Distal Esophageal Stricture Research Articles

Successful Esophago-Pleural Fistula Closure via Esophageal Stent-in-Stent Anchored With Endoscopic Suturing

Clinical Vignette: A 70-year-old male with a past medical history of metastatic distal esophageal squamous cell cancer status-post chemoradiation complicated by distal esophageal stricture, esophago-pleural fistula, and right-sided empyema with chest tube placement presented with an increase in purulent chest tube drainage. The patient was previously treated with a 23mm x 155mm esophageal fully covered self-expanding metallic stent (FCSEMS) for dysphagia secondary to stricture with no evidence of fistula or leak on esophagogram prior to discharge. Esophagogram during his most recent admission showed distal stent migration and a fistulous communication between the esophagus above the proximal end of the distally migrated stent (black arrow-head) and pleural cavity (esophago-pleural fistula; black arrows) [Image A]. The existing stent was pulled up proximally using a rattoothed forceps and repositioned to cover the esophageal fistulous opening. A second 23 mm x 120 mm FCSEMS was placed overlapping into the prior stent (stent-in-stent). The proximal end of this stent was anchored with endoscopic suturing. Follow-up esophagogram showed overlapping SEMS with no contrast leakage [Image B]. Discussion: Gastrointestinal leaks and fistula have classically been managed surgically; however, endoscopic techniques have emerged providing a viable and less invasive approach. Intrathoracic leaks, as illustrated on this patient's esophagogram, have a higher mortality rate compared to cervical leaks. Endoscopic approaches may involve a variety of closure devices including endoscopic clip placement (through-the-scope clips and over-the-scope clips), endoscopic suturing, endoscopic glue application, as well as luminal stenting as was chosen for this patient. SEMS, despite a known failure rate of up to 15%, remain a useful option. Most complications arise as a result of stent migration with recent studies demonstrating FCSEMS migration rates between 30-60%. Stent-anchoring methods, including endoscopic clipping and suturing, have been used to reduce the risk of migration. Endoscopic suturing has been shown to be more effective in preventing stent migration compared to endoscopic clipping. Here we present a case of successful esophago-pleural fistula closure via stent-in-stent placement, with stentanchoring using endoscopic suturing.Figure 1

An Elderly Woman With an Uncommon Cause of Dysphagia

Question: A 68-year-old woman with a past medical history of asthma and vulvar lichen planus is referred to us for symptoms of dysphagia. Her dysphagia is to solids only. Symptoms started 1 year before presentation and have been progressive in nature. There was no associated odynophagia, regurgitation, unintentional weight loss, melena, or hematochezia. She has mild symptoms of gastroesophageal reflux disease that are well controlled with once daily proton pump inhibitor therapy. Her medications include daily maximum dose inhaled steroids for asthma. She has no history of smoking or alcohol abuse. On oral examination, no lesions including oral thrush were noted. Our patient underwent a barium esophagram that showed a distal esophageal stricture (Figure A, arrows). An upper endoscopy was pursued that showed significant mucosal changes with white plaques, ulcers, and scarring causing luminal narrowing and friability (Figure B–E). Multiple large unstained lesions on Lugol's chromoscopy were noted (Figures F, G). Multiple biopsies were obtained from the proximal to the distal esophagus (Figure H, I). Grocott’s methenamine silver stain was negative for fungal pathogens. Based on the clinical scenario, endoscopic findings and pathology images, what is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Our patient’s dysphagia is secondary to esophageal leukoplakia (also known as “epidermoid metaplasia”). Esophageal biopsies (Figure H, I) reveal marked hyperkeratosis and prominent granular cell layer consistent with esophageal leukoplakia. A repeat upper endoscopy with biopsies was performed without evidence of underlying carcinoma or dysplasia. The patient was placed on twice daily maximum dose proton pump inhibitor therapy. Her symptoms improved. Esophageal dilation was deferred considering extreme mucosal friability and improvement of symptoms with medical therapy. She is enrolled currently in an active surveillance program consisting of repeat upper endoscopies and biopsies for early detection of dysplasia. Esophageal leukoplakia is extremely rare and poorly described in the literature. It is characterized by the presence of mucosal white plaques that cannot be scraped. In a recent case series of esophageal leukoplakia in 18 patients from multiple medical centers, it was noted that the majority of the patients were smokers or exposed to secondhand smoke (61%).1Singhi A.D. Arnold C.A. Crowder C.D. et al.Esophageal leukoplakia or epidermoid metaplasia: a clinicopathological study of 18 patients.Mod Pathol. 2014; 27: 38-43Crossref PubMed Scopus (33) Google Scholar There is an unclear association between esophageal leukoplakia and squamous cell dysplasia/carcinoma. For example, the presence of high grade dysplasia or squamous cell carcinoma in 18 esophageal leukoplakia patients was 17% in 1 series.1Singhi A.D. Arnold C.A. Crowder C.D. et al.Esophageal leukoplakia or epidermoid metaplasia: a clinicopathological study of 18 patients.Mod Pathol. 2014; 27: 38-43Crossref PubMed Scopus (33) Google Scholar Another small series identified 4 patients with epidermoid metaplasia and all 4 had either synchronous or metachronous squamous cell carcinoma.2Ezoe Y. Fujii S. Muto M. et al.Epidermoid metaplasia of the esophagus: endoscopic feature and differential diagnosis.Hepatogastroenterology. 2011; 58: 809-813PubMed Google Scholar All 4 patients in that case series were heavy alcohol drinkers. Our case is unique in that this is a rare condition and our patient lacked risk factors such as smoking or alcohol abuse.

Tu1562 Identification of Risk Factors for the Development of Distal Esophageal Stricture Following Radiofrequency Ablation of Barrett's Esophagus

Radiofrequency ablation (RFA) therapy has emerged as the treatment of choice for Barrett's esophagus (BE) with dysplasia, particularly in the setting of high-grade dysplasia. The most common complication of this treatment is distal esophageal stricture (DES). Most cases have a benign course and respond readily to endoscopic dilation, however significant consequences have been documented. Characteristics that place patients at higher risk of developing structures are currently not known.

Esophagojejunal Anastomosis Fistula, Distal Esophageal Stenosis, and Metalic Stent Migration after Total Gastrectomy

Esophagojejunal anastomosis fistula is the main complication after a total gastrectomy. To avoid a complex procedure on friable inflamed perianastomotic tissues, a coated self-expandable stent is mounted at the site of the anastomotic leak. A complication of stenting procedure is that it might lead to distal esophageal stenosis. However, another frequently encountered complication of stenting is stent migration, which is treated nonsurgically. When the migrated stent creates life threatening complications, surgical removal is indicated. We present a case of a 67-year-old male patient who was treated at our facility for a gastric adenocarcinoma which developed, postoperatively, an esophagojejunostomy fistula, a distal esophageal stenosis, and a metallic coated self-expandable stent migration. To our knowledge, this is the first reported case of an esophagojejunostomy fistula combined with a distal esophageal stenosis as well as with a metallic coated self-expandable stent migration.

Epiphrenic esophageal diverticulum within a leiomyoma: A rare cause of dysphagia

Introduction: The diagnosis of symptomatic epiphrenic esophageal diverticulum is rare (15-20%). Esophageal leiomyoma and epiphrenic diverticula are both uncommon, but may rarely occur together. In this patient a leiomyoma was found within an epiphrenic diverticulum. Methods: We report the case of a 58-year-old man referred to our unit with a 4-year history of progressive and intermittent dysphagia, mainly to solids, and weight loss. Barium swallow revealed a distal esophageal stenosis secondary to a diverticulum; upper endoscopy showed an extrinsic submucosal compression of the cardia; and CT scan showed an infradiaphragmatic saccular dilation of the esophagus with a thickened wall. The patient was diagnosed with distal esophageal diverticulum with a submucosal tumor inside. Laparoscopic hiatal diverticulectomy including tumor, cardiomyotomy and a partial fundoplication was performed. Our objective is to discuss the diagnosis and treatment of this disease. Results: The pathological study confirmed a leiomyoma of 5x4 cm in an esophageal diverticulum. On the 3rd postoperative day, barium swallow confirmed good esophageal passage and gastric emptying. The patient was discharged on day 4. In the follow-up monitoring after one month and one year the patient was asymptomatic with good quality of life. Discussion: Traditionally, treatment for an epiphrenic diverticulum consists of a diverticulectomy with or without myotomy, performed through a thoracotomy. Hiatal laparoscopy obviates the need for thoracotomy and placement of a chest tube. It would also allow an easier fundoplication after myotomy and diverticulectomy. This case has several unique aspects. Firstly, an esophageal diverticulum with a leiomyoma inside, which is in a subdiaphragmatic location; and secondly, the fact that it is not associated with primary motor disorder. Here, the leiomyoma causes the epiphrenic diverticulum. Conclusion: Whenever a submucosal tumor within the diverticulum is present careful consideration should be given to the possibility of an associated neoplasm. We suggest that the majority of epiphrenic diverticula of the distal esophagus can be treated successfully by laparoscopic approach, which makes it possible to remove the associated tumor; and that it is at least as safe and effective as conventional transthoracic access but with the advantages of an early postoperative recovery.

A Calcific Mass in The Distal Esophagus

Introduction: A 76-year-old male presented to our medical center complaining of indigestion, epigastric pain, and regurgitation, which started after consuming venison the day prior. The patient had dysphagia to solids, but tolerated liquids. Evaluation in the emergency room revealed a distal esophageal calcific mass measuring 3 cm in diameter on plain films and CT (Figures 1 and 2). With endoscopy, a large food bolus impaction coated with bismuth subsalicylate was visualized in the distal esophagus. This correlated with the radiographic finding of a distal esophageal calcific mass, since bismuth is a known radio-dense substance. Also found during endoscopy were a hiatal hernia and a partially occluding distal esophageal stricture. Interestingly, in the past, bismuth was widely utilized as a gastrointestinal radiographic contrast agent, although now barium sulfate has taken its place. After the procedure the patient tolerated clear liquids and soft foods. He was discharged on protonix, carafate, and a course of levofloxacin. Follow-up upper endoscopy one week after discharge showed improvement of mucosal injury and confirmed resolution of the food bolus. This case presents a unique example of food bolus impaction with radiographic images not previously reported in the literature.Figure 1: Abdominal plain film with a peripherally enhancing 3.0-cm mass at the level of the distal esophagus. This mass was not present on a prior film taken 9 months earlier.Figure 2: Abdominal CT image showing a 3.0 x 2.9 cm peripherally calcified mass at the gastroesophageal junction.

Tu1986 Association of Mayo Dysphagia Questionnaire-30 Day Scores to the Chicago Classification Diagnosis of Esophagogastric Junction (EGJ) Outflow Obstruction

Background: The Chicago classification of esophageal motility was developed to facilitate the interpretation of high resolution esophageal pressure topography studies. A notable feature is the hierarchical organization of esophageal motor disorders into those never encountered in normal individuals (e.g. EGJ outflow obstruction) and those that lie outside of statistical norms. Given the frequency with which we detect EGJ outflow obstruction on high resolution manometry, we sought to evaluate the strength of association between manometrically defined EGJ outflow obstruction and the symptom of dysphagia via the Mayo Dysphagia Questionnaire-30 Day (MDQ-30). Methods: All patients presenting to our motility lab from May 2013 to November 2013 to receive high resolution esophageal manometry for any indication were asked to complete the MDQ-30. In total, 62 patients completed both the questionnaire and manometry. Each patient was assigned a dysphagia score based on their response to selected questions involving the symptom of dysphagia. Responses to questions assessing reflux symptoms were not included in the overall score. Given our small sample size, Fisher's exact test was used to evaluate statistical significance between the dysphagia score and the manometric diagnosis of EGJ outflow obstruction, with the level of statistical significance set at a P value of less than .05. Upper endoscopy and esophagram were reviewed in patients with a diagnosis of EJG obstruction to evaluate for underlying pathology. Results: 15 patients (24%) had EGJ outflow obstruction defined as impaired EGJ relaxation with intact peristalsis. This group had a mean MDQ-30 score of 13 whereas the mean score for those without EGJ obstruction (n=47) was 17. In both groups, 40% of patients had dysphagia as the indication for their manometry. Using a cut off dysphagia score of 25, we found no association between the symptom of dysphagia and the finding of EGJ outflow obstruction on manometry with Fisher's exact test (p-value= 1.0). The majority of patients (13/15) with EJG outflow obstruction on manometry received an EGD, EUS and/or esophagram. Of these 13 patients, only 38% were found to have pathology which was benign. These ranged from one peptic distal esophageal stricture, one esophageal ring and one fundoplication on EGD, one patient with a thickened muscularis propria on EUS, and one patient with a narrowed area in the distal esophagus not permitting passage of barium tablet on esophagram. Conclusion: Comparing MDQ-30 dysphagia scores to a diagnosis of EGJ outflow obstruction on high resolution esophageal pressure topography, we find that there is no association between the symptom of dysphagia and the finding of EGJ outflow obstruction. We also conclude that the minority of patients with EGJ outflow obstruction have evidence of pathology on endoscopy or esophagram.

Congenital esophagostenosis due to tracheobronchial remnant in infant: 3 cases report

Abstract Esophageal congenital stenosis due to tracheobronchial remnant is a rare deformation. Its scarcity incites us to report three observations of abnormal tracheal cartilage in the wall of the lower esophagus in infants (ages: 6; 12; 24 months). Authors present records of 3 children who underwent a radical procedure of surgery for esophageal congenital stenosis in Albert Royer's Pediatric Hospital from 2005 to 2009. Anatomopathological exam was performed to identify the cause of the stenosis and develop treatment recommendations. The study included two girls and one boy who presented vomiting, undernourishment and bad general state of health. The upper gastrointestinal radiological investigations established stenosis of distal esophagus with dilatation above. Endoscopy performed in one case showed not passable regular stenosis, located at 25 cm from dental arches. There was no abnormality of mucosal appearance above and dilation wasn't attempted for lack of pediatric dilator. Diagnosis of megaesophagus was formulated and all the infants underwent esophageal distal resection with terminal end-to-end anastomosis, HIS corner repairing and anterior partial stomach fundoplication to prevent reflux. The postoperative follow up was good and the upper gastrointestinal radiological investigations were normal after one month. The anatomopathological exam revealed tracheobronchial remnant in all cases. Authors discuss about standpoint to adopt in front of esophageal congenital stenosis due to tracheobronchial remnant. We believe that radical surgery is essential for the removal of stenosis.

AAA Syndrome: Successful Management of a Rare Cause of Dysphagia

Introduction: AAA syndrome (also known as Allgrove syndrome or triple A syndrome) is a rare autosomal recessive disorder characterized by the triad of ACTH-resistant adrenal insufficiency, achalasia, and alacrima. This case highlights the gastroenterological presentation of this multisystem disorder and successful management. Case presentation: A 35-year-old Indian woman presented to the outpatient office with recurrent episodes of dysphagia to solids and liquids since childhood. Over the years, she modified her diet by avoiding meats and eating soft foods but reported an inability to gain weight. At age 17 years, she was reported to have a distal esophageal stricture at an outside facility. Four empiric endoscopic esophageal dilations were performed over a 10-year period with minor symptom improvement. In her 20s, she was diagnosed with primary adrenal insufficiency of an idiopathic nature (Addison's disease), and has been continuously treated with oral hydrocortisone. She also reported chronic dry eyes. On examination, she was 4'10”, 75 lbs with a BMI of 15.6. She had a nasal tone of voice and pigmentation of her lips and tongue. Other than a slender build, the remainder of the physical examination was unremarkable. High-resolution manometry was performed, which showed elevated lower esophageal sphincter (LES) pressures (27.2 mmHg) with abnormal LES relaxation (LES residual pressure of 34.4 mmHg), and absent esophageal body peristalsis with panesophageal compartmentalization of intrabolus pressure. These findings were consistent with achalasia, categorized as type II by the Chicago classification scheme. Upper endoscopy (EGD) revealed a mildly dilated esophageal body with a puckered and hypertonic LES. The findings on manometry and EGD confirmed the diagnosis of achalasia. The additional diagnoses of Addison's disease and longstanding alacrima were consistent with the AAA syndrome. The patient was referred for laparoscopic Heller myotomy to treat the achalasia and has remained asymptomatic 18 months after surgery. Discussion: AAA syndrome is rare, with fewer than 200 cases reported since it was initially described in 1978 by Allgrove. It usually manifests in childhood although neurological symptoms and autonomic instability may manifest later. The gene has been mapped to chromosome 12 and the protein it encodes is involved in the normal development of the nervous system. Achalasia in young patients is best treated surgically with laparoscopic myotomy and provides significant long-term relief of symptoms. AAA syndrome is uncommon, but a high index of suspicion in patients with any of the classic findings can result in early recognition and successful management.

Update on Foreign Bodies in the Esophagus: Diagnosis and Management

Foreign body impaction in the esophagus is an important emergency that carries significant morbidity and potential mortality. The most common cause of esophageal foreign body obstruction in adults is meat bolus impaction above a pre-existing distal esophageal (mucosal) ring, peptic or malignant esophageal stricture, or eosinophilic esophagitis. Immediate evaluation of the airway, assessment of the urgency of removal, radiological evaluation to localize the object, endoscopic or surgical retrieval, and subsequent monitoring for complications are essential steps in the management.

Pneumoabdomen With Abdominal Compartment and Aortic Collapse Due to Gastric Bursting Acute Release by Trocar Insertion

A 63-year-old man was admitted to our emergency department because of abdominal pain with distension and ischemia of both lower limbs for the past 2 hours. Previously, he had vomited extremely following alcoholic excess and an opulent meal. In his previous history, distal esophageal stenosis was obvious after surgical therapy of Boerhaave syndrome 3.5 years earlier with primary suturing of the distal esophageal perforation and anterior semifundoplication. At clinical examination, the patient presented with stable cardiopulmonary function. The abdomen was massively distended and tender, and both legs were blue, revealing signs of prolonged ischemia with absent palpable pulses of the femoral artery in both groins. Palsy of the legs was not yet apparent. Computed tomography of the chest and abdomen …

Endoscopic ultrasound-guided fine needle aspiration for smooth benign appearing esophageal stricture due to metastatic breast cancer

Metastatic breast cancer is an uncommon cause of esophageal stricture. We present an 80 year-old woman with past medical history of locally advanced breast cancer who admitted for evaluation of dysphagia. Barium swallow (i.g. esophageal fluoroscopy) demon­strated moderate irregular narrowing in the distal thoracic esophagus. Endoscopy revealed distal esophageal stricture with normal esophageal mucosa and computed tomography demonstrated thickened wall in the distal esophagus and the proximal stomach. Endoscopic biopsy of esophagus revealed no malignancy. Thus, we performed endoscopic ultrasound-guide fine needle aspiration (EUS-FNA) and cytological results were consistent with metastatic breast cancer. Diagnosis of malignant esophageal stricture due to metastasis from other primary is often challenging and requires a high index of suspicion. EUS-FNA is an alternative diagnostic technique in such cases when endoscopic biopsy fails to obtain adequate specimen.

The Unusual Occurrence of Esophageal Pseudodiverticulosis Associated with Monilial Candidiasis and Esophageal Stricture

Purpose: Intramural pseudodiverticulosis of the esophagus is an uncommon benign disorder and was first described by Mendel et al. in 1960. The condition usually presents with mild dysphagia which is usually intermittent and slowly progressive. Few cases of esophageal pseudodiverticulosis have been reported in literature. About 50% of these cases are associated with stricture formation. Case Presentation: A 58-year-old woman presented to our emergency department with dysphagia, non bloody vomiting and weight loss of about 30 pounds over the prior 3 months to admission. She denied abdominal pain, or irregular bowel habits. Her medical comorbidities included HIV/AIDS, depression and asthma. Physical examination apart from revealing a cachectic middle aged woman was otherwise unremarkable. An upper endoscopy performed two days after admission revealed severe stenosis in the esophagus 18 cm from the incisors. The stenosis could not be traversed with a regular upper endoscope. A marked area of whitish plagues, inflammation and ulceration were noted above the stenotic segment. Biopsies revealed severe active esophagitis associated with numerous fungal forms consistent with Candida species. She was subsequently treated with fluconazole and double dose PPI. A barium swallow obtained on the 7th day of admission revealed distal esophageal stricture; however, pseudodiverticulosis was not seen at this time. A repeat upper endoscopy revealed multiple small red openings protruding from the esophageal lumen (pseudodiverticulosis) in the previously noted stenotic segment. This time; however, we were able to gently traverse the previously seen stenosis suggesting improvement of stenosis. An esophageal dilation was, therefore, not necessary. Her dysphagia improved and she was able to tolerate solid chopped diet. Discussion: Esophageal intramural pseudodiverticulosis is a rare condition characterized by multiple flask-shaped outpouchings in the esophageal wall representing dilated excretory ducts of submucosal glands. Dysphagia is the leading symptom. On endoscopy, minute openings in the esophageal wall, and sometimes a segmental Candida esophagitis or a benign stenosis not originating from an erosive reflux esophagitis are found. Treatment aims at ameliorating symptoms. When dysphagia due to esophageal stricture develops, dilatation is the treatment of choice. Reflux or Candida esophagitis must be treated as well. In conclusion, we present a rare case of esophageal pseudodiverticulosis associated with esophageal stenosis and monilial candidiasis.

Immediate Placement of a Temporary Covered Stent for the Management of Iatrogenic Malignant Esophageal Perforation

Traditional therapy for esophageal perforation has been surgical repair of the esophagus. However, perforations diagnosed and treated surgically within 24 h continue to have a mortality rate between 12% and 36% [1]. Recently, covered stents have been introduced as a safe and effective therapeutic modality to treat esophageal perforation after surgery or medical procedures [2]. Only a few reports have explored the effectiveness of treating malignant esophageal perforation using retrievable stent placement [3, 4]. However, in most reported series of stent removal, has required general anesthesia and esophagoscopy. A 65-year-old man had dysphagia for 2 months, initially with solid foods and subsequently with liquids. A barium esophagogram demonstrated a distal esophageal stricture involving the esophagogastric junction (Fig. 1A). The stricture was proven by endoscopic biopsy to be esophageal squamous cell carcinoma. The patient underwent chemotherapy, but his dysphagia worsened. The patient was admitted to our institution, and balloon dilation with subsequent chemotherapy and radiation therapy was planned because of concern for the risk of stent migration and gastroesophageal reflux after stenting of a short-segmental stricture involving the gastroesophageal junction. Written informed consent was obtained from this patient before stent placement. After topical anesthesia was applied to the pharynx before the procedure using an aerosol spray, a 0.035-inch angled guidewire (Radiofocus Guide Wire M; Terumo, Tokyo, Japan) was inserted under fluoroscopic guidance through the mouth, across the esophagogastric junction stricture, and into the stomach. A balloon catheter (20 9 80 mm; Cordis-Johnson & Johnson, Miami Lakes, FL) was passed over the guidewire to the esophagogastric junction stenosis, and the balloon catheter was slowly inflated under fluoroscopic guidance with a diluted water-soluble contrast medium until the ‘‘hour-glass deformity’’ created by the stricture disappeared from the balloon contour. After balloon dilation, a water-soluble contrast medium study showed contrast leakage into the mediastinum from the esophagogastric junction (Fig. 1B). Retrievable covered stent insertion and placement (18 9 60 mm, polytetrafluoroethylene covered; Taewoong, Seongnam, Korea) were performed immediately to occlude the leakage (Fig. 1C). After stent placement, the patient had mild chest pain but no leukocytosis or fever. Barium esophagographs obtained both 1 and 3 days after stent placement showed a patent stent lumen with no leakage. The patient was initially allowed a soft diet and subsequently a solid diet. The patient underwent chemotherapy and radiation therapy (total dose 6,000 cGy) after stent placement. The stent was successfully removed 3 weeks after being placed without complications, and a water-soluble contrast medium study performed after stent removal showed improvement of the stricture with no leakage (Fig. 1E). The patient’s remaining scheduled chemotherapy and radiation therapy were performed after stent removal. Follow-up esophagograms obtained 1 week and 2 months after stent removal demonstrated good flow of contrast H.-T. Hu J. H. Kim Department of Radiology, Henan Tumor Hospital, Zhengzhou 450008, Henan Province, People’s Republic of China

Unconventional Esophageal Stricture

Purpose: Background: Occasionally patients present with poorly defined conditions where we extrapolate our therapeutic approach from better known disorders. This case presented with a sloughing esophagitis which was not well characterized. Case Presentation: A 47 year old female with prior endoscopic esophagitis presented with solid and liquid dysphagia. She had a history of lichen planus. Prednisone therapy for her skin condition led to some improvement in dysphagia. EGD showed LA class IV esophagitis with sloughing mucosa. Immunoflurescence staining did not show a linear band of IgG and C3 immunoreactants as would be seen with mucous membrane pemphigoid. With double dose PPI there was initial improvement. Dysphagia progressed with persistent LA class IV esophagitis and development of distal esophageal stricture. Pathology examination excluded viral or fungal etiology, increased eosinophils or mucous membrane pemphigoid. She underwent three separate dilations while on double dose PPI without response. A trial of a budesonide/sucralfate suspension led to symptom resolution. The suspension was compounded of 1 mg oral budesonide/500 mg sucralfate/5 ml with methylcellulose taken twice daily. Subsequent EGD showed dramatic improvement of the esophagitis and no esophageal stricture. She has had no recurrence of dysphagia. Discussion: This case illustrates an unconventional approach for undefined sloughing esophagits with clinical response. Topical steroid therapy has had success in conditions like eosinophilic esophagitis and mucous membrane pemphigoid. A similar approach used in this case with less well defined etiology had clinical success. The compounded suspension of budesonide and sucralfate was acceptable to the patient. Conclusion: Topical steroid suspension may be considered for the treatment of esophagitis with esophageal stricture when peptic, infectious, neoplastic and other etiologies of esophagitis have been excluded.

Psuedomelanosis of the Duodenum: A Rare Case Report

Purpose: Pseudomelanosis of the GI tract is a brownish discoloration of the mucosa described to be secondary to lipofuscin accumulation in the macrophages of the lamina propria of the intestinal villi. Commonly correlated with chronic anthranoid laxative use, psuedomelanosis is also associated with the following conditions: hypertension, diabetes mellitus, chronic renal failure and use of the following medications: antihypertensives such as hydralazine, beta blockers, and furosemide, and iron supplements. Symptoms include postprandial abdominal pain, early satiety, nausea and vomiting. A 72 year-old African American female with a past medical history of CAD, HTN, and CKD was evaluated for complaints of post-prandial discomfort, nausea, and vomiting not alleviated by Prevacid®. Medications included Ecotrin®, hydralazine, furosemide, Coreg®, Diovan®, iron tabs, and Prevacid®. The patient did not use laxatives. Flexible sigmoidoscopy in 1999 was pertinent only for diverticulosis. EGD revealed a distal esophageal peptic stricture, hiatal hernia and mild antral gastritis. The duodenum revealed darkly pigmented mucosa (Figure 1) with diverticula in the duodenal bulb. Colonoscopy showed diverticulosis with no signs of melanosis. Pathology illustrated mild inactive chronic gastritis (no H. pylori) and duodenal mucosa with dark pigmentation. Iron stain was negative. A diagnosis of pseudomelanosis of the duodenum was made. Pseudomelanosis of the upper GI tract is less prevalent than the well-described pseudomelanosis coli, with the duodenum being the most reported extracolonic site. Our patient's history was pertinent for hypertension, chronic renal failure, use of furosemide, hydralazine, and iron pills. This finding has generally been attributed to intramucosal hemorrhage vs. luminal absorption with cases revealing varying electron microscopy findings suggesting that iron metabolism may be impaired. Iron staining on pathology has been unpredictable. Treatment of this condition has not been established, but given that pseudomelanosis duodeni carries a benign prognosis, treatment has focused on symptomatic relief of the patient's complaints.Figure

A Biodegradable Esophageal Stent in the Treatment of a Corrosive Esophageal Stenosis in a Child

A Biodegradable Esophageal Stent in the Treatment of a Corrosive Esophageal Stenosis in a Child

Esophageal atresia and tracheoesophageal fistula with distal esophageal stenosis: Preoperative Diagnosis

This is a presentation of a case of preoperative diagnosis of apparent esophageal atresia and an apparent distal and tracheoesophageal fistula from a peripheral hospital. After surgery, histopathologic findings showed the absence of cartilage and bronchial glands, suggesting the etiology as a fibromuscular stenosis.

Polyflex or Ultraflex Stents to Treat Peptic Refractory Esophageal Strictures?

TO THE EDITOR: I read with interest the recent report from Velasco et al. (1) about the treatment of a distal esophageal peptic stricture by means of permanent covered Ultraflex stents.

Capsule Endoscopy for Screening for Short-Segment Barrett's Esophagus

The rise in the incidence of esophageal adenocarcinoma has led to the development of new methods to screen for the precursor lesion, Barrett's esophagus. To evaluate the potential role of esophageal capsule endoscopy in identifying the presence of short-segment Barrett's esophagus. Patients with biopsy-proven short-segment Barrett's esophagus underwent esophageal capsule endoscopy. The images were reviewed by two expert observers with no knowledge of the purpose of the study. The data collected included transit time, quality of image, presence or absence of Z-line, Schatzki's ring, hiatal hernia, and Barrett's esophagus (long or short, definite or suspected). Twenty patients were studied; in 18, the capsule passed into the stomach. Barrett's esophagus was identified or suspected in eight cases (44%) by one observer and three (16%) by the second (P= 0.14). Although the Z-line was seen in the 18 cases that were qualified by both observers, there was an agreement in only six cases as to whether it was regular or irregular. Erosive gastroesophageal reflux disease (GERD) was scored as present in three and absent in six patients by both readers. Nonexisting feline esophagus, varices, and distal esophageal stricture were suspected in one patient each. Esophageal capsule endoscopy had a high interobserver variability and a low yield for short-segment Barrett's esophagus. Esophageal capsule endoscopy cannot be recommended for screening for short-segment Barrett's esophagus.