Found 94 Abstracts CONTROL ID: 1703114 TITLE: Esophageal Involvement as a First Clinical ...

155 Pages·2013·14.99 MB·English

Found 94 Abstracts

CONTROL ID: 1703114
TITLE: Esophageal Involvement as a First Clinical Presentation in a Patient with Newly-Diagnosed Pemphigus
Vulgaris and a Review of Literature
PRESENTER: Kalaiyarasi Kaliyaperumal
PRESENTER (INSTITUTION ONLY): Tan Tock Seng Hospital
PRESENTER (COUNTRY ONLY): Singapore
ABSTRACT BODY:
Purpose: Sir William Osler once famously said that the mouth is the window to the body. Fittingly enough, many
systemic diseases have oropharyngeal manifestations, and pemphigus vulgaris is no exception. However, esophageal
involvement in pemphigus is a rare manifestation, and to date, this has only been described in small case series and
case reports. However, it is an important clinical presentation that physicians have to be aware of, as timely
intervention and appropriate therapy can alter clinical outcome in such patients. Here, we report a 57-year-old woman
of Malay descent, who presented with odynophagia and few oral lesions with no cutaneous or pharyngeal
involvement, and was found to have newly-diagnosed pemphigus vulgaris after undergoing a diagnostic
esophagogastroduodenoscopy (OGD). She was initially treated for presumed oropharyngeal candidiasis, and failed to
improve with a one-week course of oral fluconazole. Diagnostic OGD showed the presence of characteristic bullous
blisters in the esophagus, commonly seen in pemphigus vulgaris. She then underwent a biopsy of her lip ulcers, which
confirmed the diagnosis. The patient was started on a course of oral prednisolone with marked improvement of her
symptoms. To date, she remains well.

By highlighting this unusual presentation, we hope to draw attention to the rarer presentations of pemphigus so that
these manifestations can be recognized early and uneccessary investigations, treatment and costs can be avoided.
Methods: N/A
Results: N/A
Conclusion: N/A
CURRENT CATEGORY: G. Clinical Vignettes/Case Reports
CURRENT SUB-CATEGORY: A. Esophagus
PRESENTATION TYPE: Oral or Poster
ACG Research Grant Support: No
Supported by Industry Grant: No
Commercial Products or Services: No
Initiated Research: Investigator
Financial Relationships: No
FDA Approval: No
Designed Study: Investigator
Abstract Author: Investigator
AUTH DESIG: ACG Membership Status <font color="red">*</font>:
Kalaiyarasi Kaliyaperumal : ACG Non-Member
Charles Vu : ACG Non-Member
(No Image Selected)
(no table selected)
AVERAGE SCORE: 5
REVIEWER FLAGS: (none)
REVIEWER RECOMMENDATION CODE DESCRIPTION: None
REVIEWER COMMENTS:
Somashekar Krishna: [No Comments]|Julia LeBlanc: [No Comments]|Girish Mishra: [No Comments]|Rayburn Rego:
[No Comments]
CONTROL ID: 1710045
TITLE: Non-Surgical Management Of A Fish Jaw Causing Esophageal Perforation
PRESENTER: Simi Singh
PRESENTER (INSTITUTION ONLY): Beth Israel Medical Center
PRESENTER (COUNTRY ONLY): United States
ABSTRACT BODY:
Purpose: The chosen treatment modality for foreign bodies causing esophageal perforation is crucial in determining
survival, but no therapeutic “gold standard" exists. We report a man with a foreign body esophageal perforation and
review the literature on esophageal perforation management.

Case Report: An 83-year-old man presented with hematemesis after ingesting a fish bone. Computed tomography
revealed a foreign body in the mediastinal esophagus and a focal tear with loculated pneumomediastinum. Endoscopy
found necrosis of the esophageal mucosa at 20-25 cm and an impacted fish jaw without visual perforation. The bone
was removed via rat-tooth forceps and a percutaneous endoscopic gastrostomy (PEG) was placed. On day 10,
esophagram showed no leak. Oral diet was advanced until day 15. The PEG tube was removed and he was
discharged home. After > one year, he is asymptomatic.

Discussion: Foreign bodies account for 7-14% of esophageal perforations. In a review of 2,394 esophageal foreign
body cases, the most commonly found objects were bones of fish (60%) and chickens (16%). Esophageal foreign
body perforations most often occur at the cervical level. Accepted criteria for non-surgical treatment include
perforation confined to the mediastinum, drainage of the cavity back into the esophagus, and clinical stability.
Perforations of the lower 2/3 of the esophagus may require surgery, but indications are controversial. In concordance
with suggested treatment algorithms, our patient’s confined cervical perforation was managed successfully with
conservative therapy. Given the variability in severity and presentation of esophageal perforations, it is important to
note that while preserving well-established principles, treatment cannot be limited to a simple algorithm.
Methods: N/A
Results: N/A
Conclusion: N/A
CURRENT CATEGORY: G. Clinical Vignettes/Case Reports
CURRENT SUB-CATEGORY: A. Esophagus
PRESENTATION TYPE: Oral or Poster
ACG Research Grant Support: No
Supported by Industry Grant: No
Commercial Products or Services: No
Initiated Research: Investigator
Financial Relationships: Not Applicable
FDA Approval: No
Designed Study: Investigator
Abstract Author: Investigator
AUTH DESIG: ACG Membership Status <font color="red">*</font>:
Simi Singh : ACG Non-Member
Lan Wang : ACG Member
William Brown : ACG Member
IMAGE CAPTION:
(no table selected)
AVERAGE SCORE: 5
REVIEWER FLAGS: (none)
REVIEWER RECOMMENDATION CODE DESCRIPTION: None
REVIEWER COMMENTS:
Somashekar Krishna: [No Comments]|Julia LeBlanc: [No Comments]|Girish Mishra: [No Comments]|Rayburn Rego:
[No Comments]
CONTROL ID: 1716684
TITLE: Subsquamous Esophageal Adenocarcinoma After Radiofrequency Ablation of Barrett’s Esophagus with High
Grade Dysplasia
PRESENTER: Subhash Chandra
PRESENTER (INSTITUTION ONLY): Greater Baltimore Medical Center
PRESENTER (COUNTRY ONLY): United States
ABSTRACT BODY:
Purpose: Buried metaplasia has been reported following ablation. However, the true potential for buried metaplasia to
progress to malignancy has not been established. Here, we report a case of adenocarcinoma beneath neo-squamous
epithelium following RFA for dysplastic long-segment Barrett’s esophagus (BE).
Case: A 67-year-old man with a history of coronary artery disease and tobacco abuse was referred to our center for
dysplastic BE (C5M7). The patient underwent RFA and optimal endoscopic ablation was achieved (initially with HALO-
360 and subsequently with HALO-90, total 2 sessions). On post-ablation surveillance EGD, no obvious residual BE
was seen, and biopsies from the original length of BE as per Seattle protocol (4 quadrant biopsies every centimeter)
revealed a single, small focus of well-differentiated adenocarcinoma underneath the squamous epithelium, invading
into the muscularis mucosa (Figure 1). Circumferential multiband mucosectomy was subsequently performed at the
site/level of adenocarcinoma. No further adenocarcinoma was detected in these specimens, but there was HGD
underneath the squamous epithelium. Surgical consultation was obtained; tumor board consensus (as well as patient
decision) was to proceed with endoscopic therapy. Repeat sessions of endoscopic resections and extensive biopsies
have not revealed dysplasia or carcinoma.
Discussion: To the best of our knowledge, only three definitive cases of subsquamous adenocarcinoma post-RFA
have been reported in the literature. One of the patients had a nodule, whereas the other appeared endoscopically
normal. Our case had an endoscopically normal appearing post-ablation esophagus. These emerging reports of
subsquamous adenocarcinoma highlight important aspects regarding the endoscopic management of dysplastic BE.
First, surveillance biopsies should be performed from the entire length of the original Barrett’s segment despite
endoscopically normal-appearing esophageal mucosa. Second, the biopsies should be performed meticulously
(Seattle protocol), and ensuring adequate depth to include subepithelial tissue. Finally, utilizing dedicated
gastrointestinal pathologists and consensus diagnosis and management plans are absolutely imperative.
Methods: N/A
Results: N/A
Conclusion: N/A
CURRENT CATEGORY: G. Clinical Vignettes/Case Reports
CURRENT SUB-CATEGORY: A. Esophagus
PRESENTATION TYPE: Oral or Poster
ACG Research Grant Support: No
Supported by Industry Grant: No
Commercial Products or Services: No
Initiated Research: Investigator
Financial Relationships: No
FDA Approval: No
Designed Study: Investigator
Abstract Author: Investigator
AUTH DESIG: ACG Membership Status <font color="red">*</font>:
Subhash Chandra : ACG Member
Danielle Marino : ACG Member
Vivek Kaul : ACG Member
Figure 1: Subsquamous Adenocarcinoma under low power.
IMAGE CAPTION: Figure 1: Subsquamous Adenocarcinoma under low power.
(no table selected)
AVERAGE SCORE: 2.75
REVIEWER FLAGS: Somashekar Krishna - Newsworthy?: 1
REVIEWER RECOMMENDATION CODE DESCRIPTION: None
REVIEWER COMMENTS:
Somashekar Krishna: [No Comments]|Julia LeBlanc: [No Comments]|Girish Mishra: [No Comments]|Rayburn Rego:
[No Comments]
CONTROL ID: 1722120
TITLE: A Broken Heart That's Hard to Swallow
PRESENTER: Rupa Sharma
PRESENTER (INSTITUTION ONLY): University of Illinois Hospital and Health Science
PRESENTER (COUNTRY ONLY): United States
ABSTRACT BODY:
Purpose: Introduction: Syncope is a common complaint for general practitioners though an uncommon presentation to
a GI office. We present a case of deglutition syncope, a rare syndrome that is often misdiagnosed.
Case Description: A 62-year-old female presented with a 3-year history of dysphagia and “passing out while eating”.
Her initial symptoms consisted of a sensation of food "sticking" at the lower aspect of her esophagus, followed by brief
loss of consciousness. She denied known trigger foods. Episodes occurred within the first few minutes of meals and
loss of consciousness lasted for several seconds. In addition, she noted a burning epigastric pain and a 30-pound
weight loss due to fear of eating. Previous upper endoscopy showed LA grade A esophagitis, with biopsies negative
for celiac disease and H. pylori. She was initiated on a protein pump inhibitor which improved her reflux symptoms.
Neurological evaluation had been negative for seizure and demyelinating disorders. High-resolution esophageal
manometry was performed, which showed normal peristalsis and normal EGJ relaxation. A 24-hour holter monitor was
then performed, which revealed both high degree atrioventricular block and sinus arrest associated with swallowing.
The patient was referred for cardiology evaluation and ultimately a dual chamber pacemaker was placed. Her
dysphagia and syncope completely resolved after pacemaker placement and symptoms have not recurred in nearly 1
year of follow-up.
Discussion: Forty-eight percent of syncopal episodes are non-cardiogenic and 5% of these are related to deglutition
syncope. Deglutition syncope is a vagally mediated response to stretch receptors in the LES that send efferent stimuli
to the heart, with the end result of sympathetic withdrawal. Susceptible patients include those with a history of
achalasia, esophageal diverticulum, esophageal stricture/spasm/cancer, and hiatal hernia. The temperature
(specifically colder) and stickiness of foods, as well as eating habits are thought to be triggering factors, however not
universal. Cessation of aggravating medications (antihypertensives, etc) is an initial approach to therapy. Surgical
correction has been successful in cases such as esophageal carcinoma and stricture. Treatment with anticholinergic
medications which block the vagal response can be initiated if not contraindicated. Pacemakers are a more invasive
option for patients without structural heart disease. It is also thought that esophageal muscular hypertrophy may play a
role, and thus myotomy vs. dilatation may play a role in treatment.
Methods: N/A
Results: N/A
Conclusion: N/A
CURRENT CATEGORY: G. Clinical Vignettes/Case Reports
CURRENT SUB-CATEGORY: A. Esophagus
PRESENTATION TYPE: Oral or Poster
ACG Research Grant Support: No
Supported by Industry Grant: No
Commercial Products or Services: No
Initiated Research: Investigator
Financial Relationships: No
FDA Approval: No
Designed Study: Investigator
Abstract Author: Investigator
AUTH DESIG: ACG Membership Status <font color="red">*</font>:
Rupa Sharma : ACG Non-Member
Benjamin Bryant : ACG Non-Member
Vijay Khiani : ACG Non-Member
Melissa Robinson : ACG Non-Member
Brian Boulay : ACG Member
(No Image Selected)
(no table selected)
AVERAGE SCORE: 3.25
REVIEWER FLAGS: (none)
REVIEWER RECOMMENDATION CODE DESCRIPTION: None
REVIEWER COMMENTS:
Somashekar Krishna: [No Comments]|Julia LeBlanc: [No Comments]|Girish Mishra: [No Comments]|Rayburn Rego:
[No Comments]
CONTROL ID: 1723758
TITLE: Use of a Fully Covered Self-Expanding Metal Stent (SEMS) for the Treatment of Dysphagia Due to Severe
Tortorous Presbyesophagus
PRESENTER: Andrew Mazulis
PRESENTER (INSTITUTION ONLY): Lutheran General Hospital Division of Gastroenterology
PRESENTER (COUNTRY ONLY): United States
ABSTRACT BODY:
Purpose: We describe a minimally invasive treatment option for chronic refractory dysphagia due to
presbyesophagus-associated acute angulation of the distal esophagus. The patient is an 80-year-old man who has
had chronic post-prandial vomiting and dysphagia for over 10 years. EGD with biopsies, manometry and imaging
studies were all normal. Antacids, Savary dilation and Botox therapy yielded only slight improvement. Patient had
been on a liquid and pureed diet, but solid foods continued to cause dysphagia with regurgitation.

Repeat esophagram revealed a torturous distal esophagus with a 90-degree angulation causing a “zig-zag”
appearance where a barium pill had obstructed [FIG 1A]. This angulation was further verified by EGD [FIG 1B]. The
patient was not a surgical candidate, so a 22x120-mm fully-covered SEMS (Boston Scientific) was placed under
endoscopic and fluoroscopic guidance. Distal stent migration was prevented by the acute angulation, causing a
stricture-effect below the proximal flare. Proximal migration was prevented by having the distal flare below the
gastroesophageal junction. Within two days, the patient was able to introduce solid foods into his diet for the first time
in years. Mild chest discomfort and heartburn during the first week was controlled with antacids. Repeat esophagram
at three months confirmed correct stent positioning and improved angulation [FIG 1C]. At six months, the patient was
extremely pleased with the significant improvement in his quality of life.

We demonstrate a novel use of a fully covered SEMS as a reversible, less invasive treatment option for benign
dysphagia due to severe tortuous presbyesophagus in select patients who are not surgical candidates. Patients
should be made aware of possible heartburn symptoms if the lower esophageal sphincter is stented. To our
knowledge, there have been no previous reports in the literature for the use of fully covered removable SEMS in this
clinical setting, and may pose to be an alternative treatment option when all other treatments have failed.

Methods: n/a
Results: n/a
Conclusion: n/a
CURRENT CATEGORY: G. Clinical Vignettes/Case Reports
CURRENT SUB-CATEGORY: A. Esophagus
PRESENTATION TYPE: Poster Only
ACG Research Grant Support: No
Supported by Industry Grant: No
Commercial Products or Services: No
Initiated Research: Investigator
Financial Relationships: Not Applicable
FDA Approval: No
Designed Study: Investigator
Abstract Author: Investigator
AUTH DESIG: ACG Membership Status <font color="red">*</font>:
Andrew Mazulis : ACG Member
Sarosh Bukhari : ACG Member
Kenneth Chi : ACG Member
IMAGE CAPTION:
(no table selected)
AVERAGE SCORE: 4.25
REVIEWER FLAGS: (none)
REVIEWER RECOMMENDATION CODE DESCRIPTION: None
REVIEWER COMMENTS:
Somashekar Krishna: [No Comments]|Julia LeBlanc: [No Comments]|Girish Mishra: [No Comments]|Rayburn Rego:
[No Comments]
CONTROL ID: 1724408
TITLE: Rapid Onset Oropharyngeal and Esophageal Dysphagia as the First Symptom of Botulism
PRESENTER: Carol Morris
PRESENTER (INSTITUTION ONLY): Einstein Medical Center
PRESENTER (COUNTRY ONLY): United States
ABSTRACT BODY:
Purpose: A 47-year-old African-American male presented to the emergency room after a fall resulting in an open tibial
and fibular fracture. He underwent incision and debridement (I&D), external fixation, with vacuum-assisted closure
device (VAC). Over the following two weeks, he had six subsequent I & D for a persistent non-healing wound. On day
14, he developed symptoms of rapidly progressing solid and liquid dysphagia over one day, associated with the
sensation of something “stuck” in his upper esophageal region. Most liquids caused immediate regurgitation. Head
maneuvers allowed esophageal transit of liquids. He had no other esophageal or abdominal symptoms. In retrospect,
he had noticed blurry vision, slurring of his speech and voice changes worsening over the past two days prior to the
occurrence of dysphagia symptoms. On exam, he was found to have bilateral ptosis, restricted range of motion in all
gazes, mildly reactive pupils, and no proptosis or conjunctival injection. He had no cervical lymphadenopathy, no oral
thrush or lesions, no skin rash. Laboratory values were within normal limits. Esophagogastroduodenoscopy was
normal. Manometry demonstrated severe ineffective peristalsis and poor bolus movement with both liquids and
viscous swallow. His upper-esophageal sphincter pressure was decreased, as were proximal muscle and pharyngeal
contractions. Barium esophagram with pill was not consistent with achalasia. Subsequently, the diagnosis of Wound
Botulism was confirmed. Supportive care was maintained and he required parenteral nutrition via dobhoff tube for two
weeks. One month later, he was able to tolerate a regular diet, and all symptoms resolved. Botulism is the most lethal
toxin known with spores that can survive in boiling temperatures for up to three to four hours. Traumatic injury to an
extremity can cause local production of toxin by Clostridium botulism in devitalized tissue at the site of a wound
causing a lack of acetylcholine release and disabling muscle contractions, resulting in descending paralysis. Little data
exists regarding the effects of the toxin on esophageal function. This case suggests the infection results in dysfunction
of both proximal and smooth muscle.
Methods: N/A
Results: N/A
Conclusion: N/A
CURRENT CATEGORY: G. Clinical Vignettes/Case Reports
CURRENT SUB-CATEGORY: A. Esophagus
PRESENTATION TYPE: Poster Only
ACG Research Grant Support: No
Supported by Industry Grant: No
Commercial Products or Services: No
Initiated Research: Investigator
Financial Relationships: Not Applicable
FDA Approval: No
Designed Study: Investigator
Abstract Author: Investigator
AUTH DESIG: ACG Membership Status <font color="red">*</font>:
Carol Morris : ACG Member
Yogesh Govil : ACG Member
Philip Katz : ACG Member
IMAGE CAPTION:
(no table selected)
AVERAGE SCORE: 3.25
REVIEWER FLAGS: (none)
REVIEWER RECOMMENDATION CODE DESCRIPTION: None