Distal Esophageal Obstruction Research Articles

S1878 Sarcina ventriculi Associated With Poorly Differentiated Esophageal Adenocarcinoma With Signet Features

INTRODUCTION: Sarcina ventriculi is an anaerobic gram-positive bacterium primarily found in soil, air (as spores), also found in human feces. Around 20 case reports have been published in medical literature, associating this infection with gastroparesis, gastric perforation, bariatric surgery, gastric adenocarcinoma. There is no specific treatment listed however usually the infection is treated with metronidazole, proton pump inhibitors (PPI), along with other antibiotics. The pathogenicity of this organism in humans is uncertain. We report a case report to discuss Sarcina Ventriculi coexisting with esophageal adenocarcinoma diagnosed via esophageal biopsy during Esophagogastroduodenoscopy (EGD). CASE DESCRIPTION/METHODS: A 73-years-old Caucasian male presented for epigastric pain, nausea, weight loss, early satiety. He underwent gastric emptying study, EGD and colonoscopy. On EGD there was distal esophageal obstruction. Biopsy was taken and pathology was consistent with poorly differentiated esophageal adenocarcinoma with signet ring features. Computed tomography of chest, abdomen and pelvis was suggestive of extensive metastasis to the bone and the lungs. Biopsy taken by EGD found to have Sarcina Ventriculi. Patient underwent radiation oncology and chemotherapy .Patient’s treatment was further complicated by heart failure with reduced ejection fraction and limited treatment options. Patient was made DNR-CCA during repeated hospitalizations. DISCUSSION: In conclusion, the clinical importance of sarcina has been debatable. Cases has been reported in the past with association of sarcina with gastric adenocarcinoma. It is debatable whether sarcina has some clinical implications and association in patients with adenocarcinoma, whether it is just a bystander colonizer or if it is of clinical importance in determining prognosis and clinical course.Figure 1.: H&E stain showing Sarcina organisms arranged in tetrad packets in esophageal biopsy.Figure 2.: H&E stain showing Sarcina organisms arranged in tetrad packets in esophageal biopsy.

S2013 A Rare Cause of Dysphagia – Epiphrenic Esophageal Diverticulum Complicated by Complete Esophageal Obstruction

INTRODUCTION: Epiphrenic esophageal diverticulum (EED) are a rare protrusion of the distal esophagus arising a few centimeters above the lower esophageal sphincter and is estimated to occur in 1:500,000 individuals per year. It results in motility dysfunction and typically presents as dysphagia and weight loss. Complications include upper GI bleed, esophageal carcinoma, and formation of atypical esophagorespiratory fistulas. CASE DESCRIPTION/METHODS: 66-year-old male with known history of Barrett’s esophagus and daily alcohol ingestion presented for 3 months of dysphagia with 22 kg weight loss. The initial esophagogastroduodenoscopy (EGD) demonstrated a large obstructive distal esophageal stricture for which Bougie French #60 dilation was performed at an outlying facility. Biopsy showed normal squamous mucosa. Two weeks later, dysphagia remained in which patient underwent CT chest that showed distended proximal thoracic esophagus and wall thickening with soft tissue mass involving the distal esophageal lumen consistent with obstruction; no extrinsic mass was noted (Figure 1). Laboratory workup including a complete blood count and comprehensive metabolic panel were within normal limits. Subsequent esophagram showed patulous and dilated esophagus with a large obstructive epiphrenic esophageal diverticulum (Figure 2). Esophageal ultrasound demonstrated food content within the esophageal false lumen (Figure 3). The patient subsequently had a PEG tube placed with plan to undergo traditional open transthoracic surgery with diverticulectomy and esophageal myotomy in the future. DISCUSSION: Most cases of epiphrenic esophageal diverticula are asymptomatic and do not warrant treatment though some may present with dysphagia, dyspepsia, and aspiration pneumonia. It is important to have a broad differential diagnosis including EED in patients with dysphagia. Delayed diagnosis and treatment could put patient at risk for life-threatening complications. Esophageal endoscopy is needed to rule out other dysphagia etiologies. Our case demonstrates complete esophageal obstruction leading to significant weight loss because of EED. In contrast to Zenker’s diverticulum, which occur in the proximal esophagus, EED are much rarer and occur in the distal esophagus. To contrast their rarity, EED occur at a ratio of 1:5 with that of Zenker’s. Traditionally, surgical resection is the treatment of choice. However, endoscopic techniques are being investigated.Figure 1.: CT chest shows dilated, obstructed, and irregular-shaped distal esophagus (red arrow) posterior to the pulmonary artery (PA). There is no extrinsic paraesophageal mass compression.Figure 2.: Esophagram shows epiphrenic esophageal diverticulum (red arrow) with complete distal esophageal obstruction indicates by the absence of contrast in the distal esophagus (black arrow); only an occasional trickle of contrast can be seen to transgress the distal esophagus into the fundus of the stomach. Note the proximity of the diverticulum to the cardiac silhouette.Figure 3.: Esophageal ultrasound showing food content within the esophageal false lumen at the 6 o’clock position.

2189 Lavaging the Esophagus of Food Obstruction

INTRODUCTION: Esophageal obstructions are usually due to a food bolus or foreign body ingestion in the setting of underlying esophageal disease. They are medical emergencies, requiring endoscopy within 24 hours of presentation, as failure to intervene can lead to perforation, fistula formation, or aspiration. Standard treatment consists of using a fiberoptic endoscope to advance the object into the stomach or retrieving it proximally. We describe the case of an esophageal obstruction from mashed potatoes. Due to its consistency, the obstruction could not be fully cleared with standard techniques and required an off-label use of gastric lavage for removal. CASE DESCRIPTION/METHODS: A 94-year-old female presented to our hospital complaining of three weeks of nausea, vomiting, and poor oral intake. Despite primarily consuming mashed potatoes, her symptoms worsened, with emesis of any solid foods or medications. She denied any history of dysphagia, esophageal dysmotility, or food impaction. Vital signs were stable and her abdominal exam was benign with no peritoneal signs. Abdominal computed tomography demonstrated a distal esophageal obstruction with proximal dilation. Upper endoscopy revealed food impaction with thick fibrinous food particles extending the entire length of the esophagus. Proximal retrieval with Roth Net retrievers, biopsy forceps, and tripod forceps was attempted for over two hours with minimal clearance. Given poor visualization and extent of esophageal involvement, the push technique could not be safely performed. Food particles repeatedly clogged the endoscope despite the use of diet ginger ale to break up the food. Hours later, success was finally achieved through gastric irrigation with the Ewald tube. DISCUSSION: Esophageal obstruction due to mashed potatoes is rare, and the standard methods of clearance may be ineffective at clearing its fibrinous content. Gastric lavage, routinely used in drug overdose to clear toxic ingestions, consists of inserting a tube (such as an Ewald tube) into the stomach via the mouth with sequential passing of water or saline to remove stomach contents. The same approach was applied to our patient to clear the fibrinous remnants adhering to her esophagus. This case appears to be the first reported use of gastric lavage to clear esophageal obstructions. When available, gastric lavage appears to be an effective method of managing esophageal soft food obstructions and may be considered as a last resort measure when all other methods have failed.

1802 A Hard Truth to Swallow

INTRODUCTION: Pseudoachalasia is a condition typically caused by lower esophageal sphincter (LES) obstruction in the setting of invasive neoplasm. In rare cases, a syndrome known as paraneoplastic achalasia can present similarly, but is not associated with tumor invasion into the esophageal mucosa. CASE DESCRIPTION/METHODS: 76-year-old female with history of breast cancer status post mastectomy and radiation presented to her oncologist with one month of progressive dysphagia. She was referred to gastroenterology and scheduled for an outpatient EGD, but presented to the ED with weakness, fatigue and weight loss prior to completion of the EGD. CT scan in the ED showed two right lung masses, mediastinal adenopathy and esophageal wall thickening. Patient was admitted for further workup. Day 1 of admission, patient underwent EGD that was pertinent for severe Candida esophagitis, but was aborted after progressing only 1/3 of the way into the esophagus. Patient was started on fluconazole for esophagitis with improvement in dysphagia. On day 2, patient underwent bronchoscopy with biopsy and was discharged home with oncology follow up. Five days later, she was directly readmitted from the oncology office for worsened dysphagia and continued weight loss. Esophagram showed distal esophageal obstruction presumably secondary to post-inflammatory stricture. EGD the following day showed dilated and poorly contractile esophagus with a spastic LES concerning for achalasia. Manometry revealed absence of esophageal body contractility, but was unable to assess the LES due to intolerance of the procedure by the patient. Further workup including pathology showed that patient had metastatic non-small cell carcinoma (NSCC), lung primary. It was determined that patient had pseudoachalasia due to paraneoplastic syndrome in setting of non-small cell carcinoma of the lung without invasion of the tumor into the LES. Patient ultimately underwent palliative botox injection at the LES with improvement in symptoms. DISCUSSION: Paraneoplastic syndromes are considered rare disorders triggered by an altered immune response in the setting of malignancy. Paraneoplastic achalasia is a type of paraneoplastic syndrome that presents as a rapidly progressive dysphagia. Though it has been reported in the setting different malignancies, this is one of the very few case reports of paraneoplastic achalasia due to NSCC. This case also emphasizes the importance of considering other causes of achalasia when evaluating patients with abnormal presentations.

A Peculiar Initial Presentation of Achalasia

Introduction: A 56-year-old man with history of Roux-en-y gastric bypass presented with a 2 year history of progressively worsening hiccups. They occurred every few seconds and greatly impacted his quality of life. Eating or drinking exacerbated the symptom, while self-induced vomiting led to a 15-30 minute symptom free period. Several months after the start of the hiccups, he began experiencing symptoms of dysphagia to solids and liquids as well as regurgitation. He was evaluated on multiple occasions by a variety of specialists without reaching a diagnosis. He was given thorazine which helped him greatly but was unable to tolerate side effects. Baclofen was then tried but with only mild improvement. His outside evaluation included several imaging studies of the brain, abdomen and chest as well as upper endoscopy. Apart from LA Grade B esophagitis, gastritis, and evidence of a prior gastric bypass, no etiology was found. At presentation, his blood pressure was 140/90 mmHg, with a heart rate of 88 beats/min. He had hiccups every 2-3 seconds, which hampered his speech. Abdominal examination and laboratory testing were normal. A barium esophagram showed a narrowed inferior esophageal sphincter with intermittent relaxation. A repeat upper endoscopy showed a nodular mid esophageal segment, but was otherwise normal. Computed tomography (CT) showed a thickened wall in the lower third of the esophagus as well as residual contrast within the esophagus, suggestive of a narrowing of the distal esophagus. Finally, he received esophageal manometry testing which was consistent with Type II Achalasia which was supported by EUS showing diffuse wall thickening in the lower esophagus without signs of malignancy. Subsequently, botulin toxin was injected which led to complete resolution of symptoms, including the hiccups. In light of his gastric bypass, we opted for surgical myotomy as opposed to pneumatic dilation for more definitive therapy. Though still present, the frequency and intensity of the hiccups are significantly less. Overall, his quality of life has improved dramatically and he has successfully returned to work. Achalasia is a disease characterized by failure of lower esophageal sphincter relaxation and loss of esophageal peristalsis which leads to the classic symptoms of dysphagia to solids and liquids, regurgitation, chest pain and weight loss. In a minority of patients, hiccups can develop and are felt to be a result of distal esophageal obstruction leading to stimulation of esophageal afferent vagal fibers. To our knowledge, this is the first case where hiccups preceded the development of the more typical symptoms of achalasia.

Watch It Grow: Esophageal Impaction With Chia Seeds

Introduction: A 39-year-old male with asthma and seasonal allergies presented with the acute onset of persistent, severe dysphagia. The patient had a long history of intermittent dysphagia to solids which had worsened over the preceding 2 weeks. Twelve hours before presentation, he swallowed a tablespoon of dry chia seeds followed by a glass of water. He immediately experienced epigastric discomfort and was unable manage his oral secretions. Glucagon did not relieve his symptoms. Emergent EGD showed complete distal esophageal obstruction with a gel of hydrated chia seeds. Attempts at traversing or advancing the bolus using an adult diagnostic upper endoscope were unsuccessful. Removal of the seeds using a Roth net and grasping forceps was also unsuccessful due to a semi-solid consistency. A neonatal gastroscope was advanced past the obstruction revealing a stricture at the GE junction. The neonatal gastroscope was then used to push small amounts of the chia seed gel into the stomach until the impaction was relieved. The patient was started on twice daily PPI, and a liquid diet was recommended until repeat endoscopy was performed. Chia seeds (Salvia hispanica) are small (2mm x 1.5mm), oval seeds native to Mexico and Guatemala. They have been used for food, medicine, and paint since Aztec civilization. They were initially introduced to the U.S. by terracotta “pets” on which the seeds would grow. Over the last 5 years, their use as a food product has been growing in popularity due to high protein, omega-3 fatty acid, and fiber content. Chia seeds are marketed to improve cardiovascular health, promote weight loss, and improve glycemic control. When added to liquid, dry chia seeds immediately begin to form a hydrogel capsule absorbing up to 27 times their weight in water. In the stomach, this process contributes to a feeling of satiety. In our patient, an underlying esophageal stricture resulted in the formation of a hydrogel in his esophagus causing complete esophageal obstruction. This is the first report of esophageal food impaction with chia seeds. With the increasing popularity of chia seeds, patients with a history of dysphagia or esophageal strictures should be cautioned about their use, especially in their dry form.Figure 1

Unusual intussusception within a hiatal hernia sac, reduced endoscopically

D A 70-year-old man was admitted with acute dysphagia to solids and liquids. He had a history of gastroesophageal reflux disease, Barrett’s esophagus, and large hiatal hernia, and he had previously undergone three antireflux surgical procedures, including a Nissen fundoplication, and then two repeated operations, the first through a left thoracoabdominal approach and the second through a right thoracotomy. His most recent endoscopy, performed for surveillance of Barrett’s esophagus 2 months before admission, showed long segment Barrett’s esophagus, a hiatal hernia with patent hiatal narrowing (A) and large gastric wrap folds around the cardia on retroflexed view (B). Upon admission, an esophagogram revealed distal esophageal obstruction. Upper endoscopy showed a mildly dilated esophagus and intussusception of gastric folds within t

High-resolution manometric characteristics help differentiate types of distal esophageal obstruction in patients with peristalsis

High-resolution manometry (HRM) can identify obstructive motor features at the esophagogastric junction and abnormalities in esophageal bolus transit. We sought to determine if HRM patterns can differentiate functional from organic mechanical lower esophageal sphincter (LES) obstruction. Segmental characteristics of peristalsis were examined using HRM in symptomatic subjects with elevated postdeglutitive residual pressure gradients across the LES (≥5mmHg). Sixteen consecutive patients with non-achalasic mechanical fixed obstruction were compared with 13 patients with elevated pressure gradients yet no mechanical obstruction and 14 asymptomatic controls. Pressure volumes were determined in mmHg cm s for peristaltic segments defined on HRM Clouse plots using an on-screen pressure volume measurement tool. Residual pressure gradients were similarly elevated in both patient groups. A visually conspicuous and distinctive shift in the proportionate pressure strengths of the second and third peristaltic segments was apparent across groups. Whereas the ratios of peak pressures and pressure volumes between second and third segments approached 1 in controls (0.92, 0.98), pressures shifted to the second segment in mechanical obstruction (peak pressure ratio: 1.2±0.4; pressure volume ratio: 1.8±0.9) and to the third segment in functional obstruction (peak ratio: 0.7±0.2; volume ratio: 0.5±0.2; P<0.02 for any comparison of either group with controls). A threshold volume ratio of 1.0 correctly segregated 93% of obstruction (P<0.0001); visual pattern inspection was equally effective. When elevated residual pressure gradients are present in non-achalasic patients, topographic characteristics of peristalsis can differentiate fixed mechanical obstruction from functional obstruction.

Treatments for pediatric achalasia: Heller myotomy or pneumatic dilatation?

The treatment of achalasia consists of reducing distal esophageal obstruction by either Heller myotomy surgery or endoscopic pneumatic dilatation. The aim of the present study was to evaluate the short- and middle-term results of these procedures in children. For technical reasons, children under six years old (n=8) were treated by surgery only, whereas patients over six years old (n=14) were treated by either Heller myotomy or pneumatic dilatation. Of the children aged under six years, 75% were symptom-free at six months and 83% at 24 months of follow-up. Of the patients aged over six years, complete remission was achieved by Heller myotomy in 44.5% vs. 55.5% by pneumatic dilatation after six months, and in 40% vs. 65%, respectively, after 24 months. Both pneumatic dilatation and Heller myotomy showed significant rates of failure. These results suggest that pneumatic dilatation may be considered a primary treatment in children over six years old. Also, where necessary, Heller myotomy and pneumatic dilatation may be used as complementary treatments.

Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum

Epiphrenic diverticulum is a rare disease associated with distal esophageal obstruction and a weakened muscularis propria. We have adhered to an operative strategy of excision (diverticulectomy), repair of esophageal wall, and relief of functional and mechanical obstruction. We sought to assess this pathophysiology-directed treatment strategy. From 1987 to 2005, 44 patients underwent surgery for epiphrenic diverticulum. Diverticulectomy, repair, and relief of distal obstruction was performed in 35 (80%) and esophagectomy in nine (10%). Outcome (symptoms, diet, subsequent therapies and morbidity) was assessed by follow-up. Forty of 44 patients had preoperatively identifiable esophageal obstruction (91%). Distal obstruction was functional in 32 patients and mechanical in 24; these conditions coexisted in 16. After surgery, there were no in-hospital deaths; 15 patients experienced 22 in-hospital complications. Survival was 90% at 5 years and 72% at 10 years. Symptoms improved in most patients (P = 0.0004), except for gastroesophageal reflux; new symptoms of gastroesophageal reflux occurred in 9/27 (33%) without this symptom preoperatively. Diet was less restricted postoperatively (P < 0.0001). Of 35 patients undergoing diverticulectomy, three (8.6%) required dilatation and two (6%) reoperation; 6/9 esophagectomy patients required dilatations. Preoperative assessment must include evaluation for mechanical obstruction. Adherence to a pathophysiology-directed operative strategy is safe and will improve the symptoms of most patients, with little need for reintervention. However, occasional patients will experience new symptoms, particularly reflux. Esophagectomy is the alternative for patients who are not candidates for diverticulectomy, repair of esophageal wall, and relief of distal obstruction.

Laparoscopic modified Thal fundoplication for gastroesophageal reflux in a patient with severe scoliosis and sliding esophageal hiatal hernia

A 14-year-old girl with severe scoliosis and sliding esophageal hiatal hernia underwent laparoscopic fundoplication for gastroesophageal reflux. Of various fundoplication procedures, anterior partial fundoplication (Thal fundoplication) was performed because it is effective, with less postoperative gas bloat syndrome. Laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach. In our “modified anterior partial fundoplication,” the sutures between the crura and the esophagus and the sutures on the left of esophageal wall with the fundus of the stomach could be exactly performed by laparoscopic surgical technique. The wrapping of the esophagus in fundoplication was done over the ventral 180° to 270°. Six months postoperatively, the patient did not develop gas bloat syndrome, distal esophageal obstruction from fundoplication, and delayed gastric emptying. Modified anterior partial fundoplication achieves effective control of reflux symptoms.

A unique approach to foreign body retrieval

Clinical Presentation: A 46 year old morbidly obese male presented to the emergency room with acute onset of dysphagia to solid food after having lunch. Patient was only able to swallow small quantity of liquid. Patient denied excessive salivation, nausea, vomiting, hematemesis, abdominal pain or chest pain. Past medical history was significant for recent laparoscopic band ligation for weight reduction. There was no previous history of achalasia or reflux symptoms. He was not taking any medications. He was neither an alcoholic nor a smoker. Physical exam revealed a morbidly obese male in no acute distress. Endoscopic examination was performed which revealed mildly dilated esophagus with moderate amount of saliva. A grape was noted in the distal esophagus. It appeared to cause intermittent distal esophageal obstruction. Attempts at pushing the grape through the lower esophageal sphincter (LES) with the scope were hampered by the slithering of the grape along the side of the scope. Attempts to grasp the grape with tripod forceps were unsuccessful due to slippery surface of the grape. A unique approach was adopted to retrieve the grape. An esophageal band ligator was applied to the tip of the scope. The grape was suctioned and anchored into the barrel and removed successfully.

Radionuclide esophageal emptying and long-acting nitrates (Nitroderm) in childhood achalasia.

Radionuclide esophageal emptying and long-acting nitrates (Nitroderm) in childhood achalasia.

The risk of esophageal cancer in patients with achalasia. A population-based study

<h3>Objective.</h3> —To determine more precise and accurate cancer risk estimates for achalasia that could be used to plan surveillance. <h3>Design.</h3> —Cohort. <h3>Setting.</h3> —Swedish population. <h3>Participants.</h3> —All patients with achalasia listed in the population-based Swedish Inpatient Register from 1964 through 1989. <h3>Main Outcome Measures.</h3> —The observed number of cancers in the cohort was compared with expected numbers of cancers (standardized incidence ratio [SIR]) for each 5-year age group and calendar year of observation, calculated using data from the Swedish Cancer Registry. <h3>Results.</h3> —A total of 1062 patients with achalasia accumulated 9864 years of follow-up. The mean age at entry was 57.2 years, and the mean age at cancer diagnosis was 71.0 years. Esophageal cancer occurred in 24 patients. The risk of esophageal cancer in the first year after achalasia diagnosis was extremely high (SIR, 126.3; 95% confidence interval [Cl], 63.0 to 226.1) as a consequence of prevalent cancers leading to distal esophageal obstruction simulating achalasia. During years 1 to 24, the risk was increased more than 16-fold (SIR, 16.6; 95% CI, 8.8 to 28.3). Annual surveillance after the first year would require 406 endoscopic examinations in men and 2220 in women to detect one cancer. <h3>Conclusions.</h3> —Patients with achalasia are at markedly increased risk of developing esophageal cancer. A substantial number of surveillance examinations might be required to screen for cancers, especially in women. It is not known whether surveillance will result in improved survival. (<i>JAMA</i>. 1995;274:1359-1362)

The Risk of Esophageal Cancer in Patients With Achalasia

To determine more precise and accurate cancer risk estimates for achalasia that could be used to plan surveillance. Cohort. Swedish population. All patients with achalasia listed in the population-based Swedish Inpatient Register from 1964 through 1989. The observed number of cancers in the cohort was compared with expected numbers of cancers (standardized incidence ratio [SIR]) for each 5-year age group and calendar year of observation, calculated using data from the Swedish Cancer Registry. A total of 1062 patients with achalasia accumulated 9864 years of follow-up. The mean age at entry was 57.2 years, and the mean age at cancer diagnosis was 71.0 years. Esophageal cancer occurred in 24 patients. The risk of esophageal cancer in the first year after achalasia diagnosis was extremely high (SIR, 126.3; 95% confidence interval [CI], 63.0 to 226.1) as a consequence of prevalent cancers leading to distal esophageal obstruction simulating achalasia. During years 1 to 24, the risk was increased more than 16-fold (SIR, 16.6; 95% CI, 8.8 to 28.3). Annual surveillance after the first year would require 406 endoscopic examinations in men and 2220 in women to detect one cancer. Patients with achalasia are at markedly increased risk of developing esophageal cancer. A substantial number of surveillance examinations might be required to screen for cancers, especially in women. It is not known whether surveillance will result in improved survival.

Adenocarcinoma of the Esophagus in a Patient with Paraesophageal Hernia

A 67-year-old female with a known paraesophageal hernia presented with dysphagia and weight loss. Workup revealed distal esophageal obstruction without a mass lesion. At operation a distal esophageal

Cellulose Fiber Diet Pills: A New Cause of Esophageal Obstruction

Cellulose fiber diet pills have recently become a popular form of weight control. In the past 2 months, we have seen two patients in whom ingestion of these pills has resulted in complete distal esophageal obstruction. Further studies revealed that each patient had a previously undiagnosed anatomical abnormality of the distal esophagus; in one case a Schatzki's ring, and in the other a stricture probably secondary to chronic reflux. We conclude that patients with known esophageal narrowing, or with a history of reflux and/or dysphagia, should use cellulose fiber diet pills only with extreme caution.

Diagnosis of epiphrenic esophageal diverticulum by computed tomography

Epiphrenic diverticulum is typically demonstrated by computed tomography examination as a thin walled, air or air-fluid filled structure communicating with the esophagus. However, those not associated with a distal esophageal obstruction (stricture, achalasia) may remain contracted in resting state and thus may not be visible. Occasionally the diverticulum may have to be differentiated from mediastinal abscess or tumors and even hiatus hernia.

Mega-aeroesophagus in children: a sign of gastroesophageal reflux.

Mega-aeroesophagus or massive pneumoesophagus, visible on plain chest radiographs of children, almost invariably is associated with gastroesophageal reflux. The finding is especially common in children with cerebral palsy and/or mental retardation. Occasionally, it is seen on a transient basis in severely ill or moribund patients, but even in these cases, it is usually due to gastroesophageal reflux. Only rarely is mega-aeroesophagus seen with other problems such as distal esophageal obstruction or acute lye burns.

Cricopharyngeal myotomy as a method of treating cricopharyngeal dysphagia secondary to gastroesophageal reflux

Food obstruction at the cricopharyngeal level is a common symptom of gastroesophageal reflux. In selected patients, cricopharyngeal myotomy is effective in relief of symptoms. We have used myotomy in patients whose only symptom was dysphagia, in patients too debilitated for major surgery, and in patients with persistent pharyngoesophageal dysphagia following hiatal hernia repair. All were studied by barium esophagogram, endoscopy, and manometry. Radiologic aspiration of barium was apparent in five of 19 patients. High-speed manometric tracings showed intermittent cricopharyngeal incoordination in the six consecutive patients most recently studied. This finding of incoordination has been shown to be present in 38 patients with reflux and in all with major cricopharyngeal symptoms. Myotomy was effective in relieving symptoms in patients in whom this was the only reflux symptom and in the five patients too debilitated for major surgery. Good symptomatic improvement was obtained in nine of the 12 with persistent dysphagia following hernia repair, but in three relief was partial, with persistent symptoms being secondary to distal esophageal obstruction. Investigation is necessary to exclude other causes of dysphagia. However, withcareful selection, myotomy has proved to be an effective method of treatment.