Esophageal Radiography Interpretation: a Primer for the Gastroenterologist.

PURPOSE OF REVIEW: Radiological studies can be helpful when evaluating patients with suspect esophageal disorders. From benign strictures to malignancy and motility disorders such as achalasia, imaging modalities play a significant role in diagnosis. This review explores the role of different imaging modalities in the most frequently encountered esophageal pathologies. RECENT FINDINGS: Conventional barium esophagram has long been considered the primary imaging modality of the esophagus. In the same fashion, a timed barium esophagram is a valuable tool in the evaluation of achalasia and esophagogastric junction outlet obstruction. Over the last few decades there has been an increase in CT and MRI studies, which also play a role in the evaluation of esophageal pathologies. However, not infrequently, these newer imaging techniques can result in incidental esophageal findings. It is important that gastroenterologists appreciate the value of different modalities and recognize key imaging features. The diagnosis and management of esophageal disorders is evolving. A basic understanding of esophageal radiology is essential to any gastroenterologist caring for patients with esophageal complaints.

Esophageal epidermoid metaplasia. An unusual find.

A 62-year-old woman presented with an episode of upper gastrointestinal bleeding. Upper endoscopy revealed white exudates at the middle and lower third of the esophagus. Biopsies proved epidermoid metaplasia of the esophagus with low-grade dysplasia. We discuss the risk factors, preneoplastic potential and available treatments of this entity.

Black esophagus.

A 76-year-old man with multiple cardiovascular risk factors (hypertension, DM2, LD, smoker) and severe peripheral arterial disease (iliofemoral bypass, supracondylar amputation) came to the emergency with coffee ground emesis and mild anemia. Urgent gastroscopy showed diffuse circumferential black mucosa covered by fibrin affecting the middle and distal esophageal third. Acute esophageal necrosis is a rare cause of gastrointestinal bleeding that should be suspected in patients with cardiovascular risk factors with an image of a black esophagus that is abruptly interrupted at the EGJ.

Esophageal stricture as an initial manifestation of Crohn's disease.

Crohn's disease located in the esophagus is rare, being exceptional as the initial manifestation of the disease. Erosive ulcerative esophagitis, stricture and fistula are forms of presentation, as in other esophageal pathologies, so the differential diagnosis is broad. The histologic features of esophageal Crohn's disease can be nonspecific and increase the diagnostic challenge. Esophageal Crohn's disease should be included in the differential diagnosis of esophageal strictures and may require esophagectomy if medical-endoscopic treatment is not effective.

Heterotopic Gastric Mucosa in Middle Esophagus Complicated with Esophageal Ulcers.

Heterotopic gastric mucosa (HGM) of esophagus, primarily occurring in cervical esophagus, is usually asymptomatic. A healthy woman (mid-40s) with postprandial heartburn was diagnosed with middle esophageal HGM and esophageal ulcers by esophagogastroduodenoscopy. Using 8-channel pH monitoring, a sensor near the HGM area detected postprandial acid phase (pH 3-4), while areas adjacent to the proximal and distal sensors were neutral, suggesting acid secretion from the HGM. A biopsy showed fundic gland tissue expressing H+/K+-ATPase and pepsinogen-I. Oral vonoprazan improved the clinical symptoms and endoscopic findings. This is the first report using 8-channel pH monitoring to diagnose extremely rare middle esophageal HGM.

Recidivant odynophagia secondary to persistent esophageal candidiasis in an immunocompetent patient: the importance of brush cytology.

We present the case of a 53-year-old smoker woman without any relevant medical history who was attended as an outpatient due to several-month persistent odynophagia. An upper gastrointestinal endoscopy was performed, showing white cotton-like plaques throughout the esophagus, suggestive of candidiasis. An esophageal brushing plus biopsy sampling were done, empirically prescribing oral fluconazole for 21 days. A viral serology was also requested, with negative results. Clinical improvement was present until the suspension of antifungal treatment, with an odynophagia relapse afterwards. Cultures were positive for C.albicans sensitive to fluconazole.

Evolution, lessons learned, and contemporary outcomes of esophageal replacement with jejunum for children.

BACKGROUND: The jejunal interposition is our preferred esophageal replacement route when the native esophagus cannot be reconstructed. We report the evolution of our approach and outcomes. METHODS: The study was a single-center retrospective review of children undergoing jejunal interposition for esophageal replacement. Outcomes were compared between historical (2010-2015) and contemporary cohorts (2016-2019). RESULTS: Fifty-five patients, 58% male, median age 4 years (interquartile range 2.4-8.3), with history of esophageal atresia (87%), caustic (9%) or peptic (4%) injury, underwent a jejunal interposition (historical cohort n = 14; contemporary cohort n = 41). Duration of intubation (11 vs 6 days; P = .01), intensive care unit (22 vs 13 days; P = .03), and hospital stay (50 vs 27 days; P = .004) were shorter in the contemporary cohort. Anastomotic leaks (7% vs 5%; P = .78), anastomotic stricture resection (7% vs 10%; P = .74), and need for reoperation (57% vs 46%; P = .48) were similar between cohorts. Most reoperations were elective conduit revisions. Microvascular augmentation, used in 70% of cases, was associated with 0% anastomotic leaks vs 18% without augmentation; P = .007. With median follow-up of 1.9 years (interquartile range 1.1, 3.8), 78% of patients are predominantly orally fed. Those with preoperative oral intake were more likely to achieve consistent postoperative oral intake (87.5% vs 64%; P = .04). CONCLUSION: We have made continuous improvements in our management of patients undergoing a jejunal interposition. Of these, microvascular augmentation was associated with no anastomotic leaks. Despite its complexity and potential need for conduit revision, the jejunal interposition remains our preferred esophageal replacement, given its excellent long-term functional outcomes in these complex children who have often undergone multiple procedures before the jejunal interposition.

Caracterización de pacientes con lesiones premalignas de esófago / Characterization of patients with esophagus premalignant lesions

Introducción: Los tumores de esófago constituyen lesiones benignas o malignas, que afectan las diferentes capas del órgano. Objetivo: Caracterizar a pacientes con lesiones premalignas de esófago halladas en endoscopia bucal, según variables seleccionadas. Métodos: Se efectuó un estudio observacional, descriptivo y transversal en el Servicio de Gastroenterología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, durante el 2015. El universo estuvo constituido por 57 pacientes de 20 años y más, con diagnóstico endoscópico e histológico de lesión premaligna de esófago. Las variables analizadas fueron: edad, sexo, lesiones premalignas de esófago, grado de esofagitis y diagnóstico histológico. Resultados: La endoscopia mostró un predominio de la esofagitis por reflujo en los pacientes de 62 años y más (61,7 %), así como del grado A de la clasificación de los Ángeles en ambos sexos (39,7 y 30,1 % de mujeres y hombres, respectivamente). Según el diagnóstico histológico primaron la esofagitis crónica (48,4 %) y la esofagitis crónica con displasia (17,1 %). Conclusiones: La identificación de pacientes con lesiones premalignas de esófago constituye el punto de partida para futuras acciones preventivas e intervencionistas, con vistas a disminuir la incidencia del cáncer de esófago.

Introduction: The esophagus malignancies constitute benign or malignant lesions that affect the different layers of the organ. Objective: To characterize patients with esophagus premalignant lesions found in oral endoscopy, according to selected variables. Methods: An observational, descriptive and cross-sectional study was carried out in the Gastroenterology Service of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba, during 2015. The universe was constituted by 57 patients aged 20 and over, with endoscopic and histologic diagnosis of esophagus premalignant lesion. The analyzed variables were: age, sex, esophagus premalignant lesions, degree of esophagitis and histologic diagnosis. Results: The endoscopy showed a prevalence of the esophagitis by reflux in patients aged 62 and over (61.7 %), as well as of the grade A of Los Angeles classification in both sexes (39.7 and 30.1% of women and men, respectively). According to the histologic diagnosis there was a prevalence of chronic esophagitis (48.4 %) and chronic esophagitis with dysplasia (17.1 %). Conclusions: The identification of patients with esophagus premalignant lesions constitutes the starting point for future preventive and interventionists actions, aimed at diminishing the incidence of esophagus cancer.

Clinical Functional Lumen Imaging Probe Testing in Esophageal Disorders: A Need for Better Quality Evidence.

In their article "Use of the Functional Lumen Imaging Probe in Clinical Esophagology," Savarino et al. report the outcomes of a Grading of Recommendations Assessment, Development, and Evaluation analysis performed by experts in the use of functional lumen imaging probe (FLIP) evaluation of esophageal disorders. For essentially all clinical indications, the recommendation for use was conditional with a very low quality of evidence. FLIP is an expensive, invasive technology examining limited aspects of esophageal function. Its role in complementing or replacing existing technology is uncertain, particularly when compared with manometric testing with additional provocative studies. Performing properly designed studies to demonstrate FLIP's true effectiveness and cost-effectiveness will be costly.