History Of Gastroesophageal Reflux Disease Research Articles

Hiatal hernia, lower esophageal sphincter and their combined effect on the natural history of gastroesophageal reflux disease: implications for surgical therapy

: The modern surgical therapy of gastroesophageal reflux disease (GERD) is based upon the concept that the antireflux barrier has two components that form a “double-sphincter” and work synergistically to protect from reflux of gastroduodenal contents: the lower esophageal sphincter (LES) and the crural diaphragm. Factors implicated in the pathogenesis of hiatal hernia (HH) are the thoraco-abdominal pressure gradient, the esophageal shortening secondary to reflux-induced fibrosis, and the hiatal enlargement due to peri-esophageal tissue deterioration. Genetic and biologic factors can predispose to HH formation through alterations in extracellular matrix protein metabolism, and through structural changes of the muscular crura, central tendon, and phreno-esophageal ligament. This will eventually result in loss of tensile strength and/or loss of recoil ability of elastic fibers. Failure of LES or the crural diaphragm or both contribute to progression of GERD and development of complications such as Barrett’s esophagus and esophageal adenocarcinoma. Patients’ selection for antireflux surgery is critical for optimal outcomes. While laparoscopic cruroplasty and Toupet or Nissen fundoplication remain the current gold standard in antireflux surgery, the high rates of anatomical and clinical recurrence in patients with large hiatus hernia still represent a matter of concern. To reduce recurrence rates after surgical repair, it is clear that both axial and radial tension at the esophago-gastric junction (EGJ) must be minimized. This has led to an increasing interest for the use of prosthetic mesh to reinforce the esophageal hiatus. Recognition of anatomical and functional abnormalities at an early disease-stage is critical to prevent complications and to provide the most appropriate surgical therapy and the best clinical outcomes.

S3707 Pancreatic Acinar Metaplasia at the Gastroesophageal Junction in a Patient With Chronic Reflux

Introduction: Pancreatic acinar metaplasia (PAM) is defined as pancreatic glandular tissue forming acini outside of the pancreas. Recent studies have shown a possible association between chronic use of proton pump inhibitors (PPIs) and nonsteroidal anti-inflammatory drugs (NSAIDs). Here, we present a case of PAM in a patient with chronic reflux on PPIs without a history of NSAID use. Case Description/Methods: A 41-year-old female with a longstanding history of gastroesophageal reflux disease (GERD) presented to clinic for evaluation of chronic reflux. The patient reported having symptoms of reflux for over 20 years. Over this time, she trialed multiple medications such as PPIs and antacids, but denied the use of NSAIDs. She also underwent multiple esophagogastroduodenoscopies (EGDs) for evaluation of her reflux, the last being 5 years ago, which showed mild gastric erythema but was otherwise unremarkable. Due to persistent symptoms despite medical management, she was scheduled for repeat EGD. EGD showed salmon-colored mucosa and gastric erythema. Pathology from esophagus biopsies revealed junctional mucosa with focal pancreatic acinar metaplasia (PAM). The patient was transitioned to Dexlansoprazole for symptomatic management and was scheduled for repeat EGD in 1 year for surveillance of PAM. Discussion: Pancreatic acinar metaplasia (PAM) is a term used to describe pancreatic glandular tissue organized in nests found outside of the pancreas. It is most commonly found in the gastric antrum, but can be found elsewhere in the gastrointestinal tract such as at the gastroesophageal junction (GEJ). While endoscopic findings of PAM differ, one study showed that the most commonly found appearance is salmon-colored mucosa. PAM is diagnosed histologically by pancreatic acinar-like cells that have a prominent cytoplasm with eosinophilic apical areas and basophilic basal areas. The exact pathogenesis of PAM is unknown; studies have shown that PAM may be associated with chronic NSAID or PPI use. While our patient used PPIs for years, she denies a history of NSAID usage. Another study by Schneider et al. showed that there was no association between PAM and reflux or gastritis, suggesting that PAM be have a congenital component. Further research is needed to determine the etiology of PAM. It can be found in patients with Barrett’s esophagus and may be associated with Helicobacter pylori. Therefore, it is important that these patients undergo routine surveillance.

S3474 Symptomatic Cholelithiasis in the Setting of Porcelain Gallbladder and SARS-CoV-2 (COVID-19) Infection

Introduction: Porcelain gallbladder, a rare entity with female preponderance, is a manifestation of chronic inflammation of the gallbladder. It is an incidental finding characterized by calcification of the gallbladder wall on imaging studies. The affinity of SARS-CoV-2 for angiotensin converting enzyme 2 (ACE2) which is widely expressed in the lungs, heart, intestines, gallbladder, kidneys, and adipose tissue may account for its ability to accentuate indolent inflammation in the gastrointestinal tract. Case Description/Methods: 56 year old African American female with medical history of gastroesophageal reflux disease, obesity and hypertension presented with a 3 day history of fever, shortness of breath, cough and sudden onset intermittent, burning epigastric and right upper quadrant (RUQ) pain with no aggravating or relieving factors. Vital signs at presentation; Temperature 100.8 F, Respiratory rate 20 breaths/ minute, pulse of 89beats/min, oxygen saturation 97% on room air and blood pressure 147/105mmHg. Physical examination findings were reduced air entry at the lower lung zones bilaterally and moderate epigastric and RUQ tenderness. She was positive for SARS-CoV-2 RNA. Chest X-ray showed large bilateral lower lobe atelectasis and increased interstitial process in the lower lung fields. She was admitted for COVID pneumonia. On admission day 1 patient continued to complain of RUQ pain, warranting RUQ ultrasound scan which showed prominent gallbladder calculus with posterior shadowing, likely porcelain gallbladder in the setting of existing gallstones. Patient was managed with vitamins, ceftriaxone, azithromycin, remdesivir, famotidine and tylenol for pain. Abdominal pain improved and she was discharged home on day 3 of hospitalization for outpatient follow up. Discussion: Our patient presented with symptomatic cholelithiasis, in the setting of COVID infection and porcelain gallbladder. We believe this finding bolsters the assertion that COVID infection accentuates gallbladder inflammation which consequently leads to precipitation/ worsening of symptoms of underlying chronic gall bladder disease. In light of the aforementioned, we believe the diagnostic challenge is the ability to make a clear distinction between de novo inflammation of the gallbladder and accentuation of an ongoing chronic inflammatory process. Given that there is a risk of porcelain gallbladder progressing to gallbladder cancer, should routine surveillance be performed in this population of patients?

S2066 Actinomyces Esophagitis Presenting as Esophageal Mass

Introduction: Actinomyces is a gram-positive, facultatively anaerobic genus of the Actinobacteria class of bacteria. Actinobacteria are residential microbial flora of the oropharynx, gastrointestinal tract, and genitourinary tract. Actinomycetes esophagitis is a rare infectious process reported mostly in immunocompromised patients; literature sources reveal approximately 24 cases reported to date in 2015. We discuss a 92-year-old female in the hopes of providing more information regarding this infectious process. Case Description/Methods: A 92-year-old female with a history of gastroesophageal reflux disease presented to the emergency department with three weeks of progressive dysphagia. The patient stated initial dysphagia was to solids, and subsequently progressed to difficulty in swallowing liquids and pills. CT of neck and soft tissues was performed that noted transfacial mass involving the left thyroid gland and esophagus, estimated to measure 6 × 4 × 4.8 cm. The mass involved the posterior tracheal wall with mild extension into the lumen and was noted to arise from or invade the cervical esophagus with occlusion or near occlusion. Due to worsening of her symptoms, dehydration, and weight loss, the patient was admitted and the gastroenterology team was consulted for evaluation. The patient underwent esophagogastroduodenoscopy (EGD) which revealed no true esophageal mass, but rather abnormal tissue at the site of stricture which was noted to be invasion by tumor or irritation due to compression; the esophagus appeared normal after the area of stricture, and biopsies were taken of the site. Pathology results noted ulcerative esophagitis and bacterial organism clusters with Actinomyces. Infectious disease was consulted and the patient was initiated on 3 million units q4hr IV penicillin G, with plan of repeat EGD in the outpatient setting. Discussion: There have been multiple different causes of infectious esophagitis recorded, with actinomyces being one of the rarest. Presenting symptoms are usually nonspecific and entail odynophagia and dysphagia, with imaging and EGD often mimicking malignancy. The findings on imaging studies are consistent with the predisposition of actinomycosis to spread through tissue planes. Overall, our case highlights the importance of carefully evaluating endoscopy and pathologic examination in patients who present with odynophagia and dysphagia.Figure 1.: CT abdomen and pelvis w contrast.

S2153 A Case of Proton Pump Inhibitor Causing Systemic Drug-Induced Lupus

Introduction: Drug induced lupus erythematosus (DILE) is a well documented autoimmune phenomenon that can be triggered by exposure to certain medications. Presented here is a case of systemic drug induced lupus erythematosus from a proton pump inhibitor (PPI), which represents a fairly uncommon reaction to this medication. Case Description/Methods: A 63 year old female with history of gastroesophageal reflux disease (GERD) presented to clinic complaining of typical heartburn pain and globus sensation for which she was prescribed pantoprazole. After 2 weeks of daily use, she developed pain and swelling of bilateral metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, photosensitive malar rash, patchy alopecia, ‘gnawing’ diffuse abdominal pain (different than GERD symptoms), and oral ulcers. Her pantoprazole was stopped, and 2 weeks later her symptoms resolved. Review of the her medical record revealed that she had prior exposure to 2 other PPI's in the past that both were associated with development of similar symptoms. Use of omeprazole caused pain and swelling of her right MCP joints, and several years later use of esomeprazole caused severe pain and swelling of the left elbow. In both cases, discontinuation of her PPI caused resolution of symptoms. Her labs were notable for positive anti histone antibody and negative ANA, dsDNA, RF, anti CCP. Discussion: DILE has three basic variants; systemic, subacute cutaneous, and chronic cutaneous. The type of drug induced lupus and severity of symptoms is strongly associated with the specific drug of exposure. PPI's are most associated with subacute cutaneous DILE, although this remains an overall rare adverse reaction. Subacute cutaneous DILE presents with formation of annular or papulosquamous skin lesions and mild (if any) systemic symptoms. Our case is more consistent with systemic DILE. Review of literature reveals few case reports of systemic DILE from PPI use. Systemic DILE presents with multi-system involvement with constitutional symptoms, myalgias, arthralgias, and serositis. Symptoms resolve with withdrawal of the agent. The case above clearly demonstrates this illness script through multiple exposures to PPI. Classic SLE is ruled out in this case due to this temporal relationship with drug exposure, as well as her antibody profile positive for anti-histone and negative for other SLE-associated antibodies. This case highlights the importance of considering atypical drug reactions, even when prescribing relatively common medications.

S3547 Lymphocytic Esophagitis: An Unlikely Mimicker of Gastroesophageal Reflux Disease in the COVID-19 Era

Introduction: Lymphocytic esophagitis (LE) is a recently-recognized disease entity characterized by peripapillary chronic inflammation with an endoscopic appearance resembling Eosinophilic esophagitis (EoE). The condition is characterized by esophageal intraepithelial lymphocytosis accompanied by low granulocyte count and spongiosis. Rarely observed in clinical patients, testing for LE is seldom performed and its pathology remains poorly-understood. We present a case report of a patient with prior normal endoscopic appearance who developed severe LE 6 months post SARS-CoV-2 (COVID-19) infection. Additionally, the goal of this case report is to contribute to the limited information about LE with regards to symptoms, signs and endoscopic appearance. Case Description/Methods: A 60-year-old African American gentleman with a history of gastroesophageal reflux disease (GERD), well managed on pantoprazole 40 mg once daily for 3 years who presented with worsening reflux symptoms and regurgitation six months post SARS-CoV-2 infection. He did not have severe respiratory illness secondary to COVID-19 infection. An Esophagogastroduodenoscopy (EGD) was performed, and revealed longitudinal furrowing and white plaque throughout the esophagus suggestive of EoE. These results differed from the normal EGD performed 2 years prior. Esophageal pathology from the mid and distal esophagus displayed lymphocytosis coupled with decreased neutrophil and eosinophil counts consistent with severe lymphocytic esophagitis. Spongiosis was also observed and no fungal components or malignancies were reported. Patient was advised to increase proton pump inhibitors (PPI) twice daily for treatment, and symptoms continue to be monitored. Discussion: LE is a rare disease with limited available knowledge. While the patient’s older age aligns with the established range for this condition, his race and sex deviate from the white, female demographic predominantly associated with LE. We raise the possibility of COVID-19 triggering manifestation of lymphocytic infiltration in the esophagus causing GI symptoms in this patient. The symptoms for this occurrence remained subtle and were confined to the patient’s complaints of heartburn. SARS-CoV-2 changed how we practice medicine in many ways. This case highlights the need to be more vigilant and keep LE in the differential diagnosis even for common diseases like GERD. Our patient did well by increasing PPI to twice daily for two months in this setting.Figure 1.: A. Pre-COVID-19 EGD showing normal Esophagus B & C. Post-COVID-19 EGD showing longitudinal furrows & microabscesses D, E, & F. Post-COVID-19 pathology showing lymphocytic infiltration and spongiosis throughout.

S3685 A Case of Duodenal Polyposis

Introduction: Duodenal polyps can be sporadic or associated with genetic conditions. Only a small percentage of duodenal polyps have malignant potential (Table). Hyperplastic polyps are often found in the colon but have rarely been described in the duodenum. Here, we present a case of numerous hyperplastic polyps found in the duodenum. Case Description/Methods: A 72-year-old male with a history of gastroesophageal reflux disease (GERD), colonic adenomas, and a family history of colon cancer presented with difficulty swallowing. He underwent laryngoscopy which was negative. He then underwent esophagoduodenoscopy (EGD). Numerous sessile polyps (2-15mm) were seen and biopsied in the second portion of the duodenum (Figure 1a). Pathology showed hyperplastic polyps (Figures 1b and 1c). We advised the patient undergo a repeat EGD in six months for surveillance given the number of polyps, and capsule endoscopy was also discussed to assess for polyps further along the small intestine. Discussion: The prevalence of duodenal mucosal tumors is estimated to be 4.6%. Non-neoplastic polyps include inflammatory polyps, Brunner’s gland hyperplasia, hyperplastic polyps, ectopic pancreatic mucosa, and hamartomatous polyps. Neoplastic polyps include adenomas, gastrointestinal stromal tumor (GIST), Brunner’s gland adenoma, carcinoid tumor, leiomyoma, lipoma, schwannoma, and serrated adenoma. Duodenal polyps may be associated with genetic disorders or inflammation, but most are sporadic. Less than 20 cases of duodenal hyperplastic polyps (HPs) have been described. Histology shows crypt serration with mucinous glands and goblet cells without cytologic atypia. Three types of HPs include microvesicular (most common), goblet-cell, and mucin-poor. Immunostaining shows patterns similar to colonic HPs. HPs (both colonic or duodenal) have been shown to have BRAF mutations in 75% of cases and KRAS mutations in 10%, and the proportion of each mutation depends greatly on location of the HP. Some case reports suggest HPs could be associated with inflammation, including one showing resolution of a duodenal HP after Helicobacter pylori (H. pylori) was eradicated. Many cases show associations with gastritis, peptic ulcer disease, and duodenitis as well. Duodenal HPs are not well characterized given their rarity and are likely benign lesions. At this time, patients with duodenal HPs should have follow up surveillance on a case-by-case basis considering family history, size and number of polyps, comorbidities, and associated symptoms.Figure 1:: Sessile duodenal polyps (2-15mm) (1A). Duodenal mucosa with slightly dilated crypts demonstrating a serrated or star shaped pattern with no cytologic atypia (Black arrows, H & E, 200x) (1B). Additional finding of a duodenal villous demonstrating an abrupt transition of the epithelium from normal epithelium on the left to a foveolar metaplastic epithelium on the right (H & E, 400x) (1C).Table 1:: Types of duodenal polyps, both non-neoplastic and neoplastic

DELAYED DIAGNOSIS OF COCCIDIODES IMMITIS INFECTION WITH PULMONARY ABSCESS AND ARDS DIAGNOSED IN CHICAGO

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Coccidiodes immitis is a highly pathogenic fungus that is found in western and southern California's desert's regions. It frequently presents as a pneumonia that does not get better after anti-biotic therapy. With less than 5% of immunocompetent patient's progressing to have disseminated or severe infections (1). A disseminated Coccididiodes infection can be treated with liposomal amphotericin B, fluconazole, and steroids when there is Acute Respiratory Distress Syndrome (ARDS) (1,2). CASE PRESENTATION: In this case, a relatively healthy 80-year-old male with a past medical history of gastroesophageal reflux disease, hypertension, and hyperlipidemia who comes in shortness of breath, cough, and congestion. He had completed a course of azithromycin without resolution of symptoms. His initial chest x-ray showed a right upper lobe consolidation (Figure 1a). Bronchoscopy with transbronchial biopsies was performed which showed an acute organizing pneumonia (Figure 2). Despite antibiotic therapy and steroids, the patient did not have significant clinical improvement. So liposomal amphotericin B was started. An open lung biopsy was performed on day 14 as his chest X-ray was significantly worse with significant hypoxia (Figure 1b). Open lung biopsy showed a large abscess. A chest tube was placed. The abscess was irrigated with saline containing antibiotics. Pathology reported numerous coccidiodes spores (Figure 3). Antibiotics were discontinued. The patient's hospital course was complicated by a persistent air leak post lung biopsy and ARDS. Adjunctive steroids were added with improvement of his hypoxia. The patient was transitioned to a lower dose of steroids and to high dose fluconazole for long term treatment of his Coccidiodes infection. He was stable for placement of a tracheostomy and discharged to a long term acute care hospital (LTACH) for further care. His chest x-ray showed significant fibrosis (Figure 1c). DISCUSSION: When we re-examined the patient's history, he had a short trip to the southwestern United states for a total of 10 days with his family. This is the source of the patient's exposure. A thorough history may have helped, but urine Coccidiodes antigen testing was negative even after the open lung biopsy was performed. Despite clinical improvement, the patient passed 6 weeks after discharge to long term acute care hospital. CONCLUSIONS: Severe Coccoidiodes pulmonary infections can progress to ARDS. While, it is responsive to liposomal amphotericin B and steroids, it is still associated with a high morbidity and mortality (2). A high index of suspicion for a fungal infection should be maintained in patient's who have pneumonia refractory to antibiotic therapy. Speaking directly with the pathologist will also aide in the diagnosis of fungal infections non-endemic to the area especially like in this case (3). REFERENCE #1: Kirkland TN, Fierer J. Coccidioides immitis and posadasii; A review of their biology, genomics, pathogenesis, and host immunity. Virulence. 2018;9(1):1426-1435. doi:10.1080/21505594.2018.1509667 REFERENCE #2: Shibli M, Ghassibi J, Hajal R, O'Sullivan M. Adjunctive corticosteroids therapy in acute respiratory distress syndrome owing to disseminated coccidioidomycosis. Crit Care Med. 2002 Aug;30(8):1896-8. doi: 10.1097/00003246-200208000-00037. PMID: 12163812. REFERENCE #3: Pitcher JH, Zuckerman JB. Coccidioides Immitis Infection with Involvement of the Airway. Conn Med. 2016 Oct;80(9):539-541. PMID: 29772139 DISCLOSURES: No relevant relationships by Justin Ching, source=Web Response

S3379 Comparing Common Anti-Reflux Surgeries to Their Outcomes and Complications

Introduction: Gastroesophageal reflux disease (GERD) is caused by frequent relaxation of lower esophageal sphincter for multiple reasons. Laparoscopic anti-reflux surgery is an alternative treatment for patients with refractory gastro-esophageal reflux disease. Our aim is to describe the outcomes of the four more common types of anti-reflux surgeries and their associated complications in patients with a long-standing history of GERD. Methods: A retrospective review of 278 patients undergoing four different anti-reflux surgeries at a tertiary care center for esophageal reflux excellence was performed between 2015 and 2020. Primary outcomes included identifying all-cause readmission rates at 30 and 90-days, length of stay, whether they were put on anti-reflux medications postoperatively and whether they needed a secondary surgery for revisions. Secondary outcomes included analyzing postoperative complications such as bleeding requiring transfusions, infections such as urinary tract infections (UTI), pneumonias or central line associated blood stream infections (CLABSI) as well as post-operative cardiac arrythmias. Analysis included age, gender, body mass index, surgery duration, and perioperative data. STATA 14.2 was used for appropriate statistical analysis. Descriptive analysis as well as a simple and multiple regression analysis were used. Results: The laparoscopic repair of paraoesophageal hernia was the most commonly performed procedure 137/278 (49.3%), followed by laparoscopic repair of hiatal hernia in 98/278 (35.3%), the Nissen Fundoplication procedure in 31/278 (11.2%) and Redo Nissen fundoplication in 12/278 (4.3%). The average length of stay was 4.8 days (95% CI 4.5-5.2). Women were the majority of patients 207/278 (75%) and the average age was 65-year-old (95% confidence interval: 64-67). Obesity defined as BMI >30 was present in 42.9% of patients with a (95% confidence interval: 0.37-0.48). Only 12% of the patients required surgical revision (95% confidence interval: 0.09-0.17). Complications including need for surgical revision, readmission, infection, bleeding or arrythmia occurred in 73 patients (26%) of the patients. Conclusion: There was a low risk for peri-operative complications, readmission and need for repeat surgery. Different procedures were effective in treating GERD with laparoscopic repair of hiatal hernia having significantly more need for post-operative medications to treat GERD. The data includes significantly more women which could limit the generalizability to men.

Prevalence of Laryngopharyngeal Reflux Symptoms, Dysphonia, and Vocal Tract Discomfort in Amateur Choir Singers

IntroductionVocal tract discomfort (VTD), dysphonia, and laryngopharyngeal reflux (LPR) symptoms are complaints frequently reported by amateur singers. There are two aims of this study. The first is to evaluate the prevalence of these symptoms using validated questionnaires. The second is to correlate singing-related variables with the questionnaire responses. MethodsA total of 392 amateur choir singers (ACS) and 514 control subjects completed an online survey divided into four parts: (1) clinical and demographic characteristics, (2) training in singing and singing experience, (3) history of gastroesophageal reflux disease and LPR symptoms, (4) validated questionnaires. Specifically, the reflux symptom index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) were included to analyze the actual burden related to LPR symptoms, VTD, and dysphonia. ResultsACS demonstrated a healthier lifestyle and a lower prevalence of gastroesophageal reflux disease symptoms in comparison with control subjects. ACS scored significantly higher in VTDS and VoiSS than control subjects, while no differences in the RSI results were found. Significant correlations among the questionnaires’ results were demonstrated. Occasional professional singing was the variable influencing VTDS and VoiSS results the most. ConclusionACS do not evidently manifest a higher impairment connected to LPR (RSI score), while they do report higher levels of voice (VoiSS score) and vocal tract (VTDS score) impairments, in comparison with control subjects. The relevant correlations among the PRO measures suggest that LPR symptoms, VTD, and dysphonia are related to each other. Given the relevant repercussion on the severity of VTD and dysphonia, providers should specifically ask about occasional professional singing when treating amateur singers.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy.

There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. Level III, retrospective case-control study. A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware). A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy. Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Central Pontine Myelinolysis in Association with Correction of Hypokalemia with Asymptomatic Case of Gastroesophageal Reflux Disease

This case report has described the patient having the central pontine myelinolysis (CPM) associated with hypokalemia correction with asymptomatic history of gastroesophageal reflux disease (GERD). It was suspected that due to GERD and vomiting there might be loss of electrolytes resulting to hypokalemia. The hypokalemia was corrected and patient was discharged from the tertiary neurological center in Nepal.Central Pontine Myelinolysis in Association with Correction of Hypokalemia with Asymptomatic Case of Gastroesophageal Reflux Disease

Association between infection with Campylobacter species, poor oral health and environmental risk factors on esophageal cancer: a hospital-based case\u2013control study in Thailand

BackgroundPrevious studies have shown the association between Campylobacter species infection and that environmental factors, poor oral hygiene in particular, are linked to an increased risk of esophageal cancer (EC). However, no study has reported on these factors in Thailand. Thus, this study’s objective was to evaluate the impact of the relationship between Campylobacter infection and environmental factors on EC incidence in the population of Thailand.MethodsData from a case–control study were collected from 105 newly diagnosed EC cases and 105 controls recruited from 2007 to 2017. Infection with Campylobacter spp. was detected in the formalin-fixed paraffin-embedded (FFPE) tissue of EC taken from gastroesophageal biopsy specimens obtained from the participants, and evaluated using TaqMan® real-time PCR. Multivariable logistic regression was performed to calculate the odds ratios (ORs) and perform data analysis.ResultsSmoking, alcohol use, a family history of cancer, history of gastroesophageal reflux disease, poor oral hygiene and Campylobacter spp. infection were shown to be significant risk factors for EC (p < 0.05). The combination of poor oral hygiene and infection with Campylobacter spp. constituted significant risk for EC (p < 0.001). In addition, the risk of EC in subjects co-infected with C. rectus and C. concisus that practiced poor oral hygiene was even higher and was significant (ORadj = 4.7; 95% CI 2.41–9.98; p = 0.003).ConclusionsIn Thailand, the major risk factors for EC are smoking status, alcohol drinking, family history of cancer, GERD, poor oral hygiene and Campylobacter spp. infection. This study found Campylobacter spp. prevalence to be associated with EC and appears to be enhanced by poor oral hygiene, suggesting that a combination of poor oral hygiene and Campylobacter species infection may together act as an important etiological risk factor for EC.

Comparative analysis of connective tissue disease-associated interstitial lung disease and idiopathic pulmonary fibrosis from a tertiary care centre in Pakistan.

To compare the characteristics of connective tissue disease-associated interstitial lung disease with idiopathic pulmonary fibrosis at a tertiary care hospital. The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised demographical, clinical and radiological data of patients with interstitial lung disease between October 2016 and October 2017 accessed through the outpatient data registry. Data was compared in terms of characteristics and key features of patients with connective tissue disease-associated interstitial lung disease with those of idiopathic pulmonary fibrosis. Statistical analysis was done using STATA 12. Of the 184 patients, 52(29.3%) had connective tissue disease-associated interstitial lung disease and 62(35%) had idiopathic pulmonary fibrosis. The most prevalent conditions among connective tissue disease-associated interstitial lung disease patients were rheumatoid arthritis 22(42.3%) and scleroderma 13(25%). Compared to patients with idiopathic pulmonary fibrosis, those with connective tissue disease-associated interstitial lung disease were predominantly younger (p<0.001) and female (p<0.001). History of gastroesophageal reflux disease was also significantly lower in connective tissue disease-associated interstitial lung disease (p=0.05). Connective tissue disease-associated interstitial lung disease patients were found to be younger and predominantly female compared to patients of idiopathic pulmonary fibrosis.

An Unusual and Unexpected Post-Esophagectomy Complication

Question: A 44-year-old man with a history of gastroesophageal reflux disease initially presented to an outside hospital emergency department with worsening of his symptoms. Over the next several months he developed mid-back pain, odynophagia, and dysphagia to solids and occasionally liquids, resulting in a 30-pound weight loss. A computed tomography (CT) examination of the chest, abdomen, and pelvis demonstrated marked wall thickening of the distal esophagus causing luminal narrowing. Follow-up esophagogastroduodenoscopy (EGD) 2 weeks later revealed a 6-cm mass in the lower esophagus causing partial obstruction.

Esophageal granular cell tumor and eosinophils: a multicenter experience

BackgroundEsophageal granular cell tumor (eGCT) is rare, and the recent literature suggests a link between eosinophilic esophagitis (EoE) and eGCT. The aim of our study was to determine if EoE or other disorders associated with eosinophilia are consistently associated with eGCT.MethodsWe retrospectively searched pathology databases of three academic institutions from 1999 to 2018 for eGCTs. The archived slides and medical records were reviewed.ResultsFrom 294,855 esophagogastroduodenoscopy procedures, 45 patients (17 males and 28 females) with eGCTs were identified. The patients (30–73 years in age, median 50) had eGCT 0.2–2.0 cm in size (average 0.71). Thirteen had a history of gastroesophageal reflux disease, 5 had Barrett esophagus/goblet cell metaplasia and 1 had EoE. Thirty-four eGCTs had intralesional eosinophils (14 with peak > 10 eosinophils/400x hpf); of these, 21 also had eosinophils in lamina propria (9 with peak > 10 eosinophils/hpf). eGCT with atypical features (including nuclear enlargement and prominent nucleoli) were more likely to have increased eosinophils in non-epithelial compartments than those without atypia. Pleomorphism and spindled cells were seen in 3 eGCT cases (mean peak intralesional eosinophils: 43 per hpf); 2 of these had goblet cell metaplasia. We found no association between EoE and eGCT, p = 0.5966, (95% C.I. 0.0276, 6.5389, Fisher’s exact test). Instead, most patients had gastroesophageal reflux disease or Barrett esophagus.ConclusionEosinophilia, common in eGCT and adjacent stroma, likely drives atypical/reactive histologic features, but a pathogenic relationship between eosinophil rich inflammatory conditions and eGCT has not yet been established.

Pseudopheochromocytoma as a Presentation of Amyotrophic Lateral Sclerosis

Introduction: Pseudopheochromocytoma presents as paroxysmal events of hypertension and other noradrenergic symptoms similar to pheochromocytoma (PCC) but do not meet tumoral diagnosis. Case Report: A 70-year-old Caucasian male with history of gastroesophageal reflux disease (GERD) and Barrett’s esophagus presented to the Emergency Department with fatigue, shortness of breath, palpitations, and fasciculations in the anterior chest wall. He reported recent diagnosis of PCC. Patient had episodes of non-exertional palpitations, diaphoresis, dizziness, facial flushing, and facial involuntary movement along with self-monitored average blood pressure (ABP) of 160/100 mmHg and heart rate (HR) of 90 beats per minute (bpm). Spells occurred 2 to 3 times per month at first, later increased. Between episodes self-monitored ABP was 120/70 mmHg and HR of 50 bpm and asymptomatic. He reported unintentional weight loss of 40 pounds in the same interval and newly muscle weakness that he attributed to weight loss and malnutrition. Patient had no remarkable past medical history. Medications included coq10 enzyme, glucosamine, flax seed oil, primrose oil and recently added doxazosin 1 mg tab per day. Evaluation revealed a cachectic patient (body mass index 17.46 k/m2) with normal vital signs, otherwise unremarkable physical exam except for diffuse fasciculations in chest and upper extremities. Outpatient work up included normal complete blood count, comprehensive metabolic panel, drug screening, thyroid function test. He had elevated free plasma metanephrine (FPM) of 73 pg/mL (< 57 pg/mL), free plasma normetanephrine (FPN) of 487 pg/mL (<148 pg/mL), before doxazosin. Repeated FPM of 55 pg/mL (< 57 pg/mL), FPN of 347 pg/mL (<148 pg/mL). The 24-hour urine for metanephrine was normal with total metanephrine of 157 ug/d (55-320 ug/d) and normetanephrine 432 ug/d (114-865 ug/d) with a creatinine of 900 mg/dL (800-2100 mg/d). He also had outpatient computed tomography (CT) scan of thorax, abdomen, and pelvis that was normal. Positron emission tomography CT scan did not reveal any tumors. Our initial suspicion, later confirmed with electromyography, was a neurodegenerative disease with motor neuron dysfunction. Patient was diagnosed with Amyotrophic Lateral Sclerosis (ALS) and started in riluzole with improvement of spells. Since, his muscle weakness progressed, he now requires noninvasive ventilation. Discussion: Pseudopheochromocytoma is an idiopathic disease that mimics catecholamine-secreting PCC and needs adequate and complete evaluation. Catecholamine levels can be affected by illness, stress, medications, and sample collection. In the case presented, the patient’s muscular weakness and fasciculations was caused by ALS. Neurodegenerative diseases such as ALS can cause a central nervous system stress response, consequently causing elevated norepinephrine levels.

Elevated Liver Enzymes, Ferritin, C-reactive Protein, D-dimer, and Age Are Predictive Markers of Outcomes Among African American and Hispanic Patients With Coronavirus Disease 2019

Elevated Liver Enzymes, Ferritin, C-reactive Protein, D-dimer, and Age Are Predictive Markers of Outcomes Among African American and Hispanic Patients With Coronavirus Disease 2019

Stomach in the chest or what we know about giant hiatal hernias

A hernia of the esophageal aperture of the diaphragm is considered as one of the factors contributing to the development of gastroesophageal reflux disease and requires a complete and comprehensive examination of the patient. Routine esophagogastroduodenoscopy does not give a complete picture of the disease, and therefore patients receive symptomatic treatment for a long time. Paraesophageal hernia of the esophageal aperture of the diaphragm are not well understood yet due to their relatively low frequency of occurrence, may be asymptomatic or manifest as chest pain of noncardiac origin. A patient with a long history of gastroesophageal reflux disease associated with a giant paraesophageal hernia of the esophageal aperture of the diaphragm is presented as a clinical case.

Family History of GERD Does Not Predict Anti-Reflux Surgery Outcomes

Background and Objectives:Gastroesophageal reflux disease is a common disease and there is little known about the role family history plays in its disease process and incidence. Our study was designed to compare the patients with first degree relatives with and without the disease and see if there was any difference in patients needing antireflux surgery, the outcomes after antireflux surgery, and whether they needed redo surgery.Methods:An institutional review board approved registry for patients undergoing antireflux surgery at a single institution was used. Patients were asked specific questions about their family history of gastroesophageal reflux disease at their pre-operative visit. Patients with a family history and those without were compared.Results:There was no statistical difference between the patients with family history of gastroesophageal reflux disease for likelihood to undergo surgery, outcomes from surgery, or the need for redo surgery. There were more females than males in the study and there were more patients with a positive family history in the study than those without.Conclusion:Since there is no impact of family history of gastroesophageal reflux disease on antireflux surgery, patients can be counseled that their decision to undergo antireflux surgery is independent from the response of their first degree relatives.