S898 Abstracts
the esophagus. A follow-up esophagram one week after discharge revealed no extravasation and normal
[1659B] Left Muscle Sparing Thoracotomy with Myotomy and Intercostal Muscle Flap
Repair.
[1659C] Successful Treatment and Closure of the Esophageal Rupture with
Transesophageal Mediastinal Drainage.
bilateral tube thoracostomies he had worsening respiratory status and subcutaneous emphysema. An
esophagram (EG) revealed an intrathoracic ER with extensive contrast extravasation (Figure1). In the
operating room; a flexible bronchoscopy was unremarkable but an esophagogastroduodenoscopy (EGD)
confirmed a 5cm transmural linear rupture of the distal esophagus extending to just above the z-line.
A left muscle-sparing thoracotomy followed by a myotomy and intercostal muscle flap was performed
to close the defect (Figure 2). He tolerated the procedure well, and was extubated on postoperative day
(POD) #1. On POD #5 new leukocytosis and increasing oxygen requirement were noted; an esophagram
followed by a chest CT were performed. Together, these confirmed a small, contained esophageal leak
within the mediastinum, not accessible by percutaneous drainage. Gastroenterology was consulted; the
EGD revealed a residual 1-cm defect at the superior aspect of the initial 5cm ER. A nasogastric tube
(NGT) was guided fluoroscopically through the defect to the most dependent point of the mediastinal
cavity for drainage followed by placement of a nasoduodenal tube (NDT) for feeding. Within a week
profound clinical improvement was noted and the NGT was eventually removed. An esophagram prior
to discharge demonstrated a small residual, nondependent, cavity; that drained immediately back into
The American Journal of GASTROENTEROLOGY
mucosa. The NDT was removed and he was gradually advanced to a regular diet without dysphagia
(Figure 3). ER due to blunt trauma is rare, and likely under-diagnosed. It is associated with high rates
of morbidity and mortality. It is part of the “overlooked six” conditions that include traumatic rupture
of the aorta, rupture of the diaphragm, bronchial tree injury, lung contusion, blunt heart injury. Prompt
recognition of the clinical signs and symptoms are key in the diagnosis and management of this uncom-
mon but potentially fatal injury. In this case, delayed treatment with a suboptimal single layer mucosal
repair buttressed with an intercostal muscle flap, followed by TMD enabled us to preserve the integrity
his native esophagus.
1660
Dysphagia Lusoria in a Patient With Down Syndrome
Lydia Assioiun, MD1, Scott Holmes, DO1, Ashley Vareedayah, MD2, Muhammad B. Hammami, MD2,
Christine Hachem, MD2, Charlene Prather, MD1. 1Saint Louis University, St. Louis, MO; 2Saint Louis Uni-
versity School of Medicine, St. Louis, MO
Introduction: Dysphagia lusoria is a rare cause of dysphagia in which a vascular anomaly causes extrin-
sic compression of the esophagus. A number of vascular abnormalities can cause dysphagia lusoria, the
most common is an aberrant right subclavian artery.
Case Report: A 23-year-old man with Down’s syndrome presented to clinic with cough, hoarseness and
dysphagia. His symptoms were previously thought to be due to asthma with allergic rhinitis, postnasal
drip and chronic sinusitis. Thusly he was treated with multiple courses of antibiotics with only partial
symptoms relief. Otolaryngology then offered tonsillectomy with septoplasty for a deviated septum. This
was declined by the patient’s guardian and his symptoms progressed so he was referred to gastroenterol-
ogy. Initial evaluation was done with barium esophagogram and upper endoscopy (EGD). Barium esoph-
agogram showed normal emptying and a small filling defect near the gastroesophageal junction. The EGD
revealed an esophageal ulcer at the gastroesophageal junction and a dilated esophagus (Fig 1). Biopsy of
the ulcer showed acute and chronic inflammation. The patient was on doxycycline for acne vulgaris and
folliculitis so the initial concern was for pill-induced esophagitis. A proton-pump inhibitor was initiated
and recommendations were made to avoid tetracyclines. Despite these interventions his symptoms did
not improve so esophageal manometry was undertaken. Manometry showed distal esophageal spasm and
simultaneous swallows with poor bolus transit (Fig 2). Based on his manometric results and his history
of Down’s syndrome the diagnosis of dysphagia lusoria was considered. Computed tomography (CT)
revealed an aberrant right subclavian artery exerting a mass effect on the posterior esophagus (Fig 3).
Vascular surgery was consulted but the patient’s guardian has deferred surgery at this time and plans to
monitor his symptoms.
Discussion: Dysphagia lusoria is a rare vascular anomaly resulting in extrinsic compression of the esoph-
agus. Barium esophagogram classically shows an oblique filling defect coursing from the left inferior to
right superior esophagus. Definitive diagnosis can be made by endoscopic ultrasonography or CT imag-
ing. An aberrant subclavian artery is most often asymptomatic throughout life. For symptomatic patients
the initial management should be through dietary and lifestyle modifications. For intractable symptoms
surgical intervention should be considered.
[1660A]  .
1661
A Life-threatening Case of a Hiatal Hernia: A Case Report
Eesha R. Sachdeva1, Bhoomika Bhatia, MS2, Rahul Sao, MD3, Nadeem Quazi, MD4, Rahul Arya, MD5.
1
Wake Endoscopy Center, Raleigh, NC; 2Wake Endoscopy Center, Cockeysville, MD; 3New York Medical
College at Westchester Medical Center, Valhalla, NY; 4Chambersburg Hospital, Frederick, MD; 5Radiology
Imaging Consultants, Chicago, IL
A hiatal hernia is a prolapse of the contents of the abdominal cavity into the mediastinum through the
esophageal hiatus. It is a fairly common condition seen in up to half of the individuals older than 50
years of age. Although usually asymptomatic, hiatal hernias typically present as gastroesophageal reflux
VOLUME 112 | SUPPLEMENT 1 | OCTOBER 2017 www.nature.com/ajg
 Abstracts S899

[1660B]  .

disease (GERD). Life-threatening cases are extremely rare and those reported are mostly in patients with
comorbidities and incarcerated paraesophageal or mixed hiatal hernias. This is a case of a patient with
mixed hiatal hernia presenting with chest pain and shortness of breath upon arrival, and later devel-
oped shock and lactic acidosis. We describe a case of an 85-year-old woman with a history of hyperten-
sion, hyperlipidemia and recently diagnosed GERD. She presented to the emergency room with acute
onset shortness of breath, epigastric pain and chest pain. The pain was described as sharp and tearing
in nature, 8/10 in intensity, and radiating to her back with severe associated shortness of breath. On
physical examination, she was found to be hypotensive, tachycardic and in respiratory distress. Promi-
nent bowel sounds were heard in the thoracic cavity. Initial EKG was not suggestive of ST elevation
myocardial infarction. Blood work showed lactic acidosis. She was started on intravenous fluid boluses.
An emergent CT angiogram of the chest was done to rule out aortic dissection. The CT scan (Figure 1)
revealed her entire stomach herniating into the thoracic cavity, compressing the heart and lungs. She
was taken emergently to the operating room and laparoscopic hiatal hernia repair was performed. Post-
operatively, she was monitored in the intensive care unit and underwent an uneventful recovery. In the
1970s-80s, hiatal hernia was considered an innocent bystander in regards to GERD, but recent literature
suggests the increased significance of hiatal hernia in the pathogenesis of the disease. Our patient was
recently diagnosed with GERD, probably due to a hiatal hernia. Earlier recognition and intervention
could have prevented this life-threatening complication. A new onset of GERD in an elderly patient
should raise suspicions of a hiatal hernia as a contributing factor. This case also highlights the impor-
[1660C]  . tance of maintaining a high index of suspicion of a hiatal hernia as an uncommon etiology presenting
with non-cardiac, life-threatening chest pain or shortness of breath.

[1661] CT Scan Images.

© 2017 by the American College of Gastroenterology  The American Journal of GASTROENTEROLOGY