Fibrovascular polyp
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This document describes the case of a 54-year-old male presenting with difficulty swallowing solids for 5 months. Imaging revealed a large elongated polypoid lesion extending from the cervical esophagus to the GE junction, significantly narrowing the esophageal lumen. Endoscopy and EUS confirmed a long pedunculated polyp with a thick stalk arising from the submucosa. The final diagnosis was a fibrovascular polyp. Surgical excision is the first-line treatment for fibrovascular polyps, with the pedicle needing to be resected under direct vision at the site opposite its origin to avoid hemorrhage or incomplete resection.
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The document provides an overview of the anatomy and physiology of the urinary system including the kidneys, ureters, bladder, and urethra. It discusses their structure and function in maintaining homeostasis by filtering blood and producing urine. Assessment methods for the urinary system like urinalysis, urine culture, and radiographic procedures like intravenous urograms are also outlined. The document further discusses acid-base balance and imbalances like acidosis. Treatment for acidosis aims to reverse the underlying disorder and administer sodium bicarbonate and fluids intravenously.
Hematuria and obstructive uropathy
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Fibrovascular polyp
- 2. History • 54 M • No comorbidities • Difficulty in swallowing solids for 5 months No dysphagia to liquids • Progressively worsening • ?Relevant history
- 4. Neurologic - CVA - Parkinson’s disease - Brainstem tumors - Degenerative diseases (ALS/MS) - Poliomyelitis - Syphilis - Myasthenia gravis
- 5. Non-neurologic • Obstructive lesions - Tumors - Zenker’s diverticulum - Esophageal webs - Anterior mediastinal masses - Strictures - Schatzki’s ring
- 6. • Spastic motor disorders: - Diffuse esophageal spasm - Hypertensive LES - Nutcracker esophagus
- 8. Blood investigations • Hb – 8.4 gm% • TC – 4800 /mm3 • Electrolytes Na – 138 K - 3.8 • SOB - Positive
- 11. Barium swallow
- 12. How would you like to proceed?
- 21. Diagnosis
- 22. CT neck and thorax • A large elongated polypoid soft tissue density lesion is seen extending inferiorly from the level of cervical esophagus upto GE junction, the lesion is filling and distending the lumen of esophagus causing luminal narrowing
- 23. UGI scopy ESOPHAGUS: ESOPHAGEAL LUMEN WAS SIGNIFICANTLY NARROWED STARTING FROM PROXIMAL ESOPHAGUS TILL GE JUNCTION THERE WAS A LARGE PEDUNCULATED POLYP DISTAL END WHICH WAS ~3 CM. EROSIONS WERE NOTED NEAR THE GE JUNCTION ON THE MUCOSA OVER POLYP. THE PEDUNCLE EXTENTED FROM THE LARYNX THROUGH THE ENTIRE LENGTH OF THE ESOPHAGUS. Z LINE AND GE JUNCTION AT 39 CM.DIAPHRAGMATIC INDENTATION AT 40 CM
- 24. EUS • ESOPHAGUS: A LONG PEDUNCULATED POLYP WITH A THICK STALK OF ~ 2.0 CMS AND MEASURING ~ 22 CMS IN LENGTH STARTING FROM 18 CMS AND EXTENDING TO THE GE JUNCTION SEEN. • THE TIP OF THE POLYP AT THE LEVEL OF GE JUNCTION WAS ULCERATED. • EUS: SHOWED A POLYP ARISING FROM SUBMUCOSA. THERE WAS NO MAJOR VESSELS RUNNING WITHIN THE POLYP
- 25. FINAL DIAGNOSIS
- 27. How will you proceed?
- 29. Introduction • Benign tumors of esophagus – 20% of all esophageal lesions • 60 – 80% - Leiomyomas • 2nd MC – Squamous papillomas • Hemangiomas – More common than fibrovascular polyps
- 30. Incidence • 1-2% of esophageal tumors • MC in males • Age group – 50 years
- 32. Origin • 2 areas of weakness: 1.Killian’s dehiscence: Between fibres of thyropharyngeus and cricopharyngeus. 2.Laimer Heckmann triangle: Between fibres of cricopharyngeus and circular fibres of esophagus
- 33. Factors • Anatomical weakness • Redundant submucosal folds • Pronounced peristaltic activity
- 34. Presentation • Dysphagia – MC symptom • Other complaints: - Retrosternal/ epigastric discomfort - Odynophagia - Vomiting - Weight loss - Respiratory symptoms : Shortness of breath; persistent cough
- 36. Complications • Asphyxia • Laryngeal obstruction • Aspiration pneumonia • Hemorrhage – Secondary to twisting • Occult GI bleed leading to anemia – Ulceration of tip • Malignancy – Very rare
- 37. Investigations • CXR – Posterior mediastinal mass • Barium contrast studies • Endoscopy • CT Neck and thorax • EUS
- 38. Management • Endoscopic resection of polyp - Predominantly fat - Less vascularity • Surgical excision – 1st line of therapy
- 39. PRIOR to surgery • Assess fitness of patient • NPL scopy – Assess vocal cords • Involve Plastic Sx – For local flap cover
- 40. Surgery • Neck exploration • Preferably a left sided approach • Thoracotomy may be necessary • Keep in mind the exact site of origin of polyp
- 41. Principles of surgery • Pedicle has to be resected under DIRECT vision • Incision NEEDS to be made opposite to site of origin of lesion - Hemorrhage if opened at the site of attachment - Incomplete resection leading to recurrence
- 42. • It’s NOT a tongue – It’s a polyp
- 43. Reference • Timmons B, Sedwitz JL, Oiler DW: Benign fibrovascular polyp of the esophagus. South Med J 1991, 84:1370-1372 • Drenth J, Wobbes T, Bonenkamp JJ, Nagengast FM: Recurrent esophageal fibrovascular polyps: case history and review of the literature. Dig Dis Sci 2002, 47:2598-2604 • Levine MS, Buck JL, Pantongrag-Brown L, Buetow PC, Hallman JR, Sobin LH:Fibrovascular polyps of the esophagus: clinical, radiographic, and pathologic findings in 16 patients. • AJR 1996, 166:781-787.