Pedro Cardoso Figueiredo

Unusual Cause for Smoldering Dysphagia

A 30-year-old black woman presented with heartburn and odynophagia. She had a 2-year history of Behçet’s disease and systemic lupus erythematosus and had been treated with colchicine, hydroxychloroquine, and sucralfate. Odynophagia was not related to the presence of oral ulcers as they were painless and when they were in remission the patient would still intermittently complain of substernal pain. The patient underwent upper digestive endoscopy that revealed only small mucosal irregularities in the upper third of the esophagus (Fig. 1). Biopsies of these segments showed marked acanthosis and papillomatosis of the squamous epithelium as well as intense lymphoplasmacytic infiltrate with an increased number of intraepithelial lymphocytes (IEL). There were neither granulocytes nor signs of viral infection. The endoscopic findings were then attributed to regenerative changes of the epithelium and the patient was started on a proton pump inhibitor (PPI), assuming gastroesophageal reflux disease (GERD). During the following years there were flare-ups of rheumatologic disease activity due to the patient’s lack of adherence to therapy. However, there was no correlation of the patient’s maintained (although scarce) complaints of transitory dysphagia and substernal pain. In 2008, 2 years after the first endoscopy, the symptoms progressed to persistent dysphagia for solids and the patient localized the point of obstruction to beneath the sternum. There were also episodes of self-remitting food impaction. There were no abnormal findings on physical examination or laboratory tests. The gastroesophageal contrast radiograph was negative (Fig. 2). She was referred to our GI clinic and upper endoscopy was repeated. A narrowed esophageal lumen with multiple rings was seen in the upper third of the esophagus, suggesting a feline esophagus (Fig. 3a, b). Biopsies were undertaken in the upper and lower thirds of the esophagus.

Quality in Endoscopy: It's Time for an Audit!

ence, and cost reduction [4] . Therefore, and taking into account that only approximately 30% of colonoscopies are for screening purposes, other quality indicators should not be overlooked [5] . Nevertheless, and despite growing attention, recent studies still report significant variation in the quality of endoscopy performed across different endoscopy units [6, 7] . So, if on the one hand the importance of quality is known and there are guidelines providing endoscopists with benchmarks against which they can compare their service, but on the other hand significant variation in quality still persists, what should be done? Part of the answer is provided in this issue with the work by Taveira et al. [8] , as well as in a previous issue [9] : an audit! Quality audits allow for identification of underperformance, providing both individual endoscopists and endoscopy units with an opportunity for discussion and implementation of strategies for improvement [4] . For instance, in their retrospective study, Taveira and colleagues found opportunities for improvement in their unit, namely by adopting a better scale for bowel preparation evaluation. Interestingly, the authors also adopted and proposed a minimum set of 8 pictures per exam (at least 3 photos for segmental documentation of bowel preparation, at least 2 photos to document the cecum and ileocecal valve, and 3 for documentation of findings and

Ulcerous Esophagitis in a Young Immunocompetent Patient

ttp://dx.doi.org/10.1016/j.jpge.2016.02.004 341-4545/© 2016 Sociedade Portuguesa de Gastrenterologia. Published C BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4 owel syndrome (IBS). The patient denied regular mediation or recent use of any drugs, namely antibiotics or on-steroidal anti-inflammatory drugs. Laboratory studies howed an increased C-reactive protein and a negative HIV erology. An esophagogastroduodenoscopy (EGD) revealed everal ulcers in the lower third of the esophagus, the largest ith 15 mm and raised borders (Fig. 1). Biopsies were taken rom the edges and bottom of the ulcer. The patient was dmitted and empirically started on proton pump inhibitor PPI) and acyclovir. Serologies ruled out HSV 1 and 2, CMV, BV and VZV recent infections and syphilis. Histological xamination showed an intense chronic inflammatory infilrate involving the mucosal, submucosal and muscular layers Fig. 2a) and an epithelioid granuloma with a giant cell Fig. 2b). There were no viral cytopathic effects or acid-fast acilli. Hence, our patient had a non-caseous esophageal ranulatomatosis. We excluded tuberculosis, sarcoidosis and ranulomatosis with polyangiits (Wegener’s granulomatosis) ased on a negative Mantoux and IGRA tests and normal hest X-ray, angiotensin conversion enzyme levels, serum lectrophoresis and renal function. At this point, we conidered the hypothesis of Crohn’s disease and given the atient’s complaints of intermittent diarrhea and abdominal iscomfort, labeled as IBS, an ileocolonoscopy was perormed. Several areas of erythema with aphthous erosions, nd ulcers, stellar and circular, the largest with 10 mm,

Right adrenal gland prospective evaluation through transgastric endoscopic ultrasound: an alternative approach

Background and aims: Endoscopic ultrasound (EUS) guided right adrenal gland (RAG) evaluation is frequently unsuccessful and, when feasible, requires a cumbersome maneuver through the duodenum. In our experience, the use of a recent ultrasound platform has enabled transgastric detection of the RAG with a simple maneuver. The aim of this study was to determine the RAG transgastric EUS detection rate and identify predictive factors for failure. Methods: Consecutive patients referred to EUS in a single center were prospectively included over a 6-month period. Success was defined as RAG transgastric EUS detection within 180 seconds. Logistic regression analysis was used to assess factors associated with failure. Results: Among 100 patients, the success rate for RAG transgastric EUS detection was 75 %, with a median maneuver duration of 45 seconds [interquartile range, 25 – 70 seconds]. Two incidental RAG lesions were detected. Of possible demographic and anthropometric predictive factors for failure, only age (OR 1.04; P = 0.04) was statistically significant on multivariate analysis. Conclusions: The transgastric EUS approach for RAG detection is simple, fast and effective.