Peptic Stricture Research Articles

1573 Ixekizumab-Induced Gastritis and Colitis in an Elderly Female With Plaque Psoriasis

INTRODUCTION: Psoriasis and inflammatory bowel disease (IBD) share common pathogenesis pathways including cytokine mediated inflammation. Interleukin-17 (IL-17) monoclonal antibodies such as ixekizumab have demonstrated excellent results in moderate to severe plaque psoriasis and psoriatic arthritis. Antagonism of IL-17 has been demonstrated in animal models to induce or worsen existing inflammatory colitis. We hereby present a case of ixekizumab-induced gastritis and colitis in a 63-year old Caucasian female with severe plaque psoriasis successfully treated with prednisone. CASE DESCRIPTION/METHODS: A 63-year old Caucasian female with history of severe plaque psoriasis and peptic strictures presented with severe bloody diarrhea, generalized abdominal pain, and tenesmus few weeks after receiving 3 doses of ixekizumab. She had no personal or family history of IBD. Her medications included 81-mg ASA, omeprazole, metoprolol, cetirizine and levothyroxine. She denied NSAID use. A colonscopy 2-years prior showed two tubular adenomas, and a gastroscopy 3 months prior to ixekizumab therapy was normal. Her diagnostic evaluation revealed (a) normal CBC, kidney function and liver chemistries, (b) negative stool cultures, microscopy and C. Difficile testing, (c) a gastroscopy demonstrating diffuse gastritis involving the body and antrum (d) a flexible sigmoidoscopy demonstrating a diffuse area of atrophic, eroded and friable mucosa with contact bleeding and thickened mucosal folds in the recto-sigmoid colon. Gastric and colonic biopsies demonstrated focal mucosal erosions with architectural distortion concerning for a drug induced gastritis and colitis. H. Pylori testing was negative. Ixekizumab was discontinued and treatment with IV steroids was started. Symptom resolution was noted by day five of therapy and she was converted to an oral steroid taper. DISCUSSION: The temporal association, the histology and the improvement with discontinuation of the medication strongly support the diagnosis of a drug induced colitis. This case is unique in the sense that it is the first in the literature to report ixekizumab-induced gastritis and colitis. Whether the patient will require long-term immunosuppression and will manifest later with IBD is to be observed. Despite the rarity of colitis associated with IL-17 inhibitors, counseling patients on this severe adverse effect is integral to the discussion between specialists and their patients prior to initiating therapy.

1730 Esophageal Actinomycosis in a Patient With Long-Standing Esophageal Stent

INTRODUCTION: Actinomyces is a commensal in aero-digestive tracts which rarely causes infection. The commonest site is cervicofacial region. Risk factors are low immunity and pre-existing tissue damage. Esophageal involvement is rare. We report a case of esophageal actinomycosis in an immunocompetent patient. CASE DESCRIPTION/METHODS: A 71-year-old male presented with recurrent dysphagia. The patient had multiple prior EGDs for management of refractory peptic stricture due to gastrin secreting pancreatic neuroendocrine tumor. He undewent multiple prior procedures with placement of fully-covered self-expanding metal stents (SEMS) for therapy of refractory stricture, as surgical esophagectomy was not possible due to co-morbidities and patient preference. On previous EGD, one of the stents could not be removed due to tissue ingrowth at the distal end, and another SEMS was placed overlapping the imbedded stent and extending to the gastric cardia. The patient was lost to follow up for 7 months until presenting with recurrence of dysphagia. EGD now showed proximal migration of the distal stent with severe stenosis, inflammation, and nodularity distal to the esophageal stents. The distal stent was imbedded in the abnormal mucosa and could not be removed. Following balloon dilation another SEMS was placed in the distal esophagus. Pathology revealed ulcerated acute esophagitis with actinomycetes colonies. The patient was placed on a long course of IV penicillin-G. At subsequent EGD a month later, the tissue ingrowth improved allowing removal of the esophageal stents. Repeat biopsies did not reveal actinomyces. DISCUSSION: Actinomyces, a gram positive anaerobic rod, is unable to penetrate healthy tissue. It requires mucosal compromise to invade tissue, leading to abscess and sinus formation across tissue planes. Our patient had multiple risk factors - mucosal damage, endoscopic dilations and stenting. Esophageal stent in situ for longer than 3 months increases the risk of embedment. Discovery of esophageal ulceration or tissue ingrowth in this setting should raise suspicion for possible actinomycosis (among other diagnoses) and biopsies should be obtained. Gram stain and histology would reveal necrosis with yellow sulfur granules and gram-positive filamentous pathogen. Early diagnosis is necessary to initiate treatment in a timely manner to prevent the potentially debilitating sequelae of chronic infection. Treatment includes penicillin G or amoxicillin for 3-12 months.

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

DOZ047.65: Radiofrequency ablation: a promising treatment in children with early onset Barrett's esophagus

Abstract Aim of the Study Barrett's esophagus (BE) could be a rare late complication in children with repaired esophageal atresia, partly due to a long-term history of gastro-esophageal reflux disease (GERD). Radiofrequency ablation (RFA) is the best endoscopic technique in adults with BE and dysplasia. Guidelines do not support this approach for non-dysplastic BE. Aim of this study is to present our experience as Tertiary Gastroenterology referral Centers in the treatment of children and young adults with BE using RFA. Methods A multicenter retrospective study conducted on children with BE, subjected to RFA at the Digestive Surgery and Endoscopy Unit, Bambino Gesù Children's Hospital and the Department of General Surgery ‘Paride Stefanini’, Sapienza University of Rome, between June 2012 and December 2017.Demographic and clinical data were collected. BE characteristics according to Prague classification, presence and grade of dysplasia, number of RFA treatments, complications, clinic and endoscopic outcomes were described. All patients were treated with HALO RF BARRXtm (HALO 360 Covidien, Sunnyvale, California, USA). Endoscopic evaluation and treatment were performed every 3 months until complete eradication. Endoscopic follow-up was: 6 months after eradication, and then annually. Results Five patients were evaluated (M:5). Mean age at diagnosis was 14.4 years (range: 9–17); mean age at first treatment was 23 years (range: 13–36). Two patients presented with repaired esophageal atresia (long gap, type 3 atresia), 3 with peptic strictures. All patients exhibited a long-term history of symptomatic GERD and PPI dependency. Four patients underwent Nissen fundoplication before BE diagnosis. All patients presented with long segment BE (mean baseline length was 8,8 cm, range 7–10 cm). According to the Prague classification, patients were classified as follows: C0M7, C0M17, C8M10, C0M9 and C4M8. One patient presented with LGD. Patients received a mean of 3 HALO treatments (range 1–4 sessions). Eradication was 100% during 2- to 6-year follow-up (mean 4.5 year). No complications occurred. Conclusions Pediatric patients with EA present an high risk to develop early BE, therefore endoscopic surveillance is mandatory. RFA represents a safe and effective treatment option in patients with early onset BE. Treatment of BE with this technique could be a useful and minimal invasive strategy for dysplasia and cancer prevention.

Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux.

Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.

A Prospective Study Evaluating the Etiologic Spectrum in Patients with Dysphagia in Coastal Odisha Using Clinical Features and Endoscopy

Abstract Background: There is scarcity of data on the etiological spectrum of dysphagia from India. The study was conducted to determine the etiological spectrum of dysphagia in coastal Odisha. Materials and Methods: Consecutive patients presenting with dysphagia to the gastroenterology outpatient department in 2017 were studied. Patients were evaluated with meticulous history, clinical examination, esophagogastroduodenoscopy, and chest X-ray. Barium study and endoscopic biopsy were done when necessary. Results: Of 216 consecutive patients, 122 (56.48%) were male and 94 (43.52%) were female with a mean age of 42.3 ± 17.4 years. The common etiologies were benign stricture in 68 (31.48%) and esophageal carcinoma in 51 (23.62%). Other etiologies included achalasia cardia in 11 (5.09%), esophageal candidiasis in 10 (4.63%), pharyngeal cancer in 4 (1.85%), and esophageal web in 3 (1.39%). In 63 (29.17%) cases, no etiology was detected. Most of the benign strictures were due to corrosive injury in 48 (70.59%); other causes included peptic stricture (8, 11.76%), postsurgery (4, 5.88%), sclerotherapy-induced stricture (2, 2.94%), and pill-induced stricture (2, 2.94%); in 4 (5.88%) cases, the cause of stricture was not known. The most common cause of corrosive injury was acid injury in 38 (79.17%), followed by alkali injury in 4 (8.34%). In 6 (12.5%) cases, the nature of corrosive was not known. Most of the corrosive injuries were due to suicidal intake. Conclusion: In this study, the most common cause of dysphagia was benign corrosive stricture due to suicidal intake of corrosives. Esophageal carcinoma, achalasia cardia, and esophageal candidiasis were other significant etiologies. Uncommon causes of dysphagia included esophageal web, pharyngeal cancer, and reflux esophagitis.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography: Preliminary experience and technique description.

Common bile duct lithiasis after Roux-en-Y gastric bypass (RYGB) or upper gastrointestinal stenosis has become a challenging problem nowadays, especially as obesity surgery is increasing. In this study, we assess the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) and describe its technique. A retrospective review of a prospectively collected database of consecutive patients undergoing a LAERCP between February 2014 and May 2015 was performed at a single institution. Indications were common bile duct lithiasis associated with acute or past episodes of cholangitis and pancreatitis. Endoscopic access to the gastric remnant was obtained laparoscopically. In total 5 cases were identified. Four of them had undergone a RYGB and one of them presented a benign esophageal peptic stenosis, not allowing peroral gastric access. Biliary cannulation using LAERCP associated with sphincterotomy and stone extraction was successfully achieved in all patients. Mean duration of the entire procedure was 134minutes (range: 66-200min). No early major complications were observed and the mean postoperative hospital stay was 4 days (range: 2-5 days). LAERCP is a safe and successful procedure for the treatment of common bile duct lithiasis when conventional biliary access is not feasible, notably after RYGB. Larger trials still need to be performed to evaluate efficacy, technical success, and complications related to this technique.

Peptic Ulcer-related Stenosis

Peptic ulcer disease involves breakdown of the epithelial lining of the stomach or duodenum. Stenosis and associated gastric outlet obstruction is the least frequent complication of peptic ulcer disease. Most cases of stenosis occur because of duodenal or pyloric cannel ulceration. Although etiologies of peptic ulcer disease and the affected patient populations have changed, the most common etiologic factors remain Helicobacter pylori infection and use of non-steroidal anti-inflammatory drugs. In recent years, eradication of H. pylori and the use of proton pump inhibitors have reduced the incidence of complications. Because the predominant cause of gastric outlet obstruction has increasingly been attributed to malignant cancer in recent years, endoscopic examination is important to differentiate benign peptic stenosis from malignant stenosis. Medical treatment such as acid-reducing drugs or H. pylori eradication is the mainstay of treatment. Endoscopic dilation or surgical management may be considered in cases of refractory or recurrent stenosis despite medical treatment. Among the major complications of peptic ulcer disease, this report will provide an overview of peptic ulcer-related stenosis. Key words: Dilatation; Endoscopy; Helicobacter pylori; Peptic ulcer; Stenosis

TREATING SIMPLE BENIGN ESOPHAGEAL STRICTURES WITH SAVARY-GILLIARD DILATORS: IS THE RULE OF THREE STILL NECESSARY?

Bougies dilation is considered an effective technique for the treatment of simple benign esophageal strictures. The "rule of three" has been advocated to prevent reported adverse events such as bleeding and perforation. However, adherence to this rule has increased the cost and duration of treatment. To demonstrate the safety and long-term benefits of progressive bougie dilations until reaching 15 mm (45Fr) in one single session endoscopy with non-adherence to the rule of three. A retrospective analysis of a prospectively collected data of patients with simple benign esophageal strictures treated with multiple progressive bougie dilators until reaching 15 mm (45Fr) in one single session. The median age was 58 years (range 28-89), and 83.3% of patients were female. The main presenting symptom was dysphagia for solids in 11/12 cases (91.6%). The cause of their simple benign esophageal stricture was distributed as follows: 7/12 esophageal webs, 2/12 peptic stenosis, 2/12 Schatzki rings and one caustic injury. 75% required only one session for clinical success. No serious adverse events were described. No recurrence of symptoms was noted in a median follow-up of 20 months. The rule of three in patients with simple benign esophageal strictures secondary to esophageal webs, Schatzki rings and peptic strictures treated with Savary-Gilliard dilators is not necessary, showing good clinical results. Prospective studies with more patients are necessary.

Current Approaches to the Treatment of Gastroesophageal Reflux Disease in Children with Neurology

The incidence of gastroesophageal reflux in children with neurological disorders is more common than in the rest of the pediatric population. The risk of reflux development in these children is due to abnormal motility of the gastrointestinal tract, their long term staying in bed (a horizontal position), a disruption of the swallowing process, a delayed evacuation of food from the esophagus and stomach, and a weakened muscle tone that pose a serious threat to a patient by possible complications (such as reflux esophagitis, peptic stricture, erosion and bleeding), and sometimes being one of the causes of death. From 2008 to 2018, 128 patients with gastroesophageal reflux disease were hospitalized in the Department of Surgery of the Scientific Center for Pediatrics and Pediatric Surgery including 33 (26%) children with neurological disorders, of which 28 (85%) were operated. All of the patients underwent Nissen esophagofundoplications, of which in 21 (75%) children it was combined with Stamm gastrostomy and in 18 (64%) children with Mikulich pyloroplasty. The results of surgical treatment were analysed in all the 28 patients in the early period (7-14 days) after surgery. In 2 (7%) children who did not undergo the pyloroplasty there was a complication in the form of gastric distress syndrome, which required an additional surgery in order to drain the stomach. A relapse of gastroesophageal reflux disease was observed in 1 (4%) patient who was re-operated. In the remaining 25 (89%) children, the postoperative period was favourable. Their gastrostomy tube feeding was carried out according to the age requirements. The long-term results were studied in time interval from 6 months to 3 years after surgery. X-ray control examination, fibroendoscopy and 24-hour pH monitoring were conducted in all children in the distant period. The results of the treatment are favourable, the weight deficit is filled, the reflux esophagitis is stopped and the reflux-associated inflammations of the bronchopulmonary system are reduced. To a large extent, the choice of operational tactics can be adapted to the condition of a particular child, the results of objective and instrumental tests for GERD, the pseudobulbar disorders and associated pyloric functional disorders. Timely correction of reflux disorders in children with pathologies of the central nervous system helps prevent the development of serious complications, which will inevitably improve a child’s quality of life.

A Case of Systemic Sclerosis Mimicking Achalasia

Systemic sclerosis (SS) may be associated with GERD symptoms and dysphagia related to esophageal dysmotility or a peptic stricture in 50 - 90% of patients. HRM may show esophageal aperistalsis of the smooth muscle with a low LESp. We present 2 cases of SS presenting with HRM findings characteristic of type I Achalasia; onepatient with symptomatic dysphagia and the other patient with symptomatic GERD and endoscopic esophagitis. Both patients have diffuse SS, Raynaud's phenomenon, interstitial lung disease, GERD and positive SS serologies. Case 1 is a 66 year-old female who developed dysphagia 8 years following SS diagnosis. BaS noted esophageal atony, no strictures and a patulous GEJ, with a normal EGD. GERD symptoms improved with PPIs but she developed progressive solid-food dysphagia without weight loss. Re-evaluation 4 years later revealed a normal EGD while HRM showed aperistalsis, normal LESp with a ?IRP mimicking type I achalasia. Timed BaS demonstrated mild mid-esophageal dilation (3 cm), tapering at the distal esophagus with minimal barium retention at 5 minutes (Fig. 1). Repeat EGD for possible pneumatic dilation, demonstrated a mildly patulous LES that was easily distended following air insufflation and no resistance w ith endoscopic passage through the GEJ. Case 2 is a 54 year old patient with an 11 year history of SSc and GERD but no dysphagia with a mildly dilated esophagus with intraluminal debris (Fig. 2). HRM showed aperistalsis, normal LESp, and elevated IRP (Fig 3). Most recent EGD revealed LA Class B esophagitis. Caution should be exercised in making the diagnosis of achalasia in SS patients. Full evaluation must include a timed barium study, and EGD to be certain that one is dealing with GEJ obstruction. Measurement of the LESp and relaxation are dependent upon: (1) the crural diaphragm which does not relax during swallowing, (2) the intrabolus pressure generated by the fluid passing through the GEJ, and (3) the cephalad movement of esophagus related to longitudinal muscle contraction which shortens the esophagus and momentarily pulls the stomach into the GEJ during swallowing. It is possible that in SS with a dilated esophagus and no muscle contraction, the esophagus did not shorten and LES remained stationary at the level of the crural diaphragm. Few cases exists of SS having HRM criteria for achalasia. These 2 cases presents a hypothesis for further research in SS patients having HRM criteria for achalasia.1722_A Figure 1. Mild esophageal dilation with distal esophageal tapering and minimal barium retention in case 11722_B Figure 2. Mild esophageal dilation with intraluminal debris in case 21722_C Figure 3. Representative esophageal topography of elevated IRP in case 2

Lymphocytic Esophagitis Masquerading as Gastroesophageal Reflux Disease-Induced Peptic Strictures

Lymphocytic Esophagitis Masquerading as Gastroesophageal Reflux Disease-Induced Peptic Strictures

Four Year Results of Conservative Treatment of Benign Strictures of the Esophagus with Savary Gilliard Technique of Bougienage: Cross-Sectional Study Representing First Experiences in Republic of Macedonia.

Abstract Background: Benign esophageal strictures are complications resulting from various causes. They can be structurally categorized in two groups: simple and complex. Treatment is similar in most cases that require dilatation and means use of three general types of dilators that are currently in use. However, despite the last guidelines on esophageal dilatation, the therapeutic response, optimal timing of treatment and interval between sessions may vary and there is no strong consensus in the literature regarding this fact. Aims: To analyzethe first 4 year experience of Digestive Endoscopy Unit at the University Clinic of Gastroenterohepatology of the Medical Faculty, Skopje, Republic of Macedonia in treating benign esophageal strictures, since the Savary-Gilliard technique of “bougienage” was introduced for the first time in Republic of Macedonia, at our Institution, in December 2013, by assessing etiology, length of stricture, number of dilations required to achieve satisfactory therapeutic response, as well as the relationship between the type, extent of stenosis and therapeutic response. Methods: One hundred and forty five dilations, during a period from 20th December 2013, until March 2017, have been analyzed in 31 patients Results: The caustic strictures were the most prevalent, occurring in 15 (48%) of patients, followed by peptic stenosis presenting 26% of patients. The long and corrosive strictures needed more sessions to the absence of dysphagia. Peptic and short stenoses best respondedon treatment and needed fewer dilatation sessions per patient. Conclusion: Caustic stricture is the most common type of benign esophageal stenosis and the most refractory to treatment, especially the long one. Peptic stenosis is the second cause of benign esophageal strictures and responded well to endoscopic therapy. The higher the extent of stenosis, the greater the number of sessions required. Short strictures have good prognoses in most cases. The number of dilations depended directly on the cause and extent of stenosis. Bouginage using Savary-Gilliard or American type of technique, irrespective of the type and the extent of esophageal stenosis, is safe and purposeful procedure.

Proximal third esophageal peptic stricture in an elderly patient: a case report and review

Proximal third esophageal peptic stricture in an elderly patient: a case report and review

Oesophageal causes of dysphagia localised only to the pharynx: Implications for the suspected head and neck cancer pathway.

Dysphagia is a presenting symptom of both pharyngeal and oesophageal cancers. The referral pathway choice is determined by whether it is thought to be oropharyngeal or oesophageal, and this is in turn influenced by whether dysphagia is perceived to be above or below the suprasternal notch. We studied the concordance between the presence of pharynx-localised dysphagia (PLD) and the location of the underlying disease processes. A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis. Information about patient demography and presenting symptoms were recorded. The incisor-to-pathology distance, and the nature of the pathology, were recorded. Logistic regression analysis was used to identify independent predictors of malignancy. The study included 177 patients. There were 92 males, and mean age at presentation was 74 years. The commonest benign pathologies were cricopharyngeal dysfunction with or without pharyngeal pouch (n = 67), peptic stricture (n = 44) and Schatzki's ring (n = 11). There were 49 cases of cancer, including one hypopharyngeal cancer, one cervical oesophageal cancer, 28 cancers of the upper/mid-thoracic oesophagus, 15 cancers of the lower thoracic oesophagus and 4 cardio-oesophageal cancers. In 105 (59%) patients, PLD was caused by oesophageal disease. Independent predictors of malignancy were weight-change (loss >2.7 kg), a short history (<12 weeks) and presence of odynophagia. Nineteen (39%) of oesophageal cancers that presented with dysphagia that was localised only to the pharynx would have been beyond the reach of rigid oesophagoscopy. Pharynx-localised dysphagia is more likely to be a referred symptom of structural oesophageal disease, including cancer, than a primary symptom of structural pharyngeal disease. Absence of additional alarm symptoms such as a short history, weight-loss, and odynophagia, do not adequately exclude the possibility of oesophageal cancer. When the differential diagnosis of PLD includes malignancy, cancer should be presumed to be arising from the oesophagus or the cardio-oesophageal region until proven otherwise. This requires direct visualisation of the mucosal surfaces of the oesophagus and the cardio-oesophageal region, using either transoral or transnasal flexible endoscopy, irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.

Dysphagia from a gastroenterologist's perspective

Swallowing disorders (dysphagia) comprise a common cause of medical consultation and are defined as a subjective sensation of difficulty or abnormality of swallowing. In the initial step, a clear differentiation of dysphagia from odynophagia and globus sensation for further diagnostic procedures is mandatory. The careful questioning of patients symptoms and complaints is often helpful for the differentiation of oropharyngeal and esophageal dysphagia. Oropharyngeal dysphagia is mainly caused by neurological disorders (cerebral ischemia, Parkinson's disease, dementia) or local compression of malignancies, thyroid gland or lymph nodes. In contrast, stenosis of the tubular esophagus (peptic stricture, rings and webs, diverticula, malignancies, infections) can lead to esophageal dysphagia, mostly only after ingestion of solids. Esophageal dysphagia after ingestion of solids and liquids is often caused by motility disorders of the esophagus (achalasia, hypertensive or hypercontractile esophagus). Important diagnostic procedures comprise endoscopy, barium swallow and high-resolution manometry. Overlap syndromes are frequent and need to be supervised interdisciplinary. The diagnostic algorithm and interpretation of exam results is complex. If the results are ambiguous, a reevaluation and, when appropriate, repetition of diagnostics are recommended. Whereas oropharyngeal dysphagia is treated by neurologists or ENT physicians, diagnostic and treatment of esophageal dysphagia is a challenging role for gastroenterologists.

Low Prevalence of Biopsy-Proven Eosinophilic Esophagitis in Patients with Esophageal Food Impaction in Mexican Population.

Eosinophilic esophagitis (EoE) is the most common cause of dysphagia and esophageal food impaction (EFI) in the USA, Western Europe, and Australia. In Mexico, the uncomplicated form of this disease is infrequent, and prevalence in patients with EFI is unknown. To determine the prevalence and causes of EFI, endoscopic and therapeutic aspects, and establish the prevalence of biopsy-proven EoE in patients with EFI. Diagnostic upper gastrointestinal endoscopy reports from January 2011 to December 2016 were retrospectively reviewed. Patients with therapeutic procedures, gastrointestinal hemorrhage, or non-food foreign body impaction were excluded. The number of patients with EFI was determined. Additionally, patients with esophageal biopsy were retained for EoE prevalence calculation. The diagnosis of EoE was defined with the presence of eosinophil infiltration count ≥ 15/high-power field with or without typical endoscopic abnormalities. A total of 4700 reports of the same number of patients were selected; 2209 were males (47%) with a mean age of 57.6 ± 12.3years (range 14-93). We identified 36 patients with EFI (0.76, 95% CI 0.51-1.01), 16 males (44.4%) with a mean age of 54.9 ± 19.7 (range 22-92). Esophageal biopsies were obtained in 17/36 (47.2%) cases. The diagnosis of EoE was confirmed in 2 patients (11.7%). Peptic stenosis was the most frequent cause of EFI. EoE is an infrequent cause of EFI in the Mexican population (11.7%). EoE had the lowest prevalence compared to that reported in Caucasian populations. The prevalence of EFI was also low.

Biodegradable Stents in Resistant Peptic Oesophageal Stricture: Is It the Right Way to Go?

Peptic oesophageal stricture can be considered as the end result of prolonged gastro-oesophageal reflux. The ‘gold standard’ treatment for peptic stricture is endoscopic dilatation with balloon or bougie. It is predicted that up to 40% of patients remain symptomatic with dysphagia due to refractory (resistant to treatment) or recurrent strictures, needing frequent interventions at short intervals. Such patients have poor nutritional status due to the primary disease and are susceptible to complications related to repeated endoscopic dilatation such as bleeding and perforation. This general review aims to analyse existing published evidence and address the role of biodegradable stents in resistant peptic strictures as an alternative treatment to provide long-term dysphagia-free intervals.

Esophageal Reconstruction with the Stomach, a Functional Dilemma?

Background: A few decades ago, esophageal substitution was mainly dedicated particularly in postcaustic esophageal stenosis; currently, the reconstruction has expanded its palette of indications to other areas of benign esophageal pathology (severe motor disorders, esophageal achalasia with multiple relapses, peptic stenosis, etc.) but has also become a quasi-obligatory final time in the esophagectomy for cancer whenever it is possible. The techniques of esophageal reconstruction using the stomach, regardless of the indication and the chosen technical option, remain a valuable and effective method. A number of striking arguments advocate for one or another type of gastric graft: anatomic factors more than convenient (vascularization, sufficient length, a wall structure favorable for suture, etc.) and a sustainable surgical intervention (length, approach, complexity of the surgical steps digestive disorders after surgery, post-therapeutic functionality, etc.). Choosing a technique or another, beyond pathological arguments, should take into account remote functionality, with a clear impact on metabolic status and quality of life. So, according to this criterion, can we functionally justify a type or another of gastric restoration? Finally, the proof of an adequate solution is relatively easy to appreciate: has swallowing been restored and if so, the result has been maintained over time? For oncological cases, the assessment should also take into account the chronological criterion of the postoperative survival rate. Methods: The statistically rated lot ranged from 1981 to 2016 and included 268 patients with surgical interventions for esophageal stenosis, distributed according to etiopathogenesis and indication in 201 reconstructions for post-caustic stenosis, and 67 for post-esophagectomy replacement for neoplasm. The techniques used for remote functional evaluation included: barium swallow, endoscopy + biopsy, and in cases with obvious changes pH measurement/24 h and manometry and, only in exceptional cases, scintigraphy with marked foods. Results: two types of problems have been identified: a particular type of neuro-motor dysfunction of the esophageal substitute in 6 patients (1 patient with Gavriliu reconstruction and 5 with Nakayama reconstruction, using the whole stomach), with difficulty, delayed gastric graft evacuation, with major stasis and abdominal discomfort vomiting, inability to eat, aspiration phenomena) respectively a reflux pathology - 8 patients, being proved by a specific simptomatology, barium lunch, endoscopic examination and pH-metric examination. Reflux was alkaline in 7 patients, all with pyloroplasty, 5 with whole stomach and 2 with Akiyama procedure; in 1 case with Gavriliu procedure the reflux was acid. Conclusions: Stomach is a good option in esophageal substitution. Concerning the remote results, a good functionality is found with a reasonable metabolic status. The two phenomena on which the function of the graft depends - secretory activity and motor activity - seem to be restored in time but these does not occur concurrently, the recovery of the secretory function being much faster.