The dark side of the esophagus

Acute esophageal necrosis (AEN), also known as "black esophagus," is an entity characterized by the circumferential black appearance of esophageal mucosa, usually associated with hypoperfusion and gastric outlet obstruction. This entity has a reported prevalence of up to 0.2%, affecting predominantly elderly men with multiple comorbidities. Most cases resolve with conservative treatment with no need of surgical intervention. However, the overall prognosis is poor, with mortality reaching one-third of cases due to the patient's underlying illness. In this article we present three cases of patients with AEN.

Esophageal lichen planus: An unusual cause of dysphagia in the elderly / Líquen plano esofágico: uma causa incomum de disfagia em idosos

Summary An 82-year-old man sought our service with dysphagia and was referred for upper endoscopy with biopsies, which evidenced multiple ulcers of the esophagus and oropharinx. Histopathology confirmed the unusual diagnosis of esophageal lichen planus. The correct clinical suspicion of this disease can facilitate the diagnosis and guide specific treatment, which can drastically change the natural course of the disease.

Resumo Paciente do sexo masculino, de 82 anos, com disfagia, foi encaminhado para realização de endoscopia digestiva alta com biópsias, na qual foram evidenciadas múltiplas úlceras de esôfago e orofaringe. O estudo histopatológico confirmou o diagnóstico raro de líquen plano esofágico. A correta suspeita clínica dessa doença pode facilitar o diagnóstico e direcionar para um tratamento específico, o que pode drasticamente alterar o curso natural dessa comorbidade.

Esophageal lichen planus

Abstract Lichen planus is a chronic inflammatory disease that affects the skin, mucous membranes, nails and scalp. Esophageal lichen planus is a rarely reported manifestation of lichen planus, presenting itself commonly in middle-aged women, with symptoms such as dysphagia. We report a case of esophageal lichen planus in a 54-year-old woman associated with oral, cutaneous and ungual lichen planus. Although lichen planus is a disorder well known by dermatologists, reports of esophageal lichen planus are rare in dermatologic literature. The esophageal lichen planus is little known and underdiagnosed, with a significant delay between the onset of symptoms and diagnosis.

Rendu-Osler-Weber syndrome: dermatological approach

The Rendu-Osler-Weber syndrome is a rare systemic fibrovascular dysplasia, recognized by mucocutaneous telangiectasias, arteriovenous malformations, epistaxis and family history. Recurrent bleeding, hypoxemia, congestive heart failure, portosystemic encephalopathy, and symptoms related to angiodysplasia of the central nervous system may occur. Since the treatment is based on supportive measures, early recognition is of utmost importance. This article reports the case of a 53-year-old male patient who presented telangiectasias on fingers, oral cavity and nasal mucosa for 10 years, with a history of recurrent epistaxis of varying severity since childhood. Mother, sister and daughter have similar lesions.

Prótesis esofágica autoexpansible para tratamiento de síndrome de Boerhaave: a propósito de un caso / Self-expanding esophageal stent for treatment of Boerhaave syndrome: report of a case

La perforación esofágica espontánea (PEE) o síndrome de Boerhaave es una entidad poco frecuente, consiste en la ruptura del esófago no relacionada con traumatismos, exploraciones invasivas, patología esofágica previa o cuerpos extraños. Independientemente de su mecanismo de producción, la perforación esofágica se considera como la más grave del tracto digestivo. Si su diagnóstico y reparación quirúrgica se retrasan, el pronóstico se ensombrece de forma notable. Presentamos un caso de paciente masculino de 37 años, sin antecedentes de interés que consulta a emergencia por cuadro brusco de dolor epigástrico irradiado a región retroesternal, posterior a vómito de contenido alimentario. El paciente presenta progresivamente deterioro de sus condiciones ventilatorias, que ameritan traslado a UCI y 72 horas posterior a ingreso a UCI se realizó esofagograma con bario evidenciándose extravasación de medio de contraste en tercio distal esofágico, aproximadamente 3 cm por encima de hemidiafragma izquierdo, por lo que de inmediato se decide colocación de stent metálico parcialmente cubierto Wilson-Cook (Evolution) bajo visión endoscópica y fluoroscópica, con resolución completa de la sintomatología

Spontaneous esophageal perforation (SEP) or Boerhaave syndrome is a rare entity that consists in the rupture of the esophagus unrelated to trauma, invasive examinations, previous esophageal disease or the presence of foreign bodies. Regardless of its mechanism, esophageal perforation is considered the most serious of the digestive tract. If diagnosis and surgical repair are delayed the outlook worsens considerably. We present the case of a 37-year-old male patient in good health, who attends the emergency room because of sudden onset of epigastric pain radiating to the retrosternal region after vomiting. The patient´s ventilatory condition deteriorated progressively meriting transfer to the intensive care unit; 72 hours after admission, a barium esophagram showed dye extravasation in the distal esophagus, approx 3 cm above the left diaphragm. We immediately decided to place a Wilson-Cook partially covered metal stent (Evolution) through endoscopic and fluoroscopic guidance with complete resolution of symptoms

Cambios mínimos esofágicos: ¿desapercibidos en la video endoscopia de pacientes con enfermedad de reflujo gastroesofágico no erosiva? / Esophagus minimal changes: unobserved in the video-endoscopy of patients with non erosive gastroesophageal reflux?

La mayoría de pacientes con enfermedad de reflujo gastroesofágico no tienen lesiones erosivas en esófago. Los cambios mínimos esofágicos que incluyen alteraciones blancas, rojizas, edematosas y/o acantósicas usualmente no percibidos durante la endoscopia se incluyen en Japón como parte de la enfermedad de reflujo no erosiva. Previo consentimiento se incluyeron a los individuos con síntomas de reflujo gastroesofágico y se compararon con un grupo sin éstos. Se utilizó equipo Fujinon HR250. La endoscopia se grabó en DVD y de rutina se fotografió la unión Esófago Gástrica y la Escamo Columnar. Se empleó la clasificación de Los Ángeles modificada por los japoneses que incluye Cambios Mínimos Esofágicos. Se practicó endoscopia digestiva superior en 146 pacientes 86 hombres y 60 mujeres con rango de edad 15-83 años y promedio 38,71 años. Se diferenciaron tres grupos: I) Sin cambios esofágicos, II) Con cambios esofágicos erosivos y III) Con cambios mínimos esofágicos. Los Cambios Mínimos Esofágicos se pudieron haber reportado en 53,44% y en 36,66% de pacientes con y sin síntomas de reflujo gastroesofágico respectivamente. Los Cambios Mínimos Esofágicos son frecuentes y pasan desapercibidos si no sabemos que investigar y no insistimos en buscarlos en pacientes con Enfermedad de Reflujo No Erosiva...

Most patients diagnosed with gastroesophageal reflux disease do not show erosive lesions in the esophagus. The esophagus minimal changes, which include white, reddish, edematous and/or acanthotic disturbances, are usually not perceived during endoscopic procedure and in Japan are included as part of the non erosive reflux disease. With prior consent, subjects with symptoms of gastroesophageal reflux were included, and were compared with a group without said symptoms. Fujinon HR250 equipment was used. The endoscopy was recorded on DVD and, routinely, photographs of the gastroesophageal and the squamous columnar junctions were taken. Los Angeles classification was used, as modified by the Japanese which includes Esophagus Minimal Changes. Upper digestive endoscopy was used in 146 patients: 86 men and 60 women, with ages ranging between 15 and 83, and an average of 38.71. Three groups were distinguished: I) Without changes in the esophagus; II) With erosive changes in the esophagus; and III) With esophagus minimal changes. Esophagus Minimal Changes might be reported in 53.44% and in 36.66% of patients with and without gastroesophageal reflux symptoms, respectively. Esophagus Minimal Changes are frequent but are unobserved if researcher does not know what the investigation must be on and if researcher does not insist in looking for them in patients with a diagnosis of Non Erosive Reflux Disease...

Pólipo fibrovascular esofágico: Estudio por imágenes multimodalidad / Endoluminal excision of an esophageal fibrovascular polyp: Report of one case

We report a 47 years old woman presenting with dysphagia. A chest CAT scan and barium swallow showed an endoluminal mass that extended to four vertebrae. An endoluminal sonography localized the pediculum of the mass, that was excised endoscopically. The pathological study disclosed a fibrovascular polyp. After 18 months of follow up, the patient is asymptomatic.

Esophageal candidiasis: An endoscopic and histopathologic study

To determine the frequency of endoscopic esophageal candidiasis and to compare the results with histopathological findings while assessing the relationship between positive oral swabs and stool examinations for Candida and esophageal candidiasis, a study was conducted on 778 patients in Iraq-Baghdad /Alyarmuk Teaching Hospital, Department of Medicine, from January 1999 to December 2000. The major presenting symptom was hematamesis. During upper GI endoscopy 22 [2.8%] had lesions suggestive of esophageal candidiasis but this could be confirmed histopathologically in only fourteen. Oral candidiasis was found in 10 of the 22 patients [45.4%]; stool examinations for Monilia were positive in only two [9%] who also gave positive oral swabs. Twenty control patients gave negative oral swabs and only three [15%] positive stools

Over-expression of cyclooxygenase-2 in endoscopic biopsies of ectopic gastric mucosa

Ectopic gastric mucosa (EGM) is considered to be a congenital condition. Rare cases of adenocarcinoma have been described. There are no data justifying regular biopsies or follow-up. Cyclooxygenase-2 (COX-2) is a protein involved in gastrointestinal tumor development by inhibiting apoptosis and regulating angiogenesis. The aim of this prospective study was to evaluate COX-2 expression in EGM and compare it with normal tissue and Barrett's esophagus. We evaluated 1327 patients. Biopsies were taken from the inlet patch for histological evaluation and from the gastric antrum to assess Helicobacter pylori infection. Biopsies taken from normal esophageal, gastric antrum and body mucosa and Barrett's esophagus were retrieved from a tissue bank. EGM biopsies were evaluated with respect to type of epithelium, presence of H. pylori, and inflammation. COX-2 was detected by immunohistochemistry using the avidin-biotin complex. EGM islets were found in 14 patients (1.1 percent). Histological examination revealed fundic type epithelium in 58.3 percent of cases, H. pylori was present in 50 percent and chronic inflammation in 66.7 percent. Expression of COX-2 was negative in normal distal esophagus, normal gastric antrum and normal gastric body specimens (10 each). In contrast, EGM presented over-expression of COX-2 in 41.7 percent of cases and Barrett's esophagus in 90 percent of cases (P = 0.04 and 0.03, respectively). COX-2 immunoexpression in EGM was not related to gender, age, epithelium type, presence of inflammation or intestinal metaplasia, H. pylori infection, or any endoscopic finding. Our results demonstrate up-regulation of COX-2 in EGM, suggesting a possible malignant potential of this so-called harmless mucosa.

Tratamento endoscópico das varizes esofágicas utilizando alças pré-atadas confeccionadas com fio de poliamida / Endoscopic treatment of esophageal varices, using pretied loop made with polyamide thread

BACKGROUD: The elastic band ligation is the method of choice for treatment of esophageal varices. The action mechanism is a mechanical varices compression with thromboses. Based on this concept we developed a ligature method using pretied loop made with polyamide thread for the treatment of esophageal varices. OBJECTIVE: The present study describes and evaluates the feasibility of the treatment of esophageal varices by the ligature method using pretied loop made with polyamide thread and analyzes the local changes of the ligations and the results, concerning safety, efficiency and complications of this procedure. PATIENTS AND METHODS: Between March, 1998 and May, 2000, 58 patients with esophageal varices were treated with pretied loop, made with polyamide thread (26 patients with schistosomiasis, 11 with alcoholic cirrhosis, 9 with hepatitis C, 5 with hepatitis B, 4 of unknown etiology, 2 with hepatitis B and C, and one with Budd-Chiari syndrome/ 42 men and 16 women/ average age of 47,67 ± 13,12 years, range 16-74). A plastic tube was attached to the endoscope tip featured as an accessory working channel, allowing the pretied loop made with polyamide thread to be conducted to the esophagus facilitated by a flexible metallic tube, to perform the esophageal varices ligature. A total of 506 ligatures were done, distributed in 223 sections (average of 2,26 ± 1,08 ligature, varying from 1 to 6 per section). The sessions were perform with the interval of 15 days, until the complete eradication of the esophageal varices. The ecoendoscopy was used as a complementary method to evaluate the varices eradication RESULTS: The esophageal varices were treated successfully in all patients. The complete eradication of varices was achieved in 47 (81,03%) patients. In 37 (63,79%) patients the ligatures resulted in pseudopolyps. It was not identified systemic complications or obits. The ecoendoscopy showed thrombosis in the pseudopolyps...

RACIONAL: A ligadura com bandas elásticas tem se tornado o tratamento de escolha das varizes esofágicas, devido aos bons resultados e as menores taxas de complicações quando comparada à esclerose. Seu mecanismo de ação baseia-se na compressão mecânica do cordão varicoso com interrupção do fluxo sangüíneo e posterior trombose. Tendo como base este mecanismo de ação, desenvolveu-se um método alternativo no qual o cordão varicoso é ligado com uma alça confeccionada com fio de poliamida OBJETIVO: Avaliar a viabilidade do tratamento das varizes esofágicas por método de ligaduras com alças pré-atadas confeccionadas com fio de poliamida, analisando as alterações locais, a segurança, a eficácia e as complicações deste método de tratamento. CASUíSTICA E MÉTODOS: Entre março de 1998 e maio de 2000, 58 pacientes com varizes de esôfago foram tratados com ligaduras com alças pré-atadas, confeccionadas com fio de poliamida (26 esquistossomóticos, 11 com cirrose alcoólica, 9 com hepatite C, 5 com hepatite B, 4 de causa não esclarecida, 2 com hepatite B e C e 1 com síndrome de Budd-Chiari; 42 pacientes eram do sexo masculino e 16 do sexo feminino, com média de idade de 47,67 ± 13,12 anos). Confeccionou-se artesanalmente um canal acessório que acoplado à extremidade do endoscópio, permitia que alças pré-atadas feitas com fio de poliamida fossem conduzidas ao esôfago com auxílio de tubo metálico flexível para se proceder às ligaduras das varizes esofágicas. No total, 506 ligaduras foram realizadas, distribuídas por 223 sessões (média 2,26 ± 1,08 ligaduras por sessão). As sessões foram realizadas com intervalos de 15 dias até a completa erradicação das varizes esofágicas. A ecoendoscopia foi utilizada como método complementar para avaliar a erradicação das varizes em 10 doentes RESULTADOS: O procedimento foi realizado com sucesso em todos os pacientes. A completa erradicação das varizes foi obtida em 47 (81,03%) doentes. Em 37 (63,79%) as...

Magnifying Endoscopy in Upper Gastrointestinal Tract / 대한소화기학회지

For the diagnosis of upper gastrointestinal (GI) lesions, magnification method is usually used in conjunction with chromoscopy, enabling the endoscopist to view subtle mucosal patterns in exquisite detail. Recently published datas have shown that magnifying endoscopy might be a valuable adjunct for the diagnosis, detection, and characterization of inflammatory and neoplastic lesions of the upper GI tract. It is also proven to be an useful surveillance protocol in identifying dysplastic epithelium or early cancer within a segment of Barrett's esophagus. Possible indications for magnifying endoscopy in upper GI tract include screening and surveillance of Barrett's esophagus, defining the extent of esophageal and gastric adenocarcinoma, detecting synchronous/metachronous gastric and esophageal cancers, diagnosing Helicobacter pylori infection, and recognizing minimal mucosal changes in gastroesophageal reflux disease. By grading the quality of evidence for the currently published trials, it is clear that the majority are case series, case reports, and/or observational studies without randomization, control, or blinding. Moreover, other evidence-based criteria such as independent, blind comparisons of magnifying endoscopy with a standard method which evaluates this technology in an appropriate spectrum of patients to whom the test may be applicable, and standardizing methodology would be crucial before magnifying endoscopy becomes a standard procedure in clinical practice. In the future, a uniform classification system for staining and magnifying patterns should be devised and observer agreement should be tested. Futher studies then could be performed based upon consistent, validated, and standardized terminologies and criteria.

Significance of Non-erosive Minimal Esophageal Lesions in Gastro-esophageal Reflux Disorder

BACKGROUND: Non-erosive reflux disorder, which represents more than 60% of gastro-esophageal reflux disorders, lacks objective parameters for diagnosis. The purpose of this study was to evaluate the correlation between non-erosive minimal lesions at the lower esophagus and gastro-esophageal reflux disorder. METHODS: Patients were asked to answer a symptom questionnaire. The endoscopic findings were either graded by LA classification or recorded as non-erosive minimal lesions. Patients with minimal lesions were treated with rabeprazole or a placebo and responses were evaluated at weeks 1 and 4. RESULTS: In 8 centers, 3454 patients were screened. In patients with heartburn or acid regurgitation as the most bothersome symptom, 23.7% had endoscopy negative reflux disorder, 40.1% showed minimal lesions, and 36.2% had mucosal break esophagitis. Thirty-four percent of patients with minimal lesions and 39.1% of patients with LA 'grade A' mild esophagitis reported typical reflux symptoms as their main symptom. In patients with minimal lesions, medication with rabeprazole reduced symptoms significantly at weeks 1 and 4, but not with the placebo. CONCLUSION: Patients with non-erosive minimal esophageal lesions had similar reflux symptoms comparable to those with mild erosive reflux esophagitis, and reflux symptoms were improved with a short-term proton pump inhibitor. Thus, non-erosive minimal esophageal lesion constitutes a great part of gastro-esophageal reflux disorder.

The Spectrum of Benign Esophageal Lesions: Imaging Findings

Benign esophageal lesions occur in various diseases. Barium studies are useful for the evaluation of mucosal surface lesions but provide little information about the extramucosal extent of disease. Computed tomography and magnetic resonance imaging, on the other hand, permit the assessment of wall thickness, mediastinal involvement, adjacent lymphadenopathy, and distant spread. In diseases such as fibrovascular polyps, duplication cysts, scleroderma, trauma, caustic esophagitis, hiatal hernia, esophageal diverticulum, achalasia, and paraesophageal varices, the findings of imaging studies are specific, obviating the need for further invasive diagnostic work-up. The advent of helical computed tomography and its volume data set allows the acquisition of multiplanar images, and magnetic resonance imaging is useful both for this and for tissue characterization. Thus, multiplanar cross-sectional imaging further extends the role of imaging modalities to the evaluation of benign esophageal lesions. Through an awareness of the multiplanar cross-sectional appearances of various benign esophageal lesions, the radiologist can play an important role in the detection, diagnosis, further diagnostic planning, and treatment of the diseases in which they occur.

A importância da endoscopia digestiva alta com soluçäo de lugol no diagnóstico de câncer superficial e displasia em esôfago de doentes com neoplasias de cabeça e pescoço / The importance of the upper digestive endoscopy using lugol dye solution for diagnosis of the superficial esophageal cancer and dysplasia in patients with head and neck cancer

Head and neck cancer has a high incidence in Brazil, with cancer of the oral cavity being one of the five most common cancers among Brazilians. Alcohol and tobacco consumption may contribute to synchronous or metachronous head and neck cancer and esophageal cancer. A prospective study involving 60 patients with head and neck cancer was carried out at the State University of Campinas--UNICAMP, Campinas, SP, Brazil to screen for superficial esophageal cancer and dysplasia using endoscopy and a 2 per cent lugol dye solution followed by biopsy of the suspicious areas. Five patients (8.3 per cent) had superficial esophageal cancer, which was diagnosed as intraepithelial carcinoma in three of them (5.0 per cent). In four patients, the superficial esophageal cancer was synchronous and in one it was metachronous to head and neck cancer. Five patients (8.3 per cent) had dysplasias in the esophageal epithelium (three were classified as mild and two as moderate). These results demonstrate the value of endoscopic screening of the esophagus using lugol dye in patients with head and neck cancer, particularly since superficial esophageal cancer is extremely difficult to detect by conventional methods in asymptomatic patients

Adenocarcinoma of cervical esophagus arising in aberrant gastric mucosa.

Ectopic gastric epithelium is common in the cervical esophagus. However, complications arising from such tissue are rare. We report an adenocarcinoma arising in ectopic gastric mucosa of the cardiac type in the cervical esophagus of a 60-year-old man.

Reconstrucción de segmento esofágico con intestino delgado libre vascularizado / Reconstruction of esophageal segment using free vascularized small bowel

Reportamos el primer caso en nuestro medio de reconstrucción exitosa de un segmento esofágico, usando injerto libre de intestino. Se describe la técnica de dicho procedimiento. Esta operación es considerada como la de elección para ciertos defectos esofágicos considerando las ventajas funcionales sobre los colgajos cutáneos o miocutáneos tradicionales. Se resalta la importancia de la participación de un equipo conformado por cirujanos generales y cirujanos especialistas en microcirugía. Estas consideraciones limitan la aplicación de éste método de reconstrucción a centros que tengan la infraestructura para desarrollar procedimientos microquirúrgicos