Esophageal Wall Thickness Research Articles

812. INTRAOPERATIVE USE OF IMPEDANCE PLANIMETRY FOR RECURRENT ACHALASIA AFTER HELLER-NISSEN

Abstract Background Re-operations after Heller myotomy for esophageal achalasia is a challenging operation due to the fibrotic tissue surrounding the esophago-gastric junction (EGJ). The risk of both undertreatment or, on the other hand, esophageal perforation is significant. The impedance planimetry could guide the operation and assess whether the patients needs further dissection of adhesions, an extension of the previous myotomy and anti-reflux treatment. Methods A 70-year-old woman treated with Heller-Nissen in 1983 for type II achalasia was referred to our tertiary care center with absolute dysphagia for three days. In the past 41 years she reported occasional and self-limited episodes of dysphagia, regurgitation and chest pain. Aside from that, her medical history was unremarkable. An esophagogastroduodenoscopy (EGD) with airway protection was performed, showing retained solid food. A water-soluble swallow study showed a tortuous megaesophagus and a misaligned esophageal gastric junction (EGJ), which did not allow endoscopic dilation. Esophageal wall thickening and focal lesions were ruled out by a CT scan. Results A laparoscopy with impedance planimetry technology support was scheduled. The first EGJ distensibility index (EGJ-DI) measurement was 2.1 mm2/mmHg. Esophagus was freed, encircled and released from the hiatus. An EGD confirmed the reposition of the cardia in the abdomen and the previous anterior esophageal myotomy. The Nissen fundoplication was not detectable. At this stage, an EGJ-DI of 4,2 mm2/mmHg was found. To obtain a regular esophageal outflow an anterior myotomy of the EGJ and proximal stomach was carried out and the edge was everted with absorbable barbed suture. A posterior cruroplasty was then performed. The final EGJ-DI was 8,8 mm2/mmHg. Conclusion The postoperative course was uneventful and she was discharged on post-operative day 4 eating a soft diet. In conclusion, the intraoperative use of the impedance planimetry technology has been crucial for a correct decision-making process during complex redo operations for esophageal achalasia as it has helped to tailor the surgical treatment. https://www.dropbox.com/scl/fi/pednopcqnalooidynge3q/ISDE-Definitivo.mov?rlkey=8exx0oe6ompxoex8wqmlsgi0i&st=xgnfnjyt&dl=0

Comparative evaluation of imaging methods for prognosis assessment in esophageal squamous cell carcinoma: focus on diffusion-weighted magnetic resonance imaging, computed tomography and esophagography.

To identify the most sensitive imaging examination method to evaluate the prognosis of esophageal squamous cell carcinoma (ESCC). Thirty patients with esophageal squamous cell carcinoma (ESCC) participated in the study and underwent chemoradiotherapy (CRT). They were divided into two groups based on their survival status: the survival group and non-survival group. The diagnostic tests were utilized to determine the most effective imaging examination method for assessing the prognosis. 1. There were no significant differences in tumor length shown on esophagography or computed tomography (CT) or the maximal esophageal wall thickness shown on CT at the specified time points between the two groups. 2. The tumor length on diffusion-weighted imaging (DWI) in the survival group was significantly lower than in the non-survival group at the end of the sixth week of treatment (P=0.001). The area under the ROC curve was 0.840 (P=0.002), and the diagnostic efficiency was moderately accurate. 3. The apparent diffusion coefficient (ADC) values of the survival group were significantly higher than those in the non-survival group at the end of the fourth week and sixth week of treatment (both P<0.001). Areas under the curve were 0.866 and 0.970, with P values of 0.001 and <0.001 and good diagnostic accuracy. Cox regression analyses indicated the ADC at the end of the sixth week of treatment was an independent risk factor. Compared with esophagography and CT, DW-MRI has certain advantages in predicting the prognosis of ESCC.

EUS in children with eosinophilic oesophagitis – a new method of measuring oesophageal total wall thickness area. An artificial intelligence application feasibility study. A pilot study

Aim: In the study, we aimed to introduce a formula for measuring the oesophageal total wall thickness area, which could be used for developing an artificial intelligence-based algorithm for the detection of patients whose total wall thickness area exceeds the norms. Material and methods: Mathematical formulas for measuring the square area of the oesophageal total wall thickness area were introduced and applied. Children were grouped according to their weight in clusters. For each cluster, the range (minimal and maximal value) were established. The measurements were done by using the formula for the area of the circular ring according to the formula A = π (B2–b2); the product of π and subtraction square b (smaller radius) and square B (bigger radius). The basic data for our calculations were derived from papers published by Dalby et al., 2010 and Loff et al., 2022. Results: The square area (in mm2) of the oesophageal wall was calculated and proposed to be introduced for further analysis. This value set could be used for creating an algorithm for computer-aided analysis of patients diagnosed with sonographic examination and isolating patients for surveillance. Our newly introduced approach could be implemented in sonographic, computer tomography, and magnetic resonance examinations in eosinophilic oesophagitis and other oesophageal diseases. Conclusions: Total wall thickness area could be used for monitoring children with eosinophilic oesophagitis and other oesophageal diseases. The method could also be applied for adults. Therefore, it can be a foundation for further progress with applying artificial intelligence algorithms.

A retrospective study of 3D measurement and analysis applied in the morphological evaluation of achalasia cardia.

Achalasia cardia (AC) is defined as a disorder of esophageal motility whose diagnostic gold standard depends on high-resolution manometry (HRM). The invasiveness of HRM can cause difficulties in diagnosis, treatment, and follow-up for patients with AC. Thus, we aimed to investigate the function of 3D reconstruction and measurement to prove the wide application of this alternative non-invasive approach for AC. A total of 126 patients with AC and 40 healthy subjects in Tianjin Medical University General Hospital from January 2018 to October 2022 were enrolled in this retrospective study. Chest CT images of these subjects were used to reconstruct the 3D models of the esophagus, stomach, spine, left crus, and right crus. Measurements of esophagus length, volume of esophagus, gastroesophageal insertion angle (His angle), max thickness of esophageal wall, esophagus maximum transverse and longitudinal diameter, esophagus-spine angle, and spine-lower esophageal sphincter (LES) angle were applied based on the models. Retrocardiac esophagus length, volume of esophagus, max thickness of esophageal wall, esophagus maximum transverse and longitudinal diameter, thoracic esophagus-spine angle, and spine-LES angle in the AC group were higher than those in the control group (all P values <0.05). Among the three subtypes of AC, thoracic esophagus length, intra-abdominal LES length, volume of esophagus, His angle, esophagus maximum transverse and longitudinal diameter, and thoracic esophagus-spine angle all presented statistical differences (all P values <0.05). Correlation analysis revealed that manometric types were positively associated with His angle [r=0.196; 95% confidence interval (CI): 0.009, 0.372; P=0.028] but negatively associated with volume of esophagus (r=-0.480; 95% CI: -0.639, -0.310; P<0.001), esophagus maximum transverse diameter (r=-0.551; 95% CI: -0.679, -0.400; P<0.001), esophagus maximum longitudinal diameter (r=-0.518; 95% CI: -0.649, -0.366; P<0.001), and thoracic esophagus-spine angle (r=-0.324; 95% CI: -0.479, -0.157; P<0.001). This study successfully presented the differences in esophageal length, volume, thickness, and angles between healthy subjects and different AC subtypes on the basis of 3D reconstruction and measurement. Thus, 3D model and measurement can be regarded as a good support for further research and make a valuable contribution to developing non-invasive approaches for AC management.

Clinical findings of acute necrotizing esophagitis complicated by diabetic ketoacidosis.

Acute necrotizing esophagitis (ANE) is a rare and potentially life-threatening complication of diabetic ketoacidosis (DKA). While its association with DKA is established, specific clinical characteristics that predict ANE in DKA patients remain less understood. This study aimed to identify these characteristics by analyzing data from 30 DKA patients admitted from January 2018 to September 2022. Seven patients in this study presented with ANE, forming the ANE group. The remaining 23 constituted the non-ANE group. We compared the clinical parameters and computed tomography (CT) between the groups. The mean age of participants was 57.7 ± 20.4 years, and their mean HbA1c was 11.1 ± 3.3%. Notably, ethanol intake was significantly higher in the ANE group (44.4 ± 25.4 g/day) compared to the non-ANE group (6.8 ± 14.0 g/day; p = 0.013). Additionally, sodium-glucose transport protein 2 inhibitor use was significantly more prevalent in the ANE group (p = 0.013). Gastrointestinal symptoms were also significantly more pronounced in the ANE group, with vomiting occurring in 85.7% of patients compared to only 13.0% in the non-ANE group. Admission CT scans revealed further distinguishing features, with the ANE group showing significantly higher rates of esophageal wall thickening, intra-esophageal effusion, and calcification of the celiac artery origin (p < 0.0001, 0.0038, 0.0038, respectively). In conclusion, our study suggests that heavy alcohol consumption and strong gastrointestinal symptoms in DKA patients warrant a heightened suspicion of ANE. Early consideration of CT or upper gastrointestinal endoscopy is recommended in such cases.

A Case of Suspected Acute Esophageal Anisakiasis With Dysphagia

Anisakiasis is a zoonotic parasitic infection associated with consumption of raw fish or uncooked seafood. We report a rare case of suspected esophageal anisakiasis-induced dysphagia. A 66-year-old man patient without any medical history was admitted to our hospital for evaluation of acute dysphagia. Following intake of abalone sashimi for dinner, he experienced sudden difficulty with swallowing the day before his emergency department visit. He developed skin rash and pruritus throughout his body, shortly thereafter. He also had chest and upper abdominal pain and diarrhea. He had experienced similar symptoms after consumption of raw fish on two previous occasions. Dysphagia improved 9 days later. Gastroscopy performed after symptom onset showed small erosions and edematous mucosa in the mid esophagus. Abdominopelvic computed tomography (CT) showed distal esophageal wall thickening and small bowel obstruction with concomitant ascites. We suspected anisakiasis based on the following criteria: 1) Skin rash after the third episode of consumption of raw fish or seafood (anisakiasisspecific immunoglobulin E class 4). 2) CT-documented small intestinal obstruction and ascites. 3) Eosinophil-dominant fluid observed on ascitic fluid analysis. Therefore, it is reasonable to conclude that temporary dysphagia in this patient was attributable to esophageal anisakiasis associated with raw seafood consumption.

The Usefulness of Magnetic Resonance Imaging in the Management of Acute Phlegmonous Esophagitis.

Acute phlegmonous esophagitis is a rare life-threatening disease that often requires surgical intervention in case of complications, including esophageal abscess, perforation, or mediastinitis. We present a case of acute phlegmonous esophagitis, in which magnetic resonance imaging (MRI) proved useful in planning the treatment strategy. An 89-year-old woman was admitted to the emergency department with painful swallowing and respiratory distress. She was diagnosed with acute phlegmonous esophagitis and a hypopharyngeal abscess based on computed tomography (CT) findings. However, there was a discrepancy between the clinical course and CT findings. Given the improvement of the patient's condition with conservative treatment with ampicillin/sulbactam, the CT findings suggested an apparent abscess due to increased esophageal wall thickness. However, MR diffusion-weighted images showed a slightly high-intensity signal, suggesting that the enlargement was due to edema rather than an abscess. The patient recovered successfully following conservative treatment. Thus, our findings demonstrate the utility of MRI in the treatment planning of acute phlegmonous esophagitis, especially in cases with unreliable contrast-enhanced CT findings. However, future studies are warranted to explore the utility of MRI in the management of such cases.

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults

Objectives Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery. Methods A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated. Results Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47–100%, and 54–100%, which increased to 53–100%, and 60–100%, respectively, when considering only radiologists’ reinterpretations. Conclusions In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

Increase in distal esophageal wall thickness with time in adult patients with eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic disease which may progress to a fibro-stenotic phenotype due to esophageal sub-epithelial fibrosis. Esophageal wall thickening in patients with EoE has been demonstrated in a few studies using endoscopic ultrasound (EUS). The aim of this study was to longitudinally assess the endoscopic appearance, wall thickness, histology, and dysphagia score of EoE patients. Patients with EoE were recruited and studied between February 2012 and April 2021. Patients were evaluated on two separate occasions at least 12 months apart with endoscopy, EUS, and esophageal mucosal biopsies. The dysphagia score and epidemiology data were also assessed. A total of 16 EoE patients were included with a mean follow-up duration of 2.2 ± 1.2 years. In 14/16 (88%) patients, the total wall thickness of the distal esophagus significantly increased (P=0.0012) as a result of thickening of the muscularis propria (P=0.0218). However, only 1/14 (7%) patient had an increase in the dysphagia score, while 8/14 (57%) and 5/14 (36%) had a stable and reduced dysphagia score, respectively. No differences were found in the total thickness of other esophageal regions, dysphagia score, endoscopic appearance, and eosinophil count over time. Distal esophageal wall thickness increases with time in EoE patients, independent of the dysphagia score and eosinophil count.

Oesophageal wall thickness assessment at endoscopic ultrasound in children and adolescents with eosinophilic oesophagitis: a case-control study.

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disease, and an endosonographic evaluation may help the diagnosis. The main objectives of this study were to measure the thickness of the oesophageal wall using a radial endoscopic ultrasound (EUS), mucosa/submucosa (MSM), muscularis propria (MP) and mucosa to muscularis propria (MMP); to compare these measurements between patients with and without EoE; to correlate them with the Endoscopic Reference Score (EREFS); and to evaluate the diagnostic accuracy of these measurements. Children and adolescents (aging from 4 to 17years) were evaluated in this prospective cross-sectional study. A radial EUS at 12MHz frequency was used, and EREFS was employed to grade macroscopic findings. Accuracy of the measurements for the diagnosis of EoE was assessed by receiver operating characteristics (ROC) curve. Twenty-six (19M/7 F) patients (median age 10.83years, range 5.65-17.46) were evaluated. EoE was diagnosed in 6 patients. The mean (and SD) oesophageal wall thicknesses in the distal oesophagus in millimetres in groups with and without EoE, respectively, were: MSM 1.07 (0.44) and 1.11 (0.33); MP 0.67 (0.25) and 0.60 (0.19); and MMP 1.73 (0.46) and 1.72 (0.32). Mid-oesophagus: MSM 1.16 (0.34) and 1.15 (0.34); MP 0.63 (0.16) and 0.60 (0.2); and MMP 1.79 (0.41) and 1.74 (0.34). In the ROC curve, the distal MP layer thickness presented better discriminative performance, with an area under the curve of 0.61 (95% CI 0.28-0.93) at 0.73mm cut-off (66.67% sensitivity, 80% specificity, likelihood ratios of 3.33 for positive and 0.42 for negative test). The evaluation of oesophageal thickness measurements by EUS is not useful for diagnosing EoE.

An Unusual Case of Significant Cervical Esophageal Stricture

Question: A 65-year-old man was referred to our facility for solid-food dysphagia without other disease history. He lived a happy and healthy life without abuse of alcohol or tobacco. The symptom started about 2 years before, without accompanying heartburn and regurgitation, and did not progress significantly. A stricture at the upper orifice of the esophagus was found (Figure A) and hampered the routine endoscopic examination (GIF-Q260; Olympus). Instead, an ultrathin endoscope (GIF-XP290N; Olympus) was used, which revealed a well demarcated translucent white scaly lesion with shaggy surface distributed in a two-thirds circumferential arrangement from 15 cm to 25 cm of the esophagus distal to the incisors (Figure B, Video A). Narrow-band imaging endoscopy showed a distinct white irregular map-like area (Figure C, Video A). Computer tomography (CT) did not show any neck mass or thickness of the cervical esophageal wall (Figure D). Multiple biopsies were obtained from the proximal esophagus. No malignancy was confirmed pathologically (Figure E).

Chronic Inflammatory Changes In Esophageal Mucosa of Albino Rats Following Prolonged Intake of Carbonated Drinks.

Abstract&#x0D; Background: Carbonated beverages include soft drinks or sodas which contain carbondioxide and that when ingested for prolonged period of time lowers the intra-esophageal pH and can lead to histopathological changes in the mucosa.&#x0D; Objective: To study the effects of prolonged intake of carbonated drinks on the oesophagus of albino rats.&#x0D; Method: This experimental study was carried out at Shaheed Mohtarma Benazir Bhutto Medical College for a period of six months. Seventy five rats of wistar strain (gender non specific) were divided into ‘control groups ‘A1 n=10, A2 n=10, A3 n=10 &amp; ‘exposed groups’ B n=15, C n=15 and D n=15.The controls and the exposed animals were fed the same balanced diet, prepared at the lab’s kitchen. The fluid intake of exposed animals was restricted to carbonated drinks only, whereas, the controls were fed water.At the end of the first, third and sixth months, groups A1&amp;B, A2&amp;C and A3&amp;D were sacrificed and histological section of oesophagus were obtained for histomorphological studies.&#x0D; Results:&#x0D; On micrometry, width of the oesophagus of the exposed animals for one month;Group B was higher (17.87) than those of Group A1 (5.70). Those rats sacrificed at the end of the third month; Group C had significantly enlarged wall thickness of the oesophagus compared to A2 group. The average oesophageal wall thickness 13.60?m was found to be more in the exposed group ‘D’, as compared to 4.50?m measured in Control Group A3 (p&lt;0.01).&#x0D; Conclusion: Prolonged consumption of carbonated drinks resulted in gross and histomorphological changes in the esophageal mucosa. The results of this research will help provide awareness to the general public of the adverse effects afflicted by these beverages.&#x0D;

Esophageal stenosis as an independent factor of poor prognosis in patients with ESCC treated with definitive chemoradiotherapy.

Aim: To evaluate the clinical outcome and elucidate the prognostic factors in patients with esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiotherapy (CRT). Patients: Data for patients newly diagnosed with ESCC receiving definitive CRT at our institution between 2012 and2018 were retrospectively reviewed. Results: A total of201 patients were included. Severe stenosis after radiotherapy was an independent factor relevant to prognosis. Maximal esophageal wall thickness, short-term responses, severe stenosis at diagnosisand a high neutrophil-to-lymphocyte ratio were independent risk factors for the occurrence of severe stenosis after radiotherapy. Conclusion: Severe stenosis after radiotherapy is a useful predictive indicator in patients with ESCC receiving definitive CRT. Further studies are needed to verify these findings.

Evaluating Neoadjuvant Chemotherapy for Lower Esophageal Squamous Cell Carcinoma by Measuring Esophageal Wall Thickness.

The aim of this study was to evaluate the efficacy of preoperative chemotherapy for stage II-III esophageal squamous cell carcinoma based on an objective computed tomography method. A total of 82 patients who underwent preoperative chemotherapy followed by surgery for advanced esophageal squamous cell carcinoma from January 2006 to June 2019 were included. Treatment effect was evaluated by measuring the esophageal wall thickness before and after neoadjuvant chemotherapy using contrast-enhanced thoracoabdominal computed tomography. The percentage decrease in esophageal wall thickness was calculated using the following formula: reduction (%)=(wall thickness before preoperative chemotherapy - wall thickness after preoperative chemotherapy)/(wall thickness before preoperative chemotherapy)×100. We demonstrated the efficacy of this measurement method and then analyzed which patient factors might affect the treatment effect. Receiver operating characteristic analysis showed the percentage tumor reduction to be a good predictor of histological therapeutic effect (grade ≥2) (area under the curve=0.727). In the multivariate analysis, tumor location (lower versus upper esophagus) was identified as an independent factor associated with tumor reduction (odds ratio=0.15; 95% confidence interval=0.03-0.79; p=0.025). We demonstrated an association between the reduction of esophageal wall thickness in the tumoral area and the histological therapeutic effect of chemotherapy. Secondary analysis showed poorer tumor reduction in patients with lower esophageal cancer than in those with upper esophageal cancer.

Change in Density Not Size of Esophageal Adenocarcinoma During Neoadjuvant Chemotherapy Is Associated with Improved Survival Outcomes

BackgroundChanges in the size and density of esophageal malignancy during neoadjuvant chemotherapy (NCT) may be useful in predicting overall survival (OS). The aim of this study was to explore this relationship in patients with adenocarcinoma. MethodsA retrospective single-centre cohort study was performed. Consecutive patients with esophageal adenocarcinoma who received NCT followed by en bloc resection with curative intent were identified. Pre- and post-NCT computed tomography scans were reviewed. The percentage difference between the greatest tumor diameter, esophageal wall thickness and tumor density was calculated. Multivariate Cox regression analysis identified variables independently associated with OS. A ROC analysis was performed on radiological markers to identify optimal cut-off points with Kaplan–Meier plots subsequently created. ResultsOf the 167 identified, 88 (51.5%) had disease of the gastro-esophageal junction and 149 (89.2%) were clinical T3. In total, 122 (73.1%) had node-positive disease. Increased tumor density (HR 1.01 per % change, 95% CI 1.00–1.02, p = 0.007), lymphovascular invasion (HR 3.23, 95% CI 1.34–7.52, p = 0.006) and perineural invasion (HR 2.51, 95% CI 1.03–6.08, p = 0.048) were independently associated with a decrease in OS. Patients who had a decrease in their tumor density during the time they received NCT of ≥ 20% in Hounsfield units had significantly longer OS than those who did not (75.5 months versus 34.4 months, 95% CI 38.83–105.13/18.63–35.07, p = 0.025). ConclusionsInterval changes in the density, not size, of esophageal adenocarcinoma during the time that NCT are independently associated with OS.

S2415 A Common Procedure Leads to the Diagnosis of an Uncommon Cause of Dysphagia

Introduction: Epithelioid angiosarcoma is a rare and aggressive soft-tissue endothelial cell neoplasm that accounts for less than 1% of sarcomas and rarely occurs in the gastrointestinal tract. We report a case of a 41-year-old female without prior medical history who presented with progressive dysphagia and unintentional weight loss. Case Description/Methods: Initial upper endoscopy found to have a narrowed gastroesophageal junction (GEJ) that required balloon dilation to 10mm and the use of a pediatric upper endoscope to traverse. Only thickened gastric folds at the cardia were seen, which were biopsied. Histology revealed chronic active moderate gastritis with Helicobacter pylori and patient was treated with triple therapy. However, due to ongoing dysphagia a contrast enhanced computed tomography (CT) of the chest was obtained and demonstrated thickening of the distal esophageal wall. Next, an endoscopic ultrasound (EUS) was performed and demonstrated unusual thickening of the distal esophageal wall. Fine needle biopsy (FNB) revealed high-grade esophageal epithelioid angiosarcoma of the distal esophagus. She was treated with neoadjuvant chemo- and radiotherapy followed by a robotic laparoscopic Ivor Lewis esophagectomy. The patient has been disease free after 1 month of follow up (Figure). Discussion: This case highlights the importance of timely recognition and diagnosis of dysphagia caused by pseudo-obstruction. Timely CT and EUS/FNB should be performed to evaluate for less common entities.Figure 1.: Case image.

S2358 Black Esophagus: A Case of Acute Esophageal Necrosis Secondary to Binge Drinking

Introduction: Acute esophageal necrosis (AEN) is a rare, potentially life threating and under-diagnosed syndrome that presents most commonly with upper GI bleeding, hematemesis, and abdominal pain. Here we present a case of an otherwise healthy, middle-aged man with coffee ground emesis who had classic findings of black, necrotic, ulcerative esophageal mucosa on esophagogastroduodenoscopy (EGD) after presenting in the setting of binge drinking. Case Description/Methods: A 47-year-old man with a history of alcohol use disorder presented to the hospital with multiple episodes of coffee ground emesis and epigastric pain. He recently restarted drinking alcohol. He denied any blood thinner use. He was hypertensive and tachycardic on arrival. His physical exam was overall non focal. His relevant lab work included a BUN 24, lactate of 8.3, lipase 11, Hgb 14.5 g/dL; AST, ALT, platelets, and INR were all normal. The patient was treated with IV fluids and started on a PPI drip. A CT scan of the abdomen/pelvis was performed and it was remarkable for nonspecific wall thickening of the thoracic esophagus. The GI service was consulted and an EGD was performed showing a 4 cm hiatal hernia and black mucosal necrosis in the mid and distal esophagus (Figure). The patient was made NPO, continued PPI therapy, and cardiothoracic surgery (CTS) was consulted. After gradual symptomatic improvement, he was discharged on lansoprazole, sucralfate, and morphine. He was maintained on a clear liquid diet until outpatient follow up with CTS, at which point his diet was gradually advanced without complications. Discussion: AEN is a rare condition with an incidence of 0.01-0.28% of patients undergoing EGD. The pathophysiology is usually multifactorial due to ischemic injury, gastric acid exposure and impaired mucosal repair mechanisms. Multiple medical comorbidities such as diabetes, hypotension, and alcohol abuse have been associated with an increased risk of developing AEN. In our case, binge drinking, and emesis likely contributed to AEN in an otherwise healthy patient. Management is largely supportive with hydration and acid suppression but can include surgery or balloon dilation if the course is complicated by perforation or stricture formation. Prompt performance of an EGD with timely referral to CTS is recommended for risk stratification and to guide follow up management. Repeat EGD is warranted after a month to document healing.Figure 1.: Esophagogastroduodenoscopy of the mid and distal esophagus.

S2449 A Unique Case of Simultaneous Anal Squamous Cell Carcinoma and Esophageal Squamous Cell Carcinoma

Introduction: Anal cancer (AC) is uncommon and comprises only 3% of all digestive system malignancies. It is associated with HPV, tobacco use, and HIV. Esophageal cancer (EC) is the 8th most common cancer and 6th most common cause of death worldwide. Among other associations, HPV and tobacco use has been strongly linked to development of esophageal SCC. Though they have similar risk factors, the literature is limited when it comes to cases of simultaneous anal SCC and esophageal SCC. Case Description/Methods: A 50-year-old male with history of tobacco use presented with dysphagia, dyspnea, and weight loss. His symptoms were progressive with 20 lbs. of weight loss in 3 months. He initially had solid food dysphagia which progressed to liquids and constant regurgitation of food. His cough and dyspnea were acute and worsened 1 week prior to his presentation. He endorsed a bulging growth around his anus that grew over several months. He was found to have a left lower lobe necrotizing pneumonia (NP) on CT scan as well as thickening of the esophagus with liver lesions suspicious for metastatic disease. Labs showed leukocytosis, macrocytic anemia, and a mild transaminitis. He was tested for tuberculosis and HIV which was negative. He underwent an EGD which showed a large, friable, fungating esophageal mass whose biopsies showed SCC. For his anal lesion, he underwent an excisional biopsy which was positive for SCC as well. The patient was treated with antibiotics for his NP with a plan of 6 weeks of therapy followed by repeat imaging to determine if any surgical interventions would be needed. Oncology planned for palliative chemoimmunotherapy once his NP resolved. To improve his dysphagia, a palliative esophageal stent was placed (Figure). Discussion: This patient had both a primary anal SCC and esophageal SCC with his only risk factor being tobacco use. Though both AC and EC commonly metastasizes to the liver, EC is more likely to metastasize. For esophageal SCC, local lymph node invasion typically occurs early since the lymphatics are in the lamina propria rather than beneath the muscularis mucosa. In this case, the patient presented with a NP and though no definitive fistula was noted on imaging, local invasion of esophageal SCC can present with fistulizing disease. Unfortunately, Stage 4 esophageal SCC is incurable though systemic therapies may provide a palliative effect and survival benefit. In this case, an endoscopic esophageal stent was placed for palliation of his dysphagia while awaiting chemoimmunotherapy.Figure 1.: Image A demonstrates the CT scan finding of esophageal wall thickening. Image B is the EGD finding of a large, friable, fungating, circumferential esophageal mass. Image C shows the successful placement of an esophageal stent for palliative treatment of the patient’s dysphagia.

Diagnostic Value of Ultrasound Findings in Eosinophilic Esophagitis Versus Gastroesophageal Reflux Disease in Children

Background: Eosinophilic esophagitis (EoE) is a disease involving the esophagus due to an immune system reaction and has clinical symptoms similar to gastroesophageal reflux disease (GERD). Currently, the only definitive way to diagnose this disease is the endoscopy and biopsy of the esophageal tissue. Objectives: In this study, we investigated the diagnostic value of ultrasound to differentiate EoE from GERD and normal patterns. In addition, we assessed the possibility of replacing ultrasound with an invasive endoscopic method for the diagnosis and follow-up of EoE. Methods: This cross-sectional study was conducted on 4-12-year-old children in three groups of definitely diagnosed GERD, EoE, and healthy controls. Each group consisted of 30 participants who were evaluated for ultrasound parameters. The obtained values were compared between groups. The sensitivity and specificity of ultrasound findings were determined by receiver operating characteristic curve analysis. Results: Ultrasound findings, including wall thickness and distensibility of the cervical and abdominal esophagus, gastric wall thickness, and cervical esophagus diameter had significant differences between the three groups. The EoE group had the highest mean ± SD abdominal esophageal wall thickness of 2.73 ± 0.66 mm, gastric wall thickness of 4.30 ± 0.79 mm, and cervical esophageal wall thickness of 2.32 ± 1.21 mm. The GERD group had the lowest mean ± SD cervical esophagus diameter and distensibility of the abdominal esophagus. On the other hand, this group had the highest mean distensibility of the cervical esophagus. The highest area under the curve (AUC) for discriminating EoE from controls were 0.83 and 0.80 for gastric wall thickness and abdominal esophageal wall thickness, respectively. Moreover, the highest AUCs for discriminating EoE from GERD were 0.80 and 0.71 for gastric wall thickness and cervical esophageal wall thickness, respectively. Conclusions: Although the mean of ultrasound findings in the EoE group was significantly different from the control and GERD group, the ability to discriminate EoE from the control and GERD groups was moderate (0.70

Selection of dilution material for non-iodinated iodine as an oral contrast agent for esophageal cancer: a preliminary clinical trial

PurposeTo investigate the filling state of the esophagus using different oral contrast agents for the diagnosis of esophageal cancer by computed tomography (CT).Materials and methodsThis preliminary clinical trial enrolled patients with suspected esophageal carcinoma and admitted from January 2015 to January 2018. The patients were randomized into the yogurt (mixed with ioversol), lotus root powder (mixed with ioversol), gas-producing powder, and control (pure iodine water) groups. Chest CT examinations were performed. The degree of esophageal filling and the detection of esophageal lesions were compared.ResultsFinally, 136 participants were enrolled (n = 34/group). There were no significant differences in esophageal filling degree among the yogurt, lotus root powder, and gas-producing powder groups (P = 0.093). There were 30/3/1 and 30/3/1 confirmed/false-negative/false-positive diagnoses in the yogurt and lotus powder groups, respectively, compared with 28/5/1 and 25/8/1 in the gas-producing powder and control groups, respectively. The concordance rates were the highest for the yogurt (88.2%, with 91.7% specificity and 86.4% sensitivity) and lotus root powder groups (88.2%, with 92.3% specificity and 85.7% sensitivity) and the lowest for the control group (73.5%, with 90.0% specificity and 66.7% sensitivity).ConclusionYogurt mixed with ioversol could fill and expand the esophagus with minimal preparation, displaying the structure of the esophageal lumen and wall thickness. This mixture might be used as a positive contrast agent for esophageal CT. Similar results were observed for the lotus root powder mixed with ioversol, but its preparation was more arduous.