Schatzki Ring Research Articles

Esophageal Food Bolus Impaction in Community Hospitals in the Era of Rising Health Care Costs: Epidemiology, Clinical Characteristics and Management

Purpose: Esophageal food bolus impaction is a common gastrointestinal emergency. Significant data from a community hospital set up along with the initial management at the emergency room under any set up are lacking. This study was designed to investigate the current management practice of esophageal food impaction at the community hospital level and correlate with the American Society of Gastrointestinal Endoscopy guidelines. Methods: The charts of all patients showing symptoms of esophageal food bolus impaction from 2005 to 2009 at two area hospitals were reviewed. Those patients having endoscopy for the food impaction were included in the study. Their charts were reviewed and relevant demographic, clinical and management information was recorded and analyzed. Results: A total of 312 patients, 200 from Hospital A (HA) and 112 from Hospital B(HB), were analyzed. Of those, 64.7% were male, 57.6% were above 60 years, and 80% were white. Forty nine percent of the patients arrived at the emergency room (ER) less than 6 hours after symptom onset while 22.8% arrived more than 18 hours later. The patients were evaluated with imaging studies in 62.2% of cases. HB used more imaging tests than HA (81.3% vs. 51.5%). In most cases, the imaging studies were either negative for foreign bodies or did not change the management plan. HB used more glucagon than HA (58.4% versus 28.5%). In HA 48.5% had an EGD in less than 3 hours after arrival in ER against 26% in HB. Forty-five percent of the patients had dysphagia to saliva. Sedation and the extent of anesthesia services used also varied between the two hospitals: midazolam was the most used in HB (54.8%), while propofol was used more in HA at 75.5%. A food bolus was detected in esophagus or stomach in 98.2% cases. The endoscopic findings were stricture in 37% cases, esophagitis in 24.4% cases, and Schatzki's ring in 6.4% of cases. Esophageal biopsies were conducted in 45 cases, and eosinophllic esophagitis was identified in 2.4% of these cases (3% in HA, 1% in HB).There were wide variations in the duration of endoscopies, with 11.7% and 6.4% cases requiring 30-60 minutes and more than 60 minutes, respectively. Conclusion: Esophageal food impaction, a widely prevalent gastrointestinal emergency, is managed with variations at different hospitals. Initial management approach in the ER may be modified to minimize unnecessary imaging studies and encourage early disposition of patients. Broader consensus on sedation may minimize requirements. An observant look may help to identify more cases like eosinophillic esophagitis.

Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures

Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.

Modification of the Standard Esophageal Dilation Technique Improves Efficacy in the Treatment of Schatzki Rings and Strictures

Purpose: Historically, Schatzki Rings and strictures at the gastroesophageal junction have been managed with a variety of techniques that include Maloney Bouigenage, Savory dilation and balloon dilation. Balloon dilation has become the preferred technique by experienced endoscopists with or without adjuvant Endoincision. Some dilation procedures result in a single deep tear that prevents further dilation while allowing the majority of the ring to remain intact. This paper describes a modification on the current technique of 3 stage controlled radial expansion (CRE) balloon dilatation. Methods: 20 patients (17 with Schatzki Rings and 3 with strictures) had initial dilations that resulted in deep submucosal tears that prevented further dilatation. None of the patients had experienced relief of dysphagia from these procedures and returned to the endoscopy suites for a second procedure. All patients underwent a second dilation with a Microvasive CRE Balloon® (Boston Scientific). Rather than dilating at the traditional 3 stages based on measurements in French or millimeters, a modified technique was carried out where balloon pressure was increased by 0.5 ATM (stopping at each 0.5 ATM stage for 1 minute). Results: Using the slow dilation technique, all patients averaged 3 adequate tears (range 2-5), without the need to stop prematurely. All patients had a greater percentage of their ring or stricture disrupted with this technique. 16 patients had an increase in the circumference of the balloon by 9 French and 4 by 6 French as compared to their initial dilation using the traditional technique. Mean follow-up time was 9 months (range 6-18 months). The only recurrence was in a patient with Scleroderma Esophagus with refractory Grade D esophagitis. Conclusion: 1) The slow dilation techniques improve the end-result in patients experiencing early deep-tears and premature cessation of the procedure. 2) 95% had lasting success and the only failure was a Scleroderma Esophagus with persistent esophagitis. 3) All patients had greater ring destruction and future studies may prove the slow dilation method to be the preferred method in all patients.

Same Day Bidirectional Outpatient Endoscopy for Suspected Gastroenterology Bleeding at Veterans Affairs Tertiary Referral Center

Purpose: Patients (Pts) with minor gastrointestinal (GI) bleeding are often scheduled for expedited outpatient EGD and colonoscopy on the same day at our institution. Our aim was to determine the diagnostic yield of scheduling bidirectional outpatient procedures for minor GI bleeding and to determine if the pre-test data can predict the test yield to conclude whether this practice should continue or be modified. Methods: We reviewed all records of outpatients who had EGD and colonoscopy scheduled the same day in 2005 at Veterans Affairs Medical Center, Buffalo. Our study population included pts with minor GI bleed which was defined as occult GI bleeding with or without iron deficiency anemia or iron deficiency anemia alone. Pts with melena were also included if EGD/Colonoscopy were performed as outpatient. Base line laboratories including: CBC, INR, BUN, Creatinine, iron studies and Fecal Occult Blood Test (FOBT) status were recorded. GI symptoms, number of blood transfusion and hospital admission in one year prior to the procedure were obtained as well. Significant EGD findings include: ulcer (Duodenal, Gastric), portal Hypertension, gastropathy, varices, mild gastritis, superficial erosions, mild duodenitis, friable mucosa, Arterio-Venous Malformations and active bleeding. Non-significant findings include: normal study, candida infection, hiatal hernia, polyps, Barrett's esophagus, Schatzki's ring and lipomas. Multivariate regression analysis conducted. Results: Total of 91 pts (Male=88; Female=3) were included in the study. 81 were white and 10 African American. Median age was 68. Study indications were: Iron deficiency without anemia (n=4), Iron deficiency with anemia (n=42), FOBT positive without anemia (n=14), FOBT positive with anemia (n=28), and melena with anemia (n=2). Significant medications received within one month prior to the study were Aspirin (n=28), Nonsteroidal anti inflammatory drugs (n=14), Plavix (n=12) and Coumadin (n=12). Upper GI symptoms were reported by 25 pt including nausea, vomiting, dysphagia, abdominal pain or heartburn while 5 had lower GI symptoms as change in bowel movement habits. Only 17 pts had significant findings while 74 had non-significant ones (including 37 normal studies). Our analysis revealed no statistically significant correlation between any of the baseline labs mentioned above or the GI symptoms and the results of the EGD. Conclusion: In summary we were unable to find any pre-procedure predictive factor that can help in deciding the endoscopic procedure of choice in pts with minor GI bleed. The study is limited with sample size, recommend following prospective studies.

Etiologies of Esophageal Dysphagia Vary Among Different Age Groups

Purpose: Dysphagia is a common problem presenting to gastroenterologists. The purpose of this study was to determine if certain types of dysphagia were more prevalent in different age groups. This knowledge will serve the clinician to provide a focused evaluation when diagnosing and planning treatment strategies for the patients. Methods: Patients were stratified by age based on decade of life. Diagnoses included obstructive disorders (Schatzki Rings, strictures and tumors); Erosive (Reflux) Esophagitis, Eosinophilic Esophagitis, motility disorders, functional disorders and miscellaneous (infections, Sjogrëns, pill-induced, Scleroderma, etc.). Results: Over 600 patients were referred to our tertiary center as diagnostic dilemmas or for treatment of dysphagia. We eliminated patients with oropharyngeal dysphagia and those with radiation strictures and anastomotic strictures. Our final patient population was 488. The Table above summarizes the findings.Table. DiagnosisConclusion: 1. SR's are relatively common in all age groups but most prevalent in groups over 50. 2. STX are relatively uncommon in patients <40 but increase with each decade of life. 3. Cancers were seen with similar frequency in ages 40-79. 4. EE causes dysphagia with greatest frequency in ages 30-59. 5. EOS is most common in patients <39. 6. IE was seen throughout all groups but is more common in patients <50. 7. Motility disorders were the leading cause of dysphagia in all age groups. a. <50 mixed disorders, achalasia, primary motility disorders. b. >60 Presbyesophagus was most common. c. 50-59, all of the above.

Sublingual Nitroglycerine for Esophageal Meat Impaction

Purpose: A 48 year old female presented to a community hospital emergency room with sudden onset of dysphagia to liquids and solids 3 hours after eating meat for supper. She denied heartburn, tobacco or alcohol use and had no previous problems with swallowing. She was not taking any medications and was unable to tolerate saliva. A trial of glucagon resulted in no improvement. The emergency room physician contacted the endoscopist on-call at the teaching hospital who suggested that she be given a trial of sublingual nitroglycerine 0.3 mg. This agent was suggested as it has been shown to cause a significant reduction in lower esophageal sphincter pressure in normal subjects as well as in patients with achalasia, Chagas' disease and esophageal spasm (1-4). Within 20 minutes after sublingual nitroglycerine adminstration, the patient passed the meat bolus spontaneously. She did develop mild transient hypotension from the nitroglycerine which responded to intravenous fluids. Follow-up elective endoscopy 2 months later revealed a Schatzki ring which was dilated with a 48 French Maloney dilator. Biopsies of the esophagus showed only mild non-secific inflammation, without evidence of eosinophilic esophagitis. Based on this experience, it appears that sublingual nitroglycerine may be helpful in emergency room management of esophageal meat impaction and may reduce the need for urgent endoscopy.

Uvular Necrosis after Endoscopy

A 28-year-old man presented with a sore throat 72 hours after undergoing upper endoscopy with dilation of a Schatzki ring. He noted a sore throat, starting 24 hours after the procedure.

Transnasal Balloon Dilation of the Esophagus

To describe the safety of transnasal balloon dilation of the esophagus. Retrospective case series. Two tertiary care institutions. All patients undergoing transnasal balloon dilation of the esophagus. Complications. Fifty-four transnasal esophageal balloon dilations were performed in 38 patients. The mean age of the cohort was 65 years (range, 13-88 years). Twenty-nine patients were male (76%). Twenty procedures were performed using only topical anesthesia in the office setting. Seven patients (18%) were postlaryngectomy, and 15 patients (39%) had a history of head and neck radiation therapy. The upper esophageal sphincter (UES) was the most frequent dilation site (63%), followed by proximal/mid esophagus (26%), lower esophageal sphincter (LES) (7.4%), and both the UES and LES (3.7%). Indications included cricopharyngeal dysfunction, benign stricture, web, and Schatzki ring. Two procedures (3.7%) were aborted secondary to self-limited laryngospasm or gagging. There were no clinically significant complications. Transnasal esophageal balloon dilation can be performed in unsedated or sedated patients with a very low complication rate. The procedure is well tolerated in 96% of patients. This technique, formerly available only through larger caliber oral gastroscopes and under sedation, allows for office-based esophageal balloon dilation in an otolaryngology practice.

W1872 DNA Markers for the Pan-Detection and Site-Prediction of Aerodigestive Cancers: Evaluation of a Candidate Panel

Background and aims: In this prospective study, we determined the long term clinical course of patients with symptomatic schatzki rings, who were treated by single dilatation. Besides we analyzed the frequency of associated esophageal disorders and their influence on the outcome. Methods: Since 1984 all patients with newly diagnosed symptomatic Schatzki rings were prospectively collected. They underwent structured interviews as well as endoscopic and/or radiographic examinations. 167 patients (124 male, 43 female) with a mean age of 57 +/14.6 (mean +/-1SD) years were studied. 133 (56,3%) patients were treated by single dilatationwith the use of malloney or savary gillard bougies (46-58F). No complications occurred. Follow up information was available in 94 of 133 patients and the average duration of follow up was 65months (range 12-254). All patients were symptom-free at the first followup examination, but late symptomatic recurrences were frequent. Duration of remission was evaluated by Kaplan-meier estimates of time to recurrence. Results: According to the KaplanMeier estimate, after 2 years of follow-up 71% (SE 4%), after 5 years 56% (SE 4%), and after 10 years 52% (SE 4%) had not yet received any repeated treatment. 40(42,2%)of the 94 patients showed further esophageal lesions like refluxesophagitis (24 patients), esophageal membranes (14 patients) and eosinophilic esophagitis (2 patients), but there were no significant influence on the time of recurrence. Conclusion: : The Schatzki Ring is frequently associated with other esophageal lesions. The most frequent of these are reflux esophagitis and esophageal membranes. However there is no influence on the likelihood of symptomatic recurrences, which is common in patients with Schatzki Ring after a successful dilatation.

M1837 Schatzki's Ring and GERD: Association Between Esophageal Acid Exposure and Imaging Findings

M1837 Schatzki's Ring and GERD: Association Between Esophageal Acid Exposure and Imaging Findings

Results of an intervention in an academic Internal Medicine Clinic to continue, step-down, or discontinue proton pump inhibitor therapy related to a tennessee medicaid formulary change.

In July 2005, the State of Tennessee Medicaid Program (TennCare) announced formulary changes for proton pump inhibitors (PPIs) to be implemented in August 2005. Prior to these changes, pantoprazole was the only preferred PPI, and there were no restrictions to its use. The revised formulary included 3 preferred PPIs (esomeprazole, lansoprazole, and omeprazole OTC), all of which required prior authorization (PA). In order to obtain an approved PA for a PPI, the patient was required to have either (a) a diagnosis of erosive esophagitis, Barrett's esophagus, Schatzki's ring, a pathological hypersecretory condition (e.g., Zollinger-Ellison syndrome, multiple endocrine adenoma), grade III-IV gastroesophageal reflux disease (GERD), non-steroidal anti-inflammatory drug gastropathy, significant gastrointestinal bleed; or (b) another indication for acid suppression therapy (e.g., GERD, hyperacidity in cystic fibrosis, gastric or duodenal ulcer, gastroparesis) with a history of failure of prior therapy with a histamine-2 receptor antagonist (H2-blocker). The internal medicine clinic of a regional medical center implemented an intervention to address these changes in formulary status of PPIs. To (a) describe the process used by an internal medicine clinic to ensure that patients requiring acid suppression therapy received appropriate treatment according to revised TennCare formulary criteria without unnecessary interruption of therapy, and (b) assess self-reported symptom control 8 months after intervention in the patients who either discontinued therapy or stepped-down to H2-blocker therapy. This study involved TennCare patients in an internal medicine clinic who received a new or refill prescription for pantoprazole between April 20 and June 20, 2005, from the medical center's outpatient pharmacy. A clinical pharmacist and an internal medicine physician collaborated to develop a protocol for adjusting acid suppression therapy. A clinical pharmacist reviewed medical records for all patients identified to verify indications for acid suppression therapy and review medication history. Patient telephone interviews were also conducted for patients whose indication or medication history could not be determined by chart review. Patients who met TennCare criteria for PPI therapy were continued on PPI therapy after a PA was obtained (PA group). Patients who had a documented indication for acid suppression therapy but did not meet the PA criteria for PPI therapy were changed to H2-blocker therapy (step-down group). Patients without a documented indication for acid suppression therapy were discontinued from acid suppression therapy (discontinue therapy group). A follow-up chart review and patient telephone interview were conducted 8 months after the intervention for patients in the step-down and discontinue therapy groups. The purpose of this follow-up review was to determine (a) the proportion of patients who were taking acid suppression therapy, (b) the type of acid suppression therapy (PPI or H2-blocker), and (c) self-report of adequate control of symptoms (defined as symptoms once weekly or less). Of 135 TennCare beneficiaries who were active patients of the internal medicine clinic and received a prescription from the outpatient pharmacy for PPI therapy (pantoprazole) between April 20 and June 20, 2005, 6 patients were excluded because they reported stopping PPI therapy on their own. Of the remaining 129 patients, 18 (14.0%) did not have an indication for PPI therapy and acid suppression therapy was discontinued (discontinue therapy group), 40 (31.0%) met the TennCare PA criteria for continuation of PPI therapy (PA group), and 71 (55.0%) did not meet the TennCare PA criteria and were stepped down to a H2-blocker (step-down group). At the 8-month follow-up, acid suppression therapy was assessed in 68 patients (21 patients were lost to follow-up): 13 patients (19.1%) had resumed PPI therapy; 38 (55.9%) were using an H2-blocker; and 17 (25.0%) were not using acid suppression therapy. Telephone interviews were completed for 45 of the 75 patients in the step-down and discontinue therapy groups who did not receive an escalation in acid suppression therapy after the initial intervention (i.e., who did not make a change from H2-blocker therapy to PPI therapy or from no acid suppression therapy to H2-blocker or PPI therapy). Twenty-eight patients (62.2%) reported symptoms once per week or less; 14 patients (31.1%) reported symptoms more often than once weekly. Symptom control was unable to be determined in 3 patients (6.7%) because of incomplete information obtained from the patient during the interview. After a proactive collaboration between physicians and clinical pharmacists in response to changes in TennCare formulary criteria for PPIs, more than one-half of patients were stepped down to H2-blocker therapy, and 14% were discontinued from acid suppression therapy. Among the step-down or therapy discontinuation patients for whom data were available at the 8-month follow-up, 81% were still using either an H2-blocker or no acid suppressing therapy at all, and 19% had resumed PPI use.

W1871 Single Dilatation of Symptomatic Schatzki Rings: Late Results of a Prospective Follow Up Investigation

W1871 Single Dilatation of Symptomatic Schatzki Rings: Late Results of a Prospective Follow Up Investigation

Endoscopic Findings in Patients Presenting with Dysphagia: Analysis of a National Endoscopy Database

Background: Dysphagia is a common indication for upper endoscopy. The different endoscopic findings are well known but the prevalence of these findings is not. There is also no data on the prevalence according to demographics or by single vs repeat EGD. Purpose: To determine the prevalence of endoscopic findings in patients (pts) presenting with dysphagia and if these findings differ with regards to age, gender, ethnicity and repeat procedure. Methods: The Clinical Outcomes Research Initiative (CORI) data base was queried from 1/2000 - 9/2006 for upper endoscopies performed for dysphagia. The overall frequency of endoscopic findings was determined and by gender, age, ethnicity and single vs. multiple procedures. Findings were grouped into normal esophagus, esophagitis/esophageal ulcer (EU), esophageal food impaction (EFI), suspected malignancy, stricture and Schatzki ring (SR). Chi-square analysis was used to analyze categorical variables. Results: 30,377 total pts were identified. For race/ethnicity analyses, a total of 29,337 was used. Esophageal stricture was the most common finding followed by normal, EU, SR, EFI and suspected malignancy. Males were more likely to undergo multiple endoscopies than females (15.3% vs 12.8%, p=0.001). Women were more likely to have a normal exam (37.2% vs 25.4%, p<0.0001). Men were more likely to have EU, EFI, stricture & suspected malignancy (p< 0.001 for all comparisons). The prevalence of SR among males and females was not different (p = 0.90). Pts over 60 (vs<60) had a higher prevalence of suspected malignancy (1.3% vs 0.4%), stricture (45.9% vs 35.6%) & SR (14.7% vs 11.9%) (p<0.0001 for all comparisons). (Esophageal stricture was most common in white non-Hispanic pts compared to other ethnic groups. Asian/pacific islander pts were most likely to have normal exams (65.5% vs 30.7%) and a lower prevalence of stricture (9.4% vs 42.3%) and SR (3.7% vs 13.8%) compared to whites. 4202 (13.8%) pts had multiple endoscopies for dysphagia during the time period. Males were more likely to undergo multiple EGD's than females (15.3% vs 12.8%, p=0.001). Normal and EU were more frequent in single EGD. Stricture, EFI, suspected malignancy and SR were more frequent in pts undergoing multiple EGD's (p<0.0001 for all comparisons). Conclusion: The prevalence of endoscopic findings among pts with dysphagia differs significantly by gender, age, and repeat procedure. For all pts, the most common findings in descending order were: stricture, normal, EU, SR, EFI, and suspected malignancy. For pts undergoing repeat procedure, normal and esophagitis were significantly less and all abnormal findings were significantly more common.

Schatzki’s Ring in Angelman Syndrome: A Diagnostic Dilemma in Neurodevelopmentally Disabled Patients

Angelman Syndrome is a neurodevelopmental condition with a characteristic phenotype that includes epilepsy and lack of communication. We describe its first reported association with Schatzki's ring that presented as a life-long history of intermittent retching. Because of associated cognitive dysfunction, careful diagnostic consideration is required to detect this underlying condition.KeywordsSchatzki's ring; Angelman Syndrome; Esophageal "B" ring; Barium esophagogram; Neurodevelopmental delay; Retching

Ring(s)-related esophageal meat bolus impaction: biopsy first, dilate later

Distal esophageal or Schatzki's rings are a common cause of intermittent solid food dysphagia requiring endoscopic dilation for relief. Similarly, eosinophilic esophagitis (EE) is a rapidly emerging disease in both children and young adults, and manifests as dysphagia to solids and/or episodic food bolus impaction. Endoscopic findings vary considerably among patients with EE, posing significant recognition and management challenges. Esophageal dilation in EE can be painful and risky. This case report describes a patient with acute food bolus impaction due to underlying Schatzki's ring and associated but clinically indolent EE, and highlights some safety aspects of esophageal dilation.

Double Take

Purpose: A 47-year-old woman with history of GERD on chronic PPI and hyperplastic colon polyps presents to GI clinic with iron deficiency anemia of unknown etiology. She has a family history significant for a brother with a Schatzki's ring of the esophagus as well as Barrett's esophagus, a father with colon cancer detected at age 50, two paternal uncles with colonoscopies revealing less than 100 polyps, a paternal great-grandfather with colon cancer, and a maternal grandfather with gastric cancer. Patient's hemoglobin and hematocrit were 10.5 g/dL and 31.6%, respectively. Iron studies revealed an iron level of 25 ug/dL, TIBC of 488 ug/dL, ferritin of 6 ng/ml, transferrin of 390 mg/dL, and transferrin saturation of 5%. Colonoscopy revealed a sessile, 3 mm polyp in the ascending colon and a sessile, 4 mm polyp in the rectum both with biopsy results consistent with a hyperplastic polyp. EGD revealed a mild Schatzki ring in the lower third of the esophagus, a medium-sized hiatal hernia, and 30–50, 5 to 30 mm pedunculated and sessile polyps with no stigmata of recent bleeding in the gastric antrum and body of the stomach. The examined duodenum was normal. Histology confirmed these were fundic gland polyps. Video capsule endoscopy revealed multiple large pedunculated and sessile polyps with no bleeding or stigmata of recent bleeding in the gastric body, fundus and antrum. The patient was evaluated for genetic mutations of the APC or MYH genes because of the multiple, large fundic gland polyps and her family history of colon cancer. Genetic testing came back negative for any mutations in the APC or MYH genes. Ultimately, it was felt that the patient's multiple polyps were secondary to chronic PPI use and were not secondary to malignancy. Polyps are often incidentally discovered on endoscopy and should not simply be overlooked. They require a “double take”. Biopsy is necessary for histological evaluation. When multiple gastric polyps are found, particularly to the degree in this case, further evaluation should be undertaken, regardless of histologic type. Assessing the possibility of genetic mutations that could predispose to GI malignancy is reasonable. APC or MYH gene mutations may be revealed which correlate highly with FAP. In addition, there is a clear correlation between fundic gland polyps and FAP. This could have serious implications for a patient leading to colon cancer. Suddenly, the incidental finding of a gastric polyp which may have been overlooked is very significant. In conclusion, gastric polyps need diagnostic evaluation beyond what is seen during endoscopy which is a change from the current practice during many endoscopies. Methods: N/A Results: N/A Conclusion: N/A

Gender Differences in Patients Presenting with Dysphagia

Background: Dysphagia is a common cause of referral for upper endoscopy. Gender differences within such a cohort have not been previously described in the literature. We hypothesized that the etiology of dysphagia would differ by gender. Aim: To determine if gender differences exist among the etiology of dysphagia in patients presenting for upper endoscopy. Methods: A prospective analysis was performed on all patients undergoing upper endoscopy for the indication of dysphagia between 1/1/2006 and 6/1/2007 at the University Hospital. All patients completed dysphagia symptom assessment along with validated gastroesophageal reflux questionnaires. Endoscopic findings and demographics were also recorded. Results: A total of 190 patients were enrolled (92 males, 98 females). Males and females were similar in age of presentation (49.7 ± 15.0 vs. 52.8, ± 16.3), duration of symptoms (8.2 ± 9.0 vs. 6.0 ± 8.7), and severity of dysphagia scores (median 1.9 ± 1.4 vs. 2.1 ± 1.5). A significant difference in the distribution of endoscopic findings exist between males and females (p < 0.004). Multiple esophageal rings are more prevalent in males than females (28.6% vs. 13.9%, p < 0.02). Schatzki's Rings (SR) are described more in females than males (20.8% vs. 6.1%, p < 0.01) [see table]. A history of esophageal food impaction (EFI) occurred more frequently in males (30.4% vs. 17.3%, p < 0.04). A high prevalence of multiple esophageal rings was found in both genders who described prior EFI (males 55.6%, females 46.7%). Prior food impaction increased the likelihood of finding multiple esophageal rings in females (OR 7.7, p < 0.03), but not in males (OR 1.8, p = NS). Conclusion: The endoscopic findings and history of esophageal food impaction in patients presenting with dysphagia differ significantly by gender. History of esophageal food impaction greatly increases the likelihood of finding multiple esophageal rings in females. Suspicion of multiple esophageal rings should be high not only in men, but also in women who present with EFI and dysphagia.

W1889 Long Term Outcome Following Pneumatic Dilatation for Idiopathic Achalasia

copist and uncomfortable for the patient, 3) the protracted and profound sedation frequently needed to perform the procedure increases the risk of aspiration and hypotension and 4) the use of an overtube increases the risk of esophageal perforation. We have developed a quick and simple technique of through-the-scope (TTS), wire-guided esophageal balloon dilation to treat EFI. Method: After initial endoscopic evaluation of the impacted food bolus, a TTS, wire-guided, 12mm balloon dilator is passed through the endoscope, and the guide wire is advanced gently through the bolus under direct endoscopic visualization. If the endoscopist encounters resistance or observes any bowing of the wire, the attempt is discontinued and the wire is redirected. When the wire is successfully advanced through the bolus and beyond the stenotic area, the uninflated balloon is passed over the wire into the stomach. The balloon is inflated within the stomach to its 12mm size, and then gently pulled back into the esophagus until resistance is encountered at the level of the stenosis. The balloon is then deflated, pulled back into the stenotic area, and reinflated to its 12 mm size. The balloon is finally deflated and removed, and the endoscope is used to gently push the bolus into the stomach. Results: We have treated 11 patients with this technique. Their mean age was 69.6 years (range 49-83 years) and all were men. All of the EFIs were caused by the ingestion of meat, and esophageal pathology was found in all 11 patients. Five patients (45%) had Schatzki's rings, 3 (27%) had benign esophageal strictures, and 3 (27%) had eosinophilic esophagitis. TTS, wire-guided esophageal balloon dilation successfully dislodged the EFI within 5 minutes in all 11 patients, and there were no major procedure related complications. Conclusions: TTS, wire-guided esophageal balloon dilation is a simple, quick and effective technique to treat EFI. We feel that this technique is less likely to result in complications than the conventional practice of endoscopic extraction using an overtube, but comparative studies are needed to establish the relative merits of these treatments.

A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki's) rings

Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring, but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement. There are no data on the treatment of Schatzki's rings in the presence of acid suppression treatment. Our purpose was to compare the efficacy of bougie dilation with electrosurgical incision of symptomatic Schatzki's rings at 1-year follow-up in the presence of rabeprazole treatment. Randomized, prospective trial. University of Utah Health Sciences Center and the Veterans Affairs Salt Lake. Fifty patients referred for endoscopic evaluation of dysphagia between January 2002 and March 2005. Symptom-free survival time (in months), dysphagia, and GERD scores. Twenty-five patients each underwent bougie dilation and electrical incision and were followed up for 12 months. Symptom-free survival times were significantly longer in the incision group (7.99 months) compared with the bougie dilation group (5.86 months) (P = .03). Dysphagia and GERD scores significantly improved in each group comparing baseline with each time interval. The incision group had greater relief of dysphagia at 1 month (P = .05) compared with the bougie group. There was no difference between GERD scores in both groups. Dysphagia and GERD symptoms were self-reported. Electrosurgical incision of Schatzki's rings is safe and offers longer symptom-free survival compared with bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

Barium Esophagography: A Study for All Seasons

Although a variety of diagnostic procedures are often performed on patients with pharyngeal or esophageal symptoms, barium esophagography is a noninvasive, inexpensive, and readily available test that can simultaneously evaluate swallowing function, esophageal motility, gastroesophageal reflux, and a host of structural abnormalities in the pharynx and esophagus. This article reviews the role of barium esophagography for assessing swallowing function, morphologic abnormalities of the pharynx (diverticula, webs, and carcinoma), esophageal motility disorders (achalasia and diffuse esophageal spasm), and morphologic abnormalities of the esophagus (reflux esophagitis, Barrett's esophagus, infectious esophagitis, drug-induced esophagitis, eosinophilic esophagitis, Schatzki's ring, and esophageal carcinoma).