Challenges in Diagnosis of Esophageal Tuberculosis.

Esophageal tuberculosis (TB) is a rare manifestation of extrapulmonary TB, accounting for <0.2% of all TB cases. Esophageal TB most commonly presents with dysphagia, odynophagia, retrosternal pain, and systemic symptoms like decreased appetite, loss of weight, and low-grade fever as associated or other presentations. We report a similar case recently encountered as an elderly male patient presented with chronic dysphagia to solids, loss of appetite, and significant loss of weight. Radiological and endoscopy pictures looked like esophageal cancer with histopathological examination (twice) negative for the same. Diagnosis of esophageal TB was confirmed by GeneXpert Ultra of biopsy sample and histopathological examination was suggestive of granulomatous esophagitis. The patient improved on 6 months antitubercular therapy. The unique aspect of this case was how the lesion mimicked an esophageal carcinoma on imaging which posed a diagnostic challenge.

Detachable string magnetically controlled capsule endoscopy for the noninvasive diagnosis of esophageal diseases: A prospective, blind clinical study.

BACKGROUND: Traditional esophagogastroduodenoscopy (EGD), an invasive examination method, can cause discomfort and pain in patients. In contrast, magnetically controlled capsule endoscopy (MCE), a noninvasive method, is being applied for the detection of stomach and small intestinal diseases, but its application in treating esophageal diseases is not widespread. AIM: To evaluate the safety and efficacy of detachable string MCE (ds-MCE) for the diagnosis of esophageal diseases. METHODS: Fifty patients who had been diagnosed with esophageal diseases were prospectively recruited for this clinical study and underwent ds-MCE and conventional EGD. The primary endpoints included the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ds-MCE for patients with esophageal diseases. The secondary endpoints consisted of visualizing the esophageal and dentate lines, as well as the subjects' tolerance of the procedure. RESULTS: Using EGD as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ds-MCE for esophageal disease detection were 85.71%, 86.21%, 81.82%, 89.29%, and 86%, respectively. ds-MCE was more comfortable and convenient than EGD was, with 80% of patients feeling that ds-MCE examination was very comfortable or comfortable and 50% of patients believing that detachable string v examination was very convenient. CONCLUSION: This study revealed that ds-MCE has the same diagnostic effects as traditional EGD for esophageal diseases and is more comfortable and convenient than EGD, providing a novel noninvasive method for treating esophageal diseases.

Esophageal Lichen Planus: A Descriptive Multicenter Report.

GOALS: To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP). BACKGROUND: ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series. STUDY: A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States. RESULTS: Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers. CONCLUSIONS: Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

Development and validation of a universal esophageal patient-reported outcome measure: The Cleveland Clinic Esophageal Questionnaire (CEQ).

OBJECTIVE: Currently, there is no validated patient-reported outcome measure (PROM) applicable to all esophageal diseases. Our objective was to create a psychometrically robust, validated universal esophageal PROM that can also objectively assess patients' quality of life (QoL). METHODS: The pilot PROM constructed based on expert opinions, literature review, and previous unpublished institutional research had 27 items covering 8 domains. It was completed by 30 patients in the outpatient clinic followed by a structured debriefing interview, which allowed for refining the PROM. The final PROM: Cleveland Clinic Esophageal Questionnaire (CEQ) included 34 items across 6 domains (Dysphagia, Eating, Pain, Reflux & Regurgitation, Dyspepsia, Dumping), each accompanied by a corresponding QoL component. Further psychometric assessment of the PROM was conducted by evaluating (1) acceptability, (2) construct validity, (3) reliability, and (4) responsiveness. RESULTS: Five hundred forty-six unique patients (median 63.7 years [54.3-71.7], 53% male [287], 86% White) completed CEQ at >90% completion within 5 minutes. Construct validity was demonstrated by differentiating scores across esophageal cancer (n = 146), achalasia (n = 170), hiatal hernia (n = 160), and other diagnoses (n = 70). Internal reliability (Cronbach alpha 0.83-0.89), and test-retest reliability (intraclass correlation coefficients 0.63-0.85) were strong. Responsiveness was demonstrated through CEQ domains improving for 53 patients who underwent surgery for achalasia or hiatal hernia (Cohen d 0.86-2.59). CONCLUSIONS: We have constructed a psychometrically robust, universal esophageal PROM that allows concise, consistent, objective quantification of symptoms and their effect on the patient. The CEQ is valuable in prognostication and tracking of longitudinal outcomes in both benign and malignant esophageal diseases.

Esophageal Stricture: An Uncommon Complication of Cervical Inlet Patch.

Esophageal heterotopic gastric mucosal patches (HGMP), also known as cervical inlet patches (CIP), is a rare but underdiagnosed condition characterized by the presence of salmon-colored, velvety mucosa located in the proximal esophagus, distal to the upper esophageal sphincter. The incidence of CIP ranges from 3% to 10% in adults, and its endoscopic appearance is characterized by a flat or slightly raised salmon-colored patch. In this case, we report a 78-year-old man who presented with symptoms of laryngopharyngeal reflux and dysphagia. An esophagogastroduodenoscopy showed a flat area of salmon-colored patch between 17 and 20 cm from the incisors, suggestive of a CIP complicated by stricture. The biopsy results showed an oxyntic-type mucosa lined with columnar cells consistent with an inlet patch. Esophageal dilation was done with a savory dilator with no resistance at 18 mm. The patient was placed on maintenance acid suppression therapy with proton-pump inhibitors and reported complete resolution of symptoms at the 1-month follow-up.

Acute Esophageal Necrosis as a Rare Complication of Metabolic Acidosis in a Diabetic Patient: A Case Report.

BACKGROUND Acute esophageal necrosis, or Gurvits syndrome, is a rare clinical process often secondary to a systemic low-flow state. It can be caused by several medical conditions, and it is thought to arise from a combination of impaired mucosal barrier and chemical and ischemic insults to the esophagus. Acute esophageal necrosis usually presents with severe complications due to delayed diagnosis and only rarely has surgical indications. We present a case of Gurvits syndrome, presumably triggered by metabolic acidosis in a diabetic patient. CASE REPORT A 61-year-old man with history of hypertension and type 2 diabetes mellitus treated with metformin, canagliflozin, glimepiride, and pioglitazone came to our attention with persistent vomiting, odynophagia, chest pain after each meal, and progressive weight loss. Arterial blood analysis showed mild metabolic acidosis, while the first esophagogastroduodenoscopy performed revealed a circumferential black appearance of the esophageal mucosa, as in concentric necrosis of the distal esophagus with possible fungal superinfection. Brushing cytology confirmed the infection by Candida spp. and the patient was treated with intravenous fluconazole. The second esophagogastroduodenoscopy, performed after 2 weeks, showed almost complete healing of the esophageal mucosa; in this case, biopsy confirmed mucosal ischemia and necrosis, without showing deep impairment of the mucosa by fungal agents. CONCLUSIONS Due to its high lethality, often caused by the underlying medical diseases, acute esophageal disease should be considered in the differential diagnosis of digestive symptoms, even without upper gastrointestinal bleeding. Prompt diagnosis and treatment of contextual collateral conditions can help clinicians to avoid the worst outcomes of the disease. Among the causative factors of metabolic acidosis leading to esophageal necrosis we recognized metformin and dapagliflozin.

[Esophageal candidiasis as an indicator condition]. / Candidaoesophagitis mint indikátorbetegség.

Esophageal candidiasis is the most common infectious disease of the esophagus. The diagnosis is based on gastroscopy, and in many cases, biopsy samples should be taken as well. If we do not know of any risk factors for an immunocompromised condition, it is a mutual responsibility to confirm or exclude any potential chronic disease in the background, thus not just the secondary complication but also the primary disease could be treated. Without this knowledge, in many cases, the correct diagnosis may be delayed for months or even years, which may risk the successful treatment. We present the case of a 58-year-old healthy woman without any chronic disease, who was referred to our clinic with dysphagia. Due to her complaints we performed a gastroscopy, upon which advanced esophageal candidiasis was diagnosed, hence she was started on oral systemic antifungal treatment. Although we could not explore any risk factors, further investigations behind the immunocompromised condition revealed a positive immunoserology test for HIV. The take-home message of our case is that in the case of esophageal candidiasis, the cause of immunosuppression must be searched for, of which HIV serology is crucial. Thanks to the prompt and correct diagnosis, we could start the suitable treatment of the underlying disease. Orv Hetil. 2023; 164(22): 878-880.

Laryngopharyngeal symptoms and oesophageal disorder: The role of heterotopic gastric mucosa in upper oesophagus.

BACKGROUND: Heterotopic gastric mucosa in the upper oesophagus (HGMUE) was considered as geneogenous manifestation. However, its clinical characteristics may be beyond our knowledge if we focus on its extra-oesophageal presentation. So the aim of this study was to investigate the relationship between HGMUE and laryngopharyngeal symptoms. METHOD: Eight hundred and eleven patients who had gastric endoscopy examination were enrolled in this study and the cervical oesophagus was examined for the patch during withdrawal of the endoscope. Questionnaire for gastroesophageal reflux disease (GERD-Q) and Reflux Symptom Index (RSI) were completed by all the patients. Pathology feature and therapeutic effect of HGMUE patients were evaluated. RESULT: About 34.53% of the patients undergoing the gastroduodenoscopy had laryngopharyngeal (LP) symptoms. The relevance rate of HGMUE in LP(+) group (10.69%) was higher than that in LP(-) group (2%). The LP symptoms were related to the histological type and expression of H+-K+-ATPase in the histological sample of HGMUE patients. The positive rate of H+-K+-ATPase was 100% in LP(+) group, and that in LP(-) group was 28.6%. PPI therapy was effective for improving the LP symptoms in HGMUE patients. The RSI score in LP(+) patients decreased from 8.12 ± 1.46 at baseline to 4 ± 0.74 at the end of 8 weeks after treatment of PPI. CONCLUSION: HGMUE was an important cause of LP symptoms in patients, especially in those who had no evidence of GERD. The mechanism of HGMUE-induced LP symptoms was due to its location and the function of acid secretion according to the endoscopic finding and histologic characteristics.

Esophageal lichen planus: Current knowledge, challenges and future perspectives.

Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.

Sebaceous Gland Ectopia of the Esophagus: A Challenging Clinical Diagnosis.

BACKGROUND/AIM: Sebaceous gland ectopia (SGE) defines the presence of normal sebaceous tissue in an unusual location. This condition is rare and was first described in ectodermal-derived organs, such as the oral cavities and palms, and later in endodermal-derived tissues including the esophagus. SGE of the esophagus is believed to represent a form of acquired metaplasia. SGE is asymptomatic and usually discovered during routine endoscopic examinations for other gastrointestinal complaints and symptoms. It is a benign entity and to date no cases of malignant transformation have been reported. Once diagnosed, SGE requires no further work up or follow up, and does not require treatment. CASE REPORT: We present two cases of SGE arising in the esophagi of two female patients who presented with complaints of gastro-esophageal reflux and underwent endoscopy. These lesions presented as patchy yellow-white nodules in the mid and upper esophagus and were endoscopically interpreted as suggestive of candidiasis or glycogen acanthosis. Biopsies showed foci of non-keratinizing squamous mucosa overlying the sebaceous glands. These glands exhibited a characteristic lobulated structure with germinative cells at the periphery and vacuolated, well-differentiated cells in the center of the lobules. After histologic examination, the endoscopic impressions of candidiasis and acanthosis were ruled out and the final diagnosis of SGE was made. There was no evidence of dysplasia or malignancy in our cases. CONCLUSION: Histopathology examination is important to differentiate SGE from malignant and infectious conditions that are more common, and which can be clinically and endoscopically similar to SGE.

The true prevalence of cervical inlet patch in a specific center dealing with esophageal diseases.

OBJECTIVE: Cervical Inlet Patch (CIP) is an interesting entity that is little known and often neglected by endoscopists. It has always been reported as less than expected. In this article, for the first time in the literature, we want to measure the true prevalence of CIP in a center dealing with specific esophageal diseases. PATIENTS AND METHODS: From October 2020 to October 2021, a total of 283 patients, aged 15-95 years, with mainly dyspeptic and reflux-like complaints were included in this study. All endoscopic procedures were performed carefully by a single endoscopist. Patients were examined for any possible presence of CIP, with adequate sedation and time. RESULTS: The prevalence of CIP, which was the primary aim of our study, was detected at a rate of 14.8%. Most CIP was observed as a single lesion (73.8%), and many of them (45.2%) were larger than 10 mm. Plenty of patients had upper endoscopy due to dyspeptic complaints, but only 2.5% of them presented with a preliminary diagnosis of laryngeal reflux. CONCLUSIONS: The true CIP prevalence is higher than reported before. Our result is the highest prevalence rate of CIP was detected in Turkey. In this regard, data coming from centers dealing with specific esophageal diseases may be more reliable and true.

Salivary biomarkers and esophageal disorders.

Saliva is a complex physiologic fluid that contains an abundance of biological analytes, or biomarkers. Recent research has shown that these biomarkers may be able to convey the physiologic health of a person. Work has been done linking derangements in these salivary biomarkers to a wide variety of pathologic disorders ranging from oncologic diseases to atopic conditions. The specific area of interest for this review paper is esophageal disorders. Particularly because the diagnosis and management of esophageal disorders often includes invasive testing such as esophagogastroduodenoscopy, prolonged pH monitoring, and biopsy. The aim of this review will be to explore salivary biomarkers (pepsin, bile, epidermal growth factor, and micro-RNA) that are being studied as they relate specifically to esophageal disorders. Finally, it will explore the benefits of salivary testing and identify areas of possible future research.

Isolated oesophageal Crohn's disease mimicking oesophageal carcinoma treated by Merendino procedure.

Oesophageal involvement is a very rare presentation of Crohn's disease. It can occur as an isolated mass causing dysphagia and can be mistaken for malignancy. Here, we report a case of a 75-year-old woman presenting with dysphagia and weight loss. Gastroscopy showed an ulcerating mass, and her barium swallow showed a bird beak appearance at the level of the gastro-oesophageal junction (GEJ). Repetitive biopsies were inconclusive. Fluorodeoxyglucose-positron emission tomography showed high glucose uptake (standardised uptake value: 10.2) at the level of the GEJ. Endoscopic ultrasound classified the lesion as uT3N1. Step-by-step surgical exploration revealed an oesophageal mass. A frozen section examination showed an absence of malignancy and the presence of inflammatory tissue. A partial oesophagogastrostomy was performed, and reconstruction was achieved by a Merendino procedure. Definitive histopathological examination revealed isolated oesophageal Crohn's disease.

Prevalence and Clinical and Endoscopic Characteristics of Cervical Inlet Patch (Heterotopic Gastric Mucosa): A Systematic Review and Meta-Analysis.

BACKGROUND: Cervical inlet patch (CIP), also called gastric inlet patch, is a heterotopic columnar mucosal island located in the cervical esophagus, which has been under-recognized by clinicians. AIM: We conducted a systemic review and meta-analysis to explore the prevalence and clinical and endoscopic characteristics of CIP. MATERIALS AND METHODS: Studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The prevalence of CIP with 95% confidence interval (CI) was pooled by using a random-effect model. The association of CIP with demographics, clinical presentations, and endoscopic features was evaluated by odds ratios (ORs). RESULTS: Fifty-three studies including 932,777 patients were eligible. The pooled prevalence of CIP was 3.32% (95% CI=2.86%-3.82%). According to the endoscopic mode, the pooled prevalence of CIP was higher in studies using narrow-band imaging than in those using white light and esophageal capsule endoscopy (9.34% vs. 2.88% and 0.65%). The pooled prevalence of CIP was higher in studies where the endoscopists paid specific attention to the detection of this lesion (5.30% vs. 0.75%). CIP was significantly associated with male (OR=1.24, 95% CI=1.09-1.42, P=0.001), gastroesophageal reflux disease (OR=1.32, 95% CI=1.04-1.68, P=0.03), reflux symptoms (OR=1.44, 95% CI=1.14-1.83, P=0.002), dysphagia (OR=1.88, 95% CI=1.28-2.77, P=0.001), throat discomfort (OR=4.58, 95% CI=1.00-21.02, P=0.05), globus (OR=2.95, 95% CI=1.52-5.73, P=0.001), hoarseness (OR=4.32, 95% CI=1.91-9.78, P=0.0004), cough (OR=3.48, 95% CI=1.13-10.72, P=0.03), Barrett's esophagus (OR=2.01, 95% CI=1.37-2.94, P=0.0003), and esophagitis (OR=1.62, 95% CI=1.27-2.07, P=0.0001). CONCLUSION: CIP appears to be common by using narrow-band imaging, especially if the endoscopists would like to pay attention to the detection of this lesion. CIP is clearly associated with acid-related symptoms and Barrett's esophagus.

Real world management of esophageal ulcers: analysis of their presentation, etiology, and outcomes.

BACKGROUND AND STUDY AIMS: Esophageal ulcers are a rare cause of upper gastrointestinal morbidity and may be due to different etiologies. We sought to systematically evaluate patients with esophageal ulcers and describe their presentations, endoscopic findings, etiologies, treatments, and outcomes. PATIENTS AND METHODS: Patients diagnosed with esophageal ulcers over an 11-year period were retrospectively identified from our institution's electronic medical records. RESULTS: We identified 100 patients with esophageal ulcers (0.49% of patients undergoing upper endoscopy). Half of them presented due to gastrointestinal bleeding and three-quarters were admitted to the hospital. The majority were in the lower esophagus. Twenty-two unique etiologies, including multiple iatrogenic causes, were diagnosed in 91 of the cases. The most common etiology was gastroesophageal reflux disease (57%), followed by non-steroidal anti-inflammatory drug use (7%), malignancies (3%), vomiting (3%), caustic ingestion (2%), pill esophagitis (2%) and radiation (2%). Many etiologies showed a predilection for specific segments of the esophagus. Nine ulcers required endoscopic intervention and all were treated successfully. Repeat endoscopies were performed 5 times for diagnostic or "second look" reasons, none of which changed the patients' diagnosis or treatment. No patients required surgery or stricture dilation. One patient's ulcer was complicated by perforation and he subsequently died. Four other patients died from non-ulcer related causes. CONCLUSIONS: While the majority of ulcers were due to gastroesophageal reflux disease, 22 different etiologies were identified. Many were due to medication or iatrogenic causes. Repeat endoscopy did not appear to be helpful. While the incidence was low, they were frequently associated with significant morbidity.