Severe Esophagitis Research Articles

Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia.

Since Inoue performed the first POEM in 2008, safety and efficacy have been well-established. Early studies focused on refining the technique and avoiding incomplete myotomy. Following the discovery that many patients with abnormal acid exposure are asymptomatic, the focus shifted to post-POEM reflux, but no studies have identified any associated procedural factors. In this study, we examined the intermediate-term results of our previous randomized controlled trial, with particular attention to post-POEM reflux. Previously, 100 consecutive patients were randomized to either double- or single-scope POEM. Endoscopy was conducted 2months post-POEM and annually thereafter. Patients were included in the present study if they completed endoscopy ≥ 6months post-POEM, and the clinical results of both groups were analyzed with particular attention to clinical efficacy and post-POEM reflux. Median follow-up was 3years, and most myotomies were performed in the posterior location. The final gastric myotomy length was longer in the double-scope group (3.3 vs. 2.6cm). Clinical efficacy (≥ 80%) and rates of post-POEM reflux (~ 60%) were similar; however, there was a higher incidence of moderate esophagitis (Los Angeles Grade B) in the double-scope group (25% vs. 4%). There were no cases of severe esophagitis (Los Angeles Grade C/D). Among patients with normal endoscopy at 2 months, > 40% developed erosive esophagitis on intermediate-term follow-up. This is the first study to demonstrate a procedural factor that increases post-POEM esophagitis. Gastric myotomy > 2.5cm results in increased rates of moderate esophagitis without improving clinical efficacy. Some patients developed esophagitis in a delayed fashion, emphasizing the importance of ongoing surveillance. We also believe that preserving the gastric sling fibers may help to reduce reflux rates. The double-scope method may help to control myotomy length (2.0-2.5cm) and direction (lesser curve to avoid the gastric sling) to help maximize clinical efficacy while minimizing post-POEM reflux.

Retrospective evaluation of factors associated with degree of esophagitis, treatment, and outcomes in dogs presenting with esophageal foreign bodies (2004-2014): 114 cases.

To characterize a population of dogs presenting for esophageal foreign body removal and evaluate factors associated with degree of esophagitis and minor and major complications. Retrospective evaluation of dogs who presented for esophageal foreign body removal between January 2004 and December 2014. University veterinary teaching hospital. Data collected from 114 dogs included signalment, history, clinical signs, physical examination findings, duration and location of foreign body, degree of esophagitis, foreign body removal success, feeding tube placement, and clinical outcomes. Owners were contacted for outcome data not available in the medical record. Data were analyzed for breed predispositions, whether duration or type of foreign body was associated with degree of esophagitis or complications, and factors associated with feeding tube placement. None. The overall success rate for foreign body removal via esophagoscopy was 95% with a complication rate of 22%. Small breed dogs were overrepresented. Dogs with a foreign body present for >24 h were significantly more likely to have severe esophagitis (P < 0.001) and major complications (P = 0.0044). Foreign body type did not predict degree of esophagitis or complications, though fishhooks were more likely to require surgical removal (P = 0.033). Feeding tubes (15 gastrostomy, 1 nasoesophageal) were placed in 14% of dogs and were more likely to be placed if the foreign body had been present for >24 h (P < 0.001). Consistent with previous studies, esophageal foreign bodies, appropriately identified and endoscopically removed, carry a good prognosis, particularly if they have been present for ≤24 h.

Can the Reflux Finding Score and Reflux Symptom Index Be Used to Evaluate the Severity of Esophagitis in Children?

Laryngopharyngeal reflux (LPR), a growing issue in ear, nose, and throat (ENT) and pediatric medicine, is the backflow of stomach contents into the laryngopharynx. Patients present with frequent upper and/or lower respiratory tract infections and coughs, associated with acid- and pepsin-mediated injury to the mucosae of the larynx and pharynx. LPR is associated with rhinosinusitis, laryngitis, pneumonia, and asthma. Children with LPR often fail to exhibit classic gastroesophageal reflux disease symptoms, or such symptoms may be intermittent. Only a few studies have sought correlations among symptoms, endoscopic findings, and the results of frequently used diagnostic tests. We sought associations among the Reflux Finding Score (RFS), Reflux Symptom Index (RSI), and the pathological extent of esophagitis. We reviewed data on children who underwent upper gastrointestinal tract endoscopy and showed LPR symptoms, as reported by the ENT department. The RSI was scored by pediatric gastroenterologists and the RFS by ENT doctors, via laryngoscopic examination. The pathological esophageal data were evaluated retrospectively. We treated 52 patients (29 boys) with a mean age of 11.4 ± 4.5 years. On pathological evaluation, one patient exhibited normal esophageal findings, while 28 showed mild esophagitis, 16 esophagitis, and 8 severe esophagitis. Thirteen patients showed esophageal pseudopolypoid lesions secondary to gastroesophageal reflux disease on endoscopic examination, but were human papilloma virus-negative. There was no correlation among the RFS, RSI score, and age, but there was a significant correlation between the pathological data and the RFS (P = 0.010; r = 0.461). The incidence of LPR/esophagitis in children may differ from that in adults. Therefore, ENT specialists should determine esophagitis status in children and, if necessary, consult pediatric gastroenterologists.

Toll-like receptor 3 (TLR3) variant and NLRP12 mutation confer susceptibility to a complex clinical presentation

Genetic aberrations in the toll-like receptor (TLR)3 pathway are associated with increased susceptibility to herpes simplex virus (HSV) infections. Leucine-rich repeat and PYD-containing protein (NLRP)12 is a component of the inflammasome apparatus, which is critical to an immediate innate inflammatory response. Aberrations in NLRP12 have been shown to mediate auto-inflammation. In this study, we present a 44-year old patient with severe HSV esophagitis and Crohn's disease. An immune and genetic investigation confirmed two coinciding genetic mutations in TLR3 and NLRP12. Our findings support conducting laboratory workup that targets TLR3 pathway in the immunocompetent host developing recurrent HSV infections.

Efficacy of Endoscopic Evaluation of Acute Radiation Esophagitis during Chemoradiotherapy with Proton Beam Therapy Boost for Esophageal Cancer

Background/Aim: To evaluate the utility of endoscopy for assessing radiation esophagitis during chemoradiotherapy (CRT) with proton beam therapy (PBT) boost for esophageal cancer. Methods: Between December 2012 and December 2016, 38 patients with esophageal cancer were treated with CRT with PBT boost. To evaluate radiation esophagitis, endoscopy was performed after administration of CRT with standard PBT boost (total dose 50–60 Gy relative biological effectiveness [RBE]). Radiation esophagitis was evaluated and classified into 5 newly developed endoscopic grades (Fukui Acute Radiation Esophagitis [FARE] grade). The additional PBT boost was then adjusted and delivered (2–20 Gy [RBE]) to a maximum total dose of 74.4 Gy (RBE) based on the degree of radiation esophagitis, probability of residual tumor, and patient’s general condition. To evaluate the utility of endoscopic examination, the incidences of adverse events graded according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE, version 4.0) were determined at the time of endoscopic examination after CRT with standard PBT boost (50–60 Gy [RBE]) and at the completion of treatment (60–74.4 Gy [RBE]), as well as during the 90 days from the beginning of treatment. Results: There was a significant correlation between FARE grade and CTCAE esophagitis grade (ρ = 0.48; p = 0.03). Moreover, endoscopy detected severe esophagitis in an asymptomatic patient. Radiation dose escalation was achieved without severe acute adverse events. There was no significant difference between the incidence of acute toxicity at the time of the CRT with standard PBT boost (50–60 Gy [RBE]) and the higher dose at the completion of treatment (60–74.4 Gy [RBE]), which suggests this dose escalation strategy is safe. Conclusion: Endoscopic evaluation of radiation esophagitis using FARE grades was safely performed and useful for adjusting added radiation to ensure the safety of escalations in CRT with PBT boost for esophageal cancer.

Demographics and Clinical and Endoscopic Characteristics of Patients with Helicobacter pylori Infection and Gastroesophageal Reflux Disease: A Case-Control Study.

Background The correlation between Helicobacter pylori (H. pylori) and gastroesophageal reflux disease (GERD) is complex. Some studies showed a protective role of H. pylori infection against GERD. This study was aimed at assessing the role of H. pylori infection in GERD utilizing a large cohort of patients diagnosed with GERD. Methods and Materials All patients who underwent gastroscopy for an indication of GERD during the study period between 2015 and 2017 at the EMMS Nazareth Hospital were considered eligible for the study and therefore were included. H. pylori infection was determined by the rapid urease test or histology. Severity of esophagitis was assessed using the Los Angeles classification. Univariate analysis was performed to figure out differences between patients according to H. pylori infection status. Multivariate regression analysis was conducted to illustrate the predictors of positivity for H. pylori infection. Results 2,508 GERD patients were included with a median age of 49.42 ± 17.96 years. H. pylori infection was detected in 299 (11.9%) patients. GERD patients with H. pylori infection were found to be younger (48.83 ± 17.42 years versus 44.57 ± 17.69 years, p < 0.001), have the tendency to smoke more (1406 (63.6%) versus 266 (89.0%), p < 0.001), and use more proton pump inhibitors or PPIs (1314 (59.5%) versus 242 (80.9%), p < 0.001). In multivariate regression analysis, age (OR 0.987, p < 0.001), smoking status (OR 0.190, p < 0.001), use of ASA/NSAIDs (OR 1.652, p = 0.004), and use of statins (OR 0.499 (95%CI 0.295-0.846), p = 0.010) were found significant among H. pylori-positive individuals. H. pylori-positive subjects have less severe esophagitis and more hiatus hernia. Conclusion Patients with GERD and H. pylori infection were significantly younger, tended to smoke more, and used more PPIs and had significantly lower grades of esophagitis compared to noninfected ones.

Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification

The current study aimed to investigate the relationship between the severity of gastroesophageal reflux disease (GERD) according to the Los Angeles (LA) classification and esophageal motility using high-resolution manometry (HRM) and 24-hour esophageal pH monitoring.We examined 124 patients with GERD from January 2016 to June 2018. The LA classification of each patient was determined by endoscopy. HRM was performed by the intraluminal water infusion method. HRM and 24-hour esophageal pH monitoring parameters of the patients were studied and statistically compared.On HRM examination, GERD symptoms were found to be associated with worsened distal contractile integral (DCI), ineffective esophageal motility (IEM), peristalsis break (PB), lower esophageal sphincter (LES) pressure, and the 4-second integrated relaxation pressure (IRP4s) of LES pressure along with the grade of LA classification, especially in patients having grade C and D GERD who had transverse mucosal breaks. The 24-hour pH monitoring study revealed that patients classified as having grade C or D GERD had an esophageal pH < 4.0 for a longer time than those with grade O, A, or B GERD. Similar results were found regarding the duration of the longest reflux event, the number of reflux episodes longer than 5 minutes, and the number of reflux episodes. Patients with higher grade esophagitis had higher De Meester scores, which suggested greater esophageal acid exposure. Hiatal hernia (HH) was more closely related to LES pressure, IRP4s, and acid exposure, whereas DCI, IEM, and PB were not statistically different between patients with GERD with and without HH.Patients with severe esophagitis may have motor dysfunction not only in the LES but also in the esophageal body, with resulting increased esophageal acid exposure, which causes esophagitis. Low LES pressure might be the main reason that patients with HH develop esophagitis. GERD without HH may be due to a variety of motor dysfunctions.

Laparoscopic One Anastomosis Gastric Bypass Versus Laparoscopic One Anastomosis Gastric Bypass with Braun Anastomosis: What's Better?

Background and Aims: Although laparoscopic one anastomosis gastric bypass (LOAGB) is a promising bariatric procedure, a large number of surgeons have strong objections mainly because of risk of bile reflux, marginal ulceration, malnutrition, and long-term risk of gastric and esophageal cancer. Lateral enteroenterostomy placed distally to a gastrojejunal anastomosis shows efficacy in preventing bile reflux after gastric resection and gastrojejunal anastomosis, but at present its efficacy in a bariatric surgery context has not been evaluated. Patients and Methods: From January 2013 to December 2018, 100 patients have been admitted to our department to be treated by performing LOAGB. Patients have been divided into two groups on the basis of the indications to this surgical procedure; Group A: presence of de novo gastroesophageal reflux disease (GERD) or severe esophagitis after laparoscopic sleeve gastrectomy, with or without weight regain; Group B: LOAGB as primary procedure. Another group of 30 patients (Group C) underwent LOAGB with Braun anastomosis as primary bariatric surgical procedure for morbid obesity. We have conducted a retrospective analysis of the surgical outcomes in terms of perioperative mortality, short-, mid-, and long-term postoperative complications and weight loss. Results: Group A: 50 patients; incidence of postoperative GERD, esophagitis, or esophageal ulcers was 26% (13 cases). All these patients have been successfully treated by performing Braun anastomosis. Group B: 20 patients; incidence of de novo reflux was 25% (5 cases); Braun anastomosis was performed with complete resolution of signs and symptoms in all cases. Group C: 30 patients; no cases of de novo reflux, esophagitis, or anastomotic ulcers occurred. Conclusion: Braun anastomosis seems to be a useful surgical tool to prevent the onset of de novo reflux, esophagitis, and anastomotic ulcers.

Visceral fat thickness of erosive and non-erosive reflux disease subjects in Indonesia's tertiary referral hospital

BackgroundThere has been an increasing number of reports regarding the correlation between obesity and gastroesophageal reflux disease (GERD). Visceral fat thickness is thought to be a risk factor for GERD and its severity. Several studies have conflicting results, so this study aimed to determine visceral fat thickness difference between erosive and non-erosive reflux disease. MethodsA cross-sectional study of 56 adult subjects with GERD symptoms was held at Cipto Mangunkusumo National General Hospital between April and November 2018. Gastroesophageal Reflux Disease Questionnaires (GERDQ) were utilized to determine the presence of GERD. Ultrasonography was used to determine visceral fat thickness. Esophageal erosions were diagnosed using upper gastrointestinal endoscopy. The difference in visceral fat thickness between esophagitis and non-esophagitis group was analysed using T-test. ResultsFrom 56 total subjects, 55.4% have erosive reflux disease (ERD), in which were dominated by subjects with grade A esophagitis (64.5%) based on Los Angeles Classification of Esophagitis (LA classifications). There was no significant difference of visceral fat thickness between non-erosive reflux disease (NERD) and ERD (p = 0,831). There was, however, an increasing trend of visceral fat thickness with the advancing severity of esophagitis, although statistical significance was not reached. ConclusionVisceral fat thickness as measured by ultrasonography has no significant difference between NERD and ERD.

Drug-induced esophagitis: Incidence, clinical and endoscopic findings, and management

Background and Aims: Drug-induced esophagitis is a rare condition, which presents with varying severity in terms of clinical and gastroscopic findings. This study aimed to investigate the incidence, clinical and endoscopic findings, and management of the disease in a prospective 1-year follow-up period. Materials and Methods: Overall, 4185 patients underwent esophagogastroduodenoscopy at the Endoscopy Unit of Erzurum Education and Research Hospital between February 2010 and February 2011. Among these, the patients diagnosed with drug-induced esophagitis were followed up prospectively. Results: Among patients who underwent esophagogastroduodenoscopy, 1926 (46%) were males with a mean age of 47.8±18.1 years (range, 12–100 years). In total, 760 patients (18%) were diagnosed with esophagitis, of which five had drug-induced esophagitis (0.012% of gastroscopies, 0.65% of esophagitis). All patients presented with symptoms of retrosternal pain, odynophagia, and dysphagia. Four patients were young women, whereas the remaining patient was an elderly man; based on the medical history and esophagogastroduodenoscopy findings, patients diagnosed with esophagitis were using doxycycline, tetracycline, and tramadol hydrochloride capsules. Drugs that were considered to be the causative agents of esophagitis were discontinued, and proton pump inhibitors were administered parenterally or orally. The patients recovered without any complications. Conclusion: Drug-induced esophagitis is considered to be a rare condition, presenting with varying esophagogastroduodenoscopy findings and severe esophagitis in some cases. Discontinuing the causative agent and administering proton pump inhibitors are sufficient to manage the condition.

Vonoprazan versus proton-pump inhibitors for healing gastroesophageal reflux disease: A systematic review.

Gastroesophageal reflux disease (GERD) is a common disease caused by reflux of gastric contents to the esophagus. Proton-pump inhibitors (PPIs) are recommended as a first-line therapy to treat GERD. Recently, a new potassium-competitive acid blocker, vonoprazan, was launched in Japan. We aimed to evaluate the comparative efficacy of vonoprazan and other PPIs in healing GERD. We used MEDLINE and the Cochrane Central Register of Controlled Trials to search the literature. Double-blind randomized controlled trials for PPIs and/or vonoprazan that were published in English or Japanese and assessed healing effects in adult GERD patients were included. To estimate the comparative efficacy of treatments, we performed a Bayesian network meta-analysis to assess the consistency assumption. Of 4001 articles identified in the database, 42 studies were eligible. One study was hand-searched and added to the analysis. For the main analysis of healing effects at 8weeks, odds ratios (ORs) of vonoprazan (20mg daily) to esomeprazole (20mg), rabeprazole (20mg), lansoprazole (30mg), and omeprazole (20mg) were 2.29 (95% credible interval, 0.79-7.06), 3.94 (1.15-14.03), 2.40 (0.90-6.77), and 2.71 (0.98-7.90), respectively. Subgroup analysis for patients with severe esophagitis at baseline showed significantly higher ORs for vonoprazan versus most of the comparator PPIs. This analysis shows that the GERD healing effect of vonoprazan is higher than that of rabeprazole (20mg) but not higher than other PPIs. Subgroup analysis indicated that vonoprazan is more effective than most PPIs for patients with severe erosive esophagitis.

Asymptomatic respiratory dysfunction in patients with gastroesophageal reflux disease

BACKGROUND: Gastroesophageal reflux disease is the primary cause for many conditions affecting extraesophageal structures. OBJECTIVE: The objective of the study is to investigate the relation between reflux disease and asymptomatic respiratory dysfunction and examine correlation between the respiratory dysfunction with severity of gastroesophageal reflux disease (GERD) spectrum. METHODOLOGY: A total of 242 patients were subjected to pulmonary function test (PFT) using spirometer-G procedures. Forced expiratory volume 1 s (FEV1), forced vital capacity (FVC), FEV1/FV C ratio, and peak expiratory flow rate (PEFR) were measured. Patients in test group were treated with proton-pump inhibitor (PPI) and esomeprazole 40 mg twice daily for 3 months. They were subjected to PEFR at the end of the study. Analysis was performed using SPSS version. RESULTS: Age and PFT parameters FEV1, forced expiratory flow (FEF) 25–75, PEF, and PEFR were compared groupwise and were found to be statistically significant except FEV. As the severity of GERD increases, severity of pulmonary disorder also increases. In Group 1A, 56.5% patients had normal PEFR and 43.4% PEFR was reduced showing statistically significant. In patients with abnormal PFT, 74.2% had mild esophagitis, 15.1% had moderate esophagitis, and 10.6% had severe esophagitis showing statistically significant. Mean PEFR before treatment showed 344.1 ± 79.22. After 3 months of esomeprazole 40 mg, twice daily mean increased 409.08 ± 100.00. In Group 1B, PEFR before treatment noted 342.0 ± 53.77. Significant improvement was seen in PEFR with mean of 506.00 ± 52.64 with PPIs. CONCLUSIONS: GERD is associated with asymptomatic respiratory dysfunction. There is strong and direct relationship between the severity of respiratory disorders, detected by FEV1 and FEV1/FVC, FEF25–75, PEF, PEFR, and severity of GERD. This study demonstrated significant improvement in PEFR values, with adequate treatment of GERD.

Varicella Zoster Virus Esophagitis in an Immunocompetent Patient.

ABSTRACTThe varicella zoster virus is highly infectious, spreading via direct contact or respiratory droplets, and can lead to life-threatening complications. Although disseminated disease tends to occur most commonly in immunocompromised patients, we present a peculiar case of varicella zoster esophagitis in a healthy, immunocompetent adult. To provide prompt treatment, clinicians should be aware that the varicella zoster virus could cause severe esophagitis, even in immunocompetent patients.

Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results

BackgroundBile reflux is a factor in the appearance of severe esophagitis and Barrett’s esophagus, which have been reported after sleeve gastrectomy (SG). Incompetent lower esophageal sphincter and increased gastroesophageal acid reflux have been demonstrated after this operation. Some reports have shown bile content in the antrum during endoscopic control, but no investigations objectively confirm the presence of duodenogastric bile reflux in these patients. ObjectivesTo evaluate the presence of duodenogastric bile reflux (DGR) after SG in patients presenting reflux symptoms. SettingUniversity hospital. MethodsProspective study of 22 patients presenting reflux symptoms who underwent SG for morbid obesity and who received endoscopic evaluation and scintigraphic study to confirm esophagitis and duodenogastric bile reflux. ResultsErosive esophagitis was observed in 11 patients and Barrett’s esophagus in 2 patients. Seven patients (31.8%) presented positive DGR. Among them, 3 had type B and C esophagitis. The other 4 patients did not present esophagitis in spite of reflux symptoms. ConclusionDGR may be present in patients with gastroesophageal reflux after SG. This line of investigation requires further studies to confirm this hypothesis.

The efficacy and safety of high dose versus standard dose radiotherapy in concurrent chemoradiotherapy for patients with esophageal squamous cell carcinoma

Objective: To compare the efficacy and treatment-related toxicity of high dose versus standard dose radiotherapy in concurrent chemoradiotherapy (CCRT) for patients with esophageal squamous cell carcinoma (ESCC). Methods: From 2005 to 2012, 183 pairs of patients with esophageal squamous cell carcinoma in the Fourth Hospital of Hebei Medical University were enrolled, all had undergone CCRT based on three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT). A propensity score was constructed to match the cohort. The overall survival (OS), local control (LC) probability, as well as the acute and late toxicities between standard-dose and high-dose groups were compared. Results: Patients in the high-dose group had significantly better OS and LC probability compared with those in the standard-dose group: the 3-, 5- and 10-year LC rate were 60.9%, 57.6%, 52.3% versus 50.8%, 46.4%, 30.8%, respectively (P=0.032). The 3-, 5- and 10-year OS were 44.3%, 36.9% and 24.5% for high-dose group, and 31.7%, 20.6% and 14.1% for the standard-dose group, respectively(P=0.002). The incidence of acute radiation esophagitis (especially in grade 2 and 3) was 63.9% in high-dose group, which was significantly higher than that in the standard-dose group (59.6%). Severe (≥ grade 3) late-onset esophagitis was observed in neither group. The grade 4 acute esophagitis was rare. There was no significant difference in the incidence of radiation pneumonitis, gastrointestinal reactions or hematological toxicities between the two groups. Six patients in high-dose group and two patients in standard-dose group experienced ≥ grade 4 leukocytopenia, while no one experienced > grade 3 thrombocytopenia and anemia in both group. Conclusions: 60 Gy was the preferred dosage of CCRT in patients with ESCC. Compared with standard-dose, the high-dose CCRT yielded slightly increased mild to moderate acute radiation esophagitis, while life-threatening toxicities were not increased.

Effect of Roux-en-Y gastric bypass in the control of erosive esophagitis

Background: Gastroesophageal reflux disease (GERD) is a multifactorial disease associated with environmental and genetic factors. Obesity is among the risk factors for its development, which also correlates with an increase in severity of clinical presentation and a higher incidence of complications associated with reflux. Aims: To evaluate the impact of Roux-en-Y gastric bypass on the control of erosive esophagitis and metabolic and anthropometric parameters related to obesity. Methods: This historical cohort study included a sample of 249 patients who had undergone bariatric surgery using the Roux-en-Y gastric bypass technique at the Hospital Sao Vicente de Paulo, Passo Fundo, southern Brazil, from January 2014 to December 2015. Results: Of 249 patients, 77.9% (190 patients) were female and the mean age was 38 years. The occurrence of reflux esophagitis was 81.1% (196 patients) in the preoperative period and 31.3% (75 patients) in the postoperative period. With regard to bariatric treatment response to control moderate and severe esophagitis (grades B, C and D), there was a reduction in prevalence from 62 (25%) to 12 (5%) patients ( p <0.05). Conclusion: Bariatric surgery using the Roux-en-Y gastric bypass technique is effective in the control of reflux esophagitis. Regression is observed mainly in cases of moderate and severe esophagitis. Keywords: Erosive esophagitis; GERD; bariatric surgery; obesity; comorbidity

Treatment of reflux esophagitis in patients with cardiofundal, subtotal and total hiatal hernias

To analyze treatment of patients with reflux esophagitis and large hiatal hernia. There were 85 patients with reflux esophagitis and large hiatal hernia. Laparoscopic repair was performed in 33 patients, laparotomy - in 52 cases. All patients underwent fundo- or gastroplication by A.F. Chernousov, correction of large defect of hiatal orifice by cruroraphy was applied in 55 (64.7%) patients. Postoperative morbidity was near 10% after laparoscopic and conventional surgery despite more difficult video-assisted endoscopic technique. Complications Clavien-Dindo grade I-II were noted in 4 (12.1%) patients after laparoscopic treatment and in 6 (11.5%) patients after laparotomy. Medication was effective in all cases. Two patients with subtotal hernias had complications Clavien-Dindo grade IIIB after endoscopic surgery: recurrent hiatal hernia followed by severe reflux esophagitis and dysphagia. These complications required redo surgery. Repair of hiatal orifice is always possible without mesh reinforcement. Posterior cruroraphy is feasible and effective in all patients. Incidence of intraoperative and postoperative complications is comparable in both approaches (p<0.05). Mean hospital-stay after laparotomy was 7.3 days, after laparoscopy - 5.8 days. Endoscopic formation of antireflux cuff by A.F. Chernousov is appropriate and effective in patients with reflux esophagitis and large/giant hiatal hernias.

Predictors of Acute Radiation Esophagitis in Non-small Cell Lung Cancer Patients Treated With Accelerated Hyperfractionated Chemoradiotherapy.

To identify the clinical and dosimetric predictors of severe acute radiation esophagitis (RE) in patients with non-small cell lung cancer (NSCLC) treated with accelerated hyperfractionated concurrent chemoradiotherapy (AH-CCRT) with concomitant boost technique. A total of 159 patients who underwent AH-CCRT (64 Gy in 40 fractions twice daily) were retrospectively identified. Severe RE was designated as grade 3 or higher according to the Common Terminology Criteria for Adverse Events, version 4.0. The incidence rate of grade 3 RE was 15.1% (24/159). The multivariate analysis that incorporated the Eastern Cooperative Oncology Group performance status (ECOG PS, ≥1 vs. 0) and the relative esophagus volume irradiated with at least 60 Gy (V60) was optimal. Patients with a V60 of ≥15% had a 37.8% risk of grade 3 RE compared to a 6.1% risk among those with a V60 of <15%. ECOG PS (≥1 vs. 0) and the V60 were found to be significant risk factors for severe RE in NSCLC patients who underwent AH-CCRT.

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults.

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety. We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults. Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims. US nursing homes (NHs). Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator). Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics. The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk. Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

BENRALIZUMAB INTENDED FOR EOSINOPHILIC ASTHMA LEADS TO COMPLETE RESOLUTION OF EOSINOPHILIC EOSPHAGITIS

Introduction A patient with severe eosinophilic asthma and eosinophilic esophagitis (EoE) with significant prompt improvement after initiating Benralizumab, anti-IL 5 therapy. Case Description We present a 64-year old female with a significant history of eosinophilic asthma and EoE. Her asthma failed optimal inhaled controller treatment, requiring monthly oral steroid rescue courses and frequent emergency department visits and hospital admissions. She was highly allergic to environmental and perennial allergens, but was unable to tolerate allergy immunotherapy due to adverse reactions. Additionally, she was having difficulty swallowing for over a decade with confirmed EoE on biopsy. By the time of diagnosis, she already had an esophageal stricture, requiring multiple dilations. Her maternal aunt and maternal grandfather died after choking on food. She started swallowed steroids and a six food elimination diet with mild improvement but continued having episodes of choking and difficulty swallowing. Benralizumab was prescribed for her eosinophilic asthma. Approximately two weeks after her first treatment, her esophageal symptoms of dysphagia and sensation of food getting stuck completely resolved. Her asthma slowly improved and months later, her EoE remains symptom free with no eosinophils found on repeat esophageal biopsy. Discussion Current and previous clinical trials have shown mixed results with anti IL-5 therapy in EoE. Studies using Mepolizumab and Reslizumab have shown significant reduction in esophageal eosinophilia, however, with inconsistent clinical benefit. Benralizumab, directly targets eosinophils for ADCC, depletes eosinophils with low levels of IL-5Rα expression and those that are independent of IL-5. The depleting effect of Benralizumab on eosinophils is particularly rapid and pronounced. A patient with severe eosinophilic asthma and eosinophilic esophagitis (EoE) with significant prompt improvement after initiating Benralizumab, anti-IL 5 therapy. We present a 64-year old female with a significant history of eosinophilic asthma and EoE. Her asthma failed optimal inhaled controller treatment, requiring monthly oral steroid rescue courses and frequent emergency department visits and hospital admissions. She was highly allergic to environmental and perennial allergens, but was unable to tolerate allergy immunotherapy due to adverse reactions. Additionally, she was having difficulty swallowing for over a decade with confirmed EoE on biopsy. By the time of diagnosis, she already had an esophageal stricture, requiring multiple dilations. Her maternal aunt and maternal grandfather died after choking on food. She started swallowed steroids and a six food elimination diet with mild improvement but continued having episodes of choking and difficulty swallowing. Benralizumab was prescribed for her eosinophilic asthma. Approximately two weeks after her first treatment, her esophageal symptoms of dysphagia and sensation of food getting stuck completely resolved. Her asthma slowly improved and months later, her EoE remains symptom free with no eosinophils found on repeat esophageal biopsy. Current and previous clinical trials have shown mixed results with anti IL-5 therapy in EoE. Studies using Mepolizumab and Reslizumab have shown significant reduction in esophageal eosinophilia, however, with inconsistent clinical benefit. Benralizumab, directly targets eosinophils for ADCC, depletes eosinophils with low levels of IL-5Rα expression and those that are independent of IL-5. The depleting effect of Benralizumab on eosinophils is particularly rapid and pronounced.