Solid Food Dysphagia Research Articles

Gastrointestinal involvement is frequent in Myotonic Dystrophy type 2

The phenotype of DM2 shows similarities as well as differences to that of Myotonic Dystrophy type 1 (DM1). Gastrointestinal dysfunction is common in DM1 and 25% of the patients consider this to be the most disabling consequence of the disease. Little is known about gastrointestinal involvement in Myotonic Dystrophy type 2 (DM2). The aim of the study was to explore the occurrence and characteristics of gastrointestinal symptoms in patients with DM2. This was compared to symptoms in adult-onset DM1 patients, and to age- and sex-matched healthy controls. Twenty-nine genetically proven DM2 patients filled out two standardized questionnaires about gastrointestinal symptoms; most important outcome measures were answers to questions about dysphagia, abdominal pain, and constipation. The results were compared to those of 29 adult-onset DM1 patients, and to 87 age- and sex-matched healthy controls. Radiological measurement of colon transit time was investigated in 18 DM2 patients. Dysphagia for liquids (38%) and solid food (41%), abdominal pain (62%), and constipation (62%) were all significantly more common among DM2 patients than among healthy controls, and comparable to their occurrence in DM1. Colon transit time was increased in 24% of the DM2 patients. Our results show that gastrointestinal symptoms are highly prevalent in DM2 patients. Gastrointestinal dysfunction may be attributed to any part of the gastrointestinal tract. The results provide new insight into the clinical picture of DM2.

Spontaneous esophageal perforation in eosinophilic esophagitis in children

A 9-year-old girl with a history of asthma, intermittent solid food dysphagia and blockage was admitted because of chest pain, pyrosis, and fever (38.3 °C). The only medication she was on at the time of our evaluation was the inhaler Salbutamol-sulfate, which she used as needed. Symptoms started a few hours after a food blockage episode. Physical examination was normal, except for tachycardia (135 bpm). Laboratory results showed: leukocytosis (17 300/mm3), 11.59 × 109 neutrophils, a high C-reactive protein (180 mg/l), and erythrocyte sedimentation rate of 74 mm/h.

Eosinophilic oesophagitis: a common cause of dysphagia in young adults?

Eosinophilic oesophagitis (EO) is an increasingly recognised chronic, relapsing inflammatory condition of the oesophagus. There has been a mini-epidemic of EO in the last decade. The incidence of this condition is higher in children and is commoner in males. There is either a family or personal history of atopic conditions present in a significant number of patients and can also be familial in up to 10%. The classical symptom in an adult is chronic, intermittent solid-food dysphagia and food impaction, often necessitating emergency endoscopic removal. Despite the history of dysphagia for a number of years, patients remain well with no weight loss, which can mislead clinicians to diagnose a functional problem with a resulting delay in the diagnosis. There are various endoscopic features of EO; commonly multiple rings and linear furrows, though these can be subtle and the mucosa may be macroscopically normal. The hallmark of this condition is the histological presence of > or =15 eosinophils/high power field (HPF) in the oesophageal mucosa. Therapeutic options include avoidance of dietary allergens, topical or systemic steroids, Montelukast, Mepolizumab (anti-IL-5 antibody) and endoscopic dilation of strictures unresponsive to medical therapy.

A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki's) rings

Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring, but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement. There are no data on the treatment of Schatzki's rings in the presence of acid suppression treatment. Our purpose was to compare the efficacy of bougie dilation with electrosurgical incision of symptomatic Schatzki's rings at 1-year follow-up in the presence of rabeprazole treatment. Randomized, prospective trial. University of Utah Health Sciences Center and the Veterans Affairs Salt Lake. Fifty patients referred for endoscopic evaluation of dysphagia between January 2002 and March 2005. Symptom-free survival time (in months), dysphagia, and GERD scores. Twenty-five patients each underwent bougie dilation and electrical incision and were followed up for 12 months. Symptom-free survival times were significantly longer in the incision group (7.99 months) compared with the bougie dilation group (5.86 months) (P = .03). Dysphagia and GERD scores significantly improved in each group comparing baseline with each time interval. The incision group had greater relief of dysphagia at 1 month (P = .05) compared with the bougie group. There was no difference between GERD scores in both groups. Dysphagia and GERD symptoms were self-reported. Electrosurgical incision of Schatzki's rings is safe and offers longer symptom-free survival compared with bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

Circumferential mucosal dissection and esophageal perforation in a patient with eosinophilic esophagitis

A young man with a previous history of episodes of mild solid food dysphagia was admitted with a total dysphagia. The esophagogastroduodenoscopy (EGDS) showed an extensive disruption of mucosal layer with a cul-de-sac in the lower part of the esophagus. Soon after the procedure, the patient suffered from an acute chest pain and subsequent CT scan demonstrated an intramural circumferential dissection of thoracic esophagus, and a mediastinal emphysema. An emergency right thoracotomy was performed, followed by a total esophagectomy with esophagogastroplasty and jejunostomy. The histopathology confirmed that mucosal and submucosal layers were circumferentially detached from muscular wall and showed an eosinophilic infiltration of the whole organ with necrosis and erosions of mucosal, submucosal and muscular layers. The diagnosis was esophageal perforation in eosinophilic esophagitis.

Eosinophilic Esophagitis in Adults with Dysphagia Summary

Eosinophilic esophagitis (EE) is recognized increasingly in both children and adults. Adults present mainly with solid food dysphagia and food

Esophageal Intramural Pseudodiverticulosis

A 59-year-old-man without significant medical history presented with a 5-year history of progressive dysphagia for solid foods. An upper endoscopy, performed 5 years earlier in another hospital, showed a benign esophageal stricture with Candida albicans infection. He was treated with antifungal drugs, but he refused further investigations for several years. Because he was unable to swallow solids, he presented for further investigation at our institution. Apart from a significant weight loss of 15 kg over several months, the patient had no symptoms. Physical examination was unremarkable, except for a body weight of 45 kg (body mass index, 15.6 kg/m2). Upper endoscopy revealed a stricture between 23 and 29 cm of the incisors that barely could be passed with a pediatric endoscope. The mucosa of the upper esophagus was inflammatory with several small white spots, suggestive for fungal infection. No signs of peptic esophagitis were present at the gastroesophageal junction; stomach and duodenum were normal. Biopsy specimens taken from the stricture showed an ulcerated esophagitis and confirmed the presence of mycosis. Barium esophagogram was pathognomonic for esophageal intramural pseudodiverticulosis (Figure). Esophageal intramural pseudodiverticulosis is a benign condition of which only about 250 cases have been reported worldwide. The condition is characterized by multiple flask-shaped outpouchings in the esophageal wall. These pseudodiverticula, formed by dilatation of the esophageal submucosal glands, typically are diagnosed on barium esophagogram.1Teraishi F. Fujiwara T. Jikuhara A. et al.Esophageal intramural pseudodiverticulosis with esophageal strictures successfully treated with dilation therapy.Ann Thorac Surg. 2006; 82: 1119-1121Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In many cases the multiple small orifices of the intramural pseudodiverticula can be appreciated on endoscopy.2Hahne M. Schilling D. Arnold J.C. et al.Esophageal intramural pseudodiverticulosis: review of symptoms including upper gastrointestinal bleeding.J Clin Gastroenterol. 2001; 33: 378-382Crossref PubMed Scopus (46) Google Scholar Computerized tomography sometimes shows esophageal wall thickening with diffuse irregularity of the lumen and intramural gas collection. Presenting symptoms are dysphagia and bleeding, but patients may remain asymptomatic.2Hahne M. Schilling D. Arnold J.C. et al.Esophageal intramural pseudodiverticulosis: review of symptoms including upper gastrointestinal bleeding.J Clin Gastroenterol. 2001; 33: 378-382Crossref PubMed Scopus (46) Google Scholar Even though esophageal intramural pseudodiverticulosis is a benign condition, severe complications including fistula formation, perforation, and mediastinitis have been reported. As was the case in our patient, the condition often is complicated by stricture formation. Treatment of the inflammation and endoscopic dilatation of the stenosis is an effective therapy for the dysphagia. Our patient was treated successfully with endoscopic dilatation. Six months after dilatation, he remains asymptomatic and has gained weight.

Predicting Endoscopic Complications in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is characterized by solid-food dysphagia, strictured esophagus marked by multiple intraesophageal rings and trachea-like

Prevalence and Predictive Factors of Eosinophilic Esophagitis in Patients Presenting With Dysphagia: A Prospective Study

Eosinophilic esophagitis (EE) is an increasingly recognized cause of dysphagia. We prospectively assessed the prevalence of EE using midesophageal biopsies in patients presenting with no endoscopically evident cause of dysphagia. We also aimed to determine the clinical and endoscopic factors predictive of EE in outpatients undergoing endoscopy for dysphagia. Outpatients (18-60 yr of age) undergoing endoscopy for dysphagia at Mayo Clinic, Rochester between June 2005 and June 2006 were enrolled. Patients completed the validated Mayo Dysphagia Questionnaire (MDQ). Biopsies were obtained from the midesophagus if there was no endoscopically evident cause of dysphagia or there were endoscopic findings suggestive of EE. EE was defined as the presence of >20 eosinophils/high-power field. Logistic regression was performed to identify predictors of EE. Of 376 patients enrolled, 238 (63%) completed the MDQ and 222 (59%) had midesophageal biopsies; 33 (15%, 95% CI 6%-12%) had EE by biopsy. Ten of 102 (9.8%) patients who appeared endoscopically normal had EE by biopsy, while 8 of 21 (38%) patients with endoscopic changes suggestive of EE had EE on biopsy. Predictors of EE were younger age, endoscopic features suggestive of EE, absence of use of proton pump inhibitors, and a history of any food impaction for greater than 5 min. Midesophageal biopsies from normal-appearing mucosa should be obtained in all patients with unexplained solid food dysphagia; this may diagnose EE in about one in 10 cases.

Dysphagia soon after off-pump coronary surgery: the single suture technique

We report a case of a 76-year-old man complaining of dysphagia for solid food associated with a weight loss following an off-pump double vessel coronary artery revascularization. Multislice spiral computed tomography showed a 6 cm x 2.5 cm solid formation next to the posterior wall of the left atrium, adjacent to the pericardium and the right anterolateral side of the esophagus. The mass was confirmed to be an intramural esophageal hematoma by endoscopic ultrasound-guided fine-needle aspiration cytology. Injury to esophagus during the placement of deep pericardial sutures and postoperative infusion of heparin are claimed to be causes of this complication.

Dysphagia in Post-Carotid Endarterectomy: A Prospective Study

Dysphagia can be a debilitating complication in carotid endarterectomy. This study describes our experience in the management of this complication. We prospectively assembled an inception cohort of 19 consecutive, hospital-referred patients with dysphagia post-carotid endarterectomy. We performed swallowing evaluation in all the recruited patients both at the bedside and by fiberoptic endoscopic evaluation of swallowing (FEES) 5 days and 3 months after the operation, using standardized methods and diagnostic criteria. The degree of dysphagia was scored using the Penetration-Aspiration Scale (PAS). All patients were undergoing early rehabilitation treatment and were followed up prospectively for 3 months, during which time recovery of swallowing function and any occurrence of pneumonia were recorded. At baseline, 15 patients presented dysphagia for liquid and solid food and four for solid food only, eight were on parenteral nutrition, and six presented bronchial aspiration (by FEES). The mean PAS score at the first evaluation was 5.2. Ten patients completely recovered swallowing function and returned to their preoperative diet within 1 month, and six did so within 3 months; the other three patients did not complete the follow-up. No patient presented pneumonia. At the 3-month follow-up, one patient presented bronchial aspiration and the mean PAS score was 1.2. This preliminary experience suggests that careful evaluation of swallowing and early rehabilitation may be advisable in these patients.

Ösophageale Schluckstörungen

Dysphagia can be caused by a number of disorders such as benign or malignant obstruction of the esophagus, inflammatory alterations of the mucosa or primary esophageal motility disorders. Endoscopic evaluation is recommended for all patients to exclude malignancy and to establish or confirm a diagnosis. This article provides an overview of the most frequent inflammatory and functional esophageal disorders causing dysphagia. Clinical findings, diagnostic procedures and therapeutic management of primary esophageal motility disorders such as achalasia and diffuse esophageal spasm as well as of GERD and eosinophilic esophagitis are discussed. The diagnosis of achalasia is made by barium swallow with fluoroscopy and by manometry. Therapeutic options for achalasia are pneumatic dilatation of the esophagogastric junction, laparoscopic cardiomyotomy combined with fundoplication and botulinum toxin injection of the lower esophageal sphincter Diffuse esophageal spasm is manometrically characterized by normal peristalsis intermittently interrupted by simultaneous contractions. Potential medical therapies are PPIs for underlying GERD, smooth-muscle relaxants and antidepressant medications. GERD is a multifaceted disease caused by abnormal reflux of gastric contents into the esophagus leading to chronic symptoms or mucosal damage. Therapy includes lifestyle modifications, acid suppressive medications mainly by PPI and laparoscopic fundoplication in selected patients. Eosinophilic esophagitis is a chronic inflammatory disorder of the esophagus diagnosed histologically. The main symptom of eosinophilic esophagitis is dysphagia for solid food with imminent risk of food impaction. Systemic or topical corticosteroids are the therapy of choice.

A Randomized, Prospective Trial of Electrosurgical Incision Followed By Rabeprazole Versus Bougie Dilation Followed By Rabeprazole of Symptomatic Esophageal (Schatzki's) Rings

Background: Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki's rings. Aim: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki's rings at one year follow up in the presence of rabeprazole treatment. Methods: Fifty consecutive patients referred for endoscopic evaluation of dysphagia found to have a schatzki's ring were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki's ring. All patients were placed on rabeprazole (20-40 mg/day) for the duration of the study. Analysis between groups was made using Wilcoxon rank-sum test for independent samples (dysphagia score) and t-test (GERD scores). Paired data were analyzed using Wilcoxon signed rank (dysphagia score) and paired t-test (GERD scores) within groups. A Kaplan-Meier survival curve measured symptom-free survival times. Results: Twenty-five patients each underwent bougie dilation and electrosurgical incision. All patients were followed for 12 months and final analysis performed. One episode of bleeding in the incision group was controlled with epinephrine injection. Symptom free survival times were significantly longer in the incision group (7.99 months) compared to bougie dilation group (5.86 months) (p = 0.03). The improvement in dysphagia scores was significant within each group comparing baseline to each time interval. The incision group experienced a significant improvement of dysphagia symptoms at one month compared to the bougie dilation group (p = 0.05). GERD scores improved significantly in both groups at all time intervals in the bougie dilation group and at all time intervals in the incision groups with the exception of 12 months. There was no significant difference in GERD scores between the groups. Conclusion: Electrosurgical incision of lower esophageal (Schazki's) rings is safe and offers longer symptom free survival compared to bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

Fulminant Supraglottitis fromNeisseria meningitidis

Fulminant Supraglottitis from<i>Neisseria meningitidis</i>

Cutaneous rhinosporidiosis

Rhinosporidiosis is a chronic granulomatous disease of the mucocutaneous tissue, which clinically presents as polypoidal growths. Cutaneous lesions are infrequent and are generally associated with mucosal lesions. We present a case of cutaneous rhinosporidiosis in association with recurrent nasopharyngeal rhinosporidiosis in a 65-year-old male patient. He presented with dysphagia for solid foods and skin growth on the left side of jaw of 2 years duration. Histopathology of cutaneous and nasopharyngeal lesions revealed numerous thick walled sporangia in a vascular connective tissue along with a granulomatous inflammation confirming the diagnosis of cutaneous and nasopharyngeal rhinosporidiosis. Endoscopic removal of nasopharyngeal polyp was done and he was started on dapsone therapy.

Botulinum Toxin Treatment for Oropharyngeal Dysphagia Associated With Diabetic Neuropathy

No specific treatment for oropharyngeal dysphagia related to diabetic neuropathy has been described to date. Chemical myotomy of the cricopharyngeus (CP) muscle by botulinum neurotoxin type A (BoNT/A) has been effective in reducing or abolishing dysphagia associated with upper esophageal sphincter (UES) hyperactivity of different etiologies. In the present study, we evaluated the efficacy of BoNT/A injections into the CP muscle in diabetic patients with severe oropharyngeal dysphagia associated with diabetic autonomic and/or somatic peripheral neuropathy. Twelve type 2 diabetic patients with severe dysphagia for both solid and liquid foods associated with autonomic and/or peripheral somatic neuropathy were investigated. Swallowing function was evaluated by clinical examination, videofluoroscopy, and simultaneous needle electromyography (EMG) of the CP and pharyngeal inferior constrictor (IC) muscles. Clinical evaluation using a four-level dysphagia severity score was performed every other day for the 1st week and thereafter every other week until week 24. Videofluoroscopy and EMG follow-up were carried out at week 1, 4, 12, 16, 18, and 24 after BoNT/A injection. BoNT/A was injected percutaneously into the CP muscle under EMG control. BoNT/A induced the complete recovery of dysphagia in 10 patients and had a significant (P = 0.0001, ANOVA) improvement in 2 patients within 4 +/- 1.1 days (range 3-7). Clinical improvement was confirmed by videofluoroscopy and EMG. Our findings suggest a potential benefit from BoNT/A treatment in dysphagia associated with diabetic neuropathy. Randomized controlled trials are needed to confirm this observation.

Management of eosinophilic esophagitis in children

Eosinophilic esophagitis has recently emerged as a distinct clinical entity in children. The clinical spectrum varies with age and ranges from failure to thrive and food aversion in the toddler to gastroesophageal reflux disease-like symptoms in school-age children to solid food dysphagia and food impaction in adolescents. The diagnosis is based on the presence of at least 15 eosinophils per high power field in the esophageal biopsy in children pretreated with at least 8 weeks of adequate acid-suppression therapy. Although elemental diet is a more effective therapy than other less restrictive elimination diets, the latter has practical advantages over elemental therapy. Topical and systemic corticosteroids have also been used. Studies are underway to establish the safety and efficacy of anti-interleukin-5 monoclonal antibodies. The natural history of eosinophilic esophagitis is not known and prospective studies are required to understand the etiopathogenesis, optimal therapies and find noninvasive surroga...

Glucagon for the Relief of Esophageal Food Impaction Does It Really Work?

We sought to evaluate our experience with glucagon used in the emergency department setting to relieve esophageal food impaction (EFI). We reviewed the records of patients with food impaction who received glucagon between January 1998 and May 2003 and recorded patient demographics, medical history, symptoms following glucagon administration, and endoscopic findings. There were 92 episodes of food impaction in 85 patients. Thirty-three percent of the episodes resulted in resolution of symptoms following a dose of glucagon. Sixty-seven percent had symptoms of food impaction after glucagon and underwent upper endoscopy in the emergency room. Only previous solid food dysphagia was positively associated with response to glucagon. Patients who received glucagon plus a benzodiazepine were more likely to have resolution of the EFI. In our experience, glucagon appears to relieve food impaction in one third of patients treated. This result is comparable to previously published data examining glucagon and placebo. The lack of advantage over placebo questions the practice of glucagon administration for EFI.

Achalasie bei zirkumskripter Sklerodermie

HISTORY: A 38-year-old man had been suffering from circumscribed scleroderma for 12 years. Dysphagia had been diagnosed 5 years ago and for the last 2 years he had retrosternal dysphagia for solid and liquid food. His symptoms had increased markedly 6 months before presenting at our hospital and the patient had lost 15 kg of weight. 2 months ago, a percutaneous endoscopic gastrostomy (PEG) had been inserted at another hospital. INVESTIGATIONS: The patient presented in a reduced general and nutritional state. The routine laboratory tests and tumor markers were within normal range. Endoscopy showed a moderately dilated esophagus with food remnants. It was not possible to pass the cardia without exerting pressure. Esophageal manometry and barium upper gastrointestinal series revealed the classical findings of achalasia. THERAPY AND COURSE: An extramucosal Heller myotomy with anterior semifundoplication (Dor's procedure) was performed. The postoperative course was uneventful and the patient was able to take solid and liquid food without any dysphagia. CONCLUSION: The association of achalasia and circumscribed scleroderma has not been described in medical publications yet. The entity could possibly be based on common autoimmune mechanisms and an analogous pathogenesis with resulting fibrosis.

Inflammatory Pseudotumor Mimicking Invasive Esophageal Cancer on Endoscopic Ultrasound

Benign inflammatory esophageal masses, often termed 'pseudotumors', are an uncommon entity that can present like esophageal cancer. This case report describes two cases of benign inflammatory pseudotumors. Case 1: A 66 year old male presented with hematemesis and solid food dysphagia. EGD revealed a mass in the distal esophagus. Biopsy showed granulation tissue with an eosinophilic infiltrate but no evidence of malignancy. EUS revealed a hypoechoic mass extending through the muscularis propria and pathologic-appearing celiac, peritumoral and subcarinal lymph nodes (T3N1M1a). After two months of ranitidine therapy, EGD and EUS showed complete resolution of the lesion. Case 2: A 61 year old male presented with 3 months of solid food dysphagia. EGD with biopsy revealed Barrett's mucosa with inflammatory atypia without dysplasia in the distal 10 cm of the esophagus. The patient was placed on omeprazole, but his dysphagia persisted and repeat EGD in 6 weeks showed distal esophageal narrowing with a linear ulcer. Ulcer biopsy showed acute and chronic inflammation within Barrett's mucosa, indeterminate for dysplasia. EUS revealed a hypoechoic mass at the ulcer site that invaded through the muscularis propria; no pathologic-appearing lymph nodes were noted (T3N0M0). EGD 4 months after initial presentation revealed persistence of the ulcer despite omeprazole therapy. The patient was referred for esophagectomy, and final pathology showed only acute and chronic inflammation with microabscess formation within Barrett's mucosa. Discussion: Distinguishing between inflammatory pseudotumors and esophageal cancer can be difficult. Both lesions appear malignant by endoscopy and EUS, and because esophageal cancer can have significant peritumoral inflammation, the clinician may worry the negative pathology is due to sampling error, especially when EUS is suggestive of an invasive process or of nodal metastases, and do not want to delay cancer therapy. Because of the high malignant potential, the management of a refractory Barrett's esophageal ulcer or pseudotumor can be especially challenging. Diagnosis of pseudotumors requires a high index of suspicion and histopathologic exclusion of other benign and malignant esophageal disorders, as these processes can look malignant on EUS.