Occasional Alcohol Use Research Articles

Cyclic Vomiting Syndrome (CVS): A Management Challenge Across the Ages

Purpose: Case Report: A 17-year-old male presented to the ED with midepigastric pain and recurrent vomiting. He has had multiple prior episodes presenting similarly, occurring 1-2 times per month for the last 6 years. He and his family have a history of migraines, and asthma. He takes ondansetron 4m g and sumatriptan 5 mg as needed. He admits to occasional alcohol and marijuana use. Review of systems is negative except for nausea, repeated episodes of vomiting, and moderate midepigastric pain, present only when he is vomiting. His last bowel movement was one day prior to presentation, and he has had no diarrhea or hematochezia. Physical exam revealed a healthy appearing young male actively vomiting, with midepigastric tenderness and an otherwise nonacute abdomen. Laboratory work up was unremarkable except for bicarbonate of 18, AST 125, and ALT 98. KUB showed normal bowel gas pattern with no evidence of obstruction or ileus. Discussion: CVS is a functional disorder that consists of recurrent paroxysms of nausea and vomiting separated by symptom free periods, with an average of 12 episodes per year. Onset generally occurs before the age of 5. CVS is an under recognized disorder that has no laboratory, radiographic, or endoscopic markers. Acute management focuses on attempting to abort the attack and decrease symptoms while preventing the complications of prolonged vomiting. Sumatriptan can be beneficial initially. Intravenous fluid containing glucose, which limits ketosis, can be effective in terminating attacks. Intravenous ondansetron has been shown to decrease the duration of episodes by more than 50%. Standard antiemetic agents such as prochlorperazine and promethazine are seldom effective, and have the associated risk of extrapyramidal symptoms. Sedation and anxiolysis with agents such as lorazepam is important, as sleep decreases vomiting frequency. Proton pump inhibitors or H2 blockers should also be considered for children with prolonged or frequent episodes of vomiting. Numerous medications are used for prophylaxis, although the quality of evidence to support these agents is limited to anecdotal reports and poorly controlled clinical trials. Antimigraine medications may be effective in those with a family history of migraines. Anticonvulsants, tricyclic antidepressants (TCA'S), carnitine and erythromycin have been reported as effective in limited trials. It is recommended to use a sequential trial of agents starting with the safest agents first (pizotifen, cyproheptadine, propranolol, carnitine), before progressing to TCA's or anticonvulsants. Further management focuses on controlling episode triggers like anxiety, stress, infection, exercise, trauma, menstruation, or other triggers.

Return of the usual suspect

In October, 2010, a 76-year-old woman born in the USA presented to our emergency department complaining of a severe sore throat and painful swallowing. She reported having had a non-productive cough without haemoptysis 1 month previously. The cough resolved, but a sore throat then developed. At the time she was assessed by her general practitioner and specialists in the emergency and otolaryngology departments, who diagnosed pharyngitis and recommended conservative management. Her odynophagia progressed until she was unable to eat solid foods, prompting her to present to our hospital. She denied fevers, chills, night sweats, myalgias, dysphonia, dyspnoea, or dysphagia but did report a 7 kg weight loss. She also reported occasional tobacco and alcohol use. On examination she was afebrile and thin but appeared well. She had dry mucous membranes and mild erythema of the posterior pharynx without tonsilar enlargement or exudate. No oral thrush, cervical lymphadenopathy, rales, splenomegaly, or rash were noted. Leucocyte concentration was 7·9 × 109/L with a predominance of neutrophils. She was admitted for further assessment. Rapid streptococcal antigen test, monospot test, human immunodefi ciency virus (HIV) antibody test, and rapid antigen test for infl uenza A and B were negative. A temperature of 38·7°C prompted a chest radiograph, which showed bilateral airspace disease and an area of dense consolidation in the right upper lung with a rounded lucency likely to be cavitation (fi gure A), subsequently confi rmed on chest CT (fi gure B). CT of her neck showed non-specifi c epiglottis oedema. Purifi ed protein derivative skin test was negative. A few acid fast bacilli were present in the sputum, and she was started on empiric therapy for presumed pulmonary tuberculosis. DNA probe performed on sputum confi rmed Mycobacterium tuberculosis which was sensitive to all antituberculous drugs tested. Subsequently, her fever and odynophagia resolved. Laryngeal tuberculosis was the most likely cause of our patient’s sore throat as evidenced by her clinical symptoms and presumed active pulmonary tuberculosis, the non-specifi c oedema of the epiglottis noted on CT, and the resolution of her sore throat and odynophagia with antituberculous therapy. However, a defi nitive diagnosis cannot be made without laryngoscopy and histopathological confi rmation; laryngoscopy was deferred because of the substantial infectious risk associated with the procedure in the setting of active tuberculosis. She was discharged with instructions for tuberculosis testing of close contacts and plans for direct observed therapy. At last contact in February, 2011, she was well, with no recurrence of symptoms. Laryngeal tuberculosis, which accounted for 25% of all cases of tuberculosis in the early 20th century, now accounts for less than 1% of cases and is typically associated with pulmonary infection. Whereas extrapulmonary tuberculosis occurs frequently in persons with HIV, cases of laryngeal tuberculosis have been reported in immunocompetent persons. Our patient presented with odynophagia, a common presenting complaint in patients with laryngeal tuberculosis, but she denied hoarseness, the most common presenting symptom. She denied any history of tuberculosis or known contact with persons with tuberculosis, but she did report having worked as a home health aide during the 1970s. Laryngeal tuberculosis results from either direct bronchogenic spread from infected sputum or, less commonly, haematogenous spread. Laryngeal tuberculosis is highly infectious, and a delay in diagnosis can lead to disease progression and longer exposure to contacts. Therefore, physicians should consider laryngeal tuberculosis in the diff erential diagnosis of patients presenting with a persistent sore throat and odynophagia, especially in patients such as ours who also report weight loss. A chest radiograph should be considered before laryngoscopy to minimise unnecessary risk to healthcare providers.

Illicit Drug, Ischemic Bowel

h m 2 PRESENTATION In the young adult or middle-aged patient with abdominal pain and bloody diarrhea, a history of cocaine abuse is an important consideration in the differential diagnosis, as illustrated in this case. A 44-year-old male construction worker presented to our general medicine clinic reporting 1 year of recurrent, sharp, left-sided abdominal pain associated with frequent loose stools. For a few days before presentation, he had been unable to sleep because of the pain. The painful episodes were associated with some rectal bleeding and a documented weight loss of 40 lb but no nausea, vomiting, abdominal distension, food intolerance, or change in appetite. The patient denied urinary problems (hematuria, frequency, urgency, dysuria) and fever. His medical and surgical history were unremarkable except for an appendectomy 15 years previously; he had never had a colonoscopy. His social history was significant for smoking (20 pack-years) and occasional alcohol use. He denied use of illicit drugs.

A Snowflake-Like, Powdery Substance on the Head and Neck of an Adult Male

Patient: 53-year-old African-American male Chief Complaint: Shortness of breath, lower extremity swelling, nausea, vomiting, diarrhea, altered taste sensation, and decreased urine output. History of Present Illness: Patient presented to the emergency room (ER) with complaints of nausea and vomiting for 2 months, shortness of breath for the last few days, altered taste sensation, and worsening of preexisting lower extremity swelling. Other complaints included blurred vision, diarrhea, and extreme weakness. Past Medical and Surgical History: Type II diabetes mellitus and hypertension for about 10 years. No significant surgical history. Social History: No tobacco use, occasional alcohol use, and no IV drug abuse. Physical Exam Vital Signs: Temperature, 97.7°F; respiratory rate, 20/minute …

Knowledge of Substance Abuse Among High School Students in Jordan

The purpose a descriptive design was employed using a self-administrated questionnaire to collect the data from 400 high school students. A multistage, random sample was generated in selecting schools from the educational directorate located in a large urban city located in the north of Jordan. This city district contains 23 public secondary schools and serves 56.8% of the adolescents in the entire province. The results revealed the following: Students of both sexes were knowledgeable about aspects of substance abuse, including its harmful effects on the body and society and reported that even occasional or frequent use of cigarettes, alcohol, and other drugs was extremely harmful. A majority of the students perceived substance abuse as a problem, although the older students were more acutely aware than the younger group. However, the results revealed that the students lack in-depth knowledge of substance abuse. In addition, the adolescents consistently refer to Islamic principles forbidding use of intoxicants but mistakenly presume that mosques are sources for assistance regarding substance abuse. Policy makers, health workers, and religious leaders must collaborate to build structured educational programs and readily accessible, evidence-based treatment programs for adolescents. Given that young people constitute the majority of the Jordanian population and that drug trafficking is prevalent in the region, the implications of prevention programs are critical to maintaining gains in public health outcomes as well as economic progress and development in Jordan.

Colonoscopy-Associated Pneumothorax

Purpose: Colonoscopy is associated with very few complications. We present a unique case of a pneumothorax in a patient that was found in association with an elective diagnostic colonoscopy. Methods: A 30 year old, otherwise healthy woman, was referred by her primary care physician to us for evaluation of chronic constipation. She complained of constipation associated with occasional abdominal pain and nausea. She had to strain with every bowel movement and use laxatives regularly. She had a caesarian section around 14 years ago. She had a 12 pack-year history of smoking with occasional use of alcohol, and no use of opiates or any other recreational drugs. She was found to have a body mass index of 27.4 and a normal physical examination except for a small external hemorrhoid in the perianal region. An elective diagnostic colonoscopy was done for evaluation of chronic constipation of unknown etiology. Results: During the procedure, the recto-sigmoid junction was found to be acutely angled and hypertrophied necessitating a switch from a pediatric colonoscope (PCF-160 Olympus video colonoscope) to an upper endoscope (Olympus GIF-QX140). The colon proximal to the recto-sigmoid junction was dilated and tortuous. Following the procedure, the patient complained of abdominal pain, distension and was not able to pass flatus. A computed tomography (CT) of the abdomen showed no evidence of colon perforation, however, showed a moderate right-sided pneumothorax. The pneumothorax gradually increased in size over the next few days which required insertion of a chest-tube. Chest X-rays following the tube placement showed rapid re-expansion of the lung with resolution of the pneumothorax. Conclusion: The description of pneumothorax in association with colonoscopy is restricted to only a few case reports. The mechanism of pneumothorax in this case is unclear with the absence of colon perforation and pneumoperitoneum, unlike other cases reported. Pneumothorax, especially tension pneumothorax, could be life-threatening and should be promptly recognized.Figure: The arrows delineate the white line associated with the pneumothorax.

A case Report of a Scalp Arteriovenous Malformation after Trauma

A 16-year-old boy from juvenile hall presented to the Emergency Department complaining of a right scalp “bump” for approximately 2 months. The “bump” was not painful but, on occasion, felt “sore.” It apparently started after he was kicked in the head in the same area during a fight 2 months prior. He reported no loss of consciousness, headache, neck or facial pain, hearing or vision changes, or balance or gait abnormalities. Review of systems was otherwise negative. The patient’s past medical and surgical histories were unremarkable. He admitted to occasional alcohol and marijuana use. He denied a family history of bleeding disorders, strokes, or chronic diseases. He took no prescription or over-thecounter medications. On physical examination, the patient was a welldeveloped 16-year-old boy, able to walk around the examination room comfortably with normal balance and gait. He stepped up and sat on the table without difficulty. The head, ears, eyes, nose and throat examination (HEENT) was significant for a 3–4 cm 1 cm right posterolateral scalp mass with a palpable thrill. The mass was soft, pulsatile, mobile, non-tender, and had no overlying skin changes. His HEENT examination was otherwise unremarkable, as was the remainder of his physical examination. The patient had normal coagulation studies and complete blood count. With a preliminary diagnosis of scalp

Adult with painful pruritic plaques

A 27-year-old white male presented with a 1-year history of a progressive, painful, pruritic eruption in his scalp, axillae, and inguinal area. Apart from occasional alcohol use, the patient was otherwise healthy and had no systemic complaints. He had no family history of malignancy or similar skin conditions. He reported minimal improvement with oral trimethoprim/sulfamethoxazole and topical triamcinolone ointment. The clinical examination revealed that his scalp was diffusely erythematous with yellow-brown adherent crusts. Vegetative, macerated, and eroded plaques with purulent discharge were noted in the axillae, intergluteal crease, and inguinal region (Fig 6 and 7). He had no oral or ocular lesions. 10.The clinical differential diagnosis includes all of the following except: a.Hailey–Hailey disease b.Pemphigus vegetans c.Langerhans cell histiocytosis d.Candidiasis e.Paraneoplastic pemphigus

Grievous Disease

A 64-year-old man presented for 4-day history of severe epigastric pain. It was increasing with deep breath, coughing, and sneezing. He also reported having anorexia, fever, chills, and rapid shallow breathing, but there was no nausea, vomiting, diarrhea, hematochezia, or melena. His medications were amlodipine/atorvastatin, hydrochlorothiazide, betaxolol, aspirin, and ezetimibe. He had stopped smoking 15 years earlier and reported occasional social use of alcohol.

Drug Abuse by Adolescents: General Considerations

1. Ximena Sanchez-Samper, MD* 2. John R. Knight, MD* 1. *Center for Adolescent Substance Abuse Research, Children's Hospital Boston, Boston, Mass After completing this article, readers should be able to: 1. Discuss current trends in adolescent substance use and the specific substances used most commonly among 8th, 10th, and 12th graders. 2. Identify risk and protective factors, including genetic and environmental correlates, for the initiation of substance use in adolescents. 3. Discuss the most common concomitant mental health disorders and how they can affect the course of diagnosis and treatment for substance abuse. 4. Delineate the variety of treatment options available. 5. Describe the role of the pediatrician in educating patients and families on substance abuse prevention; performing screening and initial assessments; and providing support, brief counseling, or referrals for in-depth treatment. Adolescence is a time of physical, emotional, and psychological maturation as well as a period of searching for independence and experimentation. One area of experimentation associated with adolescence is substance use. (1) Although many adolescents experiment with drugs and alcohol from time to time without enduring problems, those who develop the disorders of substance abuse and dependence make substance use a major public health concern. The Monitoring the Future Study (MTFS) is a nationwide survey measuring smoking, drinking, and illicit drug use among nearly 50,000 8th, 10th, and 12th graders in more than 400 secondary schools in the United States each year. (2)(3) According to the 2006 overview of findings from the MTFS, approximately one fifth (21%) of today's 8th graders, more than one third (36%) of 10th graders, and nearly half (48%) of all 12th graders reported using an illicit drug at least once during their lifetimes. Despite a minimum legal age requirement to purchase alcohol, 6% of 8th graders, 19% of the 10th graders, and 30% of the 12th graders self-reported drunkenness during the month prior to being interviewed. (2)(3) Among the problems experienced by adolescents who use alcohol and drugs are …

Alcohol and cardio-respiratory deaths in Chinese: a population-based case-control study of 32,462 older Hong Kong adults

BackgroundIn observational studies moderate alcohol use reduces cardio-respiratory mortality. However observational studies may be biased by many factors including residual confounding by unmeasured differences between moderate alcohol users and other groups or by changes in alcohol use with ill-health and aging. We used two different analytic strategies in an under-studied population, i.e. southern Chinese, to provide an assessment of the specific impact of moderate alcohol use on mortality from ischemic heart disease (IHD) and chronic obstructive pulmonary diseases (COPD).MethodsIn a population-based case-control study of all adult deaths in Hong Kong Chinese in 1998, we used adjusted logistic regression to compare alcohol use in decedents aged ≥ 60 years from IHD (2270) and COPD (1441) with 10,320 living and 9043 dead controls (all non-alcohol related deaths). We also examined whether the association of alcohol use with death from IHD or COPD varied with sex or smoking status.ResultsUsing living controls and adjusted for age, socio-economic status and lifestyle, occasional and moderate alcohol use were generally associated with lower mortality from IHD and COPD. However, using dead controls the protection of occasional and moderate alcohol use appeared to be limited to ever-smokers for IHD (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.46 to 0.73 for moderate compared to never-use in ever-smokers, but OR 1.07, 95% CI 0.76 to 1.50 in never-smokers), and possibly to men for COPD. High alcohol use was associated with lower IHD mortality and possibly with lower COPD mortality.ConclusionHigh levels of alcohol use in an older Chinese population were associated with lower IHD mortality. Moderate alcohol use was less consistently protective against IHD mortality. Alcohol use was associated with lower COPD mortality particularly in men, either due to some yet to be clarified properties of alcohol or as the artefactual result of genetic selection into alcohol use in a Chinese population. Given the increasing use of alcohol in China with economic development, other designs and analytic strategies are needed to assess the impact of alcohol in this population, so that an evidence-based public health policy can be formulated.

Liver Injury after Consumption of High Dose Tahitian Noni Juice

Purpose: Noni juice is a popular complimentary alternative medication often consumed for its wellness effects and is recommended for consumption at a dose of 1 oz (30 ml) per day. To our knowledge this is the first reported case of idiosyncratic drug induced liver injury (DILI) from United States that occurred after high dose consumption of Noni juice. Methods: A 49 -year-old African American female with underlying liver disease presented with new onset jaundice. She had history of chronic consumption of Noni juice for several years at the recommended dose. However, two months prior to the presentation she had increased her daily consumption to 8 oz. Six weeks after increasing her dose, she developed mild constitutional symptoms eventually progressing to fatigue and jaundice. Results: Her workup revealed elevated liver tests (ALP 247, AST 365, ALT 145 and total bilirubin 3.9 gm/dL), negative titers for viral and autoimmune hepatitis and imaging studies significant only for fatty infiltration of liver. She gave a history of occasional alcohol and acetaminophen use (4–6 grams/day). She had no exposure to any other xenobiotics. Extensive biochemical work up performed excluded all competing etiologies. Upon discontinuation of consumption of Noni juice at the onset of her jaundice, she had normalization of her liver tests over a period of 4 months. She did not receive any therapy with steroids. Conclusion: This is the first reported case of idiosyncratic DILI after exposure to Noni juice from the United States. While a few cases reported from Europe showed a hepatocellular pattern of injury, this case presented with a cholestatic pattern of liver injury. The potential for toxicity caused by noni juices remains under surveillance by the food safety authorities in Europe currently and physicians in United States should be aware of this possibility.Figure: Liver test trend during recovery period.

Unprotected sex, sexually transmitted infections and problem drinking among female sex workers in Ethiopia

Background : A description of the pattern of use of alcohol and other substances among female sex workers (FSWs) is particularly important because of the high prevalence of HIV in this particular group and their potential for transmitting HIV infection to other groups. However, there is currently lack of systematic studies from developing countries like Ethiopia regarding alcohol use visa vis unprotected sex and STIs. Objective : To describe the association of risky sexual behaviour with alcohol use and problem drinking among female sex workers in Ethiopia. Methods : A total of 2,487 female sex workers aged between of 15 and 49 years were randomly sampled from seven urban centres in Ethiopia and interviewed regarding their sexual behavior and substance use. Results : About 12% of FSWs included in this study reported having unprotected sex during the 12 months prior to the interview. A history of vaginal ulcer or discharge experienced by the FSWs was reported by 5% of the study subjects. Those who reported occasional use of alcohol were found to have a two-fold increase in the odds of havingunprotected sex compared to non-users: adjusted OR (95% CI) = 2.06 (1.28, 3.33). Those who responded positively to at least one question from the four - item questionnaire known as CAGE, and which is used as an indicator for problem drinking, had a 50% increased odds of unprotected sex compared with zero scorers: adj. OR (95% CI) = 1.48 (1.07, 2.05). Those who reported alcohol use on a daily basis were found to have a two-fold increased odds of having sexually transmitted infections (STIs) compared to the non-users of alcohol: adj. OR (95% CI) = 2.50 (1.35, 4.64). Compared to those who were not literate, educational attainment was associated with a lower odds of reporting vaginal discharge or ulcers in those that have attended elementary education: adj. Or (95% CI) = 0.56 (0.35, 0.89.), and secondary education: adj. OR (95% CI) = 0.59 (0.37, 0.93). Conclusion : Unprotected sex and symptoms of STIs were associated with alcohol use, problem drinking and lower educational attainment. The Ethiopian Journal of Health Development Vol. 20 (2) 2006: 93-98

Emotional Ambivalence in Risk Behaviors: The Case of Occasional Excessive Use of Alcohol

The purpose of this paper is to study the differential and complementary role played by the theory of planned behavior (TPB) variables and by participants' emotions when recalling and describing previous experiences of such risk behavior in the prediction of the intention to repeat a risk behavior in the immediate future. We chose the behavior of occasional excessive drinking, a risk behavior characterized by evoking attitudinal ambivalence and eliciting mixed emotions, joy and sadness. The results show that emotional ambivalence is not equivalent to attitudinal ambivalence (whose indexes include that of the affective component), and that this emotional information is relevant for predicting the intention to repeat the risk behavior in the near future, enhancing the prediction of the TPB model.

Sri Lanka: alcohol now and then

Sri Lanka: alcohol now and then

The proportion of intensive care unit admissions related to alcohol use: a prospective cohort study

Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol. A prospective cohort study was conducted in a university hospital ICU. All adult patients (n = 893) who underwent emergency admission to our ICU during a period of 1 year were studied. The admitting physician determined whether there was a relationship between alcohol use and admission. ICU and hospital mortality and ICU length of stay (LOS) were recorded. The Therapeutic Intervention Scoring System (TISS) was used for ICU resource use estimation. There was a relationship between alcohol use and admission in 24% (215/893) of admissions and, in 156/893 admissions (17.5%), this seemed to be definite. ICU LOS was 1.2 days (0.7; 2.3) (median; interquartile range) for alcohol-related and 1.8 days (0.9; 3.6) for other admissions (P < 0.001). Patients with alcohol-related admissions consumed 17.8% of ICU patient-days and 18.7% of all accumulated TISS scores. ICU (8.8 vs. 10.5%, P = 0.603) and hospital (19.1 vs. 20.2%, P = 0.769) mortalities were no different between alcohol-related and other admissions. ICU admission is very often related to long-term chronic and/or occasional alcohol use.

Two Enigmatic Cases of Meningitis

Two Enigmatic Cases of Meningitis

ACUTE PANCREATITIS IN ASSOCIATION WITH SCHISTOSOMA MANSONI

Schistosomiasis is second only to malaria among diseases caused by human parasites, infecting 200 million people worldwide. Three species are known to infect humans. Only S. mansoni is found in the new world. It is rarely found in the US except in travelers and immigrants from endemic areas. Shistosomiasis has not been previously reported in association with pancreatitis in humans. A 38 year old previously healthy male, a recent immigrant from Brazil, presented with 3 days of constant epigastric pain. The patient denied any diarrhea or bloody stools. He was not on any medications but did report occasional alcohol use. His physical examintation was remarkable for a fever of 102 F, epigastric tenderness, a normal liver span and a nonpalpable spleen. Laboratory data on admission revealed a WBC of 16 TH/UL with 28 bands and no eosinophils; Lipase of 1555 U/L, Amylase of 347 U/L, AST 75 IU/L, ALT 22 IU/L, total bilirubin 1.1 and PT of 13 sec. Alcohol level was normal. Abdominal CT scan on admission showed focal inflammatory changes centered around the pancreas with indistinct margins. Abdominal ultrasound showed a normal gallbladder without stones or sludge and no biliary dilatation was noted. On hospital day 6 the patient deteriorated clinically and was transferred to the ICU. A subsequent CT scan of the Abdomen showed increasing inflammation of the pancreas with diminished visualization of the tail. He required mechanical ventilation and was started on intravenous Vancomycin and Gentamycin. One month into his hospitalization he underwent surgical debridement of necrotic pancreatic tissue involving the tail of the pancreas. Pathologic evaluation revealed necrotic debris, scattered remnants of vessels and the presence of Schistosoma mansoni eggs. Despite aggressive efforts, the patient eventually died due to complications of renal failure. This case illustrates a potential causative association between schistosomiasis and pancreatitis. Local inflamation induced by schistosoma eggs has been well studied. Shistosoma typically invades the colon and migrates via the portal tract to the left lobe of the liver. There are isolated case reports of Shistosomes in muscle, adrenal glands and the CNS. Based on literature review, Shistosoma mansoni eggs in human pancreas is a new finding. The prevalence of shistosomiasis indicates that this may be more common than described.

SYMPTOMATIC ESOPHAGEAL DUPLICATION CYST. CASE REPORT AND REVIEW OF LITERATURE

A 34 yo female with a history of gastric ulcers, gerd and asthma presented for follow up egd of her recurrent dyspepsia and recent dysphagia of solids for two months duration. Pt. denied any odynophagia, weight loss, early satiety or fevers. Pt.'s medications included omeprazole and albuterol. Pt. has a family history of colon cancer, a 15 pack year tobacco history, occasional alcohol use and no recent history of travel or risk factors for HIV disease. Physical exam was unremarkable. On EGD, extrinsic compression of the distal esophagus was noted, as well as an irregular Z line and an antral ulcer. CT scan of the chest revealed a 3.5×2.0 cm rounded, smooth walled, soft tissue mass in the anterior border of the distal esophagus. A submucosal mass imaged between 35 and 37 cm was identified on EUS. The mass was localized to the left anterior aspect of the esophageal wall and appeared to involve all layers. There was no adenopathy detected on EUS. Biopsies done at time of EUS were unrevealing for cancer. Pt. underwent Ivor Lewis esophagogastrectomy for definitive diagnosis and treatment. Surgical pathology revealed a large 2 cm, cystic structure that contained mucus and was lined by benign ciliated respiratory epithelium and goblet cells, compatible with a duplication cyst. Multiple smaller cysts were also identified. Benign foci of ectopic salivary gland seromucinous acini and their associated ducts were also present throughout. There was no evidence of malignancy. Esophageal cysts account for 10% of all primary masses of the mediastinum. They can be broadly classified into congenital versus acquired cysts. Esophageal duplication cysts, a subclass of congenital cysts have a prevalence estimated to be 1/8200. Ectopic gastric, pancreatic and salivary gland tissue within these cysts have been descibed. Esophageal cysts usually cause respiratory symptoms in children and are often asymptomatic in adults. Two thirds of esophageal cysts are located in the distal esophagus and about 10% are located in the upper third. The average age of diagnosis for distal lesions is 34 years and the most common presenting symptoms include dysphagia, retrosternal pain and cough. There have been reports of patients presenting with cardiac arrhythmias, intracystic hemorrhage, perforation, infection and transformation into cancer. Regardless of symptoms, surgical resection is the treatment of choice.

Dysphagia and weight loss in a middle-aged man

CLINICAL PRESENTATION: (Dr. J. Bini) A 48-year-old Hispanic man presented with a 4-year history of dysphagia and a 75-pound weight loss. He had been unable to tolerate solid food and described symptoms of regurgitation and aspiration. His medical history was significant 20 years of reflux symptoms. An upper gastrointestinal (UGI) barium swallow performed in January 2002 was consistent with achalasia, showing a “birdsbeak” filling defect in the distal esophagus (Fig. 1). The proximal esophagus was dilated, and only a minimal amount of barium was emptied into the stomach (Fig. 2). There were tertiary waves present in the esophagus and no mucosal defects; similar findings were seen on an UGI study in May 2003. In the past 2 years, he has undergone 2 unsuccessful endoscopic balloon dilations. He has a 30-pack/year history of tobacco use and occasional alcohol use. Review of systems was otherwise unremarkable. On physical examination, the patient appeared malnourished with a height of 5 10 and a weight of 115 pounds. His heart was regular, lungs were clear to auscultation, and abdominal and rectal examinations were benign. Laboratory studies included an albumin of 4.2 g/dl. The comprehensive metabolic and hematologic profiles were within the normal range. Upper endoscopic examination was consistent with achalasia, showing a diffusely dilated and fluid-filled esophagus. The lower esophageal sphincter had a pinhole opening, but the scope was easily passed. A colonoscopy was negative. Manometry studies showed an increased lower esophageal sphincter (LES) pressure of 40 mm Hg associated with incomplete relaxation. Esophageal body peristalsis was nonexistent.