Introduction: Esophageal squamous papillomas (ESP) are rare, small, benign epithelial lesions most often found incidentally in asymptomatic patients. Majority of cases occur in the distal esophagus where chronic mucosal injury from the gastric refluxate of gastroesophageal disease can consistently and chemically irritate the mucosa. Diagnosis of ESP often requires biopsy although endoscopy usually demonstrates a , 6mm, solitary lesion with a triad of exophytic growth, verrucous projections, and surface crossing vessels evident on narrow-band imaging (NBI). Here we discuss a rare presentation of dysphagia secondary to a large, partially circumferential esophageal squamous papilloma. Case Description/Methods: A 72-year-old woman was referred to our institution for upper endoscopic ultrasonography (EUS) with possible endoscopic mucosal resection (EMR) for suspected upper GI lesion. Previously, the patient underwent endoscopy for dysphagia and was noted to have an ulcer at 30 cm from incisors. Despite proton-pump inhibitor (PPI) use, the dysphagia did not improve. A repeat esophagogastroduodenoscopy (EGD) was performed which revealed a polypoid lesion in the lower esophagus 34 cm from incisors without an ulcer. The lesion involved 50%-60% of the esophageal lumen extending from 34 cm to 36 cm from incisor, about .5 cm above the gastroesophageal (GE) junction. Part of the lesion was suctioned and a band was deployed. Hot snare polypectomy was performed and band assisted EMR was repeated for the remainder of the lesion. The tissue was sent for histopathological examination which demonstrated squamous papilloma without dysplasia or malignancy (Figure). Discussion: Esophageal squamous papilloma is a rare and often incidental finding on endoscopy in asymptomatic patients. Prevalence of ESPs in the general population is estimated to be less than 0.01%. Practitioners should maintain a high level of suspicion for esophageal squamous papillomas in adult patients who present with symptoms of gastroesophageal reflux disease and dysphagia who are unresponsive to proton pump inhibitors. It is critical to rule out other differentials such as squamous cell carcinoma, papillary leukoplakia, polyps, leiomyoma, malignant melanoma, and ultimately rule out ESP with biopsy of the lesion. First-line treatment has not been solidified, but removal of the lesion is preferred for symptomatic patients and to decrease the potential of malignant transformation.[2335] Figure 1. 1a: Endoscopic narrow-band imaging demonstrating a solitary 2 mm lesion with crossing surface vessels in the distal esophagus Figure 1b: EGD revealing a verrucous, polypoid lesion at 340 mm from incisors Figure 1c: EUS revealing an isoechoic mass in the distal esophagus involving half of the lumen circumference without invasion into the submucosa or muscularis propria.Figure 1d: Band assisted endoscopic mucosal resection of the lesion Figure 1e: Removed verrucous lesion

Introduction: Esophageal adenoid cystic carcinoma (EACC) is an extremely rare malignancy, with very poor prognosis with distant metastases, accounting for only 0.1% of esophageal malignancies. It is most common in the parotid and salivary glands with low locoregional metastasis, hence dysphagia is rarely associated with EACC. Here we report a case that debuted with dysphagia. Case Description/Methods: An 81-year-old man with a history of smoking, chronic obstructive pulmonary disease, and acute promyelocytic leukemia in remission presented with 4 years of intermittent dysphagia to solids that improved with drinking water. He denied weight loss, chest pain, vomiting, regurgitation of food contents, odynophagia or abdominal pain. Physical exam and laboratories were unremarkable. Barium swallow showed a corkscrew appearance suggestive of esophageal spasm. GI service was consulted and recommended an EGD for direct visualization as symptoms were not consistent with esophageal spams. A chest/neck CT was ordered by Pneumology service due to associated symptoms of persistent cough and dysphonia. The CT revealed a lesion in the subcarinal compartment measuring approximately 2.732.1cm proximal to the left mainstem bronchus, inseparable from the esophagus. An endobronchial ultrasound (EBUS) with fine-needle aspiration (FNA) was performed on the mediastinal mass, and pathology reported an adenoid cystic carcinoma. Positron emission tomography-computed tomography showed abnormal metabolic activity of posterior mediastinum retrocarinal space, with no lymphadenopathy or evidence of distant metastases. EGD with normal esophageal mucosa, fixed extramural compression against the esophageal wall. An endoscopic ultrasound (EUS) with FNA confirmed the presence of EACC. Pathology showed cohesive clusters and aggregates of atypical epithelial cells in a tubular and cribriform pattern. Discussion: The most common endoscopic finding of EACC is an esophageal endoluminal mass. Histologic findings of this tumor may show 3 growth patterns: cribriform, tubular, or solid, the latter being associated with a worse prognosis. Treatment of choice for EACC is radical excision. Left main bronchus involvement require a tracheal and bronchus reconstruction. The reported 5-year survival rate of EACC is around 35%. This highlights the importance of expedited evaluation in cases of dysphagia and the awareness of rare causes such as EACC, as the diagnosis may be confused with other entities if direct visualization and biopsy are not performed.

Figure 5. EUS 2022 An anechoic and multi-cystic mass measured 48 mm by 45 mm in maximal cross-sectional diameter. The endosonographic borders were well-defined.

also brings into consideration alkaline water as a potential source for ALF. Cases such as this demonstrate that a thorough history and further understanding of herbal and dietary supplements cannot be overlooked when attempting to elucidate a source in instances of ALF.