Idiopathic Esophageal Lipomatosis: An Incidental Benign Discovery

Gastrointestinal (GI) lipomatosis has been reported in the GI medicine literature, but esophageal lipomatosis has never been reported at all. We report the case of an 86-year-old man with multiple medical comorbidities who was admitted to our hospital for community-acquired pneumonia. Computed tomography angiography of his pulmonary arteries ruled out the possibility of pulmonary embolism but showed a 9-mm circumferential wall thickening in the proximal esophagus measuring −172 HU, which is similar in opacity to the adipose tissue. The patient was asymptomatic and without any current or prior symptoms of dysphagia or odynophagia. The barium esophagogram was unremarkable; there were no strictures, masses, or mucosal abnormalities. There was no evidence of esophageal dilatation on either imaging modality. Esophageal lipomatosis is only described in a few case reports in the radiological literature and, to our knowledge, has not been reported in the GI literature at all. It is important to highlight in the GI literature this as a benign entity that does not cause symptoms and typically does not warrant invasive diagnostic or therapeutic interventions.

Aortic compression of the esophagus: A case report and literature review

Distal aortic compression of the lower esophagus with consecutive dilatation of the proximal esophagus was first described in the literature in 1932. Here, the authors describe the case of a 66 year-old male complaining of gastroesophageal reflux. Due to a positive family history of carcinoma of the esophagus and compression of the dorsal esophagus during an esophageal barium swallow test, further tests were performed. Endoscopy and CT exam revealed a dilated esophagus due to compression of a crossing aorta. Because of mild symptoms and the absence of dysphagia, no further treatment was necessary except for the use of a proton pump inhibitor and recommended follow-ups every one to two years.

708 A NEW DIAGNOSTIC PARADIGM FOR LARYNGOPHARYNGEAL REFLUX DISEASE: CORRELATION OF IMPEDANCE-PH MONITORING AND DIGITAL REFLUX SCINTIGRAPHY RESULTS

No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR. Methods Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated. Results 105 patients with LPR (31 males (29.5%), median age 60 years (range: 20–87)) were studied. Scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). Abnormal reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and longer bolus clearance times (p = 0.002). Conclusion Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.

720 CONVENTIONAL AND SIMPLE METHODS OF MEASURING MEAN NOCTURNAL BASELINE IMPEDANCE SHOW EXCELLENT AGREEMENT

Mean nocturnal baseline impedance (MNBI) is a measurement that shows promise in investigating reflux disease by reflecting esophageal mucosal integrity. The conventional method of measuring MNBI is time-consuming and operator-dependent. A new, simple method of measuring MNBI has been suggested. This study aimed to report MNBI measurements by both conventional and simple methods in a cohort of laryngopharyngeal reflux (LPR) and gastro-esophageal reflux disease (GERD) patients to validate the simple measurement method. Methods 187 patients were divided into LPR (n = 105) or GERD (n = 82) groups by predominant symptom profile, and underwent off-therapy impedance-pH monitoring. MNBI was blindly measured by both conventional and simple methods, and values were correlated. Bland–Altman plots were constructed to assess mean differences and to identify bias between the two measurement methods. Results For the two measurement methods, mean difference in the distal esophagus was −89 (±328) ohms, in the proximal esophagus was −6 (±653) ohms, and in the pharynx was 128 (±577) ohms. There was strong correlation between conventional and simple MNBI values, with r = 0.940 in the distal esophagus, r = 0.463 in the proximal esophagus, and r = 0.712 in the pharynx (all p < 0.001). Conclusion There was excellent agreement between conventional and simple methods of measuring MNBI, with no evidence of proportional bias. Conventional and simple MNBI values correlated excellently in the distal esophagus, and moderately well in the proximal esophagus and pharynx. This study supports the use of the simple method of measuring MNBI to enhance diagnosis of reflux disease.

500 THE PATHOLOGICAL GASTROESOPHAGEAL REFLUX IN PATIENTS WITH CYSTIC FIBROSIS

The presence of gastroesophageal reflux in patients after lung transplantation rises the risk of posttransplantant complications. The aim of our study was to evaluate the severity of gastroesophageal reflux (GER) in patients with cystic fibrosis before lung transplantation. Methods 14 patients with cystic fibrosis, who refferred to our Centre, were included in this study, mean age 28,86 ± 2,5 (6 males and 8 females). The diagnosis of cystic fibrosis was established at the age of 1–5 y.o. according to clinic, sweet test and genetic tests. All patients were performed upper endoscopy, X-ray, esophageal manometry and 24 h impedance monitoring. PPI treatment was excluded for 7 days before monitoring. Pathologic GER was established when total number of refluxes in distal esophagus was more than 75, the total number of refluxes in proximal esophagus was more than 20% of those in the distal part. Results According to endoscopy, none of patients had erosions of the esophagus. Five patients had ineffective motility and one—diffuse esophageal spazm. 56% of patients had pathologic number of refluxes in distal esophagus. 80% subjects had pathologic refluxes in proximal esophagus. The mean number of total refluxes in distal part was 54,93 ± 5,7, in proximal part—27,64 ± 2,6 (it is 40% of those in distal part). The distribution of acid and non-acid refluxes in patients with pathologic refluxes was 2:1. We didn’t reveal any correlation between number of refluxes, ineffective motility and gastric emptying. Conclusion despite normal upper endoscopy, 56% of patients with cystic fibrosis have pathologic gastroesophageal reflux. Besides, the study showed high propagation of GER to proximal esophagus in 80% of subjects, which may play role in posttransplantation period.

779 USE OF INDOCYANINE GREEN TO ASSESS THE CORRECT VASCULARIZATION OF GASTROPLASTY IN MCKWEON ESOPHAGECTOMY

Cervical anastomostic leakage in esophageal surgery is one of the most serious complications and its incidence is 10–30% according to series. ndocyanine green is being used in multitude of surgical procedures in colorectal and hepatobiliary surgery. In this video we try to prove its usefulness to assess the adequate vascularization of the gastroplasty with the aim of reducing anastomotic leak due to not-well perfusion. Methods A left lateral cervicotomy was performed and proximal esophagus was divided. Then a handsewn purse-string suture was performed and the anvil of CEA 25 stapler was introduced into the esophagus. Gastroplasty was performed with endoGIA section by minilaparotomy. An intravenous infussion of Indocyanine green was used to assess the vascularization "in situ" of the gastroplasty. The gastroplasty was pull up through the retrosternal space and when the plasty was positioned in a correct way, the optimal site for the anastomosis was chosen. Mechanical T-L anastomosis with CEA 25 stapler was performed and it was covered with an omental flap. Video https://drive.google.com/file/d/1kqmNzJCdlJFOcxKBYRp0jamoHz6Gwgt7/view?usp=sharing.

Zenker’s diverticulum in an 85-year-old Ugandan man

Background Zenker’s diverticulum (ZD) is an uncommon disorder due to an outpouching of tissue through the Killian triangle that is thought to be caused by dysfunction of the cricopharyngeal muscle. Case presentation An 85-year-old male patient presented with odynophagia and dysphagia of initially solid food followed by fluids that was associated with a significant weight loss over a one-year period. Barium swallow videofluoroscopy demonstrated a posterior outpouching of proximal esophagus that was 2 cm from the epiglottis. With the diagnosis of medium sized ZD, the patient underwent endoscopy guided diverticulotomy. Six months after the procedure, he was asymptomatic and had gained weight. Conclusions Dysphagia and weight loss raises a clinical suspicion for a malignancy. Barium swallow examination is an inexpensive method for the diagnosis of ZD.

A Case Study Vignette for a Pediatric Patient With Eosinophilic Esophagitis

Objectives Eosinophilic Esophagitis (EoE) is a chronic inflammatory, immune/antigen-mediated condition of the esophagus. It is common in pediatric patients and can lead to several complications such as esophageal remodeling/fibrosis, growth stunting, and low bone mineral density. Nutrition interventions, such as elimination or elemental diets, are the first therapeutic tool for EoE management along with pharmacological interventions. Methods KS is a 20 month-old female whose weight-for-length has fallen above the 55th percentile since birth. She has a history of gastroesophageal reflux, dysphagia, and aspiration requiring thickened liquids for almost 2 years. During infancy she tolerated milk based thickened formula and transitioned to 1% milk at 1 year. She was diagnosed with EoE during a triple endoscope for laryngeal cleft repair. The pathology revealed rings and furrows in the mid/distal esophagus, and > 20 eosinophils per high powered field (HPF) in distal, mid, and proximal esophagus with evidence of subepithelial fibrosis. At that time she had no dietary restrictions or use of antacids. Since cleft repair, dysphagia improved and she started on a dairy free diet for EoE. However, she experienced an adverse reaction to dairy free nut-based cheese with subsequent positive radioallergosorbent testing to tree nuts. Follow-up endoscopy improved on an 8-week dairy and tree nut free diet, but eosinophils persisted in proximal esophagus with evidence of basal cell hyperplasia. Results The patient was able to make important strides towards remission by eliminating suspected trigger foods, with diagnosis and intervention initiation before signs of inadequate growth or nutrition. Conclusions Nutrition interventions are often imperative to achieve remission of EoE. There are potential nutrition related concerns including increased risk of nutrient deficiencies, inadequate growth, and poor quality of life as the patient follows an elimination/elemental diet. EoE should become a consideration when feeding or swallowing difficulties arise, especially in pediatric patients. Proper diagnosis, tailored interventions, and appropriate monitoring and evaluation with the help of a multidisciplinary team can lead to successful management. Funding Sources N/A.