Substernal Discomfort Research Articles

Giant fibroepithelial polyp of the esophagus successfully managed endoscopically.

An 68-year-old woman complained of substernal discomfort and occasional regurgitation of a fleshy mass into her mouth. There was no history of weight loss, dysphagia or dyspnea. Upper endoscopy revealed a polypoid digitiform mass with a single pedicle arising from the upper esophagus and extending 8 cm downward. A CT scan demonstrated an elongated intraluminal esophageal mass extending from the cervical esophagus with a longitudinal length of more than 7 cm. Endoscopic ultrasound revealed a subepithelial lesion sparing the muscularis propria layer. The decision was made to proceed with endoscopic polypectomy, which was successfully performed using a hot snare after prophylactic hemostasis with an endoloop. Histology revealed a fibrovascular polyp. The patient had an uneventful recovery and became asymptomatic. We present this case due to its rarity and atypical presentation.

Abstract 17616: The Association Between Hypokinetic Left Ventricle And Pulmonary Embolism

Case Description: A 49-year-old male patient working as a public transport driver presented with syncope lasting a few minutes, followed by non-exertional substernal discomfort. He was hemodynamically stable with a normal physical examination. Laboratory tests revealed an elevated D-dimer of 1146 mg/L and troponin peaking at 1.38 ng/mL. CT Pulmonary angiography was performed, revealing a saddle embolus with signs of right heart strain (Figure 1). A transthoracic echocardiogram revealed a left ventricular (LV) ejection fraction (EF) of 31-35%, and moderately decreased left ventricular systolic function. A venous duplex and hypercoagulability workup yielded negative results. Left-heart catheterization showed normal coronary arteries. A repeat transthoracic echocardiogram three days later showed improvement in LV systolic function with an EF of 41-45% and normal LV function. He was discharged on apixaban with appropriate follow-up. Discussion: Saddle embolism is one of the rare but life-threatening forms of pulmonary embolism. It causes RV dilatation and flattening of the interventricular septum towards the left side, decreasing cardiac output via the “Reverse Bernheim Effect". Rarely, it affects LV contractility and LV ejection fraction. Together, this can lead to severe hemodynamic instability and increase the risk of complications like pulmonary infarction, cardiac arrhythmias, and cardiogenic shock. Therefore, clinicians must be aware of this possibility, as early detection and timely treatment improve patient outcomes.

Efficacy and safety of digestive tract stent placement under direct visual endoscopy without X-ray monitoring in treatment of digestive tract stricture

To evaluate the efficacy and safety of digestive tract stent implantation under direct visual endoscopy without X-ray monitoring in the treatment of digestive tract stricture. The clinical data of patients undergoing digestive tract stent placement under direct visual endoscopy without X-ray monitoring in the First Affiliated Hospital of Zhejiang University School of Medicine from March 2003 to November 2017 were retrospectively analyzed. The process of procedures, the postoperative complications and the postoperative follow-up data were documented. The survival time of patients with malignant gastrointestinal stricture was compared between those with and without stent implantation. Among 562 patients, there were 310 cases of esophagus and cardia stricture, 40 cases of gastroduodenus stricture, 212 cases of colorectum stricture, and 63 cases with esophagus-tracheal fistula,esophagus-mediastinal fistula or anastomotic fistula. The stents were implanted successfully in 560 cases (99.64%) and the symptoms were alleviated in all patients after stent implantation (100%). Postoperative substernal discomfort, chest pain or abdominal pain occurred in 26 cases (4.64%), bleeding in 18 cases (3.21%), displacement of esophageal stents in 9 cases (1.61%), and restenosis in 15 cases (2.68%), in whom the stents were successfully placed again. None of the patients died within 7 days after the procedure. The incidence of postoperative abdominal pain, bleeding and stent displacement in esophageal/cardiac stricture patients was higher than that in the colorectal stricture patients (P<0.05). In 284 cases of malignant stenosis, the median survival time of colorectal stricture patients[(27.5±1.94) months] was significantly higher than that of esophagus/cardia stricture patients[(13.40±0.71) months] and gastroduodenal stricture patients[(11.00±1.78) months]. The survival time of stenting patients with upper gastrointestinal malignant stenosis was significantly longer than that of the non-stenting patients (P<0.05). Stent implantation under direct visual endoscopy without X-ray monitoring is safe and effective for the treatment of benign and malignant stricture of digestive tract and closure of fistula.

A Rare Case of Odynophagia as a Result of Radiation and Candida Esophagitis

Radiation esophagitis is inflammation of the esophagus caused by radiation therapy. It is characterized by inflammation, edema, erythema and erosion of the esophageal mucosa. Acute radiation esophagitis develops within 3 months, while late onset occurs 3 or more months after radiation. Symptoms of acute radiation esophagitis include dysphagia, odynophagia, and substernal discomfort. We are presenting a young patient who developed dysphagia and odynophagia two weeks after starting radiotherapy and was found to have radiation esophagitis with superimposed candidiasis. A 34-year-old man with a history of thymoma and myasthenia gravis, who underwent thymectomy and resection of pleural metastases was treated with radiotherapy and presented with symptoms of fever, dysphagia, and chest pain 5 days after the last radiation session. He started having intermittent dysphagia two weeks into radiation therapy. The symptoms were temporally related to his radiation sessions, maximal symptoms occurring 1 week after sessions. A week after his last radiation the dysphagia worsened and he developed nausea and chills. He reported odynophagia and pleuritic chest pain on admission and was febrile and tachycardic. Fluids and antibiotics were given and a CT chest was performed to rule out pulmonary emobolism (PE). CT was negative for PE and thymoma recurrence but showed esophagitis. An EGD showed esophagitis with exudative mucosa and leukoplakia, consistent with either radiation or candida esophagitis. Biopsies were taken. When white oral lesions were noted, he was treated empirically for candida esophagitis. Biopsies were positive for Candida. The patient's pain improved with fluconazole. He was discharged with a 14-day course. Radiation esophagitis is a common complication of radiation therapy characterized by progressive fibrosis and degeneration of vessels and smooth muscle. Endoscopically, mucosal friability and damage ranging from small erosions to large ulcers are found. Injury to the esophageal mucosa caused by thoracic radiation can be accompanied by Candida infection. Indeed, esophageal candidiasis has been reported in up to 15% of patients who had thoracic radiation. It is a common opportunistic infection in immunocompromised hosts. The typical endoscopic presentation is characterized by linear, white, mucosal, plaquelike lesions on the esophagus. Generally, candidiasis should be expected in patients with fever and suspected radiation esophagitis.1752_A Figure 1 No Caption available.1752_B Figure 2 No Caption available.

Unexpected Causes of Dysphagia

Case 1: A sixty-nine year old male presented with nausea, substernal discomfort, and a forty pound weight loss over 4-6 weeks. Pertinent review of systems showed that he expressed weakness, heartburn, dysphagia, and new onset indigestion for one month. He was a former 25 year pack per day smoker, former 2 beer a day drinker, and formerly a carpet maker with no reported chemical exposures. His initial work-up included a cbc significant for an elevated WBC count at 21,000 on admission with normal liver function tests. A CT chest showed a large mass at the GE junction with associated lymphadenopathy within the partially imaged abdomen and adjacent to the esophagus. He then underwent a diagnostic EGD/EUS that showed a partially obstructing malignant appearing mass at the GE junction that was biopsied. Endosonographically, the mass was staged. Four enlarged lymph nodes were visualized in the middle paraesophageal mediastinum. Pathology of the mass returned as primary high-grade neuroendocrine carcinoma of the esophagus. Further immunostains showed that synaptophysin was positive and ki 67 at 70%. He was then referred to medical oncology with further staging workup ordered with a PET-scan. Case 2: A sixty- two year old male, prior 1 ppd 35 yr smoker and 2 beer/daydrinker, was admitted for solid dysphagia of one month duration with a 40 lb unintentional weight loss. Ct abdomen with contrast reported a mass at the ge junction and questionable retroperitoneal metastases. EGD/EUS was done. EGD showed a large, fungating mass in the distal 1/3 of the esophagus that was partially obstructing. Pathology results returned consistent with high grade neuroendocrine carcinoma. Immunostains of the tumor returned positive for synaptophysin and Ki-67 showed a high proliferative index (over 50%). Taken together, the morphology and immmunostain profiles support a diagnosis of primary high grade neuroendocrine carcinoma of the esophagus. He was then referred to medical oncology. Discussion: Though the two most common causes of esophageal cancer are adenocarcinoma and squamous cell carcinoma, neuroendocrine carcinoma of the esophagus should remain in the differential. Neuroendocrine tumors of the esophagus can occur anywhere in the body. In the GI tract, neuroendocrine carcinomas are quite rare with an annual incidence in the US noted to be 3.65 per 100,000. Typical immunostaining is positive for synaptophysin and KI 67 percentage correlates to prognosis.

Stable Ischemic Heart Disease.

Classical angina refers to typical substernal discomfort triggered by effort or emotions, relieved with rest or nitroglycerin. The well-accepted pathogenesis is an imbalance between oxygen supply and demand. Goals in therapy are improvement in quality of life by limiting the number and severity of attacks, protection against future lethal events, and measures to lower the burden of risk factors to slow disease progression. New pathophysiological data, drugs, as well as conceptual and technological advances have improved patient care over the past decade. Behavioral changes to improve diets, increase physical activity, and encourage adherence to cardiac rehabilitation programs, are difficult to achieve but are effective.

A rare cause of dilated cardiomyopathy, the left coronary artery from the pulmonary artery (ALCAPA): Accurate diagnosis with dual-source CT

An anomalous origin of the left coronary artery (LCA) from the pulmonary artery (ALCAPA syndrome) or Bland–White–Garland syndrome is a rare congenital cardiac anomaly. This syndrome is a rare cause of dilated cardiomyopathy. We report an 8-year-old male patient who presented with intermittent atypical substernal discomfort and mild exertional dyspnea. Dual Source CT and Coronary angiography demonstrated the dilated left atrium and left ventricle with consistent dilated cardiomyopathy and the right coronary artery (RCA) arising from the aorta, rich collaterals from the RCA to LCA and the LCA originated from the pulmonary trunk.

Achalasia With Dense Eosinophilic Infiltrate Responds to Steroid Therapy

A patient presented with chronic substernal discomfort and intermittent dysphagia for solids. High-resolution impedance manometry (HRIM) of the esophagus showed that there was no peristalsis in the esophageal body but incomplete relaxation of the lower esophageal sphincter and incomplete bolus transit, so the patient was diagnosed with achalasia. Moreover, probably because of esophageal stasis, eosinophilic infiltration that mimicked a pattern of eosinophilic esophagitis was observed, on the basis of multiple biopsies of the esophagus. The patient was given 50 mg prednisolone once daily; the symptoms improved dramatically, and HRIM showed complete recovery of esophageal peristalsis, deeper relaxation of the lower esophageal sphincter, and complete bolus transit profile. HRIM can therefore be used to assess dysmotility abnormalities in patients with achalasia and eosinophilic-like esophagitis, and steroids relieve these symptoms. Treatment with a high dose of prednisolone resulted in a complete disappearance of dysphagia because of improved esophageal motility and reduced eosinophilic infiltrate. It is therefore important to control the inflammatory process in patients with idiopathic achalasia, which is likely to result from an autoimmune reaction.

A Case of Eosinophilic Esophagitis With Food Hypersensitivity

Eosinophilic esophagitis (EoE) is a disorder characterized by isolated eosinophilic infiltration of the esophagus with esophageal symptoms. Although some patients with EoE are related to food hypersensitivity, it is hard to identify causative foods. This report describes a case of EoE with dysphagia. A 28-year-old man presented with dysphagia and substernal discomfort for 15 days. He had taken a protein complex for 2 months. Endoscopy showed several linear furrows and multiple mucosal nodularities on the lower and mid esophagus, and the biopsies of esophagus revealed marked eosinophil infiltration in the mucosa. The skin testing for the protein complex was positive. The patient was successfully treated with withholding treatment.

A 57-Year-Old Man with a Chest Pain

A 57-year-old man was admitted to the emergency room because of a chest pain for one hour that radiated to the shoulder and arm. The pain was similar to the chest pain he usually had experienced, except for the one hour's duration. Six months before admission, he experienced a chest pain with a squeezing nature, causing central, substernal discomfort. The pain lasted 2 to 5 min. The pain usually occurred between 2 a.m. and 7 a.m. during sleeping, once or twice per month, and was not caused by exertion. He was a heavy smoker. The blood pressure was 100/60mmHg and the pulse rate was 85/min. The remainder of physical examination was normal. Electrocardiogram showed tall and tented T waves in lead V1 through V4. Fourteen minutes after admission, the electrocardiogram changed and showed a left bundle branch block pattern with an ST elevation and tall T waves without P waves in lead V1 through V4. This rhythm was accelerated idioventricular rhythm. The electrocardiogram obtained 23 minutes after admission showed a right bundle branch block pattern with an ST elevation and tall T waves without P waves in lead V1 through V4. He was treated for variant angina with sublingual and intravenous nitroglycerine, with complete resolution of the chest pain. The electrocardiogram obtained after resolution of the chest pain was normal. At the emergency room, the creatine kinase(CK) level was 144 U/L (normal, 55~170) and the troponin T level was 0.033 ng/ml (normal, 0.000~0.100). Eight hours after admission, the CK level was 598 U/L. The coronary angiogram, performed on the fourth hospital day, showed 99% spasm on the proximal left anterior descending artery by intravenous ergonovine provocation test. He was treated with long-acting nitrate and calcium antagonist, and experienced no more chest pain. The final diagnosis of this patient was acute myocardial infarction by variant angina.

Dysphagia—A Cough Masquerader

The most common diagnoses in patients with a chronic cough and a normal chest radiograph include asthma, chronic rhinitis, sinusitis, gastro-esophageal reflux disease, or a combination of these. Failure to respond to appropriate treatment should cause the treating physician to consider alternative diagnoses. We report the case of a 16-year-old girl with chronic cough who failed to improve despite a prolonged course of oral prednisone, inhaled corticosteroids, short- and long-acting beta agonists, and theophylline used for suspected cough variant asthma. She was also treated empirically for sinusitis and gastroesophageal reflux disease without improvement. Further history revealed symptoms of episodic aphonia, early satiety, substernal discomfort, and the sensation of mucus lodging in the throat after eating. A diagnosis of dysphagia was entertained and referral was made for evaluation by a speech pathologist. A video fluoroscopic swallowing function study was obtained. She had a moderate stage 1 and stage 3 dysfunction. Following outpatient dysphagia therapy, her coughing and choking resolved. Esophageal dysphagia needs to be considered in patients with chronic cough who fail to respond to treatment for more common causes.

Ingestion of coins and batteries.

Witnessing the ingestion of a foreign body by a toddler is alarming and immediately raises several questions. What are the risks of aspiration and airway obstruction? Where do foreign bodies get stuck? Are investigations necessary in the absence of symptoms? How long can objects be watched at different locations? What complications can result? When should objects be removed and which procedure should be used? When can cathartics or enemas be given safely? Predisposing Factors The peak age range for foreign body ingestion is 6 months to 3 years. There are underlying social, developmental, or psychiatric risk factors in up to 30% of cases. Ingestions in older children usually are accidental. Symptoms occasionally can suggest an underlying abnormality such as an esophageal stricture or might be related to a previous surgical procedure such as the repair of an esophageal atresia or a pyloromyotomy for pyloric stenosis. Children who have had esophageal atresia repaired also have associated dysmotility of the distal segment. The Need For Radiologic Investigations The nature of the ingested foreign body obviously influences management. Directed questions or a search of the home for missing objects often will reveal the nature of the ingested object. The presence of symptoms such as choking, dysphagia, substernal discomfort, persistent cough, or of physical findings such as drooling mandates a radiologic search for foreign bodies from oropharynx to anus.

Consultation with the Specialist

Witnessing the ingestion of a foreign body by a toddler is alarming and immediately raises several questions. What are the risks of aspiration and airway obstruction? Where do foreign bodies get stuck? Are investigations necessary in the absence of symptoms? How long can objects be watched at different locations? What complications can result? When should objects be removed and which procedure should be used? When can cathartics or enemas be given safely? Predisposing Factors The peak age range for foreign body ingestion is 6 months to 3 years. There are underlying social, developmental, or psychiatric risk factors in up to 30% of cases. Ingestions in older children usually are accidental. Symptoms occasionally can suggest an underlying abnormality such as an esophageal stricture or might be related to a previous surgical procedure such as the repair of an esophageal atresia or a pyloromyotomy for pyloric stenosis. Children who have had esophageal atresia repaired also have associated dysmotility of the distal segment. The Need For Radiologic Investigations The nature of the ingested foreign body obviously influences management. Directed questions or a search of the home for missing objects often will reveal the nature of the ingested object. The presence of symptoms such as choking, dysphagia, substernal discomfort, persistent cough, or of physical findings such as drooling mandates a radiologic search for foreign bodies from oropharynx to anus.

Static lung volumes in healthy subjects assessed by helium dilution during occlusion of one mainstem bronchus.

Single lung function is usually assessed by radioisotopes or, more rarely, by bronchospirometry in which a double lumen catheter is used to separate ventilation of the two lungs. The latter is more precise but less comfortable. An alternative bronchoscopic method is described for determining the volume of a single lung. One mainstem bronchus was temporarily occluded with an inflatable balloon during fibreoptic bronchoscopy in 12 healthy volunteers aged 18-29 years. The functional residual capacities (FRC) of the right, left, and both lungs were measured in duplicate by closed circuit helium dilution. Supplementary vital capacity (VC) manoeuvres permitted calculation of single lung capacities (TLC) and residual volumes (RV). The standard deviation of a single determination of capacities of the right, left, and both lungs were: TLC, 80, 96, and 308 ml; VC, 56, 139, 171 ml; FRC, 131, 74, and 287 ml; RV, 112, 185, and 303 ml, respectively. The sum of the right and left unilateral TLC was not different from bilateral TLC (6.12 v 5.95 l) and the sum of the unilateral FRC was not different from the bilateral FRC (2.60 v 2.78 l). The sum of the unilateral VC was lower than bilateral VC (4.52 v 4.80 l), that of the unilateral RV was higher than bilateral RV (1.60 v 1.16 l). For all subdivisions of lung volume, the right lung was larger than the left. The most common complaint was substernal discomfort during complete exhalation. Oxygen saturation rarely fell below 90%. Temporary occlusion of a mainstem bronchus in normal subjects is safe, relatively simple, and allows fairly precise and accurate measurements of unilateral static lung volumes. Occlusion at TLC, however, probably prevents proper emptying of the non-occluded lung.

Pathogenesis, Diagnosis, and Management of Reflux Esophagitis

The most common symptoms associated with reflux esophagitis are heart­ burn and regurgitation. Heartburn is usually described as a substernal or retrosternal burning pain or discomfort with a moving quality from the xyphoid area up toward the suprasternal notch. The pain may radiate up toward the neck and jaw as well as down into the epigastric area. Rarely, the pain may radiate into the arms and simulate the pain of cardiac origin (1). Heartburn is frequently associated with regurgitation of sour or bitter fluid. These symptoms are exacerbated by meals or postural changes, usu­ ally made worse when the patient is recumbent or tenses his abdominal muscles as in lifting. Most patients (84%) experience symptoms of reflux for more than one year before seeking medical attention (2). Intermittent dysphagia occurs frequently with the first swallows of every meal. The symptom is often reported by patients with severe reflux eso­ phagitis. They do not often have mechanical obstruction to the passage of food. Usually the dysphagia will be mild and nonprogressive with no asso­ ciated weight loss. This is the result of a motility disturbance within the body of the esophagus induced by reflux of gastroduodenal contents (3) and occurs most frequently with the first bolus swallowed. Persistent dysphagia of solids in a patient with reflux esophagitis should indicate to the clinician that a peptic stricture has formed or that a carcinoma may have developed within the esophagus. Anemia has been described as the presenting symp­ tom in some patients with reflux esophagitis; it is a result of low-grade

DETECTION AND REVERSAL OF PULMONARY ABSORPTION COLLAPSE

Six healthy seated male subjects (aged 36–54 yr) inhaled 100% oxygen for 10 min at normal lung volume and then for a further 5 min with forced maximal expirations. Following this manoeuvre, changes in arterial Po2 ranged from a decrease of 16.7 kPa to an increase of 2 kPa (—125 to +15 mm Hg) while breathing 100% oxygen, and a decrease of 1.8 kPa to an increase of 1.1 kPa (—13.5 to + 8.6 mm Hg) while breathing air. Functional residual capacity (FRC) was unchanged in one subject, but decreased by 0.04–1.15 litre in the others. The chest radiograph was unaltered in the subjects with zero and 0.04 litre decreases in FRC. Three of the other subjects showed line shadows at the bases, while the subject with the largest decrease in FRC showed extensive areas of collapse. There was a good correlation between changes in arterial Po2, FRC and the chest radiograph. Substernal discomfort was felt when those subjects with positive radiographic changes attempted to make a maximal inspiration. All changes were reversed by taking five maximal forced inspirations. Arterial Po2 changes while breathing 100% oxygen provided the most sensitive indication of collapse. Changes in FRC and arterial Po2 while breathing air were generally within the normal reference range of these variables, and therefore of little diagnostic value in the absence of control measurements. Under such circumstances, chest radiography seems to be the most sensitive indication of pulmonary collapse occurring in the upright position.

Granular cell tumors of the esophagus

Three cases of granular cell tumor of the esophagus are added to the 17 previously reported in the literature. These tumors, thought to be of neural origin, are difficult to diagnose preoperatively. The diagnosis should be considered in adult females presenting with an intramural mass of the proximal or distal third of the esophagus. Symptoms of dysphagia and substernal discomfort are likely to occur with lesions greater than one centimeter in diameter. Preoperative biopsy is not advised as a mistaken diagnosis of squamous cell carcinoma can result.

Angina-Like Syndrome with Diazoxide Therapy for Hypertensive Crisis

In 14 patients with hypertensive crisis treated with diazoxide, close monitoring of blood pressure, heart rate, and symptoms was performed. Standard 12-lead electrocardiograms were recorded before and after diazoxide. All patients showed a significant fall in blood pressure after drug administration. Seven patients (50%) showed significant ST-T changes after diazoxide. Six patients (43%) developed substernal discomfort demonstrated by substernal pain of tightness. Five patients (35%) had both chest discomfort and ST-T changes. One of these patients with substernal pain and ST elevation had evidence of acute myocardial infarction with serial enzyme studies. In the patients with significant ST-T changes, the average fall in blood pressure was significantly greater than the average fall in blood pressure in the patients without significant ST-T changes. These findings suggest that both ST-T changes and substernal discomfort were due to myocardial ischemia secondary to a sudden severe drop in blood pressure.

A clinical trial of the oral form of 4′-demethyl-epipodophyllotoxin-β-D ethylidene glucoside (NSC 141540) VP 16–213

A clinical trial of the oral form of VP 16-213 (NSC-141540), a semisynthetic podophyllotoxin, was undertaken. In 20 patients, treatment was started at 200 mg/day p.o. for 5 days; courses were repeated after a rest period of 16 days. Five patients were treated at the same dose, repeated with only 9-day rest periods. Subsequently, 65 patients were given 300-400 mg/day for 5 days, with rest periods of 9 days between courses. The side effects encountered included anorexia, nausea and vomiting, stomatitis, diarrhea, leukopenia, thrombocytopenia, alopecia, and pruritus. Substernal discomfort with or without palpitations was reported by 18 patients; no explanation for this symptom could be found. No complete remissions (CR) were observed. Parital remissions (PR) and improvement (IMP) were seen as follows: small cell carcinoma, lung (10 patients)--2 PR, 3 IMP; adenocarcinoma, lung (4 patients)--1 PR; alveolar cell carcinoma, lung (1 patient)--1 IMP; mesothelioma (4 patients)--1 IMP; ovarian cancer (12 patients)--3 PR, 3 IMP; breast cancer (20 patients)--4 IMP; colon cancer (8 patients)--2 IMP; bladder cancer (4 patients)--2 IMP; histiocytic lymphoma (7 patients)--2 PR, 3 IMP; chronic myeloid leukemia (1 patient)--1 IMP.

Clinical manifestations of esophagitis.

Most patients with esophagitis have substernal discomfort or pain, swallow with difficulty, or experience pain while swallowing. Although the causes can vary from lye ingestion to moniliasis, most esophagitis probably occurs when acid peptic juice refluxes. Esophagoscopy, radiographic studies, manometry and biopsy all have their place in diagnosis, but perhaps biopsy should be used more often.