Daily PPI Research Articles

Long-term outcomes of magnetic sphincter augmentation in sleeve gastrectomy and Roux-en-Y gastric bypass patients: a comprehensive analysis

IntroductionManagement of gastroesophageal reflux disease after bariatric procedures can be challenging. There are very few long-term studies in this arena. This study aims to evaluate the long-term outcomes of the magnetic sphincter augmentation (MSA) reflux management system in a cohort of bariatric patients who had previously undergone sleeve gastrectomy and Roux-en-Y gastric bypass, with a focus on assessing gastroesophageal reflux disease (GERD) scores, medication use, and patient-reported symptoms.MethodsWe conducted a retrospective chart review of 16 consecutive bariatric patients who received MSA implants following sleeve gastrectomy (n = 14) or gastric bypass (n = 2) surgeries. Data were collected regarding BMI, GERD quality of life assessments (GERD-HRQL), reflux symptoms, and use of PPIs in the sleeve/RGB patients through an extended period with a mean follow-up of 48 months.ResultsPatients were followed up for a range of .5–84 months. Preoperative assessments included upper gastrointestinal imaging (UGI), high-resolution manometry, Bravo pH studies, and esophagogastroduodenoscopy (EGD). Three patients exhibited reflux on UGI, and 13/13 patients had positive Bravo studies preoperatively. Sixteen patients had a lower esophageal sphincter (LES) pressure under 18 mmHg, and eight patients had biopsy-proven esophagitis. Long-term outcomes are as follows. Daily PPI use fell from 88 to 25% at greater than three years. GERD-HRQL scores fell from 50.6 at baseline (range 27–70) and normalized at long-term follow-up. GERD symptom of regurgitation completely resolved. At long term, two patients had dysphagia and two patients had ongoing reflux. No adverse events were noted.ConclusionThis is the first long-term outcomes study of magnetic sphincter augmentation placement after bariatric surgery. Our study showed the majority of patients had long-term improvement in GERD-HRQL scores and resolution/ relief of their reflux symptoms, with decreased use of PPIs. MSA is a safe, effective and durable management tool for reflux after bariatric surgery in carefully selected patients.

Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity

BackgroundPatients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG.MethodsThe primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage.ResultsThirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or > = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038).ConclusionsPost-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.Graphical

Observations of increased gastroesophageal reflux symptomology in an anhydrous ammonia exposed population

ObjectiveThis case series describes a cohort of patients exposed to anhydrous ammonia vapors with clinical findings of laryngopharyngeal reflux (LPR). The study characterizes the identification of LPR as a consequence of vapor inhalation and the utility of PPI therapy in LPR secondary to inhalational ammonia exposure. MethodsThis is a case series of 15 patients exposed to anhydrous ammonia from a single chemical spill who experienced LPR several months after exposure. Symptoms of LPR were assessed at their initial consultation and by phone at least 30 days after treatment with low-dose PPI or diet modification. At this visit, patients underwent complete head and neck examination and flexible direct laryngoscopy. Results15 patients were available for analysis before and after treatment. 93.3 % experienced at least three cardinal symptoms of LPR. 66 % of these patients had at least one LPR finding on flexible laryngoscopy. 73 % were treated with daily standard dose PPI, and 82 % of these patients experienced reduction of symptoms after 30 days of PPI treatment. Four of 15 patients were not taking the PPI as prescribed, and only one of these patients had resolution of LPR symptoms. ConclusionWe conclude that there is an association between anhydrous ammonia exposure and the development of LPR symptoms. In this study, treatment with PPIs was successful in reducing symptoms for most patients, and patients who did not receive PPIs experienced symptoms for a longer time.

S3567 No Barrett's, No Way! A Case of De novo Esophageal Adenocarcinoma

Introduction: Instances of esophageal adenocarcinoma have been increasing at a more drastic rate in the United States and Western Europe in recent years. This calls for more aggressive and comprehensive screening processes for patients with chronic reflux and for those found to have Barrett’s esophagus. Barrett’s esophagus is widely accepted as a precursor to adenocarcinoma of the esophagus, but this case provides a caveat to this rule of thumb. Case Description/Methods: This is a case of a 63-year-old woman who initially presented with severe GERD and was complaining of reflux and regurgitation, as well as nocturnal coughing and wheezing. An endoscopy was conducted revealing LA class 3 esophagitis, a large hiatal hernia, and a distal esophageal inflammatory nodule. The patient was treated aggressively with a combination of a daily PPI and a nightly H2RA. A three-month follow-up endoscopy revealed improvement of her esophagitis, which was downgraded to LA class 1. There was no evidence of Barrett’s esophagus, and the esophageal nodule had healed. Despite this treatment plan the patient was still complaining of regurgitation. An upper GI series revealed a 5 cm hiatal hernia with reflux on water siphon test and valsalva maneuver. Subsequently, a laparoscopic partial fundoplication was performed with complete resolution of all symptoms and successful discontinuance of all acid suppression medications. 2 and ½ years later the patient presented with new onset dysphasia. An upper endoscopy was subsequently performed which revealed a large adenocarcinoma of the distal esophagus and 2 satellite lesions above the adenocarcinoma. Discussion: This case highlights an infrequent presentation of de novo adenocarcinoma with no evidence of Barrett’s esophagus in a conservative time interval. In the chance that the endoscopist may have missed a short segment Barrett’s because of sampling error, the standard of care would have been a 3-year interval surveillance endoscopy. A repeat endoscopy was performed in 2.5 years regardless of no evidence of Barrett’s; the standard of care was not sufficient in this case. This patient exhibited LA class 3-4 distal esophagitis and despite healing, still developed an advanced adenocarcinoma. This may indicate that there is an alternative pathway to esophageal adenocarcinoma in patients with such severe reflux. This case should provide support to potentially screen patients more aggressively who present with severe reflux.Figure 1.: Row 1: initial endoscopy Row 2: second endoscopy Row 3: third endoscopy

S2091 An Unusual Cause for a Radiographic Ulcer

INTRODUCTION: A 60 year old female with a history of GERD presented to the Emergency Department (ED) with 2 days of epigastric abdominal pain and nausea. Prior to this, the patient was feeling well and reported compliance with her daily PPI. She denied any alcohol use or significant NSAID use. Her only other medications were metoprolol and rosuvastatin. She reportedly had an unremarkable EGD 3 years prior at another institution. Laboratory work up in the ED included negative cardiac markers and normal comprehensive metabolic panel, liver function tests, and lipase. Complete blood count was only notable for a mild leukocytosis of 12.7 × 10^9/l. Physical exam revealed tenderness to palpation over the epigastric area. An abdominal computed tomography (CT) scan with contrast was obtained showing circumferential wall thickening of gastric antrum with evidence of a deep ulcer along the posterior wall without signs of perforation. CASE DESCRIPTION/METHODS: The patient subsequently underwent an esophagogastroduodenoscopy (EGD) for further evaluation. She was discovered to have a penetrating pre-pyloric toothpick. The 3 cm toothpick was pulled from the gastric wall with a snare with no persistent wall defect. After revealing the findings to the patient after the procedure, she remembered ingesting bacon-wrapped dates secured by toothpicks at a party 4 weeks prior. She did not have any specific recollection of swallowing one, however. The following day after the procedure, her symptoms were significantly improved and she was discharged home with a 7 day course of Amoxicillin Clavulanate and instructions to continue her proton-pump inhibitor. DISCUSSION: Although foreign bodies are more commonly considered in the pediatric and adult with psychiatric disorders populations, unintentional ingestions are not all that infrequently encountered in clinical GI practice. Toothpick injuries have been shown to mimic various clinical presentations including renal colic, colonic diverticulitis, and peritonitis secondary to perforation. They are associated with high morbidity and mortality and should be considered a medical emergency for all identified patients. This case describes an otherwise healthy women who accidentally swallowed a toothpick one month prior to the onset of symptoms. It highlights the importance of a detailed history as well as endoscopic evaluation of radiographic abnormalities. Foreign body injury like that from a toothpick should be considered in the differential of radiographic ulcer disease.Figure 1.: Arrow pointing to circumferential wall thickening and evidence of deep ulcer along gastric antrum.Figure 2.: Esophagogastroduodenoscopy (EGD) showing a sharp, linear foreign material embedded in the gastric antrum.Figure 3.: The broken wooden toothpick which was approximately 3 cm long.

Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results

BackgroundRefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected.MethodsIn a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction.ResultsThere were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects.ConclusionThe new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced.Trial registrationClinicalTrials.gov, NCT02759094. Registered 3 May, 2016,

Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study.

Background and study aims Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3. Results A total of 146 patients were included from 11 academic medical centers. Mean (± SD) age was 49.8 (± 16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9–60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy. Conclusion POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.

1951 Not All Diverticular Bleeds Are Colonic: A Rare Case of Zenker's Diverticulum Bleeding and Endoscopic Treatment

INTRODUCTION: Zenker's diverticulum (ZD) is a retropharyngeal pouch formed with herniation through Killian’s triangle. The diverticulum is thought to be developed through traction &amp; pulsion but precise mechanism is unknown. Prevalence estimated to be 0.01–0.11%; ZD is predominantly in adults age &gt;60. ZD is associated with dysphagia, halitosis, regurgitation &amp; cough. But very rarely associated with bleeding - only 7 cases reported in the literature. Aspirin irritation is theorized as the etiology, as all reported cases involved aspirin or other anti-platelet medication. CASE DESCRIPTION/METHODS: A 73 year-old male with history of obesity, GERD, former smoker, &amp; coronary artery disease presented with hematemesis &amp; hemoptysis. 1 week prior to onset of bleeding, he was hospitalized for STEMI requiring intubation which was traumatic with minor bleeding, &amp; he underwent drug eluting stent placement to the left anterior descending artery. He was discharged home on aspirin &amp; clopidogrel. Patient had awakened due to the sensation of liquid pooling in the back of his throat; he cleared this with a cough &amp; noted the liquid to be gross blood. He then had ongoing small volume hemoptysis &amp; hematemesis. He denied dysphagia, NSAID usage &amp; breakthrough reflux symptoms on daily PPI. On exam, tachycardic to 120s, otherwise vitals normal; diaphoretic &amp; pale but otherwise benign exam. Patient’s hemoglobin had decreased from 13.3 g/dL at discharge to 8.7 g/dL in the ER; also notable for blood urea nitrogen of 45 mg/dL. ENT evaluated initially due to complaint of hemoptysis &amp; recent traumatic intubation. Laryngoscopy revealed blood pooling at the esophageal inlet; this could be cleared voluntarily by patient, but it immediately reaccumulated. Otherwise the oropharyngeal exam was normal. EGD was subsequently performed &amp; this revealed large ZD which was filled with fresh blood. This area was lavaged &amp; small ulcer seen at base; multiple clips were placed with successful hemostasis. Further exam of esophagus, stomach &amp; proximal duodenum revealed no additional source. Patient’s bleeding stopped &amp; tolerated resumption of aspirin &amp; clopidogrel without further incident. DISCUSSION: ZD bleeding is an extremely rare event, so treatment modalities may not be readily familiar to most medical staff. We report the third case of ZD bleeding treated with endoscopic hemostasis; all cases have been successful &amp; well tolerated. Traditionally, ZD bleeding has been treated surgically, but this may not be an option in certain populations or situations.

1891 Esophageal Intramural Pseudodiverticulosis and Concomitant Esophageal Candidiasis

INTRODUCTION: This case pertains to a 65 yo AA M who presented with chronic dysphagia. Multiple EGDs were performed and Esophageal Intramural Pseudodiverticulosis (EIP) was noted along with Esophagitis, strictures and esophageal candidiasis. Esophageal Pitting, or EIP, is described as longitudinal rows of multiple small flask-shaped outpouchings protruding from the esophagus (1,4). Although EIP is not particularly prevalent, esophageal candidiasis is found in 50% of these cases (1). Consisely, clinicians should be aware of EIP and it’s strong association with dysphagia, strictures, and esophageal candidiasis, as such, biopsies should be taken on EGD. CASE DESCRIPTION/METHODS: 65 yo AAM, with significant PMHx of IDDM and GERD, presented with chronic dysphagia (pills and solid food). On presentation, patient denied any other GI or chest complaints. Patient underwent EGD: Numerous pits were seen in the mid esophagus [Figure 1]. Multiple biopsies were taken and pathology demonstrated fragments of esophageal mucosa with acute esophagitis and yeast forms were identified. Patient also had distal esophageal stricture, which was balloon dilated. He was then lost to follow up. Several years later he returned with dysphagia. On Repeat EGD, diffuse esophageal pitting was seen from 25 cm to the EGJ [Figure 2]. Pathology demonstrated acute esophagitis with focal fungal elements [Figure 3]. No malignancy was seen. Patient was started on appropriate antifungal and daily PPI. Repeat EGD was scheduled for 3 months. DISCUSSION: EIP, as noted in our patient, although a rare finding, can be seen in patient’s with Dysphagia (1). 80% of symptomatic patients present with intermittent or progressive dysphagia (1,3). Etiology of EIP to date is unclear. Some association has been seen with inflammatory disease of the esophagus (chronic esophagitis or infectious) (1–4). Management focuses on symptomatic relief along with treating the underlying disease (1,3).

Eosinophilic Esophagitis (EoE) - Successful Treatment With PPI Therapy in a Single-Center - Education and Engagement Are Key

Introduction: Recently, the international EoE consensus eliminated the cumbersome terminology of PPI-responsive esophageal eosinophilia. This supports our practice over the last 7 years of using PPI’s as first line therapy for EoE patients because of convenience, cost, and ease of administration. Here we present our single-center experience in treating EoE. Keys to success involve intense education on appropriate drug dosing, the mechanism of PPIs being anti-eosinophilic, and the key role of strict adherence to a proper PPI trial. Methods: From 2011 to 2017, patients at our institution with confirmed EoE were enrolled sequentially into a database. EoE diagnosis required the combination of clinical symptoms, endoscopic features, and histologic confirmation. In a retrospective manner, data was analyzed as outlined in Figure 1.379 Figure 1 No Caption available.Results: 77 patients (mean age 37, range 17-71, 69% male) with confirmed EoE were treated at our center. A PPI trial was completed on 71/77 (92%) patients with 50/71 (70%) patients having response. Complete response was seen in 44/50 (88%) and partial response in 6/50 (12%). Of those with a complete response, 27/32 (84%) were able to be reduced to once daily PPI maintenance therapy, but 5/32 (16%) relapsed. Of 33 patients with fibrostenotic EoE, an average of 2.3 dilatations were needed to reach a final average esophageal diameter of 17mm. Symptom relief was achieved in 85%; no perforations occurred. Ten patients (13%) were treated with topical steroids. Overall, 7/10 (70%) were steroid responsive. Selective diet elimination based on food allergy testing was successful in 7/8 (88%). Six-food elimination diet as primary therapy in one patient received a complete response. Conclusion: Our 70% response to PPI therapy in our EoE population over 7 years is on the high end of the reported range of 33-80%. The reason for our success in this unselected population may be due to intense education and engagement fostered in our patients. Our patients understand the drug mechanism of action/dosing, are very compliant with the PPI trial, and often rewarded by not needing topical steroids or diet restriction. In addition, the 85% with complete response were decreased to once daily PPIs, thereby lessening concern over potential side effects of long term high dose PPIs. Conclusion In our practice, PPIs have a 70% response rate in unselected EoE patients. Our excellent success may be related to intense education and engagement with our patients.

A Case of an Inlet Patch Causing Laryngopharyngeal Reflux

Larynopharyngeal reflux (LPR) is retrograde movement of gastric and upper esophageal (UE) contents into the laryngopharynx, leading to symptoms of dysphonia, dysphagia, chronic cough, and throat clearing. Whether or not LPR is caused by GERD or by an independent mechanism is under debate, as some patients have LPR without GERD. This is an example of LPR caused by a large inlet patch. 65 yo F with history of breast cancer s/p lumpectomy, normal colonoscopy, presented with chronic symptoms of coughing, dysphagia, spitting, and continuous clearing of her throat. Her symptoms were exacerbated in a recumbent position. Her vitals and physical exam were unremarkable. Her EGD showed a Schatzki's ring at the GEJ which was dilated with a balloon to 20mm. A tighter stricture with ulceration was found in the UE at 19cm with a circumferential patch of salmon colored mucosa extending 2-3cm proximally. Pathology revealed “gastric fundic/cardia-type mucosa interposed between squamous mucosa with associated chronic inactive inflammation; consistent with heterotopic gastric mucosa (inlet patch)”. Patient had significant improvement with daily PPI, and later underwent balloon dilation of the upper esophageal stricture with good effect. Now, considering ablation for long term symptom management.We feel this patient's LPR symptoms were caused by the large patch of gastric acid producing mucosa in the UE, rather than GERD. Reported incidence of inlet patches range from 1-14% of EGDs with autopsy rates up to 70%. Complications include bleeding, perforation, fistula, stricture formation, and adenocarcinoma. In our case, an ulcerated UE stricture was evidence of the local acid produced by the inlet patch. Acid produced from inlet patches in the UE can be enough to induce LPR symptoms, as laryngeal exposure to a pH of 6 can induce symptoms. Inlet patches are often overlooked during rapid withdrawal of the endoscope in the UE and are frequently not documented in endoscopy reports. Treatment includes behavioral modifications, PPIs, neuromodulators, alginate, radiofrequency ablation, or surgery. This case illustrates the value of inlet patch detection and documentation in patients presenting with LPR symptoms. More time should be spent in evaluation of the UE, with a focus on detection and documentation of each inlet patch. Inlet patches may provide a target for treatment for long term management of LPR symptoms.

Reclassifying Functional Heartburn Using Impedance pH in Refractory GERD Patients

Introduction: Background: Functional heartburn as a term has changed in meaning over the years. The most recent definition was introduced based upon Rome IV criteria, as typical heartburn symptoms in the presence of normal upper endoscopy findings (including normal biopsies), normal esophageal pH testing, and a negative association between symptoms and reflux events. Functional heartburn is very common, affecting women more than men. The majority of GERD patients respond to 4-8 weeks of proton-pump inhibitors therapy but up to 40% will demonstrate partial or complete lack of response. This defines the refractory group. 24 hr-impedance pH is the current gold standard for diagnosing all GERD types including acid and non-acid reflux. Symptom index is used as an adjunctive diagnostic tool to link symptoms to specific reflex events. Aim: The aim of the study is to review and reclassify functional heartburn patients using impedance pH.2767 Figure 1 No Caption available.Methods: Retrospective chart review of patient who continued to have GERD symptoms despite being on antisecretory therapy. We reviewed impedance pH studies for adult patients (>18 years old) between 2012-2018. Only patients with refractory symptoms were included. Data including esophageal acid exposure, number of reflux episodes (acids and non-acid), symptoms index and upper endoscopy findings (including esophageal biopsies) were collected. The data was reviewed and classified based on reflux events and symptom index. Cut off for abnormal of reflux episodes was 48, counting both acid and nonacid episodes. All patients were studied while on PPI therapy, once or twice a day. Results:Results 166 patients were included, 68% were females, mean age was 51±19 years, and 62% were on once daily PPI dosing.73% had positive symptom index (see figure). Conclusion: Patients with persistent GERD symptoms on PPI therapy represent a heterogenous group. Exclusively using pH esophageal monitoring, such as in the current functional heartburn classification, risks missing patients who's persistent symptoms are due to non-acid reflux.

Tu1134 - Twice Daily PPI is Associated with Better Delineation of PPI-REE Diagnosis than Once Daily PPI Trial Regardless of Total Daily Dosage

Tu1134 - Twice Daily PPI is Associated with Better Delineation of PPI-REE Diagnosis than Once Daily PPI Trial Regardless of Total Daily Dosage

The efficacy of step-down therapy in adult patients with proton pump inhibitor-responsive oesophageal eosinophilia.

Proton pump inhibitor-responsive oesophageal eosinophilia (PPI-REE) is common in patients with suspected eosinophilic oesophagitis (EoE). However, the long-term efficacy of PPIs and the best maintenance doses are yet to be defined. To evaluate the durability of the response to PPI therapy after tapering PPI doses in PPI-REE patients. Prospective study conducted on PPI-REE patients. Upon complete remission on high-dose PPI therapy (omeprazole 40 mg b.d. for 8 weeks), PPI doses were tapered followed by an endoscopic procedure after each dose reduction. The primary outcomes were sustained clinical and histological remission (<15 eos/HPF) after decreasing PPI doses. From a total of 121 patients with suspected EoE, 40 (33%) achieved complete remission on high-dose PPIs and were given a diagnosis of PPI-REE. No patient in histological remission showed symptom relapse, but half of patients with relapsing oesophageal inflammation were in clinical remission. After reduction to omeprazole 40 mg once daily, 38/31 (81%) remained in complete remission. Among these latter patients, 15/18 (83%) were kept in remission with omeprazole 20 mg once daily. As for side effects, only asymptomatic hypertransaminasemia and oesophageal candidiasis were observed in two patients while receiving high doses of omeprazole. Most PPI-responsive oesophageal eosinophilia patients show sustained clinical and histological remission with daily PPI doses equal to or below 40 mg of omeprazole. As adverse effects only appeared with the highest dose of omeprazole, it would be advisable to individualise the dose of PPIs for each patient, lowering it to the minimum capable of maintaining the disease controlled.

Fractures Rise With Prolonged PPIs Plus Risk

Fractures Rise With Prolonged PPIs Plus Risk

Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium difficile Infection

The incidence and severity of Clostridium difficile infections are increasing. Acid-suppressive therapy has been suggested as a risk factor for C difficile, but this remains controversial. We conducted a pharmacoepidemiologic cohort study, performing a secondary analysis of data collected prospectively on 101 796 discharges from a tertiary care medical center during a 5-year period. The primary exposure of interest was acid suppression therapy, classified by the most intense acid suppression therapy received (no acid suppression, histamine(2)-receptor antagonist [H(2)RA] therapy, daily proton pump inhibitor [PPI], and PPI more frequently than daily). As the level of acid suppression increased, the risk of nosocomial C difficile infection increased, from 0.3% (95% confidence interval [CI], 0.21%-0.31%) in patients not receiving acid suppressive therapy to 0.6% (95% CI, 0.49%-0.79%) in those receiving H(2)RA therapy, to 0.9% (95% CI, 0.80%-0.98%) in those receiving daily PPI treatment, and to 1.4% (1.15%-1.71%) in those receiving more frequent PPI therapy. After adjustment for comorbid conditions, age, antibiotics, and propensity score-based likelihood of receipt of acid-suppression therapy, the association persisted, increasing from an odds ratio of 1 (no acid suppression [reference]) to 1.53 (95% CI, 1.12-2.10) (H(2)RA), to 1.74 (95% CI, 1.39-2.18) (daily PPI), and to 2.36 (95% CI, 1.79-3.11) (more frequent PPI). Similar estimates were found with a matched cohort analysis and with nested case-control techniques. Increasing levels of pharmacologic acid suppression are associated with increased risks of nosocomial C difficile infection. This evidence of a dose-response effect provides further support for the potentially causal nature of iatrogenic acid suppression in the development of nosocomial C difficile infection.

Risks of proton‐pump inhibitors: what every doctor should know

Medical Journal of AustraliaVolume 190, Issue 3 p. 109-110 Editorial Risks of proton-pump inhibitors: what every doctor should know Nicholas J Talley MD, PhD, FRACP, Corresponding Author Nicholas J Talley MD, PhD, FRACP Professor of Medicine and Epidemiology, and Chair of Department of Medicine talley.nicholas@mayo.edu Mayo Clinic, Jacksonville, Fla, USA.Correspondence: talley.nicholas@mayo.eduSearch for more papers by this author Nicholas J Talley MD, PhD, FRACP, Corresponding Author Nicholas J Talley MD, PhD, FRACP Professor of Medicine and Epidemiology, and Chair of Department of Medicine talley.nicholas@mayo.edu Mayo Clinic, Jacksonville, Fla, USA.Correspondence: talley.nicholas@mayo.eduSearch for more papers by this author First published: 02 February 2009 https://doi.org/10.5694/j.1326-5377.2009.tb02305.xCitations: 10Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume190, Issue3February 2009Pages 109-110 RelatedInformation

The Impact of Normalization of Esophageal Acid Profile by Incremental Protein Pump Inhibitors Dosing in Difficult Asthma Patients with Proven Gastro-esophageal Acid Reflux

Background. GER is common in patients with asthma and some, although not all, studies have shown benefit from identification and treatment of GER. Methods. patients with persistent symptoms after optimisation of asthma therapy underwent pH monitoring and adjustment of GER therapy based on the results of repeated pH monitoring. Gastrointestinal symptom scores and asthma therapy requirements were recorded. Results. Over a 2 year period, 51 patients with a definite diagnosis of asthma underwent pH monitoring with GER being identified in 32 (63%). Normal oesophageal acid exposure was achieved in 11 patients, 7 requiring a daily PPI dose greater than 20mg; 8 patients had persisting abnormal oesophageal acid exposure (OAE) despite daily PPI doses up to 80mg. 13 patients declined further pH studies. 8 (73%) patients with normalisation of OAE had meaningful reductions in long term asthma therapy with 2 patients stopping and 2 patients reducing long term oral corticosteroids and 4 others halving the dose of inhaled corticosteroids. No patient who had persisting GER had asthma therapy reduced, neither did any of the group of patients in whom GER was not identified. Conclusion: Tailoring GER therapy with repeated pH studies had a major impact in a subgroup of patients, greater than any other intervention employed in our clinic over the same period. This uncontrolled data adds to the evidence that effective management of GER reduces asthma symptomatology and allows therapy to be reduced in a subgroup of patients with difficult to control asthma.

The Effects of Once Daily Versus Twice Daily Proton Pump Inhibitor Therapy on NSAID Induced Gastric Ulcers

Purpose: The effects of once daily versus twice daily PPI therapy administered for an average of 12 weeks on gastric ulcer healing was compared. Methods: A retrospective chart review was preformed on adult patients presenting to a large teaching community hospital over a 5 year period (2001–2006) with melena or hematemesis and a history of NSAID use, who underwent endoscopy revealing gastric ulcers. Patients between the ages of 18 and 95 years, with a non-malignant gastric ulcer who had a history of any NSAID use for at least one week prior to presentation were eligible for enrollment. Patients were divided into two groups according to the anti-secretory therapy received. Group 1 comprised of once daily PPI therapy versus group 2 receiving twice daily PPI therapy. The primary endpoint was evidence of gastric ulcer healing during repeat endoscopy at 8 to 12 weeks. Results: 135 patients met our inclusion criteria, of these, 68 received daily PPI therapy while 67 received twice daily therapy. There was no statistical difference in demographics or co-morbidities in either group. The mean ages of the groups were 73 and 72 respectively. 83.3% of patients with active bleeding (P= 0.015) and 67% of patients with visible vessels on endoscopy (P= .216), were prescribed twice daily therapy. The average time for repeat endoscopy was 12.57 weeks for group 1 and 9.82 weeks for group 2. Healing rates of gastric ulcers at repeat endoscopy were 92.6% and 86.5% respectively with no statistical difference (P= .622) using Pearson Chi-square test. Conclusion: Our retrospective chart review revealed no statistical difference in healing rates of NSAID induced gastric ulcers among patients receiving daily versus twice daily PPI therapy. The lower healing rates in patients receiving twice daily group, maybe related to more severe disease and earlier second endoscopy.

Endoscopic Full-Thickness Plication for the Treatment of GERD: Five Year Multi-Center Results

Background: The Plicator® (NDO Surgical, Inc., Mansfield, MA) procedure, which is an endoscopic procedure that delivers a full-thickness plication, was previously reported to be effective at reducing GERD symptoms and medication use for up to 3-years post-plication with no long-term procedural adverse events. The purpose of this study was to assess the long-term safety and treatment durability of the Plicator up to 5-years post-plication. Methods: Patients with chronic heartburn who had originally participated in the open-label study and received a single plication in the gastric cardia 1 cm below the gastroesophageal junction were eligible. Subjects were evaluated at baseline for GERD symptoms and medication use. Long-term subject follow-up was completed to evaluate safety and long-term treatment durability. Results: Thirty-three subjects completed the long-term follow-up (mean follow-up interval: 5 years (59 months), range: 50-65 months). All procedure-related adverse events occurred acutely, as previously reported, and no new adverse events were observed during extended follow-up. At 5-years post-procedure, 67% of baseline PPI dependent patients remained off daily PPI therapy. Treatment effect remained stable from the 3 to 5-year follow-up interval, with 11/28 patients requiring daily PPI at 3-years compared to 12/30 patients at 5-years. Median GERD-HRQL scores remained significantly improved at 5-years versus baseline off-meds scores (10 vs. 19, p < 0.001). In addition, the proportion of patients achieving ≥ 50% improvement in GERD-HRQL score was consistent from 3-years (55%) to 5-years (50%). Conclusions: Endoscopic full-thickness plication can effectively reduce GERD symptoms and medication use for at least 5-years post-procedure. Treatment effect is stable for 5-years and there are no long-term procedural adverse effects.