Letters to the editor
3.
4.
5.
6.
gastroentérologues des hôpitaux généraux group. Clin Gastroenterol Hepatol 2009;7:911. Soncini M, Chilovi F, Triossi O, et al. Weekend effect in non-variceal upper gastrointestinal bleeding: data from nine Italian gastrointestinal units. Am J Gastroenterol 2012;107:635-6. Tsoi KK, Chiu PW, Chan FK, et al. The risk of peptic ulcer bleeding mortality in relation to hospital admission on holidays: a cohort study on 8,222 cases of peptic ulcer bleeding. Am J Gastroenterol 2012;107:405-10. Shaheen AA, Kaplan GG, Myers RP. Weekend versus weekday admission and mortality from gastrointestinal hemorrhage caused by peptic ulcer disease. Clin Gastroenterol Hepatol 2009;7:303-10. Ananthakrishnan AN, McGinley EL, Saeian K. Outcomes of weekend admissions for upper gastrointestinal hemorrhage: a nationwide analysis. Clin Gastroenterol Hepatol 2009;7:296-302.
http://dx.doi.org/10.1016/j.gie.2015.01.012
High-grade dysplasia in thoracic inlet patch treated by focal endoscopic mucosal resection and radiofrequency ablation To the Editor: A 73-year-old male ex-smoker presented with intermittent dysphagia to solids for approximately 6 months. Upper endoscopy revealed a Schatzki’s ring, which was dilated to 18 mm with a balloon dilator. In addition, an inlet patch was noted involving 75% of the circumference in the proximal esophagus at 19 to 22 cm from the incisors.
Within that area was an 8-mm nodule adjacent to a small 5-mm diverticulum (Fig. 1A). A careful EMR was performed with a Duette EMR kit (Wilson Cook Endoscopy, Winston-Salem, NC) avoiding the diverticulum (Fig. 1B). Histological evaluation revealed intestinal metaplasia with high-grade dysplasia, which extended to lateral margins. Biopsies of the adjacent mucosa revealed gastric cardia-type mucosa with mild chronic inflammation. Subsequently, he underwent radiofrequency ablation of the thoracic inlet patch with a HALO90 device (BÂRRX Medical Inc, Sunnyvale, Calif) (Fig. 1C). Follow-up at 6 months revealed complete eradication of the inlet patch. To our knowledge, this is the first case of endoscopic therapy for high-grade dysplasia arising in the inlet patch. Heterotopic gastric mucosa of the proximal esophagus, commonly known as the inlet patch, is an island of ectopic gastric mucosa found in the proximal esophagus just distal to the upper esophageal sphincter.1 Most patients are asymptomatic, although some may have a variety of symptoms caused by ectopic gastric acid secretion such as regurgitation, dysphagia, hoarseness, globus, throat discomfort, and chronic cough. Other adverse events include stricturing, erosions, ulcerations, webs, fistula formation, perforation, and neoplastic transformation.2 To date, 3 cases of highgrade dysplasia and 31 cases of adenocarcinoma arising from the inlet patch have been reported.1 Risk factors for
Figure 1. A, Thoracic inlet patch with nodule. B, s/p endoscopic mucosal resection. C, Ablation with Halo-90 device.
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Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1297
Letters to the editor
neoplasia appear to be male sex and smoking. In symptomatic cases, acid suppressive therapy, endoscopic mucosectomy, and surgical resection have been described. In cases of dysplasia or cancer arising from inlet patch, surgery in combination with chemoradiation was used. Richard H. Cartabuke, MD Department of Internal Medicine Prashanthi N. Thota, MD Department of Gastroenterology and Hepatology Cleveland Clinic Cleveland, Ohio, USA REFERENCES 1. Chong VH. Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus. World J Gastroenterol 2013;19:331-8. 2. Sahin G, Adas G, Koc B, et al. Is cervical inlet patch important clinical problem? Int J Biomed Sci 2014;10:129-35. http://dx.doi.org/10.1016/j.gie.2014.12.004
What goes in should not always come out: migration of a prosthetic mesocaval shunt via erosion through the duodenum To the Editor: The condition of a 48-year-old woman with a history of HIV infection was evaluated because of hematemesis. An
EGD revealed bleeding esophageal and gastric varices. CT of the abdomen showed thrombosis of the main, right, and left portal veins. A 5-cm prosthetic mesocaval shunt (PMCS) was placed to decompress the varices. Three years later, the patient was found to have thrombosis of the PMCS extending into the inferior vena cava. After attempts to salvage the thrombus were unsuccessful, the patient underwent a gastric devascularization procedure. Three months later, she was examined because of abdominal pain. EGD showed that the PMCS had eroded into the second portion of the duodenum (Fig. 1A). CT of the abdomen showed thrombosis of the PMCS (Fig. 1B). The patient’s PMCS thrombosis was treated conservatively because of the absence of an infection. An EGD performed 8 months later showed large ulcerations with edema in the second portion of the duodenum and absence of the previously seen PMCS (Fig. 1C). CT of the abdomen showed no evidence of PMCS within the GI tract (Fig. 1D). The PMCS had migrated out through the patient’s GI tract. In the past, PMCSs have been used to decompress the mesenteric venous system. Migration of a PMCS is quite rare.1 Spontaneous expulsion of a shunt from the GI tract is very rarely reported.2 Generally, shunts are surgically retrieved when there is evidence of infection or GI hemorrhage from shunt erosion. With the advancement of interventional radiology, PMCS placement is no longer performed routinely. Nevertheless, recognition of adverse events associated with
Figure 1. A, Prosthetic mesocaval shunt (PMCS) eroding into the second portion of the duodenum. B, CT of the abdomen showing thrombosis of PMCS at the level of the L2 vertebral body. C, The previously seen PMCS is no longer visualized in the duodenum. D, CT of the abdomen showing absence of previously placed PMCS at the level of the L2 vertebral body.
1298 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
3.
4.
5.
6.
gastroentérologues des hôpitaux généraux group. Clin Gastroenterol Hepatol 2009;7:911. Soncini M, Chilovi F, Triossi O, et al. Weekend effect in non-variceal upper gastrointestinal bleeding: data from nine Italian gastrointestinal units. Am J Gastroenterol 2012;107:635-6. Tsoi KK, Chiu PW, Chan FK, et al. The risk of peptic ulcer bleeding mortality in relation to hospital admission on holidays: a cohort study on 8,222 cases of peptic ulcer bleeding. Am J Gastroenterol 2012;107:405-10. Shaheen AA, Kaplan GG, Myers RP. Weekend versus weekday admission and mortality from gastrointestinal hemorrhage caused by peptic ulcer disease. Clin Gastroenterol Hepatol 2009;7:303-10. Ananthakrishnan AN, McGinley EL, Saeian K. Outcomes of weekend admissions for upper gastrointestinal hemorrhage: a nationwide analysis. Clin Gastroenterol Hepatol 2009;7:296-302.
http://dx.doi.org/10.1016/j.gie.2015.01.012
High-grade dysplasia in thoracic inlet patch treated by focal endoscopic mucosal resection and radiofrequency ablation To the Editor: A 73-year-old male ex-smoker presented with intermittent dysphagia to solids for approximately 6 months. Upper endoscopy revealed a Schatzki’s ring, which was dilated to 18 mm with a balloon dilator. In addition, an inlet patch was noted involving 75% of the circumference in the proximal esophagus at 19 to 22 cm from the incisors.
Within that area was an 8-mm nodule adjacent to a small 5-mm diverticulum (Fig. 1A). A careful EMR was performed with a Duette EMR kit (Wilson Cook Endoscopy, Winston-Salem, NC) avoiding the diverticulum (Fig. 1B). Histological evaluation revealed intestinal metaplasia with high-grade dysplasia, which extended to lateral margins. Biopsies of the adjacent mucosa revealed gastric cardia-type mucosa with mild chronic inflammation. Subsequently, he underwent radiofrequency ablation of the thoracic inlet patch with a HALO90 device (BÂRRX Medical Inc, Sunnyvale, Calif) (Fig. 1C). Follow-up at 6 months revealed complete eradication of the inlet patch. To our knowledge, this is the first case of endoscopic therapy for high-grade dysplasia arising in the inlet patch. Heterotopic gastric mucosa of the proximal esophagus, commonly known as the inlet patch, is an island of ectopic gastric mucosa found in the proximal esophagus just distal to the upper esophageal sphincter.1 Most patients are asymptomatic, although some may have a variety of symptoms caused by ectopic gastric acid secretion such as regurgitation, dysphagia, hoarseness, globus, throat discomfort, and chronic cough. Other adverse events include stricturing, erosions, ulcerations, webs, fistula formation, perforation, and neoplastic transformation.2 To date, 3 cases of highgrade dysplasia and 31 cases of adenocarcinoma arising from the inlet patch have been reported.1 Risk factors for
Figure 1. A, Thoracic inlet patch with nodule. B, s/p endoscopic mucosal resection. C, Ablation with Halo-90 device.
www.giejournal.org
Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1297
Letters to the editor
neoplasia appear to be male sex and smoking. In symptomatic cases, acid suppressive therapy, endoscopic mucosectomy, and surgical resection have been described. In cases of dysplasia or cancer arising from inlet patch, surgery in combination with chemoradiation was used. Richard H. Cartabuke, MD Department of Internal Medicine Prashanthi N. Thota, MD Department of Gastroenterology and Hepatology Cleveland Clinic Cleveland, Ohio, USA REFERENCES 1. Chong VH. Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus. World J Gastroenterol 2013;19:331-8. 2. Sahin G, Adas G, Koc B, et al. Is cervical inlet patch important clinical problem? Int J Biomed Sci 2014;10:129-35. http://dx.doi.org/10.1016/j.gie.2014.12.004
What goes in should not always come out: migration of a prosthetic mesocaval shunt via erosion through the duodenum To the Editor: The condition of a 48-year-old woman with a history of HIV infection was evaluated because of hematemesis. An
EGD revealed bleeding esophageal and gastric varices. CT of the abdomen showed thrombosis of the main, right, and left portal veins. A 5-cm prosthetic mesocaval shunt (PMCS) was placed to decompress the varices. Three years later, the patient was found to have thrombosis of the PMCS extending into the inferior vena cava. After attempts to salvage the thrombus were unsuccessful, the patient underwent a gastric devascularization procedure. Three months later, she was examined because of abdominal pain. EGD showed that the PMCS had eroded into the second portion of the duodenum (Fig. 1A). CT of the abdomen showed thrombosis of the PMCS (Fig. 1B). The patient’s PMCS thrombosis was treated conservatively because of the absence of an infection. An EGD performed 8 months later showed large ulcerations with edema in the second portion of the duodenum and absence of the previously seen PMCS (Fig. 1C). CT of the abdomen showed no evidence of PMCS within the GI tract (Fig. 1D). The PMCS had migrated out through the patient’s GI tract. In the past, PMCSs have been used to decompress the mesenteric venous system. Migration of a PMCS is quite rare.1 Spontaneous expulsion of a shunt from the GI tract is very rarely reported.2 Generally, shunts are surgically retrieved when there is evidence of infection or GI hemorrhage from shunt erosion. With the advancement of interventional radiology, PMCS placement is no longer performed routinely. Nevertheless, recognition of adverse events associated with
Figure 1. A, Prosthetic mesocaval shunt (PMCS) eroding into the second portion of the duodenum. B, CT of the abdomen showing thrombosis of PMCS at the level of the L2 vertebral body. C, The previously seen PMCS is no longer visualized in the duodenum. D, CT of the abdomen showing absence of previously placed PMCS at the level of the L2 vertebral body.
1298 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
