Intermittent Dysphagia Research Articles

Giant liposarcoma of esophagus: a rare case report

BackgroundLiposarcoma is a malignant mesenchymal tumor that most commonly involves the retroperitoneum and lower extremities. However, liposarcoma of esophagus has been rarely reported in the literature.Case presentationWe report a case of a 46-year-old man with complaint of intermittent dysphagia for 6 years, accompanied with paroxysmal vomiting of pedicled tumor to the mouth. Imaging studies showed a huge mixed density lesion in the middle esophageal lumen. Surgical resection of the tumor was performed through an external cervical approach. Microscopically, the tumor was composed of mature adipocytes in normal adipose tissue prominently intersected by sparsely cellular fibrous septa containing atypical, enlarged spindle cells with hyperchromatic nuclei. Immunohistochemically, the tumor cells were positive for Vimentin, S-100, CD34 and MDM2. Besides, fluorescence in situ hybridization (FISH) analysis indicated the presence of amplification involving MDM2 gene. The patient was diagnosed as having esophageal well-differentiated liposarcoma and recovered well after the operation.ConclusionsEsophageal liposarcoma is an extremely rare tumor. Due to the nonspecific clinical manifestation and lack of experience, it is challenging to make a clear diagnosis before operation. Definite diagnosis of esophageal liposarcoma depends on histopathology, immunohistochemistry and molecular analysis.

56-Year-Old Woman With Bilateral Lower Extremity Edema

A 56-year-old woman presented to the primary care clinic for evaluation of a 2-year history of bilateral lower extremity edema. She denied dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. She also denied having any abdominal pain, nausea, vomiting, or diarrhea. Review of systems was positive for long-standing intermittent dysphagia with solid foods. Her medical history was notable for mild intermittent asthma, allergic rhinitis, and long-standing peripheral eosinophilia of unclear significance. Her medication list included rare meloxicam, daily ciclesonide inhaler, and albuterol inhaler as needed. She denied tobacco, alcohol, or recreational drug use. CORRECT ANSWERS: 1. e. 2. e. 3. c. 4. a. 5. a.

Acute food impaction in an adult with previously undiagnosed eosinophilic esophagitis.

A 31-year-old man with a history of allergic rhinitis, asthma and eczema presented to the emergency department with sudden dysphagia and food impaction while eating steak. He reported intermittent dysphagia and gastroesophageal reflux over several months despite proton pump inhibitor therapy. We

Severe Intermittent Dysphagia is not a Contraindication for Total Nissen Fundoplication

Aim: To study the effect of total Nissen fundoplication on severe intermittent esophageal dysphagia according to a hiatal hernia. Methods: Twenty-three consecutive patients (12 men, 11 women, median age 43 yrs) with severe intermittent dysphagia and with hiatal hernia verified by endoscopy were included in the study. They were investigated with esophageal high-resolution manometry (HRM)-, and 24-hr pH- monitoring prior to hiatal hernia repair and at follow-up 6 months after surgery. On both test occasions, the patients were asked to fill in a questionnaire comprising 17 questions on esophageal and chest symptoms (severity grades 0-3). Results: A hiatal hernia was recorded via HRM in all 23 patients prior to surgery and in no one at follow-up. Prior to surgery, all patients had either severe no stenotic dysphagia or frequent retention symptoms in the chest while eating. These two mechanical problems were relieved by surgery (p< 0.0001). Motility disturbances in the distal esophagus were recorded in 35 % of patients prior to surgery, but in no one at follow-up. The median total reflux time prior to surgery was 2.2 % (range 0.2 – 36.5 %) and at follow-up 0 % (0 – 0.3 %). Five patients had no pathological gastro-esophageal reflux prior to surgery. Conclusion: Severe intermittent esophageal dysphagia in hiatal hernia patients can be successfully treated with total Nissen fundoplication, and this should be a strong indication for hiatal hernia surgery even in the absence of pathological gastro-esophageal reflux.

Three-dimensional laparoscopic approach to distal oesophageal diverticula: Single-centre experience.

Epiphrenic oesophageal diverticula are rare and often asymptomatic. When symptoms are present, minimally invasive diverticulectomy is considered the gold standard of treatment. While there is an agreement on the pre-operative assessment, no consensus is achieved when it comes to surgical technique. In the present study, we report our experience and propose a standardised approach to manage this rare oesophageal disorder. We prospectively analysed data of all consecutive patients who underwent three-dimensional (3D) laparoscopic distal oesophageal diverticulum resection during 2015-2020 at Upper gastrointestinal surgical department, St Thomas' Hospital, regarding pre-operative assessment, surgical technique, peri-and post-operative outcomes. Six patients were submitted to 3D laparoscopic diverticulectomy, five of which with additional anterior myotomy and fundoplication and one with additional hiatal hernia repair only. Three patients followed a specific diet in preparation for surgery. Median pre-operative Eckardt symptom score was five. Two patients had normal manometry. Median operative time was 180 min, median estimated blood loss was <100 ml, neither intraoperative complications nor conversions to open approach occurred. All patients reported a complete resolution of symptoms directly after surgery. Median follow-up was 66 months. Five patients have none or minimal residual symptoms. One had recurrence requiring a revision operation for intermittent dysphagia. 3D laparoscopic diverticulectomy offers a reasonable chance of treatment in patients with epiphrenic diverticula. Optimal selection of patients, optimisation for surgery, gaining the surgical experience of carrying out these techniques and impact on short- and long-term results are issues that still remain under debate.

S2419 A Motility Study in a Patient With Isolated Diaphragmatic Agenesis: An Interesting Study in a Very Rare Entity!

Introduction: Diaphragmatic agenesis is a very rare congenital defect. Diagnosis is typically made in infancy and it is commonly associated with other congenital malformations and high mortality. However, it has also been described in the literature as a distinct clinical entity with potentially later in life diagnosis, as in the case reported here. Case Description/Methods: Our subject is a 57-year-old male who was diagnosed to have diaphragmatic agenesis at the age of 45 during a thoracotomy for a suspected diaphragmatic hernia. He presented to the gastroenterology clinic with a chief complaint of life-long intermittent but progressive dysphagia to both solids and liquids. Chest x-ray showed bowel loops and air-fluid level in the left-side of the chest with a cardiac and a mediastinal shift to the right side. Barium swallow was done and was negative for any abnormalities. A motility study was also done and with details showing in Tables 1-4 (Figure). Findings of the motility study are summarized as the following: 1) Normal resting pressure at lower esophageal sphincter with incomplete relaxation during swallows (high IRP), 2) Normal amplitude peristaltic contractions in esophageal body (Normal DCI), 3) Complete bolus transition, 4) Esophagogastric morphology I, and 5) Normal upper esophageal sphincter resting pressure. A chest X-ray obtained and attached in figure A shows the position of the probe used in the esophageal manometry with the gastroesophageal junction in the thoracic cavity. Figure B shows our patient's manometric study evaluating pressure changes that occurred during liquid swallowing. The diagnosis of esophagogastric junction (EGJ) outflow obstruction was made based on study results. Discussion: Esophagogastric junction outflow obstruction is a major motility disorder based on the Chicago Classification of esophageal motility disorders. This entity involves a heterogenous group of underlying etiologies with diaphragmatic agenesis being one potential but rare cause evidenced by our reported case. Management of (EGJ) outflow obstruction is dependent on the underlying etiology.Figure 1.: (Top) Motility study details. A) Chest Xray showing the position of the probe used in the esophageal manometry. B) Patient's manometric study evaluating pressure changes that occurred during liquid swallowing.

S3626 Large Type IV Hiatal Hernia Complicated by Organo-Axial and Mesentero-Axial Gastric Volvulus: A Case Report

Introduction: A type IV hiatal hernia is characterized by displacement of the stomach along with other organs into the intrathoracic cavity and is associated with laxity of the peri-gastric ligaments. This condition is extremely rare, accounting for less than 5 percent of all hiatal hernias. Due to mechanical issues, paraoesophageal hernias can lead to serious complications such as gastric volvulus. Depending on the axis of rotation, gastric volvulus can be divided into organo-axial, mesentero-axial or a mixed type of volvulus. This case vignette discusses a rare case of a large type IV hiatal hernia with both organo-axial and mesentero-axial gastric volvulus. Case Description/Methods: A 75-year-old female with past medical history of a large hiatal hernia was referred to GI clinic for intermittent post-prandial and right sided non-exertional chest pain of a few years. She denied any associated shortness of breath, diaphoresis, palpitations, and nausea/vomiting. A subsequent diagnostic esophagogastroduodenoscopy (EGD) revealed a significant anatomic distortion of the stomach with a posteroinferior positioning of the pylorus and a large 10 cm paraoesophageal hernia with associated mucosal erythema, edema, and hematin material. To further characterize the anatomy, an upper GI series demonstrated a large type IV hiatal hernia with an intrathoracic stomach measuring 9.3 cm x 15.8 cm and evidence of both organo-axial and mesentero-axial gastric volvulus. Patient was referred to surgery for gastric detorsion, fixation, and repair of the large paraesophageal hernia. (Figure) Discussion: Gastric volvulus is a rare condition and can develop as a complication of a paraesophageal hernia. Due to fixation of the stomach along the GE junction and pylorus axis, the herniated stomach tends to rotate along this longitudinal axis resulting in an organo-axial volvulus. Less frequently, the stomach can rotate along the transverse axis resulting in a mesentero-axial volvulus. Organo-axial and mesentero-axial volvuli occurring together is extremely rare. Chronic gastric volvulus can present with nonspecific symptoms such as intermittent epigastric discomfort, postprandial fullness, nausea, dysphagia, dyspnea, or chest discomfort. Imaging via upper GI series or cross-sectional imaging are required to make the diagnosis. Chronic gastric volvulus secondary to the hiatal hernia can be managed surgically on a nonemergent basis with detorsion, fixation of the gastric volvulus and repair of the hiatal hernia.Figure 1.: Upper GI Series Demonstrated A Large Type IV Hiatal Hernia with An Intrathoracic Stomach measuring 9.3 cm x 15.8 cm.

S2379 Squamous Cell Carcinoma of the Gastroesophageal Junction as an Unusual Underlying Cause of Pseudoachalasia

Introduction: Achalasia is a rare esophageal motility disorder characterized by progressive dysphagia to solids and eventually liquids[1-2]. Pseudoachalasia refers to an achalasia secondary to an underlying etiology, such as masses, post-operative complications, or paraneoplastic syndromes[1-2]. The most common cause of pseudoachalasia is adenocarcinoma of the cardia or esophagus [1] however, we discuss a rare case that deviates from the typical etiology of esophageal cancer. Case Description/Methods: This is a 71-year-old male presenting with intermittent dysphagia for years with rapid progression for a month including intolerance of oral intake and 6-pound weight loss. On examination he was hemodynamically stable with a soft, nontender abdomen. His initial barium esophagram revealed decreased esophageal peristalsis, esophageal distention, and narrowing at the gastroesophageal junction (GEJ) with “bird beak” appearance consistent with possible achalasia. Further imaging studies were performed with computed tomography (CT), esophagogastroduodenoscopy (EGD) with dilation, and endoscopic ultrasound with biopsies revealing an invasive squamous cell carcinoma of the GEJ with submucosal involvement extending into the gastric cardia (Figure). We present our patient as the first reported case of pseudoachalasia due to SCC of the GEJ. The patient underwent esophageal stenting and mediport placement with plans for neoadjuvant chemotherapy with concurrent radiotherapy followed by definitive resection. Discussion: Pseudoachalasia is often misdiagnosed for primary achalasia because of its rarity, indistinguishable symptomatology, and normal findings on CT, EGD, and biopsy[1-2]. Nearly 75% of pseudoachalasia cases are due to adenocarcinoma of the gastric cardia[1]. Only one case of pseudoachalasia has been known to be caused by SCC in the distal esophagus[3]. SCC of the GEJ is an extremely rare esophageal malignancy and has never previously been reported as an underlying cause of pseudoachalasia.Figure 1.: Esophagogastroduodenoscopy revealed severe stricture at the GEJ with a 4 cm submucosal mass at the GEJ with extension to the gastric cardia.REFERENCES 1. Campo SM, Zullo A, Scandavini CM, Frezza B, Cerro P, Balducci G. Pseudoachalasia: A peculiar case report and review of the literature. World J Gastrointest Endosc. 2013;5(9):450-454. 2. Roushan N, Zolfaghari A, Asadi M, Taslimi R. Pseudoachalasia: a diagnostic challenge. Med J Islam Repub Iran. 2014;28:54. 3. Kahrilas, P., Kishk, S., Helm, J., Dodds, W., Harig, J. and Hogan, W., 1987. Comparison of pseudoachalasia and achalasia. The American Journal of Medicine. 1987;82(3):439-446.

S2374 Recurrent Strictures in a Patient With Missed Diagnosis of Eosinophilic Esophagitis

Introduction: EoE is an antigen-mediated inflammatory disorder of the esophagus that affects both children and adults. Diagnosis requires symptoms related to esophageal dysfunction and esophageal biopsy showing >15 eosinophils/hpf is confirmatory for diagnosis. Proton pump inhibitors (PPIs) are considered the first line agents for the treatment of EoE, together with elimination diet and topical corticosteroids. Nonadherence to therapy and undiagnosed disease can increase the risk of fibro-stricturing disease and food impactions. Practicing evidence-based guidelines in diagnosing and managing patients with EoE can allow standardization of care and prevent complications in patients with EoE. Case Description/Methods: A 34-year-old man presented with a longstanding history of intermittent dysphagia to solids. He had an emergent esophagogastroduodenoscopy (EGD) for food impaction about 3 years prior to presentation. No biopsies were obtained at that time, and he was prescribed a short course of PPI before discharge. On current presentation, the patient underwent an EGD which showed multiple untraversable strictures requiring dilation (Figure). Biopsy from multiple sites showed >200 eosinophils/hpf, consistent with a diagnosis of eosinophilic esophagitis (EoE). Thereafter, the patient was initiated on PPIs but had to undergo further dilations for recurrent strictures. Topical steroids were subsequently added to the therapy with satisfactory response. Discussion: Once considered rare, EoE is now a well-known entity, with an estimated prevalence of 51.6/100000 in the US. However, variability and deviations from standard therapy continues to persist among gastroenterologists. According to a national survey conducted in 2020 among 240 gastroenterologists, only 24 % were “very familiar” with the EoE guidelines and only 12 % followed EoE guidelines in their clinical practice. The current case underscores the need to standardize clinical practice related to the care of patients with EoE in order to provide quality and evidence-based care and improve overall outcomes.Figure 1.: EGD showed trachealization of the esophagus.

P27 Challenging management of GI complications in Systemic Sclerosis

Introduction/BackgroundSystemic sclerosis is a chronic, progressive, multisystemic autoimmune disease in which there is excessive collagen deposition in the dermis and internal organs. It is commonly categorized into limited cutaneous or diffuse cutaneous systemic sclerosis. In more than 80% of patients there is GI involvement. Gut complications can impair oral intake, absorption and even faecal continence, and consequently can have severe adverse effect on quality of life. With disease progression, management of GI symptoms may become more of a challenge. We present a challenging case of SSs with esophageal involvement along with severe regurgitation who eventually responded to a specific prokinetic.Description/Method70 y/o female initially presented to gastroenterology clinic in 2013 due to dysphagia to solids and was found to have benign fibrotic oesophageal stricture for which she had therapeutic dilatation, (normal biopsy result). Subsequently, she had barium swallow which showed severe regurgitation. Manometry confirmed severely hypo-contractile oesophagus thus she was referred to rheumatology for suspected connective tissue disorder.On initial review, she did not describe typical inflammatory symptoms, scleroderma, sclerodactyly, Raynaud’s phenomenon, digital ulcers, calcinosis, telangiectasia or any other connective tissue features but was diagnosed with limited cutaneous systemic sclerosis due to ANA & anti-centromere antibody positivity, severe oesophageal dysmotility and diagnosis of mild pulmonary hypertension (on right heart catheter studies).Her main disabling SSs symptom was refractory belching, intermittent dysphagia and reflux disease resulting in poor oral intake and resultant malnutrition. She had 4-week trial of antibiotics to treat for presumptive small intestine bacterial overgrowth (SIBO) due to persistent belching but had no evident improvement. She had multiple endoscopies which only showed grade B oesophagitis due to which she remained on high dose PPI (Omeprazole 40mg BD) but showed no recurrent stricture. She was also given dual therapy with Ranitidine 150mg bd but derived no benefit.In Rheumatology clinic she was started on erythromycin 250 mg BD as a pro-kinetic and in liquid form for better tolerability (due to the dysphagia) with gradual but significant improvement of her upper GI symptoms. Switching liquid form to tablets/capsule form via GP resulted in worsening symptoms so was switched back to liquid form. GI symptoms worsened again in 2017 and impression was tachyphylaxis to erythromycin. She was started on trial of another pro-kinetic (metoclopramide) but symptoms continued worsening. In view of this she was started back on liquid erythromycin and her symptoms gradually improved again and has remained stable since.Discussion/ResultsSystemic sclerosis (SSc) is an incurable connective tissue disorder. It is estimated that approximately 90% of patients with SSc have some form of oesophageal involvement. For first three years, this patient’s main symptoms were her upper GI tract issues with reflux and oesophageal dysmotility causing delayed gastric emptying.Considering the severity of her GI symptoms, it was of great importance for her to maintain a regular follow up with gastroenterology team for a regular review of symptoms and repeat investigations as needed such as multiple repeat UGI endoscopy to ensure no recurrence of oesophageal stricture, monitoring of GORD, and hydrogen breath testing.We recommend for patients with severe oesophageal dysmotility to be started on prokinetics early to control GI symptoms and have minimal impact of these on quality of life. Liquid preparation has shown a significant improvement in symptoms in our patient as compared to tablet or capsule form which actually worsened the symptoms.Key learning points/ConclusionDysphagia can be a presenting symptom of systemic sclerosis in some cases. Upper gastro-intestinal symptoms can be severe with significant effect on quality of life.Management of these symptoms can be challenging and may require a combination of treatments.Pro-kinetics mainly erythromycin can have a major positive impact in controlling GI symptoms,Liquid form had better outcome in this case as compared to tablet or capsule form.Poor control of GI symptoms can result in significant malnutrition which is associated with more aggressive disease progression, so GI symptoms management plays a key role in disease control.

A lump in the throat

A 73-year-old man with hypertension, gastroesophageal reflux disease, and no history of smoking, drinking, or previous cancer, presented to the emergency department at the University of California, Irvine Medical Center (Orange, CA, USA) after acute onset of a protruding oral mass, difficulty breathing, and dysphagia. The patient had been walking his dog on a leash when the dog jerked him forwards, resulting in an episode of coughing, choking, and emesis. Before this event, the patient reported intermittent dysphagia, and feeling as if something was stuck in his throat, which improved with swallowing. The incident while walking his dog caused dislodging of a large non-tender soft-tissue mass (figure A) into the oral cavity and out of his mouth. The patient had never experienced this before, although he did recall a couple of episodes of coughing after which he felt a lump in his throat that resolved. (A) Hypopharyngeal mass protruding from the mouth. The patient's tongue is inside of his mouth. (B) Endoscopic view of mass.

A Rare Cause of Dysphagia: Diagnosis and Treatment

Question: A 55-year-old woman presented to our hospital with intermittent dysphagia for 2 months and progressive dysphagia for 44 days. A preliminary computed tomography scan had been performed at an outside hospital and revealed circumferential thickening of the middle and distal esophageal wall, and no thoracic neoplasm outside of the esophagus.

Progressive dysphagia caused by IgG4-related sclerosing disease involving the esophagogastric junction

A 46-year-old man presented at our clinic because of intermittent dysphagia sensations for 1 year, and this symptom had progressed in the recent 2 months. EGD showed a protruding mass with a lobulated surface and firm density, causing a stenotic lumen at the esophagogastric junction (A). The initial pathologic examination of the biopsy specimen showed ulcerated mucosa with granulation tissue and leukocytic infiltration. Repeated EGD was performed to obtain multiple biopsy specimens, and no evidence of malignancy or specific pathogens such as viral and fungal infection was identified by serial stains. Because of the suspicion of esophageal cancer, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT was arranged and showed increased FDG uptake at the cardiac portion of the stomach and distal end of the lower esophagus (B). Because of progressive dysphagia and a concern regarding malignancy, esophagectomy was performed, and multiple nodular lesions with fibrotic changes at the esophagogastric junction were found (C). Immunostaining showed increased IgG4-positive plasma cells, finding ≤225 per high-power field, with a 50.2% IgG4+/IgG+ plasma cell ratio (IgG4 stain, orig. mag. ×200) (D). These findings were consistent with IgG4-related sclerosing disease involving the esophagogastric junction.

Failure to Thrive and Severe Malnutrition due to a Jest of Nature: Dysphagia Lusoria

Dysphagia Lusoria is a rare condition in which dysphagia results from external vascular compression of the esophagus. We describe a 69-year-old man with longstanding intermittent solid-food dysphagia with failure to thrive who was found to have an aberrant right subclavian artery resulting in dysphagia lusoria. This caused a mass effect upon the posterior esophagus resulting in dilatation of the mid and upper esophagus. A diagnosis of dysphia lusoria was made and surgery was consulted for surgical correction and total parental nutrition started. Definitive diagnosis of dysphagia lusoria involves imaging modalities such as barium esophagram or a CT/MRI. Upper endoscopy is often normal though a pulsatile extrinsic mass can sometimes be seen. There are no pathognomonic manometric findings. Given the rarity of the condition, a high index of suspicion is often required for diagnosis. Definitive management of patients with dysphagia lusoria often involves surgical correction of the anatomical aberrancy. In patients who decline to undergo surgical correction, have mild-moderate symptoms, or are poor surgical candidates, eating slower, chewing well, taking smaller bites, and taking PPIs could be effective therapy options.

What Is Wrong With This Wireless Motility Capsule?

CASE REPORT A 37-year-old woman was evaluated for suspected gastroparesis with nausea, heartburn, and constipation. She reported bowel movements every 2 weeks (Bristol Stool Scale Type I–III) with excessive straining. She was taking pantoprazole, famotidine, promethazine, and bisacodyl. Her history included esophageal stricture requiring dilation 3 years previously. She reported intermittent dysphagia for solids. A wireless motility capsule (WMC) study was performed for the evaluation of gastrointestinal motility disorder. The WMC profile is presented (Figure 1). The horizontal axis shows the time scale, and the vertical axis shows pressure (red), pH (green), and temperature (blue). The pH was 5–7 with occasional decreases to 2.0 coinciding with drinks/meals, indicating esophageal capsule retention. Ten hours later, the patient vomited and expelled the capsule, confirmed by a temperature decline. A week later, an upper endoscopy confirmed distal esophageal stricture with mucosal changes of esophagitis (Figure 1). Pantoprazole was increased to twice daily, and repeat esophagogastroduodenoscopy in 8 weeks was recommended (Figure 2).Figure 1.: Wireless motility capsule profile of the patients. The horizontal axis shows the time scale, and the vertical axis shows pressure (red), pH (green), and temperature (blue). The pH was 5–7 with occasional decreases to 2.0 coinciding with drinks/meals, indicating esophageal capsule retention. Ten hours later, the patient vomited and expelled the capsule, confirmed by a temperature decline.Figure 2.: Upper endoscopy 1 week after wireless motility capsule testing confirming distal esophageal stricture with mucosal changes of esophagitis.The WMC study is contraindicated in patients with dysphagia, stricture, or bowel obstruction. Capsule retention, although rare (0.33%), can occur, especially if the contraindications for this test are not carefully ruled out before ordering the test.1 The test was incorrectly requested for the patient presented here, but fortunately, the patient vomited the capsule. In patients with dysphagia, stricture, or bowel obstruction, gastrointestinal dysmotility symptoms should be evaluated using alternative tests, such as scintigraphy. Although WMC is significant advance and clinically useful for the diagnosis of gastrointestinal motility disorders, the manufacturer's recommendations and precautions should be followed carefully to prevent potentially serious complications.2 DISCLOSURES Author contributions: L. Mosley wrote the manuscript. A. Jehangir edited the manuscript. S. Sridhar, A. Sharma, and S.S.C. Rao revised the manuscript for intellectual content. S.S.C. Rao is the article guarantor. All authors approve the final version of the manuscript. Financial disclosure: None to report. Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting; October 22–27, 2021; Las Vegas, Nevada. Informed consent was obtained for this case report.

Esophageal hyperkeratosis as uncommon manifestation of gastroesophageal reflux disease

We present the case of a 66-year-old woman with intermittent dysphagia and esophageal food impaction. The endoscopic examination showed an upper and middle esophagus with a diffuse circumferential, white, crackleware epithelium. Esophageal biopsies revealed acanthosis and papillomatosis with diffuse hyperkeratosis. High dose of Proton pump inhibitors was initiated with improvement of all symptoms 6 weeks later.

S2974 Disseminated Kaposi Sarcoma Presenting as a Small Bowel Obstruction: A Rare Entity

Introduction: Kaposi’s Sarcoma (KS) is the most common neoplasm associated with AIDs. Less than 4% of cases involve the gastrointestinal (GI) tract. Patients usually present with skin manifestations, and in rare cases involve the GI tract. We present a case report of a young African American male who presented with a small bowel obstruction and was found to have KS. Case Description/Methods: A 24 year old male with a history of cutaneous Kaposi Sarcoma, HIV, SIADH, adrenal insufficiency, and recurrent GI bleeding presented to the hospital for evaluation of abdominal pain and intermittent dysphagia. On physical exam: he appeared frail, cachetic, with a distended abdomen: Lab work showed significant transaminitis and elevated AST and ALT. He underwent a CT scan with contrast revealed a small bowel obstruction diffuse and anasarca. He underwent an exploratory laparotomy which showed a small bowel obstruction in the distal ileum secondary to intussusception, and subsequent small bowel resection. His hospital course was complicated by septic shock, disseminated intravascular coagulopathy, ventilator dependent respiratory failure with eventual tracheostomy. He developed an ileus and a CT scan revealed narrowing in the sigmoid colon. GI did not perform a colonoscopy as they did not suspect a mass. A dobhoff was eventually placed for nutrition. Surgical Pathology of the distal ileum revealed a submucosal neoplasm consistent with Kaposi Sarcoma. Discussion: The clinical presentation of Kaposi's Sarcoma is variable. Advanced lesions can manifest as: GI bleeding, protein-losing enteropathy, chronic diarrhea, intussusception, obstruction, or even perforation. Given the wide variety of presentations, it is important for clinicians to have a broad differential with patients who have KS and recurrent abdominal pain. Kaposi's Sarcoma rarely involves the GI tract which can make it challenging to diagnose. Currently, there is no current consensus on endoscopic screening guidelines to evaluate Kaposi Sarcoma of the GI tract. Thus further studies are needed in this patient population in order to decrease complications.

S2491 Diagnosis of Papillary Thyroid Carcinoma by Transesophageal Endoscopic Ultrasound-Guided Fine-Needle Biopsy (EUS-FNB)

Introduction: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) can be used as a diagnostic modality with tissue sampling of both intra- and extra-luminal lesions. EUS allows for a less invasive, real-time image-guided biopsy of adjacent extraluminal structures. We present EUS-guided FNB evaluation in a patient with suspected recurrent thyroid cancer and a suspicious portocaval lymph node (PCNL). Case Description/Methods: A 36-year-old male with recurrent papillary thyroid cancer that had been previously treated with total thyroidectomy and modified radical neck dissection and iodine ablation presents with intermittent dysphagia to solid foods and a pressure sensation in his mid-neck. He reported poor compliance with follow-up appointments, surveillance imaging, and post-treatment TSH-suppressive T4 therapy. CT neck showed non-specific bilateral nodular changes in the thyroidectomy bed which were thought to reflect postsurgical changes versus recurrent neoplasm. A whole-body PET/CT showed no substantial FDG uptake in the neck but rather increased uptake in a PCNL concerning for intra-abdominal metastases. Surface ultrasound-guided FNA (USG-FNA) of the left neck mass was non-diagnostic. As the lymph node was inaccessible by percutaneous biopsy, and previous USG-FNA of thyroid bed was non-diagnostic, a EUS guided biopsy of both, the left neck mass and PCNL was pursued. The EUS revealed a 12mm x 8mm mass in the thyroid resection bed. EUS-guided thyroid biopsy was performed from the level of the upper esophageal sphincter, with 5 passes of a 25 gauge SharkCoreTM needle (C-25-05 Medtronic, Dublin, Ireland). Two enlarged ( >1cm) hypoechoic PCNL with well-defined borders were identified with EUS. Using a 22 gauge SharkCoreTM needle biopsy, FNB x 3 was performed on the PCNL. The pathology from the left thyroid mass revealed papillary thyroid carcinoma, and the histopathology from the PCNL was a benign lymphoid sample. The patient did well on follow-up and had no periprocedural adverse events. By demonstrating recurrent cancer, without PCNL involvement. This allowed the patient to undergo local surgical resection. Discussion: The evaluation and management of suspicious lesions in the superior mediastinum have evolved since the inception of EUS. We demonstrate that EUS can be used in the evaluation of recurrent thyroid cancer when USG-FNA is not diagnostic. An additional advantage of EUS is the ability to sample suspicious lymph nodes adjacent to the GI tract at the same time.Figure 1.: EUS guided fine needle biopsy of the enlarged lymph node in the porta hepatis region (a) revealed a benign lymphoid sample (c). A 1.2 x 0.8 cm lesion found in the left thyroid bed on EUS (b) with EUS-FNB showing malignant cells diagnostic of papillary thyroid carcinoma (d).

A case of lymphocytic esophagitis in a woman with multiple allergies

BackgroundLymphocytic esophagitis is a newly recognized entity of unknown origin. Dysphagia is defined as difficulty swallowing and represents a common symptom in the general population with a prevalence of approximately 20%. Chronic inflammation of the esophageal wall may manifest itself clinically and endoscopically, mimicking inflammation of another origin. However, little is known about the pathogenesis of the disease, as patients are seldom suspected and rarely diagnosed with lymphocytic esophagitis.Case presentationHere, we present a rare case of lymphocytic esophagitis in a patient with multiple allergies and suspected eosinophilic esophagitis. A 28-year-old woman with polyvalent sensitization to food and inhalant allergens presented with intermittent dysphagia, a sensation of a foreign body in the throat, itchiness of the oral cavity after ingesting certain foods, heartburn, and prolonged chewing time. A skin prick test showed positive results for birch-tree, alder, hazel, and rye pollen, as well as house dust mites. Apart from obesity (BMI 30 kg/m2), multiple pustules and excoriations on the skin, her physical examination was insignificant. Esophagogastroduodenoscopy (EGD) was performed revealing full-length but discrete trachealization of the esophagus. A barium swallow test showed slowing of esophageal peristalsis in the recumbent position. No esophageal pathology was observed. A histopathological analysis of mucosal samples revealed slight hyperplasia of the basal layer of the esophagus, and the stomach showed changes typical of chronic gastritis.ConclusionsIn summary, this clinical case illustrates that lymphocytic esophagitis, as a newly recognized entity, should be considered in the differential diagnosis of chronic dysphagia. Additionally, when treating allergic patients, clinicians should be aware that lymphocytic esophagitis, distinct from eosinophilic esophagitis, should be considered in the diagnosis of patients with atopy and upper gastrointestinal symptoms.

Multifactorial dysphagia: Azygos vein aneurysm (AVA) and esophagogastric junction outflow obstruction (EGJOO).

IntroductionVascular impingement of the esophagus is a rare cause of dysphagia, and is most commonly due to aortic arch anomalies such as arterial lusoria. Dysphagia resultant from venous compression is even further less likely.Presentation of caseWe present a highly unusual case of dysphagia secondary to a large aneurysm of the azygous vein near its confluence with the superior vena cava, which was managed with endovascular modalities. Despite initial treatment success, patient reported some intermittent solid food dysphagia, and was also found to have esophagogastric junction outflow obstruction (EGJOO) on high resolution impedance manometry (HRIM) which was successfully managed with surgical myotomy and partial fundoplication.DiscussionThe azygos vein has an intimate anatomic relationship with the esophagus as it traverses the posterior mediastinum. Because of this anatomic association, the azygos vein may present a point of esophageal obstruction in the setting of significant pathology.ConclusionThis case highlights the possibility of multifactorial causes of dysphagia, and that HRIM is a key aspect of this workup. Additionally we discuss the pertinent anatomy, diagnosis, and treatments for azygos vein aneurysm and EGJOO.