Clinical pathological cases in gastroenterology: Esophagus

INTRODUCTION — The following cases are meant to illustrate clinical, pathological, and endoscopic findings in patients with a variety of esophageal conditions. Detailed discussions on the specific disorders are presented on corresponding topic reviews.

PILL ESOPHAGITIS — A 62-year-old woman awakened with severe odynophagia and dysphagia. Her only medical problem is osteoporosis treated with alendronate (Fosamax®) over the past eight months. Her weight has been stable and she denies having fevers, nausea, vomiting, or abdominal pain. She denies a prior history of dysphagia. An upper endoscopy was performed (picture 1A-B). (See "Pill esophagitis".)

GLYCOGEN ACANTHOSIS AND BARRETT'S ESOPHAGUS — A 36-year-old obese male underwent an upper endoscopy with biopsies for the evaluation of worsening heartburn over the past nine months. He has no other medical problems and denies any nausea, vomiting, abdominal pain, odynophagia, dysphagia, or weight loss. Endoscopy revealed multiple elevated gray-white nodules in the upper and middle third of the esophagus (picture 2 and picture 3) A long segment of salmon colored mucosa was seen in the distal esophagus (picture 4).

ESOPHAGEAL ADENOCARCINOMA — An 83-year-old man presented to his primary care physician with worsening dysphagia, initially to solids and now to liquids. His medical problems include hypertension treated with atenolol, chronic obstructive pulmonary disease treated with inhaled steroids and bronchodilators, and long history of heartburn self-treated with over the counter antacids. His weight has been trending down and he has lost 16 lbs over the past two months. He denies fevers, nausea, vomiting, abdominal pain, or odynophagia. An upper endoscopy (picture 5A-B) with biopsies (picture 6) was performed. An endoscopic ultrasound showed the following (image 1). (See "Clinical manifestations, diagnosis, and staging of esophageal cancer".)

Further evaluation revealed metastatic disease. The patient refused chemotherapy or radiation therapy. Endoscopic palliation therapy was performed (picture 7 and image 2). (See "Endoscopic palliation of esophageal cancer".)

EOSINOPHILIC ESOPHAGITIS — A 25-year-old male was referred for evaluation of increased frequency of intermittent episodes of dysphagia to solids. The first episode was three years ago. A barium swallow revealed multiple concentric rings in the proximal and mid esophagus giving it the appearance of a trachea (picture 8), which were also seen on endoscopy (image 3). Biopsies were obtained in the proximal, mid and distal esophagus (picture 9). Because of persistent symptoms despite medical therapy, the patient underwent esophageal dilation, which was complicated with a deep esophageal tear (picture 10). Dilation should be performed extremely cautiously in patients with eosinophilic esophagitis because of an increased risk of perforation. Deep mucosal tears can occur without noting resistance after passing a dilator or upper endoscope. (See "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)".)

BARRETT'S ESOPHAGUS WITH LOW GRADE DYSPLASIA — A 43-year-old male with no significant past medical history was referred for the evaluation of worsening heartburn. He denies any dysphagia, odynophagia, weight loss or any other constitutional symptom. An upper endoscopy with biopsies was performed (picture 11 and picture 12). (See "Barrett's esophagus: Surveillance and management".)

BARRETT'S ESOPHAGUS WITH HIGH GRADE DYSPLASIA — A 59-year-old male with no significant past medical history was referred for the evaluation of worsening heartburn. He denies any dysphagia, odynophagia, weight loss, or any other constitutional symptom. An upper endoscopy with biopsies was performed (picture 13 and picture 14). (See "Barrett's esophagus: Surveillance and management".)

ESOPHAGEAL SQUAMOUS CELL CARCINOMA — A 63-year-old woman with a long history of tobacco use underwent an upper endoscopy for the evaluation of a positive fecal occult blood test, iron deficiency anemia, 15 lb weight loss over a three month period and progressive dysphagia to solids. The patient has no other medical problems. She denies fevers, nausea, vomiting, or abdominal pain. Endoscopic evaluation with multiple biopsies revealed the following (picture 15 and picture 16). (See "Epidemiology and pathobiology of esophageal cancer".)

ESOPHAGITIS MIMICKING SHORT-SEGMENT BARRETT'S ESOPHAGUS — A 43-year-old woman underwent an upper endoscopy for the evaluation of longstanding heartburn and regurgitation. The patient has no medical history and denies any fever, vomiting, or changes in weight. An upper endoscopy with biopsies showed the following (picture 17 and picture 18A-B).

FOOD IMPACTION FROM A SCHATZKI RING — A 43-year-old man with a long history of heartburn treated with over the counter antacids, presented to the emergency department soon after eating a hot dog and inability to swallow his own saliva. The patient recalls that bread and meat sometimes pass slowly requiring him to take sips of water. An urgent upper endoscopy was performed in the emergency department, which revealed a distal esophageal ring (Schatzki ring) that was ulcerated (picture 19A-B). The patient was discharged home on a soft solid diet, a proton pump inhibitor with a scheduled upper endoscopy for possible treatment in two weeks. The ring was successfully dilated with a balloon (picture 20A-C). (See "Ingested foreign bodies and food impactions in adults".)

CANDIDA ESOPHAGITIS — A 24-year-old male with AIDS underwent an upper endoscopy for the evaluation of substernal chest pain and a five day history of severe and worsening odynophagia. Endoscopy revealed candida esophagitis (picture 21), which was confirmed by cytology. (See "Evaluation of the patient with HIV, odynophagia, and dysphagia".)

FOREIGN BODY — A 49-year-old man with past medical history significant for schizophrenia presented to the emergency department with chest and lower abdominal pain after swallowing his necklace. Chest and abdominal imaging were obtained to assess the location of the foreign body and rule out perforation (image 4).

An upper endoscopy was performed during which two coins, a cigarette butt, and a necklace with a large gold cross were extracted. (See "Ingested foreign bodies and food impactions in adults".)