Esophageal Contents Research Articles

The use of the territorial sea by Lepidochelys olivacea (Eschscholtz, 1829) in front of nesting beaches in Oaxaca, Mexico

Scientific research focused on sea turtle monitoring and management has relied on nesting beaches, but little attention has been paid to surveying turtles in the territorial sea off nesting beaches. This study aimed to evaluate how the Olive Ridley turtle, Lepidochelys olivacea, uses the territorial sea off the nesting beaches in Puerto Escondido, Puerto Ángel, Santa María Huatulco, and Morro Ayuta, in Oaxaca, Mexico. Between December 2017 and August 2018, 2394 individuals were sighted in the territorial sea engaged in the following activities: feeding (6 individuals), mating (164 individuals), swimming (2172 individuals), and resting (49 individuals). We analyzed the diet and body condition of L. olivacea and identified which biophysical factors affect the distribution of these sea turtles in the region. We also recorded direct interactions with fishers and tourism service providers. We captured 40 individuals, collected morphometric data, and analyzed esophageal content to characterize feeding habits, which were correlated with a body condition index. Diet items included crustaceans, tunicates, four commercially important fish species, jellyfish, mollusks, and algae. Approximately 95% of turtles exhibited very good body condition. The largest turtle aggregations were recorded in Morro Ayuta (898 individuals) and Puerto Ángel (808 individuals). In situ sea surface temperature and chlorophyll-a concentrations from satellite images were used to characterize the territorial sea. Sea surface temperature was negatively correlated with turtle abundance. Management and conservation actions are needed for sea turtles that address the negative interactions with fishers (e.g., competition for commercially important fish species) and tourism service providers that occur in the territorial sea off nesting beaches to protect these crucial reproductive habitats in the long term.

The Upper Esophageal Sphincter Distensibility Index Measured Using Functional Lumen Imaging Probe Identifies Defective Barrier Function of the Upper Esophageal Sphincter.

Background/AimsThe mechanism via which supra-esophageal symptoms are generated is unclear. We assessed upper esophageal sphincter (UES) function in novel fashion using functional lumen imaging probe (FLIP) topography. We hypothesize that symptoms related to aspiration of esophageal contents may be associated with a more distensible UES.MethodsFLIP and reflux symptom index score data from patients undergoing diagnostic evaluation for an esophageal complaint over a 10-month period were analyzed retrospectively. UES distensibility on FLIP was studied at 40-70 mL volumes with in-depth analysis at 50 and 60 mL. Symptoms were compared between patients with low, middle, and high UES-distensibility index (UES-DI). Receiver-operating characteristic analysis was performed to determine associations between the UES-DI and individual reflux symptom index symptom item scores.ResultsOne hundred and eleven subjects were included. Overall, the associations between UES-DI and symptoms that could be related to supra-esophageal aspiration were strongest at the 50 mL FLIP volume. Choking item score was highest in the high UES-DI group (2.8) vs 1.4 (P < 0.001) in the middle UES-DI and 1.1 (P = 0.004) in the low UES-DI groups. Similarly, the cough item score was highest in the high UES-DI group (2.7) vs 1.5 (P = 0.009) and 0.9 (P = 0.002) groups.ConclusionA higher UES-DI measures defective barrier function which could may be the main pathophysiology that generates supra-esophageal symptoms.

A New Preparation Method for Peroral Endoscopic Myotomy in Patients with Achalasia Can Effectively Reduce the Esophageal Residual Contents: A Comparative Retrospective Study.

Methods This retrospective study enrolled 65 achalasia patients who underwent POEM from June 2017 to October 2021. Based on the preoperative diet strategies, patients were divided into carbonated beverage group (n = 48) and control group (n = 17). Demographic and clinical data, duration of preoperative endoscopy, quality of esophagus cleansing, and patient satisfaction on preoperative procedure were collected and compared. In the current study, we established the quality of esophagus cleansing: Grade A, no remnants or only liquid or frothy discharge; Grade B, a little amount of solid content remained; and Grade C, a large amount of solid content remained. Results There were 41 Grade A, 6 Grade B, and 1 Grade C patients in the carbonated beverage group, while there were 8 Grade A, 6 Grade B, and 3 Grade C patients in the control group (p value = 0.001). The esophagus cleansing degrees were significantly ameliorated after drinking carbonated beverages in all the three subtypes of achalasia according to the degree of dilatation. The mean duration of preoperative endoscopy was 6.54 ± 2.250 minutes in the carbonated beverage group and 10.27 ± 4.788 minutes in the control group (p value = 0.010). The score of patient satisfaction concerning the procedure before the POEM in the carbonated beverage group was 4.5 ± 0.652, while the score in the control group was 4.35 ± 0.702 (p value = 0.436). In the multivariate analysis, patient satisfaction was significantly associated with male (odds ratio 0.296, 95% CI: 0.097-0.905, p value = 0.033). Conclusions Drinking carbonated beverages reduce the duration of preoperative endoscopy and ameliorate the esophagus cleansing degrees without impairing patient satisfaction.

Retained metal fragments following esophageal button battery impaction.

Button battery (BB) impaction in the esophagus requires immediate endoscopic removal and meticulous follow-up, including serial cross-sectional imaging, preferably with magnetic resonance imaging (MRI). However, BBs quickly degrade in the esophagus, and metallic fragments may remain in the injured mucosa following removal. This metallic debris can cause thermal injury during MRI, potentially aggravating local injury. We aimed to explore whether such metallic fragments could be identified on imaging following BB removal. In this study, we conducted a retrospective review of children (0-18years) presenting with BB impaction in the esophagus between 2014 and 2020. Endoscopy reports and imaging studies were blindly reviewed by a pediatric gastroenterologist and a pediatric radiologist. Of 161 cases of battery ingestion, 14 (8%) underwent endoscopy, and in 9 (5%) a BB was impacted in the esophagus. The median time from ingestion to BB removal was 8h (range 2-48h). The median time from removal to CT was 44h (range 0.5-104h). BB appearance ranged from mild corrosion to visible debris. Pre-removal plain films showed irregular battery contour suggesting corrosion (5/7 plain films). In 7/9 CT scans (78%), high-attenuation esophageal content (median 266HU (range 140-1151)), which may represent metallic debris, was identified. Five patients had a follow-up CT which still showed gradual resolution of the high-attenuation content.Conclusions: we describe a new finding on CT following BB removal which might represent metallic debris. Clinicians should be aware of these findings which potentially may be harmful during MRI used in the ongoing assessment of esophageal injury. What is Known: • Button batteries are a dangerous pediatric foreign body with potentially fatal vascular complications. What is New: • Metallic debris was identified on computerized tomography following button battery removal in most children. • We bring to attention this new finding which may affect clinical management, as minimal metallic content can cause burns during MRI.

Особливості перебігу патології шлунково-кишкового тракту у хворих на гастроезофагеальну рефлюксну хворобу на тлі гіпотиреозу

The article identifies the features of the pathology of the gastrointestinal tract in patients with gastroesophageal reflux disease on the background of hypothyroidism. The frequency of gastroesophageal reflux disease and the severity of this disease increase with age and the presence of comorbid pathology. In the elderly, the frequency of the typical esophageal manifestations decreases, and the erosive esophagitis with atypical symptoms is more common. The growing number of cases of combined thyroid dysfunction with gastropathology requires in-depth study of the reasons for the relationship between these processes. Pathological changes in the gastrointestinal tract in these patients make their condition severer, contributing to the development and progression of metabolic disorders. An important aggravating effect on the regulatory mechanisms of esophageal kinetics has a pathological functioning of the thyroid gland on the background of iodine deficiency. Results and discussion. In patients with gastroesophageal reflux disease with hypothyroidism, all changes in gastric and duodenal function are associated with a decrease in the acid-forming function of the gastric mucosa, due to its atrophy, decreased tone and contractility of the stomach. This in turn leads to a slowing of gastric and duodenal evacuation, dysfunction of the closing capacity of the cardia and, as a consequence, the development of duodenogastroesophageal reflux. The esophageal contents are not so pronounced, so patients with non-erosive forms of esophagitis predominate (46.2%) against 16% of patients in the second group (patients with gastroesophageal reflux disease). At the same time, erosive forms predominate among patients in the control group with predominant acid reflux. It should be noted that there is a clear relationship between the frequency of erosive changes in the esophageal mucosa and the duration of the disease. Thus, among patients of the main group with a 5-year history of the disease, the number of erosive forms of gastroesophageal reflux disease was minimal. The number of erosive changes in the esophageal mucosa increased sharply in patients with a 10-year history and reached its maximum after 15 years from the onset of the disease. Conclusion. The delay in gastric evacuation is more pronounced in patients with gastroesophageal reflux disease on the background of hypothyroidism. It can be explained by a decrease in gastric motility and the presence of duodenostasis. The slowing of gastric evacuation was more pronounced in patients with gastroesophageal reflux disease on the background of reduced thyroid function. In patients with gastroesophageal reflux disease on the background of hypothyroidism there is an alkaline duodenogastroesophageal reflux as a consequence of reduced acid-forming function of the gastric mucosa and reduced contractility of the stomach and duodenum

Non-medicine Methods of Treatment of Gastroesophageal Reflux Disease

Few decades away a problem of throwing of acidic gastric content into an esophagus was reduced to the concept of reflux-esophagitis. In-depth study of pathogenesis of a disease resulted in “gastroesophageal reflux disease” (GERD) term which is acknowledged as leading disease of digestive system in terms of frequency and dangerous complications. GERD formation is determined by influence of numerous factors, however, it is generally accepted, that it is mainly related to insufficiency of lower esophageal sphincter (LES). Also, role of vasoactive intestinal peptide (VIP) in regulation of functional state of LES is determined. In spite of success in field of pharmacology, number of GERD patients has no downward trend which mainstreams search for non-medicine treatment methods. Physical factors affecting pathological processes by influencing regulatory processes are among these methods. Goal of this study is elaboration, scientific justification and clinical implementation of natural and preformed physical factors and acupuncture in treatment of patients with gastroesophageal reflux disease. Materials and Investigation methods: Randomized placebo-controlled study included 137 patients with gastroesophageal reflux disease, 63 (46%) men and 74 (54%) women, at the age of 18 to 65. Investigation included patients with no contraindications for physiotherapy. Patients with Barrett’s esophagus, stricture of esophagus, esophagus ulcer have also been excluded from investigation. Patients were divided into 3 groups: Ist group – 40 GERD patients, including high-frequency electromagnetic field effect and general iodine bromine bathes. II nd group - 67 GERD patients passing acupuncture treatment course. Control group was comprised of 30 GERD patients, receiving placebo MEF therapy. Treatment was carried out without medicines. Therapeutic effectiveness of complex influence of microwave electromagnetic field therapy (MEF-therapy) applied to collar area alternated with general iodine-bromine bathes on clinical manifestations of GERD is determined. Treatment course contributed to reliable decrease of increased count of VIP – a neurotransmitter, regulating LES tonus. In term, it contributed to improve of functional state of LES, reliable decrease of reflux index, and, as a result, improvement of clinical and functional indicators. Estimation of clinical manifestations of a disease among patients of 2nd group displayed positive dynamics of clinical and functional indicators. Round-clock pH-monitoring of stomach and esophageal content shows reliable decreaseof transitory relaxations of LES during single acupuncture procedure and increase of pH of gastric content. Acupuncture course also resulted in decrease of elevated VIP numbers.

Prospective randomized double blind study for determining the efficacy of Sellick’s maneuver for preventing gastric distension during mask ventilation

Sellick’s maneuver is a technique in which pressure is applied over the cricoid cartilage to occlude the upper part of esophagus which passes behind it. It is used to prevent regurgitation of gastric and esophageal contents and gastric distension during intubation and mask ventilation. This research is conducted to determine the efficacy of Sellick's maneuver in preventing gastric distension during mask ventilation using ultrasound. Sixty patients posted for elective surgery were selected and randomly allocated to a group receiving Sellick's Maneuver (SM) or No Sellick's Maneuver (NSM). Patients of both groups had their gastric antral cross sectional area (CSA) measured using ultrasound before induction of anesthesia and after intubation and mask ventilation. The SM group was intubated after application of Sellick's maneuver. Gastric volume was then calculated from the gastric antral CSA. Changes in gastric volume among SM and NSM group were assessed to determine whether Sellick's maneuver is effective in preventing gastric distension. Changes in gastric antral CSA and gastric volume before anesthesia induction and post-intubation is lower in the SM group as compared to the NSM group. Sellick's Maneuver is effective in preventing gastric distension.

Combination of Forestier’s disease and laryngeal cancer: a rare clinical case

The objective of the scientific report is to describe a rare clinical case of a combination of Forestier’s disease (diffuse idiopathic skeletal hyperostosis) and laryngeal cancer that have common symptoms. Case report. A 68-year-old male patient presented with hoarseness lasting for a year. Indirect laryngoscopy revealed a vocal fold tumor. Histological examination confirmed well-differentiated keratinizing squamous cell carcinoma of the larynx. A 6-cm tumor was located in the projection of the right vocal fold and had no signs of invasion into the supraglottis, subglottis, and anterior commissure. No other focal disorders were detected. The patient has undergone endolaryngeal laser resection of the larynx and tracheostomy. After probe removal, the patient had swallowing difficulties with esophageal content passing to the trachea mainly due to organic changes in the cervical spine at the СЗ–С4 level, where there was a massive local calcification of the anterior longitudinal ligament. We also noticed severe movement restriction in the cervical spine: the amplitude of movements did not exceed 10°. The formation of the C3–C4 segment was removed via ventrolateral approach. Conclusion. Dysphagia, dysphonia, and dyspnea may indicate both malignant tumor and large osteophyte causing compression of the trachea and esophagus. In this case, no symptom resolution after tumor removal led to the suspicion of a second disease, namely Forestier’s disease.

Fall diet in sharp-tailed grouse (Tympanuchus phasianellus jamesi) and consumption of the grasshopper Melanoplus dawsoni in Alberta, Canada

Sharp-tailed grouse (Tympanuchus phasianellus) are an important component of northern grassland food webs, a reliable indicator species, and considered to be valuable to the preservation of biodiversity. Ecological stressors imposed on this species include habitat alteration, fragmentation, encroachment from agricultural development, insecticides, and the effects of climate change on prairie landscapes, all of which have the potential to alter food availability and trophic dynamics. Insects and spiders are an important food source for many grassland birds. The ecological roles of many arthropod species as prey and as contributors of other important ecosystem services remain relatively unexplored. This study examined esophageal crop contents from 164 plains sharp-tailed grouse (T. phasianellus jamesi) that were collected in 2017 and 2018 from three sites in southern and central Alberta, Canada. The remains of grasshoppers (Orthoptera: Acrididae, 18 species) were detected in 80% of esophageal crops collected in September, and 31% in October. Of the grasshopper samples, 91% and 63% respectively, were a single species identified as Dawson's grasshopper (Melanoplus dawsoni). Juvenile grouse consumed more grasshoppers than adult grouse in all cases. Studies on other gallinaceous game birds have also identified frequent consumption of single arthropod species, likely due to the range, catchability, and abundance of these species at certain times of year. This non-pest grasshopper species appears to form a significant part of the food supply for sharp-tailed grouse in the fall. Species-level arthropod ecology can contribute to a better understanding of ecosystem stability, optimal land management practices, and previously unexplored food web connections.

How to approach esophagogastric junction outflow obstruction?

The diagnosis of esophagogastric junction outflow obstruction (EGJOO) is currently based on high-resolution esophageal manometry and is characterized by impaired EGJ relaxation with preserved esophageal peristalsis. This condition has been defined by the Chicago Classification as a major esophageal motility disorder, although its clinical significance is controversial since heterogeneous and irrelevant presentations have been reported. EGJOO commonly has a benign clinical course, with spontaneous resolution, but it can also be associated with opioid usage, early achalasia, and mechanical obstruction. A careful medical, surgical, and medication history coupled with a careful manometry interpretation focused on the factors that might affect the integrated relaxation pressure are the keys for an accurate diagnosis. The advance of esophageal physiological tests can evaluate the clearance of the esophageal contents across the EGJ. The manometry technique, including testing in an upright position and provocative tests, can also complement those tests and demonstrate the evidence of EGJ obstruction. After making a diagnosis, endoscopy should be an initial step to exclude anatomical causes if it has not yet been done. Imaging studies can identify infiltrative lesions, but the reported diagnostic yield is relatively low. Management of EGJOO depends on the underlying etiology. Functional EGJOO patients with persistent dysphagia associated with the presence of outflow obstruction may require EGJ disruption therapy.

Minor esophageal functional disorders: are they relevant?

High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear. Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility. Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.

Computed tomographic features of gastric and esophageal content in dogs undergoing CT myelography and factors influencing the presence of esophageal fluid.

BackgroundGastroesophageal reflux (GER) has been reported to be a common finding in dogs under general anesthesia.ObjectivesThe aim of this retrospective study was to assess the esophageal and gastric contents in a population of dogs undergoing computed tomographic myelography (myelo-CT) examination and to evaluate the factors influencing the presence of esophageal fluid (gastric content, duration of anesthesia, body position, and intrinsic factors).MethodsEsophageal and gastric contents of 83 non-brachycephalic dogs were retrospectively assessed based on plain and myelo-CT scans. Age, weight, breed, sex, and the time between the 2 computed tomography [CT] scans were included.ResultsEsophageal fluid was present in 19% (16/83) of the animals, and 14% (12/83) and 46% (37/83), respectively, had fluid or food material in their stomachs. The frequency of observing esophageal fluid on myelo-CT scans was significantly increased compared with plain CT scans (p = 0.006). The presence of gastric fluid was significantly associated with an increased frequency of observing esophageal fluid compared to other gastric contents (p = 0.049; odds ratio, 3.1). The presence of esophageal fluid was not correlated with alimentary gastric contents (p = 0.17). Increased body weight and duration of anesthesia were significantly associated with an increased frequency of observing esophageal fluid (p = 0.022, p = 0.021).ConclusionsUnlike alimentary gastric contents, fluid gastric contents were correlated with the presence of esophageal fluid upon myelo-CT. The observation of fluid in the esophagus may be consistent with GER. This study provides data additional to pH monitoring studies of GER and may support previous studies recommending shorter pre-anesthetic fasting periods in dogs.

“Dr. Google” Will See You Now—Assessing the Quality of Information on Oesophageal Cancer on the Internet

BackgroundIncreasingly, patients are consulting the internet for medical information, where the quality is highly variable. We must ensure patients are directed towards high-quality websites. This is particularly true of oesophageal cancer which is often detected at an advanced stage and is frequently fatal. We aim to assess the quality of information on oesophageal cancer available for patients on the Internet. Methods and MaterialsWe searched the top 3 search engines for “Esophageal Cancer”. We analysed the top 20 websites returned by Google and the top 10 websites returned by Yahoo and Bing. All free, English language websites which did not require a password were included. We excluded paid advertisement websites and websites for medical professionals. Duplicate websites were removed. Each website was then evaluated using the JAMA benchmarks, DISCERN tool, presence or absence of the Health On The Internet (HON) seal and the Esophageal Cancer Specific Content Score (ECSCS). ResultsThe average JAMA score was 2 with only three of the eighteen unique websites scoring the maximum of 4 points (17%). The average DISCERN score was 51.5 (64%) with no website achieving the maximum of 80. The HON seal was present in only 5 websites (28%). The average ECSCS was 9.2 with only two websites achieving the maximum of 12 (11%). ConclusionsWhilst there are certainly websites providing high-quality information for patients in relation to oesophageal cancer, our study has identified obvious issues. We must ensure that only the highest-quality information is available on the Internet for patients.

1775 Tracheoesophageal Fistula Managed With Double Stenting of Bronchus and Esophagus

INTRODUCTION: Malignancy is responsible for 5-15% of acquired tracheoesophageal fistulas (TEF). Such patients have a short survival and management of these fistulas is a challenge. We present a case of TEF secondary to esophageal malignancy that was managed with double stenting of the bronchus and esophagus. CASE DESCRIPTION/METHODS: The patient is a 56 year old black female with no known past medical history who presented to our emergency department with complaints of chest pain, shortness of breath and a productive blood tinged cough. She had been recently discharged from another facility for a diagnosis of bronchitis, however symptoms had not abated. She reported a fifty-pound weight loss with poor oral intake. Her vital signs and labs on arrival were stable. Initial imaging in the ER was consistent with pneumonia of the right middle and lower lobes. She underwent a CT Neck, which showed esophageal wall thickening and a mass suspicious for an esophageal neoplasm. Due to concern of her recurrence of pneumonia and esophageal mass, she underwent an esophagram, which showed a stricture of the middle third of the esophagus with a fistula from the esophageal tumor to the right lower lobe bronchus. Due to concern of airway collapse with upper endoscopy, Pulmonology was consulted. The patient first underwent a bronchoscopy in which a Novatech Y-stent was deployed stabilizing the airway. The patient then underwent an endoscopy in which an esophageal stent was placed. Both procedures were successful and she tolerated oral intake well thereafter. She was discharged in stable condition to palliative hospice services. DISCUSSION: The case has relevance from both an interesting initial clinical presentation as well as management of this patient from both a technical and procedural aspect. This patient had continual infections from continuous overspill of esophageal contents into the respiratory tree. Although her prognosis to begin with was quite poor, these interventions allowed the patient some quality of life. This case also commands procedural respect. The patient’s left mainstem bronchus was extremely friable and actually ruptured during the initial course of balloon dilation. The stent in position did not completely cover the TEF however it did keep the central airway open. A long esophageal stent was placed by gastroenterology, which did completely cover the fistula. This patient’s case highlights potential difficulties in double stenting and anticipatory management by utilization of other services.

2148 A Mediastinal Abscess Due to Actinomcyes Odontolyticus Diagnosed by Endoscopic Ultrasound-Guided FNA

INTRODUCTION: Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury. CASE DESCRIPTION/METHODS: A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort &amp; fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5 × 2 × 2 cm posterior mediastinum collection (Figure 1) abutting the esophagus with mid and distal esophagitis. An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31 cm with a mucosal fistula at 27 cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative. On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 × 2 cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed &gt;100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus. DISCUSSION: Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.

A Case of an Inlet Patch Causing Laryngopharyngeal Reflux

Larynopharyngeal reflux (LPR) is retrograde movement of gastric and upper esophageal (UE) contents into the laryngopharynx, leading to symptoms of dysphonia, dysphagia, chronic cough, and throat clearing. Whether or not LPR is caused by GERD or by an independent mechanism is under debate, as some patients have LPR without GERD. This is an example of LPR caused by a large inlet patch. 65 yo F with history of breast cancer s/p lumpectomy, normal colonoscopy, presented with chronic symptoms of coughing, dysphagia, spitting, and continuous clearing of her throat. Her symptoms were exacerbated in a recumbent position. Her vitals and physical exam were unremarkable. Her EGD showed a Schatzki's ring at the GEJ which was dilated with a balloon to 20mm. A tighter stricture with ulceration was found in the UE at 19cm with a circumferential patch of salmon colored mucosa extending 2-3cm proximally. Pathology revealed “gastric fundic/cardia-type mucosa interposed between squamous mucosa with associated chronic inactive inflammation; consistent with heterotopic gastric mucosa (inlet patch)”. Patient had significant improvement with daily PPI, and later underwent balloon dilation of the upper esophageal stricture with good effect. Now, considering ablation for long term symptom management.We feel this patient's LPR symptoms were caused by the large patch of gastric acid producing mucosa in the UE, rather than GERD. Reported incidence of inlet patches range from 1-14% of EGDs with autopsy rates up to 70%. Complications include bleeding, perforation, fistula, stricture formation, and adenocarcinoma. In our case, an ulcerated UE stricture was evidence of the local acid produced by the inlet patch. Acid produced from inlet patches in the UE can be enough to induce LPR symptoms, as laryngeal exposure to a pH of 6 can induce symptoms. Inlet patches are often overlooked during rapid withdrawal of the endoscope in the UE and are frequently not documented in endoscopy reports. Treatment includes behavioral modifications, PPIs, neuromodulators, alginate, radiofrequency ablation, or surgery. This case illustrates the value of inlet patch detection and documentation in patients presenting with LPR symptoms. More time should be spent in evaluation of the UE, with a focus on detection and documentation of each inlet patch. Inlet patches may provide a target for treatment for long term management of LPR symptoms.

Microbiota of the Esophagus and Stomach in Patients with Gastroesophageal Reflux Disease and Healthy Volunteers

This paper is aimed at investigating the microbiota of the esophagus and stomach in patients with gastroesophageal reflux disease (GERD) and healthy volunteers.Materials and methods. The study included 15 patients suffering from GERD and 6 healthy volunteers. All subjects underwent sampling of esophageal and gastric contents. The study of the microbiota in the obtained samples was performed by sequencing the 16S gene of ribosomal RNA (rRNA).Results. The most common types of bacteria in the esophagus and stomach in patients with GERD and healthy volunteers are found to be Bacteroidetes, Firmicutes, Actinobacteria, Proteobacteria, Fusobacterium. By comparing the relative contents of the main types of bacteria in the esophageal mucus and gastric contents, a significant decrease in the proportion of Proteobacteria was observed in patients with GERD as compared to healthy volunteers. The decrease in the relative number of bacteria belonging to the Acetobacteraceae, Bacillaceae, Bdellovibrionaceae, Clostridiales Insertae Sedis XI, Fusobacteriaceae, Moraxellaceae, Pasteurellaceae and Rhodocyclaceae families was observed in the esophagus in patients with GERD as compared to healthy volunteers. A higher bacterial content of the Leptotrichiaceae and Veillonellaceae families was detected in the stomach of patients with GERD.Conclusions. The obtained results indicate differences in the intraluminal microbiota of the esophagus and stomach in patients with GERD and healthy volunteers. Further study should be carried out to study the effect of changes in bacterial composition on those in the esophagus and stomach.

New record of Hyachelia tortugae Barnard, 1967, an amphipod epibiont on green turtles Chelonia mydas (LINNAEUS, 1758) from Gorgona island (colombian pacific)

Objectives: Characterize the amphipods collected in esophageal lavages of the green turtle Chelonia mydas (Linnaeus, 1758). Scope: Increase the characterization of diversity of a poorly known group, but of great importance in benthic environments, in Colombia. Methodology: Amphipods were collected from esophageal lavages carried out on 77 green turtles between February and December 2012 at Gorgona Island, Colombian Pacific. Main results: We report the occurrence of the amphipod Hyachelia tortugae Barnard, 1967, a species that lives exclusively as an epibiont of sea turtles, for the first time for the Colombian Pacific. Three H. tortugae individuals occurred in two of the analyzed turtles. The hyperiid amphipods Paralycaea gracilis Claus, 1879, Schizoscelus ornatus Claus, 1879, and Parascelus sp. were also collected in the esophageal contents of the turtles. Conclusions: This study highlights that systematic studies should be carried out to characterize the associated fauna in sea turtles in the Colombian Pacific.

Imaging of iatrogenic oesophageal injuries using optimized CT oesophageal leak protocol: pearls and pitfalls.

Iatrogenic injury to the oesophagus is a serious complication which is increasingly seen in clinical practice secondary to expansion and greater acceptability of surgical and endoscopic oesophageal procedures. Morbidity and mortality following such injury is high. This is mostly due to an inflammatory response to gastric contents in the mediastinum, and the negative intrathoracic pressures that may further draw out oesophageal contents into the mediastinum leading to mediastinitis. Subsequently, pulmonary complications such as pneumonia or abscess may ensue leading to rapid clinical deterioration. Optimized and timely cross-sectional imaging evaluation is necessary for early and aggressive management of these complications. The goal of this review is to make the radiologist aware of the importance of early and accurate identification of postoperative oesophageal injury using optimized CT imaging protocols and use of oral contrast. Specifically, it is critical to differentiate benign post-operative findings, such as herniated viscus or redundant anastomosis, from clinically significant postoperative complications as this helps guide appropriate management. Advantages and drawbacks of other diagnostic methods, such as contrast oesophagogram, are also discussed.

Trophic ecology of green turtleChelonia mydasjuveniles in the Colombian Pacific

Gorgona National Park (GNP) protects the only known feeding aggregation of juvenile green turtlesChelonia mydason the Pacific coast of Colombia. This study was undertaken to compare the diet of the two knownC. mydasmorphotypes (black and yellow), and to determine availability, selectivity, and quality of food resources at GNP. Oesophageal lavages and isotopic analysis of epidermal tissue were performed on turtles captured between February and December 2012. Food quantity was estimated by determining per cent cover in quadrats randomly placed on the reefs. Food quality of algae species was estimated by proximate analysis. Food selection was estimated using Ivlev's electivity index, and the trophic level of sea turtles at GNP was calculated. A total of 30 black (mean = 63.9 cm SCL) and 47 yellow (mean = 54.3 cm SCL) morphotype turtles were lavaged. Eight invertebrate and nine algae food items were identified in oesophageal contents. The most frequently found and abundant items in lavages were terrestrial plants, plastic fibres, invertebrates and algae. A total of 27 items, including 15 algae species, were identified on the reefs, of whichCladophorasp. was selected by black turtles, andHypnea pannosaandDictyotasp. were selected by both morphotypes; the latter species had the highest protein and lipid content, and low lignin content. A trophic level of 3.5 for black and 3.4 for yellow turtles was calculated. No significant difference in diet between the two morphotypes could be determined through lavage or isotopic analysis.