Esophageal Diagnoses Research Articles

Trends in the use of granulocyte colony stimulating factors for older patients with cancer, 2010 to 2019

IntroductionOlder patients with cancer receiving myelosuppressive treatment are at an increased risk for developing febrile neutropenia (FN) or having chemotherapy dose-reductions or delays, resulting in suboptimal health outcomes. Granulocyte colony stimulating factors (G-CSF) are effective medications to reduce these adverse events and are recommended for patients ≥65 years receiving chemotherapy with >10 % FN risk. We sought to characterize the trends and predictors of G-CSF use between the youngest-old (66–74 years), middle-old (75–84 years), and oldest-old (≥85 years) patients with cancer. Materials and MethodsWe used registry data from SEER-Medicare for breast, lung, ovarian, colorectal, esophageal, gastric, uterine, prostate, pancreatic cancer, and non-Hodgkin lymphoma (NHL) diagnoses from 2010 to 2019. Cox proportional hazard analysis was used. ResultsOverall, 41.4 % of patients received G-CSF from chemotherapy initiation to three days after completion of the first chemotherapy course. The use rate remained relatively stable for all cancers, except for an increase in use for those with pancreatic cancer. G-CSF use decreased as patients got older. The oldest-old were 43.0 % (95 % confidence interval: 40.7–45.2 %) less likely to receive G-CSF compared to the youngest-old. Patients with breast cancer or NHL were more likely to receive G-CSF than those with other cancers. Patients who were female, married, White or Hispanic, and had fewer comorbidities were more likely to receive G-CSF. DiscussionG-CSF is used less often in populations at higher risk of developing FN and related complications. Improving adherence to recommendations can improve health outcomes, especially in the oldest adults, older males, and Black patients.

Large-Caliber Empiric Esophageal Dilation Results in Sustained Improvement for Selected Patients With Nonobstructive Dysphagia.

Empiric esophageal dilation (EED) remains a controversial practice for managing nonobstructive dysphagia (NOD) secondary to concerns about safety and efficacy. We examine symptom response, presence of tissue disruption, and adverse events (AEs) after EED. We examined large-caliber bougie EED for NOD at 2 tertiary referral centers: retrospectively evaluating for AEs. Esophageal manometry diagnoses were also reviewed. We then prospectively assessed EED's efficacy using the NIH Patient-Reported Outcomes Measurement Information System disrupted swallowing questionnaire to assess dysphagia at baseline, 1, 3, and 6 months after EED. Treatment success was defined by improvement in patient-reported outcome scores. AE rate for large-caliber dilation in the retrospective cohort of 180 patients undergoing EED for NOD was low (0.5% perforations, managed conservatively). Visible tissue disruption occurred in 18% of patients, with 47% occurring in the proximal esophagus. Obstructive motility disorders were found more frequently in patients with tissue disruption compared with those without (44% vs 14%, P = 0.05). The primary outcome, the mean disrupted swallowing T -score was 60.1 ± 9.1 at baseline, 56.1 ± 9.5 at 1 month ( P = 0.03), 57 ± 9.6 at 3 months ( P = 0.10), and 56 ± 10 at 6 months ( P = 0.02) (higher scores note more symptoms). EED resulted in a significant and durable improvement in dysphagia and specifically solid food dysphagia among patients with tissue disruption. EED is safe in solid food NOD and particularly effective when tissue disruption occurs. EED tissue disruption in NOD does not preclude esophageal dysmotility.

Exploratory Study of a New Technique of Pixelated Chromoendoscopy in the Diagnosis of Early Esophageal Cancer.

Chromoendoscopy is an effective method for early screening of esophageal cancer, but diagnosis can depend on subjective judgment. The study aimed to explore a new technique of pixelated chromoendoscopy in the diagnosis of early esophageal cancer. The study included patients with symptoms of esophageal cancer who attended Jiangyin People's Hospital between January 2015 and July 2021. Chromoendoscopy was performed on each patient. The images then underwent digital analysis; the lesion area (the sensitive region) was pixelated by dividing it into the smallest image unit and the red, green, and blue color components. The diagnostic performance of pixelated chromoendoscopy was evaluated by calculating the area under the receiver operating characteristic. The study finally enrolled 86 patients (aged 51.34 ± 5.82y), including 54 males and 32 females. Pathologic diagnosis identified 54 cases in the cancer group and 32 cases in the non-cancer group. Traditional judgment had a diagnostic sensitivity of 70.73% and specificity was 75.00%. Pixelated chromoendoscopy sensitivity was 80.49%, and specificity was 83.33%. The area under the receiver operating characteristic was 0.814, at a cutoff value of 0.625, indicating a good prediction effect. These results showed that pixelated chromoendoscopy might improve the rate of esophageal cancer diagnoses from early screening.

Familial aggregation of esophageal cancer.

Familial aggregation of esophageal cancer.

Civatte Bodies in Pediatric Esophageal Biopsies: Does Lichen Esophagitis Pattern Occur in Children?

Civatte bodies (CB) are associated with cutaneous and mucosal lichen planus in adults. They are a distinct feature of Lichen Esophagitis Pattern, which is not well described in children. We characterized clinicopathologic associations of archival esophageal CB at our Children's Hospital to determine whether lichen planus or Lichen Esophagitis Pattern occurs in children. Pathology records were queried for pediatric esophageal biopsy diagnoses containing "CB," "apoptosis, "necrosis," or "dyskeratosis." Cases with concurrent eosinophilic/acute esophagitis were excluded. H&E slides and clinical reports were reviewed. Biopsies with CB or similar were identified from 19 patients and had been termed "dyskeratotic cells" in 8 reports. Patients had variable age and presenting symptoms, male predominance (74%), and frequent clinical history of polypharmacy (47%), Crohn disease (42%), and/or celiac disease (21%). Civatte bodies were prominent in the distal esophagus (95%), as few isolated cells (63%), and with variable chronic inflammation (absent, pauci-inflammatory, and lichen planus-like in approximately one-third of cases each). We show that esophageal CB from pediatric patients are under-recognized and may have different features and implications compared to Lichen Esophagitis Pattern in adults. Recognition and documentation of pediatric esophageal CB is needed to understand their clinical significance.

Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0.

Chicago Classification has standardized clinical approach to primary esophageal motility disorders. With new clinical data and advancing treatments, Chicago Classification has undergone multiple revisions to reflect updated findings and enhance diagnostic accuracy. This review will describe the recently published Chicago Classification version 4.0 (CCv4.0), which aimed to enhance diagnostic characterization and limit overdiagnosis of inconclusive esophageal motility diagnoses. Key revisions outlined in CCv4.0 include (1) a modified standardized HRM study protocol performed in supine and upright positions, (2) recommended ancillary testing and manometric provocation for inconclusive manometric diagnoses (3) the required presence of obstructive symptoms for conclusive diagnoses of esophagogastric junction outflow obstruction, distal esophageal spasm and hypercontractile esophagus, and (4) requirement of confirmatory testing for esophagogastric junction outflow obstruction. These key modifications aim to improve diagnostic accuracy and consistency of clinically relevant esophageal motility disorders, and subsequently clinical outcomes.

A multi-stage machine learning model for diagnosis of esophageal manometry

High-resolution manometry (HRM) is the primary procedure used to diagnose esophageal motility disorders. Its manual interpretation and classification, including evaluation of swallow-level outcomes and then derivation of a study-level diagnosis based on Chicago Classification (CC), may be limited by inter-rater variability and inaccuracy of an individual interpreter. We hypothesized that an automatic diagnosis platform using machine learning and artificial intelligence approaches could be developed to accurately identify esophageal motility diagnoses. Further, a multi-stage modeling framework, akin to the step-wise approach of the CC, was utilized to leverage advantages of a combination of machine learning approaches including deep-learning models and feature-based models. Models were trained and tested using a dataset comprised of 1741 patients' HRM studies with CC diagnoses assigned by expert physician raters. In the swallow-level stage, three models based on convolutional neural networks (CNNs) were developed to predict swallow type and swallow pressurization (test accuracies of 0.88 and 0.93, respectively), and integrated relaxation pressure (IRP)(regression model with test error of 4.49 mmHg). At the study-level stage, model selection from families of the expert-knowledge-based rule models, xgboost models and artificial neural network(ANN) models were conducted. A simple model-agnostic strategy of model balancing motivated by Bayesian principles was utilized, which gave rise to model averaging weighted by precision scores. The averaged (blended) models and individual models were compared and evaluated, of which the best performance on test dataset is 0.81 in top-1 prediction, 0.92 in top-2 predictions. This is the first artificial-intelligence style model to automatically predict esophageal motility (CC) diagnoses from HRM studies using raw multi-swallow data and it achieved high accuracy. Thus, this proposed modeling framework could be broadly applied to assist with HRM interpretation in a clinical setting.

Validation of the Short-Form Esophageal Hypervigilance and Anxiety Scale

Esophageal hypervigilance and anxiety are emerging as important drivers of dysphagia symptoms and reduced quality of life across esophageal diagnoses. The esophageal hypervigilance and anxiety scale (EHAS) is a validated measure of these cognitive-affective processes. However, its length may preclude it from use in clinical practice. We aimed to create a short form version of the EHAS using established psychometric practices. A retrospective review of a registry of patients who visited a university-based esophageal motility clinic for diagnostic testing was conducted. Patients were included if they completed the 15-item EHAS and questionnaires assessing dysphagia severity and health-related quality of life (HRQOL) at the time of motility testing. Principle components factor analysis identified items for possible removal. Tests for reliability and concurrent validity were performed on the full EHAS and short-form version (EHAS-7). 3,976 adult patients with confirmed esophageal disease were included: 30% with achalasia or EGJOO, 13% with EoE, 13% with GERD, 39% normal motility. Eight items were removed from the scale based on a factor loading of > 0.70, resulting in a single scale 7-item EHAS-7 scored from 0 to 28. The EHAS-7 demonstrated excellent internal consistency (α = 0.91) and split-half reliability (0.88) as was found in the full EHAS in the current study and prior validation. Concurrent validity existed between the EHAS-7 and measures of dysphagia (r = 0.33) and HRQOL (r= -0.73, both P < .001). The EHAS-7 is a 7-item scale to assess esophageal hypervigilance and symptom-specific anxiety that performs as well as the original 15-item version. Shorter questionnaires allow for implementation in clinical practice. The EHAS-7 is a useful tool for clinicians to quickly assess how hypervigilance and anxiety may be contributing to their patients' clinical presentations.

The Clinical Utility of Provocative Maneuvers at Esophageal High-resolution Manometry (HRM).

Esophageal high-resolution manometry (HRM) assesses esophageal motor function and is indicated both for evaluation of esophageal symptoms and before antireflux interventions. HRM studies are interpreted and esophageal motor diagnoses made according to the Chicago Classification, version 3.0 algorithm, which is based on ten 5 mL supine water swallows. However, this practice of single liquid swallows performed in the supine position does not reflect typical "real-life" swallowing, and may not reproduce the patient's presenting symptoms. Therefore, provocative maneuvers at HRM-beyond these 10 standard swallows-can afford additional insights into esophageal motor function with clinically significant implications, and represent areas of exciting investigation and innovation. Accordingly, the 2020 American College of Gastroenterology Guidelines on Esophageal Physiologic Testing conditionally recommend their inclusion in the HRM protocol. In this clinical review, we discuss the supporting data for and clinical utility of provocative maneuvers at HRM that include changes in body position or accessories (upright swallows, "bridge" position, straight leg raise, abdominal compression), bolus consistency (solid swallows, test meals, postprandial high-resolution impedance manometry), bolus frequency (multiple rapid swallows), the volume of bolus (rapid drink challenge/multiple water swallows), and the use of pharmacological agents.

Diagnostic yield of esophagogastroduodenoscopy in France

Background and study aimsLarge scale data on esophagogastroduodenoscopy (EGD) in Western countries are scarce. We conducted a prospective study on the diagnostic yield of upper gastrointestinal endoscopy in France. Patients and methodsAn online questionnaire was sent to all French gastroenterologists practicing endoscopy. Data from EGDs performed during one week were collected. A statistical extrapolation of the results to a whole year was performed. Results342 gastrointestinal endoscopists, representative of the population of French gastroenterologists, provided data on 2735 EGDs, corresponding to 1 006 316 (95%CI=937 080−1 075 552) procedures for the entire year. 1770 (64.7%) EGDs were performed under sedation or general anesthesia, and 930 (34%) were associated with a colonoscopy. 896 (32.8%) EGDs were normal. Hiatal hernia and esophagitis were the most frequent esophageal diagnoses, in 496 (18.1%) and 374 (13.7%) cases, respectively. Barrett’s esophagus was diagnosed in 109 (4%) patients. Among gastric lesions, endoscopic gastritis was reported in 572 (20.9%) patients; ulcer, polyps, and suspected malignancy in 78 (2.9%), 62 (2.3%), and 19 (0.7%), respectively. 1597 (58.4%) EGDs included mucosal biopsies, and 141 (5.1%) were associated with a therapeutic procedure. ConclusionsWe report nationwide prospective data on upper gastrointestinal endoscopy practice in France. Our data suggest that about 300 000 normal EGDs each year in France could potentially be avoided by a diagnostic strategy relying on upper GI capsule endoscopy, providing significant relief on healthcare practitioners.

S0481 Overlap in Gastrointestinal Manifestations Among Small Fiber Neuropathy, Postural Tachycardia Syndrome, Ehlers-Danlos Syndrome, and Mitochondrial Disease Adult Patients

INTRODUCTION: Small fiber neuropathy (SFN) is characterized by damage to thinly myelinated A-delta and/or unmyelinated C-fibers in the peripheral nervous system; these fibers regulate automatic functions, including digestion. SFN is known to cause abnormalities in the neural control of smooth muscle, however, the gastrointestinal (GI) manifestations of these abnormalities have not been reported. Structural and functional small fiber abnormalities are common in patients with postural tachycardia syndrome (POTS), Ehlers-Danlos syndrome (EDS), and mitochondrial disease (MD), and clinicians frequently see overlapping GI manifestations in these patient populations. METHODS: Among adult (ages 18–74) patients, we examined the relative GI manifestations of SFN, POTS, EDS, and MD to determine whether these diseases have unique GI phenotypes. We conducted a retrospective cohort analysis of SFN (N = 506, 75.5% female), POTS (N = 255, 90.1% female), EDS (N = 413, 87.1% female), and MD (N = 175, 68.0% female) patients reporting GI symptoms presenting to an academic medical center between 2004 and 2019. Patient diagnoses were categorized by symptom clusters: esophageal, gastric, lower GI, and abdominal pain with examination of the frequency of individual diagnoses as well. RESULTS: Overall, GI diagnoses were common and most frequent in MD (92.0%) relative to POTS (86.7%), EDS (81.1%), and SFN (70.4%). Abdominal pain was common among all conditions, led by MD (69.1%) and POTS (61.2%) (Table 1). There were significant differences in symptom distribution across all disease groups (Figure 1): there was a relatively-even distribution of diagnoses in SFN, gastric diagnoses were most common in POTS (65.1%), esophageal diagnoses most common in EDS (43.8%), and esophageal diagnoses (70.9%) and lower GI diagnoses (69.1%) most common in MD. Among individual diagnoses, >50% of patients with POTS experienced nausea/vomiting, constipation, and abdominal pain and >50% of MD patients experienced GERD, nausea/vomiting, constipation, and abdominal pain. CONCLUSION: Despite similar demographics and chronic GI complaints, GI phenotypes differed significantly between patients with SFN, POTS, EDS, and MD. Patients with MD and POTS were most likely to present with GI complaints, with abdominal pain the most common manifestation among all of the disorders.Table 1.: Characteristics of adults patients diagnosed with SFN, POTS, EDS, or MD. Note. SFN = small fiber neuropathy; POTS = postural tachycardia syndrome; EDS = Ehlers-Danlos syndrome; MD = mitochondrial disease. 1. Continuous variables analyzed with ANOVA and categorical variables analyzed with Chi-Square TestFigure 1.: Overall prevalence of GI diagnoses in SFN, POTS, EDS, and MD patients. Note. Patients may have more than one diagnosis.

High-resolution Manometry Determinants of Refractoriness of Reflux Symptoms to Proton Pump Inhibitor Therapy.

Background/AimsImpaired esophageal motility and disrupted esophagogastric junction (EGJ) on high-resolution manometry (HRM) have been associated with increased reflux severity in gastroesophageal reflux disease (GERD) patients. However, there are limited data evaluating HRM parameters in proton pump inhibitors (PPI) non-responders.MethodsClinical and endoscopic data, HRM and multichannel intraluminal impedance-pH studies performed of PPI therapy in patients with typical GERD symptoms were reviewed from 3 international centers. Frequency of GERD symptoms was assessed on and off PPI therapy in both non-responders (< 50% symptom improvement on PPI therapy) and responders. Rome IV definitions identified non-erosive reflux disease, reflux hypersensitivity, and functional heartburn. Univariate and multivariate analyses were performed to determine predictors of non-response.ResultsOf 204 patients, 105 were PPI non-responders and 99 were responders. Non-responders showed higher EGJ contractile integral values, and a lower frequency of type II and III EGJ morphology (P ≤ 0.03 for each comparison). Esophageal body diagnoses on HRM (fragmented peristalsis, ineffective esophageal motility, or absent peristalsis) did not predict non-response. On multivariate analysis, non-pathological acid exposure time (OR, 2.5; 95% CI, 1.2-5.0; P < 0.001), normal mean nocturnal baseline impedance values (OR, 2.7-2.4; 95% CI, 1.0-6.1; P < 0.05), normal EGJ contractile integral values (OR, 3; 95% CI, 1.3-7.4; P = 0.012), and presence of type I EGJ morphology (OR, 1.9; 95% CI, 1.0-3.4; P = 0.044) were associated with an unfavorable response to PPIs.ConclusionsIntact EGJ metrics on HRM complement normal reflux burden in predicting non-response to PPI therapy. HRM has value in the evaluation of PPI non-responders.

Abstract D105: Differences in receipt of surgery contribute to survival disparities in esophageal and gastric cancers

Abstract Introduction: Mortality disparities for gastrointestinal cancers are well described. Differences in rates of surgery across race and ethnicity may contribute to this phenomenon. In order to evaluate this, we assessed the extent to which the mortality disparity among racial/ethnic groups for gastrointestinal cancers are due to differences in operative rates. Methods: Data for patients with stage I-III esophageal and gastric cancer diagnoses between 2004-2015 were obtained from National Cancer Database. Cancers were categorized in 3 groups: mid-esophageal (ME) cancers, distal third of esophagus and cardia gastric cancers (DEC), and non-cardia gastric (NCG) cancers. Variables included demographics, receipt of surgery, tumor stage and characteristics, and hospital factors. The racial disparity in survival was measured as the hazard ratio (HR) for Black, Latinx, and Asian/Pacific Islander patients compared to White patients. A mediation analysis was performed to quantify the contribution of variables to the observed disparity between minority and White patients. The magnitude of the contributions was estimated using two methods: the change in HR with (1) the addition of each variable of interest to a model only adjusted by age and year, and (2) the removal of each variable from a multivariate model that included all variables. Factors associated with undergoing surgery were also examined using a logistic regression model. Results: A total of 124,862 patients were included (20,852 with ME, 74,427 with DEC, and 29,583 with NCG). Black patients were more likely to be from lower-income and urban areas and had lower operative rates in all cancers. The observed HRs for Black patients compared to White patients were 1.42 (95% CI 1.36-1.49) for ME, 1.36 (1.31-1.43) for DEC and 1.01 (0.97-1.05 – no observed disparity) for NCG tumors, adjusting for age and year of diagnosis. Only Black race/ethnicity was associated with a mortality disadvantage compared to White patients. Without adjustment for any additional variables, receipt of surgery accounted for more than half of the observed survival disparity for tumors of the esophagus and cardia (ΔHRs for ME: 0.27, DECS: 0.25 and NCG: 0.07). After adjustment for tumor, patient and hospital factors, receipt of surgery remained the single strongest contributor to the Black/White disparity in survival for all cancers (ΔHRs for ME: 0.070, DEC: 0.091 and NCG: 0.07). On logistic regression, Black patients were less likely to have received surgery after adjusting for other variables compared to White patients (ME aOR: 0.41 (0.37-0.46), DECS aOR: 0.42 (0.39-0.46), and NCG aOR: 0.79 (0.73-0.86)). Conclusions: Observed survival disparities in upper GI cancers may be due to fewer surgeries being performed for Black patients. Addressing differences in receipt of surgery for stage I through III esophageal and proximal stomach cancer has potential to mitigate cancer mortality disparities. Citation Format: John Bliton, Peter Muscarella, Michael Parides, Katia Papalezova, John McAuliffe, Haejin In. Differences in receipt of surgery contribute to survival disparities in esophageal and gastric cancers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D105.

Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis.

Opioid receptors are present in the esophagus, and chronic opioid therapy may be associated with esophageal dysfunction. Given the current opioid epidemic in the United States, the potential contribution of opioids to esophageal dysmotility is important from both public health and patient care perspectives.Therefore our aim is toinvestigate the potentialcontribution of opioids to dysphagia and the prevalence of major motor disorders in patients undergoing manometric evaluation. The anonymized electronic medical records of patients linked to their de-identified high-resolution manometry (HRM) studies were reviewed. The patients were grouped based on their opioid exposure history at the time of HRM: opioid-naïve and chronic daily users. The oral morphine milligram equivalent daily dose (MMED) of opioids was computed. KEYRESULTS: 10% of patients referred for esophageal HRM were taking opioid analgesics on a chronic daily basis, and they had a significantly higher prevalence of dysphagia than their opioid-naïve counterparts. The chronic daily opioid users displayed a significantly higher prevalence of achalasia type 3 (ACH3) and esophagogastric junction outflow obstruction (EGJOO) motility phenotypes. The MMED of opioids was a significant predictor of esophageal pressure metrics and motility diagnoses (P<0.0001). Chronic daily opioid intake is associated with impaired deglutitive LES relaxation and disorganized peristaltic sequence. While a minority of patients on chronic daily opioid therapy present with major esophageal motor disorders, they comprise nearly half of ACH3 and a third of EGJOO motility phenotypes.

Evaluating the yield of gastrointestinal testing in pediatric patients in aerodigestive clinic.

To improve understanding of the interrelatedness of airway and esophageal diagnoses by evaluating the yield of procedural and radiographic testing of the gastrointestinal tract in children with airway conditions by their referring diagnoses in a pediatric aerodigestive clinic. A retrospective chart review of all 325 patients seen in the aerodigestive program from 2010 to 2013 was performed in a single academic medical center. Demographics and results from esophagogastroduodenoscopies with biopsies (EGD), upper gastrointestinal fluoroscopy studies (UGI), and pH multichannel intraluminal impedance probe (pH-MII) performed within 30 days of the clinic visit were evaluated according to presenting diagnoses. Mean patient age was 3.15 years (range 0.15-24 years) and 41.2% were born premature. 189/325 (58.1%) were on acid suppression. A total of 295 EGD, 193 pH-MII, and 54 UGI were performed. The most common diagnosis with an abnormal pH-MII was asthma. The most common diagnoses with an abnormal EGD were feeding difficulty and tracheal esophageal fistula/ esophageal atresia (TEF/EA). EGDs were normal in 188/295 (63.7%), while 39/295 (13.2%) demonstrated esophagitis, and 22/295 (7.5%) had >15 esophageal eosinophils per high power field. The majority of pH-MII (144/193 [74.6%]) and UGI (47/54 [87%]) were normal. Children with feeding difficulty, TEF/EA, and asthma were the mostly likely to have a histologic abnormality on EGD or an abnormal pH-MII. The majority of children were previously prescribed acid suppression medication and had a referring diagnosis of gastroesophageal reflux disease but were subsequently found to have normal evaluation. Prospective studies are needed to optimize care of this population.

Preoperative Gastroesophageal Reflux Disorder Is Associated With Increased Morbidity in Patients Undergoing Abdominal Surgery

BackgroundIn North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. MethodAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP–targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP–targeted procedure groups, and open versus laparoscopic surgery. ResultsOf 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P < 0.001). ConclusionsPreoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.

How to use Rome IV criteria in the evaluation of esophageal disorders.

In 2016, the Rome IV process and criteria were published. They provide a system to standardize patient diagnostic requirements for clinical studies and pharmaceutical trials on functional gastrointestinal disorders (FGIDs), which are now called disorders of gut-brain interaction (DGBI). Although the Rome criteria have limitations in clinical practice, an understanding of the criteria can help clinicians to manage symptoms in patients with DGBI, and with organic diseases as well. In this report, the Rome IV criteria for esophageal DGBI, the updated algorithms for esophageal symptoms, and the multidimensional clinical profile (MDCP) are reviewed. The esophageal DGBI comprise functional esophageal chest pain, functional heartburn, globus, functional dysphagia, and the newly introduced reflux hypersensitivity. They are characterized by the presence of chronic symptoms attributed to the esophagus without evidence of esophageal structural, inflammatory, or motility abnormalities. Also, Rome IV suggests for the first time the possibility that functional heartburn or reflux hypersensitivity might overlap with gastroesophageal reflux disease. Accordingly, testing with endoscopy and biopsies, esophageal pH ± impedance monitoring and high-resolution esophageal manometry are necessary to establish esophageal DGBI diagnoses. Algorithms aid in this diagnostic process, and the MDCP that captures the full dimension of each patient's presentation is helpful in planning personalized treatment regimens.

Trends in diagnoses after implementation of the Chicago classification for esophageal motility disorders (V3.0) for high-resolution manometry studies

To determine trends in the diagnostic distribution of esophageal motility disorders after implementation of the Chicago Classification Version 3.0 (CC V3.0) for interpretation of high-resolution manometry (HRM) studies compared to non-Chicago Classification criteria. Retrospective trends analysis of patients with an HRM study conducted at a single center from January 1, 2013 to September 30, 2015. The implementation of the CC V3.0 for manometry interpretation occurred in September 2014. Patient charts were manually reviewed for data collection including demographics and HRM diagnoses. The prevalence and relative risks (RR) of CC V3.0 diagnostic categories (i.e. normal, indeterminate, achalasia, and EGJ outflow obstruction [EJGOO], and major and minor motility disorders) were calculated before and after CC V3.0 implementation. Four hundred sixty-five HRM studies were included in the study including 268 before and 179 after CC V3.0 implementation. The mean ± SD age was 54±15.4 years and 59.8% were female (n =278). The percentage with indeterminate diagnosis decreased from 35.3% before CC V3.0 implementation to 16.8% after implementation (adjusted RR 0.5, 95%CI 0.30-0.70, p <0.001). The percentage with a major motility disorders decreased from 13.9% to 7.3% (adjusted RR 0.5, 95%CI 0.2-1.0, p <0.001). The percentage with EJGOO and minor diagnoses increased from 1.4% to 14.5% and 11.9% to 22.9%, respectively. The percentage with achalasia and normal diagnosis did not change over the study period. Implementation of CCV3.0 was associated with changes in the distribution of esophageal motility diagnoses in clinical practice. The percentage of indeterminate and major diagnosis decreased and EGJOO and minor diagnoses increased. The decrease in the number of indeterminate studies suggests that the CC V3.0 may clarify the criteria for the interpreting physician. The increase in studies with a diagnosis of EGJ outflow obstruction may reflect the heterogeneity of disorders with clinically relevant outflow obstruction.

Prediction of esophageal and gastric histology by macroscopic diagnosis during upper endoscopy in pediatric celiac disease.

AIMTo determine the sensitivity of macroscopic appearance for predicting histological diagnosis at sites other than duodenum in pediatric celiac disease (CD).METHODSEndoscopic and histologic findings in pediatric patients undergoing upper endoscopy for first-time diagnosis of CD at Stollery Children’s Hospital from 2010-2012 were retrospectively reviewed.RESULTSClinical charts from 140 patients were reviewed. Esophageal and gastric biopsies were taken in 54.3% and 77.9% of patients, respectively. Endoscopic appearance was normal in the esophagus and stomach in 75% and 86.2%. Endoscopic esophageal diagnoses were eosinophilic esophagitis (EE) (11.8%), esophagitis (7.9%), glycogenic acanthosis (1.3%) and non-specific abnormalities (3.9%). Endoscopic gastric diagnoses were gastritis (8.3%), pancreatic rest (0.9%), and non-specific abnormalities (4.6%). Histology was normal in 76.3% of esophageal and 87.2% of gastric specimens. Abnormal esophageal histology was EE (10.5%), esophagitis (10.5%), glycogenic acanthosis (1.3%) and non-specific (1.3%). Gastritis was reported in 12.8% of specimens. Sensitivity and specificity of normal endoscopy for predicting normal esophageal histology was 86.2% and 61.1%, and for normal gastric histology was 87.4% and 21.4%.CONCLUSIONIn the absence of macroscopic abnormalities, routine esophageal and gastric biopsy during endoscopy for pediatric CD does not identify major pathologies. These findings have cost and time saving implications for clinical practice.

Impact of symptom burden and health-related quality of life (HRQOL) on esophageal motor diagnoses.

High-resolution manometry (HRM) categorizes esophageal motor processes into specific Chicago Classification (CC) diagnoses, but the clinical impact of these motor diagnoses on symptom burden remain unclear. Two hundred and eleven subjects (56.8±1.0years, 66.8% F) completed symptom questionnaires (GERDQ, Mayo dysphagia questionnaire [MDQ], visceral sensitivity index, short-form 36, dominant symptom index, and global symptom severity [GSS] on a 100-mm visual analog scale) prior to HRM. Subjects were stratified according to CC v3.0 and by dominant presenting symptom; contraction wave abnormalities (CWA) were evaluated within "normal" CC. Symptom burden, impact of diagnoses, and HRQOL were compared within and between cohorts. Major motor disorders had highest global symptom burden (P=.02), "normal" had lowest (P<.01). Dysphagia (MDQ) was highest with esophageal outflow obstruction (P=.02), but reflux symptoms (GERDQ) were similar in CC cohorts (P=ns). Absent contractility aligned best with minor motor disorders. Consequently, pathophysiologic categorization into outflow obstruction, hypermotility, and hypomotility resulted in a gradient of decreasing dysphagia and increasing reflux burden (P<.05 across groups); GSS (P=.05) was highest with hypomotility and lowest with "normal" (P=.002). Within the "normal" cohort, 33.3% had CWA; this subgroup had symptom burden similar to hypermotility. Upon stratification by symptoms, symptom burden (GSS, MDQ, HRQOL) was most profound with dysphagia. Chicago Classification v3.0 diagnoses identify subjects with highest symptom burden, but pathophysiologic categorization may allow better stratification by symptom type and burden. Contraction wave abnormalities are clinically relevant and different from true normal motor function. Transit symptoms have highest yield for a motor diagnosis.