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Tu1594 Case Vignette: Malignant Esophagopleural Fistula With Gastrointestinal Bleeding Resulting in Hemothorax
Abstracts
(figure-2)
Air bubbles suggesting communication with the pleural space.
Tu1594 Case Vignette: Malignant Esophagopleural Fistula With Gastrointestinal Bleeding Resulting in Hemothorax Ketan K. Shah*2, Kenneth J. Chang1 1 UC Irvine Comprehensive Digestive Disease Center, Orange, CA; 2 Gastroenterology, University of California, Irvine, Medical Center, Orange, CA A 67-year old male with a history of aortic valvular heart disease status post mechanical valve replacement requiring chronic anticoagulation was diagnosed with metastatic adenocarcinoma of the gastroesophageal junction in 2011 with metastasis to bone, lung, spine, and intraabdominal lymph nodes. He underwent neoadjuvant chemoradiation followed by laparoscopic Ivor-Lewis esophagectomy in 2012. In 2013, he developed a recurrent malignant pleural effusion and underwent pleurodesis and placement of a pleural catheter for serial drainage of his pleural effusion, which was required every two days. Nine months later, he was hospitalized for respiratory failure related to aspiration pneumonia, requiring mechanical ventilation and resulting in improvement with intravenous antibiotics. He continued to require serial drainage from his pleural catheter and chronic anticoagulation for his mechanical aortic valve.Two weeks into his hospitalization, he developed bloody pleural output, hemorrhagic anemia, and hypotension, without hematemesis, hemoptysis, or melena. The serum urea nitrogen, however, was elevated, and an orogastric tube returned bloody fluid. Upper endoscopy demonstrated an anastomotic stricture, which was dilated with a balloon. Distal to the anastomosis, a pouch-like area was seen with large amounts of blood and clots and active arterial spurting from a visible vessel on the anterior wall. Epinephrine was injected, a hemoclip was placed, and the area was treated with argon plasma coagulation. Closer inspection of the pouch demonstrated striated walls that appeared extraluminal, and small fenestrations through which air bubbles were seen, suspicious for a communication with the pleural space. A separate lumen from the anastomosis led to normal-appearing gastric mucosa. A CT scan re-demonstrated a post-surgical pouch along the right medial lung base connected to the distal esophagus. The following day, an 18 mm x 12 cm fully-covered metal stent was placed, bridging the esophagus and remnant stomach. Contrast injection through the stent demonstrated passage of contrast into the small bowel.The patient’s bleeding did not recur for over two weeks, but he unfortunately required continued mechanical ventilation, developed septic shock, and was ultimately transferred to home hospice for palliative care.In summary, we report a case of an esophagopleural fistula resulting from gastroesophageal malignancy with gastrointestinal bleeding manifesting as bloody pleural effusion. Endoscopic therapy resulted in successful initial hemostasis, and a covered metal stent was placed across the fistula. Esophago-respiratory fistula is a rarely reported complication of esophageal malignancies and can result in atypical gastrointestinal bleeding, including pulmonary hemorrhage or hemothorax. Interventional endoscopy can be helpful in the management of these cases.
www.giejournal.org
Status post endoscopic hemostasis. Striated wall suspicious for extraluminal structure.
Tu1595 Grave Prognosis of Esophageal Cancer in Thailand Pongjarat Nunanan*, Ratha-Korn Vilaichone GI Unit, Thammasat University Hospital, Pathum Thani, Thailand Purpose: Esophageal cancer is one of the major health problems in the Southeast Asian countries including Thailand. However, limited number of studies was reported from this region. This study was design to evaluate the prevalence and clinical characteristics of esophageal cancer patients in Thailand. Methods: Clinical information, histological features, endoscopic findings were review and collected from tertiary care center in Thailand between September 2011- November 2014. Results: Total of 64 esophageal cancer patients including 58 men and 6 women with mean age of 62 18 years were enrolled. Common presenting symptoms were dysphagia (74%), dyspepsia (10%), hematemesis (8%), odynophagia (4%) and neck mass (4%). Mean duration of symptoms prior to diagnosis was 72 days. Esophageal stenosis with contact bleeding was the most common endoscopic finding (53%). The location of cancer was found in proximal (16%), middle (49%) and distal (35%) esophagus. Squamous cell carcinoma is far more common histology than adenocarcinoma (85% vs 10%; P!0.05). Moreover, esophageal cancer stage 3 and 4 was demonstrated in 38% and 58% respectively. An overall 2-year survival rate was 20% and only 16% in metastatic patients.Summary: Most esophageal cancer patients in Thailand were squamous cell carcinoma and nearly all patients presented in advance stage with grave prognosis. Screening in high risk individuals and early detection might be appropriate way to improve treatment outcome for this particular disease in Thailand.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB523
(figure-2)
Air bubbles suggesting communication with the pleural space.
Tu1594 Case Vignette: Malignant Esophagopleural Fistula With Gastrointestinal Bleeding Resulting in Hemothorax Ketan K. Shah*2, Kenneth J. Chang1 1 UC Irvine Comprehensive Digestive Disease Center, Orange, CA; 2 Gastroenterology, University of California, Irvine, Medical Center, Orange, CA A 67-year old male with a history of aortic valvular heart disease status post mechanical valve replacement requiring chronic anticoagulation was diagnosed with metastatic adenocarcinoma of the gastroesophageal junction in 2011 with metastasis to bone, lung, spine, and intraabdominal lymph nodes. He underwent neoadjuvant chemoradiation followed by laparoscopic Ivor-Lewis esophagectomy in 2012. In 2013, he developed a recurrent malignant pleural effusion and underwent pleurodesis and placement of a pleural catheter for serial drainage of his pleural effusion, which was required every two days. Nine months later, he was hospitalized for respiratory failure related to aspiration pneumonia, requiring mechanical ventilation and resulting in improvement with intravenous antibiotics. He continued to require serial drainage from his pleural catheter and chronic anticoagulation for his mechanical aortic valve.Two weeks into his hospitalization, he developed bloody pleural output, hemorrhagic anemia, and hypotension, without hematemesis, hemoptysis, or melena. The serum urea nitrogen, however, was elevated, and an orogastric tube returned bloody fluid. Upper endoscopy demonstrated an anastomotic stricture, which was dilated with a balloon. Distal to the anastomosis, a pouch-like area was seen with large amounts of blood and clots and active arterial spurting from a visible vessel on the anterior wall. Epinephrine was injected, a hemoclip was placed, and the area was treated with argon plasma coagulation. Closer inspection of the pouch demonstrated striated walls that appeared extraluminal, and small fenestrations through which air bubbles were seen, suspicious for a communication with the pleural space. A separate lumen from the anastomosis led to normal-appearing gastric mucosa. A CT scan re-demonstrated a post-surgical pouch along the right medial lung base connected to the distal esophagus. The following day, an 18 mm x 12 cm fully-covered metal stent was placed, bridging the esophagus and remnant stomach. Contrast injection through the stent demonstrated passage of contrast into the small bowel.The patient’s bleeding did not recur for over two weeks, but he unfortunately required continued mechanical ventilation, developed septic shock, and was ultimately transferred to home hospice for palliative care.In summary, we report a case of an esophagopleural fistula resulting from gastroesophageal malignancy with gastrointestinal bleeding manifesting as bloody pleural effusion. Endoscopic therapy resulted in successful initial hemostasis, and a covered metal stent was placed across the fistula. Esophago-respiratory fistula is a rarely reported complication of esophageal malignancies and can result in atypical gastrointestinal bleeding, including pulmonary hemorrhage or hemothorax. Interventional endoscopy can be helpful in the management of these cases.
www.giejournal.org
Status post endoscopic hemostasis. Striated wall suspicious for extraluminal structure.
Tu1595 Grave Prognosis of Esophageal Cancer in Thailand Pongjarat Nunanan*, Ratha-Korn Vilaichone GI Unit, Thammasat University Hospital, Pathum Thani, Thailand Purpose: Esophageal cancer is one of the major health problems in the Southeast Asian countries including Thailand. However, limited number of studies was reported from this region. This study was design to evaluate the prevalence and clinical characteristics of esophageal cancer patients in Thailand. Methods: Clinical information, histological features, endoscopic findings were review and collected from tertiary care center in Thailand between September 2011- November 2014. Results: Total of 64 esophageal cancer patients including 58 men and 6 women with mean age of 62 18 years were enrolled. Common presenting symptoms were dysphagia (74%), dyspepsia (10%), hematemesis (8%), odynophagia (4%) and neck mass (4%). Mean duration of symptoms prior to diagnosis was 72 days. Esophageal stenosis with contact bleeding was the most common endoscopic finding (53%). The location of cancer was found in proximal (16%), middle (49%) and distal (35%) esophagus. Squamous cell carcinoma is far more common histology than adenocarcinoma (85% vs 10%; P!0.05). Moreover, esophageal cancer stage 3 and 4 was demonstrated in 38% and 58% respectively. An overall 2-year survival rate was 20% and only 16% in metastatic patients.Summary: Most esophageal cancer patients in Thailand were squamous cell carcinoma and nearly all patients presented in advance stage with grave prognosis. Screening in high risk individuals and early detection might be appropriate way to improve treatment outcome for this particular disease in Thailand.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB523