Mediastinal tuberculous lymphadenitis presenting as an esophageal intramural tumor: A very rare but important cause for dysphagia

Dysphagia associated with esophageal mechanical obstruction is usually related to malignant esophageal diseases. Benign lesions are rarely a cause for this type of dysphagia, and usually occur either as an intramural tumor or as an extrinsic compression. Mediastinal tuberculous lymphadenitis is rare in adults, and even more rarely causes dysphagia. We report two cases of dysphagia in adult patients caused by mediastinal tuberculous lymphadenitis, presenting radiologicaUy and endoscopically as an esophageal submucosal tumor. Based on the clinical and imaging diagnosis, the patients underwent a right thoracotomy, and excision of the mass attached to and compressing the esophagus. Pathological examination of the specimens showed a chronic granulomatous inflammation with caseous necrosis, which was consistent with tuberculous lymphadenitis.

Self-expanding metallic esophageal stents:A long way to go before a particular stent can be recommended

We agree that the covered self-expanding metal stents (SEMSs) fare better than the uncovered stents as recurrent dysphagia due to tumor ingrowth is common with uncovered stent. Recent American College of Gastroenterology Practice Guideline on the Role of Esophageal Stents in Benign and Malignant Diseases concludes that SEMSs cannot be routinely recommended in conjunction with chemo-radiation. The comparison of ultraflex and choostent in the Italian study found no difference in the palliation of dysphagia, rate of complications and survival rate.

Inoperable esophageal cancer and outcome of palliative care

AIM:To determine the outcome of esophageal cancer patients referred for palliative care,in Gorgan and Gonbad gastrointestinal clinics,northeast of Iran. METHODS:This cross-sectional study was done on inoperable esophageal cancer cases referred to gastrointestinal clinics in Gorgan and Gonbad city(2005-2006) . Demographic data were collected during the procedure and cases were followed up every one month. Improvement proportion was calculated with 95% confidence interval,to determine the rate of improvement. Survival analysis and Kaplan-Meier methods were used to estimate the duration of palliative care effectiveness. RESULTS:We recruited 39 cases into the study. Squamous cell carcinoma was the most prevalent(92.3%) . The middle third of the esophagus was involved predominantly(51.3%) . Dilation was the most preferred method(89.7%) and stenting was done in 4 cases. Decreasing dysphagia score was not related to palliation method or pathology type of carcinoma. Age of the patients was significantly related to the improvement of dysphagia score. Mean survival time was 137.6 d and median was 103 d. CONCLUSION:Results of this study showed a low survival rate after palliative care in esophageal cancer cases despite dysphagia scores' improvement after dilating or stenting.

A rare cause of dysphagia:Herpes simplex esophagitis

Herpes simplex esophagitis （HSE） is well documented in immunosuppressed patients. However, it is rare in the immunocompetent host. We present a case of HSE in a 21 year-old healthy lady who was admitted to our unit with dysphagia, odynophagia and chest pain. Clinical examination revealed mild epigastric tenderness and admission bloods including full blood picture, electrolytes and inflammatory markers were normal. She underwent an esophagogastroduodenoscopy （EGD） which revealed severe exudative, well-circumscribed ulcerations in her distal esophagus. Biopsies confirmed severe esophagitis with acute ulceration and subsequent polymerase chain reaction （PCR） confirmed herpes simplex virus （HSV） type 1. Subsequent assessment failed to identify an immune disorder. HSE should be suspected when faced with characteristic endoscopic findings, even if the patient is immunocompetent. When the diagnosis of HSE is confirmed, an immune deficiency should be sought.

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.

Eosinophilic esophagitis: A newly established cause of dysphagia

Eosinophilic esophagitis has rapidly become a recognized entity causing dysphagia in young adults. This review summarizes the current knowledge of eosinophilic esophagitis including the epidemiology, clinical presentation, diagnostic criteria, pathophysiology, treatment, and prognosis. An extensive search of PubMed/Medline （1966-December 2005） for available English literature in humans for eosinophilic esophagitis was completed. Appropriate articles listed in the bibliographies were also attained. The estimated incidence is 43/10s in children and 2.5/10s in adults. Clinically, patients have a long history of intermittent solid food dysphagia or food impaction. Some have a history of atopy. Subtle endoscopic features may be easily overlooked, including a ＂feline＂ or corrugated esophagus with fine rings, a diffusely narrowed esophagus that may have proximal strictures, the presence of linear furrows, adherent white plaques, or a friable （crepe paper） mucosa, prone to tearing with minimal contact. Although no pathologic consensus has been established, a histologic diagnosis is critical. The accepted criteria are a dense eosinophilic infiltrate （〉20/high power field） within the superficial esophageal mucosa. In contrast, the esophagitis associated with acid reflux disease can also possess eosinophils but they are fewer in number. Once the diagnosis is established, treatment options may include specific food avoidance, topical corticosteroids, systemic corticosteroids, leukotriene inhibitors, or biologic treatment. The long-term prognosis of EE is uncertain; however available data suggests a benign, albeit inconvenient, course. With increasing recognition, this entity is taking its place as an established cause of solid food dysphagia.

Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia

AIM To investigate the behavior of pulsatile pressure zones(PPZ's) as noted on high resolution esophageal impedance manometry(HREIM), and determine their association with dysphagia.METHODS Retrospective, single center case control design scr-eening HREIM studies for cases(dysphagia) and controls(no dysphagia). Thoracic radiology studies were reviewed further in cases for(thoracic cardiovascular) thoracic cardiovascular(TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function(impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ's. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ's in these 50 cases and 59 controls was similar(average 1.4 PPZ/patient). Controls(mean 31.2 ± SD 12 years) were a significantly younger population than cases(mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls(15.7 ± 10.0 mm Hg) than cases(10.8 ± 9.7 mm Hg). Although statistically significant(P = 0.005), it was a weak predictor using logistic regression and ROC model(AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology(1 aberrant subclavian artery, 2 dilated left atrium). The posture(supine vs upright) with more prominent PPZ's impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.

Lymphocytic esophagitis: Still an enigma a decade later

Lymphocytic esophagitis (LE) is a clinicopathologic entity first described by Rubio et al in 2006. It is defined as peripapillary intraepithelial lymphocytosis with spongiosis and few or no granulocytes on esophageal biopsy. This definition is not widely accepted and the number of lymphocytes needed to make the diagnosis varied in different studies. Multiple studies have described potential clinical associations and risk factors for LE, such as old age, female gender and smoking history. This entity was reported in inflammatory bowel disease in the pediatric population but not in adults. Other associations include gastroesophageal reflux disease and primary esophageal motility disorders. The most common symptom is dysphagia, with a normal appearing esophagus on endoscopy, though esophageal rings, webs, nodularities, furrows and strictures have been described. Multiple treatment modalities have been used such as proton pump inhibitors and topical steroids. Esophageal dilation seems to be therapeutic when dysphagia is present along with esophageal narrowing secondary to webs, rings or strictures. The natural history of the disease remains unclear and needs to be better delineated. Overall, lymphocytic esophagitis seems to have a chronic and benign course, except for two cases of esophageal perforation in the literature, thought to be secondary to this entity.

因势而异抓落实

沙盖是一种生长在沙丘间和半固定沙丘上的植物,具有食用、药用和固沙的价值,深受人们的喜爱,但它只能生长在沙地上。橘树生长在淮河以南,就是香甜可口的橘子,而生长在淮河以北,就变成酸涩难食的枳。由此可见,就是再好的种子也要种植在适合它生长的土壤里,才能生根发芽,茁壮成长。班组管理亦应如此。

Gender,medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

Background:High-resolution esophageal manometry(HREM)is the diagnostic test of choice for evaluation of nonobstructive dysphagia.Studies regarding the predictors of esophageal dysmotility are limited.Therefore,our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.Methods:We performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015.After obtaining IRB approval(16–051),clinical records were scrutinized for demographic data,symptoms,medication use,upper endoscopic findings and esophageal pH findings.HREM plots were classified per Chicago Classification version 3.0.Primary outcome was prevalence of esophageal motility disorders;secondary outcomes assessed predictive factors.Results:In total,155 patients with non-obstructive dysphagia(55616 years old,72%female)were identified.HREM diagnosis was normal in 49%followed by ineffective esophageal motility in 20%,absent contractility in 7.1%,achalasia type II in 5.8%,outflow obstruction in 5.2%,jackhammer esophagus in 4.5%,distal esophageal spasm in 3.9%,fragment peristalsis in 1.9%,achalasia type I in 1.9%,and achalasia type III in 0.6%.Men were five times more likely to have achalasia than women[odds ratio(OR)5.3,95%confidence interval(CI):2.0–14.2;P=0.001].Patients with erosive esophagitis(OR 2.9,95%CI:1.1–7.7;P=0.027)or using calcium channel blockers(OR 3.0,95%CI:1.2–7.4;P=0.015)were three times more likely to have hypomotility disorders.Conclusion:From this study,we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49%of patients with non-obstructive dysphagia.Male gender,erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Cost-Effectiveness of Interventions for Alternate Food to Address Agricultural Catastrophes Globally

The literature suggests there is about a 1 % risk per year of a 10 % global agricultural shortfall due to catastrophes such as a large volcanic eruption, a medium asteroid or comet impact, regional nuclear war, abrupt climate change, and extreme weather causing multiple breadbasket failures. This shortfall has an expected mortality of about 500 million people. To prevent such mass starvation, alternate foods can be deployed that utilize stored biomass. This study developed a model with literature values for variables and, where no values existed,used large error bounds to recognize uncertainty. Then Monte Carlo analysis was performed on three interventions: planning, research, and development. The results show that even the upper bound of USD 400 per life saved by these interventions is far lower than what is typically paid to save a life in a less-developed country. Furthermore, every day of delay on the implementation of these interventions costs 100–40,000 expected lives(number of lives saved multiplied by the probability that alternate foods would be required). These interventions plus training would save 1–300 million expected lives. In general, these solutions would reduce the possibility of civilization collapse, could assist in providing food outside of catastrophic situations, and would result in billions of dollars per year of return.

Existence of spatiotemporal patterns in the reaction-diffusion predator-prey model incorporating prey refuge

The pattern formation in reaction-diffusion system has long been the subject of interest to the researchers in the domain of mathematical ecology because of its universal exis- tence and importance. The present investigation deals with a spatial dynamics of the Beddington-DeAngelis predator-prey model in the presence of a constant proportion of prey refuge. The model system representing boundary value problem under study is subjected to homogeneous Neumann boundary conditions. The asymptotic stability including the local and the global stability and the bifurcation as well of the unique pos- itive homogeneous steady state of the corresponding temporal model has been analyzed. The Turing instability region in two-parameter space and the condition of diffusion- driven instability of the spatiotemporal model are investigated. Based on the appro- priate numerical simulations, the present model dynamics in Turing space appears to get influenced by prey refuge while it exhibits diffusion-controlled pattern formation growth to spots, stripe-spot mixtures, labyrinthine, stripe-hole mixtures and holes repli- cation. The results obtained appear to enrich the findings of the model system under consideration.