Chronic Gastroesophageal Reflux Disease Research Articles

Speech-based biomarkers for automatic detection of GERD: A pilot study

This study explores the feasibility of detecting gastroesophageal reflux disease (GERD) and Barrett’s esophagus (BE) using acoustic features extracted from speech recordings. GERD is a common condition affecting up to 27.8% of adults in the US. Chronic GERD is associated with BE, the precursor to esophageal adenocarcinoma. An automatic screening tool for GERD would improve clinical outcomes by improving early detection. Biomarkers based on acoustic features of speech may hold promise as hoarseness often co-occurs with GERD. The study cohort consisted of 49 adults with and 63 without GERD based on esophagogastroduodenoscopy or ambulatory pH studies. Speech, including sustained vowels, sentences, and reading, was systematically recorded. Voice quality was validated through auditory-perceptualratings with three speech-language pathologists. Automated, cross-validated, search across multiple machine and deep learning model types was performed using the recorded speech. Detection of condition presence and severity are explored, and model performance is reported, along with an assessment of the ability of acoustic features to discern across conditions.

Clinical characteristics associated with small airways disease in systemic sclerosis.

Pulmonary manifestations of systemic sclerosis are a major cause of morbidity and mortality. Small airways disease can cause dyspnea and pulmonary function test abnormalities. We aimed to determine the prevalence of small airways disease and describe the characteristics associated with small airways disease in a cohort of systemic sclerosis patients. We performed a retrospective cohort study of adults with systemic sclerosis who met American College of Rheumatology/European League Against Rheumatism 2013 classification criteria and were evaluated at our institution between November 2000 and November 2015. Patients with prior lung transplantation were excluded. Small airways disease was defined as the presence of one or more of the following: airway-centered fibrosis on surgical lung biopsy, forced expiratory volume at 25-75% ⩽ 50% on pulmonary function tests, and/or high-resolution computed tomography scan of the chest with bronchiolitis, mosaic attenuation, or air trapping on expiratory views. The primary outcome was small airways disease diagnosis. We performed multivariable logistic regression to determine the association of clinical variables with small airways disease. One-hundred thirty-six systemic sclerosis patients were included; 55 (40%) had small airways disease. Compared to those without small airways disease, a significantly greater proportion of those with small airways disease had interstitial lung disease, chronic obstructive pulmonary disease, pulmonary hypertension, and gastroesophageal reflux disease. On multivariable analysis, pulmonary hypertension (odds ratio = 2.91, 95% confidence interval = 1.11-7.65, p-value = 0.03), gastroesophageal reflux disease (odds ratio = 2.70, 95% confidence interval = 1.08-6.79, p-value = 0.034), and anti-topoisomerase I (anti-Scl-70) antibody positivity (odds ratio = 0.42, 95% confidence interval = 0.19-0.93, p-value = 0.033) were associated with diagnosis of small airways disease. Small airways disease is prevalent among systemic sclerosis patients; those with pulmonary hypertension or gastroesophageal reflux disease may have a higher risk of small airways disease.

Are we Missing Barrett's Esophagus in Our Busy Endoscopy Practice? Improving Detection

AbstractBarrett's esophagus (BE) denotes the replacement of stratified squamous epithelium of esophagus by columnar epithelium. It is associated with a significantly increased risk of esophageal adenocarcinoma and hence patients with BE are advised endoscopic surveillance for early detection of dysplastic and neoplastic lesions. Esophageal cancer is the sixth most common cancer in terms of incidence and mortality in India. Around 15 to 25% of esophageal cancers are adenocarcinoma. BE is likely to be an important precursor of esophageal adenocarcinoma and we may be missing patients with BE in our busy endoscopy practice. The detection of BE may be improved by identifying high-risk groups, performing thorough endoscopic examination, and applying newer imaging techniques. The high-risk group includes patients with chronic gastroesophageal reflux disease, obesity, smoking, etc. During endoscopic examination, a careful assessment of the gastroesophageal junction and identification of important landmarks such as gastroesophageal junction and Z line are essential to detect BE. Management of BE depends on the detection of dysplasia and for this four quadrant mucosal biopsy is recommended every 1 to 2 cm. However, random biopsy samples only a small area of mucosa and advanced technologies for real-time detection of dysplasia and neoplasia may overcome this limitation. In this review, we discuss the current scenario of BE in India and ways to improve the detection of BE including dysplastic lesions.

Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus

Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus

Patient Factors Associated With Gastroesophageal Reflux Disease Diagnostic Evaluation Strategies: A Retrospective Cohort Study Using Real-World Evidence From a Large U.S. Medical Claims Database

Background and AimsBarrett’s esophagus (BE) screening is not highly utilized in the United States, and there are few data describing providers’ approach to screening. To fill this gap and guide the implementation of future BE screening strategies, we studied evaluation practice patterns for gastroesophageal reflux disease (GERD) by nongastroenterologists.MethodsWe performed a retrospective cohort study of patients with chronic GERD using health claims data from the United States between 2005 and 2019. We used up to 5 years of data after the diagnosis of chronic GERD to determine patient factors associated with completion of a gastroenterology encounter. We also identified patient factors associated with whether the first gastroenterology encounter was a direct-access upper endoscopy or an office visit.ResultsWe identified 484,023 patients diagnosed with chronic GERD by a nongastroenterology provider. The cumulative incidence of completing a gastroenterology encounter within 5 years was 38.7%. Gastrointestinal symptoms, such as dysphagia (adjusted hazard ratio [aHR] = 2.11, 95% confidence interval [CI] = 1.94–2.30), abdominal pain (aHR = 1.89, 95% CI = 1.85–1.94), and melena (aHR = 1.73, 95% CI = 1.65–1.82), were strongly associated with completion of a gastroenterology encounter. The patient factors strongly associated with direct-access upper endoscopy included dysphagia (aHR = 1.68, 95% CI = 1.52–1.85), weight loss (aHR = 1.46, 95% CI = 1.28–1.63), and melena (aHR = 1.42, 95% CI = 1.28–1.56).ConclusionA total of 38.7% of patients with chronic GERD complete a gastroenterology encounter within 5 years of diagnosis, and gastrointestinal alarm symptoms are the most strongly associated factors for receiving gastroenterology care. These findings highlight the importance of incorporating primary care providers in the development of new BE screening programs. Barrett’s esophagus (BE) screening is not highly utilized in the United States, and there are few data describing providers’ approach to screening. To fill this gap and guide the implementation of future BE screening strategies, we studied evaluation practice patterns for gastroesophageal reflux disease (GERD) by nongastroenterologists. We performed a retrospective cohort study of patients with chronic GERD using health claims data from the United States between 2005 and 2019. We used up to 5 years of data after the diagnosis of chronic GERD to determine patient factors associated with completion of a gastroenterology encounter. We also identified patient factors associated with whether the first gastroenterology encounter was a direct-access upper endoscopy or an office visit. We identified 484,023 patients diagnosed with chronic GERD by a nongastroenterology provider. The cumulative incidence of completing a gastroenterology encounter within 5 years was 38.7%. Gastrointestinal symptoms, such as dysphagia (adjusted hazard ratio [aHR] = 2.11, 95% confidence interval [CI] = 1.94–2.30), abdominal pain (aHR = 1.89, 95% CI = 1.85–1.94), and melena (aHR = 1.73, 95% CI = 1.65–1.82), were strongly associated with completion of a gastroenterology encounter. The patient factors strongly associated with direct-access upper endoscopy included dysphagia (aHR = 1.68, 95% CI = 1.52–1.85), weight loss (aHR = 1.46, 95% CI = 1.28–1.63), and melena (aHR = 1.42, 95% CI = 1.28–1.56). A total of 38.7% of patients with chronic GERD complete a gastroenterology encounter within 5 years of diagnosis, and gastrointestinal alarm symptoms are the most strongly associated factors for receiving gastroenterology care. These findings highlight the importance of incorporating primary care providers in the development of new BE screening programs.

The Immune Underpinnings of Barrett's-Associated Adenocarcinogenesis: a Retrial of Nefarious Immunologic Co-Conspirators.

There is no doubt that chronic gastroesophageal reflux disease increases the risk of esophageal adenocarcinoma (EAC) by several fold (odds ratio, 6.4; 95% CI, 4.6–9.1), and some relationships between reflux disease–mediated inflammation and oncogenic processes have been explored; however, the precise interconnections between the immune response and genomic instabilities underlying these pathologic processes only now are emerging. Furthermore, the precise cell of origin of the precancerous stages associated with EAC development, Barrett’s esophagus, be it cardia resident or embryonic remnant, may shape our interpretation of the likely immune drivers. This review integrates the current collective knowledge of the immunology underlying EAC development and outlines a framework connecting proinflammatory pathways, such as those mediated by interleukin 1β, tumor necrosis factor α, leukemia inhibitory factor, interleukin 6, signal transduction and activator of transcription 3, nuclear factor-κB, cyclooxygenase-2, and transforming growth factor β, with oncogenic pathways in the gastroesophageal reflux disease–Barrett’s esophagus–EAC cancer sequence. Further defining these immune and molecular railroads may show a map of the routes taken by gastroesophageal cells on their journey toward EAC tumor phylogeny. The selective pressures applied by this immune-induced journey likely impact the phenotype and genotype of the resulting oncogenic destination and further exploration of lesser-defined immune drivers may be useful in future individualized therapies or enhanced selective application of recent immune-driven therapeutics.

Role of Laparoscopic Fundoplication in the Management of Gastroesophageal Reflux Disease- A Retrospective Study

Introduction: Gastroesophageal Reflux Disease (GERD) is a common gastrointestinal disease affecting 3-7% of Asians and becoming a major health care burden in elderly population. Surgical intervention with laparoscopic fundoplication is the effective tool in the management of GERD. Aim: To evaluate the role and advantages of laparoscopic fundoplication in the management of cases with GERD and to compare the laparoscopic Nissen’s fundoplication and laparoscopic toupet’s fundoplication in management of GERD. Materials and Methods: The present retrospective and prospective study was conducted in the Department of General surgery at Government Medical College, Nizamabad from August 2019 to July 2021. A total of 36 cases of both sexes, clinically diagnosed as chronic GERD undergone laparoscopic Nissen’s fundoplication and laparoscopic toupet’s fundoplication surgery were recruited. Preoperative and postoperative assessment of disease status was done at the end of third month and sixth month. Collected data was analysed by using Statistical Package for Social Sciences (SPSS) version 16.0. The chi- square test was used to test the significance of qualitative data. The p<0.005 was considered as statistically significant. Results: In total data collected for 36 cases, majority cases were between 31-40 years (n=13) and 41-50 years (n=11). Total of 19 patients had undergone Laparoscopic Nissen's Fundoplication while 17 patients were of Laparoscopic Toupet's Fundoplication surgery. The mean difference of age was statistically not significant (p>0.05). Postsurgical significant improvement was observed in cases of grade 3 (n=7), grade 4 (n=19) and grade 5 (n=10) oesophagitis. The mean duration to start oral liquids was 1.29 days and 1.08 days, mean duration of surgery was 3.62 hours and 3.19 hours, mean duration of hospital stay was 4.12 and 3.67 days and the average ambulatory period was 1.46 and 1.62 days in laparoscopic nissen’s group and laparoscopic toupet’s group, respectively. Conclusion: The laparoscopic toupet’s fundoplication and laparoscopic nissen’s fundoplication were comparable in the management of postoperative Complications. The incidence of postoperative dysphagia was comparatively more in laparoscopic Nissen’s group than laparoscopic toupet’s group. However, the incidence was diminished within six months of postoperative follow-up.

A Case Report of 3-year Chronic Gastroesophageal Reflux Disease Treated by RSN Acupuncture with Herbal Decoction

A Case Report of 3-year Chronic Gastroesophageal Reflux Disease Treated by RSN Acupuncture with Herbal Decoction

Endoscopic diagnosis and screening of Barrett's esophagus: Inconsistency of diagnostic criteria between Japan and Western countries

Barrett's esophagus (BE) is an endoscopically identifiable premalignant condition for esophageal adenocarcinoma (EAC). To diagnose BE precisely, careful inspection of the anatomic landmarks, including the esophagogastric junction and the squamocolumnar junction is important. The distal end of the palisade vessels and the proximal end of the gastric folds are used as the landmark of the esophagogastric junction in endoscopic diagnosis, with the latter solely used internationally, except in some Asian countries, including Japan. In addition, the diagnostic criteria adopted internationally for BE are inconsistent, particularly between Japan and Western countries. Recently updated guidelines in Western countries have included length criteria, with a 1‐cm threshold of columnar epithelium by endoscopic observation and/or histologic confirmation of the presence of specialized intestinal metaplasia. Since BE is endoscopically diagnosed at any length without histologic assessment in Japan, the reported prevalence of short‐segment BE is very high in Japan compared with that in Western countries. Although guidelines on screening exist for BE, the current strategies based on the presence of chronic gastroesophageal reflux disease with multiple risk factors may miss the opportunity for early detection of EAC. Indeed, up to 40% of patients with EAC have no history of chronic gastroesophageal reflux disease. To discuss BE on the same footing worldwide, standardization of diagnostic criteria, screening indication, and establishment of effective techniques for detecting dysplastic lesions are eagerly awaited. Japanese guidelines for BE should be revised regarding the length criteria, including the minimum length and long‐segment BE, in line with the recently updated Western guidelines.

Adverse events associated with transoral incisionless fundoplication (TIF) for chronic gastroesophageal reflux disease: a MAUDE database analysis.

Transoral incisionless fundoplication (TIF) has been used for treating chronic gastroesophageal reflux disease (GERD) refractory to medical therapy. We aim to investigate the complications associated with TIF using a national database. We analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from Jan 2011 through Jan 2021. During the study period, approximately 95 event cases reported to the FDA. Approximately 131 patient complications were identified. The number of adverse events declined from 2011 to 2016 (R2 = 0.96) but increased from 2016 to 2020 (R2 = 0.99). The most common adverse event was perforation (19.8%), followed by laceration 17.6%, bleeding (9.2%), and pleural effusion (9.2%). The most common patient complications were treated using endoscopic clips (12.3%), chest tube or drain insertion (12.3%), use of endoscopic retriever device (11.1%), esophageal stent (8.6%), and emergent or open surgery (11.1%). Adverse events from TIF range from mild to severe. Further research is needed to develop approaches aimed at reducing patient risks.

S3551 Unique Communication: A Case Report of Acquired Esophageal Pulmonary Fistula

Introduction: Esophageal respiratory fistula is an abnormal communication between the esophagus and the respiratory system. We present a case of esophageal pulmonary fistula in a patient with a history of broncho-esophageal fistula treated with esophageal stent placement. Case Description/Methods: A 53-year-old homeless male with a history of alcoholism, perforated peptic ulcer status post antrectomy with type II billroth reconstruction, pseudodiverticulum of the distal third of esophagus, broncho-esophageal fistula and HIV presented with dyspnea and productive cough for 2 weeks. He reported dysphagia to liquids and unintentional weight loss. Review of medical records revealed admission for pneumonia 3 years ago with workup suggestive of broncho-esophageal fistula followed by endoscopic fully covered self-expandable metallic stent placement with removal after 2 months to reassess fistula. Repeat Computed tomography (CT) chest showed resolution of fistula. However, he lost the follow up afterwards. On this admission, the patient appeared disheveled with crackles on the right side. CT chest without contrast showed debris filling the middle and lower esophagus, right pleural effusion with multiple areas of gas. CT chest with contrast showed irregular and debris distended esophagus with locules of air extending from the region of the esophagus into the mediastinum and right lower lung parenchyma. Fluoroscopy esophagram documented contrast extravasation from the right side of the distal esophagus into the right lower lobe parenchyma compatible with esophageal pulmonary fistula. An esophageal stent placement was planned but was declined by the patient. Discussion: Non-malignant etiologies of acquired esophageal respiratory fistula include post-operative, intubation associated, history of tracheal and esophageal stents, blunt trauma and pseudodiverticulum of the esophagus. In our case, etiologies of broncho-esophageal fistula and then esophageal-pulmonary fistula were multifactorial which include esophagitis due to history of chronic gastroesophageal reflux disease (GERD), history of antral gastrectomy, history of stent placement for a broncho esophageal fistula and pseudodiverticulum of distal third of the esophagus. Given the significant morbidity and mortality associated with a missed diagnosis of esophageal pulmonary fistula, early diagnosis with prompt treatment with an endoscopically placed covered stent and close follow up is crucial.Figure 1.: The distal one third of esophagus is markedly dilated and irregular in contour. Contrast is seen extravasating from the right side of the esophagus into the right lower lobe parenchyma consistent with esophageal pulmonary fistula.

Microscopic Observation of Omeprazole Sensitivity Technology in the Diagnosis and Nursing of Chronic Obstructive Pulmonary Disease with Gastroesophageal Reflux Disease

At present, the problem of food safety has led to a variety of stomach diseases in some people, and antibiotics are mainly used in the treatment. In the clinical treatment, the treatment effect is reduced due to the excessive acidity of gastric acid. In this paper, under the microscope to observe the sensitivity of omeprazole technology, the diagnosis of chronic obstructive pulmonary disease with gastroesophageal reflux disease was proposed, and the importance of nursing intervention was emphasized. This paper first describes the use of ultrasound-guided microscopic observation technology and clinical deficiencies. Then use the microscope to observe omeprazole sensitivity technology to observe the pathological section of patients, compare the results of diagnosis and gastroscopy, and evaluate the clinical effect of nursing intervention in patients. Methods: 26 patients with suspected chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease (GERD) in our hospital were selected as the research objects. After the initial diagnosis, treatment measures were taken and nursing intervention was carried out. The results showed that 1 case, 4 cases, 8 cases and 13 cases of unsatisfied, benign, suspicious and malignant cases were diagnosed by endoscopic ultrasound-guided microscopic observation under nursing intervention, and the overall consistency with the final cytological diagnosis was 85%. Therefore, endoscopic ultrasound-guided microscopic observation in the application of gastric lesions is effective and accurate, and can replace the conventional microscopic diagnosis law.

Barrett's Epithelium to Esophageal Adenocarcinoma: Is There a "Point of No Return"?

Background: Esophageal adenocarcinoma (EA) arises from Barrett’s epithelium (BE), and chronic gastroesophageal reflux disease is considered the strongest risk factor for disease progression. All BE patients undergo acid suppressive therapy, surveillance, and BE removal by surgery or endoscopic ablation, yet the incidence of EAC continues to increase. Despite the known side effects and mortality, the one-size-fits-all approach is the standard clinical management as there are no reliable methods for risk stratification.Methods: Paired-end Illumina NextSeq500 RNA sequencing was performed on total RNA extracted from 20-week intervals (0, 20, 40, and 60 W) of an in vitro BE carcinogenesis (BEC) model to construct time series global gene expression patterns (GEPs). The cells from two strategic time points (20 and 40 W) based on the GEPs were grown for another 20 weeks, with and without further acid and bile salt (ABS) stimulation, and the recurrent neoplastic cell phenotypes were evaluated.Results: Hierarchical clustering of 866 genes with ≥ twofold change in transcript levels across the four time points revealed maximum variation between the BEC20W and BEC40W cells. Enrichment analysis confirmed that the genes altered ≥ twofold during this window period associated with carcinogenesis and malignancy. Intriguingly, the BEC20W cells required further ABS exposure to gain neoplastic changes, but the BEC40W cells progressed to malignant transformation after 20 weeks even in the absence of additional ABS.Discussion: The transcriptomic gene expression patterns in the BEC model demonstrate evidence of a clear threshold in the progression of BE to malignancy. Catastrophic transcriptomic changes during a window period culminate in the commitment of the BE cells to a “point of no return,” and removal of ABS is not effective in preventing their malignant transformation. Discerning this “point of no return” during BE surveillance by tracking the GEPs has the potential to evaluate risk of BE progression and enable personalized clinical management.

Toll-like Receptor 4 Mediates Reflux-Induced Inflammation in a Murine Reflux Model

Dysregulation of toll-like receptor (TLR) signaling within the gastrointestinal epithelium has been associated with uncontrolled inflammation and tumorigenesis. We sought to evaluate the role of TLR4 in the development of gastroesophageal reflux-mediated inflammation and mucosal changes of the distal esophagus. Verified human esophageal Barrett's cells with high grade dysplasia (CPB) and esophageal adenocarcinoma cells (OE33) were treated with deoxycholic acid for 24 hours. Cells were pretreated with a TLR4-specific inhibitor peptide 2 hours prior to deoxycholic acid treatment. Inflammatory markers were evaluated using immunoblotting and enzyme-linked immunosorbent assay. A surgical reflux mouse model was generated by performing a side-to-side anastomosis between the second portion of the duodenum and the gastroesophageal junction. Control animals underwent laparotomy with incision and closure of the esophagus superior to the gastroesophageal junction (sham procedure). Esophageal sections were evaluated using hematoxylin and eosin staining and immunohistochemistry. Deoxycholic acid increased expression of inflammatory markers including intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and interleukin 8. Pretreatment with a TLR4 inhibitor significantly decreased deoxycholic acid-induced inflammatory marker expression. C3H/HeNCrl mice demonstrated a significant increase in mucosal hyperplasia and proliferation following DGEA compared to sham procedure. TLR4 mutant mice (C3H/HeJ) undergoing DGEA demonstrated an attenuated hyperplastic and proliferative response compared to C3H/HeNCrl mice. Inhibition of TLR4 signaling attenuates reflux-induced inflammation in vivo. These findings identify TLR4 inhibition as a potential therapeutic target to halt the progression of pathologic esophageal changes developing in the setting of chronic gastroesophageal reflux disease.

Risk Factors Associated with Oral Manifestations and Oral Health Impact of Gastro-Oesophageal Reflux Disease

Background and aim: The association of gastro esophageal reflux disease with oral health manifestations faced major challenges in terms of invasive investigative approaches to be performed on patients for necessary treatment. The current study aimed to evaluate the risk factors and impact of gastro-esophageal reflux disease on oral health. Materials and Methods: The cross-sectional study was carried out on 194 gastro-oesophageal reflux disease in Gastroenterology department of Isra University Hospital, Hyderabad for duration of six from July 2020 to December 2020. The individuals underwent duodenoscopy for oesophago–gastro–reflux disease and met the inclusive criteria were enrolled. The gastro-oesophageal reflux disease patients were categorized into two group’s namely chronic gastro-oesophageal reflux disease as a group I (97 patients), while mild GORD was group II (97). The exclusion criteria for this study was individuals with limited mouth opening and unconscious patients. Mucosa oral lesion and abnormal conditions were measured as primary and secondary outcomes. Oral Health Impact Profile-14 was utilized for assessment of life quality changes with hard and soft tissue. Results: Of the total 194 patients, 113 (58.2%) were male while 81 (41.8%) were females. The mean age was 48.32±7.56 years with an age range of 20-80 years. The socioeconomic status of the participants was as follows; urban residents 127 (65.5%) and rural 67 (34.5%). The gastro-oesophageal reflux disease prevalence was found 35.6% (n=69) out of which 34.8% (24) were dental erosion (DE). Group I and II had 97 patients each. The group I was comprised of significantly common diseases such as ulceration 52 (53.6%), Oral submucous fibrosis 59 (60.8%), and xerostomia 42 (43.3%). Chronic gastro-oesophageal reflux and dental erosion diseases were statistically significant with an unhealthy pattern of diets such as ulceration, nausea/vomiting, gingivitis, angular cheilitis, and oesophagitis. The prevalence of overall oral tobacco and smoking addiction was 59 (30.4%) and 52 (26.8%). Tea was the most prevalent consumed beverage 141(72.7%). Gastro-oesophageal reflux and dental erosion diseases were positively correlated with oral health assessment scale-14 (p-value <0.05). The psychological discomfort, psychological disability, physical disability, and functional limitation were the notable impacts with their respective ranks correlation coefficient (rs) 0.29, 0.26, 0.28, and 0.19. Conclusion: Gastro-oesophageal reflux and dental erosion disease had higher severity among patients of oral manifestation compared to those with no gastro-oesophageal reflux and dental erosion disease. The systemic and oral disease severity needs to be assessed routinely with dental checkup. Keywords: Oral manifestations, Gastro-oesophageal reflux disease

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

Recurring Translocations in Barrett's Esophageal Adenocarcinoma.

Barrett’s esophagus (BE) is a premalignant metaplasia in patients with chronic gastroesophageal reflux disease (GERD). BE can progress to esophageal adenocarcinoma (EA) with less than 15% 5-year survival. Chromosomal aneuploidy, deletions, and duplication are early events in BE progression to EA, but reliable diagnostic assays to detect chromosomal markers in premalignant stages of EA arising from BE are lacking. Previously, we investigated chromosomal changes in an in vitro model of acid and bile exposure-induced Barrett’s epithelial carcinogenesis (BEC). In addition to detecting changes already known to occur in BE and EA, we also reported a novel recurring chromosomal translocation t(10:16) in the BE cells at an earlier time point before they undergo malignant transformation. In this study, we refine the chromosomal event with the help of fluorescence microscopy techniques as a three-way translocation between chromosomes 2, 10, and 16, t(2:10;16) (p22;q22;q22). We also designed an exclusive fluorescent in situ hybridization for esophageal adenocarcinoma (FISH-EA) assay that detects these chromosomal breakpoints and fusions. We validate the feasibility of the FISH-EA assay to objectively detect these chromosome events in primary tissues by confirming the presence of one of the fusions in paraffin-embedded formalin-fixed human EA tumors. Clinical validation in a larger cohort of BE progressors and non-progressors will confirm the specificity and sensitivity of the FISH-EA assay in identifying malignant potential in the early stages of EA.

Determining the potential clinical value of panel-based pharmacogenetic testing in patients with chronic pain or gastroesophageal reflux disease.

We aimed to determine the potential value of panel-based pharmacogenetic (PGx) testing in patients with chronic pain or gastroesophageal reflux disease (GERD) who underwent single-gene PGx testing to guide opioid or proton pump inhibitor (PPI) therapy, respectively. Of 448 patients included (chronic pain, n = 337; GERD, n = 111), mean age was 57 years, 68% were female, and 73% were white. Excluding opiates for the pain cohort and PPIs for the GERD cohort, 76.6% of patients with pain and 71.2% with GERD were prescribed at least one additional medication with a high level of PGx evidence, most commonly ondansetron or selective serotonin reuptake inhibitors. The most common genes that could inform PGx drug prescribing were CYP2C19, CYP2D6, CYP2C9, and SLCO1B1. Our findings suggest that patients with chronic pain or GERD are commonly prescribed drugs with a high level of evidence for a PGx-guided approach, supporting panel-based testing in these populations.

Positive bronchoalveolar lavage pepsin assay associated with viral and fungal respiratory infections in children with chronic cough.

To assess the association between commonly obtained endoscopic and serologic data and bronchoalveolar lavage pepsin assay (BAL) results in children with chronic cough. We performed a retrospective chart review of 72 children with a BAL pepsin obtained through our Aerodigestive Center over an 18-month period. BAL outcomes include evidence of viral, bacterial, or fungal infection, presence of lipid-laden macrophages, and cytology (eosinophils, neutrophils, and lymphocytes). Gastrointestinal outcomes include esophagogastroduodenoscopy (EGD) and pH impedance probe findings. Other characteristics include serum eosinophils, neutrophils, and lymphocytes; spirometry; FeNO; and IgE. Seventy-two patients underwent BAL pepsin testing. Median age was 4.9 years, 30.6% had severe persistent asthma, and 59.2% were on reflux medication. There was an association between positive BAL pepsin assay and positive viral panel (p = .002) or fungal culture (p = .027). No significant association found between positive BAL bacterial culture; BAL cytology; the presence of BAL lipid-laden macrophages; IgE; spirometry; FeNO; CBC neutrophil, eosinophil, or lymphocytes; pH impedance testing parameters; or EGD pathology. BAL pepsin is associated with a positive BAL viral PCR or fungal culture. Lack of correlation between pepsin-positivity and pH-impedance parameters or EGD pathology suggests microaspiration may be due to an acute event (such as a respiratory infection) rather than chronic gastroesophageal reflux disease. This may be especially true in the presence of a positive viral panel or fungal culture when a BAL pepsin is obtained.

Role of NBI and WLE in diagnosis of Barrett’s esophagus in patients with chronic gastroesophageal reflux disease

Abstract:Background: Recent data have emerged that a targeted biopsy technique using Narrow-Band Imaging (NBI) could be considered in patients undergoing surveillance for Barrett’s esophagus (BE).Aim of the study: to determine the role of NBI versus conventional- white light endoscopy (WLE) in diagnosis of Barrett’s esophagusSubjects and methods: the study included 274 patients with chronic reflux symptoms, conventional- white light endoscopy (WLE) was done in all cases for diagnosis of BE, 4-random biopsies were taken and examined by histopathology for detection of columnar-lined intestinal metaplasia, patients tested negative were re-examined by NBI and targeted biopsy were taken in patients for confirmation of presence of intestinal metaplasia.Results: 90 patients had columnar-lined epithelium (CLE) by WLE (32.8%); Seventy- three patients with 4 quadrant biopsy technique confirmed to have intestinal metaplasia (81.1% of cases with endoscopic BE, and 26.6% of all screened patients), 17 patients with negative histopathology for BE were re-examined endoscopically and NBI - targeted biopsies were taken, 7 patients of them showed intestinal metaplasia, so total patients confirmed to have BE has risen to 80 patients (88.9%).Conclusion: NBI- targeted biopsies could diagnose BE in patients tested negative by WLE taken biopsies