Oesophageal Lining Research Articles

Minimally Invasive Approach to Epiphrenic Oesophageal Diverticulum: A Case Report

An oesophageal diverticulum is a relatively rare disorder of the oesophagus which results in the outpouching of the oesophageal mucosa through a weak portion within the oesophageal lining. Oesophageal diverticula occur in <1% of the population and are found in approximately 1-3% of those presenting with dysphagia. A 75-year-old male patient came to the surgical Outpatient Department (OPD) with chief complaints of difficulty in swallowing for 2-3 months, initially with solids which later progressed to difficulty in swallowing liquids. He was diagnosed on a Contrast-Enhanced Computed Tomography (CECT) scan with a large oesophageal diverticulum arising from the right lower lateral thoracic oesophagus just proximal to the oesophagogastric junction in the retrocardiac region with no filling defect or mucosal thickening. The patient was treated with transhiatal laparoscopic oesophageal diverticulectomy with cardiomyotomy and Dor fundoplication. For symptomatic patients, most often, minimally invasive myotomy and removal of the pouch endoscopically are advised, which may pose a surgical challenge due to the rarity of the disease.

O05 Management of acute desloughing of the oesophageal lining in patients with dystrophic epidermolysis bullosa: a case series of six paediatric patients

Abstract Dystrophic epidermolysis bullosa (DEB) is a subtype of inherited skin disorders characterized by skin and mucosal fragility due to collagen VII (COL7A1) gene mutations. Desloughing of the lining of the oesophagus has not been reported before. We retrospectively reviewed the hospital electronic patient records between 2008 and 2021 with regard to acute treatment and long-term management. Six patients with recessive DEB (RDEB) severe (n = 4), RDEB intermediate (n = 1) and dominant DEB (DDEB) were identified. The mean age at the time of the episode was 29.6 months. Most of the patients (n = 5) suffered from severe gastro-oesophageal reflux at the time of onset. Clinically, they presented with a coughing episode (n = 6), haematemesis (n = 6), vomiting (n = 6) and choking (n = 3) with a piece of mucosae coughed up. Four patients recovered with medical management including immediate hospitalization, no oral intake (nil by mouth, NBM), pain relief and optimization of the dose of proton-pump inhibitors. Due to severe persistent dysphagia, two patients required gastrostomy insertions for feeding; one also required a Nissen's fundoplication due to severe reflux. One patient had an aspiration pneumonia. Desloughing of varying lengths of segments of the oesophagus is an emergency. The lining coughed up needs to be cut at the mouth not pulled and the emergency services called immediately. On arrival, an urgent assessment and chest X-ray should be performed to rule out any signs of perforation. The patient should be kept NBM with intravenous fluids and pain relief. Expert multidisciplinary care is needed to manage this rare but extremely serious condition.

Prevalence and Risk Factors of GERD among Stable COPD Patients

Introduction: Gastroesophageal reflux disease (GERD) is one of the most common causes of a chronic cough and is a potential risk factor for chronic obstructive pulmonary disease (COPD) exacerbation. This study aimed to determine the prevalence of GERD in COPD patients. Methods: This was a cross-sectional study involving 40 stable COPD patients recruited from outpatient asthma and COPD clinics at Persahabatan National Respiratory Referral Hospital, Jakarta, from May to November 2018. COPD was defined as having a ratio of post-bronchodilator FEV1/FVC < 0.7 and no abnormality on a chest X-ray except emphysematous. Diagnosis of GERD was based on oesophageal mucosal lining break surrounding the distal esophageal sphincter through esophagogastroduodenoscopy (EGD). Asthma patients with known esophageal diseases such as cancer, achalasia, and active peptic ulcer and patients who had used proton pump inhibitors in the last 15 days were excluded. Results: Patients were divided into GERD (+) (16/40, 40%) and GERD (-) (24/40, 60%). Subjects were predominantly elderly (25/40, 62.5%) and had a smoking history (36/40, 90%). Exacerbation and COPD assessment test (CAT) score was significantly associated with GERD (p < 0.05). No significant difference regarding age, sex, Brinkman Index, lung function, and body mass index (BMI) was found between groups. However, the GERD (+) group showed a slightly higher BMI and more severe airflow obstruction. Conclusion: The prevalence of GERD in COPD patients found in this study was as high as 40%. A cohort study and preventive strategy of GERD in COPD should be studied further.

The therapeutic effect of Oleanolic acid on experimentally induced Gastroesophageal Reflux Disease

ABSTRACT
 Objective: This study aimed to evaluate the therapeutic effect of Oleanolic acid (OA) on experimentally induced Gastroesophageal reflux disease (GERD).
 Materials and Methods: GERD was induced in twelve albino Wister rats by daily administration of 2 mL of acetic acid 15 %, pH: 2.41 for 30 days, while another group of three rats received the same volume of distilled water during the same period. The twelve rats being administered acetic acid were divided into four groups of three rats each and treated as follows; Group 1-the control group, with intra-peritoneal administration of 0.2 mL saline solution; Groups 2 and 3, with intra-peritoneal administration of 0.2 mL of OA 20 mg/kg and 40 mg/kg respectively and Group 4 with oral administration of 2 mL of Lansoprazole 20 mg/kg. All treatments were given simultaneously with the acetic acid daily for 30 days. All rats oesophagus were harvested for histological analysis.
 Results: Rats treated with 20 mg/kg and 40 mg/kg OA revealed a more intact oesophageal lining compared to the detached saline group one, there was no damage of blood vessels and the mucosal protective barrier was thick.
 Conclusion: Our results suggest that OA may protect the oesophagus against GERD.

Heterotopic Gastric Mucosa in Cervical Oesophagus: Clinical Observations

Aim. Description of the endoscopic and clinical traits of heterotopic gastric mucosa (HGM) observed in cervical oesophagus.Key points. HGM in proximal oesophagus can be asymptomatic or have various clinical manifestations. A 40-yo female patient consulted a gastroenterologist with complaints of cough and globus sensation. For several years she was visiting an otorhinolaryngologist and psychotherapist, with therapy ineffective. Esophagogastroduodenoscopy (EGDS) at the last visit revealed several foci of HGM in cervical oesophagus of 1.2 x 0.8 cm maximal size. The patient was prescribed a combined prokinetic — proton pump inhibitor therapy, which relieved the symptoms. EGDS in a 21-yo patient without active complaints revealed a 2 cm-wide HGM of 4/5 cervical oesophageal lining with acidproducing zones.Conclusion. Two different scenarios of cervical oesophageal HGM are described, the first one manifested with laryngopharyngeal reflux, and the second devoid of clinical manifestations despite a large heterotopic site.

Post-radiation tracheoesophageal fistula following salvage laryngectomy: microsurgical repair using a “bi-laminar” lateral arm flap

Post-radiotherapy tracheoesophageal fistula (TOF) is a serious complication following salvage laryngectomy, associated with severe morbidity and high mortality. In the absence of recurrent disease, they commonly follow creation of a tracheoesophageal puncture for speech rehabilitation after total laryngectomy. Frequently, direct closure, local and regional flaps repairs are unsuccessful, further making the bed hostile or challenging for definitive treatment. We report using a free fasciocutaneous lateral arm flap, folded to create a bi-laminar (epithelial) reconstruction for salvage repair of large, high output persistent TOF initiated by tracheoesophageal puncture following total laryngectomy, two previous courses of radiotherapy and two unsuccessful repairs using small local flap and a pedicled pectoralis major. The folded lateral arm free flap provided resolution of the fistula, interposition of well-vascularised soft tissue, in addition to oesophageal lining and external tension-free cutaneous coverage, while maintaining a patent endotracheostomy. Chronic high output fistulas present extremely high risk and post-operative complications and necessitate complex reconstruction. Careful surgical planning, multidisciplinary approach and conservative measures to optimise the patient are paramount to achieve success. Microsurgical reconstruction provides an alternate and important adjunct in salvage repair of persistent and large TOFs. Level of Evidence: Level V, therapeutic study.

Dinosaur lactation?

Lactation is a process associated with mammals, yet a number of birds feed their newly hatched young on secretions analogous to the milk of mammals. These secretions are produced from various sections (crop organ, oesophageal lining and proventriculus) of the upper digestive tract and possess similar levels of fat and protein, as well as added carotenoids, antibodies and, in the case of pigeons and doves, epidermal growth factor. Parental care in avian species has been proposed to originate from dinosaurs. This study examines the possibility that some dinosaurs used secretory feeding to increase the rate of growth of their young, estimated to be similar to that of present day birds and mammals. Dinosaur 'lactation' could also have facilitated immune responses as well as extending parental protection as a result of feeding newly hatched young in nest environments. While the arguments for dinosaur lactation are somewhat generic, a case study for lactation in herbivorous site-nesting dinosaurs is presented. It is proposes that secretory feeding could have been used to bridge the gap between hatching and establishment of the normal diet in some dinosaurs.

Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus

Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred. To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs. A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival. Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68]. Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).

A NEW AUSTRALIAN SPECIES OF STOMATODEX FAIN (ACARI: DEMODECIDAE) FROM THE OESOPHAGUS OF CERCARTETUS NANUS (DESMAREST) (MARSUPIALIA)

Stomatodex cercarteti sp.n. is described from adults and immatures from the oesophageal lining of the eastern pygmy possum, Cercartetus nanus. This is the first record of this genus from Australia and from a marsupial host.

The distribution of intermediate‐conductance, calcium‐activated, potassium (IK) channels in epithelial cells

Intermediate-conductance, calcium-activated, potassium (IK) channels were first identified by their roles in cell volume regulation, and were later shown to be involved in control of proliferation of lymphocytes and to provide a K+ current for epithelial secretory activity. Until now, there has been no systematic investigation of IK channel localization within different epithelia. IK channel immunoreactivity was present in most epithelia, where it occurred in surface membranes of epithelial cells. It was found in all stratified epithelia, including skin, cornea, oral mucosa, vaginal mucosa, urothelium and the oesophageal lining. It occurred in the ducts of fluid-secreting glands, the salivary glands, lacrimal glands and pancreas, and in the respiratory epithelium. A low level of expression was seen in serous acinar cells. It was also found in other epithelia with fluid-exchange properties, the choroid plexus epithelium, the ependyma, visceral pleura and peritoneum, bile ducts and intestinal lining epithelium. However, there was little or no expression in vascular endothelial cells, kidney tubules or collecting ducts, lung alveoli, or in sebaceous glands. It is concluded that the channel is present in surface epithelia (e.g. skin) where it has a cell-protective role against osmotic challenge, and in epithelia where there is anion secretion that is facilitated by a K+ current-dependent hyperpolarization. It was also in some epithelial cells where its roles are as yet unknown.

Long-term risk of oesophagitis, Barrett's oesophagus and oesophageal cancer in achalasia patients

Achalasia is a motility disorder of the oesophagus of unknown origin in which loss of relaxation of the lower oesophageal sphincter (LOS) and aperistalsis in the distal oesophagus leads to functional oesophageal obstruction. The treatment is symptomatic, aimed at lowering of the LOS pressure, and may be accompanied by various side effects, including gastro-oesophageal reflux, a risk factor for oesophagitis and its complications. Stasis and fermentation can also lead to inflammation of the oesophageal mucosa, giving rise to hyperplasia of the epithelium, multifocal dysplasia and in some patients eventually squamous cell carcinoma. Unfortunately, the sensitivity and specificity of endoscopical inspection to assess inflammation or dysplasia of the oesophageal lining is low, such that biopsy sampling is necessary for accurate assessment. Although it is generally accepted that achalasia is a pre-malignant disorder, the reported increased risk of patients with achalasia developing a squamous cell carcinoma varies from 0 to 140 times that of the normal population. In addition, achalasia may predispose to Barrett's metaplasia and oesophageal adenocarcinoma, which have been described in case reports after myotomy. Surveillance endoscopy with tissue sampling to detect pre-neoplastic lesions has been recommended, even though this can be very difficult due to mucosal adherence of food as well as hyperplastic changes of the mucosa. In the event of moderate to severe inflammation and/or persisting stasis of food despite adequate LOS pressure-lowering therapy, the surveillance interval should be shortened and performed after a 3-day liquid diet. The exact technique and time intervals still need to be established, however.

Towards defining the full spectrum of important house dust mite allergens

Towards defining the full spectrum of important house dust mite allergens

The columnar lined oesophagus: a riddle wrapped in a mystery inside an enigma

See article on page585 Just a few years ago, the definition and pathogenesis of Barrett’s oesophagus seemed straightforward. Barrett’s oesophagus was the condition in which metaplastic columnar epithelium replaced oesophageal...

Barrett's oesophagus in children and adolescents

This paper describes 12 cases of Barrett's oesophagus (BE) selected out of a population of 364 refluxing children studied by X-ray, manometric, pH-metric, endoscopic, and bioptic methods in one single institution from 1986 to 1990. Their mean age was 14 years, the male-female ratio was 5:7, and all had had gastro-oesophageal reflux (GER) symptoms since infancy. At the time of diagnosis 9 (75 %) had vomiting, 6 (50 %) respiratory tract disease, 3 (25 %) haemorrhage, and 1 (8 %) peptic stenosis. Seven were cared for in special institutions for brain-damaged patients and 2 had been operated upon for oesophageal atresia at birth. Lower oesophageal sphincter pressure was very low in 8 out of 9 children studied and propulsive peristalsis was markedly decreased. Excessive acid exposure was documented in 8 out of 10 patients studied and simultaneous gastric and oesophageal pH-monitoring demonstrated massive duodeno-gastric alkaline reflux in 3 (2 of them with “normal” oesophageal pH studies). Histological and histochemical studies, including special mucin staining revealed that the columnar-lined epithelium was of the fundic type in 2 cases, the junctional type in 7, and the specialised type in the remaining 3. Helicobacter pylori was found in the mucosa of 8 patients (in massive amounts in 3). All patients had a Nissen fundoplication with good results in terms of disappearance of the GER symptoms. The present series confirms that BE should be looked for endoscopically in children with GER and supports the hypothesis that long duration of GER and excessive acid-alkaline chemical exposure of the oesophageal lining contribute to the pathogenesis of mucosal changes. The role of H. pylori is not clear, but its intriguing presence in the majority of our cases indicates that further research along these lines is warranted.

Distribution of pimonidazole and RSU 1069 in tumour and normal tissues

The tritium-labelled analogues of pimonidazole and RSU 1069 were injected into mice bearing the KHT murine sarcoma which has a hypoxic cell fraction of approximately 10%. The distribution of activity at 24 h was recorded using autoradiography and measurement of tissue activity. Autoradiographs with both drugs showed high activity in particular cells within tumour, eye (melanin-associated cells), eyelid (Meibomian gland), liver (centrilobular area), skin (sebaceous gland and melanin), stomach (squamous area), footpad, oesophagus, labial gland, Zymbal's gland, preputial gland, parotid gland (intralobular ducts) and airway epithelium. These tissues had previously been identified as sites of binding of misonidazole. The measurement of total tissue radioactivity showed significantly higher activity in liver, eyelid (Meibomian gland), oesophageal lining, kidney and labial gland than was found in the tumour.

The Macropodid Oesophagus I. Gross Anatomical, Light Microscopic, Scanning and Transmission Electron Microscopic Observations of its Mucosa

The results of examinations on the oesophagus of 248 animals of 36 species of macropodid marsupials are presented in this paper. Four distinct morphological types of oesophageal lining are described and the species examined classified accordingly. The oesophagus of Aepyprymnus: Bettongia, Dendrolagus, Hypsiprymnodon, Onychogalea; Petrogale; Peradorcas, Setonix and Thylogale has a smooth lining with small and simple longitudinal folds (type 1). The large kangaroos of the genus Macropus (M. antilopinus. M. bernardus, M. fuliginosus, M. giganteus. M. robustus, and M. rufus) have smooth oesophageal linings with extensively pleated longitudinal folds (type 11). The so-called brush wallabies of the genus Macropus (M. agilis, M. dorsalis, M. eugenii, M. irma; M. parma and M. parryi) and Wallabia bicolor have papillated oesophageal linings (type 111). In the red-necked wallaby M. rufogriseus banksianus and the Bennett's wallaby M. r. rufogriseus the oesophagus proximal to the diaphragm is lined with longitudinal leaf-like, laminar plates. and distal to the diaphragm the lining consists of finger-like papillae (type IV). The morphology of the oesophagus in the various macropodid species is discussed in relation to dietary preferences, habitat. and phylogenetic associations between species.

The Macropodid Oesophagus. Iii. Observations on the Nematode Parasites.

Large populations of Cyclostrongylus and Spirostrongylus spp. (Pharyngostrongylinea) were found in the oesophagus of macropodid species with papillated (Macropus agilis, M. eugenii, M. irma and Wallabia bicolor) or laminated (M. rufogriseus) oesophageal linings. These nematodes possessed specialized adaptations of their outer cuticle and adopted body conformations which were instrumental in holding them in close association with the oesophageal lining. Site preference of these nematodes was investigated in 3 macropodid species. All species of Cyclostrongylus and Spirostrongylus examined in this study appear to feed on the plaque of bacteria adherent to the lining of the oesophagus. Species of Woodwardostrongylus (Pharyngostongylinea) and Gongylonema (Spiruroidea), were found in the oesophageal epithelium of several macropodid species irrespective of the type of oesophageal lining. Records of Woodwardostrongylus in Petrogale brachyotis, Peradorcas concinna and M. bernardus and of C. wallabiae in M. irma, represent new host records.

The Macropodid Oesophagus. II. Morphological Studies of Its Adherent Bacteria using Light and Electron Microscopy

The bacterial population attached to the oesophageal lining in herbivorous macropods is described. This feature which occurs in both browsing and grazing macropodid species (Macropus, Seton ix, Thylogale and Wallabia) is demonstrated by light and electron microscopy. These studies have shown that the oesophagus may support a large and diverse population of bacterial forms, many of which have extracellular fibrous coats or homogeneous capsules. These coats and capsules appear to mediate the attachment of bacteria to the surface epithelium and to each other so that microcolonies or communities are formed. Such aggregations of bacteria are responsible for the greenish coloration of the oesophageal lining of these herbivorous species. Further examination of the bacterial association with oesophageal cells demonstrated that the bacteria did not invade the mucosa but merely colonized the superficial layer of cells. Cells with ruptured cell membranes were invaded by bacteria which appeared to digest the cytoplasmic contents. Sloughing of such cells provided a new surface for bacterial attachment and proliferation. The importance of this bacterial association is discussed in the light of the anatomical studies of the macropodid oesophagus and the known digestive processes of herbivorous macropods. It is proposed that this adaptation may have an important bearing on our knowledge of foregut fermentative digestion in macropods.

Ultrastructure and Function of the Anterior Feeding Apparatus in Mononchus Aquaticus

The structure and function of the anterior feeding apparatus of Mononchus aquaticus, a predatory nematode, were studied by electron microscopic and cinematographic analysis. The lip region is composed of cuticular material and bears two sets of outgrowths, the liplets, projecting into the vestibulum. The buccal capsule, described here as a functional unit, is composed of three sets of plates. Ontogenetically, however, the anterior oblique plates belong to the cheilostome. Two sets of eight modified somatic muscles, the labial and stomatal muscles, are present at the level of the buccal capsule. During attack on the prey the lip region is pulled backwards by contraction of the labial muscles, and the anterior part of the buccal capsule, thus brought into close contact with the prey's cuticle, is dilated. Simultaneously the oesophageal muscles contract, creating suction. During ingestion the posterior oblique plates of the buccal capsule are drawn backwards into a vertical position and the oesophageal lumen becomes fully dilated. The structure of the lumen lining of the anterior oesophagus suggests a sequence of two phases of dilation necessitated by the bulky meal. The stomatal muscles probably provide a good hold for the buccal capsule on the struggling of the prey. Further they may restore the head region to its original shape after feeding, thus acting as retractors. Marginal muscles of the oesophagus are well developed and are thought to assist in the closure of the complex oesophageal lumen lining. The structure of the anterior feeding apparatus in M. aquaticus is compared with that of the Dorylaimoidea.

Oriverutus Lobatus Gen. N., Sp. N. and Sicaguttur Sartum Gen. N., Sp. N. (Nematoda: Dorylaimoidea) From Cultivated Soils in Africa

Oriverutus gen. n. differs from Eudorylaimus in having large amphids, long dorsal gland duct, anterior position of the outlets of the subventral glands in the oesophageal enlargement and glandular tissue forming a collar around the cardia. O. lobatus sp. n. is described from soil around roots of Oryza saliva in Ibadan, Nigeria. Eudorylaimus sundarus, E. hastatus and Longidorella impar are transferred to Oriverutus, and Tylencholaimus hastatus is renamed as Oriverutus hastulatus nom. nov. Sicaguttur gen. n. is similar to Thornenema but has narrow lateral hypodermal chords, two ovaries and a pointed, heavily sclerotized lip region. S. sartum sp. n. is described from soil around roots of Citrus nobilis and Oryza sativa in Abu Naama, Central Sudan. A new structure, the endolid, is found in the subventral sector of the oesophageal lining at some distance in front of the nerve ring in Sicaguttur and several other dorylaimid genera.