Defiant dysphagia: small-caliber esophagus and refractory benign esophageal strictures

Among causes of defiant dysphagia, two pose a special challenge for the clinician: the small-caliber esophagus and refractory benign esophageal strictures. The small-caliber esophagus is a major cause of dysphagia for solids in young patients with eosinophilic esophagitis. A smooth, diffusely narrow esophageal lumen can be appreciated by barium esophagography or esophagoscopy. The term "small-caliber esophagus" is preferred over "stricture" because of the absence of cicatrization. A "subtle" small-caliber esophagus may defy detection by barium esophagogram and esophagogastroduodenoscopy. The only evidence to its diagnosis is the endoscopic finding of unusually long rents in the body of the esophagus immediately after esophageal dilation. The ringed esophagus seems to be a variant of the small-caliber esophagus, with the additional endoscopic finding of a variable number of rings (few to numerous) throughout the narrowed esophagus. Classification, diagnosis, and management of small-caliber esophagus are discussed in this review. Refractory esophageal strictures have various causes, including gastroesophageal reflux disease, nasogastric tube placement, mediastinal irradiation, and corrosive ingestion. Treatments used to eliminate or reduce the need for frequent esophageal bougienage include acid-suppressive medical therapy, surgery, intralesional corticosteroid injection, and esophageal self-expandable metal stents.

Terminal ileum resection is associated with higher plasma homocysteine levels in Crohn's disease

BACKGROUND

Elevated plasma total homocysteine (tHcy) is associated with a higher risk of thrombosis. Crohn's disease (CD) is associated with hypercoagulability of undefined etiology. We investigated tHcy in patients with CD and its relationship with vitamin status, disease activity, location, duration, and history of terminal ileum (TI) resection.

STUDY

We examined fasting plasma tHcy, folate, serum vitamin B12 levels, and sedimentation rate in consecutive adult patients with CD. Harvey-Bradshaw index of CD activity and history of TI resection and thromboembolism were recorded.

RESULTS

Median plasma tHcy was 10.2 micromol/L in 125 patients with CD. Men (n = 60) had higher plasma tHcy than women (n = 65) (11.2 vs. 9.1 micromol/L; p = 0.004). Patients with a history of TI resection showed lower serum B12 levels (293 vs. 503 pg/mL; p < 0.001) and higher plasma tHcy levels (11.0 vs. 9.35 micromol/L; p = 0.027) than patients without such history. Multivariate analysis showed history of TI resection, serum B12, and creatinine levels to be significant predictors of elevated plasma tHcy. Fourteen patients with CD with a history of thrombosis had an elevated median plasma tHcy of 11.6 micromol/L.

CONCLUSIONS

Terminal ileum resection contributes to elevated plasma tHcy levels in CD cases. We recommend tHcy screening in patients with CD, especially in those with prior history of TI resection, and the initiation of vitamin supplementation when appropriate.

Erythropoietin response to post-liver transplantation anemia

Anemia frequently accompanies end-stage liver disease. Erythropoietin has recently been shown to be of benefit in a number of diseases complicated by anemia. We studied erythropoietin levels before and after orthotopic liver transplantation (OLT) and correlated these with the degree of anemia. Twenty-seven patients with end-stage cirrhosis who underwent OLT had preoperative and weekly postoperative serum erythropoietin levels determined by a highly sensitive radioimmunoassay. The relation of erythropoietin level to the values for hematocrit, serum creatinine, and cyclosporine and other biochemical test results was evaluated. Before transplantation, 23 patients were anemic; erythropoietin levels were appropriately elevated (72.7 +/- 37 mU/mL; normal, 10 to 15 mU/mL) for the degree of anemia (hematocrit, 33.1% +/- 1%) in 16 patients (70%). A blunted erythropoietin response to anemia was found in 7 of the anemic patients with cirrhosis (30%). After OLT, the hematocrit decreased to 29.5% +/- 0.6% at 4 weeks, with a reciprocal increase in serum erythropoietin levels to 36 +/- 5 mU/mL. Erythropoietin response appeared appropriate to the degree of anemia in 82% of the liver transplant recipients and blunted in 18%. We conclude that the ability to secrete erythropoietin in response to anemia is defective in many patients with end-stage liver disease, and a normal response may be restored after OLT. The results suggest that exogenous erythropoietin administration may be beneficial in anemic patients with cirrhosis and liver transplant recipients who have inappropriately low serum erythropoietin levels.