these patients will experience earlier symptom recurrence than patients without stasis. 99 treated achalasia patients who were in clinical remission (Eckardt ≤3) at 3months after treatment were divided into two groups, based on presence or absence of esophageal stasis on a timed barium esophagogram performed after 3months. Two years after initial treatment, patients with stasis after treatment still had a wider esophagus (3cm; IQR: 2.2-3.8) and more stasis (3.5cm; IQR: 1.9-5.6) than patients without stasis (1.8cm wide and 0cm stasis; both P<.001). In patients with stasis, the esophageal diameter had increased from 2.5 to 3.0cm within 2years of follow-up. The symptoms, need for and time to retreatment were comparable between the two groups. Quality of life and reflux symptoms were also comparable between the two groups. Although patients with stasis initially had a wider esophagus and 2years after treatment also had a higher degree of stasis and a more dilated esophagus, compared to patients without stasis, they did not have a higher chance of requiring retreatment. We conclude that stasis in symptom-free achalasia patients after treatment does not predict treatment failure within 2years and can therefore not serve as a sole reason for retreatment.

Esophageal Intramural Pseudo-Diverticulosis - A Case Report

Esophageal intramural pseudo diverticulosis (EIPD) is a rare benign pathology which is characterized by multiple small flask shaped evaginations of the esophageal wall, usually with the prominent symptoms of dysphagia in 80% of the patients [1]. The exact pathophysiology is uncertain but in one study, 26 postmortem studies revealed that these lesions represent cystic dilation of sub mucosal gland ducts [2]. Based on the literature review this entity is more common in men. Most cases are associated with esophageal strictures, gastro esophageal reflux disease and less commonly with esophageal candidiasis, achalasia, Crohn’s disease, Diabetes and Alcoholism. The common finding in endoscopy is the distinctive small outpouchings on direct visualization. However, Barium esophagogram is valuable in diagnosis as literature has suggested that endoscopy might be able to detect orifices in only 20% of the patients

The diagnosis and treatment for pyriform sinus fistula in children

Objective: To discuss the diagnosis and management for pyriform sinus fistula in children. Methods: Eight cases of pyriform sinus fistula admitted in Guangzhou Women and Children's Medical Center from May 2013 to August 2015 were retrospectively analyzed. The median age at onset was 54 months (range from 11 months to 12 years). All 8 cases presented recurrent neck infection (typical of redness, swelling, heat and pain) and 2 accompanied with acute suppurative thyroiditis. The diagnosis was confirmed by the preoperative barium esophagography combined with neck computed tomography scan (plain scan, enhancement and reconstruction). All the patients underwent laryngeal endoscopic-assisted surgery. Results: Preoperative imaging findings identified seven left-side cases and one bilateral (the symptom only manifested on left side). All 8 cases underwent left fistulectomy. There was no esophageal injury nor nerve injury during the operation. Postoperatively, all cases recovered well without complications (such as sound hoarse and coughing) and reoccurrence within the follow-up period (range from 7 months to 34 months). Conclusions: Preoperative barium esophagogram combined with neck computed tomography scan facilitates proper diagnosis and appropriate treatment. Laryngeal endoscopic-assisted technique at operation provides a better understanding of the anatomic relationship and the points where the fistulas penetrated into the pharynx, and essentially improves the operation outcome.

Primary Malignant Melanoma of the Esophagus

Introduction: Primary malignant melanoma of esophagus (PMME) accounts for 0.1%-0.5% of malignant tumors of esophagus. Since the first report of PMME, there have been about 300 cases. It occurs in the 6th and 7th decade with a 2:1 male to female ratio. It is assocaited with abnormal melanocytes and hyperplasia. Most commonly located in the middle and lower segments of esophagus. Case report: 73-year-old female with alcoholic cirrhosis presented with three months of fatigue, dyspepsia, regurgitation, dysphagia, diarrhea and vomiting. Denied significant weight loss. There were no skin lesions or lymphadenopathy. Abdomen was non-tender, but moderately distended with splenomegaly. CT chest/abdomen/pelvis demonstrated a large middle mediastinal mass measuring at 7.1 x 6.1 x 8.4 cm that extended to the posterior mediastinum inseparable from a markedly thickened esophagus. Esophagram revealed an irregular 5cm long stricture and soft tissue mass in the posterior mediastinum. Esophagoscopy revealed an 11cm ulcerating mass with malignant stricture originating 24cm from the incisors. Histopathology showed ulcerated necrotic debris and foci of tumor with chronic inflammation. The cells were polygonal with mild nuclear pleomorphism and mild to moderate amount of amphophilic cytoplasm. The tumor was positive for Vimentin, S100 protein and MART1. Consistent with malignant melanoma of the esophagus, T4N2N3Mx Stage IIIC. Due to the advanced stages and the patient's comorbidities, the patient was not a candidate for surgical resection or chemotherapy. The patient received palliative radiotherapy for dysphagia and tracheal compression. Discussion: PMME has high metastatic potential with 40-80% incidence of distant metastasis at diagnosis. Over 70% of the chief complaints are dysphagia and epigastralgia. The typical radiological finding on a barium esophagogram is lobular, polyploidy, or segmented tumor typically extending horizontally. The characteristic endoscopic finding is a pigmented polyploidy lesion. Definitive diagnosis is made by immuno-histochemical examination with positive S100 protein, HMB45 and neuron-specific enolase. Surgical resection is an effective treatment for early stage PMME. The postoperative 5 year survival rate is 37%. Postoperative adjuvant chemotherapy does not increase the survival, but is palliative. Recent studies show potential with immunotherapy. Patient with advanced inoperable PMME can benefit from the radiation therapy.

Esophageal Dysmotility in a Case of Undifferentiated Connective Tissue Disorder

Connective-tissue diseases (CTDs) are a variegated group of disorders manifesting with a wide range of clinical manifestations and laboratory abnormalities. Some patients present with a significant overlap of symptoms preventing them from being categorized as having a specific CTD. These patients are often diagnosed with undifferentiated connective tissue disorder (UCTD). We here present a very rare case of a relatively young woman with UCTD who presented with worsening dysphagia secondary to both striated and smooth muscle dysfunction. A 50-year-old woman with medical comorbidities of Hashimoto's thyroiditis, dyslipidemia had presented to the rheumatology clinic for diffuse myalgias and generalized weakness. Patient's laboratory testing was significant for elevated creatine phosphokinase (CPK of 281 IU/L), positive thyroid peroxidase antibody (>1000 IU/mL), thyroglobulin antibody (167 IU IU/L) and antinuclear antibody (1: 160) but other CTD specific antibodies (anti-Jo-1, antiribosomal P protein, anti-dsDNA, antihistone, anti-RNP, anti-Sm and anti-Scl-70) were negative. Patient was diagnosed with possible statin induced myopathy. However patient did not symptomatically improve after cessation of statins and was found to have persistently elevated CPK. Patient subsequently developed progressively worsening dysphagia to both solids and liquids over the next four years. Esophagogastroduodenoscopy was unremarkable while a barium esophagogram revealed pooling of contrast in the vallecular region with minimal aspiration. There was narrowing of lower esophagus with proximal dilation as well, suggestive of achalasia (Figure-1a/1b). Barium swallow with video fluoroscopy demonstrated delayed initiation of swallowing. High resolution manometry was consistent with type I achalasia (Figure-2 and 3). This rare case demonstrates dysphagia secondary to dysfunction of both striated and smooth muscles in setting of possible UCTD. UCTD is characterized by presence of positive antinuclear antibodies and symptoms for duration of at least 3 years. Patient also had chronic autoimmune thyroiditis which is commonly seen in patients with UCTD. Another distinct possibility in this case includes HMG-coA reductase antibody associated autoimmune myopathy which can have smooth muscle involvement. This case was remarkable given that initial rheumatological diagnosis of simple statin induced myopathy had to be reconsidered in light of imaging and manometric evidence.Figure 1Figure 2Figure 3