Usefulness of Contrast-Enhanced CT in a Patient with Acute Phlegmonous Esophagitis: A Case Report and Literature Review.

Acute phlegmonous esophagitis is a very rare, life-threatening form of esophagitis, characterized by diffuse bacterial infection and pus formation within the submucosal and muscularis layers of the esophagus. We describe a case in which contrast-enhanced chest CT was useful for evaluating the severity of phlegmonous esophagitis, which was overlooked and underestimated by endoscopy.

Role of Multimodality Imaging in Gastroesophageal Reflux Disease and Its Complications, with Clinical and Pathologic Correlation.

Gastroesophageal reflux disease (GERD) is a common condition and impairs the quality of life for millions of patients, accounts for considerable health care spending, and is a primary risk factor for esophageal adenocarcinoma. There have been substantial advances in understanding the pathogenesis of GERD and its complications and much progress in diagnosis and management of GERD; however, these have not been comprehensively discussed in the recent radiology literature. Understanding the role of imaging in GERD and its complications is important to aid in multidisciplinary treatment of GERD. GERD results from prolonged or recurrent reflux of gastric contents into the esophagus. Common symptoms include heartburn or regurgitation. Prolonged reflux of gastric contents into the esophagus can cause erosive esophagitis. Over time, the inflammatory response related to esophagitis can lead to deposition of fibrous tissue and development of strictures. Alternatively, the esophageal mucosa can undergo metaplasia (Barrett esophagus), a precursor to dysplasia (which can lead to adenocarcinoma). Conventional barium esophagography has long been considered the primary imaging modality for the esophagus, and the fluoroscopic findings for diagnosis of GERD have been well established. Multimodality imaging has a clear role in detection and assessment of the complications of GERD, specifically reflux esophagitis and Barrett esophagus; differentiation of benign and malignant strictures; and detection, staging, and posttreatment surveillance of esophageal adenocarcinoma. Given the dramatic changes in utilization of abdominal imaging during the past 2 decades, with significantly declining volume of fluoroscopic procedures and concomitant increase in CT and MRI studies, it is crucial that modern radiologists appreciate the value of barium esophagography in the workup of GERD and recognize the key imaging features of GERD and its complications at CT and MRI.

Acute phlegmonous esophagitis: apropos of a case.

A 43-year-old male with an uneventful history presented with fever and ingestion-triggered retrosternal chest pain of a three-day duration, which was aggravated by deep breathing and the supine position. When asked regarding the possible ingestion of a foreign body he recalled having accidentally swallowed tiny glass shards from a broken bottle.

Upper gastrointestinal endoscopy applied in pediatrics: endoscopic and histological findings, including Helicobacter pylori.

OBJECTIVE: To present and discuss the endoscopic and histological results, as well as the incidence of Helicobacter pylori and other diseases, indications and characteristics of upper digestive endoscopies performed in children. MATERIAL AND METHODS: Twenty-five endoscopies were performed in children aged six months to 11 years (mean 7.69 years), from February 2013 to January 2016. In 200 patients, endoscopies were diagnostic and serial biopsies were performed (esophagus, stomach and duodenum), in 120 of them. RESULTS: The indication of endoscopy was diagnosed in 88.89% of the patients, and in 26 patients, a therapeutic procedure was performed. The most frequent endoscopic findings were esophagitis in 49 patients, gastritis in 84 and duodenitis in 16 patients. Four duodenal ulcers were diagnosed. In the therapeutic endoscopies, six gastrostomies were performed, 14 foreign body withdrawals, five nasoenteral tube passages and esophageal dilatation. The H. pylori survey was performed by anatomopathological method and was positive in 26 (13%) of the 200 patients in whom it was searched. CONCLUSION: pediatric endoscopy is an important niche of the digestive endoscopy, where it is important to emphasize the relevance of the institutional structure that performs these procedures, in order to conduct them safely, being able to treat possible and feasible complications.

Spectrum of esophageal dysmotility in systemic sclerosis on high-resolution esophageal manometry as defined by Chicago classification.

The classic manometric findings in systemic sclerosis are aperistalsis of the esophageal body with hypotensive lower esophageal sphincter. These changes contribute to gastroesophageal reflux disease in these patients. With widespread use of high-resolution esophageal manometry, diverse abnormalities are seen. The aim of this study is to characterize esophageal dysmotility in patients with systemic sclerosis undergoing high-resolution esophageal manometry and compare demographic features and diagnostic test results among patients with varying degrees of esophageal dysmotility. Patients with systemic sclerosis who underwent high-resolution esophageal manometry between January 2008 and October 2014 at our institution were identified. High-resolution esophageal manometry studies were reinterpreted using the Chicago Classification, v3.0 criteria. We also reviewed the patient charts for demographic data, indications for manometry, esophagogastroduodenoscopy findings, pH studies, medication use, and autoantibody panel. The cohort consisted of 122 patients with a mean age of 53.3 ± 15.3 years. High-resolution esophageal manometry was normal in 23, showed ineffective esophageal motility in 22, absent contractility in 73, and one case each of type II achalasia, esophagogastric junction outflow obstruction, hypercontractile esophagus, and distal esophageal spasm. Patients with absent contractility were younger and more likely to have erosive esophagitis, hiatal hernia, and esophageal strictures than patients with ineffective esophageal motility or normal manometry. There were no statistically significant differences in the groups based on autoantibodies or indications for manometry. Diverse esophageal motility abnormalities were noted in systemic sclerosis with ineffective esophageal motility or absent contractility observed in over three-fourth of the patients. Patients with absent contractility were younger and had more severe reflux. The severity of gastroesophageal reflux disease related endoscopic findings correlated with the degree of esophageal dysmotility on high-resolution esophageal manometry.

Consensus Statement of Society of Abdominal Radiology Disease-Focused Panel on Barium Esophagography in Gastroesophageal Reflux Disease.

OBJECTIVE: The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition. CONCLUSION: Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.

Significance of 18F-Fluorodeoxyglucose Uptake at the Gastroesophageal Junction: Comparison of PET to Esophagogastroduodenoscopy.

BACKGROUND: Positron emission tomography-computed tomography (PET/CT) occasionally reveals unexpected uptake of (18)F-fluorodeoxyglucose ((18)F-FDG) at the gastroesophageal junction (GEJ). The aim of this study was to determine the importance of unexpected (18)F-FDG uptake at the GEJ on PET/CT by correlating this finding with endoscopy results. METHODS: We reviewed medical records from June 2009 to October 2012 to identify patients in our Veterans Affairs Medical Center who had an esophagogastroduodenoscopy (EGD) performed within 6 months of a PET/CT. Metabolic activity at the GEJ was quantified with standardized uptake values (SUV) and correlated with EGD and histopathology results. RESULTS: A total of 219 patients were identified and assigned to one of five groups based upon EGD findings: esophageal malignancy (n = 34), esophagitis (n = 21), Barrett's esophagus (n = 8), other non-malignant disorders (n = 5), and normal (n = 151). The mean SUV Max for the groups was 6.72, 2.47, 2.40, 3.48, and 2.06, respectively. SUV Max and SUV Mean were significantly higher in the esophageal malignancy group than in all other groups (p < 0.001). SUV for patients with high-grade esophagitis was greater than in patients with low-grade esophagitis. A SUV Max ≥ 3.5 was found to predict necessity for EGD with a positive predictive value of 79 %. A SUV Max ≤ 2.2 yielded a negative predictive value of 86 %. CONCLUSION: Differentiation between benign and potentially significant disease at the GEJ may be possible with quantification of incidental (18)F-FDG uptake at PET/CT. Our results suggest thresholds that may help determine need for further endoscopic evaluation in patients with abnormal metabolic activity at the GEJ.

[Acute necrotizing esophagitis (black esophagus) with secondary severe stenosis]. / Esofagitis necrotizante aguda (esófago negro) con estenosis compleja secundaria.

We report the case of a 67 years old patient with a history of diabetes mellitus, atrial fibrillation and chronic renal failure, who developed diabetic ketoacidosis and severe sepsis, later presenting an acute necrotizing esophagitis, and then a esophageal stenosis requiring treatment with self-expanding esophageal prosthesis with good clinical results.

[Conservative treatment improved corrosive esophagitis and pneumomediastinum in a patient who ingested bleaching agent containing sodium hypochlorite and sodium hydroxide].

A 69-year-old man was admitted to the emergency department 3 hours after ingestion of a bleaching agent containing hypochlorous acid and sodium hydroxide in a suicide attempt. Enhanced chest computed tomography scans taken on admission indicated an edematous esophagus and air bubbles in the mediastinum. He underwent endotracheal intubation and mechanical ventilation until day 9 because of laryngeal edema. On day 10, his endoscopy indicated diffuse reddish mucosal hyperemia, erosions, and lacerated mucosal lesions in the esophagus that were indicative of grade 2b corrosive esophagitis. Treatment with a proton pump inhibitor was initiated, with which the condition of the esophagus improved, and on day 44, a slight stricture of the upper part of the esophagus was observed. He was discharged on day 64 without any complaints. The ingestion of sodium hypochlorite induces corrosive esophagitis and acute phase of gastritis. Ingestion of any corrosive agent is known as a risk factor for esophagus cancer in the long-term. In such cases with esophageal stricture, esophagectomy is recommended for preventing esophagus cancer. Considering the age of the patient, however, he did not undergo esophagectomy.

A technique to use CT images for in vivo detection and quantification of the spatial distribution of radiation-induced esophagitis.

The purpose of the study was to examine whether CT imaging can be used to quantify radiation-induced injury to the esophagus. Weekly CT images for 14 patients receiving proton therapy for thoracic tumors were retrospectively reviewed. The images were registered with the original treatment planning CT image using deformable registration techniques, and the esophageal contours from the treatment plan were automatically mapped to the weekly images. The relative change in the size of the esophagus was calculated for each CT slice as the ratio of the cross-sectional area of the esophagus (minus air) in the weekly CT image to the same area in the planning CT image. The maximum relative change in cross sectional area for each CT image was calculated and examined for correlation with the clinical toxicity score for all the patients. The average maximum relative expansion of the esophagus at the end of treatment was 1.41 ± 0.26, 1.68 ± 0.36, and 2.10 ± 0.18 for patients with grade 0, 2, and 3 esophagitis, respectively. An unpaired t-test, with the level of significance corrected with a Bonferroni correction, showed that the difference between grade 3 and 0 was significant, but the differences between grade 0 and 2, and 2 and 3 were not. The timing of changes in esophageal expansion closely matched that of clinically noted changes in patient symptoms. Expansion of the esophagus on CT images has potential as an objective measure of toxicity. The ability to quantify objectively the spatial distribution of radiation-induced injury will be a useful tool in understanding the impact of partial esophageal sparing on the probability of esophagitis.

Mucosal eosinophilia: prevalence and racial/ethnic differences in symptoms and endoscopic findings in adults over 10 years in an urban hospital.

BACKGROUND: Eosinophilic esophagitis is a chronic inflammatory disease with mucosal accumulation of eosinophils. There is a paucity of data among racial/ethnic groups other than white patients. AIM: To determine if racial/ethnic differences exist in clinical presentation, endoscopic appearance, and biopsy results in adult patients (age ≥18 y) with mucosal eosinophilia and examine the prevalence of mucosal eosinophilia at an urban hospital over a 10-year period. METHODS: Pathology reports searched at Temple University Hospital 2000 to 2009; key words: "eosinophils", "esophagus", and "biopsy". Clinical and endoscopic records reviewed on patients with ≥15 eosinophils/high power field. RESULTS: A total of 64 adults (average age, 41 y; 62% male patients; 81% white, 12% black, and 6% Hispanic). White patients were significantly younger (P=0.03). Adult mucosal eosinophilia diagnosis increased by 833% (3 in 2000 to 25 in 2009); black/Hispanic diagnosis increased by 500% (1 in 2000 to 5 in 2009). Solid food dysphagia was more common among white patients (72% vs. 0.33%, P=0.02). Reflux symptoms were more common in black/Hispanic patients (42% vs. 22%, P=0.16). Normal endoscopy (42% vs. 13%, P=0.04) and reflux changes (41% vs. 21%, P=0.16) were more common in black/Hispanic patients. Furrows (42% vs. 8%, P=0.04) and rings (46% vs. 0%, P=0.002) were more common in white patients. Average eosinophil counts did not vary between groups. CONCLUSIONS: Mucosal eosinophilia presents with significant differences between racial/ethnic groups in age at onset, symptoms at presentation, and endoscopic features. Differences may reflect different phenotypes of the same disease or separate disease entities.