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Unusual Shape of Esophageal Stricture After Use of Nasogastric Tube
ELECTRONIC IMAGE OF THE MONTH Unusual Shape of Esophageal Stricture After Use of Nasogastric Tube In Kyung Yoo, Hoon Jai Chun, and Bora Keum Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
79-year-old woman presented with a 7-month history of dysphagia that was found to be caused by an esophageal stricture. Physical examination findings were unremarkable and all laboratory test results were within normal limits. A barium-swallow study showed luminal narrowing of the distal esophagus (Figure A, arrow). Esophagogastroduodenoscopy confirmed 2 esophageal strictures at approximately 20 cm and 25 cm from the incisors. The proximal esophageal stricture was found with a spiral-shaped mucosal protrusion (Figure B), and the distal esophagus was nearly obstructed insomuch as to preclude from passing a standard diagnostic gastroscope (GIF-Q260, 9.2 mm Ø; Olympus Co, Tokyo, Japan) (Figure C). Therefore, we changed to an ultrathin upper endoscope (GIF-XP260N, 5.0 mm Ø; Olympus
A
Co) that traversed the stricture lesion. Also, there was a vermiform-like mucosal tag between the proximal and distal strictures (Figure D, arrow). The patient had been hospitalized for a spine fracture 1 year ago, and was fed via a nasogastric tube for 2 months. A 16F silicone nasogastric tube (Levin tube, 5.3 mm Ø; Yushin Medical Co, Bucheon, Korea) was inserted through the left nostril with some difficulty. The patient had no history of dysphagia before the injury, taking medications, or undergoing irradiation. Judging from the fact that the repeated tube insertion history during the admission period for vertebroplasty, and the difficulty of nasogastric tube insertion as a result of the kyphoscoliosis, the stricture was suspected to be associated with the use of a nasogastric tube. Cutting dilation using IT-2
Clinical Gastroenterology and Hepatology 2015;13:e141–e142
ELECTRONIC IMAGE OF THE MONTH, continued knife was performed for the fibrosis web of the distal stricture lesion, and the mucosal covering over the stricture was removed (Figure E). There were no immediate complications, and follow-up endoscopy showed good passage at the previous lesions (Figure F). After the procedure, she was treated with oral prednisolone for 8 weeks and did not show stenosis recurrence. Esophageal stricture formation after the use of a nasogastric tube is rare worldwide, therefore only a few cases have been reported. Related symptoms according to strictures usually are dysphagia and retrosternal pain. The use of a nasogastric tube for more than 2–4 weeks should be avoided. Forced and repeated tube insertions are considered to contribute to the occurrence of tuberelated esophageal injury.1 The mainstay of treatment for a benign esophageal stricture is endoscopic balloon dilation or cutting dilation.2 However, these procedures have a substantial risk of complications. Therefore, the use of an intralesional steroid injection technique3 or oral prednisolone4 for prevention esophageal stricture have been introduced. This was a case of an unusual appearance of the esophageal stricture after the use of a nasogastric tube,
e142
which was treated effectively with endoscopic resection and oral prednisolone.
References 1.
Cho HH, Shin HJ, Choi SU, et al. Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy. Korean J Anesthesiol 2012;63:284–285.
2.
Siersema PD. Treatment options for esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008;5:142–152.
3.
Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002;56:829–834.
4.
Yamaguchi N, Isomoto H, Shikuwa S, et al. Effect of oral prednisolone on esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: a case report. Digestion 2011; 83:291–295.
Conflicts of interest The authors disclose no conflicts. Most current article © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.05.010
79-year-old woman presented with a 7-month history of dysphagia that was found to be caused by an esophageal stricture. Physical examination findings were unremarkable and all laboratory test results were within normal limits. A barium-swallow study showed luminal narrowing of the distal esophagus (Figure A, arrow). Esophagogastroduodenoscopy confirmed 2 esophageal strictures at approximately 20 cm and 25 cm from the incisors. The proximal esophageal stricture was found with a spiral-shaped mucosal protrusion (Figure B), and the distal esophagus was nearly obstructed insomuch as to preclude from passing a standard diagnostic gastroscope (GIF-Q260, 9.2 mm Ø; Olympus Co, Tokyo, Japan) (Figure C). Therefore, we changed to an ultrathin upper endoscope (GIF-XP260N, 5.0 mm Ø; Olympus
A
Co) that traversed the stricture lesion. Also, there was a vermiform-like mucosal tag between the proximal and distal strictures (Figure D, arrow). The patient had been hospitalized for a spine fracture 1 year ago, and was fed via a nasogastric tube for 2 months. A 16F silicone nasogastric tube (Levin tube, 5.3 mm Ø; Yushin Medical Co, Bucheon, Korea) was inserted through the left nostril with some difficulty. The patient had no history of dysphagia before the injury, taking medications, or undergoing irradiation. Judging from the fact that the repeated tube insertion history during the admission period for vertebroplasty, and the difficulty of nasogastric tube insertion as a result of the kyphoscoliosis, the stricture was suspected to be associated with the use of a nasogastric tube. Cutting dilation using IT-2
Clinical Gastroenterology and Hepatology 2015;13:e141–e142
ELECTRONIC IMAGE OF THE MONTH, continued knife was performed for the fibrosis web of the distal stricture lesion, and the mucosal covering over the stricture was removed (Figure E). There were no immediate complications, and follow-up endoscopy showed good passage at the previous lesions (Figure F). After the procedure, she was treated with oral prednisolone for 8 weeks and did not show stenosis recurrence. Esophageal stricture formation after the use of a nasogastric tube is rare worldwide, therefore only a few cases have been reported. Related symptoms according to strictures usually are dysphagia and retrosternal pain. The use of a nasogastric tube for more than 2–4 weeks should be avoided. Forced and repeated tube insertions are considered to contribute to the occurrence of tuberelated esophageal injury.1 The mainstay of treatment for a benign esophageal stricture is endoscopic balloon dilation or cutting dilation.2 However, these procedures have a substantial risk of complications. Therefore, the use of an intralesional steroid injection technique3 or oral prednisolone4 for prevention esophageal stricture have been introduced. This was a case of an unusual appearance of the esophageal stricture after the use of a nasogastric tube,
e142
which was treated effectively with endoscopic resection and oral prednisolone.
References 1.
Cho HH, Shin HJ, Choi SU, et al. Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy. Korean J Anesthesiol 2012;63:284–285.
2.
Siersema PD. Treatment options for esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008;5:142–152.
3.
Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002;56:829–834.
4.
Yamaguchi N, Isomoto H, Shikuwa S, et al. Effect of oral prednisolone on esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: a case report. Digestion 2011; 83:291–295.
Conflicts of interest The authors disclose no conflicts. Most current article © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.05.010