Schatzki Ring Research Articles

Capsule Endoscopy for Screening for Short-Segment Barrett's Esophagus

The rise in the incidence of esophageal adenocarcinoma has led to the development of new methods to screen for the precursor lesion, Barrett's esophagus. To evaluate the potential role of esophageal capsule endoscopy in identifying the presence of short-segment Barrett's esophagus. Patients with biopsy-proven short-segment Barrett's esophagus underwent esophageal capsule endoscopy. The images were reviewed by two expert observers with no knowledge of the purpose of the study. The data collected included transit time, quality of image, presence or absence of Z-line, Schatzki's ring, hiatal hernia, and Barrett's esophagus (long or short, definite or suspected). Twenty patients were studied; in 18, the capsule passed into the stomach. Barrett's esophagus was identified or suspected in eight cases (44%) by one observer and three (16%) by the second (P= 0.14). Although the Z-line was seen in the 18 cases that were qualified by both observers, there was an agreement in only six cases as to whether it was regular or irregular. Erosive gastroesophageal reflux disease (GERD) was scored as present in three and absent in six patients by both readers. Nonexisting feline esophagus, varices, and distal esophageal stricture were suspected in one patient each. Esophageal capsule endoscopy had a high interobserver variability and a low yield for short-segment Barrett's esophagus. Esophageal capsule endoscopy cannot be recommended for screening for short-segment Barrett's esophagus.

The yield and safety of string capsule endoscopy in patients with dysphagia

Dysphagia is a contraindication for the use of conventional capsule endoscopy (CE). Because string CE (SCE) allows for the immediate retrieval of the device, it eliminates the risk of capsule retention. To assess the yield and safety of SCE in patients with dysphagia. Comparative study of SCE and EGD. Phoenix Veteran Affairs Medical Center. Patients with dysphagia underwent SCE and EGD. In 40 patients with dysphagia, the EGD findings were normal in 13 (32.5%); Schatzki's ring in 10 (25%); esophageal tumors in 9 (22.5%), with 1 of these having 2 separate and distinct malignancies; erosive esophagitis in 4 (10%); strictures in 2 (5%); and a web and large esophageal varices in 1 patient each (2.5%). The sensitivity of SCE for diagnosing anatomic pathology as the likely cause of dysphagia was 92.9%, with a specificity of 92.3%, a positive predictive value of 96.3%, and negative predictive value of 85.7%. The overall agreement between SCE and EGD was 92.7% and the kappa index was 0.83. There were no complications with either procedure. There was no case of capsule retention. The SCE recording time was 385.8 seconds; 77.5% patients preferred SCE to EGD. (1) SCE was safe, well tolerated, and accurate for the diagnosis of pathology responsible for dysphagia; (2) SCE was preferred to EGD by more than three fourths of patients; (3) SCE can be safely performed in patients with dysphagia.

Eosinophilic Esophagitis in a Patient with Sjogrenʼs Syndrome

A 63 year-old white female with Sjogren's syndrome complained of recurrent gingivitis, oral mucosal ulcerations, chronic nausea, dyspepsia, and dysphagia for solids and pills. In the past year she had an unintentional 50 pound weight loss and had lost her sensation of taste. In recent months she also developed redness and dryness of her vulva. She had a history of erosive esophagitis and gastritis documented on two prior endoscopies and multiple esophageal dilatations were performed in the past to treat her dysphagia. Her last barium swallow revealed non-specific narrowing of the upper and distal esophagus with no clear Schatzki's ring identified. On exam was a middle aged white female who was not jaundiced. There was an irregular shaped area of erythema on her right buccal mucosa with white striations in the pattern of Wickham's striae. There were no discrete oral ulcerations. Cardiovascular and respiratory exams were normal. Her abdomen was soft and non-tender with no distention, organomegaly or masses. There was erythema and edema of her external genitalia, particularly of the labia minora, but no genital ulcerations. EGD revealed a narrow caliber esophagus with areas of friability and desquamation of the mucosal surface. Biopsies from the mid-esophagus were consistent with the diagnosis of eosinophilic esophagitis (>20 eos/hpf). Small bowel biopsies were normal, showing no evidence of celiac sprue. A minor salivary gland biopsy had confirmed the diagnosis of Sjogren's syndrome. Cutaneous immunofluorescence was negative and there was no evidence of lupus, vasculitis, or autoimmune bullous disorder. Vulvar biopsies revealed marked acute and chronic inflammation that was non-specific with no eosinophils identified. The patient's oral mucosal findings were typical of Lichen Planus however they resolved before they could be biopsied. Eosinophilic esophagitis (EE), Sjogren's syndrome (SS) and lichen planus (LP) share a number of interesting features. They are all immune mediated disorders with an association to either allergens or autoantigens. Gastrointestinal manifestations are also common in all three disorders. Though they share a number of similarities, current knowledge about their pathogenesis supports they are distinct entities. We report our case as an interesting example of a patient with three disorders that, although distinct in pathogenesis, share a number of similarities that may impact her future treatment.

Liver Abscess as a Complication of Esophgeal Balloon Dilation

Purpose: Despite the increase use of upper endoscopy, the complication rate has remained low. Infectious complications of EGD include transmission of infection by contaminated endoscopes or ancillary equipment, bacteremia and aspiration pneumonia. Here, we are reporting a liver abscess followed a routine upper endoscopy dilation in patient with gastric bypass. Methods: A 59 year old patient with history of gastric bypass 19 years ago presented with intermittent dysphagia has been going on for the last few months. Her upper endoscopy was remarkable for schatzki ring and gastric pouch contained undigested food. The gastrointestinal anastomosis was patent. The schatzki ring was dilated using CRE balloon 15–18 mm with evidence of breaking the mucosa at 16.5 and 18 mm. Her other past medical history was significant otherwise for thyroid cancer, thyroidectomy 20 years ago, tobacco and ETOH abuse. Patient presented with right upper quadrant pain 2 days after the EGD to outside facility. She was treated symptomatically. Pain returned and patient developed fever and chills. CT scan of the abdomen performed at our facility 2 weeks after the EGD showed left hepatic lobe abscess. US guided drainage grew Candida Albicans, streptococcus Solivarius, and Beta Hemolytic Strep Group B. Esophagogram failed to show any leak or perforation. The abscess resolved with IV antibiotic and percutaneous drainage without the need for surgery. Results: The timing between the onset of her symptoms and the EGD suggest causal relationship. This is most likely related to transient bacteremia secondary to the dilation. Her altered anatomy, gastroparesis and ETOH intake, probably predisposed her for the bacteremia and the immune suppression status. Conclusion: Esophageal dilation has the highest incidence of bacteremia of all gastrointestinal endoscopic procedures, occurring in approximately 45 percent of cases. In spite of this, complications of bacteremia such as endocarditis are rare. The most common reported complication is endocarditis, and less frequently meningitis. Antibiotic prophylaxis is not warranted in most patients undergoing esophageal dilation except for those at high risk. People with immunosupressed status or altered anatomy might need to be considered for prophylaxis.

Eosinophilic Esophagitis/Ringed Esophagus: The Diagnostic Conundrum

Purpose: Eosinophilic esophagitis (EoE) is defined classically as >20 eos/HPF on esophageal biopsies. Common characteristics in EoE are dysphagia with associated rings/furrows seen on endoscopy. To date, no one has determined whether all rings seen on EGD represent EoE histologically or whether all EoE patients have the classical endoscopic findings of rings/furrows. This study was designed to correlate endoscopic findings and histology in EoE. Methods: A retrospective analysis of all EGD's performed at the University for dysphagia in 2006 was performed. Per routine protocol, all cases were biopsied and evaluated for eosinophils. Patients with endoscopic findings of ringed/furrowed esophagus were identified. Cases were evaluated for evidence of EoE based on histologic criteria of >20 eos/HPF. All cases of histologically defined EoE were identified and grouped by their endoscopic findings as ringed/furrowed, normal, esophagitis, schatzki ring, or stricture. Results: Ringed esophagus was identified endoscopically in 28 patients (75% male, ave age 41 y).19/28 (67.9%) met histologic criteria for EoE (graph). In the remaining patients, distal eosinophil counts averaged 2.5/HPF while proximal eos averaged 8.2/HPF. 32 patients met histologic criteria for EoE (62.5% male, ave age 42 y). 19/32 (59%) presented with endoscopic “rings or furrows.” 13/32 (41%) had other endoscopic findings (graph). Conclusion: EoE may present as a variety of phenotypes. Strictly adhering to histologic criteria for the diagnosis may result in an underdiagnosis as eosinophilic infiltration is patchy and likley sporadic. Gastroenterologists should have a high index of suspicion for EoE in any young patient who presents with dysphagia as endoscopy may not portray classical rings/furrows. Routine biopsies in this population are warranted.[figure1][figure2]FigureFigure

Unusual Pulmonary Complication from Maloney Dilation

Purpose: Complications from bougie dilation of the esophagus are uncommon; most are related to perforation. We describe a case of breakage of Maloney dilator tip during dilation which was silently aspirated and presented with persistent cough. Results: A 70 year old white male presented with intermittent dysphagia to solid food. Upper endoscopy revealed a Schatzki ring at the gastroesophageal junction. Dilation was performed using a 58 French Maloney dilator with minimal resistance. He recovered in the endoscopy unit without incident and discharged home. Late that evening the patient developed dry cough. The cough persisted the following day and patient presented to local minor care center. Localized wheezing was present in right lower lobe; antibiotics were prescribed and patient sent home. Dry cough persisted the next day and patient came to our hospital emergency room. There was no fever, wheezing was audible in right lower lobe. Chest X-ray revealed a 3 cm linear radiopacity in the right lower lobe bronchus, suspicious for a foreign body (Fig. 1). The Maloney dilator used was inspected; the distal tip was missing and corresponded to the length and contour of the suspected pulmonary foreign body. The patient was admitted; at subsequent bronchoscopy a foreign body was seen and removed from right lower lobe bronchus. Upon inspection, it was the dilator tip (Fig. 2). The patient recovered well with cessation of wheezing and cough. Upon further inspection of our dilators, it was found that the more commonly used dilators had shallow transverse furrows in the tapered tips, resulting from frequent use and disinfectant cleansers. The smaller, less commonly used dilators had no such changes. The complete dilator kit was replaced. Conclusion: Frequently used bougie dilators should be periodically inspected for signs of damage that could result in possible breakage during dilation.[figure1][figure2]FigureFigure

Fluoroscopic guidance not needed during bougienage for the treatment of Schatzki's rings

Fluoroscopic guidance not needed during bougienage for the treatment of Schatzki's rings

Single‐session, graded esophageal dilation without fluoroscopy in outpatients with lower esophageal (Schatzki’s) rings: A prospective, long‐term follow‐up study

Distal esophageal (Schatzki's) ring is a frequent cause of dysphagia. Bougienage is generally effective but relapses are common. The aim of this study was to evaluate the safety and long-term efficacy of single-session graded esophageal dilation with Savary dilators, without fluoroscopic guidance, in outpatients who presented with Schatzki's ring. The study was performed on 44 consecutive patients with symptomatic Schatzki's ring, detected endoscopically and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session with Savary dilators, without fluoroscopic guidance. After appropriate assessment with esophageal manometry and 24 h ambulatory pHmetry, patients with documented gastroesophageal reflux disease (GERD) were treated with omeprazole continuously. All results, including clinical follow up and technical aspects of bougienage, were recorded prospectively. The necessity for re-dilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring. In four (9%) patients a second session was necessary to ensure complete symptom relief. Two (4.5%) patients developed post-dilation bacteremia and were managed with antibiotics as outpatients. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, smoke and ethanol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There was no recurrence of the ring in patients with GERD during a mean follow-up period of 43.8 +/- 9.3 months (range 27-62 months); however, in patients without GERD, during a mean follow-up period of 40.6 +/- 12.2 months (range 10-58 months), 32% of patients relapsed after a mean 19.9 +/- 10.6 months (P = 0.04). Single-session graded esophageal dilation with large caliber Savary dilators without fluoroscopic guidance can be safely used for the symptomatic relief in patients with lower esophageal (Schatzki's) rings. GERD should be treated if present in order to prevent a symptomatic recurrence of the ring.

A Randomized, Prospective Trial of Electrosurgical Incision Followed By Rabeprazole Versus Bougie Dilation Followed By Rabeprazole of Symptomatic Esophageal (Schatzki's) Rings

Background: 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 as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki's rings. Aim: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki's rings at one year follow up in the presence of rabeprazole treatment. Methods: Fifty consecutive patients referred for endoscopic evaluation of dysphagia found to have a schatzki's ring were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki's ring. All patients were placed on rabeprazole (20-40 mg/day) for the duration of the study. Analysis between groups was made using Wilcoxon rank-sum test for independent samples (dysphagia score) and t-test (GERD scores). Paired data were analyzed using Wilcoxon signed rank (dysphagia score) and paired t-test (GERD scores) within groups. A Kaplan-Meier survival curve measured symptom-free survival times. Results: Twenty-five patients each underwent bougie dilation and electrosurgical incision. All patients were followed for 12 months and final analysis performed. One episode of bleeding in the incision group was controlled with epinephrine injection. Symptom free survival times were significantly longer in the incision group (7.99 months) compared to bougie dilation group (5.86 months) (p = 0.03). The improvement in dysphagia scores was significant within each group comparing baseline to each time interval. The incision group experienced a significant improvement of dysphagia symptoms at one month compared to the bougie dilation group (p = 0.05). GERD scores improved significantly in both groups at all time intervals in the bougie dilation group and at all time intervals in the incision groups with the exception of 12 months. There was no significant difference in GERD scores between the groups. Conclusion: Electrosurgical incision of lower esophageal (Schazki's) rings is safe and offers longer symptom free survival compared to bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

Familial dysphagia and eosinophilia

Recent reports suggest a familial predisposition to eosinophilic esophagitis (EE) and a link between Schatzki's rings and EE. Our objective is to present our experience with 7 families with dysphagia and eosinophilia. Case series. One-thousand-bed community-based teaching hospital. Seventeen patients from 7 families with dysphagia and eosinophilia. Direct clinical and endoscopic examination with review of radiologic and pathologic data. Twelve patients had EE alone, one had eosinophilic gastroenteritis (EG) alone, one had EE and EG, and 3 geriatric patients had Schatzki's rings (one with EG and peripheral eosinophilia [PE] and one with PE). EE spanned 2 generations in 4 families and involved 2 brothers in one family. This was a case series. We propose a familial dysphagia syndrome characterized by eosinophilia in the form of EE, EG, or PE and Schatzki's rings in older generations.

Retrospective Analysis of Esophageal Food Impaction: Differences in Etiology by Age and Gender

Eosinophilic Esophagitis (EE) is an emerging cause of esophageal food impaction (EFI) not accounted for in previous studies. We sought to determine the causes of EFI in a recent cohort with recognition of EE. A retrospective chart review of all patients with EFI during the past 5 years was performed. Etiology was determined by endoscopy report, pathology results, and follow-up studies. A total of 85 EFIs occurred, in 79 patients (55 men, 30 women, age 18-100). The most common etiologies of EFI were Schatzki's ring (n = 18), peptic stricture (n = 18), EE (n = 9), esophagitis (n = 9), and no underlying diagnosis (n = 20). EE was significantly more frequent in men (P < .025) and those <50 years old (P < .025). There was a significant difference in the age at which men (median age = 44) and women (median age = 71) present with EFI (P < .001). The etiology of EFI differs significantly by age and gender. This information may be useful in evaluation and management of EFI.

A UNIQUE CASE OF ESOPHAGEAL PHARMACOBEZOAR IN A HUMAN IMMUNODEFICIENCY VIRUS PATIENT ON HIGHLY ACTIVE ANTIRETROVIRAL THERAPY.

Background Bezoars result from the accumulation of ingested foreign material in the form of masses or concretions and consist of three major types depending on their composition: (1) phytobezoars (compressed vegetable matter), (2) trichobezoars (hair), (3) pharmacobezoars (compacted amounts of undigested medication). Symptoms may vary depending on the location of the bezoar. Gastric bezoars may present with abdominal pain, nausea, vomiting, early satiety, anorexia, and gastric outlet obstruction, whereas esophageal bezoars present with dysphagia, odynophagia, and regurgitation of food. Therapy for bezoars should be tailored to the composition of the concretion and to the underlying pathophysiologic process. Available treatment methods include chemical dissolution, endoscopy, or surgery. Case Report A 56-year-old African American, female, active smoker with a history of CNS toxoplasmosis, HIV on highly active antiretroviral therapy (HAART) treatment, and bronchial asthma presented with dysphagia, odynophagia, and regurgitation of solid food. Physical examination and laboratory analysis did not reveal any significant abnormalities. The patient underwent upper GI endoscopy and was found to have a large pill bezoar (2-3 cm) occluding the lumen above a Schatzki ring. The pills were broken using a polypectomy snare and flushed into the stomach and the Schatzki ring was dilated. The patient improved symptomatically and was advised to take crushed pills/liquid medication where possible with a semisolid diet. Teaching Point Pharmacobezoars (most commonly associated with nifedipine, ASA, sucralfate, etc) have become increasingly recognized and are typically found in the lower GI tract. Esophageal bezoars are very rare, and pharmacobezoars as a result of HAART are rarer. The potential for complications in untreated patients emphasizes the importance of early diagnosis and treatment along with prevention of recurrence.

Motor disturbances participate in the pathogenesis of eosinophilic oesophagitis, beyond the fibrous remodelling of the oesophagus

Motor disturbances participate in the pathogenesis of eosinophilic oesophagitis, beyond the fibrous remodelling of the oesophagus

Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis

Recently recognized as an important cause of dysphagia and food impaction in adults, eosinophilic esophagitis (EE) is diagnosed by histologic findings of increased mucosal eosinophils. We examined variability in histopathologic features of adults with EE to derive a recommendation on the optimal number and location of biopsies needed for diagnosis. Charts were reviewed from 74 patients diagnosed with EE based on > or =15 eosinophils per high-power field (eos/hpf). Biopsy specimens were prospectively analyzed for the degree of eosinophilia and histopathologic features of EE. Subgroup analysis was performed in patients with biopsy specimens from both the proximal and the distal esophagus. The biopsy specimens from patients with EE were compared with specimens from biopsied Schatzki's ring. Northwestern University Feinberg School of Medicine. Charts were reviewed for 74 adult patients and biopsy specimens were available for 66 patients. A total of 341 biopsy specimens from 66 patients were available for analysis and revealed marked variability within and between biopsy specimens of individual patients. The median eos/hpf was 107 (0-557 eos/hpf). By using criteria of > or =15 eos/hpf for diagnosis, we found that 1 biopsy specimen had a sensitivity of 55%, which increased to 100% after 5 biopsies. By using stricter criteria, additional biopsy specimens were needed to achieve 100% sensitivity. Despite a higher eosinophilia in distal (82 eos/hpf) compared with proximal biopsy specimens (68 eos/hpf), this difference was not statistically significant. There was marked difference between eosinophilia in mucosal biopsy specimens of patients with EE (82 eos/hpf) compared with Schatzki's ring (0.3 eos/hpf). Significant histologic variability exists among biopsy specimens from individual patients with EE and necessitates multiple biopsies to improve diagnostic sensitivity. No significant difference in eosinophilia was demonstrated between proximal and distal sites.

Eosinophilic esophagitis: an overlooked entity in chronic dysphagia

A 40-year-old white male with atopy presented to our department in March 2004 with a history of chronic heartburn and solid-food dysphagia since 1994. The patient was taking on-demand salbutamol for asthma and ranitidine for mild heartburn, occurring less than once per week. Eight years previously, he had undergone esophageal dilatation for a Schatzki's ring. Physical examination, laboratory investigations, video esophagram, upper endoscopy with mid-esophageal biopsies, and skin testing for a number of food and environmental allergens. Diagnosis Eosinophilic esophagitis. Topical steroids with a fluticasone 220 microg multiple-dose inhaler, four puffs swallowed twice a day for 6 weeks.

The Optical Dilator: a clear, over-the-scope bougie with sequential dilating segments

The safety and efficacy of esophageal dilation is enhanced when direct visualization is possible, tactile sensation and feedback from resistance is maintained, and multiple dilations with a single passage of the dilating device is an option. The InScope Optical Dilator (InScope, a Division of Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) is a flexible, transparent bougie fitted over a standard endoscope, with 3 dilating segments allowing sequential dilation under direct visualization. We report our experience with this device in treating benign esophageal strictures. Patients with solid food dysphagia due to peptic strictures or Schatzki's ring were studied by using a 27F or 29F endoscope. Based on stricture appearance and estimated luminal diameter, 1 of 3 dilator sizes was chosen: IN0216 (14-, 15-, and 16-mm dilating segments), IN0218 (16-, 17-, and 18-mm dilating segments), or IN0220 (18-, 19-, and 20-mm dilating segments). Twenty-six patients were dilated and included 17 peptic strictures and 9 Schatzki's rings. Before dilation, most patients reported difficulties with solids at every meal. Median improvement 3 weeks after dilation was rated by patients as "substantial relief." Patients rated the dilation experience as largely "not at all unpleasant" immediately after endoscopy and had no recollection at 3 weeks' follow-up. There were no complications. Endoscopists rated dilator use as typical of experience with other bougies, and visualization was rated as high. The Optical Dilator maintains the value of tactile sensation and the convenience of 3 dilating sizes for each passage of the instrument with the added benefit of direct visualization.

Value of Preoperative Upper Endoscopy in Patients Undergoing Laparoscopic Gastric Bypass

Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.

Swallow Syncope in Association with Schatzki Ring and Hypertensive Esophageal Peristalsis: Report of Three Cases and Review of the Literature

Syncope caused by swallowing-induced cardiac arrhythmia is an uncommon condition. The recognition of this syndrome is paramount but often difficult. We report three cases of deglutition syncope evaluated at our institution over a three-year period. Two patients had distal esophageal (Schatzki) ring and two had hypertensive peristaltic waves (commonly referred to as "nutcracker esophagus"), neither of which had been described before in association with deglutition syncope. Two patients underwent placement of a demand cardiac pacemaker with subsequent resolution of their syncopal symptoms, while the third patient refused any further intervention. Swallow syncope usually follows a benign course from a cardiac standpoint. Placement of a demand cardiac pacemaker can prevent recurrence of presyncopal and syncopal attacks and their untoward consequences.

Long-Term Acid Suppressive Therapy May Prevent the Relapse of Lower Esophageal (Schatzki's) Rings: A Prospective, Randomized, Placebo-Controlled Study

Distal esophageal (Schatzki's) rings are a frequent cause of dysphagia. Bougienage is generally effective, but relapses are common. The aim of this study was to evaluate the effect of long-term antisecretory therapy on the relapse rate of lower esophageal rings after successful bougienage with Savary dilators. The study was performed on 44 consecutive patients with symptomatic Schatzki's rings, detected endoscopically, and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session. After appropriate assessment with esophageal manometry and 24-h ambulatory esophageal pH monitoring, patients with documented GERD (n = 14) were treated with long-term omeprazole therapy. The remaining patients were blindly randomized to receive maintenance treatment with either omeprazole (group A-15 patients) or placebo (group B-15 patients). The necessity for redilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring. The relapse rate was evaluated in all groups. All bougienages were performed without significant side effects. Eight patients (8 of 44, 18.2%) had one or more relapses after a mean (SD) of 19.0 (10.1) months. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, cigarette and alcohol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There were no recurrences of Schatzki's ring in the group of patients with documented GERD (follow-up [mean +/- SD]: 43.8 +/- 9.3 months, range: 27-62). In group A (follow-up [mean +/- SD]: 37.1 +/- 17.1 months, range: 11-66), one patient relapsed after 13 months, while in group B (follow-up [mean +/- SD]: 34.3 +/- 14.6 months, range: 10-58), seven patients relapsed after a mean (SD) of 19.9 (10.6) months. The actuarial probability of relapse was higher in patients without therapy (group B) (p= 0.008). Our data support the hypothesis that, in patients with symptomatic Schatzki's rings, acid suppressive maintenance therapy after bougienage may prevent relapse of the ring.

Esophageal Pseudopolyposis a Unique Endoscopic Finding in Patient with Active Crohnʼs Disease

Purpose: Esophageal pseudopolyposis: a unique endoscopic finding in a patient with active crohns disease. Background: Crohn's disease with esophageal involvement is uncommon. Reported esophageal manifestations include erythema and friability, aphthoid and deep ulcerations, strictures, fistulas and nodular masses. We report a case of Crohn's disease with esophageal pseudopolyposis. To our knowledge, there are only two other cases of esophageal polyposis in patients with active Crohn's disease and neither case reported pseudopolyposis. Case Report: A 53 year old male with known history of crohn's disease was referred to us for EGD evaluation of abnormal esophagogram with a concern for distal esophageal masses. The patient was diagnosed with Crohn's disease in 1973. More recently he underwent a total abdominal colectomy for multiple fistulae and intra-abdominal abscess. At the time of endoscopy he was complaining of dysphasia, odynophagia, nausea and vomiting and diarrhea. He was currently taking mesalamine and 6MP. The EGD showed what appeared to be extensive pseudopolyp formation in the distal esophagus and two areas possible developing fistula tracts without active inflammation or ulceration and schatzki's ring were also present. Biopsies revealed benign squamous mucosa with mild basal cell hyperplasia, focal hemorrhage and mixed leukocytes, including eosonophils. No granulomas were found. Patient presented several weeks later with nausea, vomiting and was found to have partial small bowel obstruction on CT scan. Symptoms improved with prednisone. Conclusion: Esophageal Psuedopolyposis is a rare manifestation of Crohn's disease. Crohn's disease should also be considered in the differential diagnosis of esophageal polyposis. [figure 1][figure 2]FigureFigure