Esophageal Ulcer Research Articles

Proton beam re-irradiation for gastrointestinal malignancies: a systematic review.

Radiotherapy (RT) is part of the standard of care management of most gastrointestinal (GI) cancers. Even with advanced RT, systemic therapy, and surgical techniques, locoregional recurrences or second primary cancers can still occur within previously irradiated fields, which can present challenges in delivering effective and safe treatment. Options for reirradiation are often limited, but given the favorable dosimetric aspects of proton-beam RT, it may provide an effective and safe re-irradiation option for patients with recurrent or second primary GI cancers. We conducted a systematic review as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol, assessing for reports of proton-beam reirradiation for recurrent or second primary GI cancers, primarily via PubMed. From the initial 373 articles identified, 7 articles were ultimately included in the analysis. The 7 included studies reported on proton-beam re-irradiation for the following disease sites: esophageal (n=2), pancreas (n=1), liver (n=2), rectal (n=1), and anal (n=1). Study sizes varied from as few as 1 to as many as 83 patients. Across studies, in patients who presented with tumor-related symptoms, palliation (stability/improvement) was achieved in 80-100% of the cases. Local control rates, with variable follow-up, ranged from 36-100%. All median overall survival values, when reported, were greater than 1 year. Across both liver studies, there were no cases of radiation-induced liver disease (RILD) from proton-beam re-irradiation. Across all studies, there were 2 acute (esophagopleural fistula in esophageal cancer, small bowel perforation in pancreatic cancer) and 1 late (esophageal ulcer in esophageal cancer) grade 5 toxicities, all favored to be due to progressive disease, rather than proton-beam re-irradiation. Two studies (1 esophageal, 1 rectal) generated comparison photon plans. One found that proton therapy reduced mean heart and lung doses, spinal cord dose, and lung V5Gy as compared to photon treatment, while resulting in higher lung V20Gy and V30Gy. The other found that protons decreased bowel V10Gy, V20Gy, and the dose to 200 and 150 cc of bowel, as compared to photons. Based upon the published experiences, proton-beam re-irradiation for recurrent or second primary GI cancers appears effective for palliation, with good disease-control, limited toxicity, favorable dosimetry, and overall compares well with published non-proton-beam experiences. Given short follow-up, additional studies are warranted to determine if dosimetric advantages from proton therapy will translate into comparative toxicity benefits.

Pulsed Field Ablation Versus Radiofrequency Ablation: Esophageal Injury in a Novel Porcine Model.

Pulsed field ablation (PFA) can be myocardium selective, potentially sparing the esophagus during left atrial ablation. In an in vivo porcine esophageal injury model, we compared the effects of newer biphasic PFA with radiofrequency ablation (RFA). In 10 animals, under general anesthesia, the lower esophagus was deflected toward the inferior vena cava using an esophageal deviation balloon, and ablation was performed from within the inferior vena cava at areas of esophageal contact. Four discrete esophageal sites were targeted in each animal: 6 animals received 8 PFA applications/site (2 kV, multispline catheter), and 4 animals received 6 clusters of irrigated RFA applications (30 W×30 seconds, 3.5 mm catheter). All animals were survived to 25 days, sacrificed, and the esophagus submitted for pathological examination, including 10 discrete histological sections/esophagus. The animals weight increased by 13.7±6.2% and 6.8±6.3% (P=0.343) in the PFA and RFA cohorts, respectively. No PFA animals (0 of 6, 0%) developed abnormal in-life observations, but 1 of 4 RFA animals (25%) developed fever and dyspnea. On necropsy, no PFA animals (0 of 6, 0%) demonstrated esophageal lesions. In contrast, esophageal injury occurred in all RFA animals (4 of 4, 100%; P=0.005): a mean of 1.5 mucosal lesions/animal (length, -21.8±8.9 mm; width, -4.9±1.4 mm) were observed, including one esophago-pulmonary fistula and deep esophageal ulcers in the other animals. Histological examination demonstrated tissue necrosis surrounded by acute and chronic inflammation and fibrosis. The necrotic RFA lesions involved multiple esophageal tissue layers with evidence of arteriolar medial thickening and fibrosis of periesophageal nerves. Abscess formation and full-thickness esophageal wall disruptions were seen in areas of perforation/fistula. In this novel porcine model of esophageal injury, biphasic PFA induced no chronic histopathologic esophageal changes, while RFA demonstrated a spectrum of esophageal lesions including fistula and deep esophageal ulcers and abscesses.

Endoscopic Removal of Foreign Body in Upper Gastrointestinal Tract in Dogs: Success Rate and Complications

Background: Dogs and cats with acute signs of choking, retching, cough, vomiting, regurgitation, hypersalivation, dysphagia and odynophagia should have the presence of a gastrointestinal foreign body (FB) as part of their differential diagnosis, where it is a frequent condition in the care of small animals. Most objects lodged in the esophagus, stomach, and proximal duodenum can be removed by upper digestive endoscopy, a curative, little invasive procedure. The objective of our study was to evaluate the physical aspects and location of esophageal and gastric FBs observed in 88 dogs and the age and breed of the affected animals and to determine the success rate and eventual complications associated with the procedure as well.Materials, Methods & Results: Eighty-eight cases of dogs, males and females of varying ages and breeds, submitted to upper digestive endoscopy were selected because of suspicion of esophageal or gastric FBs. The endoscopic procedure aimed at confirming the diagnosis, whether or not followed by endoscopic removal of these objects. Prior to endoscopy, the animals had laboratory tests (blood count and serum biochemistry) and subsequently to the anesthetic protocols of choice for each case. Data including breed, age, type of constituent material and anatomical location of the FB, endoscopic procedure success rate and complications were recorded and descriptively evaluated. Of the 88 dogs evaluated, 60% (n = 53) were male and 40% (n = 35) female. According to the breed of the animals, 55% (n = 49) were small-breed dogs, 29% (n = 25) large-breed dogs, and 8% (n = 7) medium-breed dogs, and 8% were of mixed breed dogs, which could assume various sizes. Shih Tzus accounted for 18% (n = 16) of the animals, Lhasa apsos 8% (n = 7) and mixed breed 8% (n = 7), where these were the most frequently affected breeds. Regarding age, animals 1 to 5 years old represented 66% (n = 58) of the patients, and those 6 to 10 years old accounted for 20% (n = 18), while 11% of the dogs were over 10 years old (n = 10). Two animals (3%) had no information about their ages. Pieces of cloth were the most frequently found FBs, representing 20%(n = 20), followed by animal bones (19%) and fruit pits (10%). As for location, 78% (n = 69) of the FBs were located in the stomach and 22% (n = 19) in the esophagus. The success rate of endoscopic FB removal in this study was 83% (n = 73). In 76% (n = 67) of the animals, there were no complications due to the presence of FB in the upper gastrointestinal tract. The most frequent complications were esophageal ulcerations (n = 7) and the inability to move the FB (n = 5) and adherences. (n = 4).Discussion: The results showed that small-breed dogs, especially Shih Tzus and Yorkshires, represented a larger number of cases, probably due to their popularity in Brazil, where the study was conducted. Males were more prevalent than females, and the most affected age was between 1 and 5 years, with emphasis on younger animals. There were more gastric FB cases compared to esophageal FB cases, which was related to the interval between the ingestion of the object and veterinary care. Although not the most prevalent FB, the high rate of mango pits can be explained by the vast number of mango trees in the Federal District. There were few complications compared to the success of cases, indicating that endoscopy is the procedure of choice for the diagnosis and removal of FBs from the gastrointestinal tract.

Megaesophagus in Mule

Background: Megaesophagus is a chronic dilation of the esophagus rarely found in horses. It’s a non-specific disease that is associated with several causes, and esophageal hypomotility is the dysfunction that most commonly results in organ dilation. In the literature, there are few reports of megaesophagus in horses and, to date, no cases in mule have been reported. The objective of this work is to describe a case of a donkey with thoracic megaesophagus.Case: A 16 year-old donkey, castrated male, mixed breed weighing 195 kg, was referred for clinical care with a history of 5 days of anorexia. On physical examination, apathy, cachexia, 8% dehydration, moderate enophthalmos, ptialism, bilateral nasal discharge, dry and bristling hair were observed. Due to the poor general condition, a nasogastric tube was chosen to perform enteral nutrition, however, it was not possible to progress the tube to the stomach. In order to confirm the suspicion of a possible esophageal obstruction, gastroscopy was performed, where it was possible to observe an esophageal dilation filled with bulky food located in the thoracic portion of the esophagus. In an attempt to stimulate esophageal motility, in order to promote the progression of the material present in the region of dilation, intramuscular metoclopramide was administered (two applications every 6 h), however the treatment had no effect. Due to the unfavorable prognosis and financial limitations of the owner, euthanasia was performed, which was followed by autopsy and histopathological examination. At necropsy, a marked dilation of the esophagus was observed in the thoracic portion, which was filled with approximately 500 grams of bulky food (grass). In the mucosa of this area, multiple ulcers were observed that occasionally coalesce, covered by a moderate amount of friable and yellowish-white material.Discussion: Megaesophagus is characterized by organ dilatation and enlargement, absence of peristalsis, presence of tertiary contractions and non-total or partial relaxation of the lower sphincter. Its origin can be congenital or secondary (acquired). In the congenital form, which corresponds to the hypomotility and generalized dilation of the esophagus, the main consequence is the underdevelopment of the foal after weaning. The acquired form occurs due to motor changes in the esophagus or gastroesophageal sphincter, causing passive dilation of the organ. Lupus erythematosus, polymyositis, polyneuritis, degenerative neuropathies, hypoadrenocorticism, hypothyroidism, thiamine deficiency, heavy metal poisoning (Lead and Thallium), tumors (mainly thymoma) and cervical injuries are among the main causes of secondary megaesophagus. Animals with esophageal paralysis or some type of esophageal obstruction, usually present nasal and oral reflux of saliva and may develop aspiration pneumonia, accompanied by nutritional deficiencies, weight loss, changes in normal development and the presence of esophageal ulcers. With the exception of pneumonia, the animal in the present report had all these signs. The prognosis of animals affected by megaesophagus is unfavorable. One of the ways to alleviate this disease is surgical treatment, however, complications such as dehiscence are common after esophageal surgery, mainly due to the fact that this organ does not have a serous layer, resulting in delayed healing. For this reason, euthanasia is considered in most cases. Megaesophagus is a non-specific and multifactorial disease that affects horses, and there are no reports in the literature in mules. In this case, endoscopy allowed the diagnosis to be made while still alive, however it was not possible to determine the primary cause of the disease.

Interaction of epidermal growth factor with COX-2 products and peroxisome proliferator-activated receptor-γ system in experimental rat Barrett's esophagus.

Mixed acidic-alkaline refluxate is a major pathogenic factor in chronic esophagitis progressing to Barrett's esophagus (BE). We hypothesized that epidermal growth factor (EGF) can interact with COX-2 and peroxisome proliferator-activated receptor-γ (PPARγ) in rats surgically prepared with esophagogastroduodenal anastomosis (EGDA) with healthy or removed salivary glands to deplete salivary EGF. EGDA rats were treated with 1) vehicle, 2) EGF or PPARγ agonist pioglitazone with or without EGFR kinase inhibitor tyrphostin A46, EGF or PPARγ antagonist GW9662 respectively, 3) ranitidine or pantoprazole, and 4) the selective COX-2 inhibitor celecoxib combined with pioglitazone. At 3 mo, the esophageal damage and the esophageal blood flow (EBF) were determined, the mucosal expression of EGF, EGFR, COX-2, TNFα, and PPARγ mRNA and phospho-EGFR/EGFR protein was analyzed. All EGDA rats developed chronic esophagitis, esophageal ulcerations, and intestinal metaplasia followed by a fall in the EBF, an increase in the plasma of IL-1β, TNFα, and mucosal PGE2 content, the overexpression of COX-2-, and EGF-EGFR mRNAs, and proteins, and these effects were aggravated by EGF and attenuated by pioglitazone. The rise in EGF and COX-2 mRNA was inhibited by pioglitazone but reversed by pioglitazone cotreated with GW9662. We conclude that 1) EGF can interact with PG/COX-2 and the PPARγ system in the mechanism of chronic esophagitis; 2) the deleterious effect of EGF involves an impairment of EBF and the overexpression of COX-2 and EGFR, and 3) agonists of PPARγ and inhibitors of EGFR may be useful in the treatment of chronic esophagitis progressing to BE.NEW & NOTEWORTHY Rats with EGDA exhibited chronic esophagitis accompanied by a fall in EBF and an increase in mucosal expression of mRNAs for EGF, COX-2, and TNFα, and these effects were exacerbated by exogenous EGF and reduced by removal of a major source of endogenous EGF with salivectomy or concurrent treatment with tyrphostin A46 or pioglitazone combined with EGF. Beneficial effects of salivectomy in an experimental model of BE were counteracted by PPARγ antagonist, whereas selective COX-2 inhibitor celecoxib synergistically with pioglitazone reduced severity of esophageal damage and protected esophageal mucosa from reflux. We propose the cross talk among EGF/EGFR, PG/COX-2, and proinflammatory cytokines with PPARγ pathway in the mechanism of pathogenesis of chronic esophagitis progressing to BE and EAC.

An esophageal-mediastinal fistula in a renal transplant patient—a late complication that shall both dither the clinician and be rapidly fatal: A case report

Although renal transplantation has said to have transformed the quality of lives of most of the end stage renal disease patients, it is attended by its own set of complications including allograft rejection, drug-related side effects, small to potentially lethal infections, and various malignancies in the long run. Esophageal ulcers are known to occur after renal transplantation due to various infections including cytomegalovirus (CMV)/Herpes and the drugs Mycophenolate mofetil (MMF) and steroids. We hereby report a rare gastrointestinal complication of esophageal-mediastinal fistula in a renal transplant patient that presented as severe mediastinitis and had a rapidly downhill course in our patient.

Laparoscopic Sleeve Gastrectomy Leakage: Case Report of A Rare Complication Management

Introduction: Laparoscopic sleeve gastrectomy (SG) is an effective method for the treatment of obesity. Leakage is the most common and unfavorable complication of SG. Use of self-expandable metal stents (SEMS) has become the gold standard management. Aortoesophageal fistula (AEF) is a rare and life-threatening complication that can result from SEMS placement. Case Presentation: A 52 year old woman underwent laparoscopic SG for morbid obesity. Eight days after an esophagogastric SEMS placement was required for gastric leakage. Twenty two days later she presented massive hematemesis and active AEF was diagnosed requiring endovascular placement of thoracic endoprosthesis. SG conversion into Roux en Y gastric bypass (RYGB) with double pigtail stent placement was necessary for the persistence of gastric fistula. 45 days after, EGD revealed the aortic prosthesis at the distal portion of esophagus. For this reason, she underwent a thoracic aorta reconstruction and an esophago jejunal anastomosis. Discussion: Esophageal ulceration is a possible complication of SEMS placement and can lead to an AEF. In order to promptly identify and treat rare and fatal complications as AEF, it is important to always keep a high index of suspicion. Conclusion: The awareness of rare complications as AEF after SEMS placement is important in order to facilitate immediate surgical treatment and to raise survival possibility. It is important to be familiar with all different treatment options, as well as being updated on the latest Guidelines. A good knowledge of timing and best treatment option, depending on the leak and patient clinical status, are mandatories.

Aorto-esophageal fistula - An autopsy series.

Fistulous tracts within the thorax are best exemplified aorto-esophageal fistulas (AEFs), which are rare exsanguinations of the upper gastrointestinal tract. Most of them are diagnosed at autopsy. This is an autopsy-based study of fatal cases of AEFs gathered over a period of 20 years. Cases of AEFs were retrieved from the autopsy records of the cardiovascular pathology sub-specialty at a tertiary care center and were studied with reference to demographic details, modes of clinical presentation, and pathological features. Ten cases of AEFs (10 males and 8 females, mean age of 46.9 years) were identified in a span of 20 years. A clinical diagnosis of AEF was made in only one patient, while the rest were identified at autopsy. All the patients had a bout of massive and fatal hematemesis. The fistulous connections, involving the middle-third of the esophagus, were caused by a fishbone, esophageal ulceration and aneurismal aortic diseases of varied etiology. AEFs are often missed or misdiagnosed. Early recognition of this rapidly fatal condition is essential as these fistulas require quick and aggressive management.

HERPES SIMPLEX VIRUS TYPE 7 AND EPSTEIN-BARR VIRUS AS STRANGE CAUSES FOR GASTRIC ULCER

Esophageal, gastric and duodenal ulcers are found in immunocompromised patients due to virus, mainly cytomegalovirus (CMV), and less frequently Epstein-Barr virus (EBV), varicella zoster virus (VZV) and herpes simplex virus (HSV) type 1 or 2.

Esophageal Ulcer Due to Ectopic Pancreatic Tissue: A Case Report

Heterotopic pancreatic tissue, known as pancreatic rest, is a pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Common locations for this tissue include the stomach, duodenum, jejunum, Meckel diverticulum, and ileum. In this report, we present a case of a patient whose pancreatic rest was diagnosed primarily during the investigation of dysphagia with solid foods and it was located in the mid esophagus as an unusual location.

Is a proton-pump inhibitor necessary after endoscopic submucosal dissection for superficial esophageal neoplasms? A propensity score analysis.

Background:Little is known about the efficacy of proton-pump inhibitor (PPI) therapy in the management of esophageal ulcers after endoscopic submucosal dissection (ESD). Therefore, the objective of this study was to investigate the efficacy of PPI in ulcer healing following ESD for superficial esophageal neoplasms, using a propensity score analytic approach.Methods:This retrospective cohort study was conducted at a single referral center. Between April 2005 and August 2015, 199 consecutive patients with superficial esophageal cancer and esophageal dysplasia underwent ESD. For patients with PPI administration, intravenous PPI therapy was commenced immediately after ESD, and oral PPI was administered daily from post-operative day 3, until ulcer healing was identified. We compared the remnant-ulcer rate at 4 weeks after esophageal ESD between the PPI administration and non-PPI groups, using propensity scores and the inverse probability of treatment weighting (IPTW) method.Results:After exclusions, a total of 88 patients were analyzed. The remnant-ulcer rate at 4 weeks after ESD was 25.5% (12/47) and 14.6% (6/41) in the PPI administration and non-PPI groups (p = 0.21). After adjusting for background factors using IPTW, the risk of a remnant ulcer in the PPI administration group was not decreased significantly compared with that in the non-PPI group [odds ratio (OR) = 2.42, 95% confidence interval (CI): 0.73–7.97, p = 0.15]. Furthermore, PPI therapy did not decrease significantly the remnant-ulcer rate on logistic regression analysis after adjusting for the propensity score (OR = 2.40, 95% CI: 0.69–8.32, p = 0.15).Conclusion:PPI administration does not promote ulcer healing after ESD for superficial esophageal squamous cell carcinoma.

Two cases of esophageal ulcer after surgical treatment for ulcerative colitis.

The incidence of postoperative esophageal ulcers has been rarely reported associated with severe ulcerative colitis (UC). We report two cases of esophageal ulcers accompanied by acute necrotizing esophagitis after undergoing surgery for severe UC. Both patients, 47- and 53-year-old, were diagnosed with severe UC and underwent subtotal colectomy with sigmoid mucous fistula and ileostomy. In both cases, they had epigastralgia or digestive track bleeding and upper gastrointestinal endoscopy revealed an esophageal ulcer with acute necrotizing esophagitis accompanied by a black degeneration of mucosa after surgery. Conservative treatments improved the lesions. Esophageal stricture requiring endoscopic dilatation occurred in both cases. An acute UC requiring surgery seems to warrant caution in the merger of esophageal ulcer and acute necrotizing esophagitis.

Pathomorphological study on gastric ulceration in horses

Equine gastric ulcer syndrome (EGUS) is characterized by ulceration in the terminal esophagus, proximal (squamous) stomach, distal (glandular) stomach, and proximal duodenum. It is a common disease in all breeds and ages of horses and foals. Risk factors for EGUS include stress, transport high-energy feed confinement in stalls, intermittent feed, and intense exercise and racing. Horses are very sensitive to any environmental change, which is cause of high prevalence of gastric ulcers especially in racing horses. Taking into consideration of high prevalence of EGUS, our research work was based on pathomorfological and gross evaluation of gastric mucosa in different breeds of horses. Assessment of the severity of lesions is most commonly achieved by assigning a grade that describes the mucosal appearance at different anatomic sites. A variety of different systems have been published for the horses. 10 stomachs were removed from a mixed population post mortem. In our study pathological classification of lesion type was evaluated by two different scoring system, with scales ranging from 0–4. Samples from areas with lesion were taken for histopathology evaluation. EGUS was confirmed on stomachs of six horses. Lesions with different score mostly localized on squamous region near margo plicatus. Changes on squamous mucosa was confirmed on stomach of four horses as well as glandular region two horses. According to score systems mentioned in publication changes on gastric mucosa was measured up 1, 2, 3 score and were characterized as hyperceratosis, erosions and deeper lesion involving the mucosa, extending to the submucosa layer and hyperemia of glandular mucosa. The results of pathomorphological examination of the condition of the wall of the gastric mucosa and histological changes, the effectiveness of the submitted classification systems was established.

IDIOPATHIC, TREATMENT RESISTANT, GIANT OESOPHAGEAL ULCER IN A KIDNEY TRANSPLANT RECIPIENT.

Giant oesophageal ulcers (GOU) are variable dened as ulcers larger than 10-20 millimeters. The initial reports were primarily in association with human immunodeciency virus (HIV). Since then they have been described in the setting of organ transplant including hematopoietic stem cell and lung transplantation. Association with kidney transplantation is rare and only three such cases have been described. The pathophysiology remains an enigma. We report a case of idiopathic, therapy unresponsive, GOU in a young male with Immunoglobulin A nephropathy (IgAN) related end stage kidney disease. Four months following the kidney transplantation he presented with graft dysfunction, reoccurrence of basic disease, odynophagia and weight loss. The endoscopic evaluation showed two GOU in the distal esophagus. The response to therapy was poor; it nally resolved spontaneously. Based on the temporal prole and the review of existing similar case reports, we believe, these GOU represent an extra-renal manifestation of IgAN.

Clinical profile of patients presenting with dysphagia - an experience from a tertiary care center in North India.

Background and AimDysphagia can lead to substantial morbidity and mortality, especially in the elderly. It has both benign and malignant causes. Despite having a varied etiology, there have been few studies in India. Therefore, a study was undertaken to evaluate the clinical profile and various etiologies of dysphagia.MethodsA prospective study was conducted on 220 patients with a complaint of dysphagia. Detailed history and examination, endoscopy and biopsies, and barium swallow were performed. Computed tomography and magnetic resonance imaging were performed wherever required. Patients who had an oropharyngeal or neurological cause of dysphagia were excluded.ResultsThe mean age of patients was 57.2 years, with the male: female ratio being 1.7:1. Of the patients, 35% (78 patients) had malignant etiology, with a mean age of 65.2 years, and 65% (142 patients) had a benign etiology, with a mean age of 51 years. Among the patients with malignancy, 56 had squamous cell carcinoma of esophagus (71.7%), 20 had adenocarcinoma of esophagus (25.7%), and 2 had gastric cardia adenocarcinoma (2.6%). Malignancy was most commonly located in distal esophagus (48 patients), and among the cases, 18 had involvement of the gastroesophageal junction. The most common benign cause was esophagitis secondary to reflux in 25.5% (56 patients), followed by esophageal ulcer in 5.9%, achalasia in 5%, corrosive stricture in 4.5%, and peptic stricture in 3.6%.ConclusionDysphagia has diverse etiology, and a majority can be diagnosed by endoscopy and barium swallow. Malignancy is an important cause of dysphagia in elderly. Esophageal squamous cell carcinoma remains the most common malignancy, but the incidence of gastroesophageal junctional adenocarcinoma is increasing.

P150 ULCERATING CMV ESOPHAGITIS – A UNIQUE COMPLICATION OF ACHALASIA

Abstract Aim Ulcerating CMV associated esophagitis in an immuncompetent patient has not been described before. This case report highlights diagnostic pitfalls in differentiating achalasia from pseudo achalasia. Background & Methods A 41-year-old man presented to the high resolution manometry lab with progressive retrosternal dysphagia and regurgitation. Endoscopy revealed a dilated esophagus with a passable stenosis of the esophagogastric junction. Between 27 to 39 cm a deep 3 x 12 cm ulcer reaching the lamina muscularis was detected. Biopsies were taken and processed to the institute for pathology and microbiology. A barium swallow revealed typical features of achalasia. A dilated hypomotile esophagus and a beak sign were seen. Histopathology described a deep ulcer with a mixed inflammatory infiltration without any signs for malignancy. The virology finally revealed a strong positivity for CMV in PCR. Therefor the diagnosis of CMV esophagitis was made. Reasons for an immunodeficiency (HIV, Trypanosoma pallidum etc.) could be excluded. After endoscopic placement of a probe, high resolution manometry was performed. It showed a disturbed EGJ relaxation, an enhanced residual pressure (IRP) and panesophageal pressurizations in almost every swallow. These are typical features of Type II Achalasia (Chicago Classification v 3.0). Results The patient received antiviral therapy (Ganciclovir) for 2 months. Only a moderate symptom relief was achieved. Endoscopic reevaluation showed a complete remission of the huge esophageal ulcer. There was no esophageal scar or other reason for EGJ obstruction. CMV was no longer detected. A second high resolution manometry confirmed again a Type II Achalasia. The patient underwent laparoscopic myotomy an 180° degree fundoplication. 6 months after the intervention the patient is well and has a complete remission of his symptoms. Conclusion Although ulcerating CMV esophagitis may be a cause of pseudoachalasia, in this case for the first time primary achalasia is described to be the reason for ulcerating CMV esophagitis.

1818 Acute Hematemesis From Kayexalate-Induced Esophageal Ulcer

INTRODUCTION: Hyperkalemia is one of the most common electrolyte abnormalities encountered in clinical practice. The treatment of hyperkalemia includes removal of the unwanted potassium from the body by cation exchange resins. e. g sodium polystyrene sulfonate (Kayexalate). The serious gastrointestinal side effects of sodium polystyrene sulfonate (SPS) have been reported with or without concomitant use of sorbitol including colonic perforation. The U.S food and drug administration (FDA) has issued a warning to avoid kayexalate administration with sorbitol. We present an individual with acute hematemesis due to bleeding esophageal ulcer immediately after treatment with kayexalate therapy. CASE DESCRIPTION/METHODS: 63-year-old Hispanic man who was recalled to ED by renal team due to elevated potassium level of 6.6mg/dl. On arrival to ED his vitals were WNL. His physical examination includes distended non- tender abdomen and 2+ pitting edema of lower extremities. Rest of physical was within normal limits. His comorbid conditions include alcohol related decompensated cirrhosis, nephrotic syndrome and small nonbleeding esophageal varices seen on endoscopy performed 3 weeks before current illness. He was treated with oral kayexalate 30mg along with intravenous (I/V) dextrose, calcium gluconate and insulin. 45 minutes after oral SPS therapy patient developed large episode of hematemesis. He was intubated for airway protection. An emergent endoscopy was performed which showed multiple round, sharply demarcated, esophageal ulcers with mucosal oozing (Figure 1A) and small non bleeding esophageal varices were again seen. The two of the esophageal ulcers were actively oozing, to achieve the hemostasis, two hemostatic clips were deployed with cessation of bleeding (Figure 1B). The esophageal ulcer biopsies were not taken due to concern of causing iatrogenic bleeding in the presence of coagulopathy. He had no evidence recurrent gastrointestinal bleeding. DISCUSSION: Kayexalate induced colonic ulcer, colonic ischemia and colonic necrosis has been repeatedly described in the literature. The kayexalate induced esophageal ulcer with significant hematemesis is rarely reported. Although the exact mechanism by which kayexalate causes esophageal ulcer to be elucidated but it is worthwhile to be vigilant about its potential adverse effects. Our case highlights the rare but certainly the life threatening complication of kayexalate therapy.

3039 Esophageal Ulcers: A Presenting Symptom of Acute HIV Infection

INTRODUCTION: Dysphagia and odynophagia are commonly encountered in patients who are immunocompromised from chronic Human Immunodeficiency Virus (HIV) infection. Acute HIV infection can also cause odynophagia due to abrupt onset of oropharyngeal mucosal disease. We describe the eventual diagnosis of acute HIV infection in a patient presenting with dysphagia and odynophagia following endoscopic finding of esophageal ulceration. CASE DESCRIPTION/METHODS: A 43-year-old man presented with one week of epigastric pain, dysphagia, and odynophagia in the setting of recent fever (TMax 102.8F) and chills. He had intermittently taken a PPI following an emergency room visit the previous week. Oropharyngeal exam was negative for ulcers or thrush and abdominal exam was benign. Initial labs were normal aside from mild leukopenia (WBC 3,100/uL) with a low absolute neutrophil count. He underwent EGD showing several deep distal esophageal ulcers. Pathology showed acute esophagitis with mild to severe neutrophilic infiltrate and neutrophilic microabscesses. Staining of the ulcer biopsy specimens was negative for cytomegalovirus (CMV), herpes simplex virus (HSV) and fungal elements. The unknown etiology of his esophageal ulcers prompted testing for HIV. HIV immunoassay was positive however antibody differentiation was indeterminate. A subsequent HIV viral load was positive indicating acute HIV-1 infection. He was placed on anti-retroviral therapy soon after. A repeat EGD was performed three months later, demonstrating complete resolution of the previously seen ulcers. DISCUSSION: Presenting signs and symptoms of acute symptomatic HIV infection are nonspecific and the diagnosis is often missed or delayed. Esophageal ulceration may be underrecognized as an acute manifestation of illness. In one study of 16 men presenting with odynophagia who were eventually found to have acute HIV infection (HIV serology negative at presentation), all 16 were found to have esophageal ulceration during index endoscopy. Identification of viral particles resembling HIV-1 within ulcer biopsies with electron microscopy and isolation of HIV-1 from an ulcer biopsy specimen raise the possibility of direct viral infection of esophageal cells. With this in mind, endoscopists and gastroenterology providers should have a high index of suspicion for acute HIV infection in patients with odynophagia secondary to esophageal ulcer of unknown etiology.

1844 A Case of Idiopathic Esophageal Ulceration as Initial Presentation of Acquired Immune Deficiency Syndrome

INTRODUCTION: Esophageal ulceration (EU) is most frequently caused by gastroesophageal reflux disease. However, immunocompromised individuals are particularly susceptible to EU caused by infections including herpes simplex virus (HSV), cytomegalovirus (CMV), and candida species. Furthermore, patients with acquired immunodeficiency syndrome (AIDS) can also develop idiopathic EU even in the absence of infection. CASE DESCRIPTION/METHODS: A 30-year-old male with no significant past medical history presented with 6 months of profound weight loss, odynophagia, dysphagia, and chest pain. He had no history of NSAID use. Symptoms had persisted despite trials of proton pump inhibitors, H2 antagonists, and sucralfate. His physical exam was notable for cachexia and bi-temporal wasting. Esophagogastroduodenoscopy revealed two large hemi-circumferential cratered distal esophageal ulcers separated by a mucosal bridge. Endoscopic ultrasound demonstrated an isoechoic mass in the lower third of the esophagus measuring 1.2 cm in thickness, obliterating the wall layer architecture, along with three enlarged gastro-hepatic lymph nodes. Pathology demonstrated granulation tissue with fibro-inflammatory debris and was negative for malignancy, HSV, and CMV. Fine needle aspiration of one of the enlarged lymph nodes was also negative for malignancy. A contrasted computed tomography scan of the chest, abdomen, and pelvis did not reveal any additional findings. Laboratory evaluation was most notable for worsening leukopenia (WBC count: 3000 cells/μL) and anemia (Hgb: 9.9 g/dL). Further history revealed unprotected sexual encounters with multiple females in the last 10 years. Subsequent workup demonstrated a positive human immunodeficiency virus (HIV) antibody screen with a CD4 count of 44 cells/µL. Patient was ultimately diagnosed with idiopathic EU from AIDS and was initiated on highly active antiretroviral therapy. DISCUSSION: While EU is a common complication in patients with AIDS, it is normally associated with infections such as CMV and HSV. Idiopathic EU in these patients are rarer and typically found in those with CD4 cell counts less than 100 cells/µL. Our case was unique in that the patient's development of large EU was his initial presentation of AIDS. In these cases, establishing the correct diagnosis and ruling out malignancy is important as misdiagnosis can significantly alter treatment plan and prognosis. This case further highlights the necessity for HIV testing in patients who present with idiopathic EU.

P5690Comparison of two methods to navigate the stereotactic body radiotherapy ablation for ventricular tachycardia, the invasive electrophysiological study and substrate identification

Abstract Purpose To compare two methods used for identifying the arrhythmogenic substrate - invasive electrophysiological study versus PET-CT scar identification. The substrate is then targeted by stereotactic body radiotherapy (SBRT) in patients with previously unsuccessful radiofrequency catheter ablation. Methodology Patients with ischemic cardiomyopathy, LVEF less than 40% and unsuccessful conventional treatment resulting in recurring ventricular tachycardias, were divided into two groups with different methods of obtaining arrhythmogenic substrate. In the group A, invasive electrophysiological mapping was used, while in the group B, scar identification by PET-CT was done, enhanced with non-invasive body surface ecg mapping of all inducible ventricular tachycardias. This target obtained was then attacked with SBRT. We compared the size of the planned target volume (PVT), the SBRT duration, the calculated dose for the esophagus, stomach and lung and the incidence of acute complications. Cohort description Patients in group A were recruited from April 2014 to December 2018, patients in group B from June to December 2018. Group A (8 patients) – mean age 66, NYHA class 2.4, LVEF 29,4%. Group B (6 patients) – mean age 71, NYHA class 2.1, LVEF 25,2%. All patients were men. Results There was a statistically significant difference in PTV – Group A (mean 24.1ml, SD = 3,9), Group B (mean 76.0ml, SD 14.1), p<0,001 (two-sample t-test). There was no difference in the calculated secondary radiation doses acquired by surrounding organs. The most frequent adverse event was acute anorexia, occurring in 4 patients from Group A and in 2 patients from Group B. The anorexia subsided in one week time. One patient from Group B suffered from esophageal ulcer, which developed 6 months after the therapy. Conclusion Using invasive electrophysiology mapping to identify arrhythmogenic substrate for SBRT yields significantly smaller volume of targeted tissue. Despite this finding, we did not find any difference neither in radiation dose delivered to the surrounding organs, nor in the radiation duration.