Novel use of esophageal overtube and water flushes as a safety indicator and facilitator for the push technique in esophageal food impaction

Esophageal food impaction requires urgent endoscopic intervention either by extraction or pushing into the stomach.Due to risks of perforation,controversy exists between when to extract verses when to push the food bolus.There are no clear guidelines on when it is safe to push a food bolus;endoscopists rely on their subjective experiences and judgment.We present a case with a novel use of an esophageal overtube and water flushes to determine the safety of pushing a food bolus and facilitate passage into the stomach.

Esophageal intramural pseudodiverticulosis,a rare cause of food impaction:case report and review of the literature

Esophageal intramural pseudodiverticulosis(EIPD)is a rare,benign condition of uncertain etiology and pathogenesis,which usually presents with either progressive or intermittent dysphagia.Acute presentation with food impaction,requiring emergency esophago-gastroduodenoscopy(EGD),is rare.We report a case of EIPD presenting as food bolus impaction in an elderly black female.The patient had no previous history of dysphagia or odynophagia.Currently accepted risk factors,such as diabetes mellitus,chronic alcoholism,and reflux esophagitis,were not present in our patient.Emergency EGD established the diagnosis and also dislodged the food bolus.Histopathological evaluation of the mucosa diagnosed co-existent acute candidal infection.Medical treatment with proton pump inhibitor and azole antifungal led to resolution of her symptoms.Review of the literature revealed that stenosis,strictures,perforation,gastro-intestinal bleed,and fistula formation are potential complications of EIPD.Multiple motility abnormalities have been described but are not consistent.Treatment of the underlying inflammatory and or infectious condition is the mainstay of management of this unusual condition.

Esophageal food impaction during cultural holidays and national athletic events

Background:Although intrinsic risk factors contributing to esophageal food impaction are well established,whether social behavior affects its occurrence has not yet been examined.Methods:We conducted a retrospective review of the gastroenterology endoscopy procedural documentation software for the period of 2001–2012 to identify all patients who presented to our emergency department for esophageal foreign-body removal at the time of national athletic events and holidays associated with dietary indiscretions.Results:We found that adults undergoing emergent esophagogastroduodenoscopy during periods celebrating cultural holidays and national athletic events were more likely to experience esophageal food impaction compared with those undergoing emergent endoscopy during periods not associated with these events(36.8% vs 3.6%;P<0.001):a 10-fold increase.During a national holiday/athletic event period,the most common impacted food item was turkey(50%)followed by chicken(29%)and beef(21%).Conclusions:Esophageal food impaction is more likely to occur on American holidays and national athletic events and is associated with large meals.Patients with intrinsic risk factors should be advised to modify their diet during cultural events associated with tachyphagia and large meals to prevent esophageal food impaction.

Genetically Modified Doubts Imported GM soybeans impact China’s local farmers and create food safety concerns

The cooking oil made from the imported soybeans does not contain transgenic proteins. So there will be no food safety threat.

Endoscopic findings in patients with Schatzki rings:Evidence for an association with eosinophilic esophagitis

AIM:To investigate endoscopic findings in patients with Schatzki rings(SRs) with a focus on evidence for eosinophilic esophagitis(EoE).METHODS:We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic,Wiesbaden,Germany between July 2007 and July 2010.All patients with endoscopically diagnosed SRs,defined as thin,symmetrical,mucosal structures located at the esophagogastric junction,were prospectively registered.Additional endoscopic findings,clinical information and histopathological findings with a focus on esophageal eosinophilia(≥ 20 eosinophils/high power field) were recorded.The criteria for active EoE were defined as:(1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf;(2) symptoms of esophageal dysfunction;and(3) exclusion of other causes of esophageal eosinophilia.Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy.The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia.RESULTS:A SR was diagnosed in 171(3.3%;128 males,43 females,mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinalendoscopy.Twenty of the 116 patients(17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia(≥ 20 eosinophils/hpf).Nine of these patients(8 males,1 female,mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE,whereas in 11(9%) patients with ≥ 20 eosinophils/hpf,a definite diagnosis of EoE was made.Three of the 11 patients(27%) with definite EoE had no suspicious endoscopic features of EoE.In contrast,in the 25 patients in whom EoE was suspected by endoscopic features,EoE was only confirmed in 7(28%) patients.Patients with EoE were younger(mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years,P = 0.012),were more likely to have a history of allergies(73% vs 29%,P = 0.007) and complained more often of dysphagia(91% vs 34%,P = 0.004) and food impaction(36% vs 6%,P = 0.007) than patients without EoE.Endoscopically,additional webs were found significantly more often in patients with EoE than in patients without EoE(36% vs 11%,P = 0.04).Furthermore,the SR had a tendency to be narrower in patients with EoE than in those without EoE(36% vs 18%,P = 0.22).The percentage of males(73% vs 72%,P = 1.0) and frequency of heartburn(27% vs 27%,P = 1.0) were not significantly different in both groups.The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger(mean age 49 ± 10 years vs 58 ± 6 years,P = 0.0008) and were more likely to have a history of allergies(78% vs 24%,P = 0.003) than patients with < 20 eosinophils/hpf.Predictors of EoE were younger age,presence of dysphagia or food impaction and a history of allergies.CONCLUSION:A significant proportion of patients with SRs also have EoE,which may not always be suspected according to other endoscopic features.

Is the schatzki ring a unique esophageal entity?

AIM： To study, whether the association of Schatzki rings with other esophageal disorders support one of the theories about its etiology. METHODS： From 1987 until 2007, all patients with newly diagnosed symptomatic Schatzki rings （SRs） were prospectively registered and followed. All of them underwent structured interviews with regards to clinical symptoms, as well as endoscopic and/or radiographic examinations. Endoscopic and radiographic studies determined the presence of an SR and additional morp- hological abnormalities. RESULTS： One hundred and sixty-seven patients （125 male, 42 female） with a mean age of 57.1±14.6 years were studied. All patients complained of intermittent dysphagia for solid food and 113 （79.6%） patients had a history of food impaction. Patients experienced symptoms for a mean of 4.7± 5.2 years before diagnosis. Only in 23.4% of the 64 patients who had endoscopic and/or radiological examinations before their first presentation to our clinic, was the SR previously diagnosed. At presentation, the mean ring diameter was 13.9 4- 4.97 mm. One hundred and sixty-two （97%） patients showed a sliding hiatal hernia. Erosive reflux esophagitis was found in 47 （28.1%） patients. Twenty-six （15.6%） of 167 patients showed single or multiple esophageal webs; five （3.0%） patients exhibited eosinophilic esophagitis; and four （2.4%） had esophageal diverticula. Four （7%） of 57 patients undergoing esophageal manometry had non- specific esophageal motility disorders. CONCLUSION： Schatzki rings are frequently associated with additional esophageal disorders, which support the assumption of a multifactorial etiology. Despite typical symptoms, SRs might be overlooked.

Endoscopic removal of foreign bodies:A retrospective study in Japan

BACKGROUND The ingestion of foreign bodies(FBs)and food bolus impaction(FBI)in the digestive tract are commonly encountered clinical problems.Methods to handle such problems continue to evolve offering advantages,such as the avoidance of surgery,reduced cost,improved visualization,reduced morbidity,and high removal success rate.However,to date,no studies have evaluated the endoscopic management of FBs in Japan.AIM To elucidate level of safety and efficacy in the endoscopic management of FBs and FBI.METHODS A total of 215 procedures were performed at Keio University Hospital between November 2007 and August 2018.Data were collected from medical charts,and endoscopic details were collected from an endoscopic reporting system.Procedures performed with a flexible gastrointestinal endoscope were only taken into account.Patients who underwent a technique involving FB or FBI from the digestive tract were only included.Data on patient sex,patient age,outpatient,inpatient,FB type,FB location,procedure time,procedure type,removal device type,success,and technical complications were reviewed and analyzed retrospectively.RESULTS Among the 215 procedures,136(63.3%)were performed in old adults(≥60 years),180(83.7%)procedures were performed in outpatients.The most common type of FBs were press-through-pack(PTP)medications[72(33.5%)cases],FBI[47(21.9%)],Anisakis parasite(AP)[41(19.1%)cases].Most FBs were located in the esophagus[130(60.5%)cases]followed by the stomach[68(31.6%)cases].AP was commonly found in the stomach[39(57.4%)cases],and it was removed using biopsy forceps in 97.5%of the cases.The most common FBs according to anatomical location were PTP medications(40%)and dental prostheses(DP)(40%)in the laryngopharynx,PTP(48.5%)in the esophagus,AP(57.4%)in the stomach,DP(37.5%)in the small intestine and video capsule endoscopy device(75%)in the colon.A transparent cap with grasping forceps was the most commonly used device[82(38.1%)cases].The success rate of the procedure was 100%,and complication were observed in only one case(0.5%).CONCLUSION Endoscopic management of FBs and FBI in our Hospital is extremely safe and effective.

Modeling Study of Seasonal Variation of the Pelagic-Benthic Ecosystem Characteristics of the Bohai Sea

Based on experiment data of the Sino-German comprehensive investigations in the Bohai Sea in 1998 and 1999, a simple coupled pelagic-benthic ecosystem multi-box model is used to simulate the ecosystem seasonal variation. The pelagic sub-model consists of seven state variables： phytoplankton, zooplankton, TIN, TIP, DOC, POC and dissolved oxygen （DO）. The benthic sub-model includes macro-benthos, meiobenthos, bacteria, detritus, TIN and TIP in the sediment. Besides the effects of solar radiation, water temperature and the nutrient from sea bottom exudation, land-based inputs are considered. The impact of the advection terms between the boxes is also considered. Meanwhile, the effects of the micro- bial-loop are introduced with a simple parameterization. The seasonal variations and the horizontal distributions of the ecosystem state variables of the Bohai Sea are simulated. Compared with the observations, the results of the multi-box model are reasonable. The modeled results show that about 13% of the photosynthesis primary production goes to the main food loop, 20% transfers to the benthic domain, 44% is consumed by the respiration of phytoplankton, and the rest goes to DOC. Model results also show the importance of the microbial food loop in the ecosystem of the Bohai Sea, and its contribution to the annual zooplankton production can be 60%-64%.

Complication rates in emergent endoscopy for foreign bodies under different sedation modalities:A large single-center retrospective review

BACKGROUND Foreign object ingestion(FOI)and food bolus impaction(FBI)are common causes of emergent endoscopic intervention.The choice of sedation used is often dictated by physician experience.Many endoscopists frequently prefer to use monitored anesthesia care(MAC)and general anesthesia(GA)as opposed to conscious sedation(CS)due to the concern for inadequate airway protection.However,there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.AIM To investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.METHODS We conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals.A standardized questionnaire was utilized to collect data on demographics,endoscopic details,sedation practices,hospital stay and adverse events.Complications recognized during and within 24 h of the procedure were considered early,whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications.Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types,namely CS,MAC and GA.Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.RESULTS Among the 929 procedures analyzed,353 procedures(38.0%)were performed under CS,278 procedures(29.9%)under MAC and the rest(32.1%)under GA.The median age of the subjects was 52 years old,with 57.4%being male.The majority of the procedures(64.3%)were FBI with the rest being FOI(35.7%).A total of 132 subjects(14.2%)had chronic comorbidities while 29.0%had psychiatric disorders.The most commonly observed early complications were mucosal laceration(3.8%)and bleeding(2.6%).The most common delayed complication was aspiration pneumonia(1.8%).A total of 20 patients(5.6%)could not adequately be sedated with CS and had to be converted to MAC or GA.Patient sedated with MAC and GA were more likely to require hospitalization,P<0.0001.Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS(14.7%),MAC(14.7%)and GA(19.5%),P=0.19.CONCLUSION For patients who present with FOI or FBI and undergo emergent endoscopic treatment,there is no significant difference in adverse event rates between CS,MAC and GA.

Dysphagia: Thinking outside the box

Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux(GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett's oesophagus, adeno-as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pretest probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.

Contributions of climate, varieties, and agronomic management to rice yield change in the past three decades in China

The long-term field experiment data at four representative agro-meteorological stations, together with a crop simulation model, were used to disentangle the contributions of climate change, variety renewal, and fertilization management to rice yield change in the past three decades. We found that during 1981-2009 varieties renewal increased rice yield by 16%-52%, management improvement increased yield by 0-16%, and the contribu- tions of climate change to rice yield varied from - 16% to 10%. Varieties renewal and management improvement offset the negative impacts of climate change on rice production. Among the major climate variables, decreases in solar radiation reduced rice yield on average by 0.1% per year. The impact of temperature change had an explicit spatial pattern. It increased yield by 0.04%-0.4% per year for single rice at Xinbin and Ganyu station and for late rice at Tongcheng station, by contrast reduced yield by 0.2%- 0.4% per year for single rice at Mianyang station and early rice at Tongcheng station. During 1981-2009, rice varieties renewal was characterized by increases in thermal requirements, grain number per spike and harvest index. The new varieties were less sensitive to climate change than old ones. The development of high thermal require- ments, high yield potential and heat tolerant rice varieties, together with improvement of agronomic management, should be encouraged to meet the challenges of climate change and increasing food demand in future.