Eosinophilic Esophagitis: Essential Steps for a Correct Diagnosis
EndoCollab Weekly Digest: February 14–28, 2025
• It's essential that we remember the endoscopic characteristics of eosinophilic esophagitis, as you can see in this video.
• You will see lines and tracks, mucosal rings, white flecks and stiplings, as we can appreciate now with narrowband imaging.
• Occasionally, the mucosa is very friable and vulnerable, such as crepe-papered mucosa.
• The mucosa appears also narrowed and fibrotic.
• The lumen appears narrow and the mucosa can be fibrotic.
• Various studies, including this very elegant study from Denmark, have shown that recognition of eosinophilic esophagitis is quite poor.
• As shown you before, eosinophilic esophagitis has brought endoscopic appearance.
• You always find some sort of rings.
• The mucosa can be fibrotic.
• There are lines and tracks, occasionally white little dots that can be confused with candida.
• But you see that often they are mixed with these lines and tracks.
• It's important that you pay attention to detail.
• And if biopsies are obtained from these areas that are white, the white stipplings, The amount of eosinophils here is highest.
WhatsApp Weekly Digest: Discussions February 14–28, 2025
Post-CPR Gastric Mucosal Injury
Case Discussion: A patient developed antral erosions and hematin deposits following CPR.
Proposed mechanisms included non-occlusive mesenteric ischemia (NOMI) due to catecholamine surge and hypoperfusion during cardiac arrest1.
Differential diagnoses: Calciphylaxis (in renal failure patients) and "Mir sign" (reversible mucosal blanching in atherosclerosis)1.
Renal Failure & Gastric Ulcers
A patient with end-stage renal disease presented with diffuse gastric ulcers. Contributing factors:
Platelet dysfunction, malnutrition, and hypotension during dialysis.
Biopsies ruled out H. pylori; sepsis was the terminal event.
Anticoagulation Management Post-GAVE
Debate on restarting oral anticoagulants (OAK) after endoscopic band ligation (EBL) for gastric antral vascular ectasia (GAVE):
Consensus: Maintain anticoagulation for ≥2 months in AF patients without prosthetic valves.
Post-EBL ulcer healing estimated at 1–3 weeks, faster than variceal banding ulcers.
Failed Fundoplication Management
Case: Recurrent GERD in a 46-year-old with migrated fundoplication.
Recommended surgical revision with hiatal hernia repair over transoral incisionless fundoplication (TIF).
Barium studies classified anatomical failure, guiding treatment plans.
Difficult CBD Stone Extraction
Approach for large, impacted stones:
First-line: Cholangioscopy-guided laser/EHL lithotripsy.
Alternatives: CRE balloon dilation + mechanical lithotripsy or temporary stenting to facilitate stone softening.
SEMS vs. plastic stents: Preference for dual plastic stents due to lower impaction risk.
Duodenal Bulb Lesion Workup
63-year-old with anemia:
Differential diagnoses: MALT lymphoma, celiac disease, or H. pylori-associated ulcer.
Recommendations: Rapid urease testing, celiac serology, and histopathology.
Complex Biliary Stricture Post-Cholecystectomy
Case: Suspected bile duct injury (BDI) vs. malignancy.
Imaging suggested Bismuth IV stricture; exploratory laparoscopy confirmed fibrosis.
Final management: Roux-en-Y hepaticojejunostomy.
Esophageal Stricture in Cirrhosis
Post-banding stricture at 35 cm with varices:
Options: Glue injection (risk of stricture recurrence), TIPS (favored given low MELD-Na), or PEG for nutrition.
Gastric Balloon Removal
4-year-old intragastric balloon:
Precaution: Orotracheal intubation to mitigate aspiration risk during extraction.
Educational Highlights
Pathophysiology Insight: CPR-induced ischemia mimics NOMI, emphasizing post-resuscitation endoscopic monitoring.
Technical Pearls: Cholangioscopy remains gold-standard for complex stones, while staged stenting offers a cost-effective alternative.
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