Esophageal Rings Research Articles

Gastrointestinal involvement of primary skin diseases

Less is known about gastrointestinal (GI) involvement of primary skin diseases due to the difference in embryology, histology, microbiology and physiology between integument and alimentary tract. Oesophagus, following the oropharyngeal mucosa, is the most common GI segment affected by primary skin diseases, especially by eosinophilic oesophagitis, lichen planus and autoimmune bullous dermatoses like pemphigus vulgaris, mucosal membrane pemphigoid and epidermolysis bullosa acquisita. Eosinophilic oesophagitis is an emerging chronic atopic disease with oesophageal dysfunction as the typical presentation, and oesophageal narrowing, rings and stricture as late complications. Oesophageal lichen planus mainly involves the proximal to mid-oesophagus in elderly aged women with long-term oral mucosal lesions. In acute attack of pemphigus vulgaris, oesophageal involvement is not uncommon but often neglected and may cause sloughing oesophagitis (oesophagitis dissecans superficialis) with acute GI bleeding in rare cases. GI manifestation of hereditary bradykininergic angio-oedema with colicky acute abdomen mostly affects small intestine, usually in the absence of pruritus or urticaria, and is more severe and long-lasting than the acquired histaminergic form. Strong evidence supports association between inflammatory bowel disease, especially Crohn disease, and hidradenitis suppurativa/acne inversa. Patients with vitiligo need surveillance of autoimmune liver disease, autoimmune atrophic gastritis or coeliac disease when corresponding symptoms become suspect. Melanoma is the most common primary tumour metastatic to the GI tract, with small intestine predominantly targeted. Gastrointestinal involvement is not uncommon in disseminated mycosis fungoides. Extramammary Paget's disease is an intraepidermal adenocarcinoma of controversial origin, and a high association between the anogenital occurrence and colorectal adenocarcinoma has been reported. As GI tract is the largest organ system with multidimensional functions, dermatologists in daily practice should be aware of the gastrointestinal morbidities related to primary skin diseases for an early diagnosis and treatment.

Esophageal Disorders

Typically, symptoms that may indicate the presence of an esophageal disorder include heartburn, dysphagia, odynophagia, and regurgitation. Endoscopy is the technique of choice to evaluate the mucosa of the esophagus and to detect structural abnormalities, whereas esophageal manometry is the standard test to diagnose motor disorders of the esophageal body and the lower esophageal sphincter. This review examines normal esophageal anatomy and physiology, the diagnosis of esophageal disorders, disease states causing dysphagia, and gastroesophageal reflux disease. Figures show the cross-sectional anatomy of the esophagus; an algorithm for the evaluation of dysphagia; the anatomy of the gastroesophageal junction; esophagograms of patients with achalasia, late-stage achalasia, and diffuse esophageal spasm; endoscopic views of esophageal strictures; a proximal esophageal web on barium swallow in a patient with Plummer-Vinson syndrome; an endoscopic view of the esophagus of a 25-year-old man with a 3-year history of severe dysphagia; photographs of midesophageal traction diverticulum, multiple epiphrenic diverticula, long-segment Barrett esophagus, and severe Candida esophagitis; and a treatment algorithm for extraesophageal manifestations of gastroesophageal reflux disease. Tables list the high-resolution manometry classification of esophageal motility disorders, causes of esophageal strictures, classic endoscopic findings in patients with eosinophilic esophagitis, the Los Angeles classification of erosive esophagitis, categories of dysplasia, surveillance of Barrett metaplasia, medications implicated in pill-induced esophagitis, and classification of caustic esophageal injury. This review contains 13 figures, 40 tables, and 82 references. Keywords: achalasia, dysphagia, esophagus, reflux, strictures, diverticula, endoscopy, larynx

Gastric Cancer Accompanying Plummer-Vinson Syndrome

Plummer-Vinson syndrome (PVS), also called sideropenic dysphagia or Paterson-Kelly syndrome, is a condition characterized by a triad of chronic iron-deficiency anemia, esophageal webs, and dysphagia. This syndrome is considered as a precancerous condition due to the occurrence of squamous cell carcinoma in the hypopharynx, upper esophagus and oral cavity. Although exact data on the prevalence of the syndrome are not evidently available, physicians need to recognize this rare syndrome. Most of the patients are elderly Caucasian women aged 40 to 70 years, but cases in children, adolescents, or men have also been described. At present, the prevalence of PVS is decreasing due to improvement in nutritional habits and intake of iron supplements. Therefore, the syndrome accompanied with gastric cancer is even more uncommon. We report a case of a 61-year-old woman with PVS who was diagnosed with gastric cancer and improved after treatment.

Sa1260 ADDITION OF DISRUPTION TO BOUGIE DILATION OF ESOPHAGEAL RINGS AND STRICTURES PROLONGS TIME TO REPEAT INTERVENTION COMPARED TO DILATION ALONE

Esophageal rings and strictures are a common cause of dysphagia. Endoscopic dilation, forceps disruption, or a combination are often employed to alleviate symptoms. Although rings have been reported to require fewer repeat dilations and increased time to repeat dilation, the clinical impact of mode of dilation remains unclear. We aimed to determine whether disruption at time of dilation would increase time to subsequent intervention. We performed a retrospective analysis of all adult patients who underwent esophageal disruption and/or dilation of a ring or stricture in 2015 at a tertiary care center. Individuals were excluded if they had had prior radiofrequency ablation, endoscopic mucosal resection, achalasia, any malignancy, history of chemotherapy or radiation, or prior foregut surgeries. From the electronic medical record, we extracted age, BMI, gender, time to next dilation, type of dilator, size of dilation, and use of anti-secretory medications. Rings or strictures were defined based on the descriptor used in the endoscopic record. Data was analyzed utilizing Fischer’s Exact Test for categorical data, Mann-Whitney for continuous variables, and Kaplan-Meier to compare time to repeat dilation. Of 548 patients, 195 met inclusion criteria (age 60.9±0.9, BMI 28.0±0.5, 66% female). Age, BMI, and gender did not influence need for repeat dilation (p=ns for each). Balloon dilation (78%) was used more often than bougie dilation (19%) or forceps disruption alone (4.1%). Antisecretory medication use with dilation compared to no use (81% vs 19%) did not reduce need for repeat dilation (52.2% vs 50.0%, 0.8) or shorten time to repeat dilation (503 vs 404 days, p=0.8). Rings were more likely than strictures (33% vs. 66%) to be disrupted with forceps prior to dilation (45.5% vs 21.7%, p=0.001) and to a larger dilation size (18.7 mm vs 17.6 mm, p=0.009).When forceps disruption was performed with dilation (29.7%), time to repeat dilation was numerically longer (504.9 vs 477.04 days, p=0.4) with similar need for repeat dilation (47% vs. 54%, p=0.3). There was no significant difference in time to repeat dilation (568.5 vs 447.3 days, p=0.2) or need for repeat dilation (47% vs 54%, p=0.3) between rings and strictures, with or without forceps disruption. When analyzing mode of dilation, patients managed with bougie dilation had significantly prolonged time to repeat dilation when forceps disruption was also performed compared to bougie dilation alone (851±248 vs. 237±76 days respectively, p=0.01), similar findings were not seen with balloon dilation (404.33 vs. 542.21, respectively p=0.3). These findings were supported by Kaplan Meier hazard analysis (Figure). Stricture or ring disruption with bougie dilation significantly prolongs time to repeat dilation, although this trend was not found with balloon dilation.

Phenotype and Natural History of Inflammatory Bowel Disease in Patients With Concomitant Eosinophilic Esophagitis.

The co-occurrence of autoimmune diseases is well recognized. Though studies have suggested that eosinophilic esophagitis (EoE) is more common in patients with inflammatory bowel diseases (IBD), whether co-occurrence of EoE modifies natural history of IBD is unknown. This was a retrospective case-control study at a referral center. Cases consisted of patients with IBD and EoE, with both diseases diagnosed using established criteria. Controls comprised patients with IBD without concomitant EoE. Two controls were selected per case and were matched for duration of IBD. Relevant covariates regarding disease presentation and natural history were extracted from the medical record and compared between the 2 groups. A total of 95 IBD-EoE cases and 190 IBD controls were included in our study. The IBD-EoE group was diagnosed with IBD at a younger age than those with IBD alone (22.3 years vs 29.0 years; P < 0.001) and were more likely to be male (80.0% vs 45.8%; P < 0.001). There were no differences in medical or surgical therapy for IBD between the 2 groups. Among those with IBD-EoE, patients for whom IBD was diagnosed first presented more commonly with dysphagia (50.8% vs 26.9%; P = 0.04) and endoscopically had evidence of esophageal rings (50.0% vs 23.1%; P = 0.02) when compared with those where EoE was diagnosed first. Patients with concurrent IBD-EoE are diagnosed at a younger age and more likely to be males but have similar natural history as those without EoE. There were differences in EoE phenotype based on whether the EoE or IBD was diagnosed first.

Signet ring gastric and esophageal adenocarcinomas: characteristics and prognostic implications.

Controversy exists as to the relevance of the signet ring carcinoma (SRC) histological subtype of esophagogastric adenocarcinoma to long-term prognosis, with some studies reporting a worsened oncological outcome and others no clinically relevant impact. A retrospective analysis of outcomes of patients who underwent surgery with curative intent in two high-volume centers (2000-2015) was undertaken. Tumors were analyzed according to location (esophageal, junctional or gastric). Propensity score matching (PSM) analysis was used to match patients with signet ring histology to those without (195 SRC vs. 573 non-SRC), based on age, tumor location, use of neoadjuvant and adjuvant chemotherapy and pathological stage. A total of 2,500 patients with esophagogastric adenocarcinomas were treated, of whom 198 (7.9%) had signet ring histology. Signet ring tumors were more likely to have positive lymph nodes at pathological analysis (59% vs. 50%, P = 0.009). The 5-year survival rate for patients with early signet ring tumors (Stage 0/I/IIa) was 65% versus 85% for other early cancers (P < 0.003). Patients with esophageal signet ring tumors had a particularly poor prognosis with 23% 2-year survival and none alive at 5years. With PSM, overall survival (OS) was significantly poorer in the signet ring group (44.3 ± 8.6 vs. 59.8 ± 8.5months, 5-year OS 41% vs. 50%, P = 0.027). Signet ring cells within esophagogastric adenocarcinoma are associated with a poorer prognosis. Genomic studies to identify the composition of such tumors as well as identify strategies to improve treatment for this subtype are warranted.

Plummer-vinson syndrome associated with lower esophageal ring (Schatzki’s Ring) and hiatus hernia

We report a case of Plummer-Vinson syndrome (PVS) and lower esophageal ring with a small sliding hiatus hernia. PVS is a rare entity formed by the combination of dysphagia, cervical esophageal web and iron deficiency anemia. It occurs mainly in middle-aged women1,2,3. Lower esophageal ring and a small sliding hiatus hernia were also observed in this case. We documented clinical manifestations of iron deficiency anemia through images and esophagus abnormalities through barium esophagogram.Keywords: Plummer-vinson syndrome; paterson-brown-kelly syndrome; sliding hiatal hernia; lower esophageal sphincter; iron-deficiency anemia

Trachealization in a Patient With Eosinophilic Esophagitis

A40-year-old man was referred for an esophagogastroduodenoscopy (EGD) for evaluation of intermittent nausea and vomiting of 2 months’ duration. The patient denied obvious dysphagia but reported occasional difficulty with swallowing large pills since childhood. The EGD showed markedly prominent mucosal rings in the proximal esophagus (trachealization of esophagus) (Figure A), along with a stricture at 23 cm (Figure B) from the incisors that could not be traversed with a regular upper endoscope. The remainder of the examination was completed using an ultraslim scope and showed the presence of prominent rings in the distal esophagus as well.

A Rare Case Report on Plummer-Vinson Syndrome with a Complication of Oral Cancer in a South-Asian Woman

Plummer-Vinson syndrome (PVS), also called "Paterson-Brown-Kelly syndrome“, is a rare medical syndrome generally affecting middle-aged women. Iron deficiency anemia is the prime etiological factor and other probable factors include malnutrition, genetic predisposition, or autoimmune processes characterized by three distinctive features: iron deficiency anemia, dysphagia, and esophageal web. The dysphagia is generally painless and intermittent or progressive over years, restricted to solids, and associated with weight loss. The exact pathogenesis of PVS is still indistinguishable, but it is interconnected with iron deficiency anemia. Plummer-Vinson syndrome, if left untreated, carries an increased risk of developing squamous cell carcinoma of the upper alimentary tract.In this case report, a 40-year-old female patient presented long-standing dysphagia for months, which progressively developed to postcricoid squamous cell carcinoma by the time she approached to medical treatment. Diagnosis was confirmed through laboratory tests, showing iron deficiency anemia and whole-body positron emission tomography-computed tomography (PET-CT) presenting squamous cell carcinoma in postcricoid region (hypopharynx).

Patterson-Kelly Syndrome: A Single Centre Experience

<i>Background</i>: Patterson Kelly syndrome is a rare entity, presenting with a triad of Iron deficiency anemia, Dysphagia and Esophageal webs. The syndrome is extremely rare and its incidence is decreasing probably due to improvements in nutritional standards. The syndrome is enigmatic in the sense that not all patients may be having anemia, the syndrome is associated with various autoimmune conditions, webs are located in post-cricoid region only and there is increased prevalence of upper gastrointestinal malignancies in these patients. The symptoms respond to iron replacement but many patients require rupture of web for relief of dysphagia. Savary dilators, TTS balloon, electro-cautery have been variably used to break the web. <i>Objectives</i>: 1. To study the profile of Patterson Kelly syndrome at our center; 2. To study if the endoscope itself can be used as effective dilator for rupturing the web; 3. To study the effect of iron replacement in these patients; 4. To study the occurrence of upper gastrointestinal malignancies in this condition. <i>Material and methods</i>: We report our experience of sixteen patients with Patterson Kelly syndrome over last fifteen years. This is a retrospective, single center, observational study. All patients had demonstrable web on endoscopy. The endoscope itself was used as a dilator to break the web in more than half of the patients. The endoscope being rigid instrument can easily break the thin web during diagnostic endoscopy itself. If the opening was too narrow, TTS balloon or Savary Guilard dilators were used. One patient had a perforation while using endoscope as the dilator. Five patients required more than one sitting of dilatation for achieving relief of dysphagia or for recurrent web formation. Most patients received intravenous iron supplementation. Ten patients had complete relief of dysphagia without recurrence. One patient had concomitant esophageal squamous cell carcinoma in lower esophagus which became evident when the scope was passed distally, post dilatation of the web. <i>Conclusions</i>: Although rare, Patterson Kelly syndrome continues to exist and can be effectively treated by iron replacement, dilatation and rupture of esophageal webs using various methods. The web can be ruptured by careful maneuvering of the endoscope itself. Intravenous iron replacement can be used prior to the procedure which can ameliorate the symptoms and reduce the need for the dilatation or can make it easier. Patients need surveillance for upper gastrointestinal malignancies however exact guidelines in this regard are lacking.

Plummer–Vinson syndrome: A case series

Plummer–Vinson syndrome (PVS), also known as Paterson–Brown–Kelly syndrome, is characterized by a triad of dysphagia, upper esophageal web, and iron deficiency anemia. It predominantly affects middle-aged females. The postcricoid webs are associated with a higher risk of squamous cell carcinoma; therefore, timely diagnosis and treatment is important. Herein, we report three cases of PVS.

1754 Plummer-Vinson Syndrome: A Time for a Redefinition and New Perspective

INTRODUCTION: Plummer-Vinson syndrome (PVS), or Kelly-Patterson syndrome, is a rare condition defined by the classic triad of dysphagia, iron-deficiency anemia, and esophageal webs, and dominated by Caucasian females. The pathophysiology remains unknown although iron deficiency is one theory as well as part of an autoimmune spectrum. We present two patients seen recently meeting criteria for PVS in whom new observations were made. CASE DESCRIPTION/METHODS: A 46-year-old Hispanic female with history of hypothyroidism presented with a Hgb of 3 and a ferritin of 16. She reported 2 weeks of fatigue, dyspnea, and constipation without overt bleeding, preceded by several months of dysphagia to solids. She was severely hypothyroid and placed on IV levothyroxine. Barium swallow suggested an esophageal web in the upper esophagus. At esophagogastroduodenoscopy (EGD) both adult and neonatal scopes could not be passed through a tight stenosis at the cricopharyngeus (Figure 1). This was dilated with Savary dilators to 8 mm. She was discharged home on iron supplements and follow up EGD with dilations scheduled. A 55-year-old Hispanic female with history of lupus, a positive ANA, Raynaud's, prior partial thyroidectomy, and chronic anemia was referred to GI clinic for evaluation of chronic dysphagia which had required multiple dilations at an outside facility over the past 18 months without improvement. She had a hgb of 6.7 with iron deficiency without any overt GI bleeding. EGD was performed and showed two benign appearing areas of intrinsic stenosis 15 and 20 cm from the incisors that were smooth and not ulcerated and could not be passed with the adult or pediatric endoscopes (Figure 2). Savary dilators were used to dilate to 11 mm diameter. Patient was placed on iron replacement and a fo llow up EGD was scheduled. DISCUSSION: Why PVS is only in females with accompanying iron deficiency anemia and a personal/family history of autoimmune phenomena and now is decreasing in recognition are not clear. The resolution of dysphagia with iron supplementation, could also be explained by the accompanying esophageal dilations restoring oral intake and hence improving iron absorption. Our cases highlight that PVS: 1) is not a true “esophageal web” but rather a tight fibrotic stricture at the level of the upper esophageal sphincter requiring aggressive dilation approach 2) occurs also in Hispanic females presenting with iron deficiency, dysphagia, and an autoimmune picture.

3105 Zenker's Diverticulum: Unusual Cause of Acute Oesophageal Impaction

INTRODUCTION: Dysphagia amongst the elderly results from increasing dysfunction of the upper esophageal sphincter (UES), which is vulnerable to effects of aging. Prevalence of dysphagia in geriatric population, especially above 80 is higher than overall prevalence in the general population. Zenker's diverticulum (ZD) is the hallmark pathology for UES dysfunction. These false diverticula are herniation of mucosa and submucosa through the Killian's Triangle. Albeit progressive dysphagia is the most common presentation, symptoms can range from globus sensation to obstruction. ZD may rarely present as complete esophageal obstruction. CASE DESCRIPTION/METHODS: An 89 years old female with hypertension, osteoarthritis and polycythemia vera presented with complaint of “having a pill stuck in my throat.” Unable to tolerate her breakfast and spitting up sputum. Similar symptoms in the past for which she changed her diet to soft bread. Initially, it worked however dysphagia gradually worsened to the extent of having to butter her pills to ease swallowing. Denies GERD. Vital signs within normal limits, physical exam revealed enlarged multinodular goiter with retropharyngeal extension however negative Pemberton's sign. Boyce sign was positive on sipping some water. Euthyroid and no other abnormalities. Urgent upper endoscopy was recommended however patient refused but agreed the next day. Endoscopy was remarkable for pill lodged in upper esophagus, upper esophageal ring and impacted food in ZD compressing esophagus. The ring was split using the endoscope and pill pushed down which was then propelled by peristalsis to the stomach. Content of ZD was retrieved with Roth net. Remaining endoscopy exam was unremarkable. ENT evaluation was recommended for ZD and goiter however patient declined intervention. DISCUSSION: ZD often presents as solid food and pill dysphagia, rarely as acute esophageal obstruction as seen in this case. A number of factors in addition to external esophageal compression by the enlarging ZD likely contributed to her presentation, including pressure from enlarged thyroid. ZD compounds the pharyngeal weakness that leads to its development, trapping the patient in a vicious cycle of worsening dysphagia that eventually results in obstruction. Furthermore, an association between esophageal webs and ZD has been demonstrated. Combination of these factors resulted in the complete obstruction in our patient. Dysphagia in old age, always have ZD in mind.

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.

Case report on Plummer Vinson syndrome

Plummer Vinson syndrome or Paterson-Brown-Kelly syndrome is a rare disorder is characterized by a triad of iron deficiency anemia, post-cricoid dysphagia and upper oesophageal web. This is a condition that is hypothesized to occur in people with long-term iron-deficiency anemia. It is more prevalent in females than in male patients. This disorder is characterized by iron deficiency anemia, post-cricoid dysphagia and oesophageal webs, symptoms typically progress over a period of six months and often include other systemic effects such as angular cheilitis, glossitis, and spooning of the fingernails. Here we report a case of 38 years female admitted in general medicine female with complaints of breathlessness and tightness of chest relieving after vomiting and had history of anemia, dysphagia insidious in onset and dysphagia associated with solid food over a year on examination patient was found to be gross pallor, angular cheilitis, spoon-shaped nails of fingers and toes. The lab findings were hemoglobin of 7.8 g/dl, serum ferritin levels 7.23 ng/ml, vitamin B12 175.2 pg/ml and upper oesophageal endoscopy revealed oesophageal web in the post-cricoid region. Treatment of Plummer Vinson syndrome includes iron supplementation followed by endotracheal dilation if necessary.

Pseudodiverticulosis: a rare presentation of eosinophilic esophagitis

Esophageal pseudodiverticulosis is a rare endoscopic finding in eosinophilic esophagitis. We report a case of a 32-year-old male who presented with dysphagia and gastroesophageal reflux disease and was found to have esophageal pseudodiveritcula along with esophageal rings. The patient was subsequently treated with endoscopic balloon dilation and a diagnosis of eosinophilic esophagitis (EoE) with pseudodiverticulosis was made based upon the endoscopic and biopsy findings. This case provides evidence of the unusual finding of pseudodiverticulosis associated with EoE and further understanding of its pathogenesis is required.

Dysphagia

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. This review contains 13 figures, 12 tables, and 68 references. Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke

Dysphagia

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. This review contains 13 figures, 12 tables, and 68 references. Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke

&lt;p&gt;Plummer-Vinson syndrome: improving outcomes with a multidisciplinary approach&lt;/p&gt;

Plummer-Vinson syndrome is a rare condition associated with dysphagia, iron deficiency, and esophageal webs. Data regarding this condition is limited to mostly case reports and a few small cohort studies. Although most cases have a benign and indolent course, the risk of malignancy warrants long-term surveillance. A multidisciplinary approach among healthcare providers is of the utmost importance in the management of this condition.

DOZ047.52: A single institutional experience with congenital H-type tracheoesophageal fistula

Abstract Aim This study presents a single institutional experience with H-type tracheoesophageal fistula (H-TEF). Methods Esophageal atresia (EA) patients who underwent primary surgery in a single center between 2006 and 2018 were retrospectively evaluated. Results Among 110 EA patients, 7 (6.4%) had H-TEF. There were 5 males and 2 females. The primary complaints were choking, cyanosis, and/or apnea with feeding, swallowing difficulty, recurrent bronchopneumonia, or bile in endotracheal tube. The relevant symptoms began during neonatal period with varying degrees of severity in all. The initial diagnosis was proximal esophageal web as demonstrated by contrast swallow and endoscopy in one patient; H-TEF was diagnosed during the course of treatment for the web. Hydrocephalus with severe neurological sequela unrelated to H-TEF and cardiac malformation were present in one. Contrast esophagography was employed in three patients for diagnosis two of which were diagnostic. All underwent diagnostic bronchoscopy. Delayed diagnosis (after 30 days of life) occurred in five (71%). The median age at operation was 3.8 months (11 days–33 months). The level of the fistulas was between C5 and T3. Preoperative bronchoscopic cannulation was successful in all but one. The operation was done via a right cervical approach in six patients and thoracotomy in one. All patients were followed up for at least one year and there was one recurrence detected five months after the first operation. She underwent a secondary surgery with a successful outcome. Right vocal cord paralysis was detected postoperatively in the patient with hydrocephalus. Conclusions H-TEF is a rare subtype of EA malformations with a delay in diagnosis in most cases. Suggestive clinical findings, especially neonatal respiratory symptoms should always be regarded as an indication for further investigations. Although contrast esophagograms may reveal the diagnosis, bronchoscopy is the gold standard diagnostic test in our practice. It should be done preoperatively in every patient not only for diagnostic confirmation but also for cannulation of the fistula to ease the operation. H-TEF might be considered a relatively innocent EA variant but its surgery is not devoid of complications. The patients should be followed up for recurrence and recurrent laryngeal nerve injury on the long term.