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Gender Differences in Patients Presenting with Dysphagia
Kathryn R. Byrne, Kristen Thomas, John C. Fang, Mae F. Go,
Scott H. Mackenzie, Kathryn A. Peterson
Background: Dysphagia is a common cause of referral for upper endoscopy.
Gender differences within such a cohort have not been previously described in the
literature. We hypothesized that the etiology of dysphagia would differ by gender.
Aim: To determine if gender differences exist among the etiology of dysphagia in
patients presenting for upper endoscopy. Methods: A prospective analysis was
performed on all patients undergoing upper endoscopy for the indication of
dysphagia between 1/1/2006 and 6/1/2007 at the University Hospital. All patients
completed dysphagia symptom assessment along with validated gastroesophageal
reflux questionnaires. Endoscopic findings and demographics were also recorded.
Results: A total of 190 patients were enrolled (92 males, 98 females). Males and
females were similar in age of presentation (49.7  15.0 vs. 52.8,  16.3), duration
of symptoms (8.2  9.0 vs. 6.0  8.7), and severity of dysphagia scores (median 1.9
 1.4 vs. 2.1  1.5). A significant difference in the distribution of endoscopic
findings exist between males and females (p ! 0.004). Multiple esophageal rings
are more prevalent in males than females (28.6% vs. 13.9%, p ! 0.02). Schatzkis
Rings (SR) are described more in females than males (20.8% vs. 6.1%, p ! 0.01)
[see table]. A history of esophageal food impaction (EFI) occurred more frequently
in males (30.4% vs. 17.3%, p ! 0.04). A high prevalence of multiple esophageal
rings was found in both genders who described prior EFI (males 55.6%, females
46.7%). Prior food impaction increased the likelihood of finding multiple
esophageal rings in females (OR 7.7, p ! 0.03), but not in males (OR 1.8, p Z NS).
Conclusion: The endoscopic findings and history of esophageal food impaction in
patients presenting with dysphagia differ significantly by gender. History of
esophageal food impaction greatly increases the likelihood of finding multiple
esophageal rings in females. Suspicion of multiple esophageal rings should be high
not only in men, but also in women who present with EFI and dysphagia.

Role of Proton Pump Inhibitor As a Predisposing Factor
of Candida Esophagitis
Etsuo Hoshino, Tadashi Fujisaki, Makoto Tatewaki, Junko Fujisaki,
Naoyuki Uragami, Rikiya Fujita
Background: Candida esophagitis is the most frequent esophageal infection in both
HIV seropositive and seronegative patients. Patients taking proton pump inhibitor
(PPI) are often diagnosed to have Candida esophagitis. PPI is known to interfere
with the cellular immunity. Aim: This retrospective study was conducted to
determine the characteristics of Candida esophagitis in HIV negative patients in
a cancer hospital in Japan with special reference to PPI. Methods: Clinical records of
all HIV negative patients with Candida esophagitis, endoscopically diagnosed and
microscopically confirmed (biopsy of esophageal mucosa), were studied. Results:
From March 2005 to September 2007, 283 patients (169 men, 114 women, mean
age: 67) fulfilled the criteria (1.45% of the diagnostic esophagogastroduodenal
endoscopies). The predisposing factors included malignancies (70 patients; 24.7%),
PPI (43 patients; 15.2%), diabetes mellitus (15 patients; 5.3%), oral or aerosolized
corticotherapy (7 patients; 2.5%). Among 43 patients taking PPI, 17 had no other
predisposing factors except PPI. PPI administered were lansoprazole (22 patients),
rabeprazole-Na (14 patients), and omeprazole (7 patients). In 103 patitents (36.4%),
no known predisposing factors were noted. The endoscopic grading as assessed by
Kodsis classification (grade I/II/III/IV) were (44%/30%/21%/5%) in patients with
cancer, (25%/51%/11%/4%) in patients taking PPI, and (41%/55%/4%/0%) in patients
with no known predisposing factors. Conclusions: Esophageal candidiasis is not
infrequent in a cancer hospital and does not always present with known
predisposing factors. PPI is one of the most important risk factors for the
development of esophageal candidiasis.

Long-Term Results of Endoscopic Injection Sclerotherapy for
Esophageal Varices in Adults: 20-Year Prospective Evaluation
Mika Yuki, Hideaki Kazumori, Satoko Takuwa, Keiko Tateishi,
Kimiko Nagasako, Hiroyuki Fukuhara, Takane Azumi,
Yoshinori Komazawa, Toshihiro Shizuku
Background and aim: Endoscopic injection sclerotherapy (EIS) is beneficial for
management of active hemorrhaging and prevention of recurrent bleeding from
esophageal varices. However, its long-term efficacy and safety is poorly defined.


The aim of this study was to determine long-term cumulative survival rates and
clarify predictive factors for mortality in patients with esophageal varices. Methods:
Between 1981 and 1987, seventy-two patients (45 men, 27 women; mean age, 58.0
years; range, 36-85 years) underwent EIS, of whom 24 were classified as Child-Pugh
grade A, 23 as grade B, and 25 as grade C. Hepatocellular carcinoma was
complicated in 18 patients. Variceal rebleeding, recurrence, and survival were
recorded during the follow-up period. Results: The follow-up periods ranged from
0-270 months (mean, 82.1 months). The cumulative survival rates were 53.6%,
26.1%, and 11.6% at 60, 120, and 240 months, respectively, with liver failure the
most common cause of death. Esophageal varices were eradicated in 93 % of the
patients following EIS and, though recurrence was seen in 57.0 % (mean 32.1
months; range, 4-83 months), they were usually small and easily re-eradicated by
another EIS procedure. Rebleeding occurred in 15.3% of the patients within 36
months after the initial EIS. Significant prognostic indicators for mortality were
Child-Pugh grade and the presence of hepatocellular carcinoma. Conclusions:
Complete eradication of esophageal varices with EIS reduces rebleeding and
prolongs long-term survival. The prognosis of patients with esophageal varices is
dependent on the severity of liver damage and presence of hepatocellular

Dysphagia in Young Patients: Worth Having a Look?
Nick Powell, Thomas A. Treibel, Joel Dunn, Joel Mawdsley,
Jonathan M. Hoare, Rupert Negus, Huw J. Thomas, Julian P. Teare,
Timothy Orchard
Dysphagia is perceived as a sinister symptom necessitating urgent
esophagogastroduodenoscopy (EGD). However, EGD is costly, disliked by patients
and has been associated with small, but finite risks of morbidity and mortality.
There are few data available regarding EGD findings in young patients with
dysphagia, in whom the risk of serious pathology such as esophageal malignancy is
likely very small. We conducted a retrospective, case control study of all patients
with dysphagia referred to our unit over a 20 year period. We calculated the
prevalence of important causes of dysphagia, including esophageal cancer,
esophagitis and peptic strictures in young patients (aged %40 years) and for
comparison in elderly patients (aged R65 years). We identified 455 patients aged
%40 years (median age 34 years, 304 males) and 1574 patients aged R65 years
(median age 76 years, 826 males) referred for EGD because of dysphagia. The
prevalence of esophageal carcinoma was significantly lower in patients aged %40
years (0%) compared to patients aged R65 years (10.4%, p ! 0.0001). The
prevalence of benign esophageal lesions was also significantly increased in patients
aged R65 years compared to patients aged %40 years, including peptic strictures
(21.6% vs 8.8%, p ! 0.0001) and esophagitis (27.4% vs 19.3%, p ! 0.0006).
However, in patients aged %40 years we did identify 5 cases of esophageal Kaposis
sarcoma (compared to 0 cases in patients aged R65 year, p ! 0.0006). Four out of
five cases were associated with candidiasis or esophagitis, likely accounting for the
dysphagia and were all associated with HIV infection. In patients aged %40 years
the prevalence of esophageal candidiasis (5.9%) was also significantly greater than
in patients aged R65 years (1%, p ! 0.0001). Malignant and benign esophageal
lesions are significantly less common in young patients (aged %40 years) with
dysphagia, compared to elderly patients. However, there was still an important
yield of treatable lesions including peptic strictures (9%) and esophagitis (19%). In
our population of young patients, the prevalence of lesions associated with
immunocompromise, including esophageal Kaposis sarcoma (1%) and esophageal
candidiasis (6%) was significantly increased. These data suggest that EGD is
a valuable investigation in young patients with dysphagia.

Feasibility Study of a New Percutaneous Endoscopic Gastrostomy
(PEG) Procedure, the Direct IDEAL PEG, in Patients with
Advanced Head and Neck Cancer Or Esophageal Cancer
Tomonori Yano, Manabu Muto, Keiko Minashi, Naomi Kiyota,
Takashi Kojima, Satoshi Takeuchi, Makoto Tahara, Kazuhiro Kaneko,
Atsushi Ohtsu
Background: Nutritional disorders are the major problem for patients with
advanced head and neck cancer (HNC) or esophageal cancer (EC) patients. PEG is
a method for improving nutritional status in these patients. Furthermore,
prophylactic PEG before chemoradiotherapy (CRT) is advocated, especially for
HNC patients. However, implantation metastasis can occur at the PEG placement
site after PEG insertion using the pull method, as the PEG tube passes the area,
which is stenotic due to the cancer. Direct IDEAL PEG is a new PEG procedure
that can be performed directly through the exterior abdominal wall without
passage through the cancerous region. Aim: This prospective study aimed to
evaluate the technical feasibility and safety of the Direct IDEAL PEG in patients
with advanced HNC and EC patients. Patients and methods: The eligibility criteria
were; 1) advanced HNC or EC; 2) preserved organ function; 3) ECOG performance
status of 0 to 2; 4) written, informed consent. The Direct IDEAL PEG (Olympus
Medical Systems Co, Ltd, Tokyo) procedure was used in PEG. The main features of