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Discoloration of the Esophagus
Clinical Challenges and Images in GI, continued Discoloration of the Esophagus Nathan Richards and Apollo Kenneth Musana Gastroenterology Associates of Central Virginia, Lynchburg, Virginia
Question: A 74-year-old white woman with a past medical history of dyslipidemia, irritable bowel syndrome, and gastroesophageal reflux disease presented with abdominal bloating and persistent cough. She had no history of heartburn, dysphagia, or odynophagia. An upper endoscopy was performed. On endoscopy, the esophageal mucosa appeared bulbous with a blue tint. The lesion was 6 cm in size between 18 and 24 cm from the incisors (Figure A, B). The rest of the examination was normal. As part of her evaluation, computed tomography of the neck, chest, and abdomen was performed (Figure C). What is this lesion? Look on page 1501 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.08.013
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December 2013
CLINICAL CHALLENGES AND IMAGES IN GI 1501
looking like a “Fabergé egg.” Treatment of psyllium bezoar is mainly endoscopic division and removal with forceps or snare. In our case, capture net was effective and easily employed. References 1. Plantago ovata (psyllium). Altern Med Rev 2002;7:155–159. 2. Angueira C, Kadakia S. Esophageal and duodenal bezoars from Perdiem. Gastrointest Endosc 1993;39:110–111. 3. Pérez-Piqueras J, Silva C, Jaqueti J, et al. Endoscopic diagnosis and treatment of an esophageal bezoar resulting from bulk laxative ingestion. Endoscopy 1994;26:710. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 1207): Cavernous Esophageal Hemangioma This is a large cavernous esophageal hemangioma. Hemangioma is a rare tumor of the esophagus, representing approximately 3% of benign tumors of the esophagus. Incidence in the population at large was 0.04% in an autopsy study.1,2 The patient had a history of irritable bowel syndrome and presented with symptoms of abdominal bloating and cough. Endoscopy was performed to evaluate her symptoms. The patient also had a prior history of gastroesophageal reflux disease and an esophagogastroduodenoscopy had been performed in 2008, which showed a smaller area of blue discoloration in the same location. Computed tomography of the chest was performed with 150 ccs Omnipaque 300 IV contrast. The lungs were clear. There was a low-density, rounded mass measuring approximately 3 2 3.5 cm adjacent to the esophagus. This was at the level of the aortic arch. Several small calcifications within this structure were consistent with a hemangioma. The mass was relatively well demarcated. No lymphadenopathy was seen. No other masses were identified. No other esophageal lesions were suspected. Esophageal hemangioma is typically asymptomatic, but because of the size of this lesion the patient was sent to a university hospital for further evaluation. The patient and thoracic surgeon elected to follow a conservative treatment plan because her symptoms had resolved. When symptomatic the most common course of treatment is operative resection, but endoscopic resections have also been successful.3
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GASTROENTEROLOGY Vol. 145, No. 6
References 1. Moersch HJ, Harrington SW. Benign tumor of the esophagus. Ann Otol Rhinol Laryngol 1944;53:800. 2. Raza W, Nasir H, Ilahi F, et al. Esophageal haemangioma: a case report and review of literature. J Pak Med Assoc 2010; 60:310–311. 3. Sogabe M, Taniki T, Fukui Y, et al. A patient with esophageal hemangioma treated by endoscopic mucosal resection: a case report and review of the literature. J Med Invest 2006;53:177. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 4 (page 1208): Mirizzi Syndrome With Anomaly of the Cystic Duct The patient was initially treated by stenting of the right hepatic duct through endoscopic retrograde cholangiopancreatography and intravenous antibiotics. In response to this treatment, the jaundice disappeared and the signs of inflammation improved. Repeat endoscopic retrograde cholangiopancreatography with choledochoscopy was performed, which revealed complete resolution of the right bile duct stenosis. A bile duct biopsy did not reveal any malignant cells. Therefore, the patient was diagnosed as a case of Mirizzi syndrome with anomaly of the cystic duct draining directly into the right hepatic duct (Figure C, arrow; RHD, right hepatic duct; LHD, left hepatic duct). Laparoscopic cholecystectomy was performed, and the magnetic resonance cholangiopancreatography one year after operation did not reveal recurrence of the stenosis (Figure D). Mirrizi syndrome was first described in 1948 by Pablo Mirizzi as an unusual presentation resulting from external compression of the common hepatic duct by gallstones.1 This case was a diagnostic challenge, as it was a special variant of Mirizzi syndrome complicated by anomaly of the cystic duct. Indeed, draining of the cystic duct directly into the right hepatic duct is already a rare condition, estimated to occur at an incidence of <1%.2 In addition, Mirrizi syndrome itself is also rare and the association of this type of anomaly could be estimated to occur at an incidence of <0.01% in patients with gallstones. References 1. Mirrizzi PL. Syndrome del conducto hepatico. J Int Chir 1948;8:731–733. 2. Onder H, Ozdemir MS, Tekbas¸ G, et al. 3-T MRI of the biliary tract variations. Surg Radiol Anat 2013;35:161–167. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Question: A 74-year-old white woman with a past medical history of dyslipidemia, irritable bowel syndrome, and gastroesophageal reflux disease presented with abdominal bloating and persistent cough. She had no history of heartburn, dysphagia, or odynophagia. An upper endoscopy was performed. On endoscopy, the esophageal mucosa appeared bulbous with a blue tint. The lesion was 6 cm in size between 18 and 24 cm from the incisors (Figure A, B). The rest of the examination was normal. As part of her evaluation, computed tomography of the neck, chest, and abdomen was performed (Figure C). What is this lesion? Look on page 1501 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.08.013
1207
December 2013
CLINICAL CHALLENGES AND IMAGES IN GI 1501
looking like a “Fabergé egg.” Treatment of psyllium bezoar is mainly endoscopic division and removal with forceps or snare. In our case, capture net was effective and easily employed. References 1. Plantago ovata (psyllium). Altern Med Rev 2002;7:155–159. 2. Angueira C, Kadakia S. Esophageal and duodenal bezoars from Perdiem. Gastrointest Endosc 1993;39:110–111. 3. Pérez-Piqueras J, Silva C, Jaqueti J, et al. Endoscopic diagnosis and treatment of an esophageal bezoar resulting from bulk laxative ingestion. Endoscopy 1994;26:710. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 3 (page 1207): Cavernous Esophageal Hemangioma This is a large cavernous esophageal hemangioma. Hemangioma is a rare tumor of the esophagus, representing approximately 3% of benign tumors of the esophagus. Incidence in the population at large was 0.04% in an autopsy study.1,2 The patient had a history of irritable bowel syndrome and presented with symptoms of abdominal bloating and cough. Endoscopy was performed to evaluate her symptoms. The patient also had a prior history of gastroesophageal reflux disease and an esophagogastroduodenoscopy had been performed in 2008, which showed a smaller area of blue discoloration in the same location. Computed tomography of the chest was performed with 150 ccs Omnipaque 300 IV contrast. The lungs were clear. There was a low-density, rounded mass measuring approximately 3 2 3.5 cm adjacent to the esophagus. This was at the level of the aortic arch. Several small calcifications within this structure were consistent with a hemangioma. The mass was relatively well demarcated. No lymphadenopathy was seen. No other masses were identified. No other esophageal lesions were suspected. Esophageal hemangioma is typically asymptomatic, but because of the size of this lesion the patient was sent to a university hospital for further evaluation. The patient and thoracic surgeon elected to follow a conservative treatment plan because her symptoms had resolved. When symptomatic the most common course of treatment is operative resection, but endoscopic resections have also been successful.3
1502 CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 145, No. 6
References 1. Moersch HJ, Harrington SW. Benign tumor of the esophagus. Ann Otol Rhinol Laryngol 1944;53:800. 2. Raza W, Nasir H, Ilahi F, et al. Esophageal haemangioma: a case report and review of literature. J Pak Med Assoc 2010; 60:310–311. 3. Sogabe M, Taniki T, Fukui Y, et al. A patient with esophageal hemangioma treated by endoscopic mucosal resection: a case report and review of the literature. J Med Invest 2006;53:177. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Answer to the Clinical Challenges and Images in GI Question: Image 4 (page 1208): Mirizzi Syndrome With Anomaly of the Cystic Duct The patient was initially treated by stenting of the right hepatic duct through endoscopic retrograde cholangiopancreatography and intravenous antibiotics. In response to this treatment, the jaundice disappeared and the signs of inflammation improved. Repeat endoscopic retrograde cholangiopancreatography with choledochoscopy was performed, which revealed complete resolution of the right bile duct stenosis. A bile duct biopsy did not reveal any malignant cells. Therefore, the patient was diagnosed as a case of Mirizzi syndrome with anomaly of the cystic duct draining directly into the right hepatic duct (Figure C, arrow; RHD, right hepatic duct; LHD, left hepatic duct). Laparoscopic cholecystectomy was performed, and the magnetic resonance cholangiopancreatography one year after operation did not reveal recurrence of the stenosis (Figure D). Mirrizi syndrome was first described in 1948 by Pablo Mirizzi as an unusual presentation resulting from external compression of the common hepatic duct by gallstones.1 This case was a diagnostic challenge, as it was a special variant of Mirizzi syndrome complicated by anomaly of the cystic duct. Indeed, draining of the cystic duct directly into the right hepatic duct is already a rare condition, estimated to occur at an incidence of <1%.2 In addition, Mirrizi syndrome itself is also rare and the association of this type of anomaly could be estimated to occur at an incidence of <0.01% in patients with gallstones. References 1. Mirrizzi PL. Syndrome del conducto hepatico. J Int Chir 1948;8:731–733. 2. Onder H, Ozdemir MS, Tekbas¸ G, et al. 3-T MRI of the biliary tract variations. Surg Radiol Anat 2013;35:161–167. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).