Solid Food Dysphagia Research Articles

Left aortic arch and aberrant right subclavian artery in children: spectrum of symptoms and response to surgical intervention.

Children with left aortic arch and aberrant right subclavian artery may present with either respiratory or swallowing symptoms beyond the classically described solid-food dysphagia. We describe the clinical features and outcomes of children undergoing surgical repair of an aberrant right subclavian artery. This was a retrospective review of children undergoing repair of an aberrant right subclavian artery between 2017 and 2022. Primary outcome was symptom improvement. Pre- and post-operative questionnaires were used to assess dysphagia (PEDI-EAT-10) and respiratory symptoms (PEDI-TBM-7). Paired t-test and Fisher's exact test were used to analyse symptom resolution. Secondary outcomes included perioperative outcomes, complications, and length of stay. Twenty children, median age 2 years (IQR 1-11), were included. All presented with swallowing symptoms, and 14 (70%) also experienced respiratory symptoms. Statistically significant improvements in symptoms were reported for both respiratory and swallowing symptoms. Paired (pre- and post-op) PEDI-EAT-10 and PEDI-TBM-7 scores were obtained for nine patients, resulting in mean (± SD) scores decreasing (improvement in symptoms) from 19.9 (± 9.3) to 2.4 (± 2.5) p = 0.001, and 8.7 (± 4.7) to 2.8 (± 4.0) p = 0.006, respectively. Reoperation was required in one patient due to persistent dysphagia from an oesophageal stricture. Other complications included lymphatic drainage (n = 4) and transient left vocal cord hypomobility (n = 1). Children with a left aortic arch with aberrant right subclavian artery can present with oesophageal and respiratory symptoms beyond solid food dysphagia. A thorough multidisciplinary evaluation is imperative to identify patients who can benefit from surgical repair, which appears to be safe and effective.

One stone two birds - Submucosal tunneling endoscopic resection for a large esophageal submucosal mass and esophageal diverticulum.

A-35-year-old woman presented our hospital with half a year's history of solid food dysphagia. An upper gastrointestinal endoscopy revealed a large submucosal mass in an esophageal diverticulum near the gastroesophageal junction. Endoscopic ultrasound (EUS) confirmed a hypoechoic lesion arising from the muscularis propria layer with the size of 25*14 mm. Therefore, submucosal tunneling endoscopic resection (STER) was proposed to remove the large submucosal lesion in addition to targeted septotomy of the esophageal diverticula. A 2-cm longitudinal mucosal access was made at 3 cm above the submucosal lesion, and a submucosal longitudinal tunnel was created until the submucosal lesion revealed using a DualKnife (Olympus, Japan). Meticulous resection was performed with the DualKnife, and the lateral border of the lesion was dissected from muscularis propria layer. It was completely removed the lesion with en bolc resection, and dissected the septum of the diverticulum using the DualKnife. The tunnel access was closed with several hemoclips. Finally, it has been demonstrated to achieve a perfect outcome for the patient. The patient was discharged three days later with symptom resolved on follow-up and to date.

Large-Caliber Empiric Esophageal Dilation Results in Sustained Improvement for Selected Patients With Nonobstructive Dysphagia.

Empiric esophageal dilation (EED) remains a controversial practice for managing nonobstructive dysphagia (NOD) secondary to concerns about safety and efficacy. We examine symptom response, presence of tissue disruption, and adverse events (AEs) after EED. We examined large-caliber bougie EED for NOD at 2 tertiary referral centers: retrospectively evaluating for AEs. Esophageal manometry diagnoses were also reviewed. We then prospectively assessed EED's efficacy using the NIH Patient-Reported Outcomes Measurement Information System disrupted swallowing questionnaire to assess dysphagia at baseline, 1, 3, and 6 months after EED. Treatment success was defined by improvement in patient-reported outcome scores. AE rate for large-caliber dilation in the retrospective cohort of 180 patients undergoing EED for NOD was low (0.5% perforations, managed conservatively). Visible tissue disruption occurred in 18% of patients, with 47% occurring in the proximal esophagus. Obstructive motility disorders were found more frequently in patients with tissue disruption compared with those without (44% vs 14%, P = 0.05). The primary outcome, the mean disrupted swallowing T -score was 60.1 ± 9.1 at baseline, 56.1 ± 9.5 at 1 month ( P = 0.03), 57 ± 9.6 at 3 months ( P = 0.10), and 56 ± 10 at 6 months ( P = 0.02) (higher scores note more symptoms). EED resulted in a significant and durable improvement in dysphagia and specifically solid food dysphagia among patients with tissue disruption. EED is safe in solid food NOD and particularly effective when tissue disruption occurs. EED tissue disruption in NOD does not preclude esophageal dysmotility.

IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias.

To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation. PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.

An odd case of immune-mediated necrotizing myopathy, complicated with sagittal, transverse and sigmoid sinus thrombosis

INTRODUCTION: Immune-mediated necrotizing myopathy (IMNM) is a rare variant of immune-mediated inflammatory myopathy (IMIM) that exhibits a severe prognosis and is unresponsive to conventional treatment. (1,2)Notably, the incidence of immune-mediated inflammatory myopathies (IMIMs) is low, estimated at 1.16 to 19/million/year and only 3-6% of IMIMs are diagnosed as IMNM. (1,3–5). Systemic inflammation has been found to play a crucial role in promoting the onset of cerebral venous thrombosis. (6,7) MATERIAL AND METHODS: We present the case of a 46-years-old Chinese woman, without any known prior pathology, who was referred to the Rheumatology Department for symmetrical, proximal muscle weakness of the limbs, dysphagia for solid food, and weight loss (5 kg within 2 months). The pathologic clinical examination revealed itchy erythematous plaques on the posterior thoracolumbar region and signs of muscle weakness. Laboratory workup showed significant inflammatory syndrome, severe muscle and hepatic cytolysis syndrome, and positivity for thyroid-specific autoantibodies but with normal thyroid function, positivity for antinuclear antibodies (more precisely: SS-A, Ro-52, SS-B), and myositis antibodies (SRP, Ro-52, SAE1, PM-Scl, MDA5). The CT scan of the thoracic, abdominal, and pelvis showed fibrosis of the lungs, hepatic hypertrophy, and an enlarged uterus, further diagnosed by transvaginal ultrasound as adenomyosis. The positive diagnosis is immune-mediated necrotizing myopathy. Differential diagnoses included dermatomyositis, toxic/infectious myositis, hypothyroidism, and neuro-muscular diseases (5,8). The initial treatment was made with glucocorticoids (pulse therapy followed by oral therapy) and immunosuppressants (Mycophenolate Mofetil – stopped because of severe dyspepsia and myelosuppression). After five days of pulse therapy, the patient developed muscle weakness and paresthesia on the left side of the body, and the cerebral CT scan revealed sagittal, transverse, and sigmoid sinus thrombosis. Thrombophilia screening uncovered the positivity of the lupus anticoagulant. (9) RESULTS: The patient was treated with anticoagulants (low molecular weight heparin, and afterward Vitamin K antagonist), low doses of oral glucocorticoids, and immunosuppressant (Methotrexate), without any other adverse event. CONCLUSION: In the presence of the lupus anticoagulant, even though the antiphospholipid syndrome is not confirmed, the only anticoagulant therapy that has proven its efficacy is the Vitamin K antagonist. Immune inflammatory myopathies, like IMNMs, create a significant inflammatory status that leads to hypercoagulability and endothelial injury, which exposes collagen and tissue factors, promoting further platelet aggregation, and can even lead to cerebral thrombosis. (2,6)

Disfajisi olan çocukların değerlendirilmesi

Purpose: Difficulty in swallowing; It is a symptom that occurs as a result of mechanical inhibition of the transfer of ingested food from the mouth to the stomach. It can be due to acute and chronic diseases. It is presented because of the limited number of studies comparing the characteristics of both types of oropharyngeal and esophageal dysphagia in healthy and chronically ill children in the pediatric population.
 Materials and Methods: 201 pediatric patients admitted with dysphagia between May 2019 and November 2020 were included. They were grouped according to the types of dysphagia.
 Results: Group-1 consisted of 80 pediatric patients with oropharyngeal dysphagia, while group-2 consisted of 121 pediatric patients with esophageal dysphagia. 51.7% of the patients were female, mean age was 9.4 years. While all patients in Group-2 had solid food dysphagia, Group-1 had 27% liquid and 53% solid-liquid dysphagia. Percutaneous endoscopic gastrostomy tube for 50 pediatric patients who could not be fed safely; A nasogastric feeding tube was placed in 4 children. Esophagogastroduodenoscopy was performed in 72.6% of the patients, and esophageal pathology was detected in 55.4%.
 Conclusions: Although the incidence of dysphagia is high in children with chronic diseases, it should not be forgotten that it can also be seen in healthy children and may be associated with treatable

Etiological Pattern & Clinical Presentation of Dysphagia

Background & objective: : Dysphagia can cause significant morbidity and mortality, especially in older and paediatric populations. The study was undertaken to determine the demographic and clinico-pathological profile of the patients diagnosed with oesophageal dysphagia in a tertiary care hospital of Bangladesh. Methods: This cross-sectional study was conducted at the Department of Medicine & Gastroenterology in Sir Salimullah Medical College & Mitford Hospital over a period of 6 months, from March to August 2015. A total of 100 adult (aged ≥ 18 years) patients (respondents) of dysphagia of both sexes were included in the study. However, patients who dropped out before investigations being completed, or unconscious patients (as endoscopy cannot be done in unconscious patients) were excluded from the study. Result: The age distribution shows that patients were predominantly older (60%), male and rural resident. In terms of occupation, retired persons comprised the main bulk (38%). About half (49%) of the patients were middle-class and smoker. Presence of both solid and liquid food dysphagia was more or less common (44%), followed by solid food dysphagia alone (36%) and liquid food dysphagia alone (20%). A substantial proportion (78%) of patients presented with heart-burn as well. Probing the clue to dysphagia, some 7% of the patients gave history of ingesting chemical substances (either accidentally or as an attempt to suicide), 15% had history of taking steroid and 12% taking NSAIDs. History of radiation injury and history of ingesting foreign substances were rare. Over 60% of the respondents had co-morbid conditions like diabetes mellitus (28%), hypertension (23%), candidiasis (6%), lymphoma (3%). Clinical examination revealed 30% of the respondents nutritionally compromised (20% underweight and 10% overweight or obese). Nearly two-thirds (63%) were anaemiac with glossitis and koilonychia being present in 47 and 17% of the patients respectively. About one-third (32%) exhibited cervical lymphadenopathy. Of the 100 respondents, only 4 respondents were found with cardiomegaly, 4 with COPD, 2 with mediastinal widening. Endoscopy of upper GI tract showed 29% with ulceroproliferative lesion, 22% with multiple white patches in the whole length of oesophagus, 18% with stricture & narrowing of the oesophagus, 13% with malignant stricture & narrowing, 10% with proliferative lesion at mid oesophagus with narrowing of lumen and 8% malignant-looking ulcer with elevated margin in the lower oesophagus. Ba-swallow X-ray of oesophagus revealed 47 with filling defect in the lower oesophagus, 5 narrowing in the middle part of oesophagus and only 4 dilatations in the mid oesophagus. Twenty respondents had positive findings on USG of whole abdomen; of them, 10 had multiple solid tumors in liver. Others had hepatoma, mass in the epigastrium, cystitis, intraabdominal lymphadenopathy and splenomegaly. Based on symptoms, signs and laboratory findings, 42% were diagnosed as oesophagial carcinoma, 16% as drug-induced oesophageal ulcer and 11% as diabetes mellitus with oesophageal candidiasis. Conclusion: The most common cause of oesphageal dysphagia is carcinoma of oesophagus followed by drug-induced oesophageal ulcer and diabetes mellitus with oesophageal candidiasis. To reduce morbidity and mortality of various etiologies leading to dysphagia, prompt and early diagnosis is essential. Ibrahim Card Med J 2022; 12 (1): 40-45

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed. To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD. A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population. Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft). The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs. Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01). Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD. ClinicalTrials.gov Identifier: NCT05069493.

Food-induced immediate response of the esophagus in pediatric eosinophilic esophagitis.

Food-induced immediate response of the esophagus (FIRE) is a new phenomenon that has been described in eosinophilic esophagitis (EoE) patients. It is suspected when unpleasant symptoms occur suddenly on contact of the triggering food with the esophageal surface and recur with repeated exposures. It can often be mistaken for pollen-food allergy syndrome (PFAS) and solid food dysphagia. Data on FIRE is limited to one survey study and case reports, and there are no screening studies conducted on either adults or children with EoE. In this study, we aimed to screen children aged ≥7 years old with EoE for FIRE. Demographic data were collected from medical records. A questionnaire about FIRE was applied to all participants. Skin prick tests were done on suspected patients to identify the triggering foods. FIRE is defined as suitable clinical symptoms with suspected food allergen exposure. A total of 78 patients (74.4% male, median age: 13.5 years) were included. Unpleasant and recurrent symptoms distinct from dysphagia with specific foods were reported in 16.7% of the patients, all of whom had concomitant allergic rhinitis (AR). The symptoms described by almost all patients were oropharyngeal itching and tingling (PFAS: 15.3%) excluding only one patient reporting retrosternal narrowing and pressure after specific food consumption (FIRE: 1.2%). Although definitive conclusions regarding the true prevalence of FIRE cannot be made, it does not seem to be common as PFAS. However, it deserves questioning particularly in the presence of concurrent AR and/or PFAS in children with EoE.

Therapy of esophageal motility disorders

Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.

P96: Using Fenestrated Stent to Increase the Flow of ECMO of Superior Vena Cava Compression Syndrome

Introduction: Superior vena cava syndrome (SVCS) is an obstruction of the venous return to the heart through SVC or any other significant branches. The obstruction may be external, like thoracic mass compressing the SVC, or internal, like thrombosis or tumor, which directly invades the SVC. Patients experiencing a medical emergency after being initially stabilized require treatment for SVCS, including endovenous recanalization and the implantation of an SVC stent to reduce the risk of abrupt respiratory arrest and death. This case report details a situation in which reduced outflow in a VA ECMO would substantially improve by using a fenestrated stent of SVC. Case Presentation: A 54-year-old female presented to our medical center with weight loss and solid food dysphagia for three months. Chest CT scan showed a new mediastinal mass of 10x9x8cm with minor pericardial and pleural effusions. A transbronchial biopsy was attempted; however, the patient arrested during the bronchoscopy procedure. CPR was initiated, and the ECMO team was contacted for VA ECMO cannulation, which was done through the right femoral artery cannula size 15 Fr due to the narrowing of the artery, and the left femoral vein cannula size 23 Fr. ROSC was achieved, and the patient was transferred to the ICU. During the night shift, the ECMO flow was hard to maintain with fluids. First, that was due to the small arterial cannula. However, the issue was realized with the ECMO outflow volume issue. The next day, In the hybrid operating room, a fenestrated SVC stent was placed in SVC, brachiocephalic, and internal jugular veins (Figure 1). All patient hemodynamics improved post stenting, including ECMO, flows, especially outflow. Discussion: Endovenous treatment of SVC syndrome includes percutaneous transluminal balloon angioplasty (PTA), stenting, and thrombolysis performed alone or in combination. Stenting is usually in the SVC rather than several locations for SVC syndrome. However, our case is unique as the primary fenestrated stent was deployed in the SVC, and additionally, brachiocephalic and IJ veins were stented through the fenestration, which relieved the SVCS. In addition, it enhanced ECMO outflow flow instantly. Conclusion: This case illustrates that stenting in SVCS is a valid therapeutic option to increase ECMO flow in this patient group.Figure 1. Image A: Fluoroscopy showing SVC stenosis. Image B: redacted view of SVC fluoroscopy Image C: Balloon angioplasty of SVC stenosis under fluoroscopy. Image D: Fenestrated stent placement in the SVC under fluoroscopy. Image E: Stent deployed Internal jugular Image F: Post stenting image showing deployed brachiocephalic Internal jugular vein through fenestrations of primary stent.

Diagnosis of esophageal motility disorders - Significance of the new Chicago classification v4.0

Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2021 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.

Empiric Esophageal Dilatation for Solid-Food Dysphagia: Presence of Mucosal Tear on Relook Endoscopy Predicts Symptomatic Response.

We hypothesized that a mucosal tear on relook endoscopy after empiric dilatation predicts symptomatic response. We evaluated symptomatic response (modified Ogilvie dysphagia score) after 161 consecutive esophageal dilatations. Comparing visible strictures, empiric dilatations with mucosal tear, and empiric dilatations without tear, baseline dysphagia scores were similar ( P = 0.34). Successful symptomatic response to dilatation occurred in 82% of visible strictures, 80% of those with tear, compared to only 37% of those with no tear ( P < 0.001). Patients with a mucosal tear after empiric dilatation have a superior symptomatic response to those without, and comparable to patients with visible strictures. We infer the tear represents disruption of an endoscopically inapparent stricture.

Lichen Planus

HomeRadioGraphicsVol. 43, No. 4 PreviousNext Cases from the Cooky JarFree AccessLichen PlanusEdward McDermott , Nadia Solomon, Annelise M. Silva, Parisa KhoshpouriEdward McDermott , Nadia Solomon, Annelise M. Silva, Parisa KhoshpouriAuthor AffiliationsFrom the Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin D07 R2WY, Ireland (E.M.); Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (N.S.); Department of Education, Wright State University Boonshoft School of Medicine, Dayton, Ohio (A.M.S.); and Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institution, Baltimore, Md (P.K.).Address correspondence to E.M. (email: [email protected], @edwardmcd).Edward McDermott Nadia SolomonAnnelise M. SilvaParisa KhoshpouriPublished Online:Mar 16 2023https://doi.org/10.1148/rg.220200MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Lichen planus is a chronic condition that predominantly affects middle-aged and older women and represents an autoimmune T-cell–mediated inflammatory disorder (Fig 1) that affects the skin, oral and genital mucosa, esophagus, hair, and nails (1). Cutaneous involvement manifests with flat violaceous papules, and mucosal manifestations typically manifest with white lacelike lesions, papules, erythematous lesions, and erosions (Fig 2) (2). Esophageal lichen planus has been reported in more than 50% of patients with mucocutaneous lichen planus and is underrecognized and underreported (2).Figure 1. Esophageal lichen planus. There are limited studies of the pathogenesis of esophageal lichen planus, but it appears to be mediated by cytotoxic CD8-positive T cells. Biopsy of affected esophageal tissue shows keratinization with inflammatory cell infiltration of the epithelium with activated T lymphocytes (6).Figure 1.Download as PowerPointOpen in Image Viewer Figure 2. Mucosal manifestations of lichen planus in a 73-year-old woman who presented with solid food dysphagia. (A) Photograph shows white plaquelike lesions on the tongue. (B) Endoscopic image demonstrates erythema and white papules (arrows).Figure 2.Download as PowerPointOpen in Image Viewer Barium esophagography is the most relevant imaging study to evaluate esophageal lichen planus. Imaging features include a smooth small-caliber esophagus with cervical esophageal webs, strictures, and pseudodiverticula (Fig 3) (3,4). Strictures most commonly occur in the proximal esophagus, and their presence correlates with a longer duration of disease (5). Squamous cell carcinoma of the esophagus has been rarely reported in patients with esophageal lichen planus; for this reason, early diagnosis is key.Figure 3. Esophageal lichen planus in a 73-year-old woman (same patient as in Fig 2). Barium esophograms show smooth long stricturing of the entire course of the esophagus with tapered margins (white arrow in A) and esophageal webs (black arrows in A). There are focal weblike strictures in an overall small-caliber lumen of the cervical esophagus (black arrow in B). Overall thin smooth luminal narrowing of the entire course of the esophagus is seen in C.Figure 3.Download as PowerPointOpen in Image Viewer Patients with esophageal lichen planus often present with dysphagia related to the strictures, with reflux-type symptoms, and weight loss. Strictures can be treated with balloon dilation, although this often requires regular repeat treatments (5). Endoscopic findings include superficial white papules, pseudomembranes, webs, and strictures.Disclosures of conflicts of interest.—All authors have disclosed no relevant relationships.AcknowledgmentWe thank Ciléin Kearns, MD, MBChB, for feedback and advice on the medical illustration in Figure 1.All authors have disclosed no relevant relationships.

An Unusual Case of Significant Cervical Esophageal Stricture

Question: A 65-year-old man was referred to our facility for solid-food dysphagia without other disease history. He lived a happy and healthy life without abuse of alcohol or tobacco. The symptom started about 2 years before, without accompanying heartburn and regurgitation, and did not progress significantly. A stricture at the upper orifice of the esophagus was found (Figure A) and hampered the routine endoscopic examination (GIF-Q260; Olympus). Instead, an ultrathin endoscope (GIF-XP290N; Olympus) was used, which revealed a well demarcated translucent white scaly lesion with shaggy surface distributed in a two-thirds circumferential arrangement from 15 cm to 25 cm of the esophagus distal to the incisors (Figure B, Video A). Narrow-band imaging endoscopy showed a distinct white irregular map-like area (Figure C, Video A). Computer tomography (CT) did not show any neck mass or thickness of the cervical esophageal wall (Figure D). Multiple biopsies were obtained from the proximal esophagus. No malignancy was confirmed pathologically (Figure E).

S2449 A Unique Case of Simultaneous Anal Squamous Cell Carcinoma and Esophageal Squamous Cell Carcinoma

Introduction: Anal cancer (AC) is uncommon and comprises only 3% of all digestive system malignancies. It is associated with HPV, tobacco use, and HIV. Esophageal cancer (EC) is the 8th most common cancer and 6th most common cause of death worldwide. Among other associations, HPV and tobacco use has been strongly linked to development of esophageal SCC. Though they have similar risk factors, the literature is limited when it comes to cases of simultaneous anal SCC and esophageal SCC. Case Description/Methods: A 50-year-old male with history of tobacco use presented with dysphagia, dyspnea, and weight loss. His symptoms were progressive with 20 lbs. of weight loss in 3 months. He initially had solid food dysphagia which progressed to liquids and constant regurgitation of food. His cough and dyspnea were acute and worsened 1 week prior to his presentation. He endorsed a bulging growth around his anus that grew over several months. He was found to have a left lower lobe necrotizing pneumonia (NP) on CT scan as well as thickening of the esophagus with liver lesions suspicious for metastatic disease. Labs showed leukocytosis, macrocytic anemia, and a mild transaminitis. He was tested for tuberculosis and HIV which was negative. He underwent an EGD which showed a large, friable, fungating esophageal mass whose biopsies showed SCC. For his anal lesion, he underwent an excisional biopsy which was positive for SCC as well. The patient was treated with antibiotics for his NP with a plan of 6 weeks of therapy followed by repeat imaging to determine if any surgical interventions would be needed. Oncology planned for palliative chemoimmunotherapy once his NP resolved. To improve his dysphagia, a palliative esophageal stent was placed (Figure). Discussion: This patient had both a primary anal SCC and esophageal SCC with his only risk factor being tobacco use. Though both AC and EC commonly metastasizes to the liver, EC is more likely to metastasize. For esophageal SCC, local lymph node invasion typically occurs early since the lymphatics are in the lamina propria rather than beneath the muscularis mucosa. In this case, the patient presented with a NP and though no definitive fistula was noted on imaging, local invasion of esophageal SCC can present with fistulizing disease. Unfortunately, Stage 4 esophageal SCC is incurable though systemic therapies may provide a palliative effect and survival benefit. In this case, an endoscopic esophageal stent was placed for palliation of his dysphagia while awaiting chemoimmunotherapy.Figure 1.: Image A demonstrates the CT scan finding of esophageal wall thickening. Image B is the EGD finding of a large, friable, fungating, circumferential esophageal mass. Image C shows the successful placement of an esophageal stent for palliative treatment of the patient’s dysphagia.

S2292 Dysphagia and Esophageal Mass: Cancer or Actinomycosis?

Introduction: Esophageal actinomycosis is a rare type of esophageal infection and presents as erosions or ulcers under endoscopy. Here we present a 63-year-old woman who complains of dysphagia, with biopsy showing actinomyces infection but repeat biopsy revealed squamous cell carcinoma. Case Description/Methods: A 63-year-old Chinese female with a history of gastritis presented with solid food dysphagia and epigastric pain for over a month. The pain was not improved after proton pump inhibitors but was relieved by self-induced vomiting. Review of systems showed 10lb weight loss over a month with a recent history of self-resolved hematemesis. Prior esophagogastroduodenoscopy (EGD) and colonoscopy were normal 3 years ago. CT of the chest demonstrated a 1.7 cm circumferential mass in the mid-esophagus with luminal narrowing (Figure 1A). EGD discovered a friable soft circumferential mass 26-29 cm from the incisors that are not actively bleeding but covered with blood clots (Figure 1B). Biopsy showed esophageal mucosal ulceration and actinomyces infection. The patient was started on amoxicillin to treat actinomyces infection. Meanwhile, the patient underwent a repeat EGD for rebiopsy given concerns for malignancy, which resulted in poorly differentiated squamous cell carcinoma. Endoscopic ultrasonography (EUS) was performed for staging but was limited staged uT3N1Mx as the mass could not be traversed by echoendoscopy (Figure 1C). Later PET-CT illustrated locally advanced disease with atrium involvement (Figure 1D). The patient underwent neoadjuvant chemotherapy with carboplatin-taxol and radiation followed by esophagogastrectomy for curative intent. Discussion: Actinomyces are facultatively anaerobic, Gram-negative bacilli. They commensally live within the oral cavity and gastrointestinal tract. Most esophageal actinomyces (EA) infection was previously described to resemble esophagitis or esophageal ulcers, with the endoscopic description being extensive necrotic areas. EA typically presents with dysphagia and odynophagia, particularly in immunocompromised patients or with malignancies. Actinomyces species capitalize on tissue injury or mucosal breach to invade adjacent structures and spreads regardless of anatomical barrier, thus mimicking malignancy. In our case, the local tissue damage caused by neoplastic disease or irradiation predisposed the actinomyces infection. Clinicians need to have a high index of suspicion and clinical knowledge regarding its unusual presentations and ability to mimic malignancy.Figure 1.: A. CT of the chest demonstrated a 1.7 cm mass present in the mid-esophagus with lumen narrowing. B. A friable mass without active bleeding but covered with blood clots on endoscopy finding. C. Limited staged uT3N1Mx under EUS D. PET-CT showed locally advanced disease with atrium involvement.

S2432 A Rare Case of Dysphagia Megalatriensis Presenting With Acute Decompensated Heart Failure

Introduction: Dysphagia is a common complaint that can manifest in a large variety of conditions. Dysphagia megalatriensis is a rare cause of esophageal dysphagia and is caused by extrinsic compression of the esophagus by a dilated left atrium. This results in solid food dysphagia in the mid-distal esophagus. Symptoms can be minimal to debilitating. Case Description/Methods: A 52-year-old male with a past medical history of dilated cardiomyopathy and heart failure with ejection fraction less than 25% presented with acute decompensated heart failure and NSTEMI. The patient reported that for the past few months he had a sensation of solid food getting stuck in his mid-chest. He denied any alcohol or tobacco use, hematemesis, nausea, or vomiting. On physical examination, the patient had no abdominal pain or distention. He denied any weight loss or family history of cancers. Vital signs were stable on admission and laboratory testing revealed an elevated troponin of 0.23 ng/mL, creatinine of 1.43 mg/dL, and INR of 2.4. He was started on 40 mg pantoprazole twice a day, upper GI series was ordered which showed smoothly marginated extrinsic compression on the esophagus related to cardiomegaly. The narrowing was positional and most pronounced in the antero-posterior (AP) plane. This was worse during atrial dilation in the cardiac cycle and resulted in delayed emptying of the upper and middle esophagus. Figures A and B show extrinsic compression in diastole and systole respectively. The patient was advised to have small frequent meals and aggressive diuretic therapy was performed. These measures resulted in the improvement of his symptoms. Discussion: This case highlights the importance of the recognition of dysphagia secondary to cardiomegaly. Patients typically have mitral valve stenosis (cause of atrial dilation) which was not present in our case. Although rare, dysphagia megalatriensis can be an early sign of impending decompensation in heart failure patients [1]. In our case, the patient’s dysphagia developed weeks before decompensated heart failure. Hence this condition should be identified sooner than later. Barium esophagram yields the best diagnostic results while diet and diuretics are the cornerstones of therapy. The most severe complication is fatal atrioesophageal fistula formation.Figure 1.: A: Mid and distal extrinsic esophageal compression during cardiac diastole. B: Mild resolution of extrinsic compression during cardiac systole.

S2372 Severe Dysphasia With Eosinophilic Esophagitis Pattern of Injury and Autoimmune Gastritis Related to Pembrolizumab Therapy

Introduction: Immune checkpoint inhibitor (ICI) therapies are effective treatments of many cancer types, including non-small cell lung carcinoma of the lung (NSCLC). While efficacious, ICI therapy can be associated with immune-related adverse effects (irAEs). We present a 67-year-old man with NSCLC who developed severe dysphasia with an eosinophilic esophagitis (EoE) pattern of injury on histopathology and concomitant autoimmune gastritis while on pembrolizumab maintenance therapy. Case Description/Methods: A 67-year-old man with NSCLC on 3 years of maintenance pembrolizumab with stable disease presented to GI clinic for evaluation of progressively worsening solid and liquid food dysphagia with regurgitation. Surveillance CT scans prior to advent of symptoms showed stable mediastinal lymphadenopathy with stable external compression of the mid-esophagus. A barium swallow study showed narrowing of the mid-esophagus. An EGD was performed and showed mid-esophageal lumen narrowing (Figure). Biopsies were obtained from the distal esophagus and showed up to 42 intraepithelial eosinophils (Eo) per high power field, consistent with an EoE pattern of injury. A subsequent EGD with stomach mapping prior to initiation of therapy showed concurrent autoimmune gastritis with no increase of Eo infiltrates. PPI therapy twice a day was initiated but the symptoms did not improve after 2 months. Topical glucocorticoid therapy with budesonide was then started. Despite dual therapy, his dysphagia progressed. Pembrolizumab was discontinued and docetaxel with ramucirumab was started, which resulted in a complete resolution of his dysphagia symptoms. Patient was maintained on PPI therapy with a plan to repeat EGD. Discussion: While GI irAEs are increasingly recognized, ICI-EoE is a rare entity. In the literature, only one other case of ICI-EoE has been reported. This patient’s dysphagia in the context of >15 intraepithelial Eo per high power field without other identifiable etiologies of increased esophageal Eo, and the resolution of symptoms with the discontinuation of pembrolizumab is consistent with ICI-EoE. In addition, the patient had concomitant autoimmune gastritis, which is also a rare but increasingly recognized irAE. Our case demonstrated both entities presenting in one patient. Treatment of irAEs often involves discontinuation of the ICI. Refractory cases may require systemic immunosuppression with corticosteroids or biologic therapy.Figure 1.: 1A – Mid-esophageal narrowing on barium swallow study Figure 1B – Intraepithelial eosinophilia consistent with EoE.

S2513 Not All That Appears Like Oral Thrush Is Candidiasis: A Case of Oral Actinomycosis

Introduction: Oral thrush is one of the most common infections that affect the oral cavity. The oral candidiasis lesions classically present as whitish confluent plaques on oral cavity examination of tongue, palate, and buccal mucosa. Oral thrush has long been associated with overgrowth of Candida albicans in the mouth in dialysis dependent patients, diabetics, immunocompromised, and who are on corticosteroid therapy. In this abstract we present a case of oral actinomycosis mimicking oral thrush upon presentation. Case Description/Methods: 51-year-old female a history of squamous cell esophageal cancer status post distal esophagectomy and gastric pull through operation 5 years ago. She with a presented with a chief complaint of odynophagia and recurrent episodes of dysphagia for solid foods that has been worsening since past few weeks. About 6 months ago the patient had an upper endoscopy, which was significant for acute gastritis and pyloric stenosis, which was dilated. No obvious thrush was identified during that visit. Patient was not on any immunosuppressive medication. A repeat upper endoscopy was performed at this visit which was revealing of thrush in the oropharyngeal area and chronic gastritis. Tongue brushings were obtained for cytopathological analysis, which were suggestive of actinomyces infection. The patient was started on amoxicillin therapy for 2 weeks, which resulted in resolution of thrush as well as her clinical symptoms. Other treatment alternatives for actinomycosis include doxycycline, clindamycin, ceftriaxone, and imipenem (Figure). Discussion: Actinomyces is a rare bacterium often found in the head and neck region. They are partially acid-fast, filamentous gram-positive microorganisms. They were originally classified with fungi organisms as they possess hyphae. Actinomyces is considered to cause chronic suppurative infection. However, actinomycosis infection of the tongue is rare, it usually presents as an abscess formation, draining sinus tracts, fistulae, and tissue fibrosis. The gold standard for the diagnosis of Actinomyces is histological examination. Identification of the underlying pathogen is crucial for management of these patients. Candida is treated with antifungals, however, for actinomyces the treatment is penicillin group of antibiotics. Therefore, it is important to have awareness for actinomyces in the setting of oral thrush for appropriate treatment.Figure 1.: Endoscopic Findings.