Supplement Abstracts Submitted for the 73rd Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
Purpose: Esophageal disorders are relatively common among patients with HIV/AIDS, especially esophagitis and esophageal ulcers. Infectious etiologies are commonly associated with esophageal ulcers, however many are idiopathic and may result in severe stricture formation. Treatments of the underlying cause, steroids and/or esophageal dilation are conventional approaches to therapy. However there is no standard approach to refractory strictures. We report a case of patient with idiopathic esophageal giant ulcers and esophageal stricture refractory to dilatation, who has been successfully treated with a self-expanding Poly-flex stent placement.
Results: Case Summary: A 35 year old gentleman with HIV/AIDS (last CD4 count of 73) and known history of esophageal stricture presented with continued dysphagia. The patient had been diagnosed with this condition three months prior to this admission and undergone several dilations with no improvement in his symptoms. A percutaneous gastrostomy tube was placed for nutritional support. Biopsies performed on several different occasions were all negative. At the time of presentation he was not able to swallow foods, liquids nor saliva. Our initial upper endoscopy showed food contents in the proximal esophagus and an almost total closure of the esophageal lumen at 27 cm from the incisors, precluding the passage of the endoscope. Multiple attempts to pass a guidewire were also unsuccessful. On a second attempt and under fluoroscopy, we were able to successfully dilate up to 15 mm. Once dilation was performed, two giant ulcers and a small inflammatory polyp were visualized immediately distal to the stricture in the lower esophagus. Interestingly the stricture was 5 cm long and had a dynamic nature. The latter demonstrated by the persistence of severe dysphagia despite a series of subsequent balloon dilatations of up to 18 mm. An alternative approach was chosen at this point in order to provide definite treatment. Using fluoroscopy we endoscopically deployed a 9 cm long by 18 mm diameter removable Polyflex® stent. Additional therapy included a steroid taper as treatment for the giant ulcers and a proton pump inhibitor. The patient had a remarkable improvement of his symptoms, without major procedure related complications. Steroids were initiated to heal the idiopathic ulcers.
Conclusion: Idopathic esophageal ulceratons and strictures are rarely seen in the age of antiretroviral therapy. We report a case of a refractory idiopathic esophageal stricture in a patient with HIV/AIDS that responded well to removable Polyflex® stent placement. Use of removable Polyflex® stents in the setting of refractory strictures in this population prevents repeat dilations and its associated complications.