Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.
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INTRODUCTION: Thoracic Actinomyces is a rare infection but potentially aggressive. It is difficult to diagnose most often requiring surgical debridement. Actinomyces species colonize the mucosa of the body with disease potentially related to barrier injury. CASE DESCRIPTION/METHODS: A 29 year old male with history of childhood asthma and recent dental extraction presented with odynophagia. He noted chest discomfort & fevers. Physical exam revealed an obese male but was otherwise unremarkable. Oral exam was unrevealing for lesions. Labs noted a WBC of 16.8 u/L. CT Chest revealed a 5 × 2 × 2 cm posterior mediastinum collection (Figure 1) abutting the esophagus with mid and distal esophagitis. An EGD noted distal esophagitis, posterior extrinsic compression from 25 to 31 cm with a mucosal fistula at 27 cm with purulent drainage. Aspirated Esophageal contents were sent for culture. An IR Guided Drainage approach was not felt to be safe due to possibility of spinal injury. Patient underwent conservative treatment with PPI, Broad spectrum antimicrobial therapy. A repeat CT CAP revealed interval decreased size of mediastinal collection. Fluid cultures from endoscopy were negative. Testing for Coccidiomycosis, HIV, and Tuberculosis were negative. On Hospital Day 4, EGD and EUS was performed to evaluate the mediastinal abscess. EGD showed that the fistula had healed but there was esophageal rings and furrows; This was biopsied. The EUS noted a 1.5 × 2 cm Posterior Mediastinal Abscess. It was loculated and hard; A EUS guided FNA needle was used to obtain material for culture. Biopsies revealed >100 Eosinophil’s per HPF, consistent with esophinophilic esophagitis. FNA culture noted Actinomcyes Odontolyticus. Treatment was tailored for Penicillin-based therapy. On Hospital Day 12 , Repeat CT Chest did not identify a mediastinal collection or evidence of esophageal leak and noted resolving mural thickening of the esophagus. DISCUSSION: Thoracic actinomyces was diagnosed in the setting of active eosinophilic esophagitis. It is possible that EOE predisposes to Actinomyces as Actinomyces is a commensal flora of GI tract and this could have spread to mediastinum directly due to barrier injury. Increasing availability of endoscopic modalities may provide more accessible diagnostic options, which will help in targeted treatment. We report a possible association of EOE and Actinomyces and also successful minimally invasive diagnosis of actinomyces in a difficult anatomical location.
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