Congenital esophageal stenosis may present in adulthood

Jenifer Lehrer

Congenital esophageal stenosis may present in adulthood

Jenifer Lehrer

2003, American Journal of Gastroenterology

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Introduction: Obesity in the United States is a national health care crisis. Approximately 6 million Americans have a BMI of 40 or greater and thus qualify for the diagnosis of morbid obesity. Roux-en-Y gastric bypass is the most frequently performed procedure in the United States. We present a case of a patient with open Roux-en-Y gastric bypass who developed stenosis at the gastro-jejunostomy site 7 weeks post surgery. Case: A 39 year old morbidly obese African American female with hypertension, diabetes mellitus, stress incontinence, and arthralgias, underwent vertical band gastroplasty with Roux-en-Y gastrojejunostomy 7 weeks ago. She started having nausea and vomiting after meals approximately 5 weeks after her surgery with progressive worsening in her symptoms. She presented with intractable vomiting for 12 hours. Physical exam was unremarkable with no orthostatic changes in her blood pressure or heart rate. She was unable to tolerate an upper GI series. Laboratory studies including CBC, chemistry profile, liver function tests, and amylase and lipase were all within normal range. Upper endoscopy showed a tight fibrotic appearing stricture at the gastrojejunostomy site, which did not allow passage of a regular or a pediatric endoscope. Using an ERCP catheter, a small amount of contrast was injected just proximal to the gastrojejunostomy site to delineate the anatomy. Next, using endoscopic and fluoroscopic guidance, the stricture was dilated to 10 mm, and on a subsequent visit to 15 mm, using through the scope pyloric balloon dilators. Following the dilatation, the patient was able to tolerate regular food with continued weight control and has not required any further dilatations at 3 months follow-up. A majority of morbidly obese patients achieve dramatic success in terms of weight reduction and improvement in comorbidities with bariatric surgery. However, a minority of patients experience gastrointestinal complications. An understanding of the postoperative anatomy, an awareness of the possible operative complications, communication whenever possible with the bariatric surgeon, and appropriate endoscopic intervention will relieve most of these symptoms.

AJG – September, Suppl., 2003 References: 1. Yamamoto K, Kadakia SC. Incarceration of a colonoscope in an inguinal hernia. Gastrointestinal Endoscopy1994;49:157–158. 2. Leisser A, Delpre G, Kadish U. Colonoscope incarceration: an avoidable event. Gastrointestinal Endoscopy 1990;36:637– 638. 3. Fulp SR, Gilliam JH. Beware of the incarcerated hernia. Gastrointestinal Endosc.1990;36:318 –319. 4. Leichtmann GA, Feingelrent H, Pomeranz IS ET AL. Colonoscopy in patients with large inguinal hernias.GastrointestinalEndoscopy 1991; 37;494. 378 STOMAL STENOSIS: A COMPLICATION OF BARIATRIC SURGERY Ameet N. Parikh, M.D., Kenneth Belitsis, M.D., Joseph Kamelgard, M.D., Sita Chokhavatia, M.D.*. UMDNJ-NJMS, Newark, NJ. Introduction: Obesity in the United States is a national health care crisis. Approximately 6 million Americans have a BMI of 40 or greater and thus qualify for the diagnosis of morbid obesity. Roux-en-Y gastric bypass is the most frequently performed procedure in the United States. We present a case of a patient with open Roux-en-Y gastric bypass who developed stenosis at the gastro-jejunostomy site 7 weeks post surgery. Case: A 39 year old morbidly obese African American female with hypertension, diabetes mellitus, stress incontinence, and arthralgias, underwent vertical band gastroplasty with Roux-en-Y gastrojejunostomy 7 weeks ago. She started having nausea and vomiting after meals approximately 5 weeks after her surgery with progressive worsening in her symptoms. She presented with intractable vomiting for 12 hours. Physical exam was unremarkable with no orthostatic changes in her blood pressure or heart rate. She was unable to tolerate an upper GI series. Laboratory studies including CBC, chemistry profile, liver function tests, and amylase and lipase were all within normal range. Upper endoscopy showed a tight fibrotic appearing stricture at the gastrojejunostomy site, which did not allow passage of a regular or a pediatric endoscope. Using an ERCP catheter, a small amount of contrast was injected just proximal to the gastrojejunostomy site to delineate the anatomy. Next, using endoscopic and fluoroscopic guidance, the stricture was dilated to 10 mm, and on a subsequent visit to 15 mm, using through the scope pyloric balloon dilators. Following the dilatation, the patient was able to tolerate regular food with continued weight control and has not required any further dilatations at 3 months follow-up. A majority of morbidly obese patients achieve dramatic success in terms of weight reduction and improvement in comorbidities with bariatric surgery. However, a minority of patients experience gastrointestinal complications. An understanding of the postoperative anatomy, an awareness of the possible operative complications, communication whenever possible with the bariatric surgeon, and appropriate endoscopic intervention will relieve most of these symptoms. 379 CONGENITAL ESOPHAGEAL STENOSIS MAY PRESENT IN ADULTHOOD Jenifer K. Lehrer, M.D.*, Philip O. Katz, M.D., FACG. The Graduate Hospital, Philadelphia, PA. The patient with congenital esophageal stenosis (CES) usually presents in infancy or early childhood. Common symptoms include dysphagia, regurgitation, or aspiration pneumonia, often concurrent with the introduction of solid foods. Lesser degrees of stenosis may allow presentation to defer until adulthood. A 22-year-old man was referred with solid food dysphagia. He noted regurgitation in childhood, and must chew thoroughly and propel his food with sips of water. A recent pill impaction resolved with glucagon administration. He reported one month of postprandial heartburn relieved with lansoprazole, and seasonal allergies. He denied changes in weight or bowel Abstracts S129 patterns, nausea, vomiting, abdominal pain, hoarseness, or asthma. He denied caustic ingestions, radiation exposure, pneumonia, food allergies, connective tissue diseases, Raynaud’s symptoms, or blistering skin diseases. Laboratory data were unremarkable. A barium esophagram revealed mid-thoracic esophageal stenosis. Thin barium ingestion was required to propel a marshmallow distally. Esophageal manometry was unremarkable, including UES evaluation. On upper endoscopy, multiple non-obstructing concentric rings were visualized from 23 to 30 cm. Uncomplicated 12-, 14-, and 15-mm Savary dilations were performed. The patient’s dysphagia resolved, but the rings remained after 14 weeks of lansoprazole. Proximal nodule biopsies revealed basal zone hyperplasia, papillary elongation, and 30 lymphocytes, and 5 eosinophils, per high power field. CES is a rare cause of dysphagia in adults. The prevalence is 1 in 25,000 –50,000 live births, with male predominance among adult presenters. The etiology remains unclear. A congenital origin is likely as symptoms begin in childhood, and echoendosonography findings complement those of pediatric surgical pathology specimens. As biopsies may reveal esophagitis or the rare case of Barrett’s epithelium, the rings may represent a response to chronic acid exposure. However, pH-metry is often normal, and PPI use does not consistently resolve the rings or dysphagia. A third theory purports an association with eosinophilic esophagitis, suggested by allergic histories, mucosal eosinophilia, and resolution with steroids. In this patient with proximal lymphocytosis and few eosinophils, childhood inception of symptoms, and lack of ring resolution after 14 weeks of PPI use, we feel that CES is likely. Current treatment includes dietary modification and gradual dilation. Dilation-related complications of chest pain and tears may be common. 380 CONCURRENT COLLAGENOUS COLITIS AND PSEUDOMEMBRANOUS COLITIS: CASE REPORT AND REVIEW OF LITERATURE Emad H. Elbadawy, M.D., Martina Ferraro, D.O., Michael Springer, M.D.*, Edmond Blades, M.D. Fairview Hospital, Cleveland, OH. Introduction: Synchronous occurrence of collagenous colitis and pseudomembranous colitis is very rare. We report a case of collagenous colitis complicated by pseudomembranous colitis with complete resolution after metronidazole and vancomycin therapy. Case: A 52-year old white female presented with 8-month history of intermittent abdominal pain and watery diarrhea. Symptoms worsened 2 weeks prior to admission and were associated with 14 lbs weight loss. Patient denied any fever, nausea, vomiting or passage of blood or mucus with stool. She denied any use of antibiotics in the past year. Examination showed diffuse abdominal tenderness with no guarding or rebound tenderness. Initial laboratory evaluation revealed WBCs of 14.2 k/␮L (4.8 –10.8) with 21% bands and hypokalemia. Stool cultures and examination for ova and parasites were negative. Stool examination for leucocytes was positive while multiple assays for Clostridium difficile toxin-A were negative. Colonoscopic evaluation showed multiple yellowish patches “pseudomembranes” covering extensive areas of the colon with friable, erythematous mucosa. Biopsy revealed marked thickening of the basement membrane with intraepithelial inflammatory cells, and prominent acute inflammatory fibrinopurulent exudates along the surface. Therapy was initiated with oral metronidazole 500mg three times daily and vancomycin 250 mg four times daily. Complete resolution of diarrhea, abdominal pain and leucocytosis ensued after 4 days of therapy. Repeat colonoscopy showed complete resolution of the pseudomembranes with residual mild hyperemia of the colonic mucosa. Repeat biopsy revealed persistent thickening of the basement membrane with complete absence of pseudomembranes and fibrinopurulent exudates. Discussion: Collagenous colitis is characterized by microscopic evidence of subepithelial collagen deposition in excess of 10 ␮m in mean thickness without specific endoscopic abnormalities. Most common manifestations are watery diarrhea and weight loss. Although stool examination for C.

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