Esophageal Function Research Articles

S0448 Characterizing Regurgitation and Heartburn Symptoms in Patients Undergoing High Resolution Esophageal Manometry With Esophageal pH-Impedance Monitoring

INTRODUCTION: Studies that characterize GERD often fail to describe regurgitation as well as they do heartburn. The study aims to: 1) describe the frequency and severity of heartburn and regurgitation in patients referred for esophageal function evaluation; 2) describe the esophageal disorders with these symptoms; and 3) investigate the pathophysiology of these symptoms. METHODS: We retrospectively reviewed data from patients undergoing High Resolution Esophageal Manometry with Impedance (HREMI) and Esophageal pH Impedance monitoring (EpHI) between December 2019 and March 2020. Patients filled out the Reflux Disease Questionnaire (RDQ) and the Patient Assessment of Upper GI symptoms (PAGI-SYM). The RDQ evaluates both severity and frequency of heartburn, regurgitation, and dyspeptic symptoms. Mean symptom severity was calculated as (symptom frequency [days per week] x symptom intensity)/7 (scoring is from 0 to 3). RESULTS: Of the 171 patients (average age 55 ± 15 years; 69% female), 164 completed HREMI (7 were unable to tolerate procedure) and 108 completed EpHI. 74 were determined to have GERD by esophageal acid exposure time and/or impedance episodes. Regurgitation movement (RDQ score 0.8; present in 52%) and regurgitation taste (RDQ score 0.6; present in 48.5%) was more prevalent than substernal burning (RDQ score 0.5, present in 35.1%) and substernal pain (RDQ score 0.5, present in 35.1%). Regurgitation taste correlated with regurgitation movement (r = 0.50, P < 0.001), substernal burning (r = 0.53, P < 0.001), and substernal pain (r = 0.39, P < 0.001). Acid exposure time correlated with substernal burning (r = 0.22, P = 0.029) and dyspepsia burning (r = 0.26, P = 0.010). The presence/absence of a hiatal hernia (HH) did not affect regurgitation symptoms. Patients with GERD had similar LES pressures (P = 0.09), hiatal hernia sizes (P = 0.07), and RDQ symptoms. Regurgitation was present in 47% of patients with ineffective esophageal motility, 20% with absent contractility, 33% achalasia, and 39% with no abnormalities (P = 0.21). CONCLUSION: Regurgitation is correlated with heartburn and dyspepsia. It is a common symptom of patients undergoing HREMI and EpHI and is present in many disorders. Additionally, increasing acid exposure was related to substernal burning and dyspepsia burning but was not correlated to regurgitation.(image 3) These results suggest that although acid suppression therapy may be helpful for heartburn, it may not be helpful for treating regurgitation.Table 1Table 2Figure 1

S0401 Higher Rates of Chronic Opioid Use Found in Patients With Esophagogastric Junction Outflow Obstruction Compared to Controls

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is defined by the Chicago Classification of Esophageal disorders (CC) as an incomplete relaxation (elevated median IRP) along with an intact or weak peristalsis. There are a number of etiologies of EGJOO, from medication effects to mechanical processes. Preliminary studies have suggested that opioids may impair lower esophageal function. The aim of our study was to assess this in a patient population by comparing the frequency of chronic opioid use in patients diagnosed with EGJOO versus patients with normal manometries. METHODS: 12 months of High-Resolution Manometry (HRM) results from a single academic center (Wake Forest Baptist Medical Center) were reviewed. Studies were designated as normal or EGJOO based on CCv3. Retrospectively, all patient’s home medications were examined, with a focus on prescription opioids. Patients who were prescribed daily opioids for greater than 6 months leading up to their HRM were labeled as chronic opioid users. The number of chronic opioid users in the normal result group were compared to the number of chronic opioid users in the EGJOO group. RESULTS: After reviewing the HRM results, 121 patients had normal manometries and 121 patients were found to have HRM consistent with EGJOO. After reviewing patient’s medication lists, 9 of the normal manometry group were found to have chronic daily opioid use (7.44%), while 20 of the EGJOO group were found to have chronic opioid use (16.53%). Using a chi square analysis, it was found there was a statistically significant difference (P-value 0.0294, P < 0.05) in number of chronic opioid users found in the EGJOO group (16.53%) compared to the group with normal HRM findings (7.44%). Table 1 summarizes the demographics. Table 2 details the initial chief complaint of the patients. CONCLUSION: In our study, chronic opioid use was found to be more prevalent in patients with the manometric diagnosis EGJOO than those with normal manometries. These results support chronic opioid use as a suspected etiology in EGJOO. As daily opioid use has become more common in recent decades, disorders of esophageal motility are one of the many adverse effects. This supports a trial off opioids in patients diagnosed with EGJOO with dysphagia to assess if symptoms resolve. Identifying opiates as a potential etiology, and improvement of symptoms after discontinuation of medications could potentially prevent other unnecessary procedures or therapies.Table 1.: DemographicsTable 2.: Chief Complaints

Esophageal Involvement and Determinants of Perception of Esophageal Symptoms Among South Koreans With Systemic Sclerosis.

Background/AimsOur study aims to characterize esophageal motor function; evaluate the relationships among esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), and 24-hour esophageal multichannel intraluminal impedance monitoring combined with pH-metry (MII-pH); and elucidate the determinants of esophageal symptom perception in South Koreans with systemic sclerosis (SSc).MethodsWe reviewed prospectively collected HRM (n = 46), EGD (n = 41), and MII-pH (n = 37) data from 46 consecutive patients with SSc (42 females; mean age 50.1 years) who underwent esophageal tests between June 2013 and September 2018.ResultsThe most common HRM diagnosis was normal (39.1%), followed by ineffective esophageal motility (23.9%) and absent contractility (21.7%). Erosive esophagitis was observed in 12.2% of total SSc patients, with a higher frequency in patients with absent contractility than those with normal motility (44.5% vs 0.0%, P = 0.01). Pathologic acid exposure was observed in 6 patients (20.0%) and positive symptom association in 18 patients (60.0%) in MII-pH tests of symptomatic patients. The proportion of SSc patients with esophageal symptoms not explained by reflux or mucosal or motor esophageal abnormalities was 33.0%.ConclusionsEsophageal involvement among South Koreans with SSc was characterized by heterogeneous motility patterns, with a higher prevalence of normal motility and lower prevalence of erosive esophagitis. Reflux hypersensitivity or functional heartburn might be partly attributed to the perception of esophageal symptoms in SSc patients who have neither gastroesophageal reflux disease nor esophageal dysmotility.

Mechanisms of Esophageal and Gastric Transit Following Sleeve Gastrectomy.

Sleeve gastrectomy (SG) patients have substantially altered anatomy. The mechanism of rapid gastric emptying and the role of esophageal contractile function in esophago-gastric transit has not been defined. We aimed to determine the mechanisms of esophago-gastric transit and role of esophageal function following sleeve gastrectomy. Prospective study of twenty-six asymptomatic participants post SG underwent nuclear scintigraphy and high-resolution manometry. Fourteen had semi-solid stress barium to model the emptying process. Concurrent video fluoroscopy and manometry were performed on 7 participants. Demographic data are as follows: age 45.3 ± 15.0years, 73.1% female, excess weight loss 62.2 ± 28.1% at 8months. Scintigraphy showed rapid gastric emptying (24.4 ± 11.4 vs. 75.80 ± 45.19min in control, p < 0.001) with 35.24 ± 17.12% of bolus transited into small bowel on initial frame. Triggered deglutitive reflux was common (54.4% vs. 18.2%, p = 0.017). Stress barium delineated separate vertical and antral gastric compartments with cyclical emptying of 8 stages, including reflux-induced repeated esophageal peristalsis. During manometry, ramping effects were noted, with sequential swallows producing sustained isobaric pressurizations in proximal stomach (33.6 ± 29.5mmHg). Video fluoroscopy showed individual esophageal peristalsis generating pressurizations at 5.0 ± 1.4cm below lower esophageal sphincter (LES), at amplitude of 31.6 ± 13.1mmHg, associated with intragastric transit. Pressurizations were sustained for 17.3 ± 8.2s, similar to the prolonged LES contraction (18.5 ± 9.0s, p = 0.355). Repeated esophageal peristaltic contractions induced isobaric pressurization of proximal stomach, thus providing the drive to pressurize and empty the vertical compartment of the gastric sleeve. Transit following SG appeared to be esophageal-mediated and followed a distinct cycle with strong associations with reflux.

356 DIVERTICULECTOMY WITH EXTEND MYOTOMY AND ANTERIOR FUNDOPLICATION AS TREATMENT OF INTRATHORACIC ESOPHAGEAL DIVERTICULUM. CASE REPORT AND REVIEW!

Abstract Diverticula of the thoracic esophagus are uncommon disorders and its most appropriate treatment continues unclear. The majority of these diverticula are results of underlying esophageal motility disorders, but some cases are results of periesophageal inflammation. The patients can be asymptomatic, or present dysphagia, regurgitation, aspirated pneumonia, retrosternal pain and weight loss. The barium esophagogram is considered the best study to show and evaluate these cases. Esophageal manometry allow study the esophageal motility abnormality. Methods Patients with small and asymptomatic diverticula could not require any treatment. Patients with symptomatic or big diverticula should be submitted a diverticulectomy and often with an esophageal myotomy. However the necessity, the esophageal extension and local of the myotomy are still unclear. We describe a case of a 70 yo woman with a intrathoracic esophageal diverticulum. She presented progressive dysphagia to solids in the last two years, associated to regurgitation, retrosternal pain, nausea and weight loss of 10 kilograms. She has no history of aspirated pneumonia. Results The upper GI endoscopy showed the diverticulum in middle esophagus (25 cm from superior dental arch) and the size in barium esophagogram was 6,5 x 4,8 cm. The high resolution esophageal manometry was normal and the patient had no tuberculosis history. She was submitted a thoracoscopic diverticulectomy with extend myotomy (intrathoracic and abdominal) and Dor’s fundoplication. She was able to resume a liquid diet by day 3, after a normal barium esophagogram, and was discharged at the 4 post-operative day. After 9 months the patient remains asymptomatic. Conclusion In our experience, the diverticulectomy associated with an extend myotomy bring excellent results at the esophageal function, allowing an adequate emptying of the esophagus, avoiding severe complications as mediastinitis or esophageal leakage even in patients without severe motility disorder.

534 WHICH IS THE BEST SURGICAL MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN PATIENTS WITH SYSTEMIC SCLEROSIS WITH PULMONARY INVOLVEMENT?

Abstract Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility (ED). Antireflux surgery have to considerate the individual esophageal dysmotility degree of each patient. They need GERD treatment as a priority to help control worsening lung function, in patients developing pulmonary fibrosis or in lung transplantation patients. Another issue is the possibility that fundoplications in this patients can cause esophageal stasis, an event that can also disrupt lung function. Methods 113 patients were referred for surgical treatment of GERD, related with pulmonary impairment. SS patients are the most critical, once the ED may be an obstacle to fundoplication. We divided this patients in three groups regarding the esophageal function. A- Partial fundoplication—without important affection of ED, checked by manometry, confirmed with a complete emptying of esophagus in barium swallow test. B- Laparoscopic gastric bypass for treatment of GERD (RYGBP)—aperistalsis or atonic esophageal body, with normal esophageal empty at barium test. C- Esophagectomy—Atonic esophageal body with important delayed emptying of esophagus in barium swallow test. Results We could follow up 4 patients in group A, 3 patients in group B and 2 patients in group C. Median follow-up was 75, 30 and 18 months for Groups A,B and C respectively. All 3 patients in the RYGB group resolved all the symptoms including heartburn and regurgitation, with a sensitive improve in lung function. Only 1 patients in the fundoplication group reported symptom improvement or resolution. The Patients at Group C have no complain of Dysphagia but referred regurgitation and difficulty feedingtill first year. Conclusion Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients with esophageal dysmotility. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication and esophagectomy.. This finding suggests that RYGBP may be an option for the primary manage- ment of scleroderma-associated gastroesophageal reflux in patients without importnat impairing of esophageal emptying.

372 ESOPHAGEAL BODY PERISTALSIS CORRELATES FOR DYSPHAGIA AND REGURGITATION: AN ASSESSMENT BASED ON BARIUM ESOPHAGRAM

Abstract Because it offers real-time assessment, barium esophagram should be the modality of choice when studying esophageal peristalsis. However, no standard reporting method is available for BE results. Presently, peristaltic disorders are defined according to high-resolution manometry (HRM), but HRM findings do not correlate with clinical symptoms. The aim of this study was to stratify esophageal peristaltic function via standardized evaluation of BE, and to define the association between esophageal peristalsis and dysphagia and regurgitation. Methods After IRB approval, a prospectively maintained database was reviewed for patients who underwent both HRM and BE from 08/01/2016 to 12/31/2019. Patients with conditions associated with outflow impairment were excluded. BEs were re-examined in blinded fashion and assigned subjective scores (0, 1, or 2) for dilation grade (DG) and contractility grade (CG). Patients were categorized according to the sum of the DG and CG: Group A = 0, Group B = 1–2, and Group C = 3–4. Mean distal contractile integral (DCI), number of failed contractions on HRM, and number of patients with dysphagia/regurgitation in each group were analyzed and compared. Results In all, 124 patients were included. The mean DCI (mmHg*cm*s) was 2539.1 ± 1357.8 in Group A, 884.4 ± 916.9 in Group B, and 77.4 ± 192.3 in Group C (p &amp;lt; 0.001). The mean number of failed contractions were 0.7 ± 1.3, 3.4 ± 3.4, and 8.6 ± 3.2, respectively (p &amp;lt; 0.001). Table 1 shows the distribution of patients with dysphagia or regurgitation across groups. The proportion of patients with dysphagia in Group C was higher than in Groups A or B (OR 3.75, p = 0.02; and OR 2.58, p = 0.07, respectively). Similarly, Group C was significantly more often associated with regurgitation than in Groups A or B (OR 4.69, p = 0.009; and OR 4.42, p = 0.005). Conclusion The combined DG and CG allowed us to identify the patients with a grade of peristaltic disfunction that was significantly more associated with dysphagia or regurgitation (Group C). However, in order to achieve a clearer definition of the different peristaltic disfunction levels according to their propensity to cause dysphagia or regurgitation, a more objective assessment of both DG and CG should be provided; therefore, further studies are required.

572 NUTRITIONAL PATTERNS MAY AFFECT ESOPHAGEAL ACID EXPOSURE, AND THE NUMBER AND TYPE OF GASTROESOPHAGEAL REFLUXES

Abstract The role of nutritional patterns on esophageal function testing parameters is not widely studied. Earlier published data focused on symptoms of GERD and their association with the food structure. Aim of the study was to assess the influence of nutritional patterns on esophageal acid exposure and types and number of gastroesophageal refluxes Methods The data of complete examination of 165 participants served as a source data for the study. Diagnosis of GERD was based on clinical data (heartburn and acid regurgitation at least once a week for not less than 6 month, actual during last 3 month, history of effective PPI treatment), GERD-Q questionnaire (≥8 points), endoscopic evaluation (Excera II, Olympus, Japan) and 24-hours esophageal pH-impedance studies (Ohmega, MMS, the Netherlands; 2 pH, 6 impedance catheters, UnisensorAG, USA). Food frequency questionnaire was used to analyse food structure. StatSoft (USA) software was used for correlation analysis. The work has been performed within RSF 19–76-30014. Results We enrolled 124 GERD patients and 41 controls. Significant (P &amp;lt; 0.05) correlation of AET was with energy value of the ration (Spearman rank R = 0.19), amount of fat (R = 0.2). Significant correlation of number of GERs was with energy values (R = 0.35), protein (R = 0.3), fat (R = 0.33), alcohol (R = 0.28) and dietary fibre (R = -0.22) consumption. Number of acid GERs correlated with calorie (R = 0.35), fat (R = 0.32), protein (R = 0.25), carbohydrates (R = 0.24) and alcohol (R = 0.24) consumption. Number of weak-acid GERs correlated with calories (R = 0.22), fat (R = 0.21), protein (R = 0.22), alcohol (R = 0.23) and dietary fibre (R = -0.24) consumption. High GERs correlated with fat (R = 0.3), protein (R = 0.22), alcohol (R = 0.25) and fibre (R = -0.25). Conclusion High energy value, consumption of fat and alcohol showed direct medium-strength correlation with esophageal acid exposure and the total number gastroesophageal refluxes. The total number of gastroesophageal refluxes, number of weak acid and high gastroesophageal refluxes had inverse correlation with the amount of dietary fibre consumed. Found trends are used to establish nutritional patterns for reflux events in GERD patients.

Updates on diagnostic modalities for esophageal dysphagia.

Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.

Safe esophageal function testing during the COVID‐19 pandemic: A modified surgical mask for patients

Safe esophageal function testing during the COVID‐19 pandemic: A modified surgical mask for patients

Long-term outcomes of Roux-en-Y gastric diversion after failed surgical fundoplication in a large cohort and a systematic review

Roux-en-Y gastric diversion (RNYG) is an alternative approach for patients with persistent or recurrent gastroesophageal reflux disease (GERD) after surgical fundoplication, especially in patients with esophageal dysmotility or morbid obesity, because redo fundoplication could offer unfavorable outcomes. To evaluate long-term outcomes of RNYG for failed fundoplication and its impact on esophageal function. A retrospective cohort study and a systematic review. Patients who underwent RNYG after failed fundoplication between 1995 and 2019 were identified. Surgical-related complications, GERD, dysphagia, and endoscopic and esophageal manometric findings were reviewed. A literature search for relevant studies was performed from several databases from database inception to September2019. A total of 101 patients (mean age, 52.1 yr; 86.1% female; mean body mass index, 35.8kg/m2) were included. Overall complication rates within and more than 30 days after surgery were 36.3% and 53.5%. GERD symptoms were resolved in 70.1% after RNYG. However, 39.7% had a recurrence during a median follow-up of 56.2 months. In patients with no baseline dysphagia (n = 36), 16 (44%) developed new-onset dysphagia after surgery. In patients with severe baseline dysphagia (n = 9), 5 patients (56%) had persistent dysphagia after surgery. Seven studies involving 381 patients were included in our systematic review. High rates of GERD improvement have been reported across studies; however, long-term GERD, dysphagia, and objective outcomes were infrequently reported. RNYG is an effective alternative surgery in a subset of patients with intractable symptoms who failed fundoplication. However, patients should be informed of the risks of postoperative GERD symptoms and dysphagia. Referral for a careful evaluation by a multidisciplinary foregut team is warranted.

Clinical characteristics and esophageal motility in Sjögren's syndrome: A single‐center study in Taiwan

AbstractSjögren's syndrome is an autoimmune disease that may cause inflammation of exocrine glands, including the salivary glands. Some patients with Sjögren's syndrome also have gastrointestinal disease, such as gastroesophageal reflux disease. A few studies have shown that an association might exist between Sjögren's syndrome and esophageal motility disorder, but the results have been inconsistent. This study aimed to investigate the relationships between clinical symptoms and esophageal motility function in patients with Sjögren's syndrome. Fifty‐six patients with suspected esophageal reflux or motility disease who had undergone esophagogastroduodenoscopy and esophageal manometry were retrospectively enrolled. Thirteen patients were diagnosed as having Sjögren's syndrome according to the American‐European Consensus Criteria. Forty‐three patients without any rheumatic disease or esophageal motor disorder were designated as the control group. We compared the clinical symptoms and endoscopic and esophageal manometric findings between the Sjögren's syndrome and the control groups. Acid regurgitation was more prevalent in the Sjögren's syndrome group (53.8%) than in the control group (11.6%) (P = .003), but the endoscopic findings of reflux esophagitis were similar in both groups (Sjögren's: 38.5%; control: 39.5%; P = .945). Barrett's esophagus was more prevalent in the Sjögren's syndrome group than in the control group (15.4% vs 0%, respectively; P = .051). The upper esophageal sphincter was shorter in the Sjögren's syndrome group than in the control group (2.38 ± 0.65 cm vs 3.07 ± 0.74 cm, respectively; P = .003). More reflux symptoms and distinct motility patterns were found in the Sjögren's syndrome group as compared with the control subjects.

Esophageal Pathophysiologic Changes and Adenocarcinoma After Bariatric Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION:To assess the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on acid reflux and esophageal motor function and to evaluate the observation of esophageal adenocarcinoma (EAC) after bariatric surgery.METHODS:We searched 5 databases for adults who underwent SG or RYGB and had esophageal pH test and/or esophageal manometry before and after surgery. A separate systemic search of observational studies and a retrospective review at 3 institutions of adults who developed EAC after these surgeries were conducted. Outcomes were changes in manometric and pH parameters and EAC cases after SG and RYGB.RESULTS:A total of 27 nonrandomized studies (SG: 612 patients; RYGB: 470 patients) were included. After SG, lower esophageal sphincter pressure and esophageal body amplitude were decreased and the risk of ineffective esophageal motility was increased. Total and recumbent acid exposure times were increased. After RYGB, an increased risk of ineffective esophageal motility was observed. Total, upright, and recumbent acid exposure times were decreased. The total reflux episodes remained unchanged but with increased nonacid reflux and decreased acid reflux events. Including our largest series, 31 EAC cases have been reported to date after SG and RYGB.DISCUSSION:This systematic review demonstrates increased acid reflux after SG and decreased acid reflux after RYGB. An observed increased nonacid reflux after RYGB might contribute to failure of gastroesophageal reflux disease improvement. This refluxate might be noxious to the esophagus, warranting further studies. RYGB might not entirely preserve esophageal function as previously believed.

Derangement of esophageal anatomy and motility in morbidly obesepatients: a prospective study based on high-resolution impedancemanometry.

Morbidly obese patients often suffer from gastroesophageal reflux disease (GERD). High-resolution impedance manometry (HRIM) allows a comprehensive evaluation of esophageal motility and esophagogastric junction (EGJ) morphology and helps to clarify GERD pathophysiology. To evaluate the esophageal function and EGJ anatomy in morbid obesity by HRIM. University Hospital, Taiwan. We consecutively enrolled 57 morbidly obese patients planning to undergo bariatric surgery and 58 healthy volunteers in this prospective study. All patients responded to validated symptom questionnaires and underwent fasting blood tests, HRIM, and esophagogastroduodenoscopy. We compared anthropometric and HRIM parameters between the 2 groups, and analyzed correlations between the GERD symptom scores and clinical variables in the obese patients. The obese patients, comprising 30 males (53%), had a median age of 35 years and body mass index of 40.5 kg/m2. The 4-second integrated relaxation pressure in the lower esophageal sphincter was significantly higher in the patients than the volunteers (median: 10.8 versus 5.6 mm Hg; P < .001). EGJ outflow obstruction and ineffective esophageal motility were diagnosed in 16% and 11% of the patients, respectively, versus 5% and 28% of the volunteers (P = .022). Manometric hiatal hernia (m-HH) was present in 19 (33%) of the patients and none of the volunteers; all m-HH were associated with erosive esophagitis. Most of the patients were considered as no GERD by the validated questionnaires, regardless of the presence of m-HH and erosive esophagitis. The obese patients had a higher lower esophageal sphincter 4-second integrated relaxation pressure and higher prevalence of EGJ outflow obstruction and m-HH than the healthy volunteers. The presence of m-HH was strongly associated with erosive esophagitis. The absence of GERD symptoms in morbid obesity was not necessarily suggestive of negative esophagogastroduodenoscopy and HRIM findings, and the discrepancy existed between esophagogastroduodenoscopy and HRIM for diagnosing HH. A comprehensive evaluation of the EGJ anatomy and esophageal function may be considered before bariatric surgery.

Optimal management of severe symptomatic gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a common disorder, and empirical proton pump inhibitor (PPI) treatment is often the first step of management; however, up to 40% of patients remain symptomatic despite PPI treatment. Refractory reflux refers to continued symptoms despite an adequate trial of PPI, and management remains challenging. The differential diagnosis is important; other oesophageal (e.g. eosinophilic oesophagitis) and gastroduodenal disorders (e.g. functional dyspepsia) should be ruled out, as this changes management. A combination of clinical assessment, endoscopic evaluation and in selected cases oesophageal function testing can help characterize patients with refractory reflux symptoms into oesophageal phenotypes so appropriate therapy can be more optimally targeted. Medical options then may include adding a H2 receptor antagonist, alginates, baclofen or antidepressant therapy, and there is emerging evidence for bile acid sequestrants and diaphragmatic breathing. The demonstration of a temporal association of symptoms with reflux events on pH-impedance testing (reflux hypersensitivity) serves to focus the management on modulating oesophageal perception and reducing the reflux burden, or identifies those with no obvious pathophysiologic abnormalities (functional heartburn). Anti-reflux surgery based on randomized controlled trial evidence has a role in reflux hypersensitivity or continued pathological acid reflux despite PPI in carefully considered, fully worked up cases that have failed medical therapy; approximately two of three cases will respond but there is a small risk of complications. In patients with persistent volume reflux despite medical therapy, given the lack of alternatives, anti-reflux surgery is a consideration. Promising newer approaches include endoscopic techniques. This review aims to summarize current diagnostic approaches and critically evaluates the evidence for the efficacy of available treatments.

Recent insights into the biology of Barrett's esophagus.

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), an aggressive cancer with a poor prognosis. Our understanding of the pathogenesis and Barrett's metaplasia is incomplete, and this has limited the development of new therapeutic targets and agents, risk stratification ability, and management strategies. This review outlines current insights into the biology of BE and addresses controversies surrounding cell of origin, cellular reprogramming theories, updates on esophageal epithelial barrier function, and the significance of goblet cell metaplasia and its association with malignant change. Further research into the basic biology of BE is vital as it will underpin novel therapies and improve our ability to predict malignant progression and help identify the minority of patients who will develop EAC.

Computerized Learning Is a Building Block But We Still Have Far to Go.

High-resolution manometry has revolutionized the diagnosis and treatment of esophageal motility disorders. The color plots are consistent with the visual pattern recognition that makes up much of our endoscopic training in gastroenterology. Computerized learning is an important addition to teaching this skill, especially because most gastroenterology training programs offer meager motility expertise and experience. However, it is just a basic building block for the development of young esophageal and motility experts. It is a good beginning, but the trainee needs a thorough understanding of the limitations of HRM, the important role of other esophageal function tests, and how best to incorporate these tests into a multidiscipline care plan for patients. The best approach is not technology alone but how it is applied by a master clinician in a busy esophageal center of excellence.

Esophageal physiology-an overview of esophageal disorders from a pathophysiological point of view.

The esophagus serves the principal purpose of transporting food from the pharynx into the stomach. A complex interplay between nerves and muscle fibers ensures that swallowing takes place as a finely coordinated event. Esophageal function can be tested by a variety of methods, endoscopy, manometry, and reflux monitoring being some of the most important. Regarding pathophysiology, motor disorders, such as achalasia, often cause dysphagia and/or chest pain. Functional esophageal disorders are a heterogeneous group with hypersensitivity as a dominant pathophysiological factor. Gastroesophageal reflux disease often causes symptoms, such as heartburn and regurgitation, and a spectrum of disease, ranging from minimal mucosal damage visible only in the microscope to esophageal ulcers and strictures in the most severe cases. Eosinophilic esophagitis is an immune-mediated condition that can result in significant dysphagia and associated luminal narrowing. In the following, we will provide an overview of the most common esophageal disorders from a combined pathophysiological and clinical view.

Flip Technology for Assessing Esophageal Structural and Motor Disorders: a Skeptic's View.

Functional lumen impedance (FLIP) technology has become commercially available to assess structural and motor abnormalities of the esophagus. Increasing numbers of papers have described novel findings with this technology. This review examines the validity of the FLIP technique, how it compares with existing diagnostic modalities, and evidence to date on diagnostic accuracy. FLIP studies require deep sedation at the time of endoscopy to complete. They assess a simulated state of esophageal obstruction in only a distal part of the esophagus rather than deglutitive motor function of the entire esophagus. The available normative dataset is small and not matched to the older age of patients typically being evaluated. The test-retest agreement in health and disease is unknown, as is the operator dependence on performing and interpreting findings. Studies to date have largely excluded patients with structural disorders, which FLIP cannot reliably distinguish from motor disorders. FLIP is an expensive technology that has been made clinically available without its true utility being established. For FLIP to be deemed a device ready for widespread clinical use, additional studies on validity, diagnostic accuracy, and outcomes need to be performed. Prospective clinical studies need to include all patients and assess the incremental cost-effectiveness of FLIP over more innovative use of existing technology, such as high-resolution manometry with provocative challenges.

Effects of Lixisenatide Versus Liraglutide (Short- and Long-Acting GLP-1 Receptor Agonists) on Esophageal and Gastric Function in Patients With Type 2 Diabetes

Short-acting glucagon-like peptide 1 receptor agonists (GLP-1 RAs) decelerate gastric emptying more than long-acting GLP-1 RAs. Delayed gastric emptying is a risk factor for gastroesophageal reflux disease. We aimed to measure esophageal reflux and function as well as gastric emptying and acid secretion during treatment with short-acting (lixisenatide) and long-acting (liraglutide) GLP-1 RAs. A total of 57 subjects with type 2 diabetes were randomized to a 10-week treatment with lixisenatide or liraglutide. Changes from baseline in the number of reflux episodes during 24-h pH registration in the lower esophagus, lower esophagus sphincter pressure, gastric emptying (13C-sodium octanoate acid breath test), and gastric acid secretion (13C-calcium carbonate breath test) were analyzed. Gastric emptying half-time was delayed by 52 min (Δ 95% CI 16, 88) with lixisenatide (P = 0.0065) and by 25 min (3, 46) with liraglutide (P = 0.025). There was no difference in the number of reflux episodes (mean ± SEM 33.7 ± 4.1 vs. 40.1 ± 5.3 for lixisenatide and liraglutide, respectively, P = 0.17) or the extent of gastroesophageal reflux (DeMeester score) (35.1 ± 6.7 vs. 39.7 ± 7.5, P = 0.61), with similar results for the individual GLP-1 RAs. No significant changes from baseline in other parameters of esophageal motility and lower esophageal sphincter function were observed. Gastric acidity decreased significantly by -20.7% (-40.6, -0.8) (P = 0.042) with the GLP-1 RAs. Lixisenatide exerted a more pronounced influence on gastric emptying after breakfast than liraglutide. Neither lixisenatide nor liraglutide had significant effects on esophageal reflux or motility. Gastric acid secretion appears to be slightly reduced by GLP-1 RAs.