Relationships of CDXs and apical sodium-dependent bile acid transporter in Barrett’s esophagus

Barrett’s esophagus (BE) is characterized by intestinal metaplasia with the differentiated epithelium replaced by another type of epithelium morphologically similar to normal intestinal epithelium. The metaplasia is preceded by bile and acid reflux into the esophagus. BE is a premalignant condition associated with increased risk of esophageal cancer, especially esophageal adenocarcinoma. The Caudal-related homeodomain transcription factors Caudal-related homeodomain transcription factor CDX1 and CDX2 are expressed exclusively in the small and large intestine, playing important roles in proliferation and differentiation of intestinal epithelial cells. Ectopic expression of CDX1 and CDX2 occurs in BE. The apical sodium-dependent bile acid transporter (ASBT) is expressed primarily in terminal ileum where it is a key factor for intestinal reabsorption of bile salts. In addition to upregulation of CDX1 and CDX2, ASBT expression is up-regulated in BE. Furthermore, both CDX1/CDX2 and ASBT expressions are down-regulated in high-grade esophageal dysplasia. The alteration of the above-mentioned factors calls for attention: what is the relationship between CDXs and ASBT aberrant expression in BE? In this commentary, we discuss this issue on basis of the recent study done by Ma et al.

Reinterpretation of follow-up, high-resolution manometry for esophageal motility disorders based on the updated chicago classification

The aim of this study was to assess changes between primary classification of esophageal motility disease and follow-up classification by high resolution manometry (HRM) and to determine whether previously classified diseases could be recategorized according to the updated Chicago Classification published in 2011. We reviewed individual medical records and HRM findings twice for each of 13 subjects. We analyzed primary and follow-up HRM findings based on the original Chicago Classification. We then reclassified the same HRM findings according to the updated Chicago Classification. This case series revealed the variable course of esophageal motility disorders; some patients experienced improvement, whereas others experienced worsening symptoms. Four cases were reclassified from variant achalasia to peristaltic abnormality, one case from diffuse esophageal spasm to type II achalasia and one case from peristaltic abnormality to variant achalasia. Four unclassified findings were recategorized as variant achalasia. In conclusion, esophageal motility disorders are variable and may not be best conceptualized as an independent group. Original classifications can be recategorized according to the updated Chicago Classification system. More research is needed on this topic.

How to perform and interpret timed barium esophagogram

Timed barium esophagogram (TBE) is a simple and objective method for assessing the esophageal emptying. The technique of TBE is similar to usual barium swallow with some modifications, which include taking multiple sequential films at pre-decided time interval after a single swallow of a fixed volume of a specific density barium solution. While many authors have used height and width of the barium column to assess the esophageal emptying, others have used the area of the barium column. TBE is being used in patients with suspected or confirmed achalasia and to follow-up those who have been treated with pneumatic dilation or myotomy. This review discusses technique of performing TBE, interpretation and its utility in clinical practice.

Esophageal lichen planus: A case report and review of the literature

Esophageal involvement by lichen planus (ELP), previously thought to be quite rare, is a disease much more common in women and frequently the initial manifestation of mucocutaneous lichen planus (LP). Considering that the symptoms of ELP do not present in a predictable manner, ELP is perhaps more under-recognized than rare. To date, four cases of squamous cell carcinoma in association with ELP have been reported, suggesting that timely and accurate diagnosis of ELP is of importance for appropriate follow-up. In this case report, a 69-year-old female presented with dysphagia and odynophagia. She reported a history of oral LP but had no active oral or skin lesions. Endoscopic examination revealed severe strictures and web-like areas in the esophagus. Histologic examination demonstrated extensive denudation of the squamous epithelium, scattered intraepithelial lymphocytes, rare eosinophils and dyskeratotic cells. Direct immunofluorescence showed rare cytoid bodies and was used to exclude other primary immunobullous disorders. By using clinical, endoscopic, and histologic data, a broad list of differential diagnoses can be narrowed, and the accurate diagnosis of ELP can be made, which is essential for proper treatment and subsequent follow-up.

Atrophic gastritis: Risk factor for esophageal squamous cell carcinoma in a Latin-American population

AIM: To study the association between atrophic gastritis (AG) and esophageal squamous cell carcinoma (ESCC) in a Latin-America population.

METHODS: A case-control study was performed at two reference Brazilian hospitals including patients diagnosed with advanced ESCC and dyspeptic patients who had been subjected to upper gastrointestinal endoscopy, with biopsies of the gastric antrum and body. All cases with ESCC were reviewed by a single pathologist, who applied standard criteria for the diagnosis of mucosal atrophy, intestinal metaplasia, and dysplasia, all classified as AG. The data on the patients’ age, sex, smoking status, and alcohol consumption were collected from clinical records, and any missing information was completed by telephone interview. The association between AG and ESCC was assessed by means of univariate and multiple conditional logistic regressions.

RESULTS: Most patients were male, and the median age was 59 years (range: 37-79 years) in both the ESCC and control groups. Univariate analysis showed that an intake of ethanol greater than 32 g/d was an independent risk factor that increased the odds of ESCC 7.57 times (P = 0.014); upon multiple analysis, alcohol intake of ethanol greater than 32 g/d exhibited a risk of 4.54 (P = 0.081), as adjusted for AG and smoking. Smoking was shown to be an independent risk factor that increased the odds of ESCC 14.55 times (P = 0.011) for individuals who smoked 0 to 51 packs/year and 21.40 times (P = 0.006) for those who smoked more than 51 packs/year. Upon multiple analyses, those who smoked up to 51 packs/year exhibited a risk of 7.85 (P = 0.058), and those who smoked more than 51 packs/ year had a risk 11.57 times higher (P = 0.04), as adjusted for AG and alcohol consumption. AG proved to be a risk factor that increased the odds of ESCC 5.33 times (95%CI: 1.55-18.30, P = 0.008) according to the results of univariate conditional logistic regression.

CONCLUSION: There was an association by univariate conditional logistic regression between AG and ECSS in this sample of Latin-American population.

Immunohistochemical study of the digestive tract of Oligosarcus hepsetus

AIM: To describe the histology of the digestive tract and to investigate the occurrence of endocrine cells in Oligosarcus hepsetus (O. hepsetus).

METHODS: The digestive tract (DT) of O. hepsetus was divided into esophagus, two stomach regions (glandular and non-glandular) and two intestinal regions (anterior and posterior). These specimens were processed by routine histological techniques and stained with hematoxylin-eosin, Gomori’s trichrome, periodic acid Schiff (PAS) and Alcian blue (AB). An immunohistochemical method using avidin-biotin-peroxidase was employed.

RESULTS: The esophagus is lined with a non-keratinized stratified squamous epithelium that is reactive to PAS and AB. The stomach has a mucosa lined with a simple columnar epithelium with mucus-secreting cells that are reactive only to PAS. The intestine has a simple columnar epithelium with a brush border and goblet cells that are reactive to PAS and AB. Somatostatin, serotonin and cholecystokinin immunoreactive cells were identified throughout the DT.

CONCLUSION: This study revealed adaptations for the species’ diet and showed that the distribution and relative frequency of immunoreactive cells are similar to those of other fish.

Epstein-Barr virus associated lymphoepithelial carcinoma of the esophagus

Lymphoepithelial carcinoma (LEC), also called lymphoepithelioma-like carcinoma, is defined as an undifferentiated carcinoma or poorly differentiated squamous cell carcinoma, accompanied by a prominent reactive lymphoplasmacytic infiltrate. LEC can occur in many organs, but is most common in head and neck regions including pharynx. LEC may be associated with Epstein-Barr virus (EBV) infection. LEC of the esophagus is extremely rare; only nine cases have been reported. A 79-year-old man presented epigastralgia and dysphagia. A blood laboratory test showed no significant findings. He was a hepatitis C virus healthy carrier. Tumor markers of CEA and SCC were normal. Upper gastrointestinal endoscopy showed a tumor in the lower esophagus. Biopsies were taken, and they identified malignant epithelioid cells and heavy infiltration of mature lymphocytes. The epithelioid cells showed large size, nuclear atypia, mitotic figure, hyperchromasia, and increased nucleo-cytoplasmic ratio. The lymphocytes were free from atypia. Immunohistochemically, the epithelioid cells were positive for cytokeratin (CK) AE1/3, CK CAM5.2, CK WSS, CK MNF16, CK KL1, CK5/6, CK7, CK8, CK14, CK18, CK19, p53, and Ki-67 (labeling=27%). They were negative for CK34BE12, CK20, p63, CEA, CA19-9, NSE, synaptophysin, CD56, chromogranin, KIT (CD117), desmin, vimentin, MUC apomucins, and several leukocytic markers. The epithelioid cells were positive for EBV associated molecules including EBV-encoded nuclear antigen2 (EBNA2), EBV latent membrane protein-1 (LMP-1), and EBV early RNAs (EBER). The lymphocytes were positive for CD45 and vimentin, and were composed of B-cells positive for CD20, CD79α, bcl-2, and CD10, T-cells positive for CD3 and CD45RO, NK-cells positive for CD56, and plasma cells positive for CD38, CD138, CD79α, κ-chain, and λ-chain. No light chain restriction was seen. Most of the lymphocytes were B and T-cells, and NK-cells and plasma cells were very scant. The lymphoplasma cells were reactive cells, because of no atypia and also because no p53 and very low Ki-67 labeling (3%). The lymphocytes were negative for CD21 and other antigens such as CKs and EMA. The pathological diagnosis was primary LEC of the esophagus. Imaging techniques revealed lymph nodes metastasis of the perigastric and periaortic regions, but identified no other tumors in the body. The patient was inoperative, and was treated by chemoradiation. The esophageal LEC and lymph nodes metastases were markedly reduced in size.

The Role of Esophagogastric Anastomotic Technique in DecreasingBenign Stricture Formation in the Surgery of Esophageal Carcinoma

INTRODUCTION

Postoperative stenosis and dysphagia after esophageal carcinoma resection is the major problem. The aim of this study is to compare two types cervical esophagogastric anastomosis in reduction of stricture formation in esophageal cancer surgery.

METHODS

The subjects of this study were 223 patients undergoing esophageal carcinoma resection during 1998 to 2007. Twenty two patients were excluded from the study because of recurrent malignancy of anastomosis, mortality and losing in follow up period. Two hundred and one patients remained by the end of study were classified into two groups: 98 patients were treated by routinely transverse hand-sewn cervical esophagogastric anastomosis (group 1); and 103 patients were treated by the proposed oblique hand-sewn esophagogastric anastomotic technique (group 2). All the operations were with high abdominal and left cervical incisions (Transhiatal esophagectomy). All patients of both groups were followed up at least 6-month for detection of anastomotic strictures.

RESULTS

Postoperative dysphagia occurred in 20 patients of group 1 versus 5 patients of group 2. In working up by rigid esophagoscopy, two patients of group 2 and four patients of group 1 had not true strictures. Anastomotic strictures occurred in 16 cases of group 1, versus 3 cases of group 2. Statistical comparative analysis results of two groups about stricture formation were significant (3% versus 16% P= 0.003).

CONCLUSION

The oblique hand-sewn esophagogastric anastomostic techniques reduce markedly the rate of stricture formation after esophagectomy.

Foreign Body Endoscopy Experience of a University Based Hospital

BACKGROUND

Guidelines support endoscopic removal of certain gastric FB and all FB lodged in the esophagus. We aim to report our experience on endoscopic foreign bodies (FB) removal in order to aid in the formation of future guidelines regarding this subject.

METHODS

Retrospective analysis of one hundred forty-four cases of FB removal involving 43 patients who underwent esophagogastroduodenoscopy (EGD) for FB removal from January 2005 through December 2010 in a university-based hospital. To evaluate to outcome of endoscopic FB removal, cost of procedures and complications.

RESULTS

Of all FB removal cases, 23 (53%) were males, with total mean age of 26.4 ± 11.3 years. Only 20% were performed on an outpatient bases. Abdominal x-ray was obtained to confirm ingestion of FB in 83%, and computed tomography scan was performed in 13%. Most procedures were performed in operation room (59%) while only 21% of the cases were performed in endoscopy lab. General anesthesia was used in 58%, while monitored anesthesia care in 28%. Average time to EGD was 17.14 hours. No major complications due to procedure were reported. Minor trauma and erosions due to FB were reported in 14%. FB extraction was unsuccessful in only three cases, and one case required surgical intervention. Cost of all procedures was over 430, 000 dollars with mean of 2,990 dollars for procedure.

CONCLUSION

Endoscopic retrieval is effective and safe procedure, but utilizes significant hospital resources.

Mussel shell impaction in the esophagus

Mussels are commonly used in cooking around the world. The mussel shell breaks more easily than other shells, and the edge of the broken mussel shell is sharp. Impaction can ultimately cause erosion, perforation and fistula. Aside from these complications, the pain can be very intense. Therefore, it is essential to verify and remove the shell as soon as possible. In this report we describe the process of diagnosing and treating mussel shell impaction in the esophagus. Physicians can overlook this unusual foreign body impaction due to lack of experience. When physicians encounter a patient with severe chest pain after a meal with mussels, mussel shell impaction should be considered when diagnosing and treating the patient.

Esophageal pyogenic granuloma: endosonographic findings and endoscopic treatments

Pyogenic granuloma is a benign inflammatory vascular lesion, mainly found in the skin and oral mucosa. A few cases of pyogenic granuloma in the gastrointestinal tract have been reported, and the esophagus was the main site in these cases. These patients were diagnosed with pyogenic granuloma after they underwent upper endoscopy and biopsy. Endoscopic resection is a favorable treatment option for esophageal pyogenic granuloma. Recently, we observed characteristic endosonographic findings in two cases with esophageal pyogenic granuloma, which were then treated successfully by endoscopic resection.

Incidental finding of esophageal pneumatosis

Pneumatosis of the gastrointestinal tract is a rare condition characterized by the presence of air filled cavities in the gastrointestinal tract wall. Its occurrence has been described throughout the gastrointestinal tract from the esophagus to the rectum, however it is most commonly reported in the small intestine. Despite multiple case reports in literature, its pathogenesis still remains unclear. Pneumatosis may be idiopathic or associated with a variety of disorders namely peptic ulcer disease, jejunoileal bypass, intestinal obstruction and non-gastrointestinal disorders like asthma, chronic obstructive pulmonary disease, systemic lupus erythematosus, infectious enteritis, etc. We here present a rare case of pneumatosis of the esophagus diagnosed incidentally at an esophagogastroduodenoscopy (EGD). A 78-year-old asymptomatic woman underwent EGD and colonoscopy at our hospital for evaluation of anemia. Few months prior to EGD, she had undergone excision of laryngocele at our hospital. EGD revealed extensive submucosal blebs distributed throughout the esophagus, otherwise unremarkable stomach and duodenum. Colonoscopy showed a tubular adenomatous polyp. Since our patient was asymptomatic she did not require any surgical intervention. Management of pneumatosis depends on the underlying cause.

Small cell neuroendocrine carcinoma of the esophagus: report of 6 cases with immunohistochemical and molecular genetic analysis of KIT and PDGFRA

Small cell neuroendocrine carcinoma of the esophagus (SCNECE) is a very rare, but a highly aggressive tumor. Six cases of SCNECE (0.25%) were found in the 2,438 archival pathologic specimens of esophagus in the last 20 years in our pathology laboratory. The ages ranged from 62 years to 81 years with a mean of 73 years. All cases were male. The presenting symptoms were dysphagia in 5 cases and vomiting in 1 case. The locations were lower esophagus in 4 cases and middle esophagus in 2 cases. Endoscopically, the tumor was ulcerated in 3 cases and polypoid in 3 cases. All the 6 patients were treated by chemoradiation therapy, and the survival ranged from 6 months to 25 months with a mean of 13 months. Histologically, 5 cases were pure SCNECE, 1 case showed triplicate differentiation into small cell carcinoma, adenocarcinoma and squamous cell carcinoma. Immunohistochemically, each SCNECE showed at least one of the neurocrine antigens. Cytokeratins were positive in 6/6, vimentin 0/6, synaptophysin in 4/6, CD56 4/6, neuron-specific enolase 3/6, chromogranin 0/6, p53 protein in 6/6, KIT in 6/6, and platelet-derived growth factor receptor-α (PDGFRA) in 6/6. Ki-67 labeling ranged from 56% to 100% with a mean of 79%. A retrospective genetic analysis using PCR-direct sequencing method in paraffin sections identified no mutations of KIT (exons 9, 11, 13 and 17) and PDGFRA (exons 12 and 18) genes in all the 6 cases.

Peroral endoscopic myotomy for treating achalasia in an animal model: a feasibility study

Background/Aims

Laparoscopic Heller myotomy with antireflux procedure is considered to be a standard treatment for achalasia. Recently, peroral endoscopic myotomy (POEM) was developed and performed on patients with achalasia. However, there is no report on POEM use in South Korea. The aim of this study was to evaluate the technical feasibility of POEM in a porcine model.

Methods

POEM was performed on two mini pigs. We performed upper endoscopy under general anesthesia. A submucosal tunnel was created and the circular muscle layer was incised using several knives. The mucosal entry was closed using resolution clips. We performed a follow-up endoscopy and sacrificed the pigs 2 weeks after the POEM. The myotomy site was evaluated grossly and histologically.

Results

POEM was successfully performed on the two mini pigs. No injuries to any abdominal or mediastinal structures occurred. Two weeks after the POEM, the esophageal mucosa healed without any endoscopic evidence of complications. Necropsy revealed that the circular muscle layer was completely lost and replaced with fibrotic tissue.

Conclusions

We found that POEM is a technically feasible method which can be performed on an animal model. However, to ensure safe use on patients with achalasia, further studies on technical methods and long-term follow-up examinations are required.

A clinicopathologic study of esophageal 860 benign and malignant lesions in 910 cases of consecutive esophageal biopsies

The author reviewed 910 cases of consecutive esophageal biopsies in the last 15 year in the pathology laboratory of our hospital. There were 693 normal mucosa and benign lesions (76.2%) and 217 malignant lesions (23.8%). No significant changes were recognized in the esophagus in 50 biopsies (5.5%). In benign lesions, the number and frequency (percentages) were as follows: 263 chronic esophagitis (28.9%), 98 heterotopic gastric mucosa (10.8%), 3 heterotopic colonic mucosa (0.3%), 71 glycogenic acanthosis (7.8%), 68 candidiasis (7.5%), 35 benign ulcer (3.8%), 41 squamous papilloma (4.5%), 4 granular cell tumor (0.4%), 1 tubular adenoma (0.1%), 2 cytomegalovirus esophagitis (0.2%), 3 leiomyoma (0.3%), 17 basal cell hyperplasia (1.9%), and 37 Barrett's epithelium (4%). In malignant lesions, the number and frequency (percentages) were as follows: 53 mild dysplasia (5.8%), 29 moderate dysplasia (3.2%), 31 severe dysplasia (3.4%), 13 carcinoma in situ (1.4%), 68 squamous cell carcinoma (7.5%), 7 primary adenocarcinoma (0.8%), 1 primary signet ring cell carcinoma (0.1%), 4 primary small cell carcinoma (0.4%), 2 primary amelanotic malignant melanoma (0.2%), 1 primary undifferentiated sarcoma (0.1%), 7 gastric cancer invasion (0.8%), and 1 primary adenoid cystic carcinoma (0.1%). In this article, the clinicopathologic features of these esophageal lesions were described.

Clinicopathologic characteristics and survival outcomes of patients with advanced esophageal, gastroesophageal junction, and gastric adenocarcinoma: a single-institution experience

Most patients with gastric or gastroesophageal junction (gej) cancer are diagnosed with inoperable advanced or metastatic disease. In these cases, chemotherapy is the only treatment demonstrating survival benefit. The present study compares clinicopathologic characteristics and survival outcomes for patients with advanced esophageal, gej, and gastric adenocarcinoma treated with first-line chemotherapy [epirubicin-cisplatin-5-fluorouracil (ecf), epirubicin-cisplatin-capecitabine (ecx), or etoposide-leucovorin-5-fluorouracil (elf)] or best supportive care (bsc) at our institution with those for historical controls.

METHODS

We retrospectively reviewed medical information for 401 patients with newly diagnosed advanced esophageal, gej, or gastric adenocarcinoma treated with first-line chemotherapy (ecf, ecx, or elf) or bsc from January 1, 2004, through December 31, 2010. Descriptive statistics were used to compare the data collected with data for historical control patients.

RESULTS

Of the study patients, 93% were diagnosed with metastatic disease (n = 374), and 63% received bsc only (n = 251). The main reasons that patients received bsc only included poor Eastern Cooperative Oncology Group performance status (55%), patient decision (31%), and comorbidities (14%). Of the remaining patients, 98 (24%) received ecf or ecx and 52 (13%) received elf as first-line treatment. Median overall survival was significantly longer in patients treated with ecf or ecx or with elf than in those receiving bsc (12.7 months vs. 12.7 months vs. 5.5 months respectively). Chemotherapy also significantly reduced the risk of death (64% reduction with ecf or ecx, 58% with elf).

CONCLUSIONS

We confirmed the substantial overall survival benefit of combination chemotherapy compared with bsc, with better survival in our patient population than in historical controls. However, novel treatment options are still warranted to improve outcomes in this patient population.

Recurrent cervical esophageal stenosis after colon conduit failure: Use of myocutaneous flap

A 53-year-old male developed cervical esophageal stenosis after esophageal bypass surgery using a right colon conduit. The esophageal bypass surgery was performed to treat multiple esophageal strictures resulting from corrosive ingestion three years prior to presentation. Although the patient underwent several endoscopic stricture dilatations after surgery, he continued to suffer from recurrent esophageal stenosis. We planned cervical patch esophagoplasty with a pedicled skin flap of sternocleidomastoid (SCM) muscle. Postoperative recovery was successful, and the patient could eat a solid meal without difficulty and has been well for 18 mo. SCM flap esophagoplasty is an easier and safer method of managing complicated and recurrent cervical esophageal strictures than other operations.

Recurrent spontaneous esophageal rupture

Spontaneous rupture of the esophagus is a relatively uncommon event, and recurrent rupture is extremely rare. We present a patient who experienced and survived 2 spontaneous perforations of the esophagus, occurring 6 years apart. A 43-year-old man was admitted to our hospital with upper abdominal pain after vomiting. Esophagoscopy, esophagogram, and computed tomography were suggestive of esophageal rupture. Emergency left thoracolaparotomy revealed a 20-mm perforation of the left lower esophageal wall that had been previously repaired. After the perforation was repaired with a single-layer closure, the mediastinum and pleural cavity were drained. The patient recovered well and was discharged from the hospital on postoperative day 29. To the best of our knowledge, only 7 previous cases of recurrent spontaneous esophageal perforation have been reported in the literature.

Primary Malignant Melanoma of the Esophagus

Primary malignant melanoma of the esophagus is an extremely rare neoplasm arising from the esophageal mucosal melanocytes. We herein describe a patient of primary malignant melanoma of the esophagus, who was managed by thoracolaparoscopic esophagectomy.

Carcinoma of the gastroesophageal junction in Chinese patients

Carcinoma of the gastroesophageal junction (GEJ) is defined as carcinoma that crosses the GEJ line, irrespective of where the tumor epicenter is located. This group of cancer is rare but controversial. Based on study results from the majority of epidemiologic and clinicopathologic investigations carried out in Western countries, this cancer is believed to arise from Barrett’s esophagus (BE) and includes both distal esophageal and proximal gastric carcinomas because of similar characteristics in epidemiology, clinicopathology, and molecular pathobiology in relation to BE. As such, the most recent American Joint Committee on Cancer staging manual requires staging all GEJ carcinomas with the rule for esophageal adenocarcinoma (EA). This mandate has been challenged recently by the data from several studies carried out mainly in Chinese patients. The emerging evidence derived from those studies suggests: (1) both BE and EA are uncommon in the Chinese population; (2) almost all GEJ cancers in Chinese arise in the proximal stomach and show the features of proximal gastric cancer, not those of EA; (3) application of the new cancer staging rule to GEJ cancer of Chinese patients cannot stratify patients’ prognosis effectively; and (4) prognostic factors of GEJ cancer in Chinese are similar, but not identical, to those of EA. In conclusion, the recent evidence suggests that GEJ cancer in Chinese shows distinct clinicopathologic characteristics that are different from EA. Further investigations in molecular pathology may help illustrate the underlying pathogenesis mechanisms of this cancer in Chinese patients and better manage patients with this fatal disease.

Esophageal tissue engineering: A new approach for esophageal replacement

A number of congenital and acquired disorders require esophageal tissue replacement. Various surgical techniques, such as gastric and colonic interposition, are standards of treatment, but frequently complicated by stenosis and other problems. Regenerative medicine approaches facilitate the use of biological constructs to replace or regenerate normal tissue function. We review the literature of esophageal tissue engineering, discuss its implications, compare the methodologies that have been employed and suggest possible directions for the future. Medline, Embase, the Cochrane Library, National Research Register and ClinicalTrials.gov databases were searched with the following search terms: stem cell and esophagus, esophageal replacement, esophageal tissue engineering, esophageal substitution. Reference lists of papers identified were also examined and experts in this field contacted for further information. All full-text articles in English of all potentially relevant abstracts were reviewed. Tissue engineering has involved acellular scaffolds that were either transplanted with the aim of being repopulated by host cells or seeded prior to transplantation. When acellular scaffolds were used to replace patch and short tubular defects they allowed epithelial and partial muscular migration whereas when employed for long tubular defects the results were poor leading to an increased rate of stenosis and mortality. Stenting has been shown as an effective means to reduce stenotic changes and promote cell migration, whilst omental wrapping to induce vascularization of the construct has an uncertain benefit. Decellularized matrices have been recently suggested as the optimal choice for scaffolds, but smart polymers that will incorporate signalling to promote cell-scaffold interaction may provide a more reproducible and available solution. Results in animal models that have used seeded scaffolds strongly sug- gest that seeding of both muscle and epithelial cells on scaffolds prior to implantation is a prerequisite for complete esophageal replacement. Novel approaches need to be designed to allow for peristalsis and vascularization in the engineered esophagus. Although esophageal tissue engineering potentially offers a real alternative to conventional treatments for severe esophageal disease, important barriers remain that need to be addressed.

Tissue engineering for neuromuscular disorders of the gastrointestinal tract

The digestive tract is designed for the optimal processing of food that nourishes all organ systems. The esophagus, stomach, small bowel, and colon are sophisticated neuromuscular tubes with specialized sphincters that transport ingested food-stuffs from one region to another. Peristaltic contractions move ingested solids and liquids from the esophagus into the stomach; the stomach mixes the ingested nutrients into chyme and empties chyme from the stomach into the duodenum. The to-and-fro movement of the small bowel maximizes absorption of fat, protein, and carbohydrates. Peristaltic contractions are necessary for colon function and defecation.

Endoscopy in screening for digestive cancer

The aim of this study is to describe the role of endoscopy in detection and treatment of neoplastic lesions of the digestive mucosa in asymptomatic persons. Esophageal squamous cell cancer occurs in relation to nutritional deficiency and alcohol or tobacco consumption. Esophageal adenocarcinoma develops in Barrett's esophagus, and stomach cancer in chronic gastric atrophy with Helicobacter pylori infection. Colorectal cancer is favoured by a high intake in calories, excess weight, low physical activity. In opportunistic or individual screening endoscopy is the primary detection procedure offered to an asymptomatic individual. In organized or mass screening proposed by National Health Authorities to a population, endoscopy is performed only in persons found positive to a filter selection test. The indications of primary upper gastrointestinal endoscopy and colonoscopy in opportunistic screening are increasingly developing over the world. Organized screening trials are proposed in some regions of China at high risk for esophageal cancer; the selection test is cytology of a balloon or sponge scrapping; they are proposed in Japan for stomach cancer with photofluorography as a selection test; and in Europe, America and Japan; for colorectal cancer with the fecal occult blood test as a selection test. Organized screening trials in a country require an evaluation: the benefit of the intervention assessed by its impact on incidence and on the 5 year survival for the concerned tumor site; in addition a number of bias interfering with the evaluation have to be controlled. Drawbacks of screening are in the morbidity of the diagnostic and treatment procedures and in overdetection of none clinically relevant lesions. The strategy of endoscopic screening applies to early cancer and to benign adenomatous precursors of adenocarcinoma. Diagnostic endoscopy is conducted in 2 steps: at first detection of an abnormal area through changes in relief, in color or in the course of superficial capillaries; then characterization of the morphology of the lesion according to the Paris classification and prediction of the risk of malignancy and depth of invasion, with the help of chromoscopy, magnification and image processing with neutrophil bactericidal index or FICE. Then treatment decision offers 3 options according to histologic prediction: abstention, endoscopic resection, surgery. The rigorous quality control of endoscopy will reduce the miss rate of lesions and the occurrence of interval cancer.

The evaluation of retrospective pathological lesions on spirocercosis (Spirocerca lupi) in dogs

From 1998 to 2012, 42 dogs with spirocercosis referred to pathology Department of Veterinary Faculty, Tehran University. Frequency of spirocercosis was higher in October, November, December, January, February, March months. Averagely, the cases were 4.73 years old of age, so that 59.3 % of them were male. The major pathological findings were located in distal part of esophagus (57 %, n = 24), stomach (24 %, n = 10), and aorta (9.5 %, n = 4), respectively. In addition, 7 % (n = 3) were in esophagus and stomach, 2 % (n = 1) in esophagus and aorta, 42 % (n = 18) indicated pulmonary lesions with hyperemia, atelectasis, edema and pneumonia. In 35 % (n = 15) of cases were with hepatic lesions hyperemia and fatty change. However, 26 % (n = 11) cases demonstrated renal lesions with hyperemia, interstitial nephritis, and 24 % (n = 10) encompassed urinary bladder lesions with hyperemia and adhesive cystitis. Furthermore, sudden death occurred in 7 % (n = 3) as well as cachexia in 7 % (n = 3) cases. Some spirocercosis cases (12 %, n = 5) were accompanied by distemper disease, mixed mammary gland tumor (2 %, n = 1) and parasitic dermatitis due to demodicosis (9.5 %, n = 4). Presumably some of pathological findings were related or emerged by other sort of diseases such as distemper.

Malakoplakia of the esophagus caused by human papillomavirus infection

Malakoplakia is a rare granulomatous disease probably caused by infection and characterized histologically by Michaelis-Gutmann bodies. We report a more rarely seen case esophageal malakoplakia in a 54-year-old woman. She presented with coughing while eating and drinking. Gastroscopy showed yellow nodules in the esophagus, and endoscopic ultrasonography showed a space-occupying lesion in the substratum of the esophageal mucosa. All findings highly resembled esophageal cancer. Histopathological examination finally indentified this space-occupying lesion as malakoplakia and not cancer. Immunohistochemistry showed that she had human papillomavirus (HPV) infection in the esophagus, which indicates that infection was responsible for the malakoplakia. This is believed to be the first case of malakoplakia in the esophagus, and more importantly, we established that HPV infection was the initiator of esophageal malakoplakia.

Intramural hematoma of the esophagus after endoscopic pinch biopsy

Intramural hematoma of the esophagus (IHE) is an uncommon form of esophageal injury, which may be an intermediate of mucosal tear (Mallory-Weiss syndrome) or transmural rupture (Boerhaave's syndrome). To date, the pathogenesis of IHE has not been well documented. IHE may occur within the submucosal layer of the esophagus following dissection of the mucosa. The most commonly presented symptoms are sudden retrosternal pain, dysphagia and hematemesis. The disorder can occur spontaneously or secondarily to trauma. In this report, we present a case of IHE which occurred after endoscopic biopsy and was recovered following conservative management in a patient who was taking long-term aspirin medication.

Pathological evaluation of gastrointestinal endoscopic submucosal dissection materials based on Japanese guidelines

Endoscopic surgery first started as snare polypectomy and then progressed to endoscopic mucosal resection (EMR). In order to resect a lesion that is more than 2 cm, endoscopic submucosal dissection (ESD) was developed. ESD therapy has now been established and is being used for early stage neoplastic lesions in the stomach, colon, esophagus, larynx and pharynx. In ESD specimens, we deal with relatively small lesions; therefore, more meticulous and precise pathological diagnosis is required compared to that in surgically resected specimens. In addition, we should be expert in the eligibility criteria of the different organs for ESD therapy. Here, we explain the biopsy diagnosis, including the Japanese group classification as well as the Vienna classification, handling the specimen, including fixation, photography, cutting and paraffin embedding, histological type, depth, vascular invasion and evaluation of the surgical margins, based on the latest Japanese guidelines. Japanese histopathology diagnostic criteria for the stomach, colon and esophagus are also described. We also demonstrate some examples of those mentioned above.

Balloon Catheter Position and its Relationship with Esophageal Temperature during Pulmonary Vein Isolation using High-Intensity Focused Ultrasound

Background

HIFU can achieve PVI, but severe esophageal complications have happened. We analyzed relative position of HIFU balloon catheter (BC) to esophageal temperature (ET) probe and correlated it to ET changes.

Methods and Results

Before each ablation relative position of HIFU BC to ET probe was recorded in RAO 30º and LAO 40º. We compared ablations where ET at end of ablation was <38.5ºC or ≥38.5ºC and <40.0ºC or ≥40.0ºC.

A total of 600 images from 311 ablations in 28 patients (18 male, age 63±7 years), were analyzed. ET ≥38.5ºC was reached when distance from BC to ET probe was: <20mm in LAO for RSPV and <29mm in LAO for RIPV. For RIPV ET ≥38.5ºC was reached when angle between BC and ET probe was significantly smaller in LAO and RAO. ET ≥40.0ºC was reached when distance of BC to ET probe was: <20mm in LAO for RIPV, <14mm in RAO for RIPV, <18mm in RAO for LIPV. ET increased to ≥40.0ºC when distance from BC to ET probe was significantly longer in LAO for LIPV. For RIPV ET ≥40.0ºC was reached when angle between BC and ET probe was significantly smaller in LAO.

Conclusion

There is a relationship between distance/angle of HIFU BC to ET probe and ET: shorter distances and smaller angles can cause higher ET.

A case of EMRC for basaloid squamous carcinoma of the cervical esophagus

Basaloid squamous carcinoma (BSC) of the esophagus is a rare esophageal tumor. A 79-year-old man with a history of proximal gastrectomy for gastric adenocarcinoma in 2000 was followed-up by esophagogastroduodenoscopy (EGD) annually. In June 2010, EGD revealed a new protruding lesion in the cervical esophagus. The small lesion was approximately 5 mm in size. A biopsy specimen showed poorly differentiated squamous cell carcinoma. We performed endoscopic mucosal resection using a cap-fitted endoscope (EMRC). The histological diagnosis of the endoscopically resected specimen was BSC and the invasion depth was limited to the muscularis mucosae. Horizontal and vertical margins were negative. We report the case of superficial BSC in the cervical esophagus successfully resected by EMRC.

Intramural hematoma of the esophagus

We report the case of a patient with an intramural hematoma of the esophagus. This rare condition is more common in elderly women and can be misdiagnosed as cardiovascular or other digestive emergent disease. The classical clinical triad includes chest pain, sudden dysphagia or odynophagia and minor hematemesis. Known precipitating factors are Valsalva maneuver, blunt, direct or iatrogenic injuries, but spontaneous cases have also been described. Chest imaging including computed tomography or magnetic resonance imaging as well as upper gastrointestinal endoscopy are useful tools for diagnosis. The treatment is conservative and the prognosis usually excellent with complete resolution within a few weeks.

Colon carcinoma with unusual metastasis to the esophagus manifesting as multiple nodules and Dysphagia: management with systemic chemotherapy

We present here the rare clinical case of a 44-year-old gentleman with metastasis from colon carcinoma to the esophagus presenting with multiple nodules and dysphagia, which was successfully managed with systemic chemotherapy. The patient presented at our institution with 3-month history of dysphagia almost 4 years after being operated for stage III carcinoma in the sigmoid colon. Endoscopic findings showed multiple nodules at the gastroesophageal junction and mid esophagus. Histological features and immunostains confirmed the diagnosis of metastatic colon carcinoma. Because of evidence of extensive metastatic disease in the spine and liver requiring systemic therapy, the patient was treated with chemotherapy with irinotecan and cetuximab, with subsequent improvement in tumor markers, liver metastasis and symptoms of dysphagia. Even though repeat endoscopy showed no improvement in esophageal nodules, the overall response to chemotherapy was positive. In conclusion, we present a very rare, previously unreported case of metastases from colon cancer to the esophagus presenting as non-obstructive nodules and dysphagia that responded to systemic chemotherapy.

Factors predicting survival in patients with proximal gastric carcinoma involving the esophagus

AIM: To investigate the clinicopathologic features which predict surgical overall survival in patients with proximal gastric carcinoma involving the esophagus (PGCE).

METHODS: Electronic pathology database established in the Department of Pathology of the Nanjing Drum Tower Hospital was searched for consecutive resection cases of proximal gastric carcinoma over the period from May 2004 through July 2009. Each retrieved pathology report was reviewed and the cases with tumors crossing the gastroesophageal junction line were selected as PGCE. Each tumor was re-staged, following the guidelines on esophageal adenocarcinoma, according to the 7th edition of the American Joint Commission on Cancer Staging Manual. All histology slides were studied along with the pathology report for a retrospective analysis of 13 clinicopathologic features, i.e., age, gender, Helicobacter pylori (H. pylori) infection, surgical modality, Siewert type, tumor Bormann’s type, size, differentiation, histology type, surgical margin, lymphovascular and perineural invasion, and pathologic stage in relation to survival after surgical resection. Prognostic factors for overall survival were assessed with uni- and multi-variate analyses.

RESULTS: Patients’ mean age was 65 years (range: 47-90 years). The male: female ratio was 3.3. The 1-, 3- and 5-year overall survival rates were 87%, 61% and 32%, respectively. By univariate analysis, age, male gender, H. pylori, tumor Bormann’s type, size, histology type, surgical modality, positive surgical margin, lymphovascular invasion, and pT stage were not predictive for overall survival; in contrast, perineural invasion (P = 0.003), poor differentiation (P = 0.0003), > 15 total lymph nodes retrieved (P = 0.008), positive lymph nodes (P = 0.001), and distant metastasis (P = 0.005) predicted poor post-operative overall survival. Celiac axis nodal metastasis was associated with significantly worse overall survival (P = 0.007). By multivariate analysis, ≥ 16 positive nodes (P = 0.018), lymph node ratio > 0.2 (P = 0.003), and overall pathologic stage (P = 0.002) were independent predictors for poor overall survival after resection.

CONCLUSION: Patients with PGCE showed worse overall survival in elderly, high nodal burden and advanced pathologic stage. This cancer may be more accurately staged as gastric, than esophageal, cancer.

Esophageal lipoma: a rare tumor

Esophageal lipomas are rare tumors, making up 0.4% of all digestive tract benign neoplasms. Most of these lesions are clinically silent as a result of their small size, however, the majority of lesions over 4 cm have been reported to cause dysphagia, regurgitation and/or epigastralgia. We report a case of a 53 year-old African American female who presented with dysphagia. Computed tomography of the chest and esophagram confirmed esophageal lipoma as the cause of the patient's symptoms. Accurately diagnosing an esophageal lipoma is crucial in order to rule out potential malignant lesions, relieve patient symptoms and plan the appropriate treatment.

Pathogenesis of achalasia cardia

Achalasia cardia is one of the common causes of motor dysphagia. Though the disease was first described more than 300 years ago, exact pathogenesis of this condition still remains enigmatic. Pathophysiologically, achalasia cardia is caused by loss of inhibitory ganglion in the myenteric plexus of the esophagus. In the initial stage, degeneration of inhibitory nerves in the esophagus results in unopposed action of excitatory neurotransmitters such as acetylcholine, resulting in high amplitude non-peristaltic contractions (vigorous achalasia); progressive loss of cholinergic neurons over time results in dilation and low amplitude simultaneous contractions in the esophageal body (classic achalasia). Since the initial description, several studies have attempted to explore initiating agents that may cause the disease, such as viral infection, other environmental factors, autoimmunity, and genetic factors. Though Chagas disease, which mimics achalasia, is caused by an infective agent, available evidence suggests that infection may not be an independent cause of primary achalasia. A genetic basis for achalasia is supported by reports showing occurrence of disease in monozygotic twins, siblings and other first-degree relatives and occurrence in association with other genetic diseases such as Down’s syndrome and Parkinson’s disease. Polymorphisms in genes encoding for nitric oxide synthase, receptors for vasoactive intestinal peptide, interleukin 23 and the ALADIN gene have been reported. However, studies on larger numbers of patients and controls from different ethnic groups are needed before definite conclusions can be obtained. Currently, the disease is believed to be multi-factorial, with autoimmune mechanisms triggered by infection in a genetically predisposed individual leading to degeneration of inhibitory ganglia in the wall of the esophagus.

Hiccups as a presenting symptom of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic esophageal disease increasingly recognized in adults for its gastrointestinal manifestations. This paper discusses a young woman with EoE who presented with persistent hiccups and intermittent dyspepsia. The patient was initially treated with trials of both H(2) blocker and proton pump inhibitor. However, her hiccups resolved only after treatment with topical fluticasone. A repeat upper endoscopy while on steroid treatment demonstrated both histologic remission of EoE and resolution of esophageal trachealization. Our patient's clinical course supports an association between hiccups and EoE, suggesting that EoE be considered in the differential diagnosis of patients with refractory hiccups.

Surgical management and outcomes of severe gastrointestinal injuries due to corrosive ingestion

AIM: To report our experience in the surgical management of severe injuries of the gastrointestinal tract due to corrosive ingestion.

METHODS: A retrospective review of patients who underwent emergency surgery for severe gastrointestinal injuries following corrosive ingestion between 1983 and 2010 was carried out. Data was extracted from a prospectively maintained esophageal disease database. Severe corrosive injuries were defined as full thickness necrosis with perforation of the esophagus or the stomach (with or without involvement of the adjacent viscera) with resultant mediastinitis or peritonitis.

RESULTS: Between 1983 and 2010, 209 patients with corrosive injury of the esophagus were managed. Of these, 13 (6.2%) patients underwent emergency surgery for severe corrosive injury. The median age of the patients was 22 years and the median interval between ingestion of the corrosive substance and surgery was 24 h. The surgical procedures done included esophagogastrectomy alone (n = 6), esophagogastrectomy with duodenectomy (n = 4), esophagogastrectomy with pancreaticoduodenectomy (n = 1), esophagogastrectomy with splenectomy (n = 1) and distal gastrectomy with duodenectomy (n = 1). Two patients died in the postoperative period and one after discharge awaiting the second surgery. The factors significantly predictive of mortality following such an injury included renal failure at the time of initial presentation, presence of metabolic acidosis, delay of more than 24 h between corrosive ingestion and surgery, and corrosive induced adjacent organ injury (pancreatic) (P < 0.001, 0.02, 0.005 and 0.015 respectively). Ten patients underwent subsequent surgery for restoration of the alimentary tract continuity with a colonic pull-up (n = 8) and gastrojejunostomy (n = 1). In one patient, the attempted colon pull-up failed due to extensive scarring of the mesocolon. The median follow up (following restoration of continuity of the gastrointestinal tract) was 36.5 mo. One patient developed dysphagia due to a stricture at the anastomotic site, which was successfully managed by dilatation. Another patient developed severe aspiration, necessitating laryngeal inlet closure and permanent tracheostomy, and 3 patients complained of occasional regurgitation.

CONCLUSION: Management of severe corrosive injury involves prompt resuscitation and urgent surgical debridement. Although the subsequent restoration of continuity may be complicated and may not always be possible, long term outcomes are acceptable in the majority.

A case of papillary thyroid cancer recurring as an esophageal submucosal tumor

A 75-year-old woman who underwent a total thyroidectomy for papillary thyroid cancer 7 years previously presented with a palpable neck mass. Computed tomography (CT) showed two metastatic masses on the thyroid bed and another mass that looked benign originating from the esophageal wall. Endoscopic ultrasonography (EUS) showed a hypoechoic mass in the esophageal wall that looked similar to a gastrointestinal stromal tumor. The mass on the esophagus had intense fluorodeoxyglucose (FDG) uptake in positron emission tomography-computed tomography (PET-CT), which suggested the possibility of malignancy. Subsequently, after surgery, the mass in the esophagus was confirmed as a metastasis from the thyroid papillary carcinoma. Here we report this unusual case of papillary thyroid cancer that recurred as an esophageal submucosal tumor.

Successful surgical treatment of a spontaneous rupture of the esophagus diagnosed two days after onset

Esophageal perforation is a relatively uncommon disease with a high rate of mortality and morbidity. Delay in the diagnosis and treatment occurs in more than 50% of cases, leading to a mortality rate of 40–60%. Primary repair is generally considered the gold standard for patients who present within the first 24 h following perforation of the esophagus. In this paper, we present a case of successful surgical treatment of spontaneous rupture of the esophagus that was diagnosed 2 days after onset. The patient was a 42-year-old man admitted to internal medicine with a diagnosis of pleuritis and complaining of chest and back pain. The next day, computed tomography revealed left-sided pleural effusion and mediastinal emphysema. An esophagogram revealed extravasation of the contrast medium from the lower left esophagus to the mediastinal cavity. These results confirmed a rupture of the esophagus, and an emergency left thoracotomy was performed. The perforation was repaired with a single-layered closure and was covered with elevated great omentum obtained by laparotomy. The patient was discharged 23 days after the first surgery. In conclusion, primary repair surgery must be selected as the best treatment beyond 24 h if the patient's general state was stable and there was no evidence of clinical sepsis.

Ectopic Sebaceous Glands in the Esophagus: Endoscopic Findings over Three Years

Sebaceous glands in the esophagus are rare and are of particular interest because of their as yet unknown origin. We report a case with ectopic sebaceous glands diagnosed by esophageal endoscopy and biopsy, with follow-up endoscopic examinations for 3 years. Few cases with follow-up endoscopic findings have been reported. In our case, there were no significant overall changes during 3 years of follow-up, but the lesions fluctuated over time. While taking the endoscopic findings of the present or past cases into account, we discuss the possible pathogenic mechanisms of this condition.

Quantitative measurement of contrast enhancement of esophageal squamous cell carcinoma on clinical MDCT

AIM

To investigate contrast-enhanced computed tomography (CECT) for discriminating esophageal squamous cell carcinoma (ESCC) from normal esophagus and evaluating outcomes within tumors after chemoradiotherapy (CRT).

METHODS

Sixty-four patients with surgical ESCC served as group A, and underwent thoracic contrast-enhanced scan with 16-section multidetector row CT 1 wk before surgery. Thirty-five patients with advanced ESCC receiving 4-wk CRT and showing response to CRT served as group B, and underwent CT scans similar with group A 4 wk after completion of CRT. In group A, differences in CT attenuation values (in HU) between the preoperative ESCC and background normal esophageal wall (delta CT(1)), or between different background normal esophageal walls (delta CT(2)) were compared. Furthermore, delta CT(1) between group A and B was also compared.

RESULTS

In group A, mean delta CT(1) was higher than delta CT(2) (23.86 ± 10.59 HU vs 6.24 ± 3.06 HU, P < 0.05). When a delta CT(1) of 10.025 HU was employed at a cut-off value to discriminate ESCC from normal esophagus, a sensitivity of 89.1% and specificity of 90.6% were achieved. Mean delta CT(1) was lower in group B than in group A (9.25 ± 10.86 vs 23.86 ± 10.59, P < 0.05), and a delta CT(1) of 15.45 HU was obtained at a cut-off value to assess the CRT changes with a sensitivity of 76.6% and specificity of 77.1%.

CONCLUSION

CECT might be a clinical technique for discriminating ESCC from normal esophagus, and evaluating outcome in the tumors treated with CRT.

High resolution impedance manometric findings in dysphagia of Huntington’s disease

Conventional manometry presents significant challenges, especially in assessment of pharyngeal swallowing, because of the asymmetry and deglutitive movements of oropharyngeal structures. It only provides information about intraluminal pressure and thus it is difficult to study functional details of esophageal motility disorders. New technology of solid high resolution impedance manometry (HRIM), with 32 pressure sensors and 6 impedance sensors, is likely to provide better assessment of pharyngeal swallowing as well as more information about esophageal motility disorders. However, the clinical usefulness of application of HRIM in patients with oropharyngeal dysphagia or esophageal dysphagia is not known. We experienced a case of Huntington’s disease presenting with both oropharyngeal and esophageal dysphagia, in which HRIM revealed the mechanism of oropharyngeal dysphagia and provided comprehensive information about esophageal dysphagia.

Esophageal combined carcinomas: Immunohoistochemical and molecular genetic studies

Primary esophageal combined carcinoma is very rare. The authors herein report 2 cases. Case 1 was a combined squamous cell carcinoma and small cell carcinoma, and case 2 was a combined squamous cell carcinoma, adenocarcinoma, and small cell carcinoma. Case 1 was a 67-year-old man with complaints of dysphagia. Endoscopic examination revealed an ulcerated tumor in the middle esophagus, and 6 biopsies were obtained. All 6 biopsies revealed a mixture of squamous cell carcinoma and small cell carcinoma. Both elements were positive for cytokeratin, epithelial membrane antigen, and p53 protein, and had high Ki-67 labeling. The small cell carcinoma element was positive for synaptophysin, CD56, KIT, and platelet-derived growth factor-α (PDGFRA), while the squamous cell carcinoma element was not. Genetically, no mutations of KIT and PDGFRA were recognized. The patient died of systemic carcinomatosis 15 mo after presentation. Case 2 was a 74-year-old man presenting with dysplasia. Endoscopy revealed a polypoid tumor in the distal esophagus. Seven biopsies were taken, and 6 showed a mixture of squamous cell carcinoma, small cell carcinoma, and adenocarcinoma. The 3 elements were positive for cytokeratins, epithelial membrane antigen, and p53 protein, and had high Ki-67 labeling. The adenocarcinoma element was positive for mucins. The small cell carcinoma element was positive for CD56, synaptophysin, KIT, and PDGFRA, but the other elements were not. Mutations of KIT and PDGFRA were not recognized. The patient died of systemic carcinomatosis 7 mo after presentation. These combined carcinomas may arise from enterochromaffin cells or totipotential stem cell in the esophagus or transdifferentiation of one element to another. A review of the literature was performed.

Esophageal space-occupying lesion caused by Ascaris lumbricoides

Ascaris lumbricoides is the largest intestinal nematode parasite of man, which can lead to various complications because of its mobility. As the esophagus is not normal habitat of Ascaris, the report of esophageal ascariasis is rare. An old female presented with dysphagia after an intake of several red bean buns and haw jellies. The barium meal examination revealed a spherical defect in the lower esophagus. Esophageal bezoar or esophageal carcinoma was considered at the beginning. The patient fasted, and received fluid replacement treatment as well as some oral drugs such as proton pump inhibitor and sodium bicarbonate. Then upper gastrointestinal endoscopy was done to further confirm the diagnosis and found a live Ascaris lumbricoides in the gastric antrum and two in the duodenal bulb. The conclusive diagnosis was ascariasis. The esophageal space-occupying lesion might be the entangled worm bolus. Anthelmitnic treatment with mebendazole improved patient’s clinical manifestations along with normalization of the radiological findings during a 2-wk follow-up. Authors report herein this rare case of Ascaris lumbricoides in the esophagus, emphasizing the importance of awareness of this parasitic infection as it often presents with different and unspecific symptoms.

Calcium channel blockers and esophageal sclerosis: should we expect exacerbation of interstitial lung disease?

Esophageal sclerosis is the most common visceral manifestation of systemic sclerosis, resulting in impaired esophageal clearance and retention of ingested food; in addition, co-existence of lung fibrosis with esophageal scleroderma is not uncommon. Both the progression of generalized connective tissue disorders and the damaging effect of chronic aspiration due to esophageal dysmotility appear to be involved in this procedure of interstitial fibrosis. Nifedipine is a widely prescribed calcium antagonist in a significant percentage of rheumatologic patients suffering from Raynaud syndrome, in order to inhibit peripheral vasospasm. Nevertheless, blocking calcium channels has proven to contribute to exacerbation of gastroesophageal reflux, which consequently can lead to chronic aspiration. We describe the case of severe exacerbation of interstitial lung disease in a 76-year-old female with esophageal sclerosis who was treated with oral nifedipine for Raynaud syndrome.

Predictability of outcome of caustic ingestion by esophagogastroduodenoscopy in children

AIM: To assess the necessity of esophagogastroduodenoscopy (EGD) to predict the outcome of caustic ingestion in children.

METHODS: The study included 206 children who underwent EGD because of ingestion of caustic substances between January 2005 and August 2010. Retrospective analysis of data of the patients was performed.

RESULTS: The male/female ratio was 1.6 and mean age was 38.1 ± 28.8 mo. The caustic substances were acidic in 72 (34.9%) cases, alkaline in 56 (27.2%), liquid household bleach in 62 (30.1%), and unknown in 16 (7.8%). Fifty-seven (27.7%) patients were symptom-free. Significant clinical findings were observed in 149 (72.3%) patients. Upper gastrointestinal endoscopy findings of esophageal injury were grade 0 in 86 (41.7%) patients, grade 1 in 49 (23.8%), grade 2a in 42 (20.4%), grade 2b in 28 (13.6%), and grade 3a in 1 (0.5%) patient. 35 patients with grade 2a, 2b, and 3a injuries underwent esophageal dilation at second week of ingestion. Esophageal stricture, which necessitated a regular dilation program developed in 13 of the aforementioned 35 patients. There is no statistically significant difference in the rate of development of esophageal stricture between the patients who ingested acidic (15.3%) and alkaline (8.9%) substances (P = 0.32). Severe gastric injury was detected in 38 (18.5%) patients. The rate of development of gastric injury was significantly higher in the acidic group (14%) than in the alkaline group (2.9%) (P = 0.001). Out of 149 patients with clinical findings, 49 (32.9%) patients had no esophageal injury and 117 (78.5%) patients had no gastric lesion. Esophageal and severe gastric injuries were detected in 20 (35.1%) and 8 (14%) of patients with no clinical findings respectively. Pyloric stenosis developed in 6 patients. Pyloric obstruction improved with balloon dilation in 2 patients. Mean hospitalization time were 1.2 ± 0.5 d for grade 0 and 2.3 ± 5 d for grade 1 and 6.3 ± 6.2 d for grade 2a and 15.8 ± 18.6 d for grade 2b. It was significantly longer for patients with grade 2a and 2b injuries (P = 0.000).

CONCLUSION: Endoscopy is an effective technique for determining the presence of esophageal and gastric damage and to avoid unnecessary treatment in patients with no or mild injury.

Esophageal foreign body causing sustained stridor in an infant

The patient was an 8-month-old boy with a 2-month history of stridor. Initially, he had been diagnosed with bronchitis and/or asthma and treated with antibiotics, a β-antagonist and a leukotriene antagonist, but his symptoms were not relieved. An enhanced computed tomography scan showed a gas filled mass and tracheal compression above the level of the aortic arch, and barium swallow revealed an approximately 3 cm mass with irregular surface. Endoscopic examination showed a yellow foreign body (FB) with surrounding granulation tissue. The FB was removed surgically. Postoperative bronchoscopy showed improvement of tracheal compression. The patient had an uneventful recovery with disappearance of his stridor.

Foreign bodies: aspirated or ingested? A report of two unusual cases

INTRODUCTION

The diagnosis of foreign bodies in the upper aerodigestive tract is usually straightforward but sometimes it can be delayed or the location of esophageal and upper airway foreign bodies can be mistakenly interchanged.

CASE REPORT

We present two interesting cases that caused diagnostic challenges which could have led to serious complications if a greater delay in diagnosis had occurred.

CONCLUSION

In order to diagnose upper aerodigestive tract foreign bodies without delay, a careful history and physical examination with proper X-rays are helpful.

Primary malignant melanoma of the esophagus: A case report

The authors present the clinical case of an 87-year-old Caucasian male admitted to the emergency room with hematemesis. He had a history of intermittent dysphagia during the previous month. Endoscopic evaluation revealed an eccentric, soft esophageal lesion located 25-35 cm from the incisors, which appeared as a protrusion of the esophagus wall, with active bleeding. Biopsies were acquired. Tissue evaluation was compatible with a melanoma. After excluding other sites of primary neoplasm, the definitive diagnosis of Primary Malignant Melanoma of the Esophagus (PMME) was made. The patient developed a hospital-acquired respiratory infection and died before tumor-directed treatment could begin. Primary malignant melanoma represents only 0.1% to 0.2% of all esophageal malignant tumors. Risk factors for PMME are not defined. A higher incidence of PMME has been described in Japan. Dysphagia, predominantly for solids, is the most frequent symptom at presentation. Retrosternal or epigastric discomfort or pain, melena or hematemesis have also been described. The characteristic endoscopic finding of PMME is as a polypoid lesion, with variable size, usually pigmented. The neoplasm occurs in the lower two-thirds of the esophagus in 86% of cases. PMME metastasizes via hematogenic and lymphatic pathways. At diagnosis, 50% of the patients present with distant metastases to the liver, the mediastinum, the lungs and the brain. When possible, surgery (curative or palliative), is the preferential method of treatment. There are some reports in the literature where chemotherapy, chemohormonotherapy, radiotherapy and immunotherapy, with or without surgery, were used with variable efficacy. The prognosis is poor; the mean survival after surgery is less than 15 mo.

Removal of foreign bodies from esophagus with flexible endoscope - a case report

To present a case of impacted artificial denture in esophagus and its removal by flexible endoscope. A 28 year old male presented with history of ingesting his denture 2 h back. It was removed by flexible endoscope and flexible fibre optic forceps. Though rigid endoscopic removal of foreign body is safe and effective, but often requires general anaesthesia. The flexible fibre optic endoscopic removal, which can be done under local anaesthesia in outpatient department is a suitable alternative.

Trends in incidence of gastrointestinal tract cancers in Western iran, 1993-2007

BACKGROUND

Few studies have addressed the secular trend of malignancies in developing countries such as Iran. This study aimed to determine the trend in the incidence of gastrointestinal cancers during a period of 15 years in Kermanshah, Iran.

METHODS

All of the confirmed positive pathologic reports for esophageal, gastric and colorectal cancers from 1993 to 2007 were collected and compared with the data compiled in the provincial health center. The incidence rate was standardized for world population using a direct method. The Fay and Feuer method was used to calculate the 95% confidence intervals for each cancer in each year. Trends were investigated using linear regression.

RESULTS

Over the period, 2951 cases of gastrointestinal cancer were reported in Kermanshah Province. The age-standardized incidence rates for gastric, esophageal and colorectal cancers were 9.2, 8.1 and 4.5 per 100,000 respectively over 15 years. In all types, the incidence increased with age. The study showed that the incidence of gastric and esophageal cancers decreased annually by 0.28 (-0.67-0.11) and 0.36 (-0.70 - (-0.02)), respectively. Colorectal cancer demonstrated an increase in the incidence [0.14 (95% CI: -0.01-0.29) annually].

CONCLUSION

A decrease in the incidence of gastric and esophageal cancers and an increase in the incidence of colorectal cancer are in line with reports from other developing countries in epidemiologic transition. Such trends warrant in depth investigation for the exact reasons.