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Esophageal heterotopic gastric mucosal patches (HGMP), also known as cervical inlet patches (CIP), is a rare but underdiagnosed condition characterized by the presence of salmon-colored, velvety mucosa located in the proximal esophagus, distal to the upper esophageal sphincter. The incidence of CIP ranges from 3% to 10% in adults, and its endoscopic appearance is characterized by a flat or slightly raised salmon-colored patch. In this case, we report a 78-year-old man who presented with symptoms of laryngopharyngeal reflux and dysphagia. An esophagogastroduodenoscopy showed a flat area of salmon-colored patch between 17 and 20 cm from the incisors, suggestive of a CIP complicated by stricture. The biopsy results showed an oxyntic-type mucosa lined with columnar cells consistent with an inlet patch. Esophageal dilation was done with a savory dilator with no resistance at 18 mm. The patient was placed on maintenance acid suppression therapy with proton-pump inhibitors and reported complete resolution of symptoms at the 1-month follow-up., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The association between eosinophilic esophagitis and celiac disease is still controversial and its prevalence is highly variable. We aimed to investigate the prevalence of esophageal eosinophilia and eosinophilic esophagitis in a large group of children with celiac disease, prospectively followed over 11 years., Methods: Prospective observational study performed between 2008 and 2019. Celiac disease diagnosis was based on ESPGHAN criteria. At least four esophageal biopsies were sampled in patients who underwent endoscopy. The presence of at least 15 eosinophils/HPF on esophageal biopsies was considered suggestive of esophageal eosinophilia; at the same time, eosinophilic esophagitis was diagnosed according to the International Consensus Diagnostic Criteria for Eosinophilic Esophagitis., Results: A total of 465 children (M 42% mean age 7.1 years (range: 1-16)) were diagnosed with celiac disease. Three hundred and seventy patients underwent endoscopy, and esophageal biopsies were available in 313. The prevalence of esophageal eosinophilia in children with celiac disease was 1.6% (95% CI: 0.54-2.9%). Only one child was diagnosed as eosinophilic esophagitis; we calculated a prevalence of 0.3% (95% CI: 0.2-0.5%). The odds ratio for an association between eosinophilic esophagitis and celiac disease was at least 6.5 times higher (95% CI: 0.89-47.7%; p = 0.06) than in the general population., Conclusion: The finding of an increased number of eosinophils (>15/HPF) in celiac patients does not have a clinical implication or warrant intervention, and therefore we do not recommend routine esophageal biopsies unless clinically indicated.

The aim of this study was to identify the economic screening strategies for esophageal squamous cell carcinoma (ESCC) in high-risk regions. We used a validated ESCC health policy model for comparing different screening strategies for ESCC. Strategies varied in terms of age at initiation and frequency of screening. Model inputs were derived from parameter calibration and published literature. We estimated the effects of each strategy on the incidence of ESCC, costs, quality-adjusted life-year (QALY), and incremental cost-effectiveness ratios (ICERs). Compared with no screening, all competing screening strategies decreased the incidence of ESCC from 0.35% to 72.8%, and augmented the number of QALYs (0.002-0.086 QALYs per person) over a lifetime horizon. The screening strategies initiating at 40 years of age and repeated every 1-3 years, which gained over 70% of probabilities that was preferred in probabilistic sensitivity analysis at a $1,151/QALY willingness-to-pay threshold. Results were sensitive to the parameters related to the risks of developing basal cell hyperplasia/mild dysplasia. Endoscopy screening initiating at 40 years of age and repeated every 1-3 years could substantially reduce the disease burden and is cost-effective for the general population in high-risk regions., (©2020 American Association for Cancer Research.)

Background: Medications can affect gastrointestinal tract motility. However, their effects on oesophageal motility in particular are often not as widely known or may be underestimated., Aim: To review the effect of existing medication use on high-resolution oesophageal manometry (HRM) in a 'real-world' setting., Methods: Adult patients with upper gut symptoms and normal endoscopy or imaging who had HRM over a 22-month period were analysed. Achalasia and major disorders of peristalsis were excluded. All medications taken within 24 hours of the procedure were prospectively recorded and compared with HRM results, controlling for age, gender and proton pump inhibitor use., Results: A total of 502 patients (323 female, mean age 51) were recruited. Of these, 41.2% had normal oesophageal HRM, while 41.4% had ineffective oesophageal motility (IOM) and 7.6% had oesophagogastric junction outflow obstruction (OGJOO). Serotonin/norepinephrine reuptake inhibitors (SNRI) and opioids were associated with significantly higher resting lower oesophageal sphincter pressure. Benzodiazepines and opioids were associated with elevated integrated relaxation pressure. SNRI and inhaled beta-agonists were associated with increased distal contractile index, whereas calcium channel blockers were associated with a lower distal contractile index. Odds ratio of being on anticholinergics was higher in IOM patients vs normal (3.6, CI 1.2-10.8). Odds ratio for anticholinergics, inhaled beta-agonists, anticonvulsants, SNRIs and opioids (trend) were all > 3 for OGJOO patients vs normal., Conclusion: Many medication classes are associated with abnormal HRM variables and diagnoses such as OGJOO and IOM; some of these associations are probably causal. These possible links should be taken into consideration during manometry interpretation., (© 2020 John Wiley & Sons Ltd.)

Introduction and Aims: An inlet patch (IP) is the presence of gastric columnar epithelium outside of the stomach. No studies have been conducted in Mexico on that pathology. The aim of the present study was to determine the prevalence of esophageal IP and the clinical characteristics of the patients that present it., Materials and Methods: A cross-sectional study was conducted that included consecutive patients referred for endoscopy within the time frame of September 2015 to May 2016. The patients answered a questionnaire, and high-definition endoscopy with digital chromoendoscopy was performed. The prevalence of IP was identified. The chi-square test was used to compare the clinical characteristics between patients that presented with esophageal IP and those without it., Results: A total of 239 patients were included in the study. Their mean age was 53 years, and 130 (54.4%) were women. IP was found in 26 patients (10.9%), 15 of whom were men (57.7%). The main reason for referral to endoscopy was gastroesophageal reflux disease, present in 69.2% of the patients with IP and in 55.9% without IP (p=.19). The most common symptoms were heartburn and regurgitation. The former was present in 69.2% of the patients with IP and in 59.1% without IP (p=.32), and the latter was present in 65.4% of the patients with IP and 69.1% without IP (p=.7). Extraesophageal manifestation distribution was: cough in 46.2% of the patients with IP and 38% without IP (p=.45) and dysphonia in 54% with IP and 47% without IP (p=.53). Twenty-three percent of the patients with IP had Barrett's esophagus, as did 23% without IP (p=.99)., Conclusions: The prevalence of IP was high. The primary referral diagnosis was gastroesophageal reflux disease. No differences were found in relation to symptoms or the presence of Barrett's esophagus between the patients with and without IP., (Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.)

The oesophagus can be a site for a variety of lesions including inflammatory disorders, infections, mechanical conditions, toxic and physical injuries, vascular disorders and neoplastic conditions. hence the oesophageal diseases have a wide spectrum of pathological features. An understanding of histopathological details of oesophageal diseases is essential for their accurate diagnosis and management. The main objective of our study was to provide a comprehensive audit of oesophageal diseases in the province of Madinah in Saudi Arabia. From January 2006 to December 2017, were viewed the histopathological patterns of oesophageal lesions in patients at a tertiary care referral hospital who were diagnosed with oesophageal disease after upper gastroendoscopy. Of the 201 patients, 144 (71.6%) cases were found to be non-neoplastic and 57 (28.4%) cases were neoplastic. Our findings were comparable with earlier studies that helped establish a baseline of an oesophageal disease pattern, on the basis of histopathological examinations.

Aims: Cryoballoon ablation is safe and efficient for achieving pulmonary vein isolation (PVI) in atrial fibrillation. Structural oesophago-mediastinal lesions, which seem to be associated with an increased risk of the lethal complication of an atrio-oesophageal fistula, have been described. MADE-PVI (Mediastino-oesophageal Alterations Detected by Endosonography after PVI) aimed at evaluating safety of cryoballoon PVI in relation to two different freeze protocols. As time-to-isolation-(TTI)-guided protocol has been reported to be as effective as conventional 'two freeze protocol', we hypothesized a TTI-guided protocol causes less oesophago-mediastinal lesions., Methods and Results: Seventy consecutive patients were scheduled for cryoballoon (2nd generation) PVI employing either a conventional protocol (n = 35: 2 × 180 s per vein) or a TTI-guided approach (n = 35: TTI + 120 s per vein or 1 × 180 s in case TTI could not be measured). Oesophagogastroduodenoscopy and endoscopic ultrasound, assessing oesophago-mediastinal alterations (e.g. ulceration, oedema) were performed blinded prior and post-ablation. Post-interventional mediastinal oedematous alterations were detected in 70% with a mean diameter of 14 mm (±0.9 mm), while only 15% revealed large mediastinal oedema >20 mm. Oesophageal lesions due to PVI occurred in 5%. Freeze protocols had a distinct impact on oesophago-mediastinal alterations as mean diameter and frequency of large oedema were significantly increased in patients after conventional protocol PVI (17 mm vs. 11 mm; 26% vs. 6%). Furthermore, every oesophageal lesion was detected in patients with conventional protocol (9%). No major complication occurred in either group., Conclusion: The present prospective study demonstrates a significant impact of freeze protocol on oesophago-mediastinal alterations. A TTI-guided protocol reduces mediastino-oesophageal lesions and may reduce short- and long-term complications of cryoballoon PVI., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Esophageal lichen planus (ELP) is a chronic inflammatory process characterized by apoptotic activity of cytotoxic CD8+ T cells on basal keratinocytes as well as regulatory and helper T cells. 1-3 Due to chronic inflammation, malignant transformation may be a concern and has been documented in case reports. 4,5 We describe the occurrence of esophageal cancer in ELP patients from a large tertiary patient population., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Oesophageal involvement in mucous membrane pemphigoid is considered rare, but it may be underdiagnosed. To assess the incidence of oesophageal involvement in a group of patients with newly diagnosed mucous membrane pemphigoid we retrospectively analysed the medical records of 30 consecutive patients with mucous membrane pemphigoid diagnosed between 2006 and 2016 at the Department of Dermatology, University Hospital Würzburg. Twenty-one patients (70%) reported symptoms indicative of oesophageal mucous membrane pemphigoid. Twelve patients (40%) underwent oesophagogastroduodenoscopy, and oesophageal pathology compatible with mucous membrane pemphigoid was endoscopically found in 9 cases (30%). In all patients indirect and direct immunofluorescence were performed. Patients with and without oesophageal involvement did not differ with regard to the results of indirect immunofluorescence on salt-split human skin and monkey oesophagus. Study results demonstrate the necessity of a standardized diagnostic work-up, including adequate tissue samples for direct immunofluorescence, to prevent underdiagnosis of oesophageal mucous membrane pemphigoid.

Background & Aims: We aimed to determine the rate of hospital readmission within 30 days of non-variceal upper gastrointestinal hemorrhage and its impact on mortality, morbidity, and health care use in the United States., Methods: We performed a retrospective study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014 (data on 14.9 million hospital stays at 2048 hospitals in 22 states). We collected data on hospital readmissions of 203,220 adults who were hospitalized for urgent non-variceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation) and resource use (length of stay and total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis., Results: The 30-day rate of readmission was 13%. Only 18% of readmissions were due to recurrent non-variceal upper gastrointestinal bleeding. The rate of death among patients readmitted to the hospital (4.7%) was higher than that for index admissions (1.9%) (P < .01). A higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation (1.5%) compared with index admissions (0.8%) (P < .01). A total of 133,368 hospital days was associated with readmission, and the total health care in-hospital economic burden was $30.3 million (in costs) and $108 million (in charges). Independent predictors of readmission were Medicaid insurance, higher Charlson comorbidity score, lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital. Older age, private or no insurance, upper endoscopy, and prolonged mechanical ventilation were associated with lower odds for readmission., Conclusions: In a retrospective study of patients hospitalized for non-variceal upper gastrointestinal hemorrhage, 13% are readmitted to the hospital within 30 days of discharge. Readmission is associated with higher mortality, morbidity, and resource use. Most readmissions are not for recurrent gastrointestinal bleeding., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: As the population ages, we will present the reality around being able to meet the health care needs of our population. In particular, we will present that providing cardiothoracic services in 2035 with a shortage of surgeons and an unknown caseload may be an impossibility., Methods: By using data from the American Board of Thoracic Surgery, we estimate that in 2010, 4000 cardiothoracic surgeons performed more than 530,000 cases. Additionally, cardiothoracic residency programs train and certify on average 90 new surgeons every year. To estimate the number of cases for 2035, we consulted the Census Bureau figures for 2010 and population projections for 2035. We then estimated the expected caseload for cardiothoracic surgeons relative to heart surgery, as well as lung and esophageal surgery. We found that among 2010 cardiothoracic surgeons in the United States, they completed more than 530,000 cases., Results: We project that by 2035 there will be 853,912 cases to perform, representing an increase from 2010 to 2035 of approximately 61% nationally. The cases per surgeon, per year, in 2010 averaged 135 for almost each of the 4000 surgeons. In 2035, the average caseload per surgeon will be 299 cases, representing an increase of 121% for the individual surgeon., Conclusions: We conclude that by 2035, cardiothoracic surgeons will be responsible for more than 850,000 patients requiring surgery. This represents a 61% increase in the national case load and a potential for a 121% increase for each cardiothoracic surgeon. We believe this is not feasible and a sign of trouble ahead., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Limited data exist describing risk factors for death, and long-term outcomes in dogs with esophageal foreign body (EFB) obstruction., Hypothesis/objectives: To evaluate short- and long-term outcomes, and analyze risk factors for death in dogs with EFB obstruction. We hypothesized duration of entrapment and treatment type would affect outcome., Animals: A total of 222 dogs were treated for EFB obstruction at an emergency and referral hospital between March 1998 and March 2017., Methods: Medical records for dogs with EFB were retrospectively evaluated., Results: Foreign material most frequently was osseous (180/222 [81%]), with distal esophagus the most common location (110/222 [49.5%]). Duration of clinical signs was not associated with risk of death (OR = 1.08, 95% CI 0.99-1.17; P = 0.2). Entrapment was treated by endoscopy (204/222 [91.8%]), surgery after endoscopic attempt (13/222 [5.9%]), and repeat endoscopy after surgery was recommended but declined (5/222 [2.3%]). In-hospital case fatality rate was 11/222 (5%). Risk of death was significantly higher with surgery (OR = 20.1, 95% CI 3.59-112.44; P = 0.001), and 5/5 (100%) of dogs died if undergoing endoscopy after surgery was recommended but declined. Increasing numbers of postprocedural complications (OR = 3.44, CI 2.01-5.91; P < 0.001), esophageal perforation (OR = 65.47, CI 4.27-1004.15; P = 0.003), and postprocedure esophageal hemorrhage (OR = 11.81, CI 1.19-116.77; P = 0.04) increased in-hospital risk of death. Esophageal strictures were reported in 4/189 (2.1%) of survivors available for follow-up., Conclusions and Clinical Importance: Death is uncommon in canine EFB; however, treatment type affects outcome, and these data should be used to guide decision-making in dogs with EFB., (Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.)

Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Traumatic, non-iatrogenic esophageal injuries, despite their rarity, are associated with significant morbidity and mortality. The optimal management of these esophageal perforations remains largely debated. To date, only a few small case series are available with contrasting results. The purpose of this study was to examine a large contemporary experience with traumatic esophageal injury management and to analyze risk factors associated with mortality., Methods: This National Trauma Data Bank (NTDB) database study included patients with non-iatrogenic esophageal injuries. Variables abstracted were demographics, comorbidities, mechanism of injury, Abbreviated Injury Scale (AIS), esophageal Organ Injury Scale (OIS), Injury Severity Score (ISS), level of injury, vital signs, and treatment. Multivariate analysis was used to identify independent predictors for mortality and overall complications., Results: A total of 944 patients with non-iatrogenic esophageal injury were included in the final analysis. The cervical segment of the esophagus was injured in 331 (35%) patients. The unadjusted 24-h mortality (8.2 vs. 14%, p  = 0.008), 30-day mortality (4.2 vs. 9.3%, p  = 0.005), and overall mortality (7.9 vs. 13.5%, p  = 0.009) were significantly lower in the group of patients with a cervical injury. The overall complication rate was also lower in the cervical group (19.8 vs. 27.1%, p  = 0.024). Multilogistic regression analysis identified age >50, thoracic injury, high-grade esophageal injury (OIS IV-V), hypotension on admission, and GCS <9 as independent risk factors associated with increased mortality. Treatment within the first 24 h was found to be protective (OR 0.284; 95% CI, 0.148-0.546; p  < 0.001). Injury to the thoracic esophagus was also an independent risk factor for overall complications (OR 1.637; 95% CI, 1.06-2.53; p  = 0.026)., Conclusions: Despite improvements in surgical technique and critical care support, the overall mortality for traumatic esophageal injury remains high. The presence of a thoracic esophageal injury and extensive esophageal damage are the major independent risk factors for mortality. Early surgical treatment, within the first 24 h of admission, is associated with improved survival., Trial Registration: iStar, HS-16-00883.

Aim: To assess the clinical characteristics of patients with complicated erosive esophagitis (EE) and their associated factors., Methods: This prospective, cross-sectional study included patients diagnosed with EE by upper gastrointestinal endoscopy between October 2014 and March 2015 at 106 Japanese hospitals. Data on medical history, general condition, gastrointestinal symptoms, lifestyle habits, comorbidities, and endoscopic findings were collected using a standard form to create a dedicated database. Logistic regression analysis was used to calculate adjusted odds ratios (aOR) and 95%CI for the association with complicated EE., Results: During the study period, 1749 patients diagnosed with EE, 38.3% of whom were prescribed proton pump inhibitors (PPIs) were included. Of them, 143 (8.2%) had EE complications. Esophageal bleeding occurred in 84 (4.8%) patients, esophageal strictures in 45 (2.6%) patients, and 14 (0.8%) patients experienced both. Multivariate analysis showed that increased age (aOR: 1.05; 95%CI: 1.03-1.08), concomitant use of psychotropic agents (aOR: 6.51; 95%CI: 3.01-13.61), and Los Angeles grades B (aOR: 2.69; 95%CI: 1.48-4.96), C (aOR: 15.38; 95%CI: 8.62-28.37), and D (aOR: 71.49; 95%CI: 37.47-142.01) were significantly associated with complications, whereas alcohol consumption 2-4 d/wk was negatively associated (aOR: 0.23; 95%CI: 0.06-0.61). Analyzing associated factors with each EE complication separately showed esophageal ulcer bleeding were associated with increased age (aOR: 1.05; 95%CI: 1.02-1.07) and Los Angeles grades B (aOR: 3.60; 95%CI: 1.52-8.50), C (aOR: 27.61; 95%CI: 12.34-61.80), and D (aOR: 119.09; 95%CI: 51.15-277.29), while esophageal strictures were associated with increased age (aOR: 1.07; 95%CI: 1.04-1.10), gastroesophageal reflux symptom (aOR: 2.51; 95%CI: 1.39-4.51), concomitant use of psychotropic agents (aOR: 11.79; 95%CI: 5.06-27.48), Los Angeles grades C (aOR: 7.35; 95%CI: 3.32-16.25), and D (aOR: 20.34; 95%CI: 8.36-49.53) and long-segment Barrett's esophagus (aOR: 4.63; 95%CI: 1.64-13.05)., Conclusion: Aging and severe EE were common associated factors, although there were more associated factors in esophageal strictures than esophageal ulcer bleeding. Despite the availability and widespread use of PPIs, EE complications are likely to remain a problem in Japan owing to the aging population and high-stress society., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report.

OBJECTIVE To evaluate perioperative morbidity and outcome in dogs and cats undergoing esophageal surgery. DESIGN Retrospective case series. ANIMALS 63 client-owned dogs and 9 client-owned cats. PROCEDURES Medical records of dogs and cats that underwent esophageal surgery were reviewed for information on signalment, history, results of preoperative diagnostic testing, condition treated, details of surgery, intraoperative complications, and postoperative complications. Long-term follow-up data were obtained via veterinarian and client telephone conversations. The relationship between complications and survival to hospital discharge was evaluated by means of regression analysis. RESULTS The most common indication for surgical intervention was an esophageal foreign body in dogs (50/63 [79%]) and esophageal stricture in cats (3/9). Complications were documented in 54% (34/63) of dogs and 3 of 9 cats. The most common immediate postoperative complications were respiratory in nature (9 dogs, 1 cat). Partial esophagectomy and resection with anastomosis were significantly associated with the development of immediate postoperative complications in dogs. The most common delayed postoperative complications were persistent regurgitation (7 dogs) and esophageal stricture formation (3 dogs, 1 cat). For dogs, a mass lesion and increasing lesion size were significantly associated with the development of delayed postoperative complications. Six dogs (10%) and 1 cat died or were euthanized prior to discharge, and pneumomediastinum and leukopenia were negative prognostic factors for dogs being discharged from the hospital. CONCLUSIONS AND CLINICAL RELEVANCE Results of this study suggested that the short-term prognosis for dogs and cats that survive surgery for treatment of esophageal lesions is favorable, with 90% of patients discharged from the hospital (57/63 dogs; 8/9 cats). However, dogs treated for more extensive esophageal lesions as well as those undergoing esophagectomy or resection and anastomosis were more likely to develop postoperative complications.

Introduction: Given the difficulty in accessing to the excluded stomach after gastric bypass and the increase in gastroesophageal reflux after sleeve gastrectomy, it is justified to perform a preoperative fibrogastroscopy.The influence of the fibrogastroscopy (FGS) findings in the therapeutic approach is analyzed., Patients and Methods: A retrospective study of preoperative FGS findings is performed, from 04/06 to 12/12. The influence of the FGS results on the surgical technique selection, in the endoscopic or medical treatment and its relation to gastric fistula is analyzed by means of multivariate regression (confounding factors: Age, body mass index, arterial hypertension, diabetes mellitus, antiplatelet therapy, surgical technique (bariatric surgery, sleeve gastrectomy)., Results: Three hundred thirty one patients are included: 32.6% biopsy of gastric lesion; 27% gastritis; 18.1% hiatal hernia; 3% metaplasia; 0.6% Barrett esophagus; 2.1% esophagitis; 0.3% dysplasia; 0.3 Schatzky&#180;s ring; 1.5% incompetent cardia; 2.4% duodenitis; 0.3% gastric erosions; 0.6% gastric xanthoma; 1.8%, gastric polyp; 1.6% duodenal ulcer; 0.6% papulo-erosive gastritis; 0.6% esophageal papilloma; 0.3% submucosal tumor. Helicobacter pylori+ 30.2% (triple therapy eradication in all patients). The FGS findings led to a variation in the surgical technique or to the completion of endoscopic treatment in 22.2% of cases.The gastric lesions did not influence the development of gastric fistula. Independent prognostic factors of fistula: Sleeve gastrectomy (7.9% vs. 2.7%; p = 0.02; OR: 1.38 IC95: 1.01-1.87) and the body mass index > 50 kg/m2) (6.7% vs. 2.2%; p = 0.04; OR: 3.7 IC95: 1.12-12.4)., Conclusions: The diagnosis of gastroesophageal disease through preoperative FGS motivated variations in the therapeutic approach in 52% of patients, so we consider essential to include the preoperative FGS in bariatric surgery.

Background: Oesophageal food bolus impaction (OFBI) is a common gastrointestinal emergency., Aim: To describe contemporary aetiologies of OFBI, and variables that may predict eosinophilic esophagitis (EoE) related OFBI as well as complications., Methods: Patients presenting to the Emergency Department between 2004 and 2014 with OFBI who underwent oesophagogastroduodenoscopy (EGD) were included. Clinical and endoscopic variables, as well as complications, were recorded. Aetiology of OFBI was determined by reviewing endoscopy reports. A diagnosis of EoE was confirmed via pathology (>15 eosinophils/high-powered field) at the index or follow-up EGD. Logistic regression was used to report associations of variables and complications., Results: Of the 173 patients with OFBI, 139 (80%) had an aetiology recognised, the most frequent being EoE (27%, n = 47), Schatzki's ring (20%, n = 34) and oesophageal stricture (13%, n = 22). Six patients (3%) had oesophageal cancer. Patients with EoE-related OFBI tended to be younger (42 vs. 69 years, P < 0.001), male (81% vs. 52%, P = 0.001), have a prior history of OFBI (45% vs. 18%, P = 0.001), and present during spring or summer (62% vs. 44%, P = 0.04). Eighteen patients (10%) had a complication associated with OFBI, with 3 (2%) perforations. On multivariate regression, patients with EoE-related OFBI were not more likely to have a complication (OR 1.07, P = 0.92), although hypoxia at presentation (OR 59.7, P = 0.006) was associated with complications., Conclusions: Eosinophilic esophagitis accounts for over a quarter of patients with oesophageal food bolus impaction. Overall complication rate was 10%, with a 2% perforation rate. Clinical characteristics of patients with eosinophilic esophagitis differ from other patients with oesophageal food bolus impaction., (© 2015 John Wiley & Sons Ltd.)

Numerous histological mimics of high-grade dysplasia in Barrett's esophagus predispose to overdiagnosis and potential serious mismanagement, including unnecessary esophagectomy. This study investigates the prevalence and sources of this problem. Biopsies from 485 patients diagnosed with Barrett's high-grade dysplasia were screened for a multi-institutional, international Barrett's endoscopic ablation trial. Screening included review of the original diagnostic slides and an additional protocol endoscopy with an extensive biopsy sampling. Observer variability by the study pathologists was assessed through two blinded diagnostic rounds on 437 biopsies from 26 random study endoscopies. Study diagnostic reassessments revealed significantly lower rates of high-grade dysplasia. Only 248 patients (51%) were confirmed to have high-grade dysplasia. The remaining patients had inflamed gastric cardia without Barrett's (n=18; 7%), Barrett's without dysplasia (n=35; 15%), indefinite change (n=61; 26%), low-grade dysplasia (n=79; 33%), adenocarcinoma (n=43; 18%), and other (n=1; <1%), yielding an alarming total of 194 or 40% of patients who were overdiagnosed with Barrett's high-grade dysplasia. Study pathologists achieved a high-level agreement (90% three-way inter-observer agreement per biopsy, Kappa value 0.77) for high-grade dysplasia. Confounding factors promoting overdiagnosis included Barrett's inflammatory atypia (n=182), atypia limited to the basal metaplastic glands (n=147), imprecise criteria for low grade neoplasia (n=102), tangential sectioning artifact (n=59), and reactive gastric cardiac mucosa (n=38). A total of 194 patients (40%) were overdiagnosed with Barrett's high-grade dysplasia, as affirmed by the extensive screening process and high-level study pathologist agreement. The multiple diagnostic pitfalls uncovered should help raise pathologists' awareness of this problem and improve diagnostic accuracy.

Benign esophageal lesions have a wide spectrum of clinical and pathologic features. Understanding the endoscopic and pathologic features of esophageal lesions is essential for their detection, differential diagnosis, and management. The purpose of this review is to provide updated features that may help physicians to appropriately manage these esophageal lesions. The endoscopic features of 2997 patients are reviewed. In epithelial lesions, the frequency of occurrence was in the following order: glycogenic acanthosis, heterotopic gastric mucosa, squamous papilloma, hyperplastic polyp, ectopic sebaceous gland and xanthoma. In subepithelial lesions, the order was as follows: hemangioma, leiomyoma, dysphagia aortica and granular cell tumor. Most benign esophageal lesions can be diagnosed according to their endoscopic appearance and findings on routine biopsy, and submucosal lesions, by endoscopic resection. Management is generally based upon the confidence of diagnosis and whether the lesion causes symptoms. We suggest endoscopic resection of all granular cell tumors and squamous papillomas because, while rare, these lesions have malignant potential. Dysphagia aortica should be considered in the differential diagnosis of dysphagia in the elderly.

Background/aims: The aim was to determine the sociodemographic and etiologic factors, endoscopic accuracy, treatment efficiency and clinical outcome of patients with nonvariceal upper gastrointestinal system bleeding in Kosova., Materials and Methods: We retrospectively evaluated patients who had applied to our Gastroenterology Department between January 2006 and December 2010., Results: There were 460 eligible cases with mean age 56.85+16.18 years, while male /female ratio was 2.71/1. The greatest occurrence was at age group of 60-69 years (27.1 %). The most common clinical symptom was melena (62.6%). Comorbid diseases were present in 57, 6% of the patients. The percentage of patients using acetylsalicylic acid and /or other non-steroidal anti-inflammatory drugs was 43.7%. Five point two percent were using anticoagulants. Peptic ulcer was the main cause of bleeding (82.2%) and most of them were Forrest III (41.6%). Endoscopic treatment was performed in 90 patients, primary hemostasis was achieved in 96.7% while rebleeding developed in 10% of these patients. The average length of hospital stay was 9.29+5.58 (1-35) days. Rebleeding was reported in 4.1% of all patients while the overall mortality rate was 5.7%., Conclusion: Age over 60 years, previous history of gastrointestinal bleeding, treatment with anticoagulants, low hemoglobin values at presentation (<7 g/dL), hematemesis, Forrest class, localization of lesion of bleeding, comorbidities, tachycardia, transfusion requirement>2 unit, type of treatment and time of endoscopy were predictors of poor outcome in study present.

Background: Digestive damage due to Chagas disease (CD) occurs in 15-20% of patients diagnosed as a result of peristaltic dysfunction in some endemic areas. The symptoms of chronic digestive CD are non-specific, and there are numerous confounders. Diagnosis of CD may easily be missed if symptoms are not evaluated by a well trained physician. Regular tests, as barium contrast examinations, probably lack the necessary sensitivity to detect early digestive damage., Methods: 71 individuals with T. cruzi infection (G1) and 18 without (G2) coming from Latin American countries were analyzed. They were asked for clinical and epidemiological data, changes in dietary habits, and history targeting digestive and cardiac CD symptoms. Serological tests for T. cruzi, barium swallow, barium enema, an urea breath test, and esophageal manometry were requested for all patients., Principal Findings: G1 and G2 patients did not show differences in lifestyle and past history. Fifteen (21.1%) of G1 had digestive involvement. Following Rezende criteria, esophagopathy was observed in 8 patients in G1 (11.3%) and in none of those in G2. Manometry disorders were recorded in 34 G1 patients and in six in G2. Isolated hypotensive lower esophageal sphincter (LES) was found in sixteen G1 patients (23.9%) and four G2 patients (28.8%). Achalasia was observed in two G1 patients. Among G1 patients, ineffective esophageal motility was seen in six (five with symptoms), diffuse esophageal spasm in two (one with dysphagia and regurgitation), and nutcracker esophagus in three (all with symptoms). There were six patients with hypertonic upper esophageal sphincter (UES) among G1. Following Ximenes criteria, megacolon was found in ten G1 patients (13.9%), and in none of the G2 patients., Conclusions: The prevalence of digestive chronic CD in our series was 21.1%. Dysphagia is a non-pathognomonic symptom of CD, but a good marker of early esophageal involvement. Manometry could be a useful diagnostic test in selected cases, mainly in patients with T. cruzi infection and dysphagia in whose situation barium swallow does not evidence alterations. Constipation is a common but non-specific symptom that can be easily managed. Testing for CD is mandatory in a patient from Latin America with constipation or dysphagia, and if diagnosis is confirmed, megacolon and esophageal involvement should be investigated.

The article presents an analysis of 34.903 esophagoscopy results performed for population of Leningrad region at the period from 2007 to 2013. A prevalence of erosive esophagitis was 4.9%, peptic strictures--0.18%, columnar-celled metaplasias--1.43% and esophageal adenocarcinoma--0.645%. The data obtained showed a high prevalence of GERD-associated syndromes with injury of mucous coat of esophagus in the local population of Russians.

Oral leukoplakia is a relatively common, painless disorder of the oral mucosa. It predominantly affects middle-aged to elderly men and has a strong association with tobacco smoking and alcohol intake. Concomitant histological findings of hyperorthokeratosis and a well-developed granular cell layer, termed orthokeratotic dysplasia, are often associated with oral squamous cell carcinoma. In contrast, analogous lesions within the esophagus, termed esophageal epidermoid metaplasia, are rarely encountered and poorly described in the literature. To better characterize the clinicopathological features of this entity, we have collected 25 cases from 18 patients. Patients ranged in age from 37 to 81 years (mean, 61.5 years), with a slight female predominance (10/18, 56%). On presentation, a majority of patients complained of dysphagia (10/18, 56%). Past medical history was significant for tobacco smoking or long history of second-hand smoke in 11 (61%) patients and alcohol intake in 7 (39%) patients. Seventeen (94%) patients with esophageal epidermoid metaplasia were located within the middle-to-distal esophagus. Histologically, all cases were sharply demarcated and characterized by epithelial hyperplasia, a thickened basal layer, acanthotic midzone, a prominent granular cell layer, and superficial hyperorthokeratosis. Adjacent high-grade squamous dysplasia and/or squamous cell carcinoma were seen in 3 out of 18 (17%) patients. Follow-up information was available for 13 out of 18 (72%) patients and ranged from 2 to 8.3 years (mean, 2.3 years). Seven of the 13 (54%) patients had persistent disease; however, none of them developed squamous dysplasia or squamous cell carcinoma. In an effort to assess the incidence of esophageal epidermoid metaplasia, 198 consecutive esophageal biopsies were prospectively surveyed over a 6-month period at three academic institutions. No cases were identified within this time frame. In summary, esophageal epidermoid metaplasia is a rare condition affecting the middle-to-distal esophagus in middle-aged to elderly females. The occurrence of adjacent high-grade squamous dysplasia and/or squamous cell carcinoma warrants close follow-up.

Background: Hen and quail eggs are commonly used in embryological research. While immunoglobin E (IgE)-associated allergy to hens' egg proteins is recognized in employees in the food industry, there are no previous reports from workers in embryological research. Two newly identified cases prompted us to examine the extent of this problem in a university laboratory., Aims: To determine the prevalence and determinants of sensitization to egg among a group of workers in an embryological research laboratory., Methods: Following the identification of egg sensitization in two research workers, we surveyed 116 employees from a single embryology research laboratory in 2005. Sensitization to egg was assessed by skin prick tests and/or specific IgE measurement and examined in relation to a number of potential determinants, including the extent of appropriate control measures., Results: Four employees were sensitized to egg, each with digestive symptoms of egg allergy. All had worked directly with eggs, giving a prevalence of specific sensitization in that group of 6.1% (95% confidence interval (CI) [1.7%, 14.8%]). There was a statistically significant trend for those sensitized to report a shorter duration of exposure to eggs and less frequent use of hygiene control measures to reduce exposure., Conclusions: Sensitization to eggs among those occupationally exposed to egg protein in research work occurs more commonly than in the general population. The presence of digestive symptoms after eating eggs may be indicative of sensitization to egg and should be incorporated into health evaluation of exposed workers.

Objectives: To investigate the clinical characteristics of SSc patients with DUs in China., Methods: The data of 267 consecutive SSc patients based on the EUSTAR DATABASE from Peking Union Medical College Hospital from February 2009 to March 2012 were prospectively collected. The patients with DUs were compared to those without DUs., Results: Seventy-nine patients (29.6%) had DUs out of 267 SSc patients analysed. There were significant differences between patients with and without DU based on sex (female/male: 65/14 vs. 174/14), age of onset of SSc (32.3±11.7 vs. 40.4±12.6 y), age of onset of Raynaud's phenomenon (31.8±12.3 vs. 38.7±12.2) (p<0.05). In addition, there was a higher rate of diffuse SSc, gastrointestinal involvement, (especially esophageal involvement), and pericardial effusion, higher mRodnan score, and more anti-scl70 antibody positivity in patients with DU (p<0.05). A multivariate analysis identified anti-Scl70 antibody positivity, gastrointestinal involvement and a younger age at disease onset as three risk factors for developing DUs in SSc patients., Conclusions: The occurrence of DUs in Chinese SSc patients is frequent. It is possible that SSc patients with DUs were influenced by the disease earlier in life, which should be detected early for effective intervention.

Background: Gastrointestinal (GI) symptoms are common in patients with eating disorders. The aim of this study was to determine, using factor analysis, whether these GI symptom factors (clusters) in eating disorder patients hold true to the Rome II classification of functional gastrointestinal disorders (FGIDs)., Methods: Inpatients in a specialised eating disorder unit completed the Rome II questionnaire. Data from 185 patients were analysed using factor analysis of 17 questions cited as present in 30% to 70% of the patients., Results: Five factors emerged accounting for 68% of the variance and these were termed: 'oesophageal discomfort', 'bowel dysfunction', 'abdominal discomfort', 'pelvic floor dysfunction', and 'self-induced vomiting'. These factors are significantly related to the Rome II FGID categories of functional oesophageal, bowel and anorectal disorders, and to the specific FGIDs of IBS, functional abdominal bloating, functional constipation and pelvic floor dyssynergia. Both heartburn and chest pain were included in the oesophageal discomfort factor. The 'pelvic floor dysfunction' factor was distinct from functional constipation., Conclusions: The GI symptoms common in eating disorder patients very likely represent the same FGIDs that occur in non-ED patients. Symptoms of pelvic floor dysfunction in the absence of functional constipation, however, are prominent in eating disorder patients. Further investigation of the items comprising the 'pelvic floor dysfunction' factor in other patient populations may yield useful results.

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as "inlet patch" or "cervical inlet patch", is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett's esophagus have also been reported but the findings so far have been conflicting. There are still many areas that are unknown or not well understood and these include the natural history of HGMPE, risk factors for complications, role of Helicobacter pylori infection and factors associated with malignant transformations. Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes. Despite the overall low incidence of clinically relevant manifestations reported in the literature, HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Background: There are no prior studies that have estimated the risk of upper gastrointestinal bleeding (UGIB) among the dialysis population relative to the general population. The aim of this study was to examine the risk of UGIB among end-stage renal disease (ESRD) patients during a 6-year period following their initiation of hemodialysis (HD) therapy in Taiwan- a country with the highest incidence of ESRD in the world, using general population as an external comparison group., Methods: Data were obtained from the Taiwan National health Insurance Research Database. In total, 796 patients who were beginning HD between 1999 and 2003 were recruited as the study cohort and 3,184 patients matched for age and sex were included as comparison cohort. Multivariate Cox proportional hazard regression models were used to adjust for confounding and to compare the 6-year UGIB-free survival rate between these two cohorts., Results: The incidence rate of UGIB (42.01 per 1000 person-year) was significantly higher in the HD cohort than in the control cohort (27.39 per 1000 person-years). After adjusting for potential confounders, the adjusted hazard ratios for UGIB during the 6-year follow-up periods for HD patients was 1.27 (95% CI=1.03-1.57) compared to patients in the comparison cohort., Conclusions: We conclude that HD patients were at an increased risk for UGIB compared with the general population.

Background: Candidia esophagitis (CE) is an AIDS-defining condition, usually occurring in individuals with low CD4 counts of <200 cells/µL. Endoscopy is a valuable definitive diagnostic method for CE but may not be indicated for asymptomatic patients or for those with high CD4 counts or without oral candidiasis. This study assessed such patients to clarify the factors associated with CE and its severity on endoscopy in the highly active antiretroviral therapy (HAART) era., Methodology Principal Findings: A total of 733 HIV-infected patients who underwent upper gastrointestinal (GI) endoscopy were analyzed. Sexual behavior, CD4(+) count, HIV-RNA viral load (VL), history of HAART, GI symptoms, GI diseases, and oral candidiasis were assessed. Endoscopic severity of CE was classified as mild (Kodsi's grade I/II) or severe (grade III/IV). Of the 733 subjects, 62 (8.46%) were diagnosed with CE (mild, n = 33; severe, n = 29). Of them, 56.5% (35/62) had no GI symptoms, 30.6% (19/62) had CD4 + ≥200 cells/μL, and 55.3% (21/38) had no oral candidiasis. Univariate analysis found lower CD4+ counts, higher HIV VL, and no history of HAART to be significantly associated with CE. With lower CD4(+) counts and higher HIV VL, CE occurrence increased significantly (P<0.01 for trend in odds). Multivariate analysis showed low CD4+ counts and high HIV VL to be independently associated with CE. Of the severe CE patients, 55.2% (16/29) had no GI symptoms and 44.4% (8/18) had no oral candidiasis. Median CD4(+) counts in severe cases were significantly lower than in mild cases (27 vs. 80; P = 0.04)., Conclusions: Low CD4+ counts and high HIV VL were found to be factors associated with CE, and advanced immunosuppression was associated with the development of severity. Endoscopy is useful as it can detect CE, even severe CE, in patients without GI symptoms, those with high CD4 counts, and those without oral candidiasis.

Our goals were: a) to detect Helicobacter pylori in gastric biopsies of symptomatic adults by PCR, b) to detect the presence of the cagA gene as well as of the allelic variants of the vacA gene, and c) to correlate genotypes with the endoscopic diagnoses. H. pylori was detected in 81 % (39/48) of patients by nested PCR for hsp60. The presence of cagA was detected in 15/22 of samples and vacA s1 - m1 was the most frequent allelic combination (15/22). Gastritis, the most frequent diagnosis, was associated with genotype cagA+ in 10/13 of patients. In this group, 9/13 showed the allelic variant vacA s1- m1. The variant vacA s2 - m2 was detected in 3/3 of gastritis cases by H. pylori with the cagA- genotype. These results are the first reported in our region and provide data of epidemiological interest.

Purpose: Esophageal candidiasis (EC) is the most frequent opportunistic fungal infection in immunocompromised host. However, we have found EC in healthy individuals through esophagogastroduodenoscopy (EGD). The aim of this study was to determine the prevalence and risk factors for EC in healthy individuals., Materials and Methods: We retrospectively reviewed the medical records of 281 patients who had been incidentally diagnosed with EC. We also conducted age and sex matched case control study to identify the risk factor for EC., Results: The prevalence of EC was 0.32% (281/88125). The most common coexisting EGD finding was reflux esophagitis (49/281, 17.4%). An antifungal agent was prescribed in about half of EC, 139 cases (49.5%). Follow-up EGD was undertaken in 83 cases (29.5%) and 20 cases of candidiasis was persistently found. Case control study revealed EC were more often found in user of antibiotics (p=0.015), corticosteroids (p=0.002) and herb medication (p=0.006) as well as heavy drinking (p<0.001)., Conclusion: The prevalence of EC was 0.32% (281/88125) in Korea. Use of antibiotics, corticosteroids and herb as well as heavy drinking were significant risk factors for EC in healthy individuals.

Herpesviruses have been recognized in marine mammals, but their clinical relevance is not always easy to assess. A novel otarine herpesvirus-3 (OtHV3) was detected in a geriatric California sea lion (Zalophus californianus), and using a newly developed quantitative PCR assay paired with histology, OtHV3 was associated with esophageal ulcers and B cell lymphoblastic lymphoma in this animal. The prevalence and quantities of OtHV3 were then determined among buffy coats from 87 stranded and managed collection sea lions. Stranded sea lions had a higher prevalence of OtHV3 compared to managed collection sea lions (34.9% versus 12.5%; p = 0.04), and among the stranded sea lions, yearlings were most likely to be positive. Future epidemiological studies comparing the presence and viral loads of OtHV3 among a larger population of California sea lions with and without lymphoid neoplasia or esophageal ulcers would help elucidate the relevance of OtHV3-associated pathologies to these groups.

Background: Esophageal hematoma recently has been reported as a form of esophageal injury after atrial fibrillation (AF) ablation, attributed to the use of transesophageal echocardiography (TEE). We sought to determine the incidence, clinical features, and sequelae of this form of esophageal injury., Methods and Results: This was a prospective series of 1110 AF ablation procedures performed under general anesthesia (GA) over 9 years. TEE was inserted after induction of GA to exclude left atrial appendage thrombus, define cardiac function, and guide transseptal puncture. The procedural incidence of esophageal hematoma was 0.27% (3/1110 procedures, mortality 0%). Odonyphagia, regurgitation, and hoarseness were the predominant symptoms, with an onset within 12 hours. There was absence of fever and neurological symptoms. Chest computed tomography excluded atrio-esophageal fistula and was diagnostic of esophageal hematoma localized to either the upper esophagus or extending the length of the mid and lower esophagus; endoscopy confirmed the diagnosis. Management was conservative in all cases comprising of ceasing oral intake and anticoagulation. Long term sequelae included esophageal stricture formation requiring dilatation, persistent esophageal dysmotility (mid esophageal hematoma), and vocal cord paralysis, resulting in hoarse voice (upper esophageal hematoma)., Conclusions: Esophageal hematoma is a rare but important differential diagnosis for esophageal injury after TEE-guided AF ablation under GA, and can result in significant patient morbidity. Key clinical features differentiate presentation of esophageal hematoma from that of an atrio-esophageal fistula.

Background & Aims: Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective β-adrenergic receptor antagonist (also called a nonselective β-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes., Methods: We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years., Results: After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival., Conclusions: Patients who have their first episode of variceal bleeding while on primary prophylaxis with a β-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

A retrospective study was performed to investigate the frequency of identification and characteristics of oesophageal disease in cats, including assessment of the utility of diagnostic techniques and clinical outcome. Thirty-three cats met the inclusion criteria, giving an in-clinic frequency of 33/2894 (approximately 1%) of feline referral cases. Vomiting and/or regurgitation were the most common presenting signs described, although a number of cats (6/33) showed neither. Useful diagnostic modalities included plain radiography, fluoroscopy, barium radiography and endoscopy. A wide range of diseases was reported including congenital disease, oesophagitis, foreign body obstruction, neoplasia, extraluminal compression and hypomotility disorder. Five of six cats with acquired oesophageal strictures had recently received doxycycline per os., (Copyright © 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess the long-term outcome of esophageal complications in the group of patients receiving intravenous immunoglobulins (IVIG) for the treatment of severe steroid-refractory esophageal involvement related to polymyositis/dermatomyositis (PM/DM)., Methods: We retrospectively reviewed the medical records of 73 patients (39 with PM, 34 with DM) with steroid-resistant esophageal involvement. Esophageal involvement was evaluated by clinical and manometric investigations., Results: Seventy-three patients with steroid-refractory esophageal involvement related to PM/DM received IVIG therapy (2 gm/kg monthly). The median interval between PM/DM diagnosis and the onset of esophageal complications was 6 months. The most common clinical manifestations revealing esophageal dysfunction were dysphagia (69.9%), coughing while eating (61.6%), and gastroesophageal reflux into the pharynx and/or mouth (34.2%). Twenty-five patients exhibited life-threatening esophageal complications requiring exclusive enteral feeding; 33 patients (45.2%) with esophageal impairment developed aspiration pneumonia. Sixty patients (82.2%) exhibited resolution of esophageal clinical manifestations, leading to a return to normal oral feeding and ablation of feeding enteral tubes. Four other patients (5.5%) improved, although they still experienced mild dysphagia intermittently. Because of impaired cricopharyngeal muscle relaxation, another patient successfully underwent cricopharyngeal myotomy. Eight patients died from aspiration pneumonia (n=6) and cancer (n=2). Muscle weakness, thoracic myopathy, and aspiration pneumonia were independent predictive factors of IVIG-treated esophageal complications in PM/DM patients., Conclusion: Our findings indicate that IVIG should be considered in life-threatening esophageal impairment complicating steroid-resistant PM/DM. We also suggest that combined therapy of IVIG and high-dose steroids may be the first-line therapy in PM/DM patients with life-threatening esophageal manifestations., (Copyright © 2010 by the American College of Rheumatology.)

Background & Aims: Lichen planus is a relatively uncommon, presumed autoimmune disease that affects middle-aged patients and is manifested in the skin, nails, and mucous membranes. Reports of esophageal involvement have been rare, despite the classification of the esophagus as a mucous membrane., Methods: Assuming esophageal involvement might not be as rare as expected, we reviewed the Mayo Clinic Pathology Database for all cases from 2000 to the present., Results: Twenty-seven cases were identified, with a mean age of 64 years; 25 were women. Patients presenting with esophageal lichen planus as the initial manifestation and those with a diagnosis of lichen planus involving other sites were equal in number. Many patients had received multiple dilations and reflux treatments before diagnosis. All patients presented with dysphagia. Endoscopy and radiology studies demonstrated a wide range of abnormalities, including strictures of varying length and location, small-caliber esophagus, and a mucosal appearance of sloughing, white discoloration, erythema, thickening, and superficial ulceration. Treatment regimens varied markedly, with some patients responding to topical or systemic corticosteroids., Conclusions: Esophageal lichen planus is rare but probably more common than previously suspected. It presents with a wide range of endoscopic signs and is commonly the presenting sign of lichen planus. In evaluating middle-aged patients with strictures, particularly proximal esophageal strictures in women, physicians should consider a diagnosis of lichen planus even in the absence of extraesophageal manifestations., (Copyright 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Radiofrequency catheter ablation is increasingly used in the treatment of atrial fibrillation. Esophageal wall changes varying from erythema to ulcers have been described by endoscopy in up to 47% of patients following pulmonary vein isolation (PVI). Although esophageal changes are frequently reported, the development of a left atrial (LA)-esophageal fistula is fortunately rare. Nevertheless, mucosal changes may just represent "the tip of the iceberg." The aim of this study was, therefore, to investigate the more subtle changes of and injuries to the posterior wall of the LA, the periesophageal and mediastinal connective tissue, and the whole wall of the esophagus, including mucosal changes by esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS)., Methods and Results: Twenty-nine patients (7 females; mean age, 57.7+/-10.5 years [range, 23-75 years]) underwent EGD and EUS before and after PVI within 48 hours. PVI was performed as a circumferential antral isolation of the septal and lateral pulmonary veins guided by a decapolar circular mapping catheter using a 3-dimensional mapping system with the integration of a preprocedurally acquired computed tomography scan of the left atrium. The maximum power applied was 30 W, with an open-irrigated catheter using a maximum flow rate of 30 mL/min. In all patients, the esophagus was reconstructed using the same computed tomography scan and displayed during the ablation procedure. In case of newly detected periesophageal changes, EGD and EUS were repeated 1 week after the PVI. In all patients, a regular contact area between the LA and the esophagus could be demonstrated before PVI. The mean vertical contact length was 4.4+/-1.5 cm (range, 2-10 cm); and the mean distance between the anterior wall of the esophagus and the endocardium was 2.6+/-0.8 mm (range, 1.4-4.0 mm). After PVI, morphological changes of the periesophageal connective tissue and the posterior wall of the LA were diagnosed by endosonography in 8 patients (27%; 95% confidence interval, 12.73-47.24). No mucosal changes of the esophagus in terms of erythema or ulcers were found. In all but one patient (who refused the control), all periesophageal and atrial changes had resolved within 1 week. No atrioesophageal fistula occurred during follow-up (mean follow-up, 294+/-110 days [range, 36-431 days])., Conclusions: Mucosal changes of the esophagus after PVI-like ulcers or erythema could not be demonstrated, yet structural changes of the mediastinum, which were only visible by endosonography, occurred in 27% of patients in the present study. This may indicate a higher than expected periesophageal injury because of PV ablation. Endosonography might prove to be a sensitive and reliable tool in the follow-up after PVI.

Highly active antiretroviral therapy (HAART) has dramatically decreased opportunistic infections (OIs) in human immunodeficiency virus (HIV)-infected patients. However, gastrointestinal disease continues to account for a high proportion of presenting symptoms in these patients. Gastrointestinal symptoms in treated patients who respond to therapy are more likely to the result of drug-induced complications than OI. Endoscopic evaluation of the gastrointestinal tract remains a cornerstone of diagnosis, especially in patients with advanced immunodeficiency, who are at risk for OI. The peripheral blood CD4 lymphocyte count helps to predict the risk of an OI, with the highest risk seen in HIV-infected patients with low CD4 count (< 200 cells/mm(3)). This review provides an update of the role of endoscopy in diagnosing OI in the upper gastrointestinal tract in HIV-infected patients in the era of HAART.

While a significant amount of clinical information has been reported concerning intestinal involvement in Behçet's disease (BD), esophageal involvement in BD has not yet been studied extensively. The aim of this study was to evaluate the prevalence of esophageal involvement in BD and its clinical characteristics. We retrospectively reviewed the medical records of 842 patients diagnosed with BD at a single tertiary institution in Korea between January 1990 and June 2006. Of the 842 patients with BD, 129 patients (15.3%) experienced upper gastrointestinal symptoms that required inspection through esophagogastroduodenoscopy. Esophageal involvement was found in 6 (4.7%) of the 129 patients. The activity index of Behçet's disease did not differ among patients with or without esophageal involvement. All patients with esophageal involvement responded well to medical treatment and no one experienced serious complications. The results of our study demonstrate that the prevalence of esophageal involvement in BD is very low and that most patients with such involvement face few complications and respond well to medical treatment.

Context: Esophageal candidiasis is often observed in patients with risk factors for its development and fluconazole is the therapeutic choice for the treatment of this disease., Objectives: To determine its frequency, by performing upper digestive endoscopy; to determine Candida species involved in its pathogenesis and verify their distribution according with the predisposing factors and to determine susceptibility to fluconazole in the samples., Methods: From March 2006 to April 2007, all patients submitted to esophagogastroduodenoscopy at the Digestive Endoscopy Unit in the Oswaldo Cruz University Hospital, Recife, PE, Brazil, were eligible for the study. Samples were collected from patients who presented lesions consistent with esophageal candidiasis in order to identify Candida species and verify their susceptibility to fluconazole. The predisposing factors for the occurrence of esophageal candidiasis were described., Results: Of 2,672 patients referred to upper endoscopy at the Digestive Endoscopy Unit, 40 (1.5%) had endoscopic findings compatible with esophageal candidiasis. The average age was 49.1 years. Twenty one patients (52.5%) were less than 50 years old, of which 82.6% were infected with HIV. Most of them (52.5%) were males and 65.0% were inpatients. Diseases were identified in 90% of the patients and 21 (52.5%) were HIV positive. Concerning endoscopic findings, severe forms of esophagitis were found in 50% of the patients with CD4 count <200. Non-albicans Candida species were isolated in 22.7% of HIV positive and in 45% HIV negative patients. A total of 6 (14.28%) samples were resistant to fluconazole, while 2 (4.76%) samples had dose depending susceptibility to this drug., Conclusions: Esophageal candidiasis prevalence was low, although within the results described by other authors. Male and inpatients were the most affected. The species isolated varied according to the characteristics of each group studied. Both, resistance and dose-depending susceptibility to fluconazole were considered high.

Background/aims: Various disorders can be developed in the esophagus. However, esophagus has been less well focused than other gastrointestinal (GI) tracts since the esophageal disorders are relatively uncommon. There has been no report on the prevalence of overall esophageal disorders in Korea. The aim of this study was to evaluate the prevalence of esophageal disorders in health examinee., Methods: We reviewed retrospectively the endoscopic reports of 6,683 subjects who underwent upper GI endoscopy for screening purpose at Gyeongsang National University Hospital from March, 2005 to May, 2006., Results: Among 6,683 health examinee, 1,154 (17.26%) had esophageal diseases. Gastro-esophageal reflux diseases (GERD) were the most common diseases (14.66%). The prevalence of erosive reflux esophagitis, minor change esophagitis, and Barrett's esophagus was 8.45%, 5.01% and 1.12%, respectively. Hiatal hernia and esophageal submucosal tumor were 2nd and 3rd common diseases (2.0% and 0.6%, respectively). A variety of other esophageal disorders were seen as well. The esophageal disorders with over 0.1% of prevalence were esophageal varices (0.37%), esophageal squamous papilloma (0.31%), esophageal candidiasis (0.25%), nonspecific esophagitis (0.16%), heterotopic gastric mucosa (0.16%), and esophageal vascular ectasia (0.12%) in order., Conclusions: The overall prevalence of esophageal disorders among health examinee was 17.3%. The GERD was the main esophageal disease and a variety of esophageal diseases were identified. The endoscopists need to take an interest in the esophageal disorders and a community-oriented well organized study should be warranted.

The BEACH program is a continuous national study of general practice activity in Australia. This analysis of encounters where patients presented with nausea and/or vomiting between April 2000 and March 2006 provides a backdrop against which related articles in this issue of Australian Family Physician can be further considered.

Background: US and Brazilian studies indicate that highly active antiretroviral therapy (HAART) has been effective in reducing morbidity and mortality from HIV/AIDS. Differences exist in the adoption and patterns of antiretroviral drug use and in the incidence of AIDS-defining illness (ADI) between the 2 countries, however, and there has not been a direct comparison of clinical response between Brazil and the United States. We sought to determine if there have been differences in the clinical response to HAART from HIV clinical practices in the United States and Brazil., Methods: We compared 2 similarly designed clinical cohorts from Baltimore, Maryland and Rio de Janeiro, Brazil. Patients who started HAART from 1997 to 2004 were compared for HIV-1 RNA suppression and CD4+ T-lymphocyte count change by 1 year of therapy and for development of an ADI up to 6 years of follow-up. A total of 1368 patients from Baltimore and 1045 patients from Rio de Janeiro were studied., Results: There was no difference by location in achieving an HIV-1 RNA level <400 copies/mL (46.9% in Rio de Janeiro, 50.8% in Baltimore), in the log change in HIV-1 RNA level (-1.65 log in Rio de Janeiro, - 1.63 log in Baltimore), or in the change in CD4 count (116 cells/mm3 in Rio de Janeiro, 122 cells/mm3 in Baltimore) by 12 months after starting HAART. By Kaplan-Meier analysis and Cox regression adjusted for demographic and clinical prognostic factors, there was no difference by location in development of the first ADI after starting HAART (relative hazard = 1.02; 95% confidence interval: 0.82 to 1.25 for Rio de Janeiro vs. Baltimore). The most commonly occurring ADI in Rio de Janeiro was tuberculosis (27.7% of patients), and the most commonly occurring ADI in Baltimore was esophageal candidiasis (36.8% of patients)., Conclusions: There were only minor differences in clinical response to the use of HAART comparing Rio de Janeiro with Baltimore, despite differences in patterns of antiretroviral drug use and ADI incidence. This analysis indicates that HAART can be similarly effective in treating HIV/AIDS in countries with different economies.

The aim of this study was to evaluate by PCR the presence of Helicobacter spp. in gastric mucus from the fundic region of the stomach and to investigate its role in oesophagogastric ulcers in swine bred and regularly slaughtered in Piedmont (Northern Italy). Stomachs from 595 regularly slaughtered swine were subjected to gross pathological examination in order to evaluate the presence of gastric ulcers (revealed in 75 cases, 12.6%). Histopathological examination was performed to better characterise erosions and ulcers. DNA extracted from gastric mucus collected from all the ulcer-affected and from 25 normal stomachs was submitted to PCR using Helicobacter spp. 16S rRNA gene target primers. Sixty-three percent (47/75) of the affected stomachs was positive as well as 24% (6/25) of the non-affected ones. Sequence analysis from 5 positive samples showed 99% homology with Helicobacter candidatus suis 16S ribosomal RNA gene.

Background: Stomach pain and discomfort have been reported since antiquity., Aim: To follow the time trends since the 18th century of dyspepsia, gastric ulcer, duodenal ulcer, and benign oesophageal disease to test when dyspepsia started to become a major clinical problem., Methods: The annual in- and out-patient records of the last three centuries from the Scottish Royal Infirmaries of Edinburgh, Aberdeen, Glasgow and Dundee were analysed. In addition, dispensary attendances, clinicians' casebooks, students' notebooks and medical texts have been scrutinized for historic statistics of upper gastrointestinal disease., Results: Dyspepsia was first recorded in the 1750s and increased markedly subsequently. Such dyspepsia persisted after gastric and duodenal ulcers appeared in the late 19th century and then declined again in the late 20th century. Non-ulcer dyspepsia has remained the commonest diagnosis made after endoscopy for stomach pain in the beginning of the 21st century., Conclusion: The current commonest diagnosis of stomach pain, dyspepsia dates from the mid-18th century. Any explanations of its causation need to consider this timing.