Dose Proton Pump Inhibitor Therapy Research Articles

A210 ESOPHAGEAL SQUAMOUS PAPILLOMATOSIS AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION

Abstract Background Squamous papillomatosis is a rare benign epithelial finding, generally found incidentally in the distal esophagus. The pathophysiology is not well understood but felt to be secondary to reflux and chemical irritation leading to leukoplakia and verrucous hyperplasia of the epithelium and papilloma formation. Aims To present a case of esophageal squamous papillomatosis after endoscopic submucosal dissection (ESD) and radiofrequency ablation (RFA) of Barrett’s esophagus (BE) and early esophageal cancer. Methods Case report and review of the literature Results A 78-year-old male with C3M3 BE and previous band mucosectomy for nodular dysplasia was referred for ESD of an early esophageal cancer. ESD was successfully performed, with histopathology identifying a low-risk well-differentiated intramucosal adenocarcinoma without lymphovascular invasion and negative margins. Radiofrequency ablation was performed 3-months post-resection for residual BE. Subsequent surveillance gastroscopy 6 months post-resection identified extensive fleshy pink granulation tissue at the ESD scar, histopathology revealing SP. This was confirmed on subsequent repeat gastroscopy and biopsy. Compliance with double dose proton pump inhibitor therapy was confirmed. Conclusions To our knowledge, this is the first reported case of SP developing post-ESD and RFA; further expanding our knowledge of potential Barrett’s endotherapy-related adverse events. Funding Agencies None

S3666 Severe Hemorrhagic Gastritis in a Patient Receiving PD-1 Inhibitor Treated With High Dose Proton Pump Inhibitor

Introduction: The programmed death 1 (PD-1) immune checkpoint is a negative regulator of T-cell function. Pembrolizumab is a monoclonal antibody which inhibits PD-1 receptor and is commonly used to treat many types of malignancies. While this therapy allows for an enhanced immune response against tumor cells, it can also cause immune-mediated adverse events with the gastrointestinal (GI) tract being the most commonly affected. Systemic corticosteroids are frequently used in patients who develop these side effects. We present a rare case of a patient with clear cell renal cell carcinoma (ccRCC) presenting with hemorrhagic gastritis while on Pembrolizumab, successfully treated with high dose proton pump inhibitor (PPI). Case Description/Methods: A 61-year-old man with metastatic ccRCC treated with Pembrolizumab, presented to the hospital with intractable vomiting and significant weight loss secondary to poor oral intake. Upper endoscopy showed diffusely friable gastric mucosa with oozing of blood (Image 1a). Biopsy revealed mucosa with regenerative changes and active non-specific inflammation with ulcerated granular tissue, negative for CMV, H. pylori, atypical infiltrating cells, or malignancy (Image 1b). These findings were compatible with Pembrolizumab induced autoimmune gastritis. He was started on pantoprazole 40 mg BID with significant clinical improvement; thus, steroid therapy was not initiated. Repeat endoscopy a month later showed resolution of prior endoscopic findings (Image 1c). Pembrolizumab was restarted two months later while on PPI therapy without recurrence of symptoms. Discussion: Gastrointestinal side effects from immunotherapy are common. However, isolated PD-1 blockage-associated gastritis is rare and hemorrhagic gastritis is even more with only a few cases reported in literature. The management of this condition is not well established although systemic steroids are usually used to suppress the immune response. In our case, high dose PPI therapy alone led to resolution of symptoms and mucosal healing. No clinical or histological signs of hemorrhagic gastritis were noted after resuming Pembrolizumab. Whether PPI therapy has a role in preventing or minimizing this immune-induced gastritis is still unknown and more studies are needed to establish this therapy as standard.Figure 1.: (a) Initial endoscopy showing hemorrhagic gastritis. (b) H&E stain at 20× showing inflammatory infiltrate. (c) Repeat endoscopy showing healing mucosa.

Post-reflux swallow-induced peristaltic wave index and mean nocturnal baseline impedance predict PPI response in GERD patients with extra esophageal symptoms

BackgroundMean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave (PSPW) index are able to increase the diagnostic yield of impedance-pH and are associated to proton pump inhibitor (PPI) response. Few data concerning these variables in patients with extra-esophageal symptoms (EES) are available. AimsTo evaluate, in EES patients, the role of the conventional and new impedance-pH variables in diagnosing GERD and the predictive value of impedance-pH variables for PPI response. MethodsConsecutive patients presenting suspected GERD-related EES underwent impedance-pH. Patients treated in the last six months with double dose PPI therapy were enrolled. The presence of concomitant typical symptoms was assessed. Results239 EES patients were studied; 102 responders and 137 non-responders. Eighty-one (34%) were affected by non-erosive reflux disease (NERD), 61 (26%) presented reflux hypersensitivity (RH) and 97 (40%) were non-GERD. In NERD and RH groups, a significantly higher proportion of patients with pathological PSPW index or MNBI values compared to non-GERD group was observed. 24 (25%) non-GERD patients presented a pathological PSPW index and/or MNBI. Pathological PSPW index, MNBI and presence of typical symptoms were associated to PPI response. ConclusionsMNBI and PSPW index measurement increases the diagnostic yield of impedance-pH; abnormal values are associated with a satisfactory response to acid-suppressive therapy in EES patients.

1281 Duodenobiliary Fistula: A Rare Complication of Peptic Ulcer Disease

INTRODUCTION: Spontaneous biliary enteric fistulas are usually late complications of cholelithiasis or choledocholitiasis. The incidence of biliary enteric fistulas in this population ranges from 0.3 – 0.9%. Biliary enteric fistula formation is usually occurs from a gallstone ulcer perforating into the normal duodenum. However in rare circumstances (3.5-10% of cases) fistula's can form from a duodenal ulcer penetrating into the biliary tree, as is the case with biliary enteric fistula's due to peptic ulcer disease (PUD). These fistula's often present with abdominal pain, malaise and/or hematemesis. We discuss a rare case of a duodenobiliary fistula as a result of long standing peptic ulcer disease. CASE DESCRIPTION/METHODS: A 57-year-old male with long standing abdominal pain who recently immigrated to the United States from the Democratic Republic of Congo presented to the ED with acute on chronic epigastric abdominal pain. He denied previous surgery. Notably, he had tested positive for h. pylori a few months prior and was questionably compliant with prescribed antibiotics. He was admitted with hypokalemia and renal failure. Persistent symptoms prompted a computed tomography (CT) of his abdomen and pelvis. Findings from the CT demonstrated air and oral contrast material within the common bile duct and intrahepatic bile ducts with a fistulous connection to the second portion of the duodenum. Endoscopic evaluation demonstrated esophagitis, gastritis and severe pyloric stenosis likely due to long-standing PUD. The standard endoscope was unable to traverse this stenosis, but was successfully traversed with an ultrathin scope. The ampulla was briefly visualized and was grossly normal. There was no definitive fistulous tract identified. The patient was placed upon high dose proton pump inhibitor therapy. A repeat CT of the abdomen and pelvis was done 6 weeks later and was unchanged. The patient was referred to surgical oncology for definitive management. DISCUSSION: Historically, biliary enteric fistulas were often diagnosed during surgical interventions. Currently, CT can often diagnose these fistulas by detecting minimal pneumobilia. Endoscopic evaluation may or may not demonstrate a biliary enteric fistula due to duodenal narrowing or edema. Antiulcer therapy usually allows clinical improvement and fistula closure for PUD associated fistulas. Surgery is reserved for cases refractory to medical care, poorly controlled symptoms, hemorrhage or biliary obstruction.

Duodenal Ulceration as a Complication of Yttrium-90 Microsphere Radioembolization of Intrahepatic Cholangiocarcinoma

Yttrium-90 (Y-90) microsphere radioembolization (RE) can be an effective regional treatment for primary hepatobiliary malignancies. RE with Y-90 has been described as safe for patients with intrahepatic cholangiocarcinoma (ICC)1. However, gastrointestinal ulceration is a rarely reported complication of Y-90 microsphere RE2. Given the increasing incidence of primary hepatobiliary tumors and an expected rise in use of Y-90 RE, we present a case of Y-90 RE-associated duodenal ulceration. A 76-year-old woman presented to the hospital with lower abdominal pain and was evaluated with a CT scan which revealed an ill-defined liver mass adjacent to the gallbladder which was diagnosed as stage IV intrahepatic cholangiocarcinoma involving segment 4 of the liver. She was treated with Y-90 RE with the intent of tumor down-sizing prior to resection. As part of the treatment application, the gastroduodenal artery was densely packed with coils with complete stasis of flow achieved. Through the medial branch of the left hepatic artery, the Y-90 spheres were super-selectively deployed through a micro-catheter. Two months after the radioembolization, she experienced mid-epigastric abdominal pain, not responsive to proton pump inhibitor. Upper endoscopy revealed two non-bleeding superficial duodenal ulcers with no stigmata of bleeding in the duodenal bulb. Pathology from biopsies of the ulcer bed revealed the presence of Y-90 beads in the lamina propria, consistent with radiation-induced duodenitis. She is currently being treated with high dose proton pump inhibitor (PPI) therapy by mouth twice daily, with good response. This case highlights a potential complication associated with radioactive microsphere embolization. Given the increasing use of this treatment modality, gastroenterologists should recognize this entity, and its delayed occurrence in particular. New-onset, or change in abdominal discomfort or pain should prompt endoscopic evaluation in patients with prior Y-90 RE. We suggest high dose PPI therapy as initial management, but the optimal treatment strategy to treat gastrointestinal ulceration as a complication of RE should be further investigated.

PTH-021 Reassessing The Value of Gastroscopy for The Investigation of Dyspepsia

Introduction The National Institute of Health and Clinical Excellence (NICE) first recommended a policy of H. pylori test and treat or empirical full dose proton pump inhibitor therapy for uninvestigated dyspepsia in 2004. 1 Following an initial fall in demand for gastroscopy (OGD), there has been a 30% increase in the last five years. 2 Whilst regarded as the gold standard, it is uncomfortable, costly, may require sedation and carries the risks of intubation. In an era when non-invasive tests are emerging, the role of OGD requires re-evaluation. Methods Data from consecutive OGDs performed between September 2015 and January 2016 to investigate dyspepsia was analysed. We determined the percentage of patients in whom OGD ± biopsy changed management as defined by an approach other than the non-invasive NICE recommendations. 1 Results 500 patients (39.8% male; mean age 58±16.1) underwent OGD for dyspepsia, some of whom also had dysphagia (6%), anaemia (4%), vomiting (4.2%) or suspected gastrointestinal (GI) bleeding (0.6%). 145 (29%) were sedated (midazolam (mean±SEM) 2.0 mg±1.0; fentanyl (when used) 50 mcg±23). 381 patients (76.2%) had abnormal endoscopy; 417 (83.4%) had biopsies taken (15.8% for histological assessment, 27.4% for rapid urease tests, 40.2% for both). Findings of uncertain relevance, or which could have been managed with empirical therapies, were seen in 299 patients (59.8%; including oesophagitis (n = 122), hiatus hernias (n = 178), gastric polyps (n = 34), gastritis (n = 236), gastric ulcers (n = 9), gastric erosions (n = 32), duodenitis (n = 40), duodenal ulcer (n = 1), duodenal erosions (n = 15) and a duodenal polyp (n = 1)). Diagnoses which would not have been appropriately managed by empirical therapies numbered 82 (16.4%). These included 71 (14.2%) patients with Barrett’s oesophagus (n = 39), oesophageal stricture (n = 2), oesophageal cancer (n = 1) and gastric cancer (n = 4) diagnosed at the time of endoscopy. An additional 11 (2.2%) diagnoses were made solely by histology, which included eosinophilic oesophagitis (n = 1), eosinophilic gastritis (n = 1), intestinal metaplasia (n = 3) and coeliac disease (n = 6). Conclusion Diagnoses which alter management are made by endoscopy in only 14.2% of patients with dyspepsia. Although the majority of patients have biopsies taken, the added value increases the yield to only 16.4%. Non-invasive, cost-effective diagnostic strategies are needed to better guide patient management and select the minority of patients who need endoscopic biopsy or therapy. References 1 www.nice.org.uk/guidance/CG184 (2014 update) 2 https://www.england.nhs.uk/statistics Disclosure of Interest None Declared

Efficacy of viscous budesonide slurry for prevention of esophageal stricture formation after complete endoscopic mucosal resection of short-segment Barrett's neoplasia.

Complete endoscopic resection (CER) of short-segment Barrett's esophagus with high grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a precise staging tool and achieves durable disease control. The major drawback is development of post-endoscopic resection esophageal stricture (PERES). No effective therapy to prevent PERES has been described. Viscous budesonide slurry (VBS) may have a role in the prevention of PERES by suppressing the post-CER inflammatory process. The study aim was to evaluate the efficacy of VBS for the prevention of PERES. Prospective data were collected on patients referred for CER of HGD or EEA. After January 2012, patients routinely received VBS (two 0.5-mg/2-mL budesonide respules mixed with sucralose) twice daily for 6 weeks following each stage of the CER schedule. All patients received high dose proton pump inhibitor therapy for the duration of CER and the following 3 months. Patients had no other intervention to prevent PERES. A validated dysphagia score was used (0 - 4, no dysphagia to aphagia). Endoscopic dilation was performed for dysphagia. Patients receiving VBS were compared with historical controls. The primary endpoint was the need for dilation. Between January 2008 and January 2015, 104 of 116 eligible patients completed CER. The VBS group (n = 29) and non-VBS group (n = 75) had similar patient, disease, and procedural characteristics. Dilations were needed in 13.8 % vs. 37.3 % (P = 0.03), with a median of one vs. two procedures (P = 0.01), and median dysphagia score during CER of 0 vs. 1 (P = 0.02) in the VBS and non-VBS groups, respectively. No VBS-related adverse events were noted. In this pilot study VBS significantly reduced PERES and shortened the dilation program after CER.

An Elderly Woman With an Uncommon Cause of Dysphagia

Question: A 68-year-old woman with a past medical history of asthma and vulvar lichen planus is referred to us for symptoms of dysphagia. Her dysphagia is to solids only. Symptoms started 1 year before presentation and have been progressive in nature. There was no associated odynophagia, regurgitation, unintentional weight loss, melena, or hematochezia. She has mild symptoms of gastroesophageal reflux disease that are well controlled with once daily proton pump inhibitor therapy. Her medications include daily maximum dose inhaled steroids for asthma. She has no history of smoking or alcohol abuse. On oral examination, no lesions including oral thrush were noted. Our patient underwent a barium esophagram that showed a distal esophageal stricture (Figure A, arrows). An upper endoscopy was pursued that showed significant mucosal changes with white plaques, ulcers, and scarring causing luminal narrowing and friability (Figure B–E). Multiple large unstained lesions on Lugol's chromoscopy were noted (Figures F, G). Multiple biopsies were obtained from the proximal to the distal esophagus (Figure H, I). Grocott’s methenamine silver stain was negative for fungal pathogens. Based on the clinical scenario, endoscopic findings and pathology images, what is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Our patient’s dysphagia is secondary to esophageal leukoplakia (also known as “epidermoid metaplasia”). Esophageal biopsies (Figure H, I) reveal marked hyperkeratosis and prominent granular cell layer consistent with esophageal leukoplakia. A repeat upper endoscopy with biopsies was performed without evidence of underlying carcinoma or dysplasia. The patient was placed on twice daily maximum dose proton pump inhibitor therapy. Her symptoms improved. Esophageal dilation was deferred considering extreme mucosal friability and improvement of symptoms with medical therapy. She is enrolled currently in an active surveillance program consisting of repeat upper endoscopies and biopsies for early detection of dysplasia. Esophageal leukoplakia is extremely rare and poorly described in the literature. It is characterized by the presence of mucosal white plaques that cannot be scraped. In a recent case series of esophageal leukoplakia in 18 patients from multiple medical centers, it was noted that the majority of the patients were smokers or exposed to secondhand smoke (61%).1Singhi A.D. Arnold C.A. Crowder C.D. et al.Esophageal leukoplakia or epidermoid metaplasia: a clinicopathological study of 18 patients.Mod Pathol. 2014; 27: 38-43Crossref PubMed Scopus (33) Google Scholar There is an unclear association between esophageal leukoplakia and squamous cell dysplasia/carcinoma. For example, the presence of high grade dysplasia or squamous cell carcinoma in 18 esophageal leukoplakia patients was 17% in 1 series.1Singhi A.D. Arnold C.A. Crowder C.D. et al.Esophageal leukoplakia or epidermoid metaplasia: a clinicopathological study of 18 patients.Mod Pathol. 2014; 27: 38-43Crossref PubMed Scopus (33) Google Scholar Another small series identified 4 patients with epidermoid metaplasia and all 4 had either synchronous or metachronous squamous cell carcinoma.2Ezoe Y. Fujii S. Muto M. et al.Epidermoid metaplasia of the esophagus: endoscopic feature and differential diagnosis.Hepatogastroenterology. 2011; 58: 809-813PubMed Google Scholar All 4 patients in that case series were heavy alcohol drinkers. Our case is unique in that this is a rare condition and our patient lacked risk factors such as smoking or alcohol abuse.

Comparison of MII-PH-metry data in patients with functional heartburn and proton pump inhibitor treatment responsive non-erosive reflux disease

Patients with non-erosive reflux disease (NERD) may or may not respond to a proton pump inhibitor (PPI). Refractoriness can be non-reflux or reflux related. In the absence of structural, motility or inflammatory causes, functional heartburn (FH) should be considered. Patients with FH have typical reflux symptoms with lack of association with reflux episodes on multichannel intraluminal impedance pH- monitoring (MII-pH-metry) and do not respond to double dose PPI therapy. Recent study demonstrated an increased acid sensitivity in patients with NERD compared with that in patients with FH. The aim of our study was to compare MII-pH-metry data in patients with NERD who responded to PPI with those who were refractory.

Patient care services: What pharmacists do

Patient care services: What pharmacists do

APhA honors outstanding achievements at Annual Meeting

Each year, APhA recognizes exceptional contributors to the profession at the Annual Meeting. The following award winners will be honored at APhA2014 in Orlando.

Esophageal Polyp Arising from a Gastric Inlet Patch Causing Dysphagia

Purpose: Heterotopic gastric mucosa is usually an aymptomatic finding. We present a 58-year-old male who was admitted for nausea, vomiting and coffee ground emesis. He also noted intermittent solid food dysphagia, heartburn and epigastric pain. His history was positive for diabetes, end stage renal disease (ESRD) on hemodialysis, hypertension and chronic alcohol use. Physical exam was positive for epigastric tenderness, mild dehydration and hypotension which stabilized with medical resuscitation. Endoscopy revealed two salmon colored patches of columnar appearing epithelium in the proximal esophagus suggestive of gastric inlet patches. There was a large, 1 cm, semipedunculated esophageal polyp arising from one of these patches. In addition, there was extensive erosive esophagitis seen in the distal and middle esophagus. The gastric mucosa appeared erythematous. Biopsies from the polyp confirmed it to consist of gastric cardia type mucosa with hyperplastic foveolar epithelium and inflammatory cells with no evidence of squamous epithelium. The salmon colored mucosal patches were positive for gastric cardia type of epithelium with evidence of ulcerative esophagitis. The inflamed esophageal mucosa showed changes of reflux esophagitis. Gastric mucosal biopsy was suggestive of non specific reactive gastropathy. The patient was started on high dose proton pump inhibitor therapy and other resuscitative measures were instituted. Plan was to repeat endoscopy and an EUS after 6 weeks of treatment with PPI. However, after resolution of his symptoms, the patient deferred further invasive work-up. Esophageal polyps are a rare occurrence and may be of diverse histopathologic types. The class of hyperplastic esophageal polyps is usually found in relation to GERD, at the GE junction and is histologically characterized by proliferation of hyperplastic gastric-type foveolar epithelium, hyperplastic squamous epithelium, or an admixture of the two linings with variable inflammatory infiltrate. This case illustrates a very rare occurrence of an esophageal polyp arising from gastric inlet patch and causing symptomatic dysphagia.

Metabolic Bone Disease as a Complication of Chronic High Dose Proton Pump Inhibitor Therapy

Metabolic Bone Disease as a Complication of Chronic High Dose Proton Pump Inhibitor Therapy

* Dysphagia in patients with the joint hypermobility syndrome

IntroductionThe Joint Hypermobility Syndrome (JHS) is a relatively frequent inherited connective tissue disorder characterised by marked joint hyperextensibility and extra-articular manifestations. Recent work suggests that gastrointestinal (GI) symptom prevalence may...

Uses of proton pump inhibitors and serum potassium levels

Proton pump inhibitor (PPI) may suppress adrenal cortical steroid synthesis and release, thereby leading to electrolyte disturbances. Both hyponatremia and hyperkalemia in the setting of PPI therapy have been documented in case reports. The objective of this study was to examine the association between serum potassium (K(+)) level and PPI use. A retrospective data analysis of hospitalized adults aged > or = 65 years during 2006, including PPI users (N = 257) and PPI non-users (N = 388), was conducted. Multiple linear and logistic regression analyses were used to assess the association between PPI use and serum K(+) level. PPI users [mean age (SD):79.7 (8.0) years; 70% female] had significantly higher serum K(+) levels than PPI non-users [80.2 (8.8) years; 64% female] on admission [4.13 (0.62) vs. 3.97 (0.57) mmol/L; p < 0.001]. The linear regression model revealed that > or = 2 defined daily dose (DDD) units of PPI use were a significantly positive contributor to serum K(+) levels (p = 0.021) after adjusting for age, serum creatinine levels, sex, history of diabetes, and uses of the following drugs: angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta blocker, diuretics, spironolactone, K(+) supplement, non-steroidal anti-inflammatory drugs, atypical antipsychotics, and narcotics. However, multiple logistic regression model revealed that high dose PPI therapy was not associated with an increased risk for hyperkalemia occurrence (p = 0.762). Higher serum K(+) levels were observed among PPI users when compared to PPI non-users. High daily dose PPI therapy may be an independent positive predictor of serum potassium levels.

Esophageal Dysmotility Confirmed by Esophageal Manometry in a Patient with Stiff-Man Syndrome and Dysphagia

Stiff-man syndrome (SMS) is a rare autoimmune condition characterized by “tin soldier” rigidity of axial muscles. Nearly 150 cases have been reported with 6 reports of pharyngeal or esophageal dysphagia. We report the first case of esophageal dysmotility documented by esophageal manometry in a patient with SMS and dysphagia. A 37 year old African American male with SMS was referred for progressive regurgitation and dysphagia to solids and liquids since the diagnosis 2 years prior. The dysphagia was less noticeable with thickened liquids or soft foods. The patient denied odynophagia, pyrosis, early satiety or constipation. Esophageal manometry revealed low amplitude contractions to wet swallows with no significant antegrade propulsion. A few secondary peristaltic waves of adequate amplitude were seen. [figure1] The patient was unable to tolerate upper endoscopy. pH-metry with Bravo revealed pathologic reflux on day #2 with regurgitation symptoms strongly correlated with acid reflux events. A barium esophogram showed a normal contour, however motility was not assessed as the procedure was terminated secondary to coughing and aspiration of contrast. A gastric emptying study was normal. Dysphagia and regurgitation did not improve with high dose proton pump inhibitor therapy. As benzodiazepines did not improve symptoms in the past, the patient was treated with steroids and intravenous immune globulin (IVIG), which resulted in transiently improved axial muscular rigidity and dysphagia. SMS is a rare disorder characterized electromyographically by continuous motor discharge. Several cases of dysphagia have been described which were responsive to benzodiazepine therapy. To our knowledge, this is the first report of esophageal manometric findings in a patient with SMS. Our findings suggest not only striated muscle, but also smooth muscle involvement. Smooth muscle involvement has been previously reported in the form of delayed gastric emptying. The lack of acid reflux on day #1 of pH-metry raised a question of possible residual effect from conscious sedation, however the patient's symptoms have not sustained a response to medical therapy.Table

Prevalence of Barrett's Oesophagus at Diagnosis and after Therapy of LA Grade C and D Reflux Oesophagitis

Introduction: Identification of patients with Barretts oesophagus will allow surveillance for dysplasia and may identify those at high risk of developing adenocarcinoma. No recommendations exist for repeat endoscopy in patients with severe reflux oesophagitis to ensure healing or screen for Barretts oesophagus. Methods: As part of a double blind, randomized, multicentre study patients with severe reflux oesophagitis (LA grade C/D) and daily heartburn received healing dose proton pump inhibitor therapy for 8 weeks.

Multipolar electrocoagulation.

Multipolar electrocoagulation (MPEC) is a readily available technique that can be applied for endoscopic ablation of Barrett's esophagus. MPEC, in combination with high dose proton pump inhibitor therapy or antireflux surgery, results in normal squamous epithelium in most patients without major adverse effects. The ultimate clinical role of MPEC has not been determined but may be adjunctive to other techniques in appropriately selected patients at high risk for neoplastic progression.

Symptom and esophageal motor response to acid infusion in the esophagus following 8 weeks treatment with double dose proton pump inhibitor therapy

Symptom and esophageal motor response to acid infusion in the esophagus following 8 weeks treatment with double dose proton pump inhibitor therapy

Approaches to uninvestigated dyspepsia.

Uninvestigated dyspepsia refers to patients with new or recurrent dyspeptic symptoms in whom no investigations have previously been undertaken. These patients are much more likely to present in primary than in secondary care. It is particularly important to be able to offer effective symptom relief to support the explanation, reassurance, and advice provided to patients, and low dose or standard dose proton pump inhibitor therapy appears to offer the most effective approach to empirical therapy of this kind.