Cytomegalovirus Esophagitis
Cytomegalovirus Esophagitis

Video Endoscopic Sequence 1 of 4.

Cytomegalovirus Esophagitis

This the case of a 38 year-old male, an upper endoscopy was performed because of chest pain, was diagnosed retrospectively which suffers of Acquired Immunodeficiency Syndrome (AIDS).

Esophagitis is the second most common gastrointestinal (GI) manifestation of cytomegalovirus (CMV) infection after colitis. CMV esophagitis has been reported in patients who have undergone transplantation, patients undergoing long-term renal dialysis, patients with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), and patients with other debilitating diseases.

Cytomegalovirus Esophagitis

 

All endoscopic images shown in this Atlas contain
video clips.

 

Cytomegalovirus Esophagitis

Video Endoscopic Sequence 2 of 4.

Mimics of the symptoms of CMV esophagitis include the following:

· Achalasia
· Barrett Esophagus and Barrett Ulcer
· Candidiasis
· Cryptococcosis
· Esophageal Cancer
· Gastroesophageal Reflux Disease
· Herpes Simplex
· Histoplasmosis
· Tuberculosis
The following conditions should also be considered in the
diagnosis:
· Aphthous/idiopathic ulcers (commonly seen in patients with AIDS)
· Drug-induced dysphagia
· Epstein-Barr virus infection

 

 

Video Endoscopic Sequence 3 of 4.

Cytomegalovirus Esophagitis

Patients with CMV esophagitis may have superimposed CMV colitis (in which case, care at a skilled nursing facility may be necessary).

Patients with HIV infection are at increased risk because
their CD4+ lymphocyte counts fall to less than 100 cells/µL
. In patients with HIV infection or AIDS, CMV infection is
an opportunistic infection that signals a decline in patient
immunity.

CMV esophagitis has been described in only 3 patients
who had been immunocompromised by conditions other
than transplantation, HIV infection, or AIDS. No cases
have been reported in healthy hosts.

 

Video Endoscopic Sequence 4 of 4.

Cytomegalovirus Esophagitis

Risk factors that predispose individuals to cytomegalovirus esophagitis include the following:

· HIV infection or AIDS
· High- or low-dose corticosteroid therapy
· Immunosuppressive therapy following transplant
· History of blood transfusion
· Advancing age
· Anything that can decrease an individual’s immunity
Potential complications of cytomegalovirus esophagitis
include the following:
· Stricture formation
· Perforation (rarely)

 

Cytomegalovirus Esophagitis

Video Endoscopic Sequence 1 of 4.

Cytomegalovirus Esophagitis

This 42 year-old male underwent a rutine upper endoscopy finding this tiny lesion in the upper third of the esophagus immediately suspect as herpes viral esophagitis or cytomegalovirus, subsequently confirmed by biopsies, subsequently confirmed by being HIV positive blood test.

Cytomegalovirus (CMV) is a member of the Herpesviridae family, along with herpes simplex viruses (HSVs) 1 and 2, Epstein-Barr virus, varicella-zoster virus, and others. CMV is a double-stranded DNA virus with a protein coat and lipoprotein envelope.







Video Endoscopic Sequence 2 of 4.

Endoscopy of Cytomegalovirus Esophagitis

Usually an opportunistic infection, among the most common
opportunistic infections in AIDS patients, but also
in non-HIV immunocompromised patients (bone marrow
transplant recipients, solid organ transplant recipients,
patients with malignancies and rheumatologic disorders,
patients receiving immunosuppressive therapy).

Endoscopic Featuressolitary (usually) or multiple shallow ulcers in the distal
esophagus, occasionally extending in the mid
esophagus.
- may become large in AIDS or other immunosuppressed
patients.

Differential Diagnosis

ENDOSCOPIC

- Herpes - small multiple ulcers
- Candida - white exudates
- Pill - mid esophageal solitary or "kissing" ulcers

MORPHOLOGIC

- Herpes - multinucleated giant cells with intranuclear
inclusions in the squamous epithelium at the ulcer edge.
- Candida - fungal pseudohyphae in the exudate.
- Pill - ulcer of squamous epithelium without viral cytopathic
effect or fungi.


 

Video Endoscopic Sequence 3 of 4.

CMV GI disease was first described in the 1960s.
Esophagitis is the second most common GI manifestation
of CMV infection after colitis. CMV esophagitis has been
reported in patients who have undergone transplantation,
patients undergoing long-term renal dialysis, patients with
HIV infection or AIDS, and patients with other debilitating
diseases.

The average time to development of CMV esophagitis
after solid organ transplantation is 5-7 months. Patients
undergoing bone marrow transplantation may develop
CMV disease much earlier, at an average of 2-3 months
with symptoms occurring as early as 10 days after allogenic
bone marrow transplantation. Patients with HIV infection
are at increased risk because their CD4+ lymphocyte
counts fall to less than 100 cells/µL.

Approximately 8-28% of patients with AIDS who undergo
esophagogastroduodenoscopy (EGD) for dysphagia or
odynophagia are found to have cultures positive for CMV.
Approximately 38% of bone marrow transplant patients
who undergo EGD for unexplained nausea and vomiting
are positive for CMV esophagitis and/or small intestine
involvement. CMV esophagitis has been described in only
3 patients immunocompromised by conditions other than
transplantation, HIV infection, or AIDS. No cases have
been reported in healthy hosts.

 

Video Endoscopic Sequence 4 of 4.

Characteristic giant cell with inclusion body in a patient
with cytomegalovirus esophagitis.


Esophageal Congenital Rings

Video Endoscopic Sequence 1 of 5.

Esophageal Congenital Rings

This is the case of a 17 year-old female, who suffers from dysphagia since childhood, endoscopy will detect these congenital rings.

 

 

Esophageal Congenital Rings

Esophageal Congenital Rings

Video Endoscopic Sequence 2 of 5.

Endoscopy of Esophageal Congenital Rings

Multiple esophageal rings are a very unusual cause of dysphagia

Esophageal Congenital Rings

Video Endoscopic Sequence 3 of 5.

Image and video clip of Esophageal Congenital Rings

Esophageal Congenital Rings

Video Endoscopic Sequence 4 of 5.

Rx of of Esophageal Congenital Rings

 

Esophageal Congenital Rings

Video Endoscopic Sequence 5 of 5.

Rx of of Esophageal Congenital Rings

Esophageal leiomyoma

Video Endoscopic Sequence 1 of 4.

Esophageal leiomyoma

Benign tumors of the esophagus are rare lesions that constitute less than 1% of esophageal neoplasms. Nearly two thirds of benign esophageal tumors are leiomyomas; the others mostly are polyps and cysts. Thus, leiomyomas are the most common benign tumors of the esophagus.

Although rare elsewhere in the gastrointestinal tract, leiomyomas (LMs) are the most common esophageal mesenchymal neoplasms. In contrast, gastrointestinal stromal tumors (GISTs) predominate in the stomach and intestines but rarely documented in the esophagus.

The majority of leiomyomas have been discovered incidentally during evaluation for dysphagia or during autopsy. Bleeding rarely occurs in cases of benign disease but typically is observed with leiomyosarcoma, the malignant counterpart of this tumor. The potential for malignant degeneration of leiomyomas is extremely small. In the distal esophagus, leiomyomas may reach large proportions and may encroach on the cardia of the stomach.



Esophageal leiomyoma

Video Endoscopic Sequence 2 of 4.

Esophageal leiomyomas comprise less than 0.6% of all esophageal neoplasms, both in the United States and worldwide.

Esophageal leiomyomas rarely cause symptoms when they are smaller than 5 cm in diameter.
Large tumors can cause dysphagia, vague retrosternal discomfort, chest pain, esophageal obstruction, and regurgitation.
Rarely, they can cause gastrointestinal bleeding, with erosion through the mucosa.

While open surgical technique is the traditional mainstay of therapy for leiomyomas, combined esophagoscopy and video-assisted resection (thoracoscopy) or laparoscopic transhiatal resection are being increasingly performed.
Endoscopic removal of these tumors has been attempted. However, this technique cannot be considered standard of care

Video Endoscopic Sequence3 of 4.

Actin to smooth muscle.

 

 

 



Video Endoscopic Sequence 4 of 4.

Actin to smooth muscle.

Histologically, the tumors are comprised of bundles of interlacing smooth muscle cells, well-demarcated by adjacent tissue or by a definitive connective tissue capsule. They are composed of fascicles of spindle cells that tend to intersect with each other at varying angles. The tumor cells have blunt-ended elongated nuclei and show minimal atypia with few mitotic figures


Video Endoscopic Sequence 1 of 5.

Gastrointestinal stromal tumors (GISTs) of the esophagus are rare, comprising only about 1% of reported GISTs

Gastrointestinal stromal tumors (GISTs) are the most common sarcoma of the gastrointestinal tract, but occur rarely in the esophagus.

A 45 year-old male, physician, previously asintomatic, a
giant GIST was found at the level of the middle third.

Hypomotility of the distal esophagus, hiatal hernias and
GERD are common findings. Therefore, evaluation for
GERD should be considered before and after surgery for
esophageal GIST.

 

Video Endoscopic Sequence 2 of 5.

Gastrointestinal stromal tumors (GISTs) are a subset of GI mesenchymal tumors of varying differentiation. Previously, these tumors were classified as GI leiomyomas, leiomyosarcomas, leiomyoblastomas, or schwannomas, on the basis of histologic findings and the fact that these tumors apparently originate in the muscularis propria layer of the intestinal wall. With the advent of immunohistochemical staining techniques and ultrastructural evaluation, GISTs now are recognized as a distinct group of mesenchymal tumors. In the present classification, GISTs account for approximately 80% of GI mesenchymal tumors.

Use of tyrosine kinase inhibitors has revolutionized therapy for GISTs but complete resection remains the treatment of choice. Esophageal GISTs require special consideration regarding perioperative treatment, evaluation, and conduct of operation.




Video Endoscopic Sequence 3 of 5.

Esophageal GISTs present unique challenges. First, the
tumor must be recognized correctly as a GIST. Due to the
similar clinical,endoscopic, and radiographic appearance as
the far more common esophageal leiomyoma, a GIST may
not be identified as such untilafter resection. Because
GISTs are fluorodeoxyglucose (FDG)avid, FDG-positron
emission tomography (PET) scanning may beused to
differentiate them from leiomyoma.

 

 

Video Endoscopic Sequence 4 of 5.

Patient have been suffered of GERD since many years.
The endoscopic image as well as the video clip displays
a reflux esophagitis with Barret esophagus.

Video Endoscopic Sequence 5 of 5.

Hypomotility of the distal esophagus, hiatal hernias and
GERD are common findings in patient with leiomyomas.
Therefore, evaluation for GERD should be considered
before and after surgery for esophageal leiomyoma.

Tracheal Bifurcation.

Tracheal Bifurcation.

The endoscope is occasionally passed inadvertently
into the trachea rather than the esophagus, for example,
in patients who have difficulty initiating the act of
swallowing.
Tracheal rings will be evident, as will the bifurcation into
right and left mainstream bronchi.

 

Traqueo Esophageal Fistula

Small Traqueo-Esophageal Fistula.

A 90 year- old male with old pulmonar tuberculosis sequels.
We found the image displays here and some biopsies
where taken at the time of the endoscopy we found this
image in the superior third of the esophagus, We did not
have a diagnosis and therefore proceed to biopsy this
lesion.
Esophagogram was obtained, showing small fistula between up third of esophagus and trachea.

 

lye ingestion

Video Endoscopic Sequence 1 of 2.

Status after 36 year of lye ingestion

Circular Scars are observed in the middle third of the Esophagus.

This 40 year-old female, at the age of 4, suffers an accident
ingesting lye, for more than two years underwent
continuous sessions of dilation of the esophagus.



Video Endoscopic Sequence 2 of 2.

In the image as well as the video clip a scar of gastrostomy is observed after 36 year .

Foreign body retrieval.

Video Endoscopic Sequence 1 of 2.

Polypectomy snare -assisted removal of a foreign body
impacted in the esophagus.

A 76 year-old man with meat and rice’s residues were
found at the cardias, which obstruct passage due a mild
stenosis of the cardias, as a consequence of reflux
esophagitis.

 

 



Foreign body retrieval.

Video Endoscopic Sequence 2 of 2.

Foreign body retrieval.

The meat and rice’s are retrieval with the polypectomy
snare.


Heterotopic gastric mucosa inlet patch

Video Endoscopic Sequence 1 of 2.

Heterotopic gastric mucosa “inlet patch”

This a 52 year-old male, in a routine endoscopy, this image of a gastric mucosa heterotopia in cervical esophagus and image of a pseudo diverticulum was found, patient was asymptomatic.

Heterotopic gastric mucosa of the proximal esophagus (HGMPE), also referred to as “inlet patch” or “cervical inlet patch”, is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%. Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints. Most consider HGMPE as clinically irrelevant entity. The clinical significance of HGMPE is mainly acid related or neoplastic transformation. The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20% to as high as 73.1%. However, most of these symptoms are mild. Clinically significant acid related complications such as bleeding, ulcerations, structure and fistulization have been reported. Although rare, dysplastic changes and malignancies in association with HGMPE have also been reported. Associations with Barrett’s esophagus have also been reported but the findings so far have been conflicting.

Heterotopic gastric mucosa inlet patch

Video Endoscopic Sequence 2 of 2.

The clinical manifestations of HGMPE can be broadly divided into non-neoplastic and neoplastic. The majority of patients found to have HGMPE are asymptomatic and the HGMPE are detected incidentally during evaluation for other gastrointestinal complaints. These patients are categorized to have type I HGMPE. The non-neoplastic manifestations (type II and III) such as LPR symptoms and strictures and bleeding are probably related to the acid produced by the patch. The least common manifestations are the histological or neoplastic changes (type IV and V). With the exception of malignancy in the pediatric population, all these have been reported both in the adult and pediatric population. Acid related symptoms are often seen in younger patients whereas neoplastic manifestations have been reported mainly in the elderly population.

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