Proximal Esophagus Research Articles

A rare cause of dysphagia due to Cicatricial Pemphigoid

A 68-year-old Hispanic woman presented with four months of dysphagia, odynophagia, and voice hoarseness. Computerized Tomography (CT) of the neck and chest was significant for thickening of epiglottis, dilated saccules, lymphadenopathy, and tracheal nodules. Laryngoscopy showed diffuse erythema and inflammation of oropharyngeal consistent with mucositis. Exam was positive for bilateral symblepharon, oral mucositis, as well as vulvar ulceration. Upper endoscopy showed esophagitis with sloughing mucosa and bullae along with a benign appearing esophageal stenosis in the proximal esophagus (Fig. 1).

Ingested removable partial denture causing esophageal perforation in a patient with autism: Management and prevention

A 60-year-old woman with autism and a repetitive swallowing behavior ingested a removable partial denture that impacted in the proximal esophagus. Attempts at endoscopic removal were unsuccessful. Esophageal perforation was recognized, necessitating emergency transcervical surgical exploration, esophagotomy with foreign body removal, and repair of the esophageal perforation. She had a prolonged postoperative stay involving mechanical ventilatory support and gastric tube feeds. This situation was predictable and preventable, and application of key principles may help avoid such catastrophic incidents in similar patients.

Diagnostic merits of the Eosinophilic Esophagitis Diagnostic Panel from a single esophageal biopsy

Eosinophilic esophagitis (EoE) is a histologically "patchy" disease with uneven eosinophil distribution along the esophagus, posing a dilemma for histologically analyzing endoscopic biopsy samples, especially when biopsy samples are limited to only the distal esophagus. We investigated whether molecular mRNA profiling of a distal esophageal biopsy sample predicts eosinophilia in the proximal esophagus. Esophageal biopsy samples (n= 507) from subjects with EoE were collected from multiple institutions, spanning adults and pediatric patients. Subjects were grouped on the basis of distinct distal (D) and proximal (P) eosinophil counts (D+P+, D+P-, D-P+, and D-P-, with+ and - defined as ≥15 or <15 eosinophils/hpf, respectively). Molecular profiles were assessed by using the EoE Diagnostic Panel (EDP), a set of 96 esophageal transcripts used to derive the EDP score. The distal EDP score was correlated with proximal eosinophil levels (r= -0.73; P< .0001). EDP analysis of a histologically negative distal biopsy sample predicted the presence of proximal esophagitis with high sensitivity (85%). In a 2-year follow-up focusing on the cases with discordant histologic and EDP results, histologically negative patients (D-P-) had higher rates of EoE relapse when the EDP was positive than when the EDP was negative (odds ratio= 11; P=.003), indicating predictive medicine capacity. EDP analysis of a single distal esophageal biopsy sample predicts remote inflammation in patients with spatially heterogeneous eosinophilia and disease relapse in patients with histologic remission, providing diagnostic merit and predictive medicine capacity for molecular diagnosis of EoE.

Normative Ambulatory Reflux Monitoring Metrics for Laryngopharyngeal Reflux: A Systematic Review of 720 Healthy Individuals.

To review the normative data for acid, weakly acid, and nonacid proximal esophageal (PRE) and hypopharyngeal reflux (HRE) events in diagnosing laryngopharyngeal reflux (LPR) using ambulatory reflux monitoring. PubMed, Cochrane Library, and Scopus. A literature search was conducted about the normative data for PRE and HRE on multichannel intraluminal impedance-pH monitoring (MII-pH), hypopharyngeal-esophageal MII-pH (HEMII-pH), or oropharyngeal pH monitoring using PICOTS (population, intervention, comparison, outcome, timing, and setting) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements. Outcomes reviewed included device characteristics, impedance/pH sensor placements, study duration, number/average and percentiles of PRE or HRE occurrence, and the event characteristics (pH, composition, and position). Of 154 identified studies, 18 met criteria for analysis, including 720 healthy individuals. HEMII-pH, MII-pH, and oropharyngeal pH monitoring were used in 7, 6, and 5 studies, respectively. The definition and inclusion/exclusion criteria of healthy individuals varied substantially across studies, with 6 studies considering only digestive symptoms to exclude potential LPR patients. Substantial heterogeneity across studies was noted, including impedance/pH sensor placements/configurations and definitions of composition (liquid, gas, mixed) and type (acid, weakly acid, nonacid) of PRE/HRE. The 95th percentile thresholds were 10 to 73 events for PRE, 0 to 10 events for HRE on HEMII-pH, and 40 to 128 for events with pH <6.0 on oropharyngeal pH monitoring. Most HREs were nonacid and occurred upright. The mean HRE among healthy individuals was 1. The low number of studies and the heterogeneity in inclusion criteria, definitions, and characterization of PRE and HRE limit the establishment of consensual normative criteria for LPR on ambulatory reflux monitoring. Future large multicenter studies are needed.

Conventional and simple methods of measuring esophageal nocturnal baseline impedance show excellent agreement.

Mean nocturnal baseline impedance (MNBI) shows promise in investigating reflux disease by reflecting esophageal mucosal integrity. This study aimed to measure MNBI by both conventional and simple methods in patients with laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD) in order to evaluate the efficacy of the simple measurement method. Altogether 187 patients were divided into LPR (n=105) or GERD (n=82) groups according to their predominant symptom profile, and underwent off-therapy impedance-pH monitoring. MNBI was measured by both the conventional and simple methods. The Bland-Altman plots were constructed to assess mean differences and to identify bias in the two measurement methods. For the two measurement methods, mean difference was (-89 ± 328) Ω in the distal esophagus, (-6 ± 653) Ω in the proximal esophagus, and (128 ± 577) Ω in the pharynx, respectively. There was a strong correlation between conventional and simple MNBI values, with the coefficient of 0.940 in the distal esophagus, 0.463 in the proximal esophagus, and 0.712 in the pharynx (all P < 0.001). There was an excellent agreement between the conventional and simple methods of MNBI measurement, with no evidence of proportional bias. Conventional and simple MNBI values correlated excellently in the distal esophagus and moderately well in the proximal esophagus and pharynx. This study supports the use of the simple method of measuring MNBI to enhance diagnoses of reflux disease.

Prevalencia de mucosa gástrica heterotópica cervical y su relación con síntomas de reflujo gastroesofágico. Estudio observacional

Introduction. The heterotopic gastric mucosal patch or inlet patch is the presence of gastric columnar mucosa outside the stomach, most frequently located in the proximal esophagus. Its manifestations vary from esophageal and extraesophageal reflux symptoms to major complications, most of them being asymptomatic. Aim. To determine the prevalence of cervical heterotopic gastric mucosa in our environment and its association with esophageal and extraesophageal reflux symptoms. Material and methods. Prospective cross-sectional and observational study; consecutive patients who came to our institution between December 2018 and October 2019 for diagnostic upper gastrointestinal videoendoscopy were included, following a questionnaire on clinical manifestations. Results. A total of 1,408 patients were included. In 89 (6.3%), a cervical heterotopic gastric mucosal patch was described. The mean age of the patients without this condition was 54.6 and 55.5 in patients with it. The esophageal symptoms of gastroesophageal reflux (heartburn, regurgitation, and chest pain) in patients with cervical heterotopic gastric mucosa was observed in 40 (44.9% / p = 0.473), 12 (13.5% / p = 0.783) and 4 (4.5% / p = 0.199) patients respectively. The presence of extraesophageal symptoms (globus, chronic cough, dysphonia, and throat clearing) in patients with cervical heterotopic gastric mucosa was: 9 (10.1% / p = 0.011); 7 (7.9% / p = 0.155); 4 (4.5% / p = 0.458) and 9 (10.1% / p = 0.036) respectively. Conclusions. A statistically significant association was found between the presence of cervical heterotopic gastric mucosal patch and symptoms of globus (p = 0.011) and throat clearing (p = 0.036). It could be interpreted that this group of patients would benefit from the research and treatment of this condition with the intention of improving their symptoms.

Esophageal mucosal sensory nerves and potential mechanoreceptors in patients with ineffective esophageal motility.

Ineffective esophageal motility (IEM) is the most common motility disorder. However, little is known about its pathophysiology. Vagal afferent nerves convey esophageal intraluminal bolus information to solitary nucleus, which is likely to be involved with esophageal primary and secondary peristalsis (SP). We hypothesized that altered mucosal sensory afferents underlie the pathogenesis of IEM. We prospectively collected esophageal biopsies from 38 patients with proton pump inhibitor-refractory reflux symptoms from January to December 2019. All patients underwent high-resolution manometry for the evaluation of primary and secondary peristalsis, and off-PPI 24-h impedance-pH studies. Biopsies were analyzed using immunohistochemistry for identification of calcitonin gene-related peptide-immunoreactive (CGRP-IR) nerves and qPCR for mRNA expression of potential mechanoreceptors. Overall 32 patients were finally analyzed which consisted of 11 patients with normal motility and 21 patients with IEM. The position of mucosal CGRP-IR nerves from the esophageal lumen did not differ between the two groups (the proximal esophagus (p=0.52), the mid-esophagus (p=0.92), the distal esophagus (p=0.29)) with the similar reflux profile. No difference was seen in the position of CGRP-IR nerves between patients with successful triggering of SP and those unable to trigger SP. There was also no difference in mRNA expression of each potential mechanoreceptors (TRPA1, TRPV1, TRPV4, ASIC1, ASIC3) between the two groups. Our study showed that mucosal sensory afferents nerve position and mRNA expression of potential mechanoreceptors did not correlate to weak esophageal contraction.

A generalized equation approach for hyoid bone displacement and penetration\u2013aspiration scale analysis

Swallowing physiology includes numerous biomechanical events including displacement of the hyoid bone, which is a crucial component of airway protection and opening of the proximal esophagus. The objective of this study was to evaluate the potential relations between the trajectory of hyoid bone movement and the risk of airway penetration and aspiration during a videofluoroscopic swallowing study. Two hundred sixty-five patients were involved in this study, producing a total of 1433 swallows of various volumes consisting of thin liquid, nectar-thick liquid, and solids during a fluoroscopic exam. The anterior and posterior landmarks of the body of the hyoid bone were manually marked in each frame of each fluoroscopic video. Generalized estimation equations were applied to evaluate the relationship between penetration–aspiration scores and mathematical features extracted from the hyoid bone trajectories, while also considering the influence of other independent variables such as age, bolus volume, and viscosity. Our results indicated that penetration–aspiration scores showed a significant relation to age. The maximum anterior (horizontal) displacement of the anterior hyoid bone landmark was significantly associated with the penetration–aspiration scores. Differences in the displacement of the hyoid bone are useful observations in airway protection.Article highlightsIn this work, the potential relations between the trajectory of hyoid bone movement and the risk of airway penetration and aspiration during a videofluoroscopic swallowing study were evaluated.We extracted features from the hyoid bone trajectories and applied generalized estimation equations to investigate their relationship to penetration–aspiration scales.The results showed that the maximum anterior (horizontal) displacement of the anterior hyoid bone landmark was significantly associated with the penetration–aspiration scales.

Characteristics of high-resolution esophageal manometry in children without dysphagia.

The absence of high-resolution esophageal manometry (HREM) norms in pediatrics limits the assessment of children with dysphagia. This study aimed to describe HREM parameters in a cohort of children without dysphagia. Children ages 9-16years with a negative Mayo Dysphagia Questionnaire screen and normal histologic findings underwent HREM after completion of esophagogastroduodenoscopy. Ten swallows of 5ml 0.45% saline boluses per subject were captured in supine position. Analyzed data included resting and integrated relaxation pressures (IRP) of lower (LES) and upper (UES) esophageal sphincters, peristaltic contractile integrals, transition zone (TZ) breaks, velocities, and lengths associated with proximal and distal esophagus. 33 subjects (15 female) with mean (range) age 12.9 (9-16) years completed the study. Two of 330 analyzed swallows failed. The UES mean resting pressure, and its 0.2s and 0.8s IRPs were 48.3 (95% CI 12.9) mmHg, 2.9 (95% CI 1.9) mmHg, and 12.1 (95% CI 2.5) mmHg, respectively. The LES mean resting pressure and its 4s IRP were 29.0 (95% CI 4.0) mmHg and 9.2 (95% CI 1.3) mmHg. The mean proximal (PCI) and distal (DCI) esophageal contractile integrals were 231 (95% CI 54.8) mmHg-s-cm and 1789.3 (95% CI 323.5) mmHg-s-cm, with mean TZ break 0.5 (95% CI 0.3) cm. This is the first study to describe HREM parameters in children without dysphagia. Most of the reported measurements were significantly different and less variable from reported adult norms. This emphasizes the need for child-specific catheters, norms, and protocols to define pediatric esophageal motility disorders.

Improved submucosal tunneling endoscopic resection with slant tunnel for submucosal tumors in proximal esophagus.

The improved submucosal tunneling endoscopic resection (STER) with slant tunnel was created by our group innovatively for submucosal tumors (SMTs) in the proximal esophagus. This study aimed to provide the preliminary results of the improved STER from our center. The key step of the improved STER is establishing a slant tunnel instead of a vertical tunnel. After a longitudinal incision was made proximally in the inclined top to the tumor, a submucosal tunnel was established from the incision to the SMT slantingly. 28 patients undergoing STER with slant tunnel were enrolled in the retrospective study. Clinical results including en bloc resection, curative resection and complication were collected. All the submucous tumors located at proximal esophagus originated from muscularis propria were successfully resected by the innovative STER. Tumor size ranged from 18-43mm, with 96.4% (27/28) en bloc resection rate and 92.9% (26/28) curative rate. Three patients suffered complication, 1 patient with mild pleural effusion and another 2 patients with fever for one day. All of the complications were cured by conservative treatment. STER with slant tunnel seems to provide an optional treatment for tumors in proximal esophagus.

A Case Study Vignette for a Pediatric Patient With Eosinophilic Esophagitis

ObjectivesEosinophilic Esophagitis (EoE) is a chronic inflammatory, immune/antigen-mediated condition of the esophagus. It is common in pediatric patients and can lead to several complications such as esophageal remodeling/fibrosis, growth stunting, and low bone mineral density. Nutrition interventions, such as elimination or elemental diets, are the first therapeutic tool for EoE management along with pharmacological interventions. MethodsKS is a 20 month-old female whose weight-for-length has fallen above the 55th percentile since birth. She has a history of gastroesophageal reflux, dysphagia, and aspiration requiring thickened liquids for almost 2 years. During infancy she tolerated milk based thickened formula and transitioned to 1% milk at 1 year. She was diagnosed with EoE during a triple endoscope for laryngeal cleft repair. The pathology revealed rings and furrows in the mid/distal esophagus, and > 20 eosinophils per high powered field (HPF) in distal, mid, and proximal esophagus with evidence of subepithelial fibrosis. At that time she had no dietary restrictions or use of antacids. Since cleft repair, dysphagia improved and she started on a dairy free diet for EoE. However, she experienced an adverse reaction to dairy free nut-based cheese with subsequent positive radioallergosorbent testing to tree nuts. Follow-up endoscopy improved on an 8-week dairy and tree nut free diet, but eosinophils persisted in proximal esophagus with evidence of basal cell hyperplasia. ResultsThe patient was able to make important strides towards remission by eliminating suspected trigger foods, with diagnosis and intervention initiation before signs of inadequate growth or nutrition. ConclusionsNutrition interventions are often imperative to achieve remission of EoE. There are potential nutrition related concerns including increased risk of nutrient deficiencies, inadequate growth, and poor quality of life as the patient follows an elimination/elemental diet. EoE should become a consideration when feeding or swallowing difficulties arise, especially in pediatric patients. Proper diagnosis, tailored interventions, and appropriate monitoring and evaluation with the help of a multidisciplinary team can lead to successful management. Funding SourcesN/A.

Ingested Foreign Bodies and Toxic Materials: Who Needs to be Scoped and When?

1. Yasemin Cagil, MD* 2. Jenna Diaz, MD† 3. Seth Iskowitz, MD‡ 4. Alisa J. Muniz Crim, MD§ 1. *Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA 2. †Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine in St Louis, St Louis, MO 3. ‡Division of Pediatric Gastroenterology, Hepatology, and Nutrition, C.S. Mott Children’s Hospital Michigan Medicine, Ann Arbor, MI 4. §Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nicklaus Children’s Hospital, Miami, FL Providers should be able to identify the signs and symptoms of foreign body and toxic material ingestion in children, select the proper diagnostic tests needed to confirm the diagnosis, and describe adequate treatment modalities for the described ingestions. After completing this article, readers should be able to: 1. Understand the common types of foreign body and toxic material ingestions. 2. Recognize the presenting symptoms of the described ingestions. 3. Recognize which patients warrant emergency endoscopic intervention. 4. Recognize which patients warrant nonemergency endoscopic intervention. 5. Recognize which patients warrant noninvasive medical management. 6. Review the role of prevention. Foreign body and toxic substance ingestions are a common reason for families to seek emergency care. Often, the pediatric patient is unable to describe the nature of the ingestion and/or the timing of the event. This can pose significant barriers to both caregivers and the medical team. Coins, button batteries, magnets, pointed and/or large objects, food, absorptive substances, alcohol, acidic and alkaline substances, detergent pods, and hydrocarbons are all frequently reported ingestions. Each ingested object or substance requires an individualized approach to management. The most common site for foreign bodies to become entrapped is in the proximal esophagus at the site of the cricopharyngeus muscle. Other common locations include the midesophagus, at the site of compression from the aortic arch, and at the lower esophageal sphincter. Most foreign bodies that are ingested by children pass spontaneously without complications; however, endoscopic removal may be necessary in some situations. Parameters that must be considered regarding the need for endoscopic removal of ingested foreign bodies include the child’s age, weight, clinical presentation, time since ingestion, type and size of the foreign body, location in the gastrointestinal tract, and underlying intestinal abnormalities. This section describes the most commonly ingested foreign bodies and their management. (1) ### Coins Coins remain the most commonly ingested …

Number of Gastroesophageal Refluxes Detected With Oesophageal pH-Impedance Study Correlates With Dietary Patterns

Abstract Objectives To evaluate association of number of gastroesophageal refluxes detected with oesophageal pH-impedance study with dietary patterns Methods Subjects referred to oesophageal pH-impedance examination were invited to participate in the study, approved by LEC. In case of agreement, they were asked to provide data of their usual nutrition based on food frequency questionnaire (Nutrilogic, Russia). Diet was assessed in accordance with healthy eating index, for the following main groups of products: grains, fruits, vegetables, dairy products, meats, fats and confectioneries. The results are shown as a quotient of dividing the actual values by the recommended. Spearman rank R was used to analyse correlation between number of gastroesophageal refluxes (GER) detected with oesophageal pH-impedance examination and dietary patterns assessment. Results Data of 40 consecutive patients (12 of them with confirmed gastroesophageal reflux disease, 28 females, age (Mean ± SD): 52.2 ± 12.9 y.o.) served as the source for the study. Mean energy value of the ration was 2302 ± 1391 kcal/day. Dietary patterns for main food groups was as follows: grains 1.4 ± 0.7, vegetables 1.1 ± 0.7, fruits 0.8 ± 0.9, dairy products 0.6 ± 0.6, meats 1.7 ± 1.0, fats 0.6 ± 0.8, confectionaries 0.3 ± 0.5. Mean number of GERs was 43.8 ± 24.4, acid GERs - 26.2 ± 20.5 per day. Direct medium-strength correlation was found between pattern of dairy products consumption and total number of GERs (Spearman R = 0.47, P &amp;lt; 0.05), weak-acid GERs (R = 0.49, P &amp;lt; 0.05), non-acid GERs (R = 0.62, P &amp;lt; 0.05). Pattern of confectionaries consumption was associated with high (that reached proximal oesophagus, ∼17 cm above LES) GERs: R = 0.47, P &amp;lt; 0.05. Conclusions This preliminary results may serve as a basis for further research in larger comparative trials and may be considered when diet modification is planned for patients with GERD. Funding Sources Russian Science Foundation research grant #19–76-30014.

Management Anesthesia of Esophagostomy in a Patient with a Double Outlet Right Ventricle

Background: Esophageal atresia is a congenital disorder in which there is no esophagus because the proximal and distal esophagus is not connected. Babies with esophageal atresia can show several symptoms: foamy mouth, cyanosis, coughing and tightness, flatulence, oliguria, or worse, pneumonia symptoms. Accompanying anomalies occur in greater than 50% of neonates with esophageal atresia. Esophageal atresia is identified by ultrasound at 18 weeks of gestation, ultrasound, and Magnetic resonance imaging (MRI) of the fetal neck, or examination of a nasogastric tube in the neck of a newborn. The management of esophageal atresia is challenging. The main choice remains the surgical procedure, which usually involves making a stoma on the proximal esophagus and gastrostomy. However, surgery has risky complications. Case: In this case, it was reported that a 22-day-old baby with tracheoesophageal fistula (TEF) type C with Ventricular Septum Defect and Atrial Septum Defect and Double Outlet Right Ventricle (DORV) underwent esophagostomy surgery with general anesthesia. Conclusion: Anesthesia management with general anesthesia, intubation using intravenous ketamine 3 mg, fentanyl 3µg, atracurium 1.5 mg gives stability for esophagostomy in a patient with a double outlet right ventricle.

Impact of Environmental and Pharmacologic Changes on the Upper Gastrointestinal Microbiome.

Diseases of the upper gastrointestinal tract have become more prevalent over time. Mechanisms of disease formation are still only partially understood. Recent literature has shown that the surrounding microbiome affects the propensity for disease formation in various parts of the upper gastrointestinal tract. A review was performed of any literature to our best knowledge concerning the effects of pharmacologic agents, environmental changes, and surgical intervention on the microbiome of the upper gastrointestinal tract. Searches of the literature were performed using specific keywords related to drugs, surgical procedures, and environmental factors. Many prescription and nonprescription drugs that are commonly used have varying effects on the upper gastrointestinal tract. Proton pump inhibitors may affect the relative prevalence of some organisms in the lower esophagus and have less effect in the proximal esophagus. Changes in the esophageal microbiome correlate with some esophageal diseases. Drugs that induce weight loss have also been shown to affect the microbiomes of the esophagus and stomach. Common surgical procedures are associated with shifts in the microbial community in the gastrointestinal tract. Environmental factors have been shown to affect the microbiome in the upper gastrointestinal tract, as geographic differences correlate with alterations in the microbiome of the gastrointestinal tract. Understanding the association of environmental and pharmacologic changes on the microbiome of the upper gastrointestinal tract will facilitate treatment plans to reduce morbidity from disease.

Development of a Core Outcome Set for Therapeutic Studies in Eosinophilic Esophagitis (COREOS): An International Multidisciplinary Consensus

Development of a Core Outcome Set for Therapeutic Studies in Eosinophilic Esophagitis (COREOS): An International Multidisciplinary Consensus

Thoracoscopic intraoperative esophageal close technique for long-gap esophageal atresia.

Long-gap esophageal atresia (EA) remains a challenging operative procedure. Several techniques have been reported to resolve the problem of distance between the proximal and distal esophagus. We report a thoracoscopic intraoperative esophageal close technique for long-gap EA. A female neonate was born at 39 weeks of gestation with long-gap EA (five vertebrae). The patient underwent thoracoscopic esophageal anastomosis after esophageal elongation. Careful dissection of the proximal and distal esophagus was performed; however, the distance between them was still long. Extra-thoracic traction sutures were placed at the upper esophagus. Then, a Neraton catheter was inserted trans-orally and the upper esophagus was pushed and opened. An internal traction suture was placed between the Neraton catheter and lower esophagus. The gap between the proximal and distal esophagus could be approximated by pulling the Neraton catheter. Esophageal anastomosis was performed successfully. Our thoracoscopic intraoperative esophageal close technique was simple and useful.

Gastroesophageal reflux with children requiring adenotonsillectomy.

Our aim is to determine the incidence of reflux in children older than 3 years requiring adenotonsillectomy and relationship between GER and diagnostic tests. Forty-four patients, who were listed for adenoidectomy/tonsillectomy at Pediatric Ear Nose Throat department due to severe hypertrophy, were evaluated for accompanying GER (Group 1). GER was diagnosed as having at least one positive GER test result (including esophagitis or pH monitoring). Twenty children without reflux symptoms were used as healthy control group (Group 2) and LPR was held. Reflux was detected in 32 children requiring adenotonsillectomy (72.7%). LPR score was negative in all patients in Group 2. There was no correlation between pH monitoring and histopathological evaluation of esophagus. There was a correlation between the LPR score and histological esophagitis in the proximal esophagus. GER was high in patients with adenotonsillary hypertrophy. LPR score and the history of patients are as effective as invasive techniques like pH monitorization and endoscopy in determining GER disease.

Usefulness of Endoscopic Hill Grade in Evaluating Children Suspected of Having Gastroesophageal Reflux Disease.

Background/AimsThis study aim to evaluate the relationship between the Hill grade confirmed by esophagogastroduodenoscopy (EGD) and the degree of gastroesophageal reflux (GER) by 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH) in children suspected of having gastroesophageal reflux disease (GERD).MethodsA retrospective review of 105 children and adolescents who underwent EGD and MII-pH for the evaluation of GERD from March 2013 to July 2019 was performed. Clinical features and results of EGD and 24-hour MII-pH were collected and statistically analyzed.ResultsHill grades 1, 2, 3, and 4 were identified using EGD in 56 (53.3%), 22 (22.0%), 16 (15.2%), and 11 (10.5%) patients, respectively. As the Hill grade increased, the proportion of neurological diseases (P < 0.001) and endoscopic erosive esophagitis (P < 0.001) increased significantly. The acid exposure index, bolus exposure index, number of reflux episodes, and number of GER reaching proximal extent on MII-pH increased significantly as the endoscopic Hill grade increased (all P < 0.001). Linear regression analysis revealed an increase in the Hill grade by 1 increased the acid exposure index by 2.0%, bolus exposure index by 0.7%, number of reflux episodes by 18.9 episodes, and the number of GER reaching the proximal esophagus increased by 10.5 episodes on average (all P < 0.001).ConclusionsHill grade on EGD was associated with GER in children. Estimating the degree of GER by applying Hill grade in the retroflexion view may be useful in practice when evaluating children suspected with GERD.

A Rare Case of Dysphagia: Diagnosis and Treatment

Question: A 75-year-old woman with a history of chronic hepatitis C virus infection was referred to our endoscopy department with several months of progressive dysphagia and weight loss. A preliminary barium study had been performed and showed a short and irregular narrowing of the proximal esophagus (Figure A).