Leiomyoma of the oesophagus managed by thoracoscopic enucleation

The authors document two patients with oesophageal leiomyoma. In the first patient, a 41-year-old man, enucleation of the oesophageal leiomyoma was initially attempted by a thoracoscopic approach, but because of adherence of the tumour to the oesophageal mucosa, enucleation was completed by thoracotomy. Thoracoscopic enucleation was successfully performed in the second patient, a 62-year-old man. This paper includes a literature review on the pathology, diagnosis and surgical approach in the management of oesophageal leiomyoma. In conclusion, prudent use of thoracoscopic approach in the enucleation of oesophageal leiomyoma could potentially result in shorter hospital stay, decreased postoperative pain and reduced requirement for postoperative analgesia.     

Oesophageal ulcer caused by warfarin

Oesophageal injury is a well recognized complication of certain oral medications but warfarin has not been implicated previously. We present a case of an oesophageal ulcer occurring in a patient with mitral regurgitation taking warfarin, and demonstrate a delayed oesophageal tablet transit time.     

Oral presentation of an oesophageal mucosal tear

Tears of the oesophageal wall following sudden forceful vomiting are well documented in literature. In Boerhaave's syndrome there is transmural rupture associated with complications including pneumothorax, pneumomediastinum, surgical emphysema and shock. In Mallory-Weiss syndrome mucosal tears are associated with haematemesis and shock. In neither of these conditions has intraluminal obstruction been described as an aetiological factor. We present a case with similar pathophysiology where oesophageal obstruction by a meat bolus followed by forceful vomiting led to an oesophageal mucosal tear and presentation of a band of oesophageal mucosa in the oral cavity. The patient did not develop any complications and made an uneventful recovery following conservative management.     

Isolated oesophageal cyst connected with the bronchus

We report an unusual case of a patient with an oesophageal cyst connected to the bronchus. A 24-year old male with a two-year history of repeated attacks of chest infection and haemoptysis was found to have a cyst of 4 x 4 cm affecting the anterior and apical segments of the right upper lobe. The cyst was excised in its entirety and the histopathological study of the cyst showed stratified squamous epithelium with submucosal and muscular layer but no cartilage. The pathological diagnosis was an oesophageal cyst. No previous case of isolated oesophageal cyst connected to the bronchus has been reported according to the available literature.     

Gastrointestinal amyloidosis complicating psoriatic arthropathy

A patient is described who developed gastrointestinal amyloidosis complicating psoriatic arthropathy. The presenting symptom was progressive dysphagia due to oesophageal involvement. Other clinical features included gastric ulceration with melaena, intestinal pseudo-obstruction and evidence of impaired renal function. The oesophageal symptoms improved after endoscopic dilatation of the cardia. Colchicine was used in an attempt to slow down progression of the condition.     

Successful outcome of gestation in a young woman with severe oesophageal varices throughout the pregnancy

During normal pregnancy there is an increase in the maternal blood volume leading to portal hypertension with some changes in liver functions. However, in an apparently healthy woman without known liver cirrhosis or other advanced liver disease, severe oesophageal varices with along with repeated variceal bleeding during pregnancy is rare. In this paper we described a case of severe oesophageal variceal bleeding in a young woman without having any pre-existing liver pathology. Due to repeated pregnancy with short intervel bleeding the patient developed severe anaemia. Packed cell transfusion was done repeatedly and oesophageal variceal ligation (EVL) was done three times. In spite of these measures variceal bleeding continued and patient's condition was deteriorating progressively; so caesarean section was at 33rd week of gestation and a preterm but healthy baby was delivered. The puerperium was uneventful with no haematemesis and there was gradual improvement of the condition. A brief review of the literature on pregnancy with oesophageal varices is also presented.     

Sudden death from perforation of a benign oesophageal ulcer into a major blood vessel

Two cases of sudden death due to perforation of a benign oesophageal ulcer into a major blood vessel are reported. In one man, anaemia and aspiration pneumonitis dominated the clinical picture. He had an oesophageal stricture and a chronic peptic ulcer associated with an incarcerated hiatus hernia. Death was due to haemorrhage caused by perforation of the ulcer into the thoracic aorta. The second patient presented with confusion and falls, backache and indigestion. She had a hiatus hernia and a large benign chronic oesophageal ulcer. Death was due to perforation of the ulcer into the left pulmonary vein. The cases are presented for their rarity, to illustrate the complex and late presentation of problems in geriatric medicine, and as a reminder that reflux oesophagitis can be dangerous.     

Clinics in diagnostic imaging (165)

Oesophageal rupture is a life-threatening complication of balloon tamponade for bleeding oesophageal varices. We herein describe the clinical course and imaging findings in a 33-year-old Indian man who had a Sengstaken-Blakemore (SB) tube inserted for uncontrolled haematemesis, which was unfortunately complicated by malposition of the gastric balloon with resultant oesophageal rupture. The inflated SB tube gastric balloon was visualised within the right hemithorax on chest radiography after the SB tube insertion. Further evaluation of the thorax on computed tomography confirmed the diagnosis of oesophageal rupture associated with right-sided haemopneumothorax. It is crucial for both the referring clinician and reporting radiologist to recognise early the imaging features of an incorrectly positioned SB tube gastric balloon, so as to ensure prompt intervention and a reduction in patient morbidity and mortality.     

Tetracycline-induced proximal oesophagitis

Medication-induced oesophagitis is an unusual cause of oesophageal damage. A patient is presented who developed sudden onset of odynophagia and dysphagia while taking tetracycline. Endoscopy revealed proximal oesophagitis which was confirmed histologically. Symptoms resolved rapidly after stopping the offending drug. Drug-induced oesophagitis should be considered in patients with unexplained oesophageal symptoms. This condition is often unrecognized as symptoms usually resolve on cessation of the drug. Prevention is the best approach.     

Duodenal stents for malignant duodenal strictures

Duodenal obstruction may be caused by inoperable malignant disease. Symptoms of nausea and vomiting have been traditionally palliated by surgery. The aim of the study was to determine the efficacy of the endoscopic placement of metal self expanding duodenal stents for the palliation of malignant duodenal obstruction. Four patients with malignant gastric outlet obstruction are described. One patient had a history of oesophagectomy for oesophageal adenocarcinoma and presented with further dysphagia. At endoscopy the recurrent oesophageal tumour and an adenocarcinoma involving the pylorus were both stented. In the other three patients there was a previous history of colonic carcinoma, cholangiocarcinoma and oesophageal adenocarcinoma respectively. All four patients were successfully stented with good palliation of their symptoms. Duodenal Wallstents are a useful alternative to surgery in patients with inoperable malignant duodenal obstruction or those who are unfit for surgery.     

Recurrent sub-mucosal dissection of the oesophagus in association with achalasia

Submucosal dissection of the oesophagus is a rare oesophageal disorder. We report a patient who had recurrent episodes of dissection and achalasia. Both recurrence and the association with achalasia are to our knowledge unique.     

Bacterial oesophagitis in an immunocompromised patient.

Bacterial oesophagitis is an uncommon and poorly described entity affecting particularly the immunosuppressed patient. The diagnosis rests on the demonstration of bacterial invasion of the oesophageal wall in the absence of other pathological processes. The causative organisms usually are Gram-positive cocci and there may be associated bacteraemia. The case report describes a leukaemic patient with bacteraemic bacterial oesophagitis.     

Tuberculous infection

A female patient presenting with post-prandial epigastric pain and weight loss was diagnosed to have oesophageal tuberculosis by endoscopic biopsy. She responded well to standard anti-tuberculosis treatment.     

Corticosteroid induced remission of oesophageal involvement in mixed connective tissue disease

Oesophageal involvement is known to be one of the most severe and resistant manifestations of connective tissue diseases, mainly progressive systemic sclerosis (PSS). A patient who had manifestations of systemic lupus erythematosus, PSS and polymyositis is described. Since some features of mixed connective tissue disease (MCTD) respond to corticosteroid treatment, fluocortolone was administered and both clinical and radiological remission of the oesophageal involvement were observed. At the same time, there was also a marked improvement of the cutaneous lesions. In view of the described observation, it seems advisable to try this treatment for oesophageal manifestations of MCTD.     

Endoscopic sclerotherapy of bleeding oesophageal varices in Jamaica

The results of oesophageal sclerotherapy (OS) in 18 patients with recurrent bleeding varices are compared with 15 patients treated medically. The total transfusion requirement pre-sclerotherapy was 112 units of blood (mean 6/patient) which decreased to 46 units (mean 2.5) after sclerotherapy treatment was started (p = 0.005). In the medically treated group, total transfusion was 74 units (mean 5 units/patient). One hundred and forty-three injection sclerotherapy sessions were given, and all but one patient had significant reduction or eradication of varices. Three patients died of recurrent bleeding (17%) and one other required surgery. In the medically treated group, 3 patients died of bleeding (20%). Complications of sclerotherapy included mild bleeding (39%), chest pain (28%) and oesophageal ulcer (5.5%). OS reduces transfusion requirements in patients with recurrent variceal bleeding.     

A life-threatening respiratory complication of gastro-oesophageal reflux in a patient with tetraplegia

Recurrent attacks of life-threatening dyspnoea and choking occurred in a patient with tetraplegia. Conventional investigations for gastro-oesophageal reflux were normal, but 24-hour oesophageal pH recording revealed gross reflux in association with an attack of dyspnoea. Surgical correction of the reflux abolished the attacks. The possibility of autonomic dysreflexia as the mechanism linking reflux and respiratory symptoms in this patient is discussed.     

Developments in the management of oesophageal atresia and tracheo-oesophageal fistulas

Since 1948, when the first patient with oesophageal atresia and a tracheo-oesophageal fistula was treated successfully at the Royal Children's Hospital, Melbourne, 569 infants with one or both conditions have been managed at that institution. The mortality rate in those in whom surgical repair of the oesophageal atresia and distal tracheo-oesophageal fistula was attempted has declined from 55% in the first 10 years to less than 1% in the last 10 years of the series. Earlier diagnosis and improvements in resuscitation, transport, neonatal intensive care, anaesthesia, the treatment of associated anomalies and surgical technique all are likely to have contributed to the decline in the mortality and morbidity rates. Problems which remain unresolved in part relate to the aetiology and embryogenesis of oesophageal atresia, the management of long-gap atresia, and the treatment of gastro-oesophageal reflux and tracheomalacia. This article outlines the improvements in management which have occurred already and speculates about what the future may hold.     

Intraperitoneal haemorrhage from anterior abdominal wall varices.

Patients with oesophageal varices frequently present with gastrointestinal haemorrhage but bleeding from varices at other sites is rare. We present a patient with hepatitis C-induced cirrhosis and partial portal vein occlusion who developed spontaneous haemorrhage from anterior abdominal wall varices into the rectus abdominus muscle and peritoneal cavity.     

Hypertrophic osteoarthropathy: two unusual causes.

Two patients with hypertrophic osteoarthropathy of unusual aetiology are described. The first patient developed the condition in association with oesophageal carcinoma and the second as a complication of active pulmonary tuberculosis. In the second case, substantial resorption of new bone was seen following treatment.     

Twist在食管鳞癌中的表达及其对预后的影响

目的研究Twist在食管鳞癌组织中的表达及其与患者预后的关系。方法搜集112例有完整临床病理资料和随访记录的食管鳞癌标本,以及30例非肿瘤食管黏膜标本作为对照,使用Twist抗体进行免疫组化染色,根据表达情况分为阴性(-)、弱阳性( )、阳性( )和强阳性组( ),分析其与患者各项临床病理指标及预后的关系。结果Twist在食管鳞癌中表达显著高于非肿瘤食管黏膜(P<0.001);Twist表达与食管鳞癌术后发生远处转移呈正相关(P=0.001);Kaplan-Meier生存分析显示患者术后生存率随Twist表达增强显著下降(Log-rank检验P<0.001);Cox单因素风险比例模型显示肿瘤T分期、N分期、pTNM分期、远处转移和Twist表达强度是食管鳞癌患者术后死亡的危险因子(P<0.05);Cox多因素风险比例模型显示Twist表达强度(相对危险度为2.394,P<0.001)和肿瘤N分期是食管鳞癌患者术后死亡的独立危险因子。结论Twist蛋白表达增强与食管鳞癌的发生和远处转移有关,对患者术后生存时间有显著影响,Twist蛋白表达增高可能是食管鳞癌患者术后预后不良的重要指标。