Fractional Flow Reserve in the Diagnosis of Ischemic Heart Disease in a Patient with Coronary Artery Ectasia

Coronary artery ectasias (CAE) are diffuse dilatations of coronary artery segments with a diameter 1.5 times greater than the largest adjacent normal segment of the vessel. They are found in 0.3–5.0% of coronary angiography. Risk factors for CAE include atherosclerosis, previous percutaneous coronary interventions, arterial inflammation and connective tissue diseases. The diagnosis of CEA in a patient is a considerable diagnostic and therapeutic problem due to the unfavorable prognosis and the lack of guidelines. We present a case of a 69-year-old male patient with a history of retrosternal pain admitted to the clinic for the diagnosis of coronary artery disease. In coronary angiography, numerous ectases of the main coronary arteries and atherosclerotic lesions causing border stenosis of the left anterior descending (LAD), diagonal (2D) and marginal branch (OM). The heart team decided to assess the significance of the changes with the fractional flow reserve (FFR). The FFR was performed and haemodynamically insignificant stenoses of the ectatically dilated coronary arteries were found. The patient was qualified for conservative treatment.

Large Hiatal Hernia Associated with Cameron Ulcers and Consecutive Sideropenic Anemia: Case Presentation

BACKGROUND: Cameron lesions are seen in 5.2% of patients with hiatal hernia who undergo esophagogastroduodenoscopic examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernial sac, with an increased prevalence in the larger-sized sac. In about two-thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. AIM: The aim of this case report is to present the patient with Cameron ulcers associated with hiatal hernia. CASE PRESENTATION: Our patient presented with postprandial retrosternal pain, especially immediately after eating, vomiting, dyspnea, weight loss, fatigue, signs, and symptoms of severe hypochromic microcytic anemia without signs of acute gastrointestinal bleeding. No history of gastroesophageal disease. Colonoscopy was done and eliminate colic cause of anemia. The endoscopy showed a large hiatal hernia and linear erosions and ulcerations at the level of gastrodiaphragmatic contact (Cameron ulcers) and one non-sanguinant subcardial elipsoid ulceration. After conservative and operative treatment, there was significant clinically and laboratory improvement definitively, after 6 months. Cameron lesion is a rare cause of refractory sideropenic anemia. Diagnosis is very difficult in developing countries, where iron deficiency anemia is more common. A history of disease, clinical course, and laboratory findings are the important facts for diagnosis. CONCLUSION: Endoscopy is the gold standard for diagnosis, although it is not uncommon to overlook these lesions due to their unique location. There are two modalities for the treatment of Cameron lesions: Medical or surgical, which should be individualized for each patient. By severe refractory anemia and large hiatal hernia, associated with clinical signs, surgical approach is very important.

Paragastric, lesser omentum neural block to prevent early visceral pain after laparoscopic sleeve gastrectomy: A randomized clinical trial protocol

The somatic pain induced by surgical trauma to the abdominal wall after laparoscopic sleeve gastrectomy (LSG) is effectively managed using conventional analgesia and transversus abdominis plane (TAP) blocks. In contrast, the visceral, colicky, pain that patients experience after LSG does not respond well to traditional pain management. Patients typically experience epigastric and retrosternal pain that begin immediately after LSG and lasts up to 72 hours after LSG. This visceral type of pain has been ascribed to the spasm of the neo-gastric sleeve. The pain is often severe and requires opioid derivatives. Patients frequently have associated autonomic symptoms such as nausea, retching and vomiting. In the last 15 years at our institutions, we have used many analgesic strategies to manage this burdensome symptom in the more than 2000 LSG procedures we have performed, but none have been satisfactorily effective1,2.

Is a Non-Caloric Sweeteners-Free Diet Good To Treat Functional Gastrointestinal Disorder Symptoms? A Randomized Controlled Trial

BackgroundA diet containing Non-Caloric Sweeteners (NCS) is used to reduce calorie intake and blood sugar peaks in overweight and obese subjects. Nevertheless, some animal studies suggest that NCS consumption may increase Functional Gastrointestinal Disorder symptoms (FGDs); however, there are scant clinical trials in humans. The aim of the study was to compare the effect of consuming a diet containing NCS (c-NCS) versus a Non-Caloric Sweetener-free diet (NCS-f) on FGDs in adult volunteers.MethodsThis was a randomized, controlled, parallel-group study using two different diets for five weeks: diet c-NCS contained 50-100 mg/day NCS (80% sucralose and 20% aspartame, acesulfame K, and saccharin); NCS-f diet contained less than 10 mg/day NCS. FGDs were recorded according to the Rome III criteria, gastrointestinal symptom questionnaire, Bristol scale, food frequency questionnaire, and consumption questionnaire at the beginning (PreTx) and at the end (PostTx) of the study by a gastroenterologist and a nutritionist. This study conducted according to the CONSORT guidelines and it was registered at clinicaltrials.gov (identifier code: NCT04129762).ResultsParticipants were more often women than men in both groups (59% and 62%), with a median age of 22 years. FGDs were similar in both groups at the beginning of the study (PreTx) but significantly increased in the diet c-NCS group after five weeks (PostTx). The percentage of participants with diarrhea (PreTx=19% versus PstTx=56%; p=0.02), post-prandial discomfort (PreTx=9% versus PstTx=39%; p=0.02), constipation (PreTx=30% versus PostTx=56%; p<0.01), and burning or retrosternal pain (PreTx=13% versus PostTx=33%; p<0.01) significantly increased in the diet c-NCS group. Conversely, abdominal pain (PreTx=15% versus PostTx=3%; p=0.04), post-prandial discomfort (PreTx=26% versus PostTx=6%; p=0.02), burning or retrosternal pain (PreTx=15% versus PostTx=0%; p=0.02), early satiety (PreTx=18% versus PostTx=3%; p<0.01), and epigastric pain (PreTx=38% versus PostTx=3%; p<0.01) significantly decreased in the NCS-f diet group.Conclusion This study shows that diet c-NCS associates with increased FGDs including diarrhea, post-prandial discomfort, constipation, and burning or retrosternal pain. Interestingly, NCS-f diet concurs with decreased FGDs such as abdominal pain, post-prandial discomfort, burning or retrosternal pain, early satiety, and epigastric pain. A NCS-f diet could be a complementary strategy to alleviate FGDs. Trial registration: The ethics committee of the hospital approved this study with the registration number DI/19/301/03/020. This trial was registered at clinicaltrials.gov (identifier code: NCT04129762).

Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature

A 15-year-old male patient presented with dysphagia, regurgitation, weight loss and retrosternal pain. The diagnosis of achalasia was made 4 years before. The esophagogram revealed severe esophagus dilatation and the classic “bird-beak” termination. A Heller myotomy plus fundoplication and endoscopic balloon dilatation were conducted four months previously. Nevertheless, the symptoms persisted and the last high-resolution manometry study still showed achalasia type II. The patient underwent a peroral endoscopic esophageal myotomy (POEM). POEM is a feasible and safe procedure for experienced and properly- equipped health care delivery centers and could be used as a rescue treatment in refr e present the youngest patient with achalasia in our region who had a successful response to rescue POEM.

Symptomatic Heterotopic Gastric Mucosa in Distal Esophagus

Introduction Heterotopic gastric mucosa (HGM) in esophagus is commonly noted as an inlet patch at endoscopy. We describe a rare patient with symptomatic distal esophageal HGM. Case Report A 40-year-old male presented with retrosternal pain and marked odynophagia for the last 4 weeks without any history of ingestion of antibiotics, foreign body, or corrosive. Endoscopy showed abrupt circumferential transition to salmon pink mucosa at 35 cm from incisors. From 35 to 41 cm, there were areas of polypoid edematous thickening with few superficial ulcers of 1 to 3 mm. Squamous epithelium was visualized at narrow band imaging from 41 cm to the Z-line at 43 cm with no hiatus hernia. Biopsy showed gastric-type mucosa with parietal cells without dysplasia. Serology for cytomegalovirus and human immunodeficiency virus was negative. He was managed with proton pump inhibitors (PPIs) and prokinetics and improved symptomatically. Follow-up endoscopy at 3 months demonstrated healing of ulcers with persistence of HGM and pseudopolyps. He remains well on maintenance with PPI at 1-year follow-up. Conclusion Symptomatic HGM in distal esophagus is rare and can be differentiated from Barrett’s esophagus histologically and by presence of squamous epithelium between HGM and stomach. Inflammatory mass lesions may develop and mimic esophageal malignancy. Symptoms are largely due to acid production and usually respond to PPI.

Extraesophageal masks of gastroesophageal reflux disease: frequency, features of diagnosis and preparation of patients for ophthalmic surgery

Purpose. Evaluation of the frequency of gastroesophageal reflux disease (GERD) in the structure of somatic diseases of patients admitted to ophthalmic surgery, features of the manifestation and difficulties in diagnosing. Material and methods. The analysis of the preoperative state of 1213 patients with pathology of the gastrointestinal tract (GIT) was carried out. The frequency of GERD with typical and extraesophageal manifestations was studied. The assessment of the adequacy and effectiveness of drug therapy is given. Results. Pathology of the gastrointestinal tract in the structure of nosological forms of somatic diseases of patients entering ophthalmic surgery is 5–6%. GERD accounts for 30% of their number. Typical clinical manifestations of GERD occurred in 287 patients (79.1%). Of these, 203 people. (70.7%) were able to compensate for the disease, received adequate therapy with proton pump inhibitors. In 84 patients (29.3%), heartburn and epigastric discomfort persisted. In 76 patients (20.9%) with GERD, its extraesophageal manifestations were revealed. Have 29 people. (38%) they manifested themselves in the form of retrosternal pain. A paroxysmal dry cough, asthma attacks arising after eating, the appearance and aggravation of nocturnal symptoms of bronchial asthma disturbed 35 people (46%). Complaints of burning tongue, hoarseness, soreness when swallowing, sore throat, periodic laryngospasm were observed in 12 patients (16%). Conclusion. GERD takes the leading place among diseases of the upper gastrointestinal tract (more than 30%). About 21% are atypical manifestations of GERD. The most clinically significant among them, limiting the possibility of conducting planned surgical treatment, are cardiological and pulmonary masks. Modern etiopathogenetic treatment of GERD makes it possible to effectively stop the symptoms of the disease, avoid polypharmacy and unreasonable refusal in planned surgical treatment for patients with ophthalmic diseases. Key words: gastroesophageal reflux disease, extraesophageal manifestations, ophthalmic surgery.

Impact of Portal Vein Thrombosis on Endoscopic Variceal Band Ligation in Liver Cirrhosis

Background. Portal vein (PV) thrombosis (PVT) is a common complication of liver cirrhosis and can refer to thrombosis within the PV that can extend to its left or right branches and in some cases to the superior mesenteric vein or the splenic vein (Chawla and Bodh, 2015). For severe PVT patients, there are possibilities of increasing PV resistance and reduction of the blood flow though PV towards liver, which exacerbate liver function damage meanwhile elevating the gastrointestinal variceal bleeding risk. Endoscopic Variceal band ligation (EVL) is often used to prevent esophageal variceal bleeding; postoperative complications such as severe gastrointestinal bleeding and bleeding-related death, fever, retrosternal pain, and esophageal stenosis may appear. There was absence of the research which evaluated the impact of PVT in liver cirrhosis on the complication of endoscopic Variceal band ligation for now. We herein aimed to compare cirrhosis patients with and without PVT of recent complications after EVL. Method. We established the retrospective investigation on 144 consecutive cirrhosis patients (excluding patients with hepatocellular carcinoma and who received portal vein-systemic circulation devascularization or shunt surgery, splenectomy, hepatectomy, liver transplantation, transjugular intrahepatic portal vein stent shunt (TIPS), endoscopic varices Variceal ligation, or sclerotherapy before) who have received first endoscopic esophageal varices band ligation in Gastrointestinal Endoscopy Center of the First Affiliated Hospital, College of Medicine, ZheJiang University, between January 2014 and December 2017. Portal vein Doppler ultrasonography, liver computerized tomography (CT), and angiography or liver-enhanced magnetic resonance imaging (MRI) were applied to evaluate the portal vein thrombosis of each patient before EVL. There were 18 patients confirmed with portal vein thrombosis while the other 126 patients without PVT. The primary end point for this research is the upper gastrointestinal hemorrhage and related death occurred from the date of ligation until leaving hospital, and the secondary end point is the appearance of postoperative fever and retrosternal pain. Results. There are no significant differences of gastrointestinal bleeding, bleeding-related death, fever, or retrosternal pain after EVL and the length of hospital stays between cirrhotic patients with or without PVT ( P = 0.34 , 0.51 , 0.58 , 0.61 , 0.88 ). Conclusion. Liver cirrhosis with portal vein thrombosis did not increase incidence of recent complications of the endoscopic Variceal band ligation.

Abelchia: inability to belch/burp—a new disorder? Retrograde cricopharyngeal dysfunction (RCPD)

Case series This is retrospective case series involving 72 patients who presented with symptoms associated with inability to burp. The following symptoms was described by almost all the patients; retrosternal pain after eating or drinking, bloating feeling in the stomach, gurgling noise in the throat, excessive flatulence. These symptoms are worse with fizzy/carbonated drinks and beer. A full clinical history and examination plus endoscopic and in some cases barium a swallow radiological investigation was done. Procedure The surgery was performed under a general anaesthesia for all cases. Suspension pharyngoscopy in supine position using a Weerda diverticuloscope to identify the cricopharyngeal bar muscle. High dose of botulinum toxin A (botox) 100 iu was injected into the cricopharynxgeus muscle under a general anaesthesia. Results A total of 72 patients were diagnosed and undergone surgery between November 2016 and December 2020. There were 50 male and 22 female patients. Their average age was 30 (range 18–68 years old). All patients were able to burp again within first 4 weeks of the injection. This persisted even after the Botox worn off beyond the 3 months in 96% of cases. The average follow-up was 24 months post injection with longest follow-up 48 months (range 1–48 months). Conclusion The author reported a new condition of inability to burp due to failure of the cricopharyngeal sphincter to relax spontaneously and outcome of treatment using botulinum toxin A injection into the cricopharyngeus muscle. It is expected that the paralysing action of botulinum toxin injection last approximately 3 months. However, this group of patients seem to be cured even after the effect of the botox is worn off. The author therefore postulated that there might me some neural dysfunction that inhibits the brain to send signals to the cricopharyngeal sphincter to initiate burping. Once burping is re-established with the help of botox injection, spontaneous burping seems to occur and sustained even after the botox is worn off.

A pedunculated esophageal chondromatous hamartoma in a child

Esophageal tumors are uncommon in pediatric population and most of them are benign. Esophageal hamartomas have been reported extremely rare in children. These can present as intramural tumors of the esophageal wall or as polyps. Dysphagia is the main symptom described in their case, but other specific symptoms are also reported. Such symptoms encountered in clinical practice are represented by obstructive apnea episodes and bradycardia, poor weight gain, epigastric or retrosternal pain, hematemesis or melena, dysphonia or tracheal sounds. Diagnosis can be delayed due to the insidious onset and non-specific symptoms, therefore patient’s compliance to follow-up and broad, careful evaluation are mandatory. Preoperative imagistic assessment is extremely important for a precise definition of the tumor’s anatomical relations, especially when facing large tumors located in the posterior mediastinum. Herein we report a case of a large chondromatous polypoid hamartoma of the esophagus in a 9 years old boy, emphasizing over the diagnosis and surgical challenges we have met, along with comments on illustrative similar cases reported in the literature.