Esophageal Food Impaction Research Articles

Eosinophilic Esophagitis: A Comprehensive Review.

Eosinophilic esophagitis (EoE) is an emerging chronic atopic clinical-pathologic disease with an estimated prevalence of 1/1000 similar to the one of Crohn's diseases. Usually, EoE is firstly suspected due to symptoms that are caused by esophageal dysfunction and/or fibrosis. EoE diagnosis is confirmed if the esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf) as a peak value in one or more of at least four specimens obtained randomly from the esophagus. Most of the patients affected by EoE have other atopic diseases such as allergic rhinitis, asthma, IgE-mediated food allergies, and/or atopic dermatitis. The local inflammation is a T helper type 2 (Th2) flogosis, which most likely is driven by a mixed IgE and non-IgE-mediated reaction to food and/or environmental allergens. Recently published genetic studies showed also that EoE is associated with single nucleotide polymorphism (SNP) on genes which are important in atopic inflammation such as thymic stromal lymphopoietin (TSLP) located close to the Th2 cytokine cluster (IL-4, IL-5, IL-13) on chromosome 5q22. When the EoE diagnosis is made, it is imperative to control the local eosinophilic inflammation not only to give symptomatic relief to the patient but also to prevent complications such as esophageal stricture and food impaction. EoE is treated like many other atopic diseases with a combination of topical steroids and/or food antigen avoidance.

Endoscopic management of ingested foreign bodies and food impaction in esophagus

AbstractForeign body (FB) in the esophagus is a common emergency presentation in all age groups, especially in children. The immediate risk can range from a minimal one to a life-threatening scenario. Food impactions generally occur when there is altered anatomy (rings, webs or strictures) or motility disorders of the esophagus. The initial management approach includes a thorough history and physical examination followed by radiological investigations. Flexible endoscopy not only confirms the diagnosis but also is the therapeutic modality of choice for removing FBs and relieving the obstruction. This review aims to provide a comprehensive approach towards endoscopic management of esophageal FBs based on current literature and personal experience. The management problems associated with different types of FBs have also been highlighted.

Esophageal Food Impaction and Eosinophilic Esophagitis: A Retrospective Study, Systematic Review, and Meta-Analysis.

Esophageal food impaction (EFI) can be the initial presentation of eosinophilic esophagitis (EoE). EoE is characterized by persistent esophageal eosinophilia (EE). Both EFI and EE are related to a variety of conditions. To date, the relationship between EFI, EE, and EoE remains unclear. To review our institutional experience with EFIs and combine our knowledge with the existing literature to conduct a systematic review and meta-analysis for delineating the relationship between EFI, EE, and EoE. We reviewed medical records of 72 children with EFI presenting to our emergency center between 2007 and 2013. PubMed, EMBASE, and Scopus databases were screened from inception until July 2014 to identify studies linking EFI and EoE. Included studies were methodically assessed for the quality and strength of association between EFI and EoE. Our institutional experience highlighted the possibility of proton-pump inhibitor therapy-responsive EE (PPI-REE) as an underrecognized risk factor for EFI. A systematic review of 14 studies, including ours, revealed that most studies did not eliminate other causes of EFI or EE. The meta-analysis revealed that esophageal biopsies were obtained from 54% (40-68) of individuals presenting with EFI, and the overall EoE-attributable EFI among those who were biopsied was 54% (43-65). Substantial heterogeneity was noted among the studies. PPI-REE is an underestimated risk factor for EFI. The quality of existing evidence linking EFI and EoE is limited by several important factors. Future studies with robust design are warranted to delineate the relationship between EFI, EE, and EoE.

899 Endoscopic Esophageal Epiphrenic Diverticulum Inversion by Using the Submucosal Tunneling Technique

instances, a bipolar coagulation probe set at 25 watts was employed to progressively burn a tract into, but not through, the food boluses. Constant contact pressure with the center of the food bolus was crucial to avoid iatrogenic thermal injury to the surrounding mucosa. Next, a tri-prong anchor device was inserted and deployed into the tract. This ensured secure anchoring of the food bolus from within, ultimately allowing for successful en bloc bolus extraction via traction pull. Reinspection of the first patient’s esophagus demonstrated a narrowed esophageal lumen with linear furrows and circular rings, suggestive of eosinophilic esophagitis. Esophageal biopsies were obtained for confirmation of diagnosis. The second patient’s esophagus also demonstrated linear furrows and circular rings, consistent with his known history of eosinophilic esophagitis. Clinical Implications: Esophageal food impaction can be refractory to standard retrieval techniques despite prolonged efforts. In such instances, the newly described burn-anchor method can be useful at extracting the challenging food bolus in a relatively safe and efficient manner. We stress the importance of airway protection when attempting such maneuvers, as patient safety

Tu1136 Clinical Factors Predictive of Eosinophilic Esophagitis Among Patients Presenting to the Emergency Room With Esophageal Food and Foreign Body Impaction

Tu1136 Clinical Factors Predictive of Eosinophilic Esophagitis Among Patients Presenting to the Emergency Room With Esophageal Food and Foreign Body Impaction

Tu1166 Intubation in Patients With Esophageal Food and Foreign Body Impactions: A Single Center Experience

Pseudoachalasia is a condition in which clinical and manometric signs of idiopathic achalasia are mimicked by another abnormality, most often a malignancy. An underlying malignancy should be recognized early to prevent delay in appropriate treatment. The aim of our study was to identify characteristics that suggest potential pseudoachalasia caused by malignancy and warrant additional investigation. Methods: All patients newly diagnosed with achalasia by manometry between January 2000 and November 2014 were included. Patients who were afterwards found to have an underlying malignancy were classified as having pseudoachalasia. Clinical (symptoms and Eckardt score), manometric, endoscopic and radiological findings were reviewed and compared between pseudoachalasia versus achalasia. Results: In total 270 patients with achalasia were included (148 male, median age 51 (38-63) (median (IQR)). Malignant pseudoachalasia was diagnosed in 16 patients (5.9%, 12 male) and caused by esophageal adenocarcinoma (n=5), esophageal squamous cell carcinoma (n=3), gastric adenocarcinoma (n=5), pancreatic adenocarcinoma (n=2) or paraneoplastic syndrome by mediastinal lymphoma (n=1). The underlying malignancy was found at EUS (19%), second or third endoscopy with biopsies (25%), CT scan (31%) or during a treatment session (25%; 2x Heller myotomy, 2x pneumodilation). In 3/16 of the patients a CT scan after achalasia treatment, performed because of quick recurrence of symptoms, eventually showed the malignancy. Patients with pseudoachalasia were older at time of diagnosis (66 (53-72) vs 51 (38-63), p .05). Manometries in both groups showed aperistalsis and dysrelaxation of the LES, with no difference in LES pressure (32 (21-35) mmHg vs 25 (18-34) mmHg, p >.05). In 91% of patients with pseudoachalasia a barium esophagogram was performed and in 77% it was typical of achalasia, showing stasis and/or luminal dilation, compared to 93% in achalasia (p >.05). In 56% of endoscopies in pseudoachalasia the LES was difficult or even impossible to pass, compared to 23% in the achalasia group (p 60 years with a clinical history <12 months had a 35 times higher chance of having pseudo-achalasia than those under 60 years and a clinical history longer than 12 months. Conclusion: Advanced age, short clinical history, considerable weight loss and difficulty in passing the LES during endoscopy are characteristics that should arouse a higher suspicion of pseudoachalasia and warrant additional investigations such as CT and EUS.

Tu1167 Pharmacological Management of Esophageal Food Impactions: Glucagon vs. Nitroglycerin Which Is Effective?

Pseudoachalasia is a condition in which clinical and manometric signs of idiopathic achalasia are mimicked by another abnormality, most often a malignancy. An underlying malignancy should be recognized early to prevent delay in appropriate treatment. The aim of our study was to identify characteristics that suggest potential pseudoachalasia caused by malignancy and warrant additional investigation. Methods: All patients newly diagnosed with achalasia by manometry between January 2000 and November 2014 were included. Patients who were afterwards found to have an underlying malignancy were classified as having pseudoachalasia. Clinical (symptoms and Eckardt score), manometric, endoscopic and radiological findings were reviewed and compared between pseudoachalasia versus achalasia. Results: In total 270 patients with achalasia were included (148 male, median age 51 (38-63) (median (IQR)). Malignant pseudoachalasia was diagnosed in 16 patients (5.9%, 12 male) and caused by esophageal adenocarcinoma (n=5), esophageal squamous cell carcinoma (n=3), gastric adenocarcinoma (n=5), pancreatic adenocarcinoma (n=2) or paraneoplastic syndrome by mediastinal lymphoma (n=1). The underlying malignancy was found at EUS (19%), second or third endoscopy with biopsies (25%), CT scan (31%) or during a treatment session (25%; 2x Heller myotomy, 2x pneumodilation). In 3/16 of the patients a CT scan after achalasia treatment, performed because of quick recurrence of symptoms, eventually showed the malignancy. Patients with pseudoachalasia were older at time of diagnosis (66 (53-72) vs 51 (38-63), p .05). Manometries in both groups showed aperistalsis and dysrelaxation of the LES, with no difference in LES pressure (32 (21-35) mmHg vs 25 (18-34) mmHg, p >.05). In 91% of patients with pseudoachalasia a barium esophagogram was performed and in 77% it was typical of achalasia, showing stasis and/or luminal dilation, compared to 93% in achalasia (p >.05). In 56% of endoscopies in pseudoachalasia the LES was difficult or even impossible to pass, compared to 23% in the achalasia group (p 60 years with a clinical history <12 months had a 35 times higher chance of having pseudo-achalasia than those under 60 years and a clinical history longer than 12 months. Conclusion: Advanced age, short clinical history, considerable weight loss and difficulty in passing the LES during endoscopy are characteristics that should arouse a higher suspicion of pseudoachalasia and warrant additional investigations such as CT and EUS.

Изменения в легочной ткани, связанные с ахалазией пищевода. Клинический случай

Esophageal achalasia is a disease of unknown etiology, accompanied by the motility disorder, which leads to the esophageal food impaction. According to statistics, the incidence of esophageal achalasia is only 1 case per 100 000 population. Despite the fact that the disease is quite rare, physician-pulmonologist still meets such patients in the practice. At night, aggressive gastric contents in patients with esophageal achalasia can enter the respiratory tract, causing mostly aspiration pneumonia, less often - pulmonary tuberculosis. Features of treatment of pulmonary tuberculosis with esophageal achalasia are under-investigated, the problem is urgent.Objective: to analyze the characteristics of pulmonary tuberculosis in patients with esophageal achalasia, to optimize the treatment regimens for such patients.Methods: from 2008 to 2012, we observed 4 cases of esophageal achalasia patients with pulmonary disease as a complication. All patients had recurrent pneumonia. One patient with a history of frequent pneumonia had pulmonary tuberculosis.Result: treatment of pulmonary tuberculosis with concomitant esophageal achalasia is difficult in some cases because of the food impaction in the gastrointestinal tract. As a result, a standard regimen of tuberculosis treatment by oral drugs may be ineffective, and parenteral or intramuscular administration of antituberculosis drugs is recommended in this case.Conclusion: injection of anti-TB drugs is mainly recommended for pulmonary tuberculosis patients with concomitant esophageal achalasia

Etiology and management of esophageal food impaction: a population based study

Objective. Esophageal food impaction (FI) is a common clinical problem with limited information on incidence. Previous population based studies are lacking. The incidence, main etiological factors, recurrence and outcome of FI was determined in the present study in a population based setting. Material and methods. This was a study of consecutive adult patients who presented with FI from 2008 to 2013 at the National University Hospital of Iceland. The mean crude incidence rate of FI was calculated. Retrospective analysis was undertaken on relevant clinical data such as type of bolus, management, complications, recurrence rate, risk factors for recurrence, and outcome. Results. Overall 308 patients had endoscopically confirmed FI, males 199/308 (65%), median age 62 years. The mean crude incidence was 25 per 100,000 inhabitants per year. The types of FI was meat (68%), fish (12%), vegetable (4%) and other food/objects (16%). Causes for the FI included: esophageal strictures (45%), hiatal hernia (22%), eosinophilic esophagitis (EoE) (16%) and esophageal carcinoma (2%). Recurrence appeared in 21%, in which 24/48 (50%) had EoE vs. 40/260 (15%) in others (p = 0.0001). The removal of the foreign body was successful in 98% of the cases during the first endoscopy. Endoscopic associated complications included four (1.3%) aspirations, one (0.3%) esophageal perforation and one Boerhaave syndrome at presentation (both had EoE). Conclusions. The incidence of FI is the highest reported to date. EoE was strongly associated with recurrence of FI. In a population based setting endoscopy is a safe and effective procedure for removing FI.

A Novel Endoscopic Method to Relieve Food Impaction Using an Inflatable Balloon.

Food impaction in the esophagus is a relatively common medical emergency. Most of these food impactions are relieved spontaneously. But for complete esophageal food impactions or impactions not relieved spontaneously, traditional endoscopic methods like using a Roth net, polypectomy snare, or rat or alligator tooth forceps are used to gently manipulate the food material into the stomach. However, these methods may not work in certain circumstances. We present a case of proximal esophageal food impaction that was relieved using an inflatable balloon after the conventional methods proved unsuccessful.

Retrospective study of upper digestive tract foreign bodies in central India

Background: Variety of foreign bodies may enter the digestive tract accidentally. Many pass spontaneously, but some become impacted, causing symptoms of obstruction. The cricopharynx and esophagus are the most common site of impaction. Nearly, all impacted objects can be removed endoscopically but, occasionally open surgery may be required. Objectives: This study was conducted on 228 patients with the aim to describe age-sex incidence, socioeconomic and geographical distribution, types of foreign body ingested and management strategy. Methods: Retrospective study was conducted in tertiary care hospital of Central India on 228 patients who had undergone rigid endoscopic removal of digestive tract foreign body from January 2007 to January 2014. Results: Foreign body ingestion was found most commonly in the age group of 1-3 year. (133; 58.33%) with male predominance. 180 patients (78.94%) belonged to lower socioeconomic status. Out of them 160 patients came from rural areas. Definitive history was found in (212; 92.98%) patients with dysphagia to solid as the most common presenting symptom. Most of the foreign bodies were detected by plain X-rays (203; 89.03%). Coin was found to be the most commonly ingested foreign body (67.54%). Cricopharynx was the most common site of impaction (86.4%). Rigid endoscopic removal under general anesthesia was successful in all 228 patients. Conclusions: Higher incidence of ingestion of foreign body is in toddlers. The most common site of lodgement was at the cricopharynx and upper third of esophagus. Early detection and rigid endoscopic removal can prevent from morbidity associated with the complications of foreign body impaction. 1. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41:39-51. 2. G. Paul Digoy. Diagnosis and management of upper aerodigestive tract foreign bodies. OCNA. 2008;41:485-96. 3. Prakash Adhikari, Bikesh Lal Shrestha, Dharma K. Baskota, Bimal K. Sinha. Accidental foreign body ingestion: analysis of 163 cases. Arch Otolaryngol. 2007;11(3):267-70. 4. Palta R, Sahota A, Bemarki A, Salama P, Simpson N, Laine L. Foreign-body ingestion: characteristics and outcomes in lower socioeconomic population with predominantly intentional ingestion. Gastrointest Endosc. 2009;69:426-33. 5. Litivitz EL, Schmitz BF. Ingestions of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992;89:747-57. 6. Hachimi-Idrissi S, Come L, Vandenpias Y. Management of ingested foreign bodies in childhood: our experience and review of literature. Eur J Emerg Med. 1998;5:319-23. 7. Naid Dehghani. Ingested foreign bodies in children: BC children’s hospital emergency room protocol. BC Med J. 2008 June;5(5):257-62. 8. ASGE Standards of Practice Committee, Steven O. Ikenberry, Terry L. Jue, M. Anderson, V. Appalaneni, S. Banerjee, et al. Management of ingested foreign bodies and food impactions. Gastrointestin Endosc. 2011;73(6):1085-91. 9. Faigel DO, Stotland BR, Kochman ML, Hoops T, Judge T, Kroser J, et al. Device choice and experience level in endoscopic foreign object retrieval: an in vivo study. Gastrointestin Endosc. 1997;45:490-2. 10. Nixon GW. Foley catheter method of esophageal foreign body removal: extension of applications. Am J Radiol. 1979;132:441-2. 11. Bonadio WA, Jona JZ, Glicklich M, Cohen R. Esophageal Bougie technique for coin ingestion in children. J Pediatr Surg. 1988;23:917-8. 12. Chu KM, Choi HK, Tuen HH, Law SY, Branicki FJ, Wong J. A Prospective randomized trial comparing the use of the flexible gastroscope versus the broncoscope in the management of foreign body ingestion. Gastrointest Endosc. 1998;47:23-7. 13. Ferruci TJ, Long JA. Radiographic treatment of esophageal food impaction using intravenous glucagon. Radiology. 1977;125:25-8. 14. Trenkner SW, Maglinte D, Lehman GA, Chernish SM, Miller RE, Johnson CW. Esophageal food impaction treatment with glucagon. Radiology. 1983;149:40. 15. Schunk JE, Harrison AM, Corneli HM, Nixon GW. Fluoroscopic Foley catheter removal of esophageal foreign bodies in children: experience in 415 episodes. Pediatrics. 1994;94:709-14. 16. Gaigel DO, Fennerty MB. Miscellaneous disease of the esophagus. In: Gaigel DO, Fennerty MB, eds. Textbook of Gastroenterology. 1st ed. Philadelphia: Lippincott Williams and Wilkins; 1999: 1304-1325. 17. Cheng W, Tam PKH. Foreign body ingestion in children: Experience with 1265 cases. J Paediatr Surg. 1999;34:1472-6. 18. Schunk JE. Foreign body ingestion/aspiration. In: Schunk JE, eds. Textbook of Pediatric Medicine. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006: 307-314.

Simultaneous Occurrence of Eosinophilic Esophagitis and Esophageal Granular Cell Tumor: Two Case Reports

Case 1: A 29-year-old female with history of asthma presented with dysphagia and globus sensation for one year. Patient was treated with omeprazole 20 mg daily with only partial symptomatic relief. Esophagogastroduodenoscopy (EGD) revealed a 20 mm-wide, submucosal nodule with normal appearing overlying mucosa located in upper esophagus at 22 cm from incisors, and focal mild rings and transient transverse folds (felinization) of esophageal mucosa. Pathologic analysis of mucosal biopsies from middle third of the esophagus was histologically consistent with EoE (>15 eosinophils/hpf). Pathologic analysis of endoscopic biopsies of esophageal nodule was consistent with GCT. Endoscopic ultrasound revealed esophageal nodule originated from deep mucosal (second esophageal wall) layer, an endosonographic characteristic consistent with GCT. The tumor was extracted using endoscopic mucosal resection (EMR) without complications. Histologic analysis of the resected specimen confirmed granular cell tumor. Patient underwent treatment with standard six food elimination diet for EoE resulting in symptomatic improvement. Case 2: A 15-year-old male with history of asthma presented with intermittent dysphagia, without heartburn or dyspepsia and with several episodes of esophageal food impaction during the prior 5 years. EGD revealed one 10-mm-wide, submucosal nodule with normal appearing overlying mucosa in upper esophagus at 25 cm from incisors without other endoscopic abnormalities. Pathologic analysis of superficial endoscopic biopsies of esophageal nodule were nondiagnostic. Histologic analysis of biopsies of middle esophageal mucosa was consistent with EoE (>20 eosinophils/hpf). Endoscopic ultrasound revealed esophageal nodule originated from deep mucosal (second esophageal wall) layer, an endosonographic feature consistent with GCT. The nodule was endoscopically extracted using EMR technique without complications. Histologic analysis of the resected specimen demonstrated GCT. Patient was recommended to undergo trial of daily omeprazole 20 mg therapy and follow-up with allergist for eventual six food elimination diet. This report adds 2 cases to the single previously published case of EoE with GCT. Although these two entities appear to have different pathophysiology and their concurrence may be coincidental, future large endoscopic studies are warranted to further investigate this potential association and determine its potential pathophysiology. Both entities should be considered in the differential diagnosis of dysphagia, particularly in young patients.

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

Retrospective Review of Airway Management and Complications in the Treatment of Esophageal Food Impaction

Retrospective Review of Airway Management and Complications in the Treatment of Esophageal Food Impaction

Review of Foreign Body Ingestion and Esophageal Food Impaction Management in Adolescents

Foreign body ingestion is a common clinical scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life threatening. Initial and follow-up management strategies depend on multiple patient and ingested object-related factors. Available literature on this topic tends to focus on the small child or adult, leaving the clinician caring for adolescents to extrapolate this information to guide decision making for individual patients. This article reviews foreign body ingestion literature with important implications to the adolescent patient and raises awareness of some highly dangerous objects such as large button batteries, high-powered magnets, long sharps, narcotic packages, and super absorbent objects. An additional focus includes the management of esophageal food impaction. We highlight the unique aspects to the care of the adolescent with intentional ingestion and co-morbid psychiatric illness. The article concludes by discussing the challenges to prevention of ingestion in the at-risk patient.

Rauðkyrningabólga í vélinda í börnum - tvö sjúkratilfelli

Eosiniophilic Esophagitis (EoE) is a relatively new disease which was first reported in 1978 but increasingly diagnosed in the last 15 years. Initially EoE was mainly described in children but later also recognized in adults. In infants it presents as a food refusal, failure to thrive and vomiting. In older children and adults symptoms include chest pain dysphagia, oesophageal food impaction and even strictures on endoscopy. The etiology of EoE is often food allergy. Diagnosis is made on biopsies from the oesophagus and by excluding other causes of eosophageal eosinophilia. It is treated by eliminating the offending food groups or using local corticosteroids. We describe different presentation of eosinophilic esophagitis in two children and discuss diagnosis and treatment.

Esophageal intramural pseudodiverticulosis

A 56-year old male patient underwent upper gastrointestinal ndoscopy for the evaluation of progressive dysphagia and recurent oesophageal food impaction. Endoscopy revealed numerous mall pseudodiverticula, yellowish follicles, and diffuse narrowng of the oesophageal lumen (Fig. 1). After topical application f indigocarmine, the ostia of the pseudodiverticula could be dentified more clearly, underlining the wide distribution of the seudodiverticula (Fig. 2, video 1). Mechanical dilatationwith bouies up to 18mm was performed in one session, after which he symptoms resolved. During one year follow-up, the patient emained asymptomatic. Oesophageal intramural pseudodiverticulosis is a rare cause of ysphagia. The pathogenesis of this condition remains unclear [1]. he diagnosis can be established with barium oesophagography or

Su1520 Epidemiology of Esophageal Food Impaction At an Urban Tertiary Care Center

The epidemiology of esophageal food impactions is poorly understood. Although there is an increasing recognition of eosinophilic esophagitis (EoE) as an etiology prevalence estimates vary widely. Our objective was to identify factors associated with Esophageal Food Impaction (EFI). We also aimed to determine the rates of esophageal biopsy in those with EFI and to assess the prevalence of EoE in those with EFI.

An Uncommon Cause of Food Impaction

Purpose: Esophageal food impaction is usually secondary to structural abnormalities of the esophagus such as Schatzki's ring, eosinophilic esophagitis or strictures. Nutcracker esophagus (NE) is an esophageal motility disorder characterized by the presence of hypertensive but peristaltic contraction waves, making food impactions rare. We describe a patient with meat impaction associated with NE. A 66-year-old male presented with chest pain and dysphagia 3 hours after ingesting a large meal. His pain was located in the mid chest associated with difficulty swallowing his own saliva. He denied any history of dysphagia, chest pain or heartburn. Physical exam revealed an alert man in mild distress with pooling of saliva in his mouth. Cardiac, pulmonary and abdominal exams were unremarkable. An EKG and three sets of cardiac enzymes ruled out cardiac causes of chest pain. All the initial laboratory results were normal except for a WBC 11,950; with a normal eosinophil count. A CT of the chest revealed foreign material in the esophagus, consistent with undigested food. Prior to endoscopic evaluation, the patient's symptoms spontaneously subsided. Endoscopy revealed mildly hemorrhagic mucosa in the mid esophagus with no strictures, concentric rings or esophageal furrows. Biopsies of the esophagus were normal, with no evidence of eosinophilic esophagitis. A single contrast esophagram revealed tertiary contractions of the esophagus. High resolution manometry (HRM) (Figure 1) revealed normal peristaltic wet swallows with normal contraction amplitudes at 7 and 11 cm above the LES. At 3 cm above the LES, however, the amplitudes ranged from 196-386 mmHg, consistent with NE. The patient was discharged the day after the procedure and returded 1 month later for follow-up. He remained asymptomatic and no treatment was required. Nutcracker esophagus can be diffuse or segmental. The manometry findings in our patient were consistent with a segmental nutcracker esophagus. Only 4 cases have reported of nutcracker esophagus and food impaction, but ours is the first one diagnosed with high resolution manometry. Although rare, nutcracker esophagus can cause esophageal food impaction and HRM is of paramount importance in diagnosing this entity in minimally symptomatic patients.Figure: [573] High resolution manometry showing hypertensive peristaltic waves in the distal esophagus.

Esofagite eosinofílica: diversidade de expressão clínica em idade pediátrica.

Eosinophilic esophagitis is an emerging chronic oesophageal inflammatory disease, increasingly recognized both in children and in adults. It is presently accepted that this entity has a chronic course with persistent or relapsing symptoms and a wide range of clinical manifestations at different age groups: in children it is responsible for feeding disorders, vomiting or abdominal pain; in teenagers and adults it causes dysphagia and oesophageal food impaction. The etiopathogenesis of eosinophilic esophagitis has not been yet well established, but immuno-allergic mechanisms associated with a Th2 immune response have been proposed. Diagnosis is based both on clinical and histological grounds, requiring that oesophageal mucosal biopsy specimens obtained from different oesophageal locations contain more than 15 intraepithelial eosinophils per high power field and the exclusion of gastroesophageal reflux disease. Currently proposed effective treatments rely on eviction of putative allergens through dietary exclusion and on treatment with swallowed steroids. We describe two cases (a young child and a teenager) illustrative of the clinical spectrum and course variability of eosinophilic esophagitis at pediatric age. A brief review of current knowledge concerning this puzzling clinical entity is presented, emphasizing specific diagnostic dilemmas and questions concerning its long-term follow-up.