Necrosis of the uvula after endoscopy

Necrosis of the uvula after endoscopy To the Editor: Many and various complications of esophagogastroduodenoscopy have been described.1.2 Recently we encountered two patients who suffered from necrosis of the uvula following upper gastrointestinal endoscopy. To the best of our knowledge, necrosis of the uvula, as a complication of upper endoscopy, has not been reported previously in the English literature. Patient 1. A 20-year-old male patient underwent endoscopy because of epigastric pain and heartburn. Physical examination was unremarkable. The patient was premedicated with 2% lidocaine gargle and 20 mg of diazepam intravenously. The introduction of the Olympus GIF-Q endoscope was uneventful. An ulcer was found in the duodenal bulb. Six hours after the procedure, the patient complained of a sore throat which was aggravated during swallowing. Examination of the pharnyx disclosed an enlarged uvula with inflammation and necrosis of its tip (Fig. 1). The patient was treated symptomatically with lidocaine gargle, and 5 days later the uvula healed and resumed its normal size. Patient 2. A 25-year-old man underwent upper endoscopy with the GIF-Q Olympus endoscope. Two percent lidocaine gargle and 20 mg of diazepam intravenously were given as premedication. Endoscopy revealed benign gastric ulcer. There was no apparent difficulty in introducing the endoscope, and the procedure was uneventful. However, 12 hours after the procedure, the patient complained of a sore throat and pain during swallowing. He noticed the projection of his uvula with a white-yellowish swollen tip lying over his tongue. Physical examination of the buccal cavity revealed a long thread-like uvula with necrotic tip surrounded by inflammation and edema. Culture for Candida was negative. Five days later the necrotic tip sloughed off and the uvula resumed its original shape. The uvula is a projection in the midline of the soft palate, the bulk of which consists of glandular tissue with diffuse intersepted muscle fibers. 3 Usually, introduction of the endoscope is done while the patient is in left lateral decubitus with flexion of the head. In this position the uvula is dis-

Figure 1. Uvular edema and necrosis following upper gastrointestinal endoscopy. VOLUME 30, NO.5, 1984

placed to the left side and slightly anterior. It is possible that in the cases presented here, the uvula was entrapped and pressed between the endoscope and the hard palate resulting in ischemia and necrosis of the tip. Edema of the uvula with necrosis has been described as a complication of general anesthesia with or without endotracheal intubation"-6 and the suggested mechanism of damage seems to be similar. As in our two reported patients, spontaneous resolution of the induced damage occurred. When patients complain of sore throat following upper endoscopy, it is usually related to the pressure of the endoscope on the walls of the pharynx. It is possible that local damage to the uvula occurs more frequently than previously thought, but it is unrecognized since postendoscopy sore throat is common. A. Fich, MD M. Ligumsky, MD J. S. Wolnerman, MD Hadassah University Hospital Jerusalem, Israel

REFERENCES 1. Davis RE, Graham DY. Endoscopic complications: The Texas

experience. Gastrointest Endosc 1979;25:146-9. 2. Mandelstam P, Sugawa CH, Silvis SE, Nebel OT, Gerald Rogers BH. Complications associated with esophagogastroduodenoscopy and with esophageal dilatation. Gastrointest Endosc 1976;23:16-9. 3. Azzam NA, Kuehn DP. The morphology of musculus uvulae. Cleft Palate J 1977;14:79-87. 4. Ravindran R, Priddy S. Uvular edema, a rare complication of endotracheal intubation. Anesthesiology 1978;48:374. 5. Seigne TD, Felske A, Del Giudice PA. Uvular edema. Anesthesiology 1978;49:375-6. 6. Shulman MS. Uvular edema without endotracheal intubation. Anesthesiology 1981;55:82-3.

Bezoar of the esophagus occurring in achalasia To the Editor: Bezoars may complicate clinical situations associated with disordered motor function or obstruction resulting in stasis within the gastrointestinal tract. Very rarely have bezoars been reported in the esophagus. Achalasia of the esophagus is characterized by grossly disordered motor function but has previously not been associated with bezoar formation. A case of bezoar formation in the esophagus occurring in achalasia has recently been observed at our institution. An 89-year-old woman was referred to the University of South Florida College of Medicine Clinic for evaluation of difficulty in swallowing liquids and solids for the past month. Twenty years ago she had a distal esophageal myotomy performed for achalasia. This procedure relieved her previous complaints of dysphagia. Her weight had fallen 5 pounds; she denied any recent episodes of recurrent pulmonary infections, but she described the recent onset of recumbent nocturnal regurgitation associated with soiling of her pillow. She denied heartburn. Her medications included quinidine gluconate, potassium chloride, and digoxin. Physical examination was unremarkable. She was eden317