Evidence Of Esophagitis Research Articles

Successful Correction of the Misdiagnosis of a Primary Liver Neuroendocrine Tumour with a Combination of Immunohistochemical and Radiological Assessments: Report of a Rare Case from Pakistan

Human neuroendocrine tumours arise in different organs including most frequently in the gall bladder, kidneys, and ovaries or testicles. Liver neuroendocrine tumours are rarer types that grow slowly and arise from neuroendocrine cells. A 50-year-old woman with a history of type 1 diabetes mellitus and hypertension presented with severe abdominal pain, fever, pallor and jaundice over two days. She had not history of cancer. Initially, she was treated medically with Ciproxin, Entamizole, Zentel, and Nospa, but her symptoms were not resolved, and she was referred for gastroduodenal endoscopy, radiological and blood tests. The gastroduodenal endoscopic evaluation revealed severe gastritis with mild erythema in the corpus and antrum of the stomach with no evidence of esophagitis or duodenitis. At the time of initial diagnosis, the patient was asymptomatic for a liver neuroendocrine tumour as she did not have anemia, weight loss, abdominal distension, severe abdominal pain, or a palpable right upper quadrant mass. The radiological investigations, abdominal and pelvic ultrasound and computed tomography scan, detected hepatomegaly with a mass of an internal necrotic area in left lobe and smaller lesions in the right lobe. Liver core biopsies taken from the left lobe contained hepatocellular carcinoma. After a hepatectomy of the left lobe, the patient was stable and managed with intravenous fluid, analgesics, antibiotics, and antiemetic drugs and was discharged. Hepatocellular carcinoma was diagnosed in the resection specimen. The resected tumour tissue was analysed through immunohistochemistry for presence of Sheppard, arginase, Cam5.2 and CDX-2, heppar, arginase, PAX8, Albumin ISH, CK7, CK20 and INSM1, synaptophysin, chromogranin, Ki67, Synaptophysin, Cytokeratin AE1/AE3, synaptophysin, CD56, and Glypican-3. Consequently, liver neuroendocrine cancer was diagnosed. The patient was treated with Sandostatin for 7 days to treat the neuroendocrine tumour. Following a left hepatectomy, post-surgery endoscopic retrograde cholangiopancreatography (ERCP) showed normal ampullary mucosa and successful surgical biliary drainage was observed for almost 45 days with bile drain effluent between 20-230 ml. In this case, the differentiation of this liver neuroendocrine tumour from hepatocellular carcinoma, hyper vascular hepatic lesions based upon detection of chromogranin, CK7, CK20, HepPar1, Ki67 allowed appropriate clinical management of the patient. During radiological analysis, it was confirmed that the liver mass was not metastasized from the primary tumour of the stomach or colon.

437. LAPAROSCOPIC RESECTION OF AN ESOPHAGEAL LEIOMYOMA WITH DOR FUNDOPLICATION

Abstract Background Leiomyomas are the most common benign esophageal tumors originating from the muscular layer. They are rare lesions that constitute less than 1% of esophageal neoplasms. In one-third of the patients leiomyomas occur at the level of the gastroesophageal junction. Minimally invasive surgery is considered today the treatment of choice with the laparoscopic approach used for distal tumors. Methods We present the case of a 79-year-old woman with an esophageal stromal tumor located above the gastroesophageal junction. The patient underwent a successful laparoscopic excision (enucleation) of the tumor. Subsequently a Dor fundoplication was performed in order to cover the muscular esophageal defect. Results The recovery from surgery was uneventful. The patient resumed liquid diet within 24 hours and was discharged from hospital on the 3d postoperative day. In one year follow-up, the patient is free of symptoms without stricture or evidence of esophagitis on endoscopy. Histology of the tumor was consistent with leiomyoma. Conclusion Distal esophageal leiomyomas can be safely and effectively treated with the laparoscopic approach.

Efficacy of Combined Hiatal Hernia Repair and Transoral Incisionless Fundoplication for Giant Paraoesophageal Hernias: Technique and Early Results.

Data is limited on hybrid transoral incisionless fundoplication (TIF) and hiatal hernia repair in giant paraoesophageal hernia (GPEH). We aimed to assess the safety, patient satisfaction, and symptom resolution following a hybrid paraoesophageal hernia (PEH) repair and TIF in patients with GPEH. All single-session hybrid TIF combined with minimally invasive PEH repair performed between February 2020 and June 2021 were evaluated. Procedures were performed in the operating room under general anesthesia with robotic or laparoscopic PEH repair followed by TIF. Twelve patients underwent combined surgical hiatal hernia repair and TIF. Primary presenting symptoms included heartburn (75.0%), dysphagia (41.7%), and chronic anemia from Cameron's ulcers (16.7%). The mean hernia defect size was 5.0 cm (range 3.0 to 6.0 cm). Hiatal hernia repairs were performed robotically in 7 patients and laparoscopically in 5 patients. The total mean operative time was 254 minutes (range: 180 to 390 min). One patient reported postoperative dysphagia requiring endoscopic dilation postdischarge with a resolution of symptoms. No gas-bloat symptoms were reported. All patients reported complete resolution of presenting symptoms at the time of follow-up. Postoperative mean follow-up for 4 patients at 6 months with upper endoscopy and pH testing showed an intact valve with no evidence of esophagitis or acid reflux. In our experience, hybrid hiatal hernia repair and TIF is a safe and effective therapeutic option for patients with GPEH. This hybrid procedure allows for more expeditious completion of the repair and results in lower rates of postfundoplication dysphagia and gas-bloat. Furthermore, this approach requires a less extensive surgical dissection on the greater curvature of the stomach, thereby minimizing the risk of vagal nerve injury and bleeding from the short gastric vessels.

Development of a Core Outcome Set for Children Aged 1-18 Years with Gastroesophageal Reflux Disease

To develop a core outcome set for clinical studies assessing gastroesophageal reflux disease (GERD) in children. This core outcome set was developed using a 2-round Delphi technique and adhering to the Outcome Measures in Rheumatology Initiative (OMERACT 2.0) recommendations. Healthcare professionals (HCPs) and (parents of) children (age 1-18years) with a GERD diagnosis (ie, the presence of bothersome symptoms), listed up to 5 harmful and/or beneficial outcomes that they considered important in the treatment of GERD. Outcomes mentioned by more than 10% of participants were put forward and rated and prioritized by HCPs, parents, and children in a second round. Outcomes with the highest rank formed the draft core outcome set. The final core outcome set was created during an online consensus meeting between an expert panel. The first round was completed by 118 of 125 HCPs (94%), 146 of 146 parents (100%), and 69 of 70 children (99%). A total of 80 of 118 HCPs (68%), 130 of 140 parents (93%), and 77 children (100%) completed round 2. "Adequate relief," "evidence of esophagitis," "feeding difficulties," "heartburn (≥4years)," "hematemesis," "regurgitation," "sleeping difficulties," "vomiting," and "adverse events" were included in the final core outcome set for GERD in children aged 1-18years. We identified a total set of 9 core outcomes and suggest these outcomes to be minimally measured in clinical studies assessing GERD in children. Implementation of this core outcome set is likely to increase comparison between studies and may thus provide future recommendations to improve treatment of GERD in children.

Single session per oral endoscopic myotomy and trans oral incisionless fundoplication – can we prevent reflux in patients with achalasia?

Background and study aims The rate of gastroesophageal reflux disease (GERD) after per oral endoscopic myotomy (POEM) is concerning. Endoscopic anti-reflux methods, such as Trans Oral Incisionless Fundoplication (TIF), are crucial for the long-term success of POEM, especially if they can be performed in the same session. Methods We completed a proof-of-concept canine pilot study (n = 6) to assess safety and feasibility of POEM and TIF in a single session (POEM-TIF). Subsequently, POEM-TIF was also performed in patients with achalasia (n = 5). Herein, we report on the safety, technical and clinical success of the first-in-human cases with symptom follow-up at 1, 3 and 6 months and pH testing at 6 months. Results POEM was completed successfully in six canines (3 anterior and 3 posterior myotomies), followed by TIF in the same session. Necropsy and extensive testing demonstrated no evidence of mucosal injury and no leaks. The reconstructed valve was 220 to 240 degrees, 3 to 4 cm in length, and resulted in concomitant esophageal lengthening (2–5 cm). Using similar principles, the first-in-human cases were performed without intraprocedural or delayed adverse events. pH testing at 6 months showed that four of five patients had no evidence of GERD (DeMeester > 14.72), and in one case, there was evidence of esophagitis. Conclusions Single session POEM-TIF appears to be safe and feasible. Early clinical human data suggests that it may be able to reduce post POEM GERD, however the additional secondary benefits such as lengthening and straightening of the esophagus, may prove to be equally important for the long-term success of POEM.

386 LAPAROSCOPIC HELLERS MYOTOMY AND ANGLE OF HIS ACCENTUATION FOR ACHALASIA CARDIA: 10 YEARS EXPERIENCE FROM A SINGLE SURGICAL CENTRE.

Abstract Achalasia is a rare disease with Laparoscopic Hellers cardio-myotomy (LHCM) being the gold standard surgical modality. An antireflux procedure is required along with myotomy to decrease the chances of reflux postoperatively. We have performed Angle of His Accentuation (AOH) as an anti-reflux procedure in 126 patients who underwent LHCM since 2010. This study presents the symptomatic and objective outcomes of LHCM with AOH. Methods Review of prospectively collected data of patients with Achalasia cardia undergoing LHCM with AOH from 2010–2019. Subjective symptoms were scored for dysphagia, heartburn, regurgitation and quality of life using scoring systems mentioned in table 1 and Achalasia specific health related Quality of life questionnaire (ASHRQoL). Objective tests included Timed Barium swallow, Endoscopy and high-resolution manometry. Patients were evaluated in pre and postoperative period at regular intervals. Success was defined as follows: Eckardt score of ≤3, Dysphagia score of 0/1, Regurgitation and heartburn score of 0, >50% clearance on timed barium swallow, IRP <15 and absence of esophagitis. Results 126 patients were operated during the study period with no mortality or conversion. Mean age was 33.5(years), symptom duration 49.8(months), 31 had preoperative dilatation. The mean operative time was 131 (minutes). Subjective outcome was available in all patients & objective data in 66. At median follow of 31 months (IQR 15–59) outcomes significantly improved (Table 1) with 93% having dysphagia relief. 14 (11%) had new onset heartburn; 6(4.7%) needed regular proton pump inhibitors. ASHRQoL improved significantly (59.51 to 19.57). Pre&post-operative IRP, Timed Barium and endoscopy available in 66,39 and 62 patients improved significantly. 6(9.6%) patients had endoscopic evidence of esophagitis (LA-A 3, B/C 3). Conclusion Laparoscopic Heller myotomy with Angle of His accentuation is safe simple and effective procedure for Achalasia cardia. It provides significant relief of symptoms, improvement in quality of life and improvement in objective parameters. Post- operative heartburn and esophagitis is acceptable. We recommend Angle of His accentuation as an adjunct to Laparoscopic Heller myotomy.

Use of a report card to evaluate outcomes of achalasia surgery: beyond the Eckardt score.

Achalasia outcome is primarily defined using the Eckardt score with failure recognized as > 3. However, patients experience many changes after myotomy including new onset GERD, swallowing difficulties, and potential need for additional treatment. We aim to devise a comprehensive assessment tool to demonstrate the extent of patient-reported outcomes, objective changes, and need for re-interventions following myotomy. We performed a retrospective chart review of surgically treated primary achalasia patients. We identified 185 patients without prior foregut surgery who underwent either per oral endoscopic myotomy (POEM) or Heller myotomy from 2005 to 2017. Eight outcome measures in subjective, objective, and interventional categories formulated a global postoperative assessment tool. These outcomes included Eckardt score, Dakkak Dysphagia score, GERD-HRQL score, normalization of pH scores and IRP, esophagitis, timed barium clearance at 5min, and the most invasive re-intervention performed. Of 185 patients, achalasia subtypes included Type I = 42 (23%), II = 109 (59%), and III = 34 (18%). Patients underwent minimally invasive myotomy in 114 (62%), POEM in 71 (38%). Median proximal myotomy length was 4cm (IQR 4-5) and distal 2cm (IQR 2-2.5). Based on postoperative Eckardt score, 135/145 (93%) had successful treatment of achalasia. But, only 47/104 (45%) reported normal swallowing, and 78/108 (72%) had GERD-HRQL score ≤ 10. Objectively, IRP was normalized in 48/60 (80%), whereas timed barium clearance occurred in 51/84 (61%). No evidence of esophagitis was documented in 82/115 (71%). Postoperative normal DeMeester scores occurred in 38/76 (50%). No additional treatments were required in 110/139 (79%) of patients. Use of the Eckardt score alone to assess outcomes after achalasia surgery shows outstanding results. Using patient-reported outcomes, objective measurements, re-intervention rates, organized into a report card provides a more comprehensive and informative view.

Development of a Core Outcome Set for Infant Gastroesophageal Reflux Disease.

In therapeutic trials for infant gastroesophageal reflux disease (GERD), ways to define GERD and measure and report study outcomes vary widely. The aim of this study was to develop a core outcome set (COS) for infant GERD. The COS was developed using the Delphi technique, adhering to the Outcome Measures in Rheumatology Initiative 2.0 recommendations. Healthcare professionals (HCPs) (predominantly pediatric gastroenterologists and general pediatricians) and parents of infants (age 0-12 months) with GERD, listed up to 5 primary goals of therapy from their perspective and up to 5 persistent signs or symptoms that would signify inadequate treatment. Outcomes mentioned by >10% of participants were included in 2 shortlists. Next, HCPs and parents rated and prioritized outcomes on these shortlists. Outcomes with the highest rank formed the draft COS. The final COS was created after 2 consensus meetings between an expert panel and patient representatives. In total, 125 of 165 HCPs (76%) and 139 of 143 parents (97%) of infants with GERD completed the first phase. The second phase was completed by 83 of 139 HCPs (60%) and 127 of 142 different parents (89%). Outcomes of these phases were discussed during the consensus meetings and a 9-item COS was formed: "Adequate Growth," "Adequate Relief," "Adverse events,", "Crying," "Evidence of Esophagitis," "Feeding Difficulties," "Hematemesis," "No Escalation of Therapy," and "Sleep Problems." We developed a COS for infant GERD consisting of 9 items that should minimally be measured in future therapeutic trials to decrease study heterogeneity and ease comparability of results.

Is There a Role for pH Impedance Monitoring in Identifying Eosinophilic Esophagitis in Children with Esophageal Atresia?

To evaluate clinical, endoscopic, and pH-impedance measures in a cohort of children with esophageal atresia and concomitant eosinophilic esophagitis (EoE) and compared it with disease-matched controls, to identify predictive factors for the development of EoE and esophageal stricture. We reviewed 63 patients with esophageal atresia assessed for refractory upper gastrointestinal symptoms between January 2015 and September 2017 at 2 tertiary referral centers. All patients underwent upper gastrointestinal endoscopy and pH-impedance monitoring. Based on esophageal histology, patients were classified as (1) esophageal atresia without evidence of esophagitis; (2) esophageal atresia with evidence of esophagitis (including esophageal eosinophilia not meeting the criteria for EoE); (3) esophageal atresia with concomitant EoE. Age and sex matched patients with gastroesophageal reflux disease were used as disease controls. The presence of atopy and peripheral eosinophilia at baseline were significantly associated with EoE (P<.05). Although there was a tendency toward an increased number of strictures in patients with esophageal atresia-EoE, this did not reach statistical significance (P=.06). Higher esophageal acid exposure time and lower baseline impedance values were significantly associated with eosinophilic infiltration (P<.05 and P<.01, respectively). Using logistic regression analysis, the presence of mucosal eosinophilia was the most predictive factor for stricture formation (P<.05). A history of atopy and the presence of peripheral eosinophilia in patients with esophageal atresia are predictive factors for the development of EoE, which in turn is a predictive factor for stricture occurrence. Higher esophageal acid exposure time and lower baseline impedance are associated with esophageal eosinophilic infiltration, suggesting their value in selecting which patients with esophageal atresia should undergo endoscopic examination.

FA02.07: BARRIER STRUCTURE AND FUNCTION OF THE NEO-SQUAMOUS EPITHELIUM FOLLOWING SUCCESSFUL BARRETT’S ENDOTHERAPY IS IMPAIRED

Abstract Background The neo-squamous epithelium that replaces columnar epithelium after successful endoscopic ablation of Barrett's esophagus (BE) has not been fully characterized in regard to its structural and functional integrity. Intercellular space is a surrogate marker for epithelial structural integrity and mucosal impedance (MI) is a surrogate for transepithelial resistance and thus epithelial functional integrity. Impairment of the structural and functional integrity may influence recurrence following successful ablation. We aimed to measure the esophageal epithelial intercellular space diameter and MI in the neo-squamous and normal squamous epithelium of patients who underwent successful radiofrequency ablation for dysplastic BE. Methods Forty patients with complete remission of intestinal metaplasia (CRIM) (defined as two negative surveillance endoscopies for intestinal metaplasia) were prospectively recruited. Patients were excluded if they had endoscopic evidence of esophagitis. MI measurements were taken at 1 cm above the GE junction and 2 cm above the prior BE segment (targeting uninvolved squamous epithelium), using a novel through the scope MI probe. Endoscopic biopsies were also taken at these corresponding sites to assess intercellular space diameter using transmission electron microscopy (TEM) using standard techniques. Results 80% of patients were male with a mean age of 69 years. Mean follow since achieving CRIM was 30 months. 39 patients underwent RFA for dysplasia. The mean intercellular space diameter was higher in the neo-squamous epithelium (1.01 μm) when compared to the untreated native squamous epithelium (0.96 μm) [Difference of 0.056 μm, 95% CI of -0.036 to 0.148, P = 0.228]. The mean MI was significantly lower in the neosquamous epithelium (4001.3 Ω) when compared to the untreated native epithelium (5168.1 Ω) [Difference of 1166.7 Ω, 95% CI 418.8 to 1914.6, P = 0.003]. Conclusion Neo-squamous epithelium that replaces BE epithelium following successful endoscopic therapy for BE appears to be functionally and likely structurally deficient with regards to acid reflux barrier function, when compared to native squamous esophageal epithelium. This impairment may be associated with recurrence following successful ablation. Disclosure All authors have declared no conflicts of interest.

Is histologic esophagitis associated with dental erosion: a cross-sectional observational study?

BackgroundGastroesophageal reflux disease (GERD) affects 15–25% of children and adolescents in the United States. The diagnosis of GERD in children is complex as reported symptoms or symptom profiles have been found to be unreliable. Frequently, the diagnosis must be confirmed by objective tests such as pH monitoring or histological evidence of esophagitis on an esophageal biopsy. Dental erosion has been shown to be associated with GERD as an atypical complication and has the potential to be a marker of GERD. The purposes of this study were to compare the frequency and patterns of dental erosion in children and adolescents with and without histologic esophagitis.MethodsTwenty-five subjects were recruited from patients scheduled for an upper gastrointestinal endoscopy. Information regarding potential GERD symptoms, food habits, and dental hygiene habits were obtained. Intra-oral photographs were taken, and a dental exam for erosion was performed. The results of a standard biopsy taken from the lower third of the esophagus during an endoscopy were used to divide subjects into either the control group or the GERD group (i.e. those with histologic esophagitis).ResultsTwenty-two subjects yielded 586 evaluable teeth. No significant difference was found between frequency or erosion patterns of those with and without histologic esophagitis. Dental erosions were more frequent in primary teeth.ConclusionsDental erosions do not appear to be associated with histologic esophagitis indicative of GERD.

Preoperative endoscopy may reduce the need for revisional surgery for gastro-oesophageal reflux disease following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy is a safe and effective bariatric operation, but postoperative reflux symptoms can sometimes necessitate revisional surgery. Roux-en-Y gastric bypass is the preferred operation in morbidly obese patients with gastro-oesophageal reflux disease. In 2011, we introduced preoperative endoscopy to assess for hiatus hernia or evidence of oesophagitis in conjunction with an assessment of gastro-oesophageal reflux symptoms for all patients undergoing bariatric surgery with a view to avoid sleeve gastrectomy for these patients. A prospectively maintained database was used to identify patients who underwent sleeve gastrectomy before and after we changed the unit policy. The need for revisional surgery in patients with troublesome gastro-oesophageal reflux disease was examined. Prior to 2011, 130 patients underwent sleeve gastrectomy, and 11 (8.5%) of them required conversion to Roux-en-Y gastric bypass for symptomatic reflux disease. Following the policy change, 284 patients underwent sleeve gastrectomy, and to date, only five (1.8%) have required revisional surgery (p = 0.001). Baseline demographics were comparable between the groups, and average follow-up period was 47 and 33 months, respectively, for each group. Preoperative endoscopy and a detailed clinical history regarding gastro-oesophageal reflux symptoms may improve patient selection for sleeve gastrectomy. Avoiding sleeve gastrectomy in patients with reflux disease and/or hiatus hernia may reduce the incidence of revisional surgery.

Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes.

The histologic changes associated with acute gastroesophageal reflux disease (GERD) have not been studied prospectively in humans. Recent studies in animals have challenged the traditional notion that reflux esophagitis develops when esophageal surface epithelial cells are exposed to lethal chemical injury from refluxed acid. To evaluate histologic features of esophageal inflammation in acute GERD to study its pathogenesis. Patients from the Dallas Veterans Affairs Medical Center who had reflux esophagitis successfully treated with proton pump inhibitors (PPIs) began 24-hour esophageal pH and impedance monitoring and esophagoscopy (including confocal laser endomicroscopy [CLE]) with biopsies from noneroded areas of distal esophagus at baseline (taking PPIs) and at 1 week and 2 weeks after stopping the PPI medication. Enrollment began May 2013 and follow-up ended July 2015. PPIs stopped for 2 weeks. Twelve patients (men, 11; mean age, 57.6 year [SD, 13.1]) completed the study. Primary outcome was change in esophageal inflammation 2 weeks after stopping the PPI medication, determined by comparing lymphocyte, eosinophil, and neutrophil infiltrates (each scored on a 0-3 scale) in esophageal biopsies. Also evaluated were changes in epithelial basal cell and papillary hyperplasia, surface erosions, intercellular space width, endoscopic grade of esophagitis, esophageal acid exposure, and mucosal impedance (an index of mucosal integrity). At 1 week and 2 weeks after discontinuation of PPIs, biopsies showed significant increases in intraepithelial lymphocytes, which were predominantly T cells (median [range]: 0 (0-2) at baseline vs 1 (1-2) at both 1 week [P = .005] and 2 weeks [P = .002]); neutrophils and eosinophils were few or absent. Biopsies also showed widening of intercellular spaces (confirmed by CLE), and basal cell and papillary hyperplasia developed without surface erosions. Two weeks after stopping the PPI medication, esophageal acid exposure increased (median: 1.2% at baseline to 17.8% at 2 weeks; Δ, 16.2% [95% CI, 4.4%-26.5%], P = .005), mucosal impedance decreased (mean: 2671.3 Ω at baseline to 1508.4 Ω at 2 weeks; Δ, 1162.9 Ω [95% CI, 629.9-1695.9], P = .001), and all patients had evidence of esophagitis. In this preliminary study of 12 patients with severe reflux esophagitis successfully treated with PPI therapy, stopping PPI medication was associated with T lymphocyte-predominant esophageal inflammation and basal cell and papillary hyperplasia without loss of surface cells. If replicated, these findings suggest that the pathogenesis of reflux esophagitis may be cytokine-mediated rather than the result of chemical injury. clinicaltrials.gov Identifier: NCT01733810.

A blind insertion airway device in dogs as an alternative to traditional endotracheal intubation

Endotracheal intubation is the standard of care to establish a secure airway; however, laryngeal airway management systems are increasingly being used in human patients for elective surgical procedures and in emergency settings. In this study, a double lumen, blind insertion airway device (BIAD) was placed in the esophagus of dogs and evaluated for its ability to ventilate the lungs. Initially, 10 euthanazed dogs were evaluated, followed by a group of 15 mixed breed dogs that were undergoing elective spay or neuter procedures, and a group of 10 healthy dogs. Post-procedure evaluation included visual examination with a laryngoscope to inspect for signs of inflammation or mucosal damage. The device provided adequate ventilation in all subjects; the dogs were under anesthesia or heavily sedated for 10 min to 2 h and recovered uneventfully. No evidence of esophagitis, aspiration pneumonia, tracheitis, subcutaneous emphysema or esophageal laceration was observed. In conclusion, the use of double lumen airway devices warrants further study as an alternative airway management system in dogs.

Integrative Treatment of Reflux and Functional Dyspepsia in Children

Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) are common problems in the pediatric population, with up to 7% of school-age children and up to 8% of adolescents suffering from epigastric pain, heartburn, and regurgitation. Reflux is defined as the passage of stomach contents into the esophagus, while GERD refers to reflux symptoms that are associated with symptoms or complications—such as pain, asthma, aspiration pneumonia, or chronic cough. FD, as defined by the Rome III classification, is a persistent upper abdominal pain or discomfort, not related to bowel movements, and without any organic cause, that is present for at least two months prior to diagnosis. Endoscopic examination is typically negative in FD, whereas patients with GERD may have evidence of esophagitis or gastritis either grossly or microscopically. Up to 70% of children with dyspepsia exhibit delayed gastric emptying. Treatment of GERD and FD requires an integrative approach that may include pharmacologic therapy, treating concurrent constipation, botanicals, mind body techniques, improving sleep hygiene, increasing physical activity, and traditional Chinese medicine and acupuncture.

Significance and degree of reflux in patients with primary extraesophageal symptoms

Patients with extraesophageal symptoms are often suspected of having gastroesophageal reflux disease (GERD). However, the true prevalence and severity of reflux disease is not well studied. In this group of patients, the objectives of our study were to determine the prevalence and severity of esophageal acid exposure and classify the endoscopic findings. Prospective cohort study. One hundred twenty-eight patients with extraesophageal symptoms underwent 48 hours of Bravo pH monitoring. Percent of time that pH was <4 (total upright and supine) was measured. Severity of reflux was categorized by the percent of total time pH was <4, with mild = >4.2% but <10%, moderate = 10% to 20%, and severe>20%. Endoscopic signs of esophagitis and Barrett's esophagus were determined. There were 104/128 (81%) patients who had abnormal esophageal acid exposure, 44% in the upright and supine position, 38% in the upright position only, and 18% in the supine position only. There were 59/128 (46%) patients with mild reflux, 40/128 (31%) with moderate, and only 5/128 (4%) patients with severe reflux. 23/128 (18%) patients had evidence of esophagitis. Only 1/128 (0.8%) patients had pathologic Barrett's esophagus. Prevalence of abnormal esophageal acid exposure was similar in those with (75%) or without (66%) concomitant heartburn and/or regurgitation (P = .3). Abnormal esophageal pH is common in patients with extraesophageal symptoms. Most have only mild (46%) to moderate (31%) reflux with a low prevalence of esophagitis (18%) or Barrett's esophagus (0.8%). The degree of esophageal acid reflux cannot be predicted from baseline presence or absence of typical GERD symptoms.

New Developments in Reflux-Associated Cough

Gastro-oesophageal reflux disease (GORD) is generally considered one of the three main causes of chronic cough, along with asthma and nasal disease. The diagnosis of GORD is often based upon a successful trial of anti-acid treatment however GORD is a complex condition taking many forms. Only recently have studies started to address the different types of GORD in patients with chronic cough and how these may infer the mechanisms linking these common conditions. GORD can be assessed in a number of ways; whilst endoscopy provides evidence of oesophagitis (i.e. erosive disease), 24-h ambulatory oesophageal pH monitoring may demonstrate abnormal oesophageal acid exposure in the absence of oesophageal damage (i.e. non-erosive disease). The development of oesophageal impedance monitoring now allows the assessment of all reflux events (regardless of degree of acidity) and further classification of reflux by the proximal extension e.g. to upper oesophagus or even pharynx. Chronic cough patients may still be considered to have GORD if there is a significant temporal association between reflux events and coughing. Recent studies have examined the relationships between cough and reflux events, the roles of distal and proximal/pharyngeal reflux and also micro-aspiration in chronic cough patients. Increasing evidence suggests a significant proportion of patients display statistical associations between reflux and cough events, in the absence of an excessive numbers of reflux events either within or outside of the oesophagus.

Is there a role for flexible oesophagogastroscopy in upper aerodigestive tract squamous cell carcinoma?

There is growing evidence to suggest that reflux (both laryngopharyngeal and gastroesophageal) has a role in the development of upper aerodigestive tract squamous cell carcinoma. This study discusses the role of identifying reflux in this patient group, and its prevalence. Prospective review of patients with head and neck cancer undergoing flexible oesophagogastroscopy as part of their diagnostic investigation. Forty-five consecutive patients were identified. All patients were found to have evidence of oesophagitis, with 28 having oesophageal erosions and two Barrett's oesophagitis. Flexible oesophagogastroscopy is a useful test in patients with upper aerodigestive tract squamous cell carcinoma.

Epidemiology of Eosinophilic Esophagitis Over Three Decades in Olmsted County, Minnesota

Data on secular trends and outcomes of eosinophilic esophagitis (EE) are scarce. We performed a population-based study to assess the epidemiology and outcomes of EE in Olmsted County, Minnesota, over the last 3 decades. All cases of EE diagnosed between 1976 and 2005 were identified using the Rochester Epidemiology Project resources. Esophageal biopsies with any evidence of esophagitis and/or eosinophilic infiltration were reviewed by a single pathologist. Clinical course (treatment, response, and recurrence) was defined using information collected from medical records and prospectively via a telephone questionnaire. Incidence rates per 100,000 person years were directly adjusted for age and sex to the US 2000 population structure. A total of 78 patients with EE were identified. The incidence of EE increased significantly over the last 3 of the 5-year intervals (from 0.35 [95% confidence interval (CI)], 0-0.87] per 100,000 person-years during 1991-1995 to 9.45 [95% CI, 7.13-11.77] per 100,000 person-years during 2001-2005). The prevalence of EE was 55.0 (95% CI, 42.7-67.2) per 100,000 persons as of January 1, 2006, in Olmsted County, Minnesota. EE was diagnosed more frequently in late summer/fall. The clinical course of patients with EE was characterized by recurrent symptoms (observed in 41% of patients). The prevalence and incidence of EE is higher than previously reported. The incidence of clinically diagnosed EE increased significantly over the last 3 decades, in parallel with endoscopy volume. Seasonal incidence was greatest in late summer and fall. EE also appears to be a recurrent relapsing disease in a substantial proportion of patients.

Medical, Surgical, and Endoscopic Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases facing society today. In the US alone, more than 19 million people have the disease. Approximately 20% of US adults have one episode of GERD in a week, with about 7% reporting significant daily heartburn symptoms requiring some type of treatment.1 Medical treatments for GERD, both prescription and over the counter, cost approximately $19 billion per year in the US. Fortunately the majority of GERD symptoms are minor and self-limiting; however, complications, including esophagitis, Barrett syndrome, and adenocarcinoma, are on the rise in Western countries, suggesting that GERD does not have a benign course in all patients. The term nonerosive reflux disease (NERD) has been used to describe the majority of patients that have a benign, uncomplicated disease course. This group has GERD symptoms without evidence of esophagitis on endoscopy. The clinical management of GERD has evolved rapidly since the early 1990s with the introduction of potent medications as well as less invasive surgical techniques to help treat patients with medically refractory disease. Novel medications to help prevent transient lower esophageal sphincter relaxations (tLESRs) are being developed and may be added to the armamentarium.2 Additionally, endoscopic therapies have gained some support, though long-term data suggest that these techniques are not durable. This article reviews the pathophysiology, presentation, workup, treatment, and emerging therapies for GERD with an emphasis on surgical management and outcomes to help primary care physicians have a better understanding of the role of surgery in this complex disease.