Normal Barium Swallow Research Articles

Diagnostic Accuracy Of Barium Swallow For Dysphagia, Keeping Rigid Esophagoscopy As The Gold Standard

Objective: To determine the diagnostic accuracy of Barium Swallow in detection of patients presenting with dysphagia.
 Study Design: Cross-sectional validation study.
 Study Setting & Duration: Department of Otorhinolaryngology, Head & Neck Surgery, District Headquarter Hospital Rawalpindi from 01-09- 2022 to 01-03-2023.
 Materials and Methods: Approval of the study was obtained from the Hospital Ethical Committee. A total of 111 patients both male and female patients were selected. The patients suffering from dysphagia as per operational definitions and who have reported for work-up to the Department of ENT, District Headquarters Hospital, Rawalpindi, and fulfill the complete inclusion and exclusion criteria, were selected. Informed consent was obtained from all the patients. Patients were selected by consecutive non-probability sampling technique. The data was analyzed using SPSS 24.
 Results: A total of 111 patients were included in this study. The mean age of these patients was 50.79 ± 13.01 years, ranging from 28 to 70 years. The frequency distribution of females 70.27 % was found to be more than that of males 29.73 %. Majority of patients' barium swallow (74.77%) revealed pathologies, while only a small percentage of patients (25.23%) had normal barium swallow. Most of patients (87.39%) had pathologies found during rigid esophagoscopy, while just a small number (12.61%) had normal rigid esophagoscopy. Comparing both investigating tools, esophagoscopy discovered 87.39% of pathologies while Barium swallow detected 74.77%, indicating that esophagoscopy was a more accurate procedure. Patients had esophageal web 55 (25.2%) on barium swallow and 69 (62.2%) on the Rigid esophagoscopy. Barium Swallow had esophageal stricture 28 (52.2) and no Pathology was detected in 28 (25.2 %) patients. As well as Rigid esophagoscopy had esophageal growth13 (11.7), esophageal stricture 15 (13.5), and no Pathology was detected in 14 (12.6 %). Rigid esophagoscopy is more efficient in detecting esophageal pathology than Barium Swallow. In Barium swallows most patients had esophageal web 55 (25.2%) than the esophageal stricture 28 (52.2) and no pathology was detected 28 (25.2). In rigid esophagoscopy most patients had esophageal web 69 (62.2%) than the esophageal growth13 (11.7), esophageal stricture 15 (13.5) and no pathology detected 14 (12.6).
 Conclusion: A range of diseases are associated with dysphagia can be found in patients. Two often used diagnostic methods are barium swallow and rigid esophagoscopy. Both Barium swallow and Rigid esophagoscopy are successful in the diagnosis of esophageal cancer. The use of a Rigid esophagoscopy is still a gold standard diagnostic and therapeutic tool for upper aerodigestive tract pathologies.

OA14 A case of scleromyxedema with muscle involvement including myotonia and dysphagia

Introduction/BackgroundScleromyxedema is a rare, para-neoplastic, progressive condition of the Lichen myxedematous family. It is clinically characterized by generalized papules with skin infiltration and underlying systemic disorders, which may be fatal as it still constitutes a therapeutic dilemma.Description/MethodWe are reporting a rare case of scleromyxedema presented to the rheumatology department mainly with dysphagia, weight loss, lower limb weakness and myotonia under dermatological and haematological review.Case description: In January 2011, a 49-year-old man who was diagnosed year earlier with papular mucinosis and paraproteinemia-M band 8g/l (Monoclonal gammopathy of undetermined significance (MGUS)) presented with dysphagia mainly for solid, weight loss about 10 kg over the period of three months without other B symptoms and stiffness mainly in the hands and hips when walking or opening a jar described as slow relaxation following contraction.On examination he looked well with full upper limb muscle strength. Scleromyxedmatous skin lesion in the form of multiple painful erythematous plaques and grouped papules involving his knees, elbows, dorsum of the hands and feet were appreciated. There were no telangiectasias or calcinosis. Neurological examination was unremarkable without muscle wasting or fasciculations, but there was a slow release of grip. Chest, heart, and abdominal examination was normal.There was marked improvement of his skin lesion on 50mg thalidomide up to 150 mg daily, however his condition, including the skin lesions fluctuated in severity. Overall, he exhibited a benign course. The myotonia seemed to improve over time.Discussion/ResultsInvestigations showed raised creatine kinase at 1200 with normal full blood counts, normal renal, liver, calcium, CRP, ANA, ANCA and thyroid function test, normal Anti GAD, normal anti-voltage-gated potassium channel antibodies, normal barium swallow, unremarkable CT scan of chest, abdomen, and pelvis. Bone marrow biopsy ruled out plasma cell proliferation, M band always stable at 8 to 10 g/l. There were typical myotonic discharges on EMG with normal NCS. Normal MD and PROMM at ZNF9 genes.Muscle biopsy showed several groups of very small atrophic fibres and patchy fibrosis with attempts of regeneration with PAS positive vacuoles deposition within the muscle fibres, replacing in places the majority of sarcoplasm with evidence of increased fibroblastic activity.Over three to four years post diagnosis he developed only mild weakness in shoulder abduction and neck flexion MMT8 77/80, his CK remained high with a range of 900 to 3000 U/L. His weight stabilized.Discussion: We present a rare case of scleromyxedema-associated with dysphagia, myotonia and muscle weakness. These symptoms in combination with cutaneous lesions raise the alternate diagnostic possibilities of systemic sclerosis-associated myositis, dermatomyositis, and myxedema. The diagnosis of scleromyxedema can be missed in this setting owing to the rarity of the disease. Histology can help make a definitive diagnosis; in our case mucinous material were demonstrated in the muscles as well as the skin lesions. Although cases of scleromyxedema remain rare, a better understanding of its mechanisms of action could have implications for the research and treatment of autoimmune conditions. As our case several authors have reported rheumatic features in association with scleromyxedema in the form of erosive seronegative rheumatoid like arthropathy, sicca complex, dysphagia with oesophageal aperistalsis and sclerodactyly with acrolysis.Key learning points/ConclusionThe pathogenesis of systemic findings in scleromyxedema remains unknown although aggressive therapy mainly in the form of corticosteroid, thalidomide and IVIG may provide disease control, the prognosis remains guarded due to the systemic complications and high relapse rate. We need further studies to look at the link between scleromyxedema and systemic features.

TU1.9 Oesophageal manometry and ambulatory pH monitoring prior to laparoscopic anti-reflux surgery – is it a necessity? An evaluation of a newly established anti-reflux surgery service at a district general hospital

Abstract Background Laparoscopic fundoplication is an effective surgical option for patients with symptoms of reflux refractory to proton-pump inhibitor (PPI) use. Oesophageal manometry and ambulatory pH monitoring are typically advocated as part of the evaluation of gastro-oesophgeal reflux disease, when anti-reflux surgery is considered. However, the requirement for these as a mandatory procedure remains controversial, particularly in the context of large hiatus hernia or presence of endoscopic reflux oesophagitis. Methods A retrospective review of all cases performed since the inception of the anti-reflux service at a single-centre district general hospital was undertaken. All patients who underwent an elective laparoscopic anti-reflux operation were included. Data pertaining to preoperative symptoms, preoperative investigations and postoperative outcomes (resolution of symptoms and PPI cessation) was collected. Results Over the three-year period, 22 anti-reflux operations were performed, of which 17 were followed up. The mean length of follow-up was 9.5 months. Most patients (91%) had typical reflux symptoms with a large hiatus hernia or endoscopic reflux oesophagitis. Only 4 (18.2%) patients underwent oesophageal manometry and ambulatory pH monitoring—each of these had either a normal preoperative OGD or barium swallow, or atypical symptoms. Alleviation of symptoms was achieved in 14 (82.3%) patients; 9 (52.9%) of which achieved complete resolution. PPI cessation was achieved in 12 (70.1%) patients, comparable with current literature. Conclusion Anti-reflux surgery can safely be performed without routine oesophageal manometry and ambulatory pH monitoring in the context of typical symptoms, a large hiatal defect or evidence of endoscopic reflux oesophagitis, as exemplified in our newly established anti-reflux service.

S473 High Prevalence of Esophageal Motility Disorders in Patients With Rheumatic Diseases

Introduction: While esophageal motor dysfunction is known to be associated with systemic sclerosis, the prevalence of esophageal dysmotility in other rheumatic conditions is not well known. The aim of this study was to examine the prevalence of esophageal motility disorders in rheumatic diseases. Methods: In this retrospective cohort study, adults with a diagnosis of a rheumatic disease [rheumatoid arthritis (RA), Sjogren’s syndrome, systemic sclerosis (SS), systemic lupus erythematous (SLE), mixed connective tissue disease (MCTD), idiopathic Raynaud’s phenomenon, and other], who underwent high-resolution esophageal manometry (HREM) were included. Demographics, clinical characteristics, rheumatic diseases and associated therapies, HREM findings, motility disorders per Chicago classification (CCv3.0) criteria and swallow characteristics, were extracted from the medical record. We analyzed the data using descriptive statistics to assess the prevalence and types of esophageal motor disorders amongst patients with known rheumatic conditions. Results: Of 118 patients, 80% were women, and 73% were white (Table). The most common esophageal symptoms were dysphagia (88%), heartburn (81%), and regurgitation (41%). Rheumatic diseases included RA (38%), Raynaud’s (30%), Sjogren’s (22%), SS (19%) and MCTD (11%). On HREM, 53% had an esophageal motility disorder per Chicago classification. Of note, 38% of the sample with a normal barium swallow had an esophageal dysmotility disorder on HREM. Esophageal hypocontractility (including ineffective esophageal motility, absent contractility, and fragmented peristalsis) was diagnosed in 29 patients (25%), achalasia and/or esophagogastric junction outflow obstruction were found in 25 (21%), and esophageal hypercontractility (including diffuse esophageal spasm and jackhammer esophagus) in 8 (7%). These esophageal disorders were found amongst rheumatic diseases including SLE, RA, Sjogren’s, SS, MCTD, psoriatic arthritis and Raynaud’s (Figure). Conclusion: Esophageal motor disorders were found in more than half of patients with rheumatic diseases who underwent HREM, even though many patients previously had a normal barium swallow. HREM should be considered in patients with rheumatic conditions who present with esophageal symptoms.Figure 1.: Disorders of Esophageal Motility by Rheumatologic DiseaseTable 1.: Patient Characteristics and Manometry Findings

S414 A Retrospective Review: Are We Under-Utilizing Barium Swallow Studies After a Normal EGD in Patients with Dysphagia?

Introduction: Upper endoscopy (EGD) is an effective tool in the initial evaluation of patients >40 years old presenting with dysphagia and concomitant heartburn, odynophagia, and weight loss. However, it can miss subtle esophageal strictures, motility disorders, and extrinsic abnormalities which may be diagnosed with barium swallow study, or esophagram. In this study, we assessed the utility of barium swallow exam in patients presenting with dysphagia who had a grossly normal EGD. Methods: A retrospective analysis was conducted at a tertiary hospital from January 2018 through March 2019. Patients presenting with dysphagia who underwent both an EGD and barium swallow study with a 13mm pill (either before or after EGD) were included. Patients with an abnormal EGD were excluded. We analyzed esophagram results in patients who had a grossly normal EGD, and data was examined with univariate analysis. Results: 67 total patients underwent both an EGD and barium swallow study, of which 27 had a grossly normal EGD. The mean age (SD) of our study population (N=27) was 56.1 years (15.5), with 16 males. Of the 27 patients, 9 (33.3%) had a normal barium swallow exam while 18 (66.7%) patients had an abnormal exam. 7 patients had findings consistent with oropharyngeal dysphagia, 7 revealed structural issues manifested by difficulty of passage of a 13mm pill suggesting gastroesophageal junction obstruction, 2 showed esophageal dysmotility characterized by tertiary contractions, and 2 patients were found to have gastroesophageal reflux disease on esophagram. Of note, 8 out of 27 patients underwent esophageal biopsies, of which 6 showed normal histology, however 3 of those patients were found to have structural abnormalities on esophagram. Esophageal biopsies were not taken in 19/27 patients, of whom 14 had abnormal findings on barium swallow study. Conclusion: Per ASGE guidelines, EGD is considered first-line for evaluation of dysphagia unless contraindicated. Barium swallow with a 13mm pill is another valuable diagnostic modality especially in patients with a normal EGD. Our study showed that barium swallow identified potential etiologies of dysphagia in 66.7% of patients with grossly normal EGD, which led to further work-up and/or treatment. We discovered structural abnormalities on barium swallow in 50% of patients with grossly and histologically normal EGD. Esophagram proved to be a helpful adjunct to EGD with biopsy in evaluating dysphagic patients, emphasizing its importance as a part of the diagnostic algorithm.Table 1.: Patient Demographics and Barium Swallow Study Results (N=27)

Diagnostic yield of barium swallow on the face of normal oesophagoduodenogastroscopy

Introduction: We aim to investigate the diagnostic benefit of barium swallow in patients who have already undergone oesophagoduodenogastroscopy (OGD), with normal findings. Materials and Methods: Data were collected for clinical indication and results of barium swallow. These were compared with the OGD findings and recorded on an excel spreadsheet. The time period was August 2016–November 2016 (15 weeks). Results: One hundred and nine cases were identified. Of those, 33 were excluded as they did not have an OGD during the period of a barium swallow. A total of 76 were reviewed. There were 51 females and 25 males. The median age was 57 years (21–97 years).Analysis of barium swallow findings in patients with normal OGD:23/76 (30%) of these patients had a normal OGD examination, 14 (61%) of which showed pathology on the barium swallow that was not picked up on OGDThe range of pathologies identified in these cases with barium swallow includes HH: 2, HH with reflux: 2, mild-to-moderate reflux: 6, motility disorder: 2, oesophageal web: 1 and gastric polyp: 1Indications for barium swallow in addition to the above normal OGDs were dysphagia (including five suspected dysmotility) (13), reflux (8), dysphagia and reflux (1) and abdominal pain (1)Seven out of nine reflux presentations showed confirmed reflux on barium swallow. One out of five suspected dysmotility showed likely dysmotility on barium swallow. Seven out of 13 dysphagia presentations showed normal barium swallow, 2 out of 13 showed possible dysmotility, 3 showed reflux and 1 oesophageal web.Conclusion: Barium swallow can be a useful additional diagnostic test, even when OGD findings are normal, in patients with symptoms of dysphagia, reflux and dysmotility.

Abnormal Esophageal Distension Profiles in Patients With Functional Dysphagia: A Possible Mechanism of Dysphagia

Dysphagia is common in the general population. Many patients with dysphagia have normal endoscopy, barium swallow, and esophageal manometry findings. Rome classification classifies these patients into the category of functional dysphagia (FD).1 Each swallow induces a wave of esophageal inhibition/distension followed by contraction, both of which travel from the top to the bottom of the esophagus in a sequential or peristaltic fashion.2,3 High-resolution esophageal manometry (HRM) and the Chicago classification assess only the contraction phase of peristalsis.

S2006 Hypercalcemia as a Cause of Dysphagia

INTRODUCTION: Severe hypercalcemia, (levels greater than 12 or 13 mg/dL) can manifest with gastrointestinal symptoms such as nausea, anorexia, constipation and pancreatitis. Hypercalcemia inhibits neuromuscular depolarization, and is associated with decreased smooth muscle tone and autonomic dysfunction. Even though hypercalcemia-induced dysphagia has been rarely described in the literature, this might be one of the mechanisms by which dysphagia may occur. CASE DESCRIPTION/METHODS: A 70-year-old male with a past medical history of diabetes mellitus, Hepatitis C, chronic kidney disease and multiple myeloma with metastases to spine, presented to the hospital due to progressive dysphagia to solids and liquids. He had a hospitalization for symptomatic hypercalcemia about a month prior, when his corrected calcium (Ca) level was 13.6 mg/dL. He had noticed resolution of his dysphagia after being treated for hypercalcemia, but had recurrence of symptoms a couple of weeks prior to this presentation. He denied odynophagia, but reported regurgitation. His corrected Ca level during this admission was 12.1 mg/dL, with ionized Ca of 1.44 mmol/L. A chest x-ray was normal. Further workup with a barium swallow did not show any evidence of mechanical obstruction (Figure 1). An MRI of the spine did not show evidence of esophageal compression, but revealed known osteolytic lesions in spine. He was treated with intravenous fluids and Pamidronate with normalization of Ca level and complete resolution of dysphagia. DISCUSSION: There have been few case reports of patients with dysphagia and hypercalcemia of malignancy (HCM), in which symptoms resolved with treatment of hypercalcemia. The reason why dysphagia only affects some patients with elevated Ca remains unknown. It could be an under recognized or a rare complication. The heterogeneity of skeletal and smooth muscle distribution in the esophagus could also explain variability in presentation. There is not enough data about dysphagia and hypercalcemia from benign etiologies. This is possibly due to lower levels of Ca in these cases compared to cases with HCM. Furthermore, contribution of hypercalcemia towards dysphagia in cases with external compression of the esophagus by a benign tumor cannot be entirely ruled out. Due to a possible causal relationship between HCM and dysphagia, it might be reasonable to treat hypercalcemia prior to attempting invasive diagnostic procedures such as endoscopy.Figure 1.: Normal barium swallow in patient with dysphagia and corrected calcium level of 12.1 mg/dL.Table 1.: Corrected Calcium Level and Work-Up in Patients with Dysphagia and Hypercalcemia. Case 1 shows calcium level and diagnostic work-up from patient admitted to our hospital (a). Cases 2 and 3 were previously reported by Grieve et al. Case 4 was previously reported by Balcombe et al. N/A = not applicable.

Esophageal Squamous Papilloma: A Case Series

Introduction Esophageal squamous papilloma (ESP) is a rare neoplasm, usually appearing as an incidental finding in 0.01-0.45% of EGDs. The prevalence has increased over the last 10-15 years. ESP arises from a chronic inflammatory reaction related to GERD, smoking, alcohol, food impaction, caustic or mechanical injury, or HPV infection. They are reportedly more common in middle-aged men. We present 2 cases found in women. Case 1 A 61 year old female with no significant medical or surgical history presented with a 6 month history of progressive dysphagia to solids and liquids. She had occasional vomiting and epigastric pain after eating. Review of systems was otherwise negative. The patient was a nonsmoker, without significant alcohol use. Her medications included a multivitamin and lansoprazole. Physical exam was unremarkable. She had a normal barium swallow study. An EGD revealed esophagitis and a single 2 mm polyp in the proximal third of the esophagus. Pathology showed ESP. Case 2 A 19 year old female with history of lupus, Sjogren's syndrome and GERD presented with intermittent dark hematemesis over the past 1 month. She denied abdominal pain, hematochezia or melena. Her medications included mycophenolate, hydroxychloroquine, prednisone, ranitidine, and celecoxib. She had no significant past surgical or family history. Vital signs and physical exam were unremarkable except for heme-positive stool on rectal exam. Labs were notable for severe anemia with hematocrit of 14.9%. An EGD revealed esophageal ulcers and multiple polypoid masses in the distal esophagus, the largest of which was biopsied and found to be squamous papilloma. HPV testing was negative. Discussion ESPs are typically asymptomatic, but can present with an array of clinical manifestations as demonstrated by the cases above. The ESP in case 1 was an incidental finding. Due to its small size, it is unlikely to have contributed to the patient's dysphagia. Conversely, in case 2, the ESP likely developed in response to corrosive reflux. The polypoid area was friable, and likely caused her anemia. Although ESP is benign, there is controversy about its malignant potential. HPV is present in 5-50% of ESPs, and may play a role in malignant transformation of ESP. Because data is lacking on ESP as a premalignant lesion, endoscopic removal is recommended. Long-term follow up of ESP is needed to better understand their potential for progression to malignancy and surveillance after removal.Figure: The 2 mm ESP described in Case 1 is shown in endoscopic view (panel A) and on H&E staining, demonstrating the branched appearance of the papillae underlying the esophageal mucosa (panel B).Figure: This is an endoscopic image from Case 2 depicting an ulcerated multi-polypoid mass which was histologically identified to be a squamous papilloma. The yellow arrows indicate site of biopsy.

Laparoscopic Retrogastric Median Arcuate Ligament Release

Introduction: Median arcuate ligament syndrome (MALS), originally described in 1963 by Harjola, is defined as compression of the celiac axis by an abnormal median arcuate ligament (MAL), characteristically causing postprandial abdominal pain and weight loss. Patients may also complain of nausea, diarrhea, and food aversion. Here we describe a laparoscopic technique for release of the MAL through a retrogastric or retrograde technique. Materials and Methods: We describe a case of an 18-year-old male with MALS, characterized by abdominal pain, 20 kg weight loss, and food aversion. On work-up, he was found to have a normal barium swallow and esophagogastroduodenoscopy. Nuclear gastric emptying study was normal. Abdominal ultrasonography revealed elevated velocities and CT angiogram showed compression of the celiac axis with velocities greater than 200 cm/s. He was taken to the operating room for release of his MAL through a laparoscopic retrogastric approach. Results: Our patient was taken to the operating room for a retrogastric MAL release. This was performed with five trocars including a liver retractor. The MAL was approached by retracting the stomach anterior. The initial goal is to identify the left gastric, hepatic, or splenic artery and then follow one or all of those branches back to the celiac trunk and aorta where the MAL can be identified and divided. He was admitted after surgery, advanced to regular diet, and discharged home on postoperative day 2. He has returned to clinic on multiple occasions for follow-up. He reported complete resolution of his symptoms, including abdominal pain and food aversion. He has recovered the majority of his weight loss at 3 months. Discussion: Traditionally, MAL is approached through laparotomy through the gastrohepatic ligament, with dissection continued through the fibrous MAL found in proximity to the diaphragmatic crura at the origin of the celiac artery.1 Laparoscopic MAL release is becoming more common and can be approached through the antegrade or retrograde (retrogastric) approach.2 The retrogastric approach has the advantage of a better angle of dissection along the aorta and a better angle to divide the MAL as it arches over the celiac trunk. The observation of the origin of the celiac and its branches with the stomach retracted anteriorly is also excellent using this approach. Conclusion: MALS is an uncommon cause of abdominal pain. Here we describe a novel approach to the release of the MAL by utilizing laparoscopy and approaching the celiac axis from beneath the stomach, providing a unique surgical exposure. No competing financial interests exist. Runtime of video: 4 mins 26 secs This research was presented at the American Pediatric Surgery Association in 2015.

The Role of Barium Swallow Pharyngoesophagography in the Management of the Globus Pharyngeus: Our Ten Years Local Experience of Asian Population

Patients with globus pharyngeus referred for barium swallow pharyngoesophagography in a local hospital from 1/7/1999 to 30/6/2009 were identified. Their fluoroscopic images were reviewed, and their outcomes were used as gold standard. A total of 908 patients with globus pharyngeus were referred for barium swallow in the period. There were 783 patients with normal barium swallow and 125 patients with abnormal barium swallow findings. All patients aged below 30years had normal barium swallow result and unremarkable follow up. The sensitivity and specificity of barium swallow were 25.6 and 97.5% respectively; and the positive predictive value and negative predictive value were 61.5 and 89.1% respectively. The overall accuracy was 87.6%. Barium swallow is of limited diagnostic value in patients with typical globus pharyngeus, and it is not recommended in these patients, especially with young age.

The Natural History of Globus Pharyngeus

Globus pharyngeus is a common disorder and accounts for 5% of all ENT referrals. Objectives. To evaluate the role of barium swallow and endoscopy in these patients, to ascertain the incidence, if any, of aerodigestive tract malignancy in this group and to assess the natural evolution of globus pharyngeus. Materials and Methods. Seventy-nine patients underwent barium swallow and rigid oesophagoscopy for globus pharyngeus between January 2005 and October 2008. Fifty-five patients were contacted by phone on average 5 years and 3 months after intervention and asked if their symptoms still persisted. Twenty-four patients were uncontactable or lost to followup, three patients were deceased, two of cardiac related disease and one of renal failure. Results. The majority of patients, 36 of 55 (65%), had a normal barium swallow. Forty-five of 55 (82%) of patients had normal rigid endoscopies. Thirty-one of 55 (56%) patients were at an average followup time of 5 years and 3 months. No patient developed a malignant lesion. Conclusion. Globus pharyngeus is a relatively common but benign condition of indeterminate origin. Our study demonstrates that many of these patients spontaneously improve with time.

Chronic cough and Holmes-Adie syndrome

In April, 2006, a 45-year-old white man—a lifelong nonsmoker—was referred to the Royal Brompton Hospital Cough Clinic. In October, 2002, he had presented to his general practitioner with a persistent dry cough. The cough had started in March, 2002, after a bout of pneumonia. In addition, he claimed to have night sweats but no systemic symptoms. Auscultation of his chest, and a chest radiograph were normal, and he had a negative (grade 1) tuberculin skin test. In January, 2003, he was referred to his local chest clinic, where further inves tigations including lung function and CT of the chest were normal. He was reassured and discharged. In June, 2004, he presented to his local eye clinic complaining of blurred vision. Anisocoria was noted with an enlarged tonic left pupil (fi gure) and near light dissociation. Ankle tendon arefl exia was present on the right and elicited on the left only with reinforcement. He was diagnosed with Holmes-Adie syndrome—a condition of unknown cause characterised by tonic pupillary reactions and absent tendon refl exes. In August 2004, he was re-referred back to his local chest clinic because his dry cough persisted. Empirical treatment with omeprazole 20 mg daily was started and he underwent a normal barium swallow. Over the course of the following year, with no improvement in symptoms, he was prescribed an inhaled antimuscarinic bronchodilator (oxitropium bromide), an oral H1-anti histamine (loratadine), and he was given a trial of an H2-receptor antagonist (ranitidine) for 1 month, with no eff ect. When seen by us in April, 2006, his cough had persisted and he reported that during one coughing paroxysm he had experienced syncope. Direct questioning revealed truncal and right arm hyperhydrosis with excessive sweating in the right armpit. Respiratory, nasopharyngeal, and cardiovascular examinations were unremarkable. In particular, the patient had no evidence of dry eyes, dry mouth, or skin changes that might suggest a diagnosis of Sjogren’s syndrome. VDRL, autoantibody screen, and fasting blood sugar were negative. CT of the chest, full lung function (including histamine challenge, nitric oxide, and reversibility testing), nasolaryngo scopy, cinevideo fl uoroscopy, and 24-hour oesophageal pH monitoring were all normal. The patient declined fi breoptic bronchoscopy and capsaicin cough challenge. Treatment with high-dose inhaled corticosteroid (fl uticasone propionate 1000 μg daily) delivered from a pressurised metered-dose inhaler and spacer attachment, induced paroxysms of cough. Two separate courses of high dose oral steroids provided no improvement in either symptomatology or diurnal peak expiratory fl ow rate measurements. The addition of a non-selective oral H1-antihistamine treatment (chlorphenamine maleate 4 mg four times a day) was of no additional benefi t. As of September, 2006, the patient is still symptomatic and awaiting neurological consultation including cardiovascular autonomic testing. Kimber and colleagues, have reported an association between Holmes-Adie syndrome and chronic cough. Our patient showed early signs of autonomic neuropathy as his cough developed, including anisocoria, hyperhydrosis and syncope. The mechanism behind the cough is poorly understood, but it has been proposed that selective loss of thinly myelinated aff erent nerves in the lung, trachea, and larynx leads to denervation hypersensitivity of secondary neurons in the nucleus solitarius. Although the patient undoubtedly had a trigger episode precipitating his chronic cough (the original episode of pneumonia), the presence of an autonomic neuropathy may well explain the persistence of his symptoms. This case also highlights the diffi culty in treating patients with no apparent cause for their cough. Although chronic idiopathic cough and Holmes-Adie syndrome are both of unknown cause, recognition of this association has led to a more accurate diagnosis and, in this case, an appropriate tertiary specialist opinion.

Is Upper Gastrointestinal Endoscopy Necessary Following a Normal Barium Swallow for Evaluation of Dysphagia?

Is Upper Gastrointestinal Endoscopy Necessary Following a Normal Barium Swallow for Evaluation of Dysphagia?

The short- and long-term efficacy of empirical esophageal dilation in patients with nonobstructive dysphagia: a prospective, randomized study

OBJECTIVE: The efficacy of empirical esophageal dilation for nonobstructive dysphagia (NOD) is unknown. Our aim was to assess the efficacy and safety of empirical dilation with a large bougie in patients with NOD. METHODS: Patients with NOD (normal barium swallow, free passage of a 13-mm barium pill, and normal esophagogastroduodenoscopy) were randomized to dilation with either a 50-Fr (Group A) or 26-Fr (Group B) Maloney dilator. Before dilation, the dysphagia (DyspSC) and diet (DietSc) scores were recorded and an esophageal manometry performed. Both scores were reassessed at 1, 3, 7, and 14 days after dilation. Success was defined at day 14 as an improvement in the DietSc of at least 25% from baseline, or a DyspSc of ≤3. Nonresponders were crossed-over to the alternate dilator and restudied. RESULTS: Twenty-three patients (58.7 ± 1.9 yr) were enrolled: 13 in Group A and 10 in Group B. Both groups were matched for age, baseline DyspSc (4.2 ± 0.6 vs 3.8 ± 0.5), baseline DietSc (13.3 ± 1.7 vs 12.0 ± 1.9), and manometric findings. A nonspecific motility disorder was seen in 43.4% patients. Group A had an initial response rate significantly greater (84.6%) than Group B (40%) ( p = 0.03; odds ratio [OR] = 8.25). The DyspSc and DietSc were better than baseline with both dilators, but only the DietSc improved significantly in patients dilated with the 50-Fr dilator (5.3 ± 1.9 vs 12.3 ± 1.4; p = 0.004). At 2 yr, 80% of the patients responding to the 50-Fr Maloney had a sustained response. CONCLUSION: Empirical dilation with a large (50-Fr) bougie is safe, effective, and long-lasting in improving nonobstructive dysphagia.

Barium swallows after free jejunal transfer: should they be performed routinely?

Fistula formation after free jejunal transfer for pharyngoesophageal reconstruction is a serious complication with potentially critical consequences. Barium swallow is used postoperatively to check for anastomotic competence before feeding but has been unreliable as a predictor of leak at our institution. The objective of this study was to evaluate the role of routine postoperative barium swallow in 41 consecutive jejunal transfers. Thirty-nine patients who underwent 41 consecutive free jejunal transfers had a routine barium swallow performed between postoperative days 12 and 17. Radiologic findings and clinical outcome were evaluated and correlated. All barium swallows were reviewed by a single experienced radiologist in a blinded fashion. One total and one partial flap failure necessitated a second free jejunal transfer. Pharyngocutaneous fistulae developed after nine free jejunal transfers, of which the barium swallow was normal in four (44 percent) and showed a leak in five (56 percent). In the 32 free jejunal transfers with no clinical leaks, 6 (19 percent) had radiologic leakage of contrast. Thus, barium swallow was normal in 30 patients and showed leakage in 11 patients. Normal barium swallow correlated with uncomplicated clinical course in 26 of 30 cases. In the remaining four cases (13 percent), however, a delayed fistula developed, which was secondary to flap necrosis in one case (negative predictive value 87 percent). On the other hand, radiologic leaks corroborated clinical fistula in 5 of 11 cases (45 percent), whereas no fistula developed in 6 cases (positive predictive value 46 percent). Of the five patients with clinical fistulae, four had early leaks (within 1 week), and the barium swallow did not provide additional information. The fifth patient developed a delayed leak 2 weeks after the barium swallow. Review of these barium swallows at the time of this study reversed the initial report of leakage in three patients, improving the predictive value to 63 percent. These patients had an uncomplicated clinical course. The positive predictive value of clinical assessment alone was 63 percent. We conclude that barium studies following free jejunal transfers can be difficult to interpret, but an experienced radiologist can improve their accuracy. A normal barium swallow, however, does not ensure an uneventful clinical course. Similarly, radiologic leaks do not imply a clinical complication of fistula. Clinical judgment should therefore be exercised in initiating oral intake after free jejunal transfer. Barium swallow should be used only as an adjunct to aid in patient management.

Primary tuberculosis of the oesophagus

There are only a few cases of primary tuberculosis of the oesophagus described in the literature. We report a 55-yearold Asian man who presented with dysphagia and at endoscopy appeared to have a carcinoma of the oesophagus. The patient reported an 8-month history of weight loss and dysphagia. Endoscopy showed a large, ulcerating, polypoid lesion, 25 cm from his incisors, with appearances typical of a carcinoma (figure, top). Histology of the lesion showed inflammatory exudate in the sub-mucosa with discrete epithelioid granulomas (figure, bottom). No acidfast bacilli were seen. Further questioning revealed a history of fever and night sweats but no known contact with tuberculosis. He had lived in the UK for the past 8 years. Examination was unremarkable and his chest radiograph was normal. A barium swallow confirmed mucosal irregularity, but showed no other abnormality. He had a mild normocytic anaemia with a raised erythrocyte sedimentation rate (30 mm/h). He was also noted to be hyponatraemic (120 mmol/L) and hypoalbuminaemic (30 g/dL). The next day he had a high fever and became drowsy. He was noted to have a transient, partial, left third-nerve palsy. Computed tomograph of his brain showed an area of contrast enhancement around the right sylvian fissure but no other abnormality. There was raised protein (2·44 g/dL) in cerebrospinal fluid and a lymphocytosis (120 cells 10/L). A diagnosis of tuberculous meningitis was suspected and antituberculosis treatment was started. Subsequently, gastric washings were found to contain acid-fast bacilli. Mantoux test and cultures were negative. He made an uneventful recovery. Most oesophageal tuberculosis appears to be secondary to spread from surrounding structures. This patient had a normal chest radiograph and barium swallow showed no evidence of extrinsic involvement. The development of tuberculous meningitis was considered a secondary phenomenon, perhaps related to the biopsy, 10 days earlier. When primary tuberculous oesophagitis does occur it may affect a previously abnormal mucosa. There was no suggestion of this in our case. The rarity of primary tuberculous oesophagus may be related to oesophageal protective mechanisms such as rapid transit and peristalsis as well as the natural defence of smooth squamous epithelium and swallowed saliva. Dysphagia is the most common presenting symptom and the endoscopic appearance often mimics carcinoma. This case underlines the important message that tuberculosis should always be considered when cancer is suspected, especially in at-risk populations.These include not only people migrating from endemic areas but also the increasing number of individuals infected with HIV.

Modified barium swallow does not affect how often PEGs are placed after stroke.

Dysphagia frequently follows stroke, but often resolves quickly. Percutaneous endoscopic gastrostomy (PEG) or other feeding tubes are placed to improve nutrition and hydration, and reduce the risk of aspiration pneumonitis. We evaluated the impact of modified barium swallow in determining PEG placements and the influence of specific swallowing abnormalities on PEG placement. The abnormalities assessed were presence of pharyngeal stasis and/or visualization of posterior pharyngeal transfer problems and aspiration of liquid or solids. A total of 302 patients with stroke were admitted to our hospital between 1989 and 1993, but only those with hemorrhagic or nonhemorrhagic stroke by computed tomographic (CT) scans or magnetic resonance imaging (MRI) or autopsy were included in our study. Patients with transient ischemic attacks (TIAs), central nervous system tumors, and traumas were excluded. Barium swallow studies were performed on 69 (23%) of patients; 49 (71%) were abnormal, based on aspiration of barium, pharyngeal stasis, or postpharyngeal transfer dysphagia. PEGs were placed in only 18% of those with abnormal studies. Of the patients with normal barium swallow studies, 25% had a PEG placed. Two hundred thirty-three patients underwent no barium swallow studies, but 11 (4.72%) of these had PEG placed. The rate of PEG placement was not related to any one of the abnormalities noted on the modified barium swallow. Rather, patients who received PEG had significant neurological deficits and increased prevalence of aspiration pneumonitis. The decision to insert PEG was made on clinical grounds and not on abnormal barium studies alone.

A prospective psychological evaluation of patients with dysphagia of various etiologies

We hypothesized that patients who complain of dysphagia without demonstrable organic abnormality may have an underlying psychological dysfunction. We thus conducted a comprehensive assessment in three groups of patients with dysphagia. Dysphagia was classified as obstructive (Obst) when an obstructive lesion was present on esophagoscopy or barium swallow, motility-related (Mot) when abnormal motility was shown on esophageal manometry in the presence of normal esophagoscopy or barium swallow, or nonobstructive, nonmotility-related (NONM) when manometry and esophagoscopy or barium swallow were both normal. We prospectively evaluated 71 patients with Obst-dysphagia, 15 patients with Mot-dysphagia and 10 patients with NONM-dysphagia with a battery of standardized psychological tests including the Minnesota Multiphasic Personality Inventory (MMPI), the Symptom Checklist-90-Revised (SCL-90-R), and the Millon Behavioral Health Inventory (MBHI). The results indicate that patients with NONM-dysphagia have psychological attributes similar to those found in patients with Obst-dysphagia or Mot-dysphagia. Combination of scores for parameters such as somatization, depression, and anxiety could not distinguish among the three groups of dysphagia patients. We thus conclude that patients with NONM-dysphagia, as a group, have similar psychological profiles compared to patients with dysphagia due to organic causes.

Solid-state computerized manometry improves diagnostic yield in pharyngeal dysphagia: simultaneous videoradiography and manometry in dysphagia patients with normal barium swallows.

Dynamic barium radiology with cine- or video recording has been the most frequently used technique for assessing patients with pharyngeal dysphagia. Although the diagnostic yield of the barium swallow has been high, many patients with pharyngeal dysphagia have normal dynamic barium radiology and remain a diagnostic dilemma. Could manometry add important diagnostic information in these patients? We examined 19 patients (12 men and 7 women, mean age 47 years, range 19-69 years) with pharyngeal dysphagia but a normal barium swallow with simultaneous videoradiography and pharyngeal manometry and compared their manometry to that found in 24 normal volunteers (11 men and 13 women, mean age 37 years, range 23-59 years). Comparing mean values, the patient group showed statistically significant differences from the control group for eight of 10 manometric parameters. Fourteen of 19 patients showed at least one (five patients) and in most cases multiple (nine patients) manometric abnormalities (values exceeding normal mean by +/- 2SD) which might have contributed to their dysphagia: five patients with high upper esophageal sphincter (UES) resting pressures, five with high UES residual pressures, three with weak pharyngeal contractions, three with pharyngeal "spasms," seven with prolonged contraction/relaxation times, five with reduced compliance, and seven with UES/P incoordination. Solid-state computerized manometry is a useful adjunct to videoradiography and can provide potentially important additional information in the diagnosis of dysphagia patients.