Radiofrequency Ablation for Esophageal Angiectasias and Barrett's Esophagus With Underlying Varices

Abstract

A 49-year-old man with a history of alcoholism presented to emergency department with melena. During the past year, he had 3 episodes of severe upper gastrointestinal bleeding, where only grade D erosive esophagitis was diagnosed in 2 upper endoscopies. At this time, laboratory analysis revealed severe anemia (hemoglobin 4.8 g/dL), altered liver tests (hypoalbuminemia, elevation of aspartate aminotransferase, and gamma-glutamyl transferase), thrombocytopenia, and coagulopathy. Esophagogastroduodenoscopy revealed a rare combination of esophageal angiectasias and Barrett's esophagus (a) with underlying varices (b). Diagnostic work-up performed during admission confirmed a diagnosis of alcoholic liver cirrhosis. It was challenging to define the best strategy for the underlying cause of upper gastrointestinal bleeding: variceal band ligation or radiofrequency ablation (RFA) of the angiectasias. As esophageal varices were small and had no signs of recent bleeding, angiectasias seemed to be the most likely cause for bleeding and the severity and recurring character of bleeding episodes made RFA of these lesions necessary as early as possible. A review of literature demonstrated sparse case reports, suggesting that RFA is safe and effective for treating superficial esophageal lesions with underlying varices, possibly because its maximal ablation depth only reaches the muscularis mucosae layer, and thus, theoretically, it would not reach the varices, which are located in the submucosal layer. Based on this, careful RFA of esophageal angiectasias and Barrett's esophagus was performed with Barrx channel RFA endoscopic cathether (c-f). There were no adverse events. After 4 weeks, the patient remained clinically stable without recurring bleeding and with stable hemoglobin levels; after that period, the patient was lost to follow-up, but with no emergency admissions known. Our approach supports the effectiveness and safety of RFA for treatment of superficial esophageal lesions with underlying varices. (Watch the Video, Supplementary Digital Content 1, http://links.lww.com/AJG/C425.) (Informed consent was obtained from the patient to publish these images.

Endoscopic management of esophageal and gastric lesions with underlying varices

“…In this case, RFA had a double therapeutic effect for both angiectasias and BE, and its maximal ablation depth only reaches the muscularis mucosae , sparing the varices in the submucosa, and therefore would be theoretically safer than argon-plasma coagulation. RFA was performed with no adverse events and clinical improvement was noted, supporting its effectiveness and safety for the treatment of superficial esophageal lesions without previous variceal eradication [ 29 ].…”

Black Esophagus as an uncommon cause of Gastrointestinal Bleeding

“…BE has a characteristic endoscopic manifestation that allows its optical diagnosis with no need for biopsies. Despite its poor prognosis, through an early diagnosis and support measures, a favorable result was achieved in the 3 exposed cases 1 2 3 .…”