Esophageal Wall Thickness Research Articles

S3413 Cholangioscopy Through the PTC Route: Suddenly I See

INTRODUCTION: Black esophagus is a rare endoscopic finding caused by acute esophageal necrosis (AEN). Studies suggest the incidence of AEN is less than 1%. We describe a case of a patient presenting with coffee ground emesis and black esophagus. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of HIV on HAART (CD4 count of 399 and undetectable VL), alcohol abuse, ESRD, DMII and HTN presented to the ED for intermittent hematemesis. The patient described several episodes of coffee ground emesis associated with worsening abdominal distention, pain and diarrhea. Two days prior, he was discharged from another hospital after being treated for the same condition, however EGD was not performed. His surgical history was significant for G-tube placement, one year prior. He was afebrile and hemodynamically stable. His abdomen was soft, distended, non-tender with normal BS. His rectal exam revealed melena. Initial labs were significant for a leukocytosis of 15.4 K/uL, Hg of 8.2 (MCV 83), Platelets 373, INR 1.3 and lactate of 1.8. CT demonstrated distal esophageal wall thickening, suggestive of esophagitis. EGD confirmed esophagitis with eschar (LA Grade D) at the mid and distal esophagus (45 cm from the incisors.) There was no extension of the lesion beyond the GE junction. No blood, clots or old heme was seen in the stomach. However, multiple non-bleeding clean base ulcers (Forrest Class III) were visualized in the duodenum. The patient's hematemesis was caused by acute esophageal necrosis. The patient was treated with fluid resuscitation and intravenous proton pump inhibitors. The patient declined further workup. He was discharged to a skilled nursing facility with plan for repeat upper endoscopy in 4-6 weeks. He declined repeat endoscopy. DISCUSSION: The pathogenesis of AEN is not fully understood however poor vascular perfusion may be a contributor. AEN manifests in the distal portion of the esophagus and frequently coexists with duodenal pathologies. Treatment begins with nil-per-os (NPO) restriction, intravenous proton pump inhibitors, fluid resuscitation and treatment of underlying medical comorbidities. Follow-up upper endoscopy is recommended in 4–6 weeks. Although uncommon, clinicians should consider AEN when evaluating patients with an upper GI bleed, as early recognition and prompt treatment may improve outcomes. Further studies are needed on treatment outcomes and survival when multiple comorbidities coexist.

Can high-frequency mini-probe endoscopic ultrasonography predict outcome of endoscopic dilation in patients with benign esophageal strictures?

Background and study aims Endoscopic dilation is first-line management for benign esophageal strictures (ES). Depth of involvement of the esophageal wall on endosonography using high frequency mini-probe (EUS-M) may predict response to dilation. This study evaluated EUS-M characteristics to predict response of ES to endoscopic dilation. Patients and methods EUS-M was used to measure the total esophageal wall thickness (EWT), involved EWT, percentage of involved wall and layers of wall involved in consecutive patients of benign ES. After a maximum of five sessions of endoscopic dilation, the cohort was divided into responders and refractory strictures. EUS-M characteristics were compared for underlying etiology as also between responders and refractory strictures. Results Of the 30 strictures (17 females, age: 47.16 ± 15.86 yrs.) 13 were anastomotic, eight corrosive, seven peptic and 2 others. Corrosive strictures had the highest involved EWT and percentage of involved wall (3.51 ± 1.36 mm; 76.38 %) followed by anastomotic (2.73 ± 1.7 mm; 65.54 %) and peptic (1.39 ± 0.62 mm; 40.71 %) ( P = 0.026 and 0.021 respectively). After five dilations, 22 were classified as responders and eight as refractory. Wall involvement > 70 % had a greater proportion of refractory strictures ( P = 0.019). Strictures with involved EWT of ≥ 2.85 mm required more dilations ( P = 0.011). Fewer dilations were required for stricture resolution with only mucosal involvement compared to deeper involvement such as submucosa and muscularis propria (2.14 vs. 5.80; P = 0.001). Conclusion EUS-M evaluation shows that corrosive and anastomotic strictures have greater depth of involvement compared to peptic strictures. Depth of esophageal wall involvement in a stricture predicts response to dilation.

The comparison of wall thickness of esophagus and gastroesophageal junction using computed tomography with endoscopy and biopsy results

This study aims to establish a cut-off value for increases in the esophageal wall thickness measured using computed tomography to differentiate between benign and malignant pathologies. A total of 144 patients (61 males, 83 females; mean age 57.2±12.4 years; range, 24 to 86 years) who underwent thoracic and/or abdominal computed tomography in the radiology clinic between January 2015 and June 2018 for any reason and who were found to have a thickening of the esophageal wall or gastroesophageal junction were retrospectively analyzed. Tomography images were examined by two radiologists who reached consensus on the wall morphology and thickness, anatomic localization, and any accompanying findings regardless of the endoscopy results. Benign and malignant patients were identified from the endoscopy and/or biopsy results. The receiver operating characteristic analysis was carried out to establish a cut-off value for the lesion wall thickness to differentiate between benign and malignant pathologies and to determine a cut-off value for the lesionlevel thickness-normal segment thickness ratio. A statistically significant difference was found in the wall thicknesses of patients with esophageal cancer and those with benign lesions. According to a cut-off value for wall thickness of 13.5 mm, sensitivity and specificity were found to be 94.3% and 100%, respectively. The lesion-level thickness-normal segment thickness ratio was found to be statistically significant in malignant-benign differentiation, and a significant correlation was found between the asymmetric thickening and malignancy. Increases in the esophageal wall thickness and asymmetry detected on computed tomography can contribute to the early diagnosis of esophageal cancers, particularly in regions endemic to esophageal cancer as in Van province in eastern anatolia region of Turkey. Asymmetric wall thicknesses over 13.5 mm would be highly significant in terms of malignancy in tomographic examinations.

Subjective Symptoms in Patients with Eosinophilic Esophagitis Are Related to Esophageal Wall Thickness and Esophageal Body Pressure.

Endoscopic ultrasonography (EUS) and high-resolution manometry (HRM) can be used in the evaluation of eosinophilic esophagitis (EoE) for frequent symptoms such as dysphagia. However, the role of these examinations is not clear. The aim of this study was to objectively evaluate the subjective symptoms of EoE patients with EUS and HRM. Patients who had endoscopic findings indicative of EoE and matched the number of eosinophil infiltrates used as diagnostic criteria were recruited between September 2018 and August 2019. Evaluable subjects underwent EUS and HRM and completed the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. The esophageal wall thickness (evaluated with EUS) and HRM parameters between patients with and without symptoms were retrospectively compared. Symptomatic patients were re-examined using EUS and HRM 6months after treatment. A total of 35 patients (29 males, median age of 49years) were divided into symptomatic (20 patients) and asymptomatic groups (15 patients). The esophageal wall was thicker, and the distal contractile integral (DCI) values were higher in the symptomatic group (P < 0.001). In addition, DCI values were positively correlated with esophageal wall thickness. After treatment, the GSRS scores showed an improving trend for each item. Esophageal wall thickness and DCI values were significantly decreased (Ps < 0.001). Esophageal wall thickening and increased esophageal body pressure may be involved in subjective symptoms. In addition, treatment may reduce esophageal thickness and pressure along with improvement of subjective symptoms.

Impact of Extracapsular Lymph Node Involving the Esophagus in Esophageal Perforation During and After Radiotherapy: A Propensity Score-Matched Analysis.

BackgroundThis study aimed to analyze the risk factors for esophageal squamous cell carcinoma (ESCC), especially extracapsular lymph node involving the esophagus (ECLNIE), occurring during or after radiotherapy (RT) in patients with esophageal perforation (EP).MethodsIn total, 306 patients with ESCC who received RT and/or chemotherapy between January 2016 and December 2017 in our hospital and who met the inclusion criteria of the study were recruited. The continuous variables were converted into classification variables using the receiver operating characteristic curve or common clinical parameters. Risk factors for EP were examined by univariable analysis using the chi-square test or Fisher’s exact and by multivariable analysis using logistic regression model. Propensity score matching (PSM) was used to compensate for the differences in baseline characteristics, and the incidence of EP was compared after matching.ResultsEP was observed in 26 patients (incidence rate, 8.5%). Univariable analysis revealed that age, BMI, T4 stage, tumor length, esophageal wall thickness, ECLNIE, necrotic areas, niche sign by esophagogram before RT, neutrophil-to-lymphocyte ratio, and prognostic nutritional index were significantly associated with EP among patients with ESCC who received radiotherapy. Multivariable analysis demonstrated that age, ECLNIE, esophageal wall thickness, and niche sign by esophagogram before RT were independent risk factors for EP. After PSM, compared with patients without ECLNIE, patients with ESCC and ECLNIE had a significantly higher risk of EP.ConclusionThe presence of ECLNIE could be a strong risk factor of EP during and after RT.

Direct and indirect CT imaging features of esophago-airway fistula in adults.

BackgroundEsophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults.MethodsWe identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients.ResultsTwenty-six patients (median age: 56 years; range, 25–79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%).ConclusionsCT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.

Differences in clinical characteristics between conservative-treatment-response group and refractory (surgical-treatment) group in patients with jackhammer esophagus.

Jackhammer esophagus (JE) is a rare disease with unclear clinical features. The objective of this study was to retrospectively compare the clinical characteristics of patients with JE whose symptoms were controlled with conservative treatment, such as observation or medication, versus those who were required surgical treatment, such as surgical myotomy or per oral endoscopic myotomy. Eighteen patients with JE were included in this study. The patients were divided into two groups: patients who responded to conservative treatment (C group) and patients who were refractory to conservative treatment and underwent surgery (S group). Patient age, sex, disease duration before treatment, symptoms, esophagogastroduodenoscopic (EGD) findings, esophagographic findings, esophageal wall thickness on computed tomography, number of swallows with hypercontractile peristalsis in 10 water swallows, and maximum distal contractile integral (DCI) were compared between the groups. Thirteen of 18 patients (72%) were in the C group and five of 18 (28%) were in the S group. There were no significant differences in age, sex, disease duration before treatment, symptoms, EGD findings, esophagographic findings, esophageal wall thickness, or number of swallows with hypercontractile peristalsis between the groups. On Starlet high-resolution manometry, the median maximum DCI value was significantly higher in the S group (32,651mmHg-s-cm) than in the C group (17,926mmHg-s-cm) (P = 0.0136). JE treatment should be carefully considered because some patients require surgery, whereas others are controlled with conservative treatment alone. A higher DCI value in patients with JE may predict resistance to conservative treatment.

Predicting pediatric esophageal wall thickness: An EUS study.

Background and Objective:EUS has been shown in two small series to be capable of documenting increases in the total esophageal wall thickness (TWT) in children and adults with eosinophilic esophagitis (EoE). To apply EUS-derived TWT in clinical situations or in scientific investigations in pediatric EoE, measurements of esophageal TWT in children of differing ages and heights are required.Materials and Methods:Thirty patients (18M: 12F, 7 months to 20 years and 10 months) with a history of esophageal symptoms, but no endoscopic or histologic criteria of EoE were studied using a through the scope 20 MHZ Olympus Ultrasound miniprobe UM-3R (Olympus America, Center Valley Pa 18034) through a GIF Q180 or 160 (Olympus) standard pediatric upper endoscope. The mucosa, the mucosa plus submucosa, and the TWT were measured in the mid- and distal esophagus immediately before taking diagnostic biopsies.Results:Measurements from both sites showed a statistically significant increase in TWT as a function of age (P < 0.001) and height (P < 0.001), as did the individual layers. The width of the mucosa and the submucosa were equivalent and together, they contributed more than half of the entire TWT. There were no significant differences between the means of the mid- and distal esophageal measurements. A multiple regression equation that can predict TWT based on age, with 95% confidence limits, is presented.Conclusions:EUS has demonstrated that esophageal TWT in a cohort of control children correlates with height and with age and has provided insights into the organization of the esophageal wall. Esophageal TWT values obtained by EUS can now be interpreted to recognize esophageal wall thickening throughout childhood.

Esophageal Thermal Injury FollowingCryoballoon Ablation forAtrialFibrillation.

This study evaluated the rate and predictors of endoscopically detected esophageal thermal lesions (EDEL) in patients who underwent cryoballoon atrial fibrillation (AF) ablation (CBA). EDEL is a known complication of catheter ablation for AF and is the inciting factor for atrial esophageal fistula formation. An observational study was conducted of patients with AF presenting for CBA. Pre-procedural magnetic resonance imaging was used to retrospectively evaluate the distance between the atrial endocardium and the esophageal lumen (AED). Intraprocedural esophageal luminal temperature and balloon temperatures were recorded. All patients underwent upper endoscopy (EGD) 24h post-ablation. Clinical, anatomical, and ablation parameters were analyzed using logistic regression for association with thermal injury. A total of 95 patients (37% women; 71% paroxysmal AF) were included in the study. Esophageal thermal injury was detected on EGD in 21 patients (22%). EDEL was mostly mild (20 of 21 patients) and severe in only 1 of 21 patients. Univariate logistic regression identified gastroesophageal reflux disease to be associated with increased risk of thermal injury (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.00 to 10.46; p=0.04), whereas a wider AED was protective (OR: 0.16; 95%CI: 0.05 to 0.515; p=0.002). Esophageal wall thickness was also protective (OR: 0.04; 95%CI: 0.002 to 0.864; p=0.04). In multivariate analysis, only AED (OR: 0.22; 95%CI: 0.06 to 0.77; p=0.018) and obesity (OR: 4.63; 95%CI: 1.13 to 18.97; p=0.033) were associated with EDEL. Esophageal luminal temperature, number, and duration of cryoballoon applications and balloon temperature were not predictors of EDEL. EDEL following CBA occurred in 22% of patients and was mostly mild. Obesity and atrioesophageal distance were independently associated with increased risk.

Pretreatment Esophageal Wall Thickness Associated with Response to Chemoradiotherapy in Locally Advanced Esophageal Cancer.

A multimodality approach using concurrent chemoradiotherapy (CRT) followed by esophagectomy has been the standard treatment in patients with locally advanced esophageal squamous cell carcinoma (ESCC). Computed tomography (CT) is widely utilized to evaluate esophageal cancer before and after CRT. This study evaluated the utility of pretreatment maximal esophageal wall thickness on CT scans to predict treatment outcomes after CRT in patients with locally advanced ESCC. Eighty-one patients with T3 locally advanced ESCC, whom were treated completely with CRT with and without surgery, and had available CT scans before and after CRT at a university hospital between 2005 and 2015, were retrospectively reviewed. Twenty patients (24.7%) had esophagectomy after neoadjuvant CRT and sixty-one patients (75.3%) had definitive CRT. The maximal esophageal wall thicknesses were measured retrospectively and correlated with the response and survival after treatment. A total of 40% of neoadjuvant CRT patients achieved a pCR. There was a significant difference in pretreatment maximal esophageal wall thickness between the pCR and non-pCR groups (mean 11.9 ± 5.3 mm versus 16.9 ± 3 mm; p = 0.01). Pretreatment maximal esophageal wall thickness < 10 mm was significantly related to better overall survival than ≥ 10 mm (median survival 79 months versus 15 months; HR 3.21, 95%CI 1.14-9; p = 0.02). The neoadjuvant CRT group had significantly better survival than the definitive CRT group (median survival 51 months versus 14.5 months; HR 0.46; 95%CI 0.25-0.85; p = 0.01). In our study, pretreatment esophageal wall thickness of T3 locally advanced ESCC is a useful indicator for predicting survival and pCR after treatment.

1746 A Surprising Case of Boerhaave's Syndrome Successfully Treated With a Single Hemostatic Clip

INTRODUCTION: Boerhaave’s Syndrome (BS), defined as transmural esophageal perforation, is rare and associated with 35% mortality. Patients with BS can develop associated mediastinitis, sepsis, and septic shock. Patients require urgent management, usually with volume resuscitation, antibiotics, surgical intervention, or occasional endoscopic placement of a metallic stent. There are few reported cases demonstrating successful repair of esophageal perforation with hemostatic clips alone. We present a case of direct repair of BS with a single hemostatic clip. CASE DESCRIPTION/METHODS: A 44-year-old male presented to the ED for food impaction with subsequent development of large volume hematemesis. He was stable, with no sign of respiratory distress. However, given his persistent hematemesis, he was intubated for airway protection. Initial labs were remarkable for leukocytosis to 14.8 and hemoglobin of 18.4. A Mallory Weiss tear was expected, but his CT chest showed inflammation in the mediastinum associated with debris in the esophagus and esophageal wall thickening. His clinical picture and imaging were consistent with BS complicated by mediastinitis and esophagitis with superimposed esophageal perforation. He was given one dose of both Zosyn and a PPI and was taken for emergent EGD. Red blood and clots were seen throughout his esophagus, and a large non-bleeding tear with stigmata of recent bleeding was seen in the distal esophagus. One hemostatic clip was placed with successful resolution of the defect. He was then admitted to the medical ICU for further management. Over the next 24 hours, he developed melena and became tachycardic. His leukocytosis peaked at 21, and his hemoglobin gradually decreased to 8.9. Repeat CT chest was obtained due to worsening symptoms, but imaging showed that the esophageal clip was in place, and there was improvement in prior esophageal wall thickening, but there was a new small left pleural effusion. Cardiothoracic Surgery evaluated the patient and recommended an esophagram, which showed no evidence of esophageal contrast extravasation. He was successfully extubated and was discharged home the following day. DISCUSSION: BS is often a medical emergency requiring urgent intervention. Most cases are treated surgically with direct repair of the rupture via thoracotomy or laparotomy. Although there is a known role for endoscopic management using a metallic stent, there is an evolving role for treatment of more mild cases of BS with clip placement alone.

1802 A Hard Truth to Swallow

INTRODUCTION: Pseudoachalasia is a condition typically caused by lower esophageal sphincter (LES) obstruction in the setting of invasive neoplasm. In rare cases, a syndrome known as paraneoplastic achalasia can present similarly, but is not associated with tumor invasion into the esophageal mucosa. CASE DESCRIPTION/METHODS: 76-year-old female with history of breast cancer status post mastectomy and radiation presented to her oncologist with one month of progressive dysphagia. She was referred to gastroenterology and scheduled for an outpatient EGD, but presented to the ED with weakness, fatigue and weight loss prior to completion of the EGD. CT scan in the ED showed two right lung masses, mediastinal adenopathy and esophageal wall thickening. Patient was admitted for further workup. Day 1 of admission, patient underwent EGD that was pertinent for severe Candida esophagitis, but was aborted after progressing only 1/3 of the way into the esophagus. Patient was started on fluconazole for esophagitis with improvement in dysphagia. On day 2, patient underwent bronchoscopy with biopsy and was discharged home with oncology follow up. Five days later, she was directly readmitted from the oncology office for worsened dysphagia and continued weight loss. Esophagram showed distal esophageal obstruction presumably secondary to post-inflammatory stricture. EGD the following day showed dilated and poorly contractile esophagus with a spastic LES concerning for achalasia. Manometry revealed absence of esophageal body contractility, but was unable to assess the LES due to intolerance of the procedure by the patient. Further workup including pathology showed that patient had metastatic non-small cell carcinoma (NSCC), lung primary. It was determined that patient had pseudoachalasia due to paraneoplastic syndrome in setting of non-small cell carcinoma of the lung without invasion of the tumor into the LES. Patient ultimately underwent palliative botox injection at the LES with improvement in symptoms. DISCUSSION: Paraneoplastic syndromes are considered rare disorders triggered by an altered immune response in the setting of malignancy. Paraneoplastic achalasia is a type of paraneoplastic syndrome that presents as a rapidly progressive dysphagia. Though it has been reported in the setting different malignancies, this is one of the very few case reports of paraneoplastic achalasia due to NSCC. This case also emphasizes the importance of considering other causes of achalasia when evaluating patients with abnormal presentations.

1822 Esophageal Neuroendocrine Tumor: A Rare Case of High-Grade Carcinoma of the Esophagus

INTRODUCTION: Neuroendocrine tumors (NET) of the esophagus are extremely uncommon. The rarity of esophageal NETs is thought to be due to an underdeveloped neuroendocrine system in the esophagus. When diagnosed, esophageal NETs are usually found in the distal esophagus where neuroendocrine cells are primarily distributed in associated mucosal glands. CASE DESCRIPTION/METHODS: We describe a unique case of a 62-year-old man diagnosed with an esophageal NET. His PMHx is notable for psoriasis, chronic tobacco use (45 pack years), cirrhosis from heavy alcohol use and illicit drug use including cocaine. He first presented to the hospital with complaints of intermittent episodes of chest pain. He underwent full cardiac workup which was unremarkable. Several months later, he returned to clinic with symptoms of progressive dysphagia to solids. Esophagram revealed a 7cm narrowed segment along the distal esophagus with mucosal irregularity concerning for esophageal neoplasm. A follow up CT abdomen/pelvis showed circumferential wall thickening of the distal esophagus, a 5.2cm necrotic lymph node within the gastrohepatic ligament, as well as a smaller necrotic lymph node at the level of the gastroesophageal junction concerning for malignancy. Follow up EGD revealed a fungating mass in the distal esophagus with biopsies confirming tumor cells positive for MNF116, CD56 and synaptophysin; the overall findings were consistent with high grade neuroendocrine carcinoma of the esophagus. The patient started chemotherapy with Carboplatin and Etoposide; he was subsequently treated with single agent Paclitaxel. The metastatic burden continued to worsen with increased involvement of the liver, lymph nodes and most recently the brain. At his most recent clinic visit, he continues to lose weight and still experiences dysphagia to solids though he is tolerating liquids. He will be starting radiation treatments to the brain and also palliative radiation to the GE junction to help alleviate his dysphagia. DISCUSSION: Prompt diagnosis of esophageal NET is critical as these tumors are known to be rapidly progressive and often have already metastasized by the time of diagnosis. Favorable prognostic factors include no lymphatic metastasis, tumor size of &lt;1.0 cm and histology that reveals well-differentiated tumor cells. For unclear reasons, men are disproportionately more likely to develop NET of the esophagus. The most frequent clinical complaint is dysphagia followed by unintentional weight loss, melena and then typical carcinoid symptoms.

1775 Tracheoesophageal Fistula Managed With Double Stenting of Bronchus and Esophagus

INTRODUCTION: Malignancy is responsible for 5-15% of acquired tracheoesophageal fistulas (TEF). Such patients have a short survival and management of these fistulas is a challenge. We present a case of TEF secondary to esophageal malignancy that was managed with double stenting of the bronchus and esophagus. CASE DESCRIPTION/METHODS: The patient is a 56 year old black female with no known past medical history who presented to our emergency department with complaints of chest pain, shortness of breath and a productive blood tinged cough. She had been recently discharged from another facility for a diagnosis of bronchitis, however symptoms had not abated. She reported a fifty-pound weight loss with poor oral intake. Her vital signs and labs on arrival were stable. Initial imaging in the ER was consistent with pneumonia of the right middle and lower lobes. She underwent a CT Neck, which showed esophageal wall thickening and a mass suspicious for an esophageal neoplasm. Due to concern of her recurrence of pneumonia and esophageal mass, she underwent an esophagram, which showed a stricture of the middle third of the esophagus with a fistula from the esophageal tumor to the right lower lobe bronchus. Due to concern of airway collapse with upper endoscopy, Pulmonology was consulted. The patient first underwent a bronchoscopy in which a Novatech Y-stent was deployed stabilizing the airway. The patient then underwent an endoscopy in which an esophageal stent was placed. Both procedures were successful and she tolerated oral intake well thereafter. She was discharged in stable condition to palliative hospice services. DISCUSSION: The case has relevance from both an interesting initial clinical presentation as well as management of this patient from both a technical and procedural aspect. This patient had continual infections from continuous overspill of esophageal contents into the respiratory tree. Although her prognosis to begin with was quite poor, these interventions allowed the patient some quality of life. This case also commands procedural respect. The patient’s left mainstem bronchus was extremely friable and actually ruptured during the initial course of balloon dilation. The stent in position did not completely cover the TEF however it did keep the central airway open. A long esophageal stent was placed by gastroenterology, which did completely cover the fistula. This patient’s case highlights potential difficulties in double stenting and anticipatory management by utilization of other services.

2677 A Rare Case of Primary Signet Ring Cell Bladder Adenocarcinoma With Metastases to the Stomach

INTRODUCTION: Primary signet ring cell adenocarcinoma (SRCA) of the urinary bladder is a rare malignancy, accounting for about 0.24% of all bladder malignancies. Additionally, metastases to the stomach regardless of primary malignancy is also rare, with rates estimated to be between 0.2-0.7%. Here we are reporting a case of primary SRCA of the bladder with eventual metastases to the stomach. CASE DESCRIPTION/METHODS: A 65-year-old male with rheumatoid arthritis on chronic immunosuppression and history of T4N0M0 primary SRCA of the bladder status-post radical cystectomy was admitted with persistent nausea, vomiting and reduced oral intake leading to acute kidney injury. Symptoms were refractory to conservative measures so CT Abdomen was obtained which revealed distal esophageal wall thickening. Due to concern for infectious esophagitis given his chronic immune suppression, esophagogastroduodenoscopy (EGD) was performed. EGD revealed multiple nodules (5-10 mm) with central umbilication scattered within the gastric fundus and body. The lesions were biopsied and stains were consistent with signet ring cell adenocarcinoma positive for CX7, CX20, CDX-2; Beta-catenin was not performed. Bladder specimen from prior cystectomy was also positive for CX7, CX20, CDX-2, and predominately membranous staining for Beta-catenin. PET scan obtained after EGD was significant only for retroperitoneal lymphadenopathy thought to represent metastases. Previous workup at the time of initial bladder adenocarcinoma diagnosis including colonoscopy and imaging were all negative for additional foci of malignancy confirming primary bladder adenocarcinoma. Hence, it was concluded that the gastric lesions represented metastasis to the stomach from primary SRCA of urinary bladder. Due to underlying comorbidities and poor baseline functionality, patient elected to proceed with hospice care. DISCUSSION: Primary urinary bladder SRCA is a rare type of malignancy that typically presents at an advanced stage. Standard therapy of local urinary bladder SRCA is radical cystectomy. Despite advances in identifying immunohistochemical markers which aid in determination of primary bladder vs. colorectal origin, rates of metastases after surgical intervention are uncertain which limits the discussion regarding the role of adjuvant therapy. Our case highlights the need for further investigation to evaluate the risk-benefit ratio of adjuvant chemotherapy after radical cystectomy in primary bladder SRCA in minimizing development of future distant metastases.

The long-term impact of tumor burden in pT3N0M0 esophageal squamous cell carcinoma: A propensity score-matched analysis.

The purpose of this study was to assess the impact of tumor burden on the survival of patients with pathologic T3N0M0 (pT3N0M0) esophageal squamous cell carcinoma (ESCC).A total of 84 patients with pathologic T3N0M0 ESCC treated with radical esophagectomy and 3-field lymphadenectomy (3-FL) from January 2008 to December 2009 in our center were analyzed. Receiver-operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff value. The Kaplan–Meier method and log-rank test were used to assess the overall survival (OS) differences between groups. A regression model was applied to identify prognostic factors for OS. Propensity score matching (PSM) was performed to adjust for the imbalance and indication biases in the 2 groups.The median follow-up time was 62 months (range, 1–84 months), and the 5-year OS rate was 62% (95% confidence interval, 52.2–71.8%). According to the ROC curve analysis, the optimal cutoff values for the maximal esophageal wall thickness, tumor length, and tumor volume were 1.3 cm, 5.9 cm, and 18.6 cc, respectively. Univariate analysis revealed that maximal esophageal wall thickness >1.3 cm (P = .014), tumor volume >18.6 cc (P < .001), and vascular invasion (P < .001) were significantly associated with OS. The multivariate Cox regression model identified tumor volume and vascular invasion as factors affecting OS. After propensity matching, patients with a tumor volume ≤18.6 cc had a better OS than those with a tumor volume >18.6 cc (5-year OS, 85% vs 50%, P = .008).Tumor volume may serve as a good prognostic factor for patients with pT3N0M0 ESCC treated with radical esophagectomy and 3-FL. Larger-scale studies are warranted to validate these findings.

Investigation of Using Diffusion-Weighted Magnetic Resonance Imaging (DWI) Combined with CT and Esophagogram to Evaluate the Therapeutic Effect of Esophageal Squamous Cell Carcinoma (ESCC) Treated with Chemoradiotherapy

To investigate the application value of using DWI combined with CT and esophagogram evaluating the therapeutic effect of ESCC treated with chemoradiotherapy (CCRT). From January 2004 to December 2015, 529 patients with ESCC underwent CCRT were enrolled. Therapeutic effect was evaluated based on the maximal esophageal wall thickness measured by CT, hyperintense expression in DWI and tumor shape changes in esophagogram. Prognosis analysis was also performed. A total of 529 patients were evaluated by esophagogram and CT -based evaluation criteria, 132 patients were in complete response (CR) and 385 in partial response (PR) after CCRT. Overall survival (OS) and local control (LC) rates of patients in CR were significantly higher than those in PR, with the 5-, 10-year OS at 37%, 30% versus 21%, 19%, respectively (P<0.001). The median survival time was 5 months for 12 patients in none response (NR). Of all enrolled patients, 83 patients received DWI examination before and after CCRT. A total of 48 patients had no hyperintense expression in DWI (defined as CR) after CCRT and 35 still had hyperintense expression (defined as PR). OS and LC rates of patients received DWI examination in CR were significantly higher than those in PR (P=0.013, 0.001). In contrast, there was a trend towards increased uncontrolled and recurrent rate of patients in PR versus CR (P<0.05). According to the evaluation criteria based on DWI combined with CT and esophagogram, OS and LC rates of patients in CR were significantly higher than those in PR, with the 5-year LC at 62% versus 33% and 5-year OS at 48% versus 16%, respectively (P=0.018, 0.002). The esophagogram and CT -based evaluation criteria can accurately evaluate the therapeutic effect and predict prognosis in patients with ESCC. The expression of hyperintense in DWI at the end of treatment may indicate a high risk of recurrence. The therapeutic effect evaluated by DWI combined with CT and esophagogram maybe more objective and more accurate.

Does esophageal wall thickness on computed tomography predict response to endoscopic dilatation in patients with corrosive esophageal strictures?

Background and AimTo evaluate the role of esophageal wall thickness (EWT) on computed tomography (CT) in predicting response to endoscopic dilatation of corrosive esophageal strictures.MethodsThis was a retrospective study. A review of the records of patients who underwent endoscopic dilatation of esophageal strictures between January 2010 and December 2017 was performed. Patients who had a CT evaluation prior to dilatations were included. CT‐EWT was measured at the maximum visible point. Clinical details and endoscopic dilatation parameters were recorded. Technical success, clinical success, and recurrent and refractory strictures were recorded. CT‐EWT and the clinical parameters were evaluated regarding their role in predicting the number of dilatations required to achieve technical and clinical success.ResultsA total of 250 patients underwent endoscopic dilatations during the study period; 84 patients underwent thoracoabdominal CT. Complete clinical, endoscopic, CT data and follow up were available for 64 patients. There were 36 males. The median age was 30 years (range, 14–70 years). A total of 750 dilatations were performed. The median number of dilatations required to achieve technical success was 8.5 (range, 1–51). Dilatations were performed after a median period of 3 months (range, 1–40). Median CT‐EWT was 7 mm (range, 3–22). On univariate, as well as multivariate, analysis, CT‐EWT and the clinical parameters were found to be poor predictors of the number of dilatations required to achieve technical and clinical success.ConclusionCT‐EWT has no additional role in predicting response to the endoscopic dilatation of corrosive esophageal strictures.

Do we need endoscopic ultrasonography for the workup of patients with esophageal motility disorder?

Endoscopic ultrasonography (EUS) is advised in the workup of achalasia patients to rule out secondary achalasia or pseudoachalasia, and search for a typical esophageal wall thickening. The purpose of this study was to assess the clinical contribution of EUS findings in achalasia and other esophageal motility disorders (EMD). We conducted a single center retrospective study at a tertiary referral centre. We included all patients with an EUS for the workup of a suspected EMD from January 2012 to December 2017. Sixty-nine patients were included, 52% were men, with a median (±SD) age of 61 ± 14 years. Median (±SD) Eckardt Score was 7 ± 2. EUS was normal in 26 (38%) patients, and showed an esophageal wall thickening in 43 (62%) patients. Three cases of secondary achalasia were diagnosed at mucosal biopsies: 2 esophageal carcinomas and one eosinophilic esophagitis. Esophageal wall thickening was not significantly associated with the type of EMD or achalasia subtype and there was no statistical correlation between the presence of a wall thickening at EUS and therapeutic outcomes. In our work, the presence of an esophageal wall thickening was not predictive of the type of EMD nor achalasia subtype or treatment outcome. The contribution of endoscopic ultrasonography in achalasia and other EMD seems limited.

Esophageal insufflation computed tomography in clinically normal dogs.

OBJECTIVE To assess the feasibility of esophageal insufflation CT (EICT) for evaluation of the esophagus in dogs. ANIMALS 7 clinically normal adult Beagles. PROCEDURES Each dog was anesthetized twice with 1 week between anesthesia sessions. Dogs were positioned in sternal recumbency during all CT scans. During the first anesthesia session, a CT scan was performed before the esophagus was insufflated (insufflation pressure, 0 mm Hg) and unenhanced and contrast-enhanced EICT scans were performed after CO2 was insufflated into the esophageal lumen to achieve a pressure of 5 mm Hg. For the contrast-enhanced scan, each dog received iohexol (600 mg/kg, IV), and the scan was performed 30 seconds later. During the second anesthesia session, unenhanced and contrast-enhanced EICT scans were performed in the same manner except the insufflation pressure achieved was 10 mm Hg. The esophageal luminal cross-sectional area and wall thickness were measured at each of 5 segments, and mean values were compared among the 3 insufflation pressures and between unenhanced and contrast-enhanced images. RESULTS Mean esophageal luminal cross-sectional area increased and esophageal wall thickness decreased as insufflation pressure increased. Measurements did not differ significantly between unenhanced and contrast-enhanced images. The stomach became distended with CO2 at an insufflation pressure of 10 mm Hg but not at 5 mm Hg. No adverse effects were observed. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested EICT was feasible for esophageal evaluation in dogs. Further research is necessary to determine the optimal insufflation pressure for the procedure and its diagnostic efficacy in diseased patients.