SciCombinator

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Concept: Esophageal stricture

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Also available: Consumer Reports Patient Resource on High-Value Care for GERD BACKGROUND: Upper endoscopy is commonly used in the diagnosis and management of gastroesophageal reflux disease (GERD). Evidence demonstrates that it is indicated only in certain situations, and inappropriate use generates unnecessary costs and exposes patients to harms without improving outcomes. METHODS: The Clinical Guidelines Committee of the American College of Physicians reviewed evidence regarding the indications for, and yield of, upper endoscopy in the setting of GERD, and to highlight how clinicians can increase the delivery of high-value health care. BEST PRACTICE ADVICE 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting). BEST PRACTICE ADVICE 2: Upper endoscopy is indicated in men and women with:      Typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy.      Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus.      History of esophageal stricture who have recurrent symptoms of dysphagia. BEST PRACTICE ADVICE 3: Upper endoscopy may be indicated:      In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus.      For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

Concepts: Esophagogastroduodenoscopy, Esophageal stricture, Achalasia, Obesity, Gastroenterology, Barrett's esophagus, Esophageal cancer, Gastroesophageal reflux disease

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Biodegradable stents overcome some of the problems encountered with self-expanding metal stents. They main advantage over self-expanding metal stents is that endoscopic removal is not needed. Single biodegradable stents are often only temporarily effective in patients with a refractory benign esophageal stricture, as in the majority dysphagia recurs. If this occurs, sequential biodegradable stent placement may be an effective alternative to avoid the burden of serial dilations. In the future, it can be expected that (covered) biodegradable stents will be available to treat benign esophageal perforations/leaks, but also that they will be used for treating malignant indications combined with other (palliative) modalities, such as bridge to surgery or to maintain luminal patency during neoadjuvant chemoradiation.

Concepts: Gastroesophageal reflux disease, Esophageal stricture

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BACKGROUND AND AIMS: Caustic esophageal injury is a rare clinical condition in adult patients. Although dilatation, or the conservative approach, is the primary treatment method, some patients require surgical intervention. Because of the rarity of such cases, standard surgical treatment algorithms cannot be utilized. In this article, we present our surgical experience and discuss the challenges in the surgical management of corrosive injury of the esophagus in adults. METHODS: A retrospective review was conducted of 28 patients who suffered from a corrosive esophageal injury between 1996 and 2011. Patient demographics, history of corrosive material ingestion, preoperative findings, treatment strategy, operative technique, postoperative course, requirements for further treatment, and the current status of the patients were investigated. RESULTS: All patients underwent a transhiatal esophagectomy in addition to a gastric pull-up with a cervical esophagogastrostomy. The mean follow-up time was 62 (12-140) months. One patient developed a deep surgical infection; anastomotic stenosis was noted and treated with dilatation in 13 patients. The mean time period between the operation and the first dilatation for 12 patients was 81 (45-161) days. The mean dilatation count for the patients was 3 (1-10). CONCLUSION: Although it comes with high anastomotic stenosis rates, transhiatal esophagectomy and gastric pull-up with cervical anastomosis is a safe procedure, which can be performed for the treatment of corrosive esophageal stricture.

Concepts: Digestive system, Hospital, Anastomosis, Time, Esophageal cancer, Esophagus, Esophageal stricture, Surgery

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In children, caustic ingestion is due to accidents at home and inadequate storage of caustic agents. In emergency, it is useful to remove the soiled clothes, rinse the affected area, and prevent vomiting and feeding. Caustic ingestion (pH<2 or>12) induces burns of the upper gastrointestinal tract requiring esophagogastro-duodenoscopy between H12 and H24. Strong alkalis cause necrosis with liquefaction of the esophagus, penetrating deeply with a high-risk of perforation. Management of these children requires a specialized care center with an intensive care unit, endoscopic equipment, and a surgical team. Esophageal stricture is the main complication; no prophylactic treatment (steroids) is effective. Strictures occur after the 3rd week, and barium swallow should be performed by the end of the 1st month. Stricture are often multiple, long, and tortuous; endoscopic dilatation is difficult with a high-rate of perforation and a low-rate of success. In situ application of mitomycin C or injection of triamcinolone could reduce the recurrence rate of stricture. In recalcitrant or recurrent strictures, it is recommended to perform an esophageal replacement using a colonic interposition or a gastric tube. Endoscopy should also be performed 15-20years after caustic ingestion to screen for early neoplastic lesions. Prevention is very important for avoiding caustic ingestions. Information and education should be given specifically to the parents of toddlers; caustic products should be stored out of reach of children and they should not be kept with food.

Concepts: Barium swallow, Carcinoma in situ, Esophageal cancer, Esophageal stricture, Human gastrointestinal tract, Digestion, Gastroenterology, Digestive system

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The study aims to evaluate the effectiveness and safety of endoscopic balloon dilatation (EBD) in childhood benign esophageal strictures. The medical records of 38 patients who underwent EBD from 1999 to 2013 were retrospectively reviewed. Demographic features, diagnoses, features of strictures, frequency and number of EBD, complications, outcome, and recurrence data were recorded. Median age was 1.5 years (0-14), and female/male ratio was 17/21 (n = 38). Primary diagnoses were corrosive esophageal stricture (n = 19) and esophageal atresia (n = 19). The length of strictures were less than 5 cm in 78.9% (n = 30). No complication was seen in 86.8% (n = 33). Perforation was seen in 10.5% (n = 4), and recurrent fistula was seen in 2.7% (n = 1). Total treatment lasted for 1 year (1-11). Dysphagia was relieved in 60.5% (n = 23). Recurrence was seen in 31.6% (n = 12). Treatment effectiveness was higher, and complication rates were lower in strictures shorter than 5 cm compared with longer ones (70% vs. 25%, P < 0.05, and 3.4% vs. 37.5%, P < 0.05). Although there was no statistical difference, treatment effectiveness rates were lower and complication and recurrence rates were higher in corrosive strictures compared with anastomotic ones (P > 0.05). EBD is a safe and efficient treatment choice in esophageal strictures, especially in strictures shorter than 5 cm and anastomotic strictures.

Concepts: Esophageal dilatation, Esophageal atresia, Demographics, Recurrence relation, Medical terms, Gastroesophageal reflux disease, Esophageal stricture

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Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.

Concepts: Phenotype, Acid, Gastroesophageal reflux disease, Stomach, Esophageal stricture, Pathology, Gastroenterology, Peristalsis

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The prevalence of gastroesophageal reflux disease (GERD) symptoms increased approximately 50% until the mid-1990s, when it plateaued. The incidence of complications related to GERD including hospitalization, esophageal strictures, esophageal adenocarcinoma, and mortality also increased during that time period, but the increase in esophageal adenocarcinoma has since slowed, and the incidence of strictures has decreased since the mid-1990s. GERD is responsible for the greatest direct costs in the United States of any gastrointestinal disease, and most of those expenditures are for pharmacotherapy. Risk factors for GERD include obesity, poor diet, lack of physical activity, consumption of tobacco and alcohol, and respiratory diseases.

Concepts: Cancer, Esophageal stricture, Barrett's esophagus, Disease, Epidemiology, Esophageal cancer, Obesity, Gastroesophageal reflux disease

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Refractory esophageal strictures are rare conditions in pediatrics, and are often due to anastomotic, congenital, or caustic strictures. Traditional treatment options include serial dilation and surgical stricture resection; endoscopic intralesional steroid injections, mitomycin C, and externally removable stents combined with dilation have had variable success rates. Although not as widely used, endoscopic electrocautery incisional therapy (EIT) has been reported as an alternative treatment for refractory strictures in a small number of adult series. The aim of the study was to evaluate the safety and efficacy of EIT in a pediatric population with refractory esophageal strictures.

Concepts: Surgery, Urethral stricture, Alternative medicine, Pediatrics, Physician, Esophageal stricture, Medicine

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Urethral reconstruction has evolved in the last several decades with the introduction of various techniques including fasciocutaneous skin flaps and buccal mucosal grafts. However, distal urethral strictures have continued to be a reconstructive challenge due to tendency for adverse cosmetic outcomes, risks of glans dehiscence or fistula formation, and stricture recurrence.

Concepts: Steve Morse, Glans penis, Buccal mucosa, Esophageal stricture, Surgery, Introduction, Urethral stricture

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Dysphagia in patients with lung cancer is usually due to direct invasion from bronchogenic carcinomas or nodal localizations, while metastases from distant lung neoplasms are considered rare. We report a case of a smooth esophageal narrowing secondary to intramural metastasis from pulmonary adenocarcinoma in a patient with no previous history of neoplasia. Since standard linear echoendoscope could not overpass the malignant stricture, we obtained a histological diagnosis by fine-needle aspiration biopsy using an echobronchoscope (EBUS), due to its lower diameter. The EBUS scope represents a valuable tool to obtain cytological specimens in patients with esophageal strictures.

Concepts: Carcinoma, Squamous cell carcinoma, Oncology, Pneumonia, Esophageal stricture, Metastasis, Lung cancer, Cancer