Esophageal Wall Thickness Research Articles

A Hidden Cause of Dysphagia

Gastroentero Question: A 78year-old man was referred to our clinic for progressive esophageal dysphagia. He had first noted intermittent difficulty with swallowing solids 6 months before the visit. His symptoms had worsened progressively over the past 2 months to both solids and liquids. He had a 10 pounds loss over this time period. His past medical history was significant for coronary artery disease and history of bypass grafting 15 years before the presentation. He had a remote history of smoking (>30 years ago). There was no pertinent finding in the physical examination. Routine blood tests were unremarkable, except for slightly elevated lactate dehydrogenase at 228. His local evaluation with upper endoscopy revealed a moderate stenosis measuring 6 cm in length 25 cm from the incisors. The mucosa was intact with the inner diameter 1 cm. The mucosal biopsies were normal. The remainder of the esophagus, the entire stomach and duodenum were normal. Barium esophagography (Figure A) showed a 6 cm area of smooth narrowing of the mid esophagus. CT of the chest (Figure B, arrow) showed a circumferential esophageal thickening with soft tissue infiltration involving the esophagus starting at the level of the carina. There were slightly enlarged lymph nodes in the adjacent mediastinum. He underwent endoscopic ultrasonography (EUS), which confirmed the diffuse esophageal wall thickening. Yet again the mucosal biopsies and a lymph node fine needle aspiration (FNA) were negative. At this point, the patient was referred to our institution. What is your diagnosis? Look on page 550 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Loss of JAM-C leads to impaired esophageal innervations and megaesophagus in mice.

Megaesophagus is a disease where peristalsis fails to occur properly and esophagus is enlarged. The etiology and mechanism of megaesophagus are not well understood. In this study, we reported that junctional adhesion molecule C (JAM-C) knockout mice on a C57/B6 background developed progressive megaesophagus from embryonic day (E) 15.5 onward with complete penetrance. JAM-C knockout mice exhibited a significant reduction in the number of nerve fibers/ganglia in the wall of the esophagus. However, histological analysis revealed that the esophageal wall thickness and structure of JAM-C knockout mice at embryonic stages and young adult were comparable to that of control littermates. Thus, megaesophagus observed in JAM-C knockout mice could be attributed, at least in part, to impaired esophageal innervations. Our data suggest JAM-C as a potential candidate gene for human megaesophagus, and JAM-C knockout mice might serve as a model for the study of human megaesophagus.

SU‐C‐BRA‐04: Use of Esophageal Wall Thickness in Evaluation of the Response to Chemoradiation Therapy for Esophageal Cancer

Purpose:To quantitatively evaluate the esophageal cancer response to chemoradiation therapy (CRT) by measuring the esophageal wall thickness in CT.Method:Two datasets were used in this study. The first dataset is composed of CT scans of 15 esophageal cancer patients and 15 normal controls. The second dataset is composed of 20 esophageal cancer patients who underwent PET/CT scans before (Pre‐CRT) and after CRT (Post‐CRT). We first segmented the esophagus using a multi‐atlas‐based algorithm. The esophageal wall thickness was then computed, on each slice, as the equivalent circle radius of the segmented esophagus excluding the lumen. To evaluate the changes of wall thickness, we computed the standard deviation (SD), coefficient of variation (COV, SD/Mean), and flatness [(Max–Min)/Mean] of wall thickness along the entire esophagus.Results:For the first dataset, the mean wall thickness of cancer patients and normal controls were 6.35 mm and 6.03 mm, respectively. The mean SD, COV, and flatness of the wall thickness were 2.59, 0.21, and 1.27 for the cancer patients and 1.99, 0.16, and 1.13 for normal controls. Statistically significant differences (p < 0.05) were identified in SD and flatness. For the second dataset, the mean wall thickness of pre‐CRT and post‐CRT patients was 7.13 mm and 6.84 mm, respectively. The mean SD, COV, and flatness were 1.81, 0.26, and 1.06 for pre‐CRT and 1.69, 0.26, and 1.06 for post‐CRT. Statistically significant difference was not identified for these measurements. Current results are based on the entire esophagus. We believe significant differences between pre‐ and post‐CRT scans could be obtained, if we conduct the measurements at tumor sites.Conclusion:Results show thicker wall thickness in pre‐CRT scans and differences in wall thickness changes between normal and abnormal esophagus. This demonstrated the potential of esophageal wall thickness as a marker in the tumor CRT response evaluation.This work was supported in part by the National Cancer Institute Grant R01CA172638.

The features of psycho-vegetative disorders and their role in the pathogenesis of gastroesophageal reflux disease with obesity

Background: Gastroesophageal reflux disease (GERD) is a disease of the XXI century, affecting the population in the developed countries. There is a clear tendency to increasing of gastroesophageal reflux disease among people of young age.Aim: The aim of the study is to determine the characteristics and role of psychosomatic and vegetative state disorders in the pathogenesis of GERD with concomitant obesity.Materials and methods: 50 young patients with GERD were examined during the study. Depending on the presence or absence of concomitant obesity, two groups were formed. They underwent pH-metery, ultrasonic scanning. State of psycho-somatic, vegetative statuses and quality of life we determined by the questionnaires of Beck, Spielberg, Sheehan, Wayne.Results: During the ultrasound examination we determined the esophageal opening diameter, the thickness of esophageal wall, the esophagus width in the lower one third of the esophagus differed significantly in 2 groups of patients (p<0.05). In the group of the GERD patients with concomitant obesity the sharp increase of depression level was found, comparing with both the standard and the second group (p<0.05). It wasn’t found the significant difference amount other figures of vegetative and psychosomatic statuses in 2 groups of patients (p>0.05). The patients with GERD of both groups had significantly higher level of motor-evacuation and psycho-vegetative disorders comparing with healthy people (p<0.05).Conclusion: GERD patients have pronounced motor-evacuation disorders and significantly greater manifestations of psycho-vegetative disorders which were more pronounced in gastroesophageal reflux disease patients with concomitant obesity.Bangladesh Journal of Medical Science Vol.14(2) 2015 p.142-145

Response evaluation with endoscopic ultrasound and computed tomography in esophageal squamous cell carcinoma treated by definitive chemoradiotherapy.

We assessed the feasibility of combined endoscopic ultrasound and computed tomography on response evaluation in patients with esophageal squamous cell carcinoma treated by definitive chemoradiotherapy, and the impact of response on prognosis. Sixty patients treated by definitive chemoradiotherapy were followed by miniprobe endoscopic ultrasound and computed tomography. The post-treatment esophageal wall thickness was measured by miniprobe endoscopic ultrasound. Metastatic tumors were evaluated by computed tomography. The correlation between post-treatment image findings and prognosis was evaluated. Twenty-four patients (40%) had esophageal stricture after chemoradiotherapy, which limited complete evaluation by endoscopy. Miniprobe successfully penetrated all strictures to measure post-treatment esophageal wall thickness. Both post-treatment esophageal wall thickness < 8 mm measured by endoscopic ultrasound and no enlargement of metastatic tumor foci on computed tomography predicted good prognosis (P = 0.001). Combined evaluation with these two modalities improved survival prediction (P < 0.001). Patients who met the above two criteria after chemoradiotherapy had the longest survival compared with those who met only one or none of the criteria. The corresponding median survivals were > 30 months, 16.8 months and 7.1 months, respectively (P < 0.001). On multivariate analysis, treatment response is the strongest independent prognostic factor (hazard ratio 3.65, P = 0.006) regardless of baseline tumor-node-metastasis staging and chemoradiation regimen. Response evaluation by miniprobe endoscopic ultrasound and computed tomography can predict the prognosis of esophageal squamous cell carcinoma patients treated by definitive chemoradiotherapy. Those who were judged as poor responder should receive additional treatment to improve outcome.

Value of two-phase dynamic multidetector computed tomography in differential diagnosis of post-inflammatory strictures from esophageal cancer.

To characterize the computed tomography (CT) findings in patients with post-inflammatory esophageal strictures (corrosive and peptic) and reveal the optimal scanning phase protocols for distinguishing post-inflammatory esophageal stricture and esophageal cancer. Sixty-five patients with esophageal strictures of different etiology were included in this study: 24 patients with 27 histopathologically confirmed corrosive strictures, 10 patients with 12 peptic strictures and 31 patients with esophageal cancer were evaluated with a two-phase dynamic contrast-enhanced MDCT. Arterial and venous phases at 10 and 35 s after the attenuation of 200 HU were obtained at the descending aorta, with a delayed phase at 6-8 min after the start of injection of contrast media. For qualitative analysis, CT scans of benign strictures were reviewed for the presence/absence of the following features: "target sign", luminal mass, homogeneity of contrast medium uptake, concentric wall thickening, conically shaped suprastenotic dilatation, smooth boundaries of stenosis and smooth mucous membrane at the transition to stenosis, which were compared with a control group of 31 patients who had esophageal cancer. The quantitative analysis included densitometric parameter acquisition using regions-of-interest measurement of the zone of stenosis and normal esophageal wall and the difference between those measurements (ΔCT) at all phases of bolus contrast enhancement. Esophageal wall thickening, length of esophageal wall thickening and size of the regional lymph nodes were also evaluated. The presence of a concentric esophageal wall, conically shaped suprastenotic dilatation, smooth upper and lower boundaries, "target sign" and smooth mucous membrane at the transition to stenosis were suggestive of a benign cause, with sensitivities of 92.31%, 87.17%, 94.87%, 76.92% and 82.05%, respectively, and specificities of 70.96%, 89.66%, 80.65%, 96.77% and 93.55%, respectively. The features that were most suggestive of a malignant cause were eccentric esophageal wall thickening, tuberous upper and lower boundaries of stenosis, absence of mucous membrane visualization, rupture of the mucous membrane at the upper boundary of stenosis, cup-shaped suprastenotic dilatation, luminal mass and enlarged regional lymph nodes with specificities of 92.31% 94.87%, 67.86%, 100%, 97.44%, 94.87% and 82.86%, respectively and sensitivities of 70.97%, 80.65%, 96.77%, 80.65%, 54.84%, 87.10% and 60%, respectively. The highest tumor attenuation occurred in the arterial phase (mean attenuation 74.13 ± 17.42 HU), and the mean attenuation difference between the tumor and the normal esophageal wall (mean ΔCT) in the arterial phase was 23.86 ± 19.31 HU. Here, 11.5 HU of ΔCT in the arterial phase was the cut-off value used to differentiate esophageal cancer from post-inflammatory stricture (P = 0.000). The highest attenuation of post-inflammatory strictures occurred in the delayed phase (mean attenuation 71.66 ± 14.28 HU), and the mean ΔCT in delayed phase was 34.03 ± 15.94 HU. Here, 18.5 HU of ΔCT in delayed phase was the cut-off value used to differentiate post-inflammatory stricture from esophageal cancer (P < 0.0001). The described imaging findings reveal high diagnostic significance in the differentiation of benign strictures from esophageal cancer.

Prior to the oral therapy, what do we know about HCV-4 in Egypt: a randomized survey of prevalence and risks using data mining computed analysis.

Hepatitis C virus (HCV) affects over 180 million people worldwide and it's the leading cause of chronic liver diseases and hepatocellular carcinoma. HCV is classified into seven major genotypes and a series of subtypes. In general, HCV genotype 4 (HCV-4) is common in the Middle East and Africa, where it is responsible for more than 80% of HCV infections. Although HCV-4 is the cause of approximately 20% of the 180 million cases of chronic hepatitis C worldwide, it has not been a major subject of research yet. The aim of the current study is to survey the morbidities and disease complications among Egyptian population infected with HCV-4 using data mining advanced computing methods mainly and other complementary statistical analysis.Six thousand six hundred sixty subjects, aged between 17 and 58 years old, from different Egyptian Governorates were screened for HCV infection by ELISA and qualitative PCR. HCV-positive patients were further investigated for the incidence of liver cirrhosis and esophageal varices. Obtained data were analyzed by data mining approach.Among 6660 subjects enrolled in this survey, 1018 patients (15.28%) were HCV-positive. Proportion of infected-males was significantly higher than females; 61.6% versus 38.4% (P = 0.0052). Around two-third of infected-patients (635/1018; 62.4%) were presented with liver cirrhosis. Additionally, approximately half of the cirrhotic patients (301/635; 47.4%) showed degrees of large esophageal varices (LEVs), with higher variceal grade observed in males. Age for esophageal variceal development was 47 ± 1. Data mining analysis yielded esophageal wall thickness (>6.5 mm), determined by conventional U/S, as the only independent predictor for esophageal varices.This study emphasizes the high prevalence of HCV infection among Egyptian population, in particular among males. Egyptians with HCV-4 infection are at a higher risk to develop cirrhotic liver and esophageal varices. Data mining, a new analytic technique in medical field, shed light in this study on the clinical importance of esophageal wall thickness as a useful predictor for risky esophageal varices using decision tree algorithm.

Stage IV Squamous Cell Carcinoma of Esophagus With Multi-Loculated Cystic Metastasis to Pancreas: A Rare Presentation

Introduction: A 60-year-old male with no significant medical history presented to the gastroenterology clinic with dysphagia. Patient did not have any odynophagia, weight loss, hematemesis, malena or abdominal pain. He did not have any family history of malignancy. He had history of tobacco and alcohol abuse. Physical examination was unremarkable. EGD was performed which showed a hemi circumferential thickening between 29-34 cm in the esophagus and another nodularity at 37cm. Biopsies from the lesions revealed a moderately differentiated invasive squamous cell carcinoma. CT chest revealed a circumferential thickening of the mid esophageal wall corresponding to the EGD findings. CT abdomen revealed multiple cysts in the pancreas, the largest measuring 5.3 x 4 cm. It was multi-loculated with macrocysts in the tail of the pancreas with thickened septum and a central calcification. The pancreatic lesion was found to be mixed solid and cystic in nature on endoscopic ultrasound. Two enlarged peritumoral nodes were also identified. USG guided aspiration of the pancreatic cyst revealed that the fluid had a CEA level of 41.1 ng/ml and an amylase level of 13 U/L. Fluid cytology revealed malignant cells consistent with metastatic squamous cell carcinoma. As per the TNM staging system, the patient was found to be in stage T3N1M1 and was started on chemotherapy with carboplatin and paclitaxel. Primary squamous cell carcinoma in pancreas is extremely rare of all pancreatic malignancies as the pancreas does not have squamous epithelium. Pancreatic metastasis occurs in 0.12% of all primary esophageal carcinomas. Only 4 cases of squamous metastasis to pancreas from esophagus have been reported in literature. Of them 2 patients had synchronous metastasis and 2 patients had metachronous metastasis. Our patient had the pancreatic metastasis at the time of presentation. Esfehani et al reported a case of pancreatic squamous metastasis that presented 4 years after the removal of esophageal primary. The pancreatic lesion was noted to be cystic on a CT abdomen but gross examination after surgery revealed a hard mass. All the other reported cases had solid metastases. Our patient is unique as he had a mixed solid and cystic metastasis.

Endoscopic ultrasound as an adjunctive evaluation in patients with esophageal motor disorders subtyped by high-resolution manometry.

Esophageal motor disorders are a heterogeneous group of conditions identified by esophageal manometry that lead to esophageal dysfunction. The aim of this study was to assess the clinical utility of endoscopic ultrasound (EUS) in the further evaluation of patients with esophageal motor disorders categorized using the updated Chicago Classification. We performed a retrospective, single center study of 62 patients with esophageal motor disorders categorized according to the Chicago Classification. All patients underwent standard radial endosonography to assess for extra-esophageal findings or alternative explanations for esophageal outflow obstruction. Secondary outcomes included esophageal wall thickness among the different patient subsets within the Chicago Classification. EUS identified 9/62 (15%) clinically relevant findings that altered patient management and explained the etiology of esophageal outflow obstruction. We further identified substantial variability in esophageal wall thickness in a proportion of patients including some with a significantly thickened non-muscular layer. EUS findings are clinically relevant in a significant number of patients with motor disorders and can alter clinical management. Variability in esophageal wall thickness of the muscularis propria and non-muscular layers identified by EUS may also explain the observed variability in response to standard therapies for achalasia.

Utility of chest CT for differentiating primary and secondary achalasia

To determine the computed tomography (CT) findings of primary and secondary achalasia and to assess the utility of CT for differentiating these conditions. A computerized search revealed 13 patients with primary achalasia and 15 with secondary achalasia who underwent chest CT during a 10-year period. The images were reviewed to determine whether there was distal oesophageal narrowing (including the length/contour of narrowing), oesophageal dilation, oesophageal wall thickening (including degree/symmetry/pattern of thickening), a soft-tissue mass at the gastro-oesophageal junction, mediastinal adenopathy, or other findings of malignant tumour. Eleven (85%) of 13 patients with primary achalasia had distal oesophageal narrowing at CT that was smooth in all patients; four (31%) had oesophageal wall thickening that was smooth and symmetric in all patients; none had a soft-tissue mass at the gastro-oesophageal junction or mediastinal lymphadenopathy; and two (15%) had pulmonary metastases from unrelated lung cancers. In contrast, 12 (80%) of 15 patients with secondary achalasia had distal oesophageal narrowing at CT; 11 (73%) had distal oesophageal wall thickening that was nodular/lobulate and asymmetric in seven (64%) and smooth and symmetric in four (36%); six (40%) had a soft-tissue mass at the gastro-oesophageal junction; seven (47%) had mediastinal lymphadenopathy; and all 15 had other findings of malignant tumour. CT is a useful technique for differentiating primary and secondary achalasia. Distal oesophageal wall thickening that is nodular/lobulate and asymmetric, a soft-tissue mass at the gastro-oesophageal junction, mediastinal lymphadenopathy, and pulmonary, hepatic, or osseous metastases are findings that favour secondary achalasia.

FRI0235 Static and Dynamic-Functional Trans-Cervical Ultrasonography of the Esophagus in Systemic Sclerosis Patients

BackgroundEsophagus is the second internal organ to be affected in systemic sclerosis (SSc), resulting in gastro-oesophageal reflux, oesophagitis and, in more advanced stages, complete atony with megaesophagus. Trans-cervical ultrasonography (TCU)...

Diagnostic performance of CT esophagography in patients with suspected esophageal rupture.

Esophageal rupture is a surgical catastrophe. The gold standard for diagnosing is iodine, water-soluble contrast medium esophagography. CT esophagography has shown promising results. This study aimed to assess the diagnostic performance of CT esophagography in patients with a suspicion of esophageal rupture. This prospective study assessed the performance of a diagnostic test and was approved by local IRB committee. Patients who presented with a clinical suspicion of esophageal rupture were included. CT esophagography findings were described by the emergency radiologist. Clinical outcomes (presence or absence of esophageal rupture) were reported by surgeons. The operative characteristics were calculated. A final predictive scale for rupture was built. A total of 64 patients were recruited (age 26.5 years, 90 % male, 82 % trauma). Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were 77.7 % (95 % confidence interval (CI) 45-100), 94.3 % (87.2-100), 14 (9.81-19.9), and 0.24 (0.05-1.22), respectively. The final model for predicting rupture included five variables: age (odds ratio (OR) 1.03; 95 % CI, 0.95-1.11; p=0.04), leakage of contrast media into the mediastinum or pleural space (OR 10.0; 95 % CI, 0.64-156.9; p=0.10), extraluminal air or fluid collections (OR 43.1; 95 % CI, 1.52-1217.3; p=0.027), esophageal wall thickening (OR 10.1; 95 % CI, 0.50-202.8; p=0.12), and left pneumothorax or pleural effusion (OR 6.5; 95 % CI, 0.31-132.7; p=0.2). The overall agreement was 0.40 (95 % CI, 0.09-0.72) for the predictive model. The model sensitivity was 50.0 %, and the specificity was 98.4 %. CT esophagography shows a good diagnostic performance in patients with a suspected esophageal rupture.

Su1756 Endoscopic Ultrasound (EUS): a Proposed Role in Pediatric Eosinophilic Esophagitis (EoE)

Previously, EUS has documented increased esophageal (esph) total wall thickening (TWT) in Pediatric Eosinophilic Esophagitis (EoE) compared to children with gastroesophageal reflux (GER) and decreased TWT in adults who responded to EoE treatment. This report describes EUS data obtained in a longitudinal study on the evolution of Pediatric EoE .

Detection of Risky Esophageal Varices by Two-Dimensional Ultrasound: When to Perform Endoscopy

ObjectiveEsophageal varices are a consequence of portal hypertension in cirrhotic patients. Current guidelines recommend that all cirrhotic patients undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This practice increases costs, involves a degree of invasiveness and discomfort and places a heavy burden on endoscopy units. several studies have evaluated possible noninvasive predictors of esophageal varices, but most of these studies remain controversial. MethodsThe intra-abdominal portion of the esophagus in 673 patients who presented with liver cirrhosis and portal hypertension was examined using standard 2-dimensional (2D) ultrasound. A direct relationship between the degree of varices observed on upper endoscopy and the intra-abdominal esophageal wall thickness was detected using 2D ultrasound. ResultsThe mean thicknesses of the esophageal wall were 3.7±0.5mm (mean±standard deviation) in normal individuals, 7.3±3.3mm in those with esophageal varices and 8.65±1.98mm in those with risky esophageal varices. The overall accuracy of 2D ultrasound was 95%. ConclusionsThe intra-abdominal esophagus should be observed during abdominal ultrasound examination in patients with liver cirrhosis. Two-dimensional ultrasound can play an important role in screening for esophageal varices.

Acute Herpes Esophagitis in an Immunocompetent Adolescent Female

Purpose: Herpes esophagitis is well-described in organ transplant and HIV-positive patients, but is rare in immunocompetent hosts. Immunocompromised patients can have severe herpes infections involving the CNS, skin, lungs, and gastrointestinal tract, while healthy patients typically present with only mild oral lesions. The few previously described cases of herpes esophagitis in immunocompetent patients have affected primarily adult males. This is a case of severe herpes esophagitis in a young healthy female. An 18-year-old Caucasian female presented to the emergency department with sudden-onset, severe (9/10) mid-anterior chest pain. She complained of three days of fever, sore throat, and odynophagia to the point of dehydration. She was a healthy high school senior with no drug or alcohol use. On physical exam, she was anxious and in distress with a temperature of 39.2°C. Palpable cervical lymphadenopathy and an erythematous oropharynx were noted. Heart and lung examinations were normal. Laboratory tests revealed a normal CBC, Chem-7, and d-dimer. Pregnancy test and rapid strep test were negative. Electrocardiogram showed only sinus tachycardia. She was discharged from the ED with empiric antibiotics and a PPI. Later that evening, she returned with continued odynophagia and chest pain. Chest CT showed wall thickening of the thoracic esophagus and no evidence of pulmonary embolus or mediastinitis. She was discharged again with instructions to continue the PPI and follow up with Gastroenterology. Two days later, she was noted to have ulceration in the posterior oropharynx and received intravenous hydration due to inability to tolerate liquids. Notably, her pain required narcotics. Antibiotics were discontinued and an esophagogastroduodenoscopy was performed. Severe, non-bleeding linear ulcers throughout the upper, middle, and lower esophagus were seen. HSV PCR of the esophageal biopsy was positive for HSV-1. She was treated with oral acyclovir for 10 days. On treatment, she improved rapidly and progressed to a solid diet. CD4 count was normal and HIV testing was negative. Repeat EGD 18 days later showed a 75% improvement in esophageal ulcers and repeat biopsies were negative. This illustrates a rare case of acute odynophagia and ulcerative esophagitis secondary to HSV-1 in an immunocompetent adolescent female. It is important to recognize that severe odynophagia is unlikely to be due to gastroesophageal reflux alone and may need referral for endoscopy. In such cases, the clinician must consider infectious causes such as candida, CMV, and herpes esophagitis regardless of immune status. The role of antiviral therapy is unclear, but is suggested in severe cases to shorten duration of illness.

Metastatic Malignant Extra-renal Rhabdoid Tumor (MERT) of the Esophagus

Purpose: We report a 61-year-old female who presented with a 5-month history of intermittent dysphagia to solids and an 8-pound weight loss. She underwent a barium swallow that revealed a partially obstructing distal esophageal lesion suspicious for malignancy. She was referred to an outside gastroenterologist for an upper endoscopy (EGD). EGD demonstrated a large, partially obstructing fungating mass in the esophagus from 33 cm to 40 cm. Cold forceps biopsies were performed revealing poorly differentiated non-small cell carcinoma. Immunohistochemistry (IHC) staining was performed for epithelial markers and was positive for epithelial membrane antigen (EMA), cytokeratin AE1/3, and CAM 5.2. The impression was that of an esophageal non-small cell carcinoma. Staging CT scan of the chest, abdomen, and pelvis showed marked concentric wall thickening of the distal esophagus with extensive mediastinal lymphadenopathy and porta caval/hepatis lymph nodes. Subsequent PET scan demonstrated uptake in the distal esophagus and adjacent lymph nodes. She was then referred to us for staging via endoscopic ultrasound (EUS). EUS revealed the partially obstructing fungating mass in the distal esophagus with poorly defined borders and evidence of extension beyond the adventitia. Malignant appearing lymph nodes were seen in the paraesophageal region, gastrohepatic ligament, and the celiac axis. The left adrenal gland also appeared enlarged. EUS-guided fine needle aspiration (EUS-FNA) was performed of a celiac lymph node and the left adrenal gland. Immediate cytological evaluation (ICE) of the celiac lymph node aspirate was positive for malignant cells. Cell block of the celiac lymph node revealed large, poorly cohesive cells with vesicular chromatin, eccentric nuclei with prominent nucleoli, and dense eosinophilic cytoplasmic inclusions. IHC staining for vimentin was performed and was positive; this confirmed a diagnosis of metastatic malignant rhabdoid tumor. Recuts of the outside slides also stained positive for vimentin-consistent with malignant extra-renal rhabdoid tumor (MERT) of the esophagus. MERT of the esophagus is rare and carries a poor prognosis with a 1-year survival of approximately 30%. MERT is defined by the presence of large, poorly cohesive cells with vesicular chromatin, eccentric nuclei with prominent nucleoli, and eosinophilic cytoplasmic inclusions. Co-expression of vimentin and epithelial cytokeratin can assist in confirming the diagnosis. Our patient with metastatic MERT was subsequently referred to an oncologist for chemotherapy (cisplatin and 5-fluorouracil). This rare case demonstrates the importance of maintaining a high suspicion of MERT in patients with esophageal non-small cell carcinoma.

Magnifying Endoscopy With Narrow Band Imaging and Endoscopic Ultrasonography for Assessing Eosinophilic Esophagitis

A 59-year-old man presented with epigastric pain during the past 4 weeks. Because his symptom was aggravated with ingestion of food, he complained of poor oral intake and weight loss of 4 kg. His medical history included bronchial asthma which had been diagnosed 4 months before, but he took medicine irregularly. Physical examination was unremarkable. Laboratory studies showed peripheral eosinophilia (920/µL, 14.5% of the circulating leukocytes), and an elevated immunoglobulin E level (895.2 IU/mL). Computed tomography of abdomen demonstrated diffuse thickening of the distal esophageal wall (Fig. 1). On upper endoscopy, the distal esophagus was edematous and pale with adherent pin point whitish exudates (Fig. 2A). Magnifying endoscopy with narrow band imaging demonstrated multiple white micronodules on the mucosal surface (Fig. 2B). Endoscopic ultrasonography (EUS) showed circumferential, mainly thickening of the deep mucosal/submucosal and inner circular muscle layers (Fig. 2C). We took biopsy specimens from proximal, middle and distal esophagus, and only biopsy from distal esophagus showed > 20 eosinophils per high-power field infiltrating the esophageal mucosa (Fig. 3A). Before the histological diagnosis of eosinophilic esophagitis, we tried proton pump inhibitor twice daily for him. However, proton pump inhibitor did not do any good, and finally the patient was diagnosed with eosinophilic esophagitis. Skin prick tests for inhalant and food allergens showed negative results. Treatment was initiated with orally administered fluticasone 500 µg 3 times a day. Epigastric pain improved rapidly. At 8 weeks after treatment, endoscopic features improved (Fig. 2D and 2E), and EUS showed decreased thickness of each layer of the esophagus (Fig. 2F). Histologic remission was also achieved (Fig. 3B). After 3 months of treatment with fluticasone, he stopped the medicine. At present, 6 months have passed without recurrence of symptom. Figure 1 Computed tomography of abdomen demonstrates diffuse thickening of the distal esophageal wall. Figure 2 Endoscopic findings (A-C, before treatment; D-F, after treatment). (A) Upper endoscopy shows edematous and pale esophagus with adherent pin point whitish exudates. (B) On magnifying endoscopy with narrow band imaging, there are multiple white micronodules ... Figure 3 Histologic findings. (A) Biopsy specimen from the distal esophagus shows greater than 20 eosinophils per high power field infiltrating the esophageal mucosa associated with epithelial cell degeneration. And eosinophilic microabscesses (white arrow) are ... The roles of magnifying endoscopy with narrow band imaging and EUS for assessing eosinophilic esophagitis are not clear yet.1-3 However, looking at this case, those could be useful tools, especially when typical endoscopic features such as concentric rings and linear furrows are not seen by conventional endoscopy.

Esophageal reconstruction with remnant stomach: A case report and review of literature

The number of patients developing esophageal cancer after gastrectomy has increased. However, gastric remnant is very rarely used for reconstruction in esophageal cancer surgery because of the risk of anastomotic leakage resulting from insufficient blood flow. We present a case of esophageal cancer using gastric remnant for esophageal substitution after distal gastrectomy in a 57-year-old man who presented with a 1-month history of mild dysphagia and a background history of alcohol abuse. Gastroscopy showed a 1.2 cm × 1.0 cm bulge tumor of the lower third esophagus with the upper margin located 39 cm from the dental arcade. Computed tomography of the chest showed lower third esophageal wall thickening. The patient underwent en bloc radical esophagectomy with a two-field lymph node dissection of the upper abdomen and mediastinum via a left-sided posterolateral thoracotomy through the seventh intercostal space. The upper end of the esophagus was resected 5 cm above the tumor. The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the left thoracic cavity. The patient started a liquid diet on postoperative day 8 and was discharged on the 10(th) postoperative day without complications. In this report, we demonstrate that the gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.

Unanticipated difficult endotracheal intubation due to an undiagnosed pharyngeal web

Unanticipated difficult endotracheal intubation due to an undiagnosed pharyngeal web

In Response

Insertion of the endoscopic guidewire-assisted esophageal dilators, with or without fluoroscopic guidance, is as commented on by Chon et al., occasionally associated with severe complications (0.1% to 0.22%) including esophageal perforation and pneumomediastinum.1–4 Causes of severe complications include patient factors such as tight esophageal strictures and malignant esophageal diseases, operator inexperience, or might be related to the Savary-Gilliard wire guide, the endoscope, and the Savary-Gilliard esophageal dilators.2 Our study excluded patients with esophageal strictures as screened by clinical history and surgical workup.5 Also, our study was related to the procedure of nasogastric tube (NGT) insertion in patients with an anatomically normal esophagus.5 Manual forward displacement of the larynx probably safeguards against laryngeal entry of the wire guide–NGT assembly, while it passes from the hypopharynx into the cervical esophagus. The Savary-Gilliard wire guide also has a progressively flexible tip, which is again sheathed inside an NGT and follows the path of least resistance in the hypopharynx to the esophagus, since the laryngeal inlet is already blocked by the cuffed tracheal tube and displaced anteriorly by gentle manual traction.5 For any blindly performed wire guide–assisted clinical procedure, the most important principle is to “stop and retreat whenever any undue resistance is encountered.” Live fluoroscopy is perhaps the “gold standard” to guide the safe placement of any esophageal device. However, it is cumbersome, costly, and involves exposing the patient and the operator to ionizing radiation. Transcutaneous cervical esophageal ultrasound is a standard technique used by radiologists and gastroenterologists to measure esophageal wall thickness and luminal diameter as an adjunct to diagnosis of gastroesophageal reflux disorders.6 This might be helpful in guiding NGT placements in patients who are not tracheally intubated.7 We performed in-plane approach high-resolution B-mode ultrasound (using a high-frequency linear probe of the LOGIQ e USG console, GE Healthcare, Wauwatosa, WI) to visualize the passage of the NGT with and without laryngeal traction in 3 anesthetized and tracheally intubated patients. Although the trachea with the tracheal tube was clearly visible entirely along the long axis, the esophagus with the NGT was barely visible and that too from the right side only. With manual laryngeal displacement, visualization was even more difficult due to artefact from the operator’s fingers in the laryngoesophageal groove. Of course, an ill-defined motion artefact induced by the NGT movement was visualized. We suggest that real-time ultrasound imaging of the cervical esophagus in tracheally intubated patients requires refinement and standardization before being useful to the clinician as a tool to monitor the safe passage of the NGT. Jyotirmay Kirtania, MD Department of Anesthesiology Tata Medical Center, Kolkata [email protected] Shreyasi Ray, MD Department of Anesthesiology Medical College Hospital Kolkata Kolkata, India