Gastrointestinal: BougieCap passage for calibration of an endoscopically equivocal peptic stricture/Schatzki ring

Abstract

A 54-year-old man presented subacutely with long-standing dysphagia after presumed spontaneous resolution of esophageal bolus obstruction 2 days before. Esophago-gastric-duodenoscopy initially indicated free esophageal passage into a larger hiatal hernia. Because the Z line could not be properly visualized in standard fashion, careful inversion within the hernia excluded active reflux disease with an unremarkable squamocolumnar junction. During slow withdrawal in the distal esophagus, a questionable short stricture/Schatzki ring (Figure 1a) came to our attention being highlighted by a scarring aspect in the vicinity and a superficial mucosal lesion, most likely reminiscent of the preceding food impaction (Fig. 1b). To better assess for the true esophageal diameter, we proceeded with esophageal BougieCap passage as a novel accessory dome-shaped cap for endoscopy-guided esophageal bougienage, potentially combining diagnostics and therapeutics in individual equivocal cases of esophageal luminal compromise. Given the formidable stature of the patient measuring 6 ft 3 in. in height, we chose a 16-mm BougieCap (Ovesco Endoscopy, Tübingen, Germany) for advancement without guidewire assistance. There was minor resistance during passage of the peptic stricture as reflected by the ring-shaped whitening of the mucosa with a minor tear at the 3 o'clock position, thus confirming functional relevance of the lesion under direct endoscopic vision (Fig. 1c). Endoscopic stricture assessment is known to be unreliable in borderline cases. Functional lumen imaging probe as the currently most reliable tool to this end is not widely available, thus limiting its routine use in stricture evaluation. Given that unrestricted swallow function typically depends on luminal width of 14 to 16 mm, BougieCap passage using such a cap size range might contribute to an endoscopic one-stop calibration of luminal diameter and same-time treatment, if appropriate.