I'm from Baylor, Dallas, and we're going to sneak in a few minutes of benign esophagus. I'm going to talk about something that we often encounter, which is esophageal strictures, and these type perplex me, so I'm going to see if I can call my friends on the panel for any insights they have. This is an 84-year-old with diabetes who presents with esophageal dysphagia and has had strictures that have been previously dilated with multiple endoscopies of dilations up to 10 millimeters with the balloon dilation as often as every six to eight weeks without relief of symptoms and persistent solid food dysphagia, and the patients referred for further management. The stricture was approximately 7 millimeters in diameter. The diagnostic endoscope did not pass the stricture, and an ultra-slim scope was able to, and was measured to be from 20 to 29 centimeters from the incisors. This is an example of a similar stricture with a similar patient, and if anyone wants to comment on anything they see in the stricture or what they're thinking as we're coming back and encountering it, and I will just say one thing to note here is there is sparing of the GE junction, which is something you want to take into account when we're encountering these sort of complex strictures, whether or not there's any involvement of the GE junction. Any thoughts from anyone? Well, you see a very long stricture. You see pseudo-diverticular, and I'll be very interested. So this is almost pathognomonic, what you see there at the top of the stricture, and if you push a little bit with the scope, it may slough on you. If you see that, I think the diagnosis even before the biopsy will be, I'll be 99% confident what it is. Should I spill it out right now? Go ahead. This looks like lichen planus. It's a typical appearance of it. This is a typical appearance of lichen planus. You have that plaque-like areas that you can see in the proximal aspect of the stricture, and just the pseudo-membrane appearance of that sloughing esophagitis is quite common and sparing of the GE junction. Other things to think about as we approach these strictures is whether or not they're simple strictures, are they complex strictures, and simple or short focal strictures. They can often be addressed in one or two dilations, where a complex, or often iatrogenic, although in this case it wasn't, angulated longer and often require more dilations. I'm going to skip this slide, if I can, in the interest of time. And just to comment on, you know, this patient has exhibited signs of what, you know, a difficult to control stricture. So refractory strictures are inability to achieve 14 millimeters over sessions of dilations at two-week intervals. And if you've done that for five times and haven't achieved that, that's a refractory stricture. Now something that that patient was undergoing was a dilation in longer intervals, and that's a common issue that we encounter is patients aren't coming back often enough. And we often can see recurrent strictures, that's after you get the diameter achieved, but then you're not able to maintain it. Now in this case, the patient was dilated, and getting dilations to 11 millimeters, getting a little bit with subsequent dilations more, injected with steroids and biopsy. Anything else we would want to do, or any thoughts that you have between balloon and savory, balloon, savory? I mean, here it certainly makes sense, savory, because the stricture is so long, just for the convenience factor, if nothing else. Yeah. And that's an important point, that savory allows you to dilate the whole stricture. I will say that histology did not show lichen planus. We also sent biopsies for direct immunofluorescence, and we see IgM deposition that's also characteristic. So oftentimes these biopsies are not diagnostic, and really it takes the recognition of the endoscopic appearance and the clinical suspicion. And when we dilate these again and again, sometimes we don't achieve what we want, because we're not controlling the inflammation. So in this case, we also want to control the inflammation, and in this case I did topical steroids. And if we don't control the inflammation in addition to dilation, then we end up doing the same thing over and over. In the interest of time, I think I will stop there. Thank you. Thank you. Great case.

video

diabetes

dysphagia

esophageal strictures

lichen planus