Further evidence for Zenker’s diverticulum in a slim woman with body figure predisposition: a case report and literature review

Zenker’s diverticulum (ZD) is a bag-like pharyngeal pouch that protrudes to the outside of the pharynx. It is thought to be an acquired disease that occurs following the dysfunction of laryngopharynx muscle, and certain body shapes may be predisposed to this condition. We report a 56-year-old female of slim build with ZD. Computed tomography scanning revealed a hypodense lesion on the left posterior side of her upper esophagus that was filled with air and had no obvious wall. To verify this finding, a barium esophagogram was carried out which showed a round pouch at the level of the 6th cervical vertebral body that communicated with the esophagus through a narrow neck. ZD was subsequently confirmed by endoscopy. These findings provide further evidence in support of a body shape predisposition for ZD.

Role of endoscopic ultrasonography in the diagnosis of dysphagia aortica

Dysphagia aortica is an unusual cause of dysphagia. Diagnosis of this condition is usually based on chest radiography, barium esophagogram, chest computed tomography, endoscopy, and aortography. We report a case of dysphagia aortica who was successfully diagnosed using endoscopic ultrasonography and treated with life style modification and medications. Keywords: dysphagia aortica; aortic aneurysm; endoscopic ultrasonography; endoscopy.

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.

Endoscopic treatment of subglottic stenosis in children

Introduction. Subglottic stenosis is one of the most common causes of upper airway obstruction. The incidence of post-intubation stenosis ranges from 0.9% to 3% (Rodríguez H. et al.), or from 0.2% to 20% (Haranal M.Y. et al.). Currently, there is no consensus on the choice of surgical tactics due to a large number of modalities for surgical restoration of the laryngeal lumen.Material and methods. 44 patients with postintubation laryngeal stenosis were treated in the surgical thoracic department of the National Medical Research Center of Children’s Health subordinate to the Ministry of Health of the Russian Federation during 2019-2021. The average age of patients in this group was 4 years 8 months ± 3 years 8 months. Endoscopic treatment was done to 24 patients (54.5%). Laryngoscopy, fibrobronchoscopy, multispiral computed tomography and, if necessary, barium esophagogram were done for additional diagnostics.Results. The average number of endoscopic procedures per patient was 2.9 ± 1.5 (range from 1 to 7). Good results were seen in 20 patients (83.3%).Conclusions. Endoscopic techniques are alternative options to open reconstructive surgery. These techniques give good results in treating stenoses in the subglottic space and give a good chance to avoid tracheostomy in a certain group of patients, which, according to the results of our study, was as large as 79.1%.

807 ASSOCIATION OF BOLUS TRANSIT TIME ON BARIUM ESOPHAGOGRAM WITH ESOPHAGEAL PERISTALSIS

The threshold criteria for diagnosing ineffective esophageal motility (IEM) has changed over the years and is based on the proportion of failed and weak peristalses. Bolus transit time (BTT) on barium esophagogram (BE) can intuitively be the ‘gold standard' for assessing the effectiveness of esophageal peristalsis. The aim of this study was to associate upright and prone BTT with esophageal peristalsis and dysphagia in patients with normal lower esophageal sphincter (LES) parameters. Methods Patients with normal LES on high-resolution manometry (HRM) who also had a standard-protocol BE from 2017 to 2020 were included. Patients with previous foregut surgery, hiatal hernia, jackhammer esophagus, distal esophageal spasm, fragmented peristalsis, and those with < or > 10 single swallows on HRM were excluded. Based on the number of normal swallows (DCI >450 mmHg.s.cm), the patients were divided into 11 groups (10 normal to 0 normal). Upright and prone BTT were measured on BE. Fractional polynomial and logistic regression analysis were used to study association (along with rate of change) between BTT, dysphagia, and peristalsis. Results In total, 146 patients met the inclusion criteria. Prone BTT increased in tandem with a decrease in the number of normal peristalses (p < 0.001), but no difference was noted in upright BTT (p = 0.317). Two deflection points were noted on the association between peristalsis and prone BTT at 50%, 40 seconds and 30%, 80 seconds on the y and x-axes, respectively, after which declining peristaltic function was independent of prone BTT. Patients with prone BTT >40 seconds had nearly 6-fold higher odds of having zero normal peristalses (p = 0.002). Increasing prone BTT was associated with increasing dysphagia (p < 0.05). Conclusion Prone, but not upright BTT, correlates with the proportion of normal esophageal peristalses and dysphagia. The phenotype of abnormal swallows (failed, weak) appears to have minimal impact on BTT. The current perspective of manometric classification may need to be adjusted to use the proportion of normal peristalses as a criterion.

Non‐operative management of bilateral contained thoracic esophageal perforation: a case report

Background Despite profound advances in conservative management of esophageal perforation, patients’ selection for this type of treatment requires expert clinical judgment. Surgical intervention has been historically introduced as the optimal management in multifocal ruptures. Case presentation Here, we presented a 30-year-old man whose barium esophagogram confirmed bilateral perforations in the lower third of the esophagus contained in the mediastinum, and contrast drained back into the esophageal lumen. Concerning available contrast imaging studies and thoracic surgeons, conservative non-operative management was considered despite pneumomediastinum, a mild right-sided pleural effusion, and minimal leukocytosis. The patient was followed up for two months without any complications. Conclusions Bilateral and multifocal esophageal perforations can be managed conservatively provided that the leaks are confined to the mediastinum and drain back to the esophageal lumen, and other criteria for conservative management are met.

339 OPTIMAL CUTOFF VALUE OF INTEGRATED LOWER ESOPHAGEAL SPHINCTER RELAXATION PRESSURE FOR ACHALASIA USING STARLET HIGH-RESOLUTION MANOMETRY SYSTEM

The Starlet high-resolution manometry (HRM) system is currently used in Japan. HRM provides integrated relaxation pressure (IRP) of which value represents adequacy of lower esophageal sphincter (LES) relaxation. The upper limit of normal IRP for the Starlet was proposed as 26 mmHg using healthy subjects. However, few studies have addressed whether this cutoff may well-distinguish patients diagnosed with/without achalasia. We propose the optimal cutoff of IRP for detecting achalasia using the Starlet. Methods Patients who underwent HRM test using the Starlet system at our institution between July 2018 and December 2019 were included. Of these, we excluded patients who had a history of achalasia surgery and/or endoscopic intervention, or whose HRM testing of poor quality. Achalasia was diagnosed if impaired esophageal emptying was evident based on timed barium esophagogram, upper endoscopy, and/or computed tomography. The optimal cutoff value of IRP was estimated using the receiver operating characteristic curve analysis. We further investigate difference in IRP values between achalasia subtypes to identify characteristics of patients who are more likely to be misdiagnosed. Results In total, 145 patients met study criteria. The mean age in our cohort was 52.5 ± 15.5 years, 89 patients (61.4%) were men. Of these, 42 patients (29.0%) were diagnosed with achalasia. In achalasia patients, IRP values extended to a wide-range from minimal 18.7 to maximal 63.9 mmHg. The optimal cutoff value of IRP was 24.7 mmHg with sensitivity 90.5% and specificity 90.3% (AUC 0.96 [95% CI; 0.92¬ to 0.99]). Patients with achalasia type I based on Chicago classification were most likely to have IRP value below the threshold of 25 mmHg (4/19 patients [21.1%]). Conclusion The optimal cutoff value of IRP to distinguish achalasia was ≥25 mmHg using the Starlet HRM system. This value was nearly close to the upper limit of normal IRP value of 26 mmHg in healthy volunteers. Achalasia type I was more likely to have normal IRP value indicating that comprehensive foregut assessment (eg, timed barium esophagogram, upper endoscopy, and computed tomography) is still valuable for management of achalasia.

374 VIDEO ESOPHAGOGRAM CORRELATES OF DYSPHAGIA IN PATIENTS WITH NORMAL LOWER ESOPHAGEAL SPHINCTER

Dysphagia is a common foregut symptom. However, there is poor association between non-obstructive dysphagia and esophageal body peristaltic parameters in patients with normal lower esophageal sphincters (LES). The objective of this retrospective study was to study bolus transit patterns noted on barium esophagogram in patients experiencing dysphagia. Methods After IRB approval, we queried our esophageal database for patients with normal manometric LES. Jackhammer esophagus, esophageal spasm, previous foregut surgery, and unavailable foregut symptom questionnaires were exclusion criteria. Patients were grouped based on reported dysphagia: 0 = None; 1 = Mild; 2 = Moderate; 3 = Severe/very severe. All barium esophagograms were re-evaluated. Bolus esophageal transit time was studied with patients in both upright and prone positions, using live time stamps at bolus entry/exit. “Barium residue” was defined as persistent contrast on the esophageal wall after bolus exit. “Retrograde escape” referred to barium escaping proximally from the bolus into previously cleared esophagus. ANOVA and χ2 were used. Results In all, 150 patients met inclusion criteria. 76 (50.1%) were women. Mean age and body mass index were 58.4 ± 14.7 years and 22.9 ± 10.4 kg/m2, respectively. The number of patients in each dysphagia group (0, 1, 2, and 3) were 82(54.7%), 29(19.3%), 25(16.7%) and 14(9.3%), respectively. The difference in mean bolus transit time among dysphagia groups was statistically significant in prone-position swallows (39.3 ± 36.7, 75 ± 74.8, 98.8 ± 85 and 69.6 ± 43.7 seconds; p < 0.001) but not in upright-position swallows (14.6 ± 22, 12.4 ± 8.1, 14.3 ± 8.8 and 12.6 ± 8.2 seconds; p = 0.929; Fig. 1). The prevalence of residual contrast and retrograde escape in prone swallows were comparable among patients reporting dysphagia (p = 0.444, p = 0.173). Conclusion Bolus transit time in prone-position barium swallows is simple to assess, and correlates with dysphagia reported by patients with normal lower esophageal sphincters. However, further studies with comprehensive dysphagia score are needed.