Esophageal Ulcer Research Articles

Heterotopic Gastric Mucosa in Middle Esophagus Complicated with Esophageal Ulcers.

Heterotopic gastric mucosa (HGM) of esophagus, primarily occurring in cervical esophagus, is usually asymptomatic. A healthy woman (mid-40s) with postprandial heartburn was diagnosed with middle esophageal HGM and esophageal ulcers by esophagogastroduodenoscopy. Using 8-channel pH monitoring, a sensor near the HGM area detected postprandial acid phase (pH 3-4), while areas adjacent to the proximal and distal sensors were neutral, suggesting acid secretion from the HGM. A biopsy showed fundic gland tissue expressing H+/K+-ATPase and pepsinogen-I. Oral vonoprazan improved the clinical symptoms and endoscopic findings. This is the first report using 8-channel pH monitoring to diagnose extremely rare middle esophageal HGM.

Esophageal ulcer after band ligation of esophageal varices

IntroductionBand ligation plays an important role in the management of esophageal varices (EV), but banding ligation carries a risk of band slippage, postbanding esophageal ulcer formation, and postbanding bleeding.AimThe predisposing factors and frequency of esophageal ulcer after banding ligation of EV were assessed.Patients and methodsA total of 130 cirrhotic patients with EV were subjected to therapeutic or prophylactic banding ligation, and then the patients were observed for 14 days for detection of incidence of esophageal ulcer bleeding after postbanding ligation. This was a prospective study done to compare the cirrhotic patients without endoscopic variceal ligation (EVL)-induced esophageal ulcer as a complication (nonbleeder group, n==118) with bleeding patients after EVL owing to postbanding ulcer (bleeder group, n = 12). Full present and past medical history taking for all patients, physical examination, laboratory investigation, ultrasonography of abdomen and/or triphasic computed tomography abdomen, upper endoscopy, and EVL, were done. Re-endoscopy was done if rebleeding happens after EVL.ResultsAfter EVL, the incidence of esophageal ulcer bleeding in cirrhotic patients was 9.2%, and the mortality within the 2-week follow-up was 16.7%. The risk factors of postbanding ulcer bleeding were esophageal reflux, increased aspartate transaminase to platelet ratio index score, and focal hepatic lesion.ConclusionBleeding of esophageal ulcer after EVL is not a rare complication of EVL, which is most commonly detected within 14 days after EVL. Reflux esophagitis, increase in aspartate transaminase to platelet ratio index score, and presence of focal hepatic lesion are predisposing factors for postbanding esophageal ulcer bleeding.

Clinical and Endoscopic Outcomes in Coronavirus Disease-2019 Patients With Gastrointestinal Bleeding.

Background and AimsOver 404 million people worldwide have been infected with coronavirus disease–2019 (COVID-19), 145 million in the United States (77 million) and Europe (151 million) alone (as of February 10, 2022). This paper aims to analyze data from studies reporting gastrointestinal bleeding (GIB) and/or endoscopic findings in COVID-19 patients in Western countries.MethodsWe conducted a systematic review of articles on confirmed COVID-19 cases with GIB in Western countries published in PubMed and Google Scholar databases from June 20, 2020, to July 10, 2021.ResultsA total of 12 studies reporting GIB and/or endoscopic findings in 808 COVID-19 patients in Western countries were collected and analyzed. Outcomes and comorbidities were compared with 18,179 non-GIB COVID-19 patients from Italy and the United States. As per our study findings, the overall incidence of GIB in COVID-19 patients was found to be 0.06%. When compared to the non-GIB cohort, the death rate was significantly high in COVID-19 patients with GIB (16.4% vs 25.4%, P < .001, respectively). Endoscopic treatment was rarely necessary, and blood transfusion was the most common GIB treatment. The most common presentation in GIB patients is melena (n = 117, 47.5%). Peptic, esophageal, and rectal ulcers were the most common endoscopic findings in upper (48.4%) and lower (36.4%) endoscopies. The GIB cohort had worse outcomes and higher incidence of hypertension (61.1%), liver disease (11.2%), and cancer (13.6%) than the non-GIB cohort. Death was strongly associated with hypertension (P < .001, r = 0.814), hematochezia (P < .001, r = 0.646), and esophagogastroduodenoscopy (P < .001, r = 0.591) in COVID-19 patients with GIB.ConclusionOverall, the incidence of GIB in COVID-19 patients is similar to that estimated in the overall population, with melena being the most common presentation. The common endoscopic findings in GIB COVID-19 patients were ulcers, esophagitis, gastritis, and colitis. Patients with GIB were more prone to death than non-GIB COVID-19 patients.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage.

BACKGROUNDLiver cirrhosis is the main cause of portal hypertension. The leading cause of death in patients with liver cirrhosis is its most common complication, esophageal variceal bleeding (EVB). Endoscopic variceal ligation (EVL) is recommended by many guidelines to treat EVB and prevent rebleeding; however, esophageal ulcers occur after treatment. Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates. Thus, the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.AIMTo evaluate the efficacy of aluminum phosphate gel (APG) plus a proton pump inhibitor (PPI) in the prevention of early rebleeding after EVL in patients with EVB.METHODSThe medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital, Guangdong Province, China from January 2015 to December 2020 were collected. According to the study inclusion and exclusion criteria, 401 cases were included in a PPI-monotherapy group (PPI group), and 377 cases were included in a PPI and APG combination therapy (PPI + APG) group. We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups. The two-sample t-test, Wilcoxon rank-sum test, and chi-squared test were adopted for statistical analyses.RESULTSNo significant differences in age, sex, model for end-stage liver disease score, coagulation function, serum albumin level, or hemoglobin level were found between the two groups. The incidence of early rebleeding in the PPI + APG group (9/337; 2.39%) was significantly lower than that in the PPI group (30/401; 7.48%) (P = 0.001). Causes of early rebleeding in the PPI group were esophageal ulcer (3.99%, 16/401) and esophageal varices (3.49%, 14/401), while those in the PPI + APG group were also esophageal ulcers (5/377; 1.33%) and esophageal varices (4/377; 1.06%); such causes were significantly less frequent in the PPI + APG group than in the PPI group (P = 0.022 and 0.024, respectively). The early mortality rate within 6 wk in both groups was 0%, which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy. The incidence of adverse events other than early bleeding in the PPI + APG group (28/377; 7.43%) was significantly lower than that in the PPI group (63/401; 15.71%) (P < 0.001). The incidence of chest pain in the PPI + APG group (9/377; 2.39%) was significantly lower than that in the PPI group (56/401; 13.97%) (P < 0.001). The incidence of constipation in the PPI + APG group (16/377; 4.24%) was significantly higher than that in the PPI group (3/401; 0.75%) (P = 0.002) but constipation was relieved after patients drank more water or took lactulose. In the PPI and PPI + APG groups, the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50% (2/401) and 0.53% (2/377), respectively, and those of hepatic encephalopathy were 0.50% (2/401) and 0.27% (1/377), respectively, presenting no significant difference (P > 0.999).CONCLUSIONPPI + APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

The relationship between gastroesophageal reflux disease and autism spectrum disorder in adult patients in the United States.

Gastroesophageal reflux disease (GERD) has been associated with psychiatric and neurocognitive disorders. Those with autism spectrum disorder (ASD) are prone to gastrointestinal (GI) diseases, but most research has been done on children. Our aim was to determine the relationship between GERD and autism in adults and assess GERD-related complications in those with autism. A national cohort of adults aged 18 and above with GERD with and without ASD were compared to those without GERD. Complications of GERD that were studied included Barrett's esophagus, erosive esophagitis, esophageal stricture, ulcer, and malignancy. Conditions associated with GERD were evaluated including chronic cough, wheezing, sore throat, non-cardiac chest pain, and hoarseness. GERD treatment that was evaluated included proton pump inhibitors (PPIs), H2 receptor antagonists (H2RA), and anti-reflux surgery. There was an increased risk of GERD in subjects with ASD (p=0.0001). Erosive esophagitis and esophageal ulcer were more likely to occur in those with GERD and ASD (p=0.0001). Those with ASD were at higher risk of suffering from wheezing following a diagnosis of GERD compared to those without ASD (p=0.0001). Those with GERD and ASD were more likely to be treated with an H2RA both as monotherapy and in combination with PPI versus those without ASD (p=0.0001 and p=0.0037, respectively). Adult patients with ASD are more likely to have GERD as well as complications including erosive esophagitis and esophageal ulcer. Treatment of patients with GERD and ASD is not consistent and may suggest health care disparities.

Drug-induced esophageal injuries with an atypical presentation mimicking acute coronary syndrome

BackgroundPill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage.Case presentationA 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later.ConclusionMedication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Correlation Analysis of circRNA Circ_0071662 in Diagnosis and Prognosis of Esophageal Squamous Cell Carcinoma.

BackgroundThe role of circRNA circ_0071662 has been studied in bladder cancer. The present study aimed to analyze its involvement in esophageal squamous cell carcinoma (ESCC).MethodsPatients with ESCC (n = 66), esophageal ulcer (EU, n = 66), or gastroesophageal reflux disease (GERD, n = 66) and healthy controls (n = 66) were enrolled in this study. Plasma samples were collected from all patients and controls. ESCC and paired non-tumor tissue samples were collected from ESCC patients. Circ_0071662 levels in these samples were determined by RT-qPCRs. Diagnostic and prognostic values of circ_0071662 for ESCC were analyzed with ROC curve and survival curve analyses.ResultsCirc_0071662 level was decreased in ESCC, but not in GERN and EU compared to the controls and in ESCC tissues compared to the non-tumor tissues. Plasma circ_0071662 was closely correlated with patients’ tumor size but not with other clinical features. Decreased plasma circ_0071662 levels separated ESCC patients from GERN patients, EU patients, and healthy controls. Low plasma circ_0071662 levels were closely correlated with worse survival outcomes of ESCC patients.ConclusionCirc_0071662 is lowly expressed in ESCC and may serve as a potential diagnostic and prognostic biomarker for ESCC.

Medication-Induced Lesion in A Young Woman Mimicking Malignancy: Linear-Extended Esophageal Ulcer Due to Tetracycline Usage

Medication-Induced Lesion in A Young Woman Mimicking Malignancy: Linear-Extended Esophageal Ulcer Due to Tetracycline Usage

Drug-Induced Esophageal Ulcer in Adolescent Population: Experience at a Single Medical Center in Central Taiwan.

Background and Objectives: Drug-induced esophageal ulcer is caused by focal drug stimulation. It may occur in adults and children. Limited research is available in pediatric patients with drug-induced esophageal ulcer; therefore, we designed this study to determine the characteristics of this disease in this population. Materials and Methods: Thirty-two pediatric patients diagnosed with drug-induced esophageal ulcers from a hospital database of upper gastrointestinal tract endoscopies were included. After treatment, patients were followed for 2 months after upper gastrointestinal endoscopy. Results: Female patients were predominant (56.2%/43.8%). The mean age of patients was 15.6 years (median, 16 years; interquartile range, 2 years). Doxycycline was administered in most cases (56.3%); other drugs were dicloxacillin, amoxicillin, clindamycin, L-arginine, and nonsteroidal anti-inflammatory drugs. Doxycycline was associated with kissing ulcers. Esophageal ulcers induced by nonsteroidal anti-inflammatory drugs were more often associated with gastric or duodenal ulcers. The most common location was the middle-third of the esophagus (78.1%). Patients were treated with proton pump inhibitors, sucralfate, or H2-blockers. The mean duration for which symptoms lasted was 9.2 days. No esophageal stricture was found in 24 patients who were followed for 2 months after upper gastrointestinal endoscopy. Conclusions: The authors suggest informing patients to take medicine with enough water (approximately 100 mL) and enough time (15–30 min) before recumbency, especially high-risk drugs, such as doxycycline or nonsteroidal anti-inflammatory drugs.

Late Toxicities, Failure Patterns, Local Tumor Control, and Survival of Esophageal Squamous Cell Carcinoma Patients After Chemoradiotherapy With a Simultaneous Integrated Boost: A 5-Year Phase II Study.

PurposeWe aimed to evaluate the long-term outcomes of concurrent chemoradiotherapy (CCRT) with a simultaneous integrated boost (SIB) of radiotherapy for esophageal squamous cell carcinoma (ESCC).Methods and MaterialsEighty-seven patients with primary ESCC enrolled in this phase II trial. The majority (92.0%) had locoregionally advanced disease. They underwent definitive chemoradiotherapy. The radiotherapy doses were 66 Gy for the gross tumor and 54 Gy for the subclinical disease. Doses were simultaneously administered in 30 fractions over 6 weeks. The patients also underwent concurrent and adjuvant chemotherapy, which comprised cisplatin and fluorouracil. The study end points were acute and late toxicities, first site of failure, locoregional tumor control, and overall survival rates.ResultsThe median follow-up time was 65.7 (range, 2.2-97.5) months for all patients and 81.5 (range, 19.4-97.5) months for those alive. There were 17 cases (19.5%) of severe late toxicities, including four cases (4.6%) of grade 5 and seven (8.0%) of grade 3 esophageal ulceration, four (4.6%) of grade 3 esophageal stricture, and two (2.3%) of grade 3 radiation-induced pneumonia. Twenty-three (26.4%) patients had locoregional disease progression. Most (86.7%) locally progressive lesions were within the dose-escalation region in the initial radiation plan, while majority of the recurrent lymph nodes were found out-of-field (83.3%) and in the supraclavicular region (75.0%). The 1-, 2-, 3-, and 5-year locoregional tumor control and overall survival rates were 79.2%, 72.4%, 72.4%, 70.8%, and 82.8%, 66.6%, 61.9%, 58.4%, respectively. Incomplete tumor response, which was assessed immediately after CCRT was an independent risk predictor of disease progression and death in ESCC patients.ConclusionsCCRT with SIB was well tolerated in ESCC patients during treatment and long-term follow-up. Moreover, patients who underwent CCRT with SIB exhibited improved local tumor control and had better survival outcomes compared to historical data of those who had standard-dose radiotherapy.

Abstract 10909: Purulent Pericarditis Can Be Near Fatal

A previously healthy 27 years-old male presented with 2 weeks of substernal chest pain, progressive dyspnea, palpitations, dizziness, and(&amp;) fever. On exam, he had tachypnea &amp; tachycardia, was hypotensive with an elevated JVP &amp; muffled heart sounds. Labs showed elevated WBC, CRP, lactate &amp; high sensitive troponin. Negative for COVID-19, flu. EKG showed sinus tachycardia. CT showed large pericardial effusion with gas in the pericardial space. Echo (Figure 1) revealed large pericardial effusion with tamponade. Emergent pericardiocentesis was performed draining a liter of straw-colored thick fluid (fluid: serum LDH &gt;3) (Figure 2). Cultures grew Strep. Anginosus &amp; Propionibacterium acnes. Extensive infectious &amp; immunological workup returned negative. He had initially improved on broad-spectrum antibiotics however declined clinically on day 5. Repeat CT (Figures 3 &amp; 4) showed recurrent pericardial effusion &amp; mediastinal abscess with trace extravasation of contrast from the esophagus to posterior mediastinum. We present a case of esophageal perforation leading to Pyopneumopericardium. Stephenson et al. reported a case series of 13 patients with esophagopericardial fistulas &amp; pyopneumopericardium with a 100% mortality rate. Another case series showed survival rates of only 17% in 60 patients with pyopneumopericardium secondary to esophageal perforation. Erosion of esophageal ulcers, ingestion of foreign body, iatrogenic, trauma, malignancy, localized inflammation can lead to esophageal perforation. Streptococcus pneumoniae &amp; Staphylococcus aureus are common pathogens involved. Constrictive pericarditis is a possible complication in up to 20 to 30%. Our patient underwent pericardial window &amp; surgical debridement followed by EGD-guided gastro-jejunal tube placement. He did well after 4 weeks of IV antibiotics. Our case demonstrates that early recognition &amp; intervention can favorably alter the course of this potentially fatal cardiac condition.

Safety of very high-power short-duration radiofrequency ablation for pulmonary vein isolation: a two-centre report with emphasis on silent oesophageal injury.

Very high-power short-duration (vHPSD) via temperature-controlled ablation (TCA) is a new modality to perform radiofrequency pulmonary vein isolation (PVI), conceivably at the cost of a narrower safety margin towards the oesophagus. In this two-centre trial, we aimed to determine the safety of vHPSD-based PVI with specific emphasis on silent oesophageal injury. Ninety consecutive patients with atrial fibrillation (AF) underwent vHPSD-PVI (90 W, 3-4 s, TCA) using the QDOT MICRO catheter, in conjunction with the nGEN (Bad Neustadt, n = 45) or nMARQ generator (Bruges, n = 45). All patients underwent post-ablation oesophageal endoscopy. Procedural parameters and complications were recorded. A subgroup of 21 patients from Bad Neustadt underwent cerebral magnetic resonance imaging (cMRI) to detect silent cerebral events (SCEs). Mean age was 67 ± 9 years, 59% patients were male, and 66% patients had paroxysmal AF. Pulmonary vein isolation was obtained in all cases after 96 ± 29 min. No steam pop, cardiac tamponade, stroke, or fistula was reported. None of the 90 patients demonstrated oesophageal ulceration (0%). Charring was not observed in the nMARQ cohort (0% vs. 11% in the nGEN group). In 5 out of 21 patients (24%), cMRI demonstrated SCE (exclusively nGEN cohort). Temperature-controlled vHPSD catheter ablation allows straightforward PVI without evidence of oesophageal ulcerations or symptomatic complications. Catheter tip charring and silent cerebral lesions when using the nGEN generator have led to further modification.

Distinct clinical characteristics of pediatric Behçet’s syndrome: A study from a referral center in China

Objectives To describe the clinical features and patterns of phenotype aggregation in pediatric Behçet’s syndrome (BS) in a tertiary center in China. Methods This was a cross-sectional study of consecutive BS patients in Huadong Hospital, Fudan University between September 2012 and January 2020. Pediatric BS was defined as diagnosed before 16 years old. We compared clinical variables between pediatric and adult patients. We calculate relative risks (RRs) of clinical variables according to sex. Moreover, a hierarchical cluster analysis was undertaken according to 29 clinical variables to determine homogeneous subgroups. Results From 1596 consecutive BS cases, we identified 69 pediatric BS. Compared with adult-diagnosed BS, pediatric-diagnosed patients had a higher frequency of folliculitis [RR 1.57 (95% CI 1.12, 2.20)], a lower frequency of arthralgia [RR 0.15 (95% CI 0.02, 1.07)] and panuveitis [RR 0.43 (95% CI 0.18, 1.03)], no cardiac lesion. There was an association between male and arterial thrombosis or aneurysms (p = .006). A cluster analysis stratified three sub-clusters (C1–C3): C1 (n = 30) showed a disease type merely affecting skin and mucosa. C2 (n = 20) represented the gastrointestinal type; most patients presented with intestinal involvement, and two cases with esophageal ulcers. In C3 (n = 19), showing a mixture of uveitis, vascular and central nervous system (CNS) involvement, six patients presented with uveitis and nine had vascular lesions, and three cases had CNS lesions. Conclusion We conducted a comprehensive statistical analysis in a cohort of pediatric patients with BS in China. Less ocular involvement and no cardiac lesions were observed in childhood-diagnosed patients. For the first time, three distinct phenotype subgroups in pediatric-diagnosed patients were identified by cluster analysis. Key messages This study demonstrated the phenotype discrepancy between childhood and adult-diagnosed BS. Three distinct clusters were identified, with skin-mucosa, gastrointestinal, panuveitis, vascular and CNS subgroups.

Coronavirus Associated Bleeding Esophageal Ulcerations

A 95-year-old woman developed hematemesis during her hospitalization for severe coronavirus disease 2019 (COVID-19) infection. She had been diagnosed 16 days prior and treated with remdesivir, dexamethasone, and tocilizumab. Her comorbidities included chronic kidney disease stage 4, atrial fibrillation (not on anticoagulation), and chronic systolic heart failure. Patient was hypotensive (96/45 mmHg) and tachycardic (110 bpm). Laboratory studies demonstrated hemoglobin 8.5 g/dL (normal, 11.6–15.0 g/dL), compared with 11.2 g/dL 2 days prior. An esophagogastroduodenoscopy was performed and showed a 7-cm hiatal hernia and multiple cratered ulcers in the upper and middle esophagus, with the largest lesion measuring 15 mm. One of the ulcerations had an adherent clot (Figures A and B) with an underlying bleeding visible vessel (Figure C), which was treated with epinephrine injection and bipolar cauterization (Figure D). Biopsies taken from the center and periphery of esophageal ulcerations were negative for cytomegalovirus and herpes simplex virus but had detectable severe acute respiratory syndrome–associated coronavirus RNA. She had no recurrence of gastrointestinal bleeding. This case highlights that esophageal ulcerations should be considered as a possible etiology of upper gastrointestinal bleeding in patients with COVID-19 infection.

S3269 Common Presentations and Outcome of Eosinophilic Esophagitis in United States: Nationwide Inpatient Cohort Study

Introduction: Eosinophilic esophagitis (EoE) is a newly described disorder characterized by esophageal dysfunction and eosinophilic infiltration of the esophagus, once considered a rare entity, is becoming a commonly encountered gastroenterological condition. In addition to increased clinical recognition of EoE, rising EoE related hospitalization in the United States has been reported. We aimed to identify the most common presentations, medical and surgical outcomes Methods: A retrospective analysis utilizing the de-identified data from the National Inpatient Sample (NIS) was used to analyze patients hospitalized with Eosinophilic esophagitis as a primary admission diagnosis from 2004 through 2014. Hospital encounters for EoE were identified using the International Classification of Diseases (ICD-9) diagnostic codes; '53013'. The NIS is a component of the Healthcare Cost and Utilization Project, a national health care database developed through a partnership among federal and state governments and health care institutions sponsored by the Agency for Healthcare Research and Quality. We extracted the most common presentations, in-hospital diagnostic procedures, medical and surgical outcomes. Results: A total of 625,380 patients with a principal diagnosis of Eosinophilic Esophagitis were obtained through data analysis (2004 through 2014). The majority of the patients were between 35 and 79 years old, the most common presentations were: 49.6% presented with gastroesophageal reflux disease symptoms, 8.3% presented with dysphagia, 5.6% with atypical chest pain, 5.1% with vomiting, 4.1% with weight loss &failure to thrive, 3.7% with abdominal pain, and 1% with acute food impaction. Interesting associations with the EoE were asthma (4.7%), Food allergy (2.7%), and Atopic dermatitis (0.8%). 44.9% of the patients had Upper Endoscopy and Biopsy upon the same admission. The most common EGD findings were: Esophageal plaques or Candida (8.2%), Esophageal strictures (5%), Esophageal Furrows (4.7%), Steroid Use Induced infection (4.6%), Esophageal Ulceration (4 %), and esophageal rings (0.7%). Conclusion: In summary, national databases such as the NIS are handy tools to address questions surrounding low-frequency events like the EoE and outcomes that would otherwise escape study on a nationally representative level. However, caution must be used when interpreting results, as they are subject to several limitations.Table 1.: We Analyzed from the NIS data the most common presentations, in-hospital diagnostic procedures, medical and surgical outcomes between the years 2004 through 2014.

S2051 Primary Esophageal Lymphoma or Lymphoma Presenting as an Esophageal Mass: Rare Disease or Rare Presentation of a Disease?

Introduction: GI tract is the most common site of extra nodal non Hodgkin lymphoma (NHL) with the usual sites being stomach, small intestine and colon. Esophageal involvement has been reported in < 1% of cases and mostly occurs as an extension of mediastinal or gastric lymphoma. Here, we present a case of diffuse large B cell lymphoma (DLBCL) presenting with obstructive esophageal symptoms and diagnosed on esophageal ulcer biopsy. Case Description/Methods: A 72-year-old White male with history of 84 pack years smoking, GERD, presented with a month of shortness of breath, dysphagia to solids, odynophagia, loss of appetite, and 20 lbs. weight loss. Labs revealed WBC count 7000/µL. CT chest without contrast showed a large mediastinal mass with hilar extension, causing esophageal obstruction and two masses within the right lobe of liver. Endoscopy showed a mid-esophageal ulcer without bleeding, and atypical lymphoid cells on biopsy. Immunohistochemistry was positive for CD20, PAX5, BCL2 and BCL6, MUM1 and negative for CD10, cyclinD1 with MIB1 90%, thus consistent with DLBCL. Biopsy of liver mass showed similar histology and immunohistochemistry. HIV testing was negative. He was started on EPOCH based chemotherapy for the DLBCL. On chart review, CT Lung screening a year ago showed several filling defects in mid esophagus, however the filling defects were not evaluated as he was lost to follow up. Discussion: Primary esophageal DLBCL is a rare NHL with only handful of cases reported in literature to date. Our patient did not satisfy Dawson’s criteria for diagnosis of primary GI lymphoma which requires absence of peripheral and mediastinal lymphadenopathy, lack of liver and spleen involvement, and normal peripheral blood count. However, the utility of Dawson’s criteria for diagnosis of primary esophageal lymphoma has been questioned. Esophagus is a mediastinal structure and has rich lymphatic network, thus, predisposing to early mediastinal lymph nodes involvement. Also, esophageal cancers have been known to spread to liver via venous channels. Our patient had several mid esophageal filling defects a year ago and now presented with a large mediastinal mass encasing esophagus, thus, supporting the diagnosis of primary esophageal lymphoma. This case highlights the importance of endoscopic evaluation of esophageal filling defects seen on imaging.Figure 1.: Low dose CT lung screening performed a year prior shows filling defects in mid esophagus (red arrow) as seen in (A) axial section and (B) sagittal section. (C) CT chest without contrast on presentation showing large mediastinal mass, at the same level as image A causing esophageal obliteration. (D) Endoscopic biopsy of esophageal ulcer showing atypical lymphoid cells.

Burden of peptic ulcer disease among patients with upper gastrointestinal bleeding

Background: Peptic ulcer disease continues to be the most common cause of non-variceal upper gastrointestinal bleeding. The clinical presentation varies depending on the intensity of bleeding. It can range from an occult bleed to melena or hematemesis and haemorrhagic shock. The diagnostic procedure Esophagogastroduodenoscopy is gold standard for confirmation of peptic ulcer disease and is also helpful in identification of bleeding source. Irrespective of recent advances in medical treatment of peptic ulcer disease, it is important to quickly identify any signs and symptoms of bleeding. This allows for appropriate management of the bleed at an early stage. Therefore, it is important to know the frequency of peptic ulcer disease amongst upper GI bleeds. Aims and Objectives: The main aim of the current study is to identify the burden of peptic ulcer disease amongst patients with upper gastro-intestinal bleeding. Methodology: This retrospective study on 100 selected patients was conducted at the gastrointestinal unit, department of General Medicine, in a South Asian tertiary care centre, over a period of 6 months between May 2020 to December 2020.This period includes review of literature, collection and analysis of data, discussion and finalization of the report. 100 selected patients presenting to the outpatient department with GI symptoms and upper gastrointestinal bleeding, both male and female and above 18 years of age were enrolled in the study. The patient’s medical history was recorded and diagnosis of peptic ulcer disease was confirmed by Esophagogastroduodenoscopy (EGD). Results: Out of 100 investigated cases of upper gastrointestinal bleeding, frequency of peptic ulcer disease was 53, of which 24 were duodenal ulcer, 21 were gastric ulcer,7 were with both gastric and duodenal ulcer and 1 was an esophageal ulcer. The age distribution in the study population ranged from 30 years to 90 years. With the youngest being 33 years of age and oldest 86years. The mean age was 55 years. Out of 100 cases 76 were males and 24 were females, giving a M: F ratio of 3:1.Risk factors included alcohol intake which was seen in 32 patients, smoking was seen in 41, and NSAID’s use was seen in 8 patients; out of a total of 100 patients. Conclusion: Knowing the burden of peptic ulcer disease amongst upper gastrointestinal bleeds makes us aware of the morbidity it can cause. This makes us more alert and ensures mandatory evaluation for bleeding in any suspected or confirmed case of peptic ulcer disease.

S3558 Esophageal Candidiasis Leading to Spontaneous Esophageal Rupture

Introduction: Spontaneous esophageal perforation (SEP) is a rare and potentially life-threatening condition usually caused by esophageal trauma due to instrumentation or prolonged vomiting and retching. SEP due to esophageal candidiasis (EC) is extremely rare. We present a case of SEP in a patient with EC despite treatment with systemic antifungals. Case Description/Methods: A 53-year-old woman with a history of stage IV lung adenocarcinoma treated with chemoradiotherapy and immunotherapy presented with fever, abdominal pain, diarrhea and hematochezia. Her symptoms were consistent with immune-checkpoint inhibitor colitis, similar to a recent episode that improved with corticosteroids. She has a history of radiation esophagitis in the form of superficial ulceration and stenosis affecting the proximal esophagus. High-dose intravenous corticosteroids were initiated. Due to minimal response, infliximab was administered. Colonoscopy was unremarkable and random biopsies were negative for cytomegalovirus (CMV). Upper endoscopy (EGD) revealed resolution of the initially seen ulceration and no evidence of stricture or stenosis. However, a new distal superficial esophageal CMV ulcer was found. CMV viral load was 6,810 IU/mL and was successfully treated with intravenous ganciclovir leading to viral clearance. EGD for ongoing hematochezia revealed severe esophageal candidiasis (EC) confirmed with histopathology (Figure 1). Despite completing a 14-day course of intravenous fluconazole was, she developed septic shock due to SEP leading to a hydropneumothorax (Figure 2 and 3). Pleural fluid culture was positive for C. albicans. At that stage, family decided to enroll her in home hospice where she died a few days later. Discussion: Although, EC is not uncommon in immunocompromised patients, it is usually treated successfully with antifungal agents in 80-90% of cases. Transmural invasive Candida infection, however, is exceptionally rare with only 4 confirmed cases in the literature. It may lead to esophageal perforation and esophageal-pleural fistula formation. A second-look EGD with culture and sensitivity is recommend in symptomatic patients with EC who fail to improve with treatment. However, there are no guidelines recommending a repeat EGD in immunocompromised patients who initially had minimal symptoms. Our case suggests that for those patients a repeat EGD should be done to ensure resolution of EC and discontinuation of immunosuppressive therapy should be considered.Figure 1.: Endoscopic picture showing mucosal yellow-white plaques throughout entire esophagus, consistent with candidiasis.Figure 2.: Non-enhanced CT (axial view) demonstrating right hydropneumothorax with loculated fluid components.Figure 3.: Esophagram with extravasation of contrast from superior upper esophagus extending into right upper chest.

S2306 Massively Bleeding Esophageal Ulcer Treated With an Over-the-Scope Clip

S2306 Massively Bleeding Esophageal Ulcer Treated With an Over-the-Scope Clip

S2111 Giant HIV-Associated Idiopathic Esophageal Ulcers: A Mimicker of CMV Esophagitis

S2111 Giant HIV-Associated Idiopathic Esophageal Ulcers: A Mimicker of CMV Esophagitis