Foregut Symptoms Research Articles

Statewide Hospital Admissions for Adult Survivors of Infant Surgical Diseases Over a 10-Year Period

IntroductionThe number of patients with congenital disease living to adulthood continues to grow. Often undergoing surgical correction in infancy, they continue to require lifelong care. Their numbers are largely unknown. We sought to evaluate hospital admissions of adult patients with esophageal atresia with tracheoesophageal fistula (EA/TEF), congenital diaphragmatic hernia (CDH), and Hirschsprung disease (HD). MethodsThe Florida Agency for Healthcare Administration inpatient database was merged with the Distressed Communities Index and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets. The dataset was queried for adult patients (≥18 y, born after 1970) with EA/TEF, CDH, and HD in their problem list from 2010 to 2020. Patient demographics, hospitalization characteristics, and discharge information were obtained. ResultsIn total, 1140 admissions were identified (266 EA/TEF, 135 CDH, 739 HD). Patients were mostly female (53%), had a mean age of 31.6 y, and often admitted to an adult internist in a general hospital under emergency. Principal diagnoses and procedures (when performed) varied with diagnosis and age at admission. EA patients were admitted with dysphagia and foregut symptoms and often underwent upper endoscopy with dilation. CDH patients were often admitted for diaphragmatic hernias and underwent adult diaphragm repair. Hirschsprung patients were often admitted for intestinal obstructive issues and frequently underwent colonoscopy but trended toward operative intervention with increasing age. ConclusionsAdults with congenital disease continue to require hospital admission and invasive procedures. As age increases, diagnoses and performed procedures for each diagnoses evolve. These data could guide the formulation of multispecialty disease-specific follow-up programs for these patients.

The role of high-resolution impedance manometry to identify rumination syndrome in children with unexplained foregut symptoms.

Diagnosis of rumination syndrome (RS) relies on Rome IV criteria. Oesophageal high-resolution impedance manometry (HRIM) can objectively demonstrate the episodes of rumination, but its role in the diagnostic pathway is not yet established. We aimed to demonstrate the clinical contribution of this tool for the timely diagnosis of RS and diagnostic work-up of children with unexplained foregut symptoms deemed to be due to other conditions. HRIMs performed between 2012 and 2021 were searched to retrieve all diagnoses of RS. Medical records were reviewed for clinical data. Out of 461 HRIMs performed, 76 children had manometric diagnosis of RS (35 male, median age: 13 years). Of them, 47% were not clinically suspected as the symptoms did not fulfil clinical criteria for RS. The indications for HRIM in these cases were investigation of unexplained foregut symptoms (37%), suspected refractory gastroesophageal reflux disease (8%) and dysphagia (2%). Among all HRIMs performed for investigations of unexplained foregut symptoms (n = 80), 35% demonstrated rumination episodes. Identification of characteristic patterns of rumination on HRIM in children with unexplained foregut symptoms enables the immediate diagnosis of RS. Thus, in situations of diagnostic uncertainty, the use of HRIM at early stages of the diagnostic pathway would reduce unnecessary investigations and treatments.

Helicobacter pylori Infection: Antibiotic Resistance and Solutions for Effective Management in Africa.

Helicobacter pylori (H. pylori) infection is ubiquitous worldwide, with prevalence rates of greater than 70% in Africa. Symptomatic patients present with foregut gastrointestinal symptoms which can be readily diagnosed with standardized non-invasive or invasive tests. The biggest challenge, however, is in the management of this condition with rising antimicrobial resistance rates to most of the antibiotics recommended for therapy. This is a problem worldwide, but more specifically in Africa, where the socio-economic and political climate is such that eradication of this organism seems impossible. Furthermore, the recommended antimicrobial susceptibility testing for drug resistance is not widely available in Africa due to the lack of infrastructural as well as human resources. With the widespread unregulated use of antibiotics in some parts of Africa, the figures of antimicrobial resistance are likely to soar. In the face of these significant challenges, this 'perspectives' article aims to address the issue of antimicrobial resistance in Africa, by providing achievable and targeted goals to curb the spread of infection and rising antimicrobial resistance.

Reconsideration of the Gastroparetic Syndrome.

Gastroparesis is a chronic disorder characterized by a constellation of foregut symptoms, including postprandial nausea, vomiting, distension, epigastric pain, and regurgitation in the absence of gastric outlet obstruction. Despite considerable research over the past decades, there remains to be only nominal understanding of disease classification, diagnostic criteria, pathogenesis, and preferred therapy. We critically reassess current approaches for disease identification and stratification, theories of causation, and treatment for gastroparesis. Gastric scintigraphy, long considered a diagnostic standard, has been re-evaluated in light of evidence showing low sensitivity, whereas newer testing modalities are incompletely validated. Present concepts of pathogenesis do not provide a unified model linking biological impairments with clinical manifestations, whereas available pharmacological and anatomical treatments lack explicit selection criteria or evidence for sustained effectiveness. We propose a disease model that embodies the re-programming of distributed neuro-immune interactions in the gastric wall by inflammatory perturbants. These interactions, combined with effects on the foregut hormonal milieu and brain-gut axis, are postulated to generate the syndromic attributes characteristically linked with gastroparesis. Research linking models of immunopathogenesis with diagnostic and therapeutic paradigms will lead to reclassifications of gastroparesis that guide future trials and technological developments. • The term gastroparesis embodies a heterogenous array of symptoms and clinical findings based on a complex assimilation of afferent and efferent mechanisms, gastrointestinal locations, and pathologies. • There currently exists no single test or group of tests with sufficient capacity to be termed a definitional standard for gastroparesis. • Present research regarding pathogenesis suggests the importance of immune regulation of intrinsic oscillatory activity involving myenteric nerves, interstitial cells of Cajal, and smooth muscle cells. • Prokinetic pharmaceuticals remain the mainstay of management, although novel treatments are being studied that are directed to alternative muscle/nerve receptors, electromodulation of the brain-gut axis, and anatomical (endoscopic, surgical) interventions.

S1469 Prevalence of Helicobacter pylori Infection Among Hispanics Living in Puerto Rico Undergoing Bariatric Surgery

Introduction: Obesity is a public health problem that affects developed and developing countries. Its prevalence is around 33% in the United States and 30-35% in Puerto Rico. Helicobacter pylori (HP) infection in bariatric patients has been linked to post-surgical foregut symptoms, marginal ulcers, and an increased incidence rate of viscus perforation. However, the feco-prevalence of H. pylori infections in this population has not been studied. Therefore, this study aimed to examine the feco-prevalence of HP infection among patients undergoing bariatric surgery in Puerto Rico. Methods: A retrospective cross-sectional chart review was conducted. The Feco-positivity was determined using stool H. pylori antigen immunoassay. Helicobacter pylori feco-prevalence was estimated with 95% confidence using the proportion z-test. Pearson's Chi-Square test was used to determine associations between the variables. Results: A total of 307 medical records of patients undergoing bariatric surgery were reviewed. The mean age of the study population was 42 ± 12 years, of whom 79.1% were female. The overall feco-prevalence of H. pylori was 18.0%, with nausea and belching the most prevalent symptoms reported (P < 0.05). A 90% eradication rate was observed with the first treatment course. The prevalence of vitamin B6 deficiency in patients with HP positive was 32% compared to patients with HP negative 20%, with a P-value of 0.05 (Figure). Conclusion: HP feco-prevalence in bariatric surgery patients is estimated to be 18%, less than the previously estimated prevalence of Helicobacter pylori using seroprevalence of Hispanics in Puerto Rico. However, the seroprevalence of HP infection is less sensitive and specific to disease than the feco-prevalence. Therefore, further investigation is warranted about HP feco-prevalence in the general population of Puerto Rico. There was a statistically significant increase in the prevalence of vitamin B6 deficiency in patients with HP positive that has not previously been reported and warrants further investigation.Figure 1.: Prevalence of H. pylori in patients with Vitamin deficiency

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m2 versus -14.87 ± 7.4 kg/m2, P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

INDICATORS AND PREDICTORS OF POSTOPERATIVE OESOPHAGOGASTRODUODENOSCOPY AFTER BARIATRIC SURGERY – ANALYSIS FROM A TERTIARY BARIATRIC CENTRE

Following bariatric surgery, patients can develop foregut symptoms like dysphagia, reflux, or pain due to stomal ulceration. Oesophagogastroduodenoscopy (OGD) is a diagnostic modality of choice to evaluate these symptoms on most occasions. The objective of this study was to assess the indications and predictors of performing an OGD after bariatric surgery and the treatment offered.

Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data wereanalyzed using univariate analysis. One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7years, 29.7 ± 5.7kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

Multicenter randomized controlled trial comparing forceps biopsy sampling with wide-area transepithelial sampling brush for detecting intestinal metaplasia and dysplasia during routine upper endoscopy

Intestinal metaplasia (IM) in the esophagus is a potentially premalignant mucosal change. The aim of this study was to compare the frequency of IM detection during upper endoscopy by forceps biopsy sampling (FB) versus wide-area transepithelial sampling (WATS) brush. Patients presenting for upper endoscopy for foregut symptoms or surveillance of Barrett's esophagus (BE) at 9 centers in the United States were randomized to either FB or WATS. Of 1002 patients, FB was done in 505 and WATS in 497. The overall frequency of finding IM was 21% and was similar with FB (19.6%) and WATS (22.7%, P= .2). Low-grade dysplasia was found in 8 patients. No patient had high-grade dysplasia. There was no difference in detection of dysplasia between FB and WATS. In patients with no history of IM, WATS found significantly more IM compared with FB when a columnar-lined esophagus (CLE) was present (32.4% with WATS vs 15.2% with FB, P= .004). In 184 patients with known BE, FB and WATS found IM with similar frequency (38.5% FB vs 41.9% WATS, P= .6) with no difference in short- or long-segment BE. Overall, FB and WATS detected a similar frequency of IM and dysplasia. WATS was twice as likely as FB to find IM in patients without a history of BE who had CLE on endoscopy. In patients with known BE, WATS and FB showed IM and dysplasia with similar frequency. These findings suggest that WATS can be used instead of FB with similar or improved efficacy at detecting IM and dysplasia. (Clinical trial registration number: NCT03859557.).

Baseline predictive factors for foregut and hindgut response to long-term gastric electrical stimulation using augmented energy.

Gastric electrical stimulation (GES) has been recommended for drug refractory patients with gastroparesis, but no clear baseline predictors of symptom response exist. We hypothesized that long-term predictors to GES for foregut and hindgut symptoms exist, particularly when using augmented energies. We evaluated 307 patients at baseline, 1week post temporary GES, and one year after permanent GES. Baseline measures included upper and lower symptoms by patient-reported outcomes (PRO), solid and liquid gastric emptying (GET), cutaneous, mucosal, and serosal electrophysiology (EGG, m/s EG), BMI, and response to temporary stimulation. Foregut and hindgut PRO symptoms were analyzed for 12-month patient outcomes. All patients utilized a standardized energy algorithm with the majority of patients receiving medium energy at 12months. Patients were categorized based on change in average GI symptom scores at the time of permanent GES compared to baseline using a 10% decrease over time as the cutoff between improvers versus non-improvers. By permanent GES implant, average foregut and hindgut GI symptom scores reduced 42% in improved patients (n=199) and increased 27% in non-improved patients (n=108). Low BMI, baseline infrequent urination score, mucosal EG ratio, and proximal mucosal EG low-resolution amplitude remained significant factors for improvement status. GES, for patients responding positively, improved both upper/foregut and lower/hindgut symptoms with most patients utilizing higher than nominal energies. Low baseline BMI and the presence of infrequent urination along with baseline gastric electrophysiology may help identify those patients with the best response to GES/bio-electric neuromodulation.

Non-steroidal anti-inflammatory drugs and the gastrointestinal tract

Non-steroidal anti-inflammatory drugs (NSAIDs) are used commonly but can cause foregut symptoms, peptic ulcer disease and small bowel enteropathy. Such iatrogenic injury can be complicated by gastrointestinal bleeding and perforation. Limiting NSAID use or co-administration with proton pump inhibitors (PPIs) reduce dyspepsia, peptic ulcer disease and rates of complications. Selective cyclo-oxygenase (COX)-2 inhibitors are as effective as adding PPIs in preventing upper and lower gastrointestinal complications. COX-2 inhibitors are suggested in those with high cardiovascular risk and the addition of PPI in those with high risk of bleeding. Where required, COX-2 inhibitor monotherapy may be preferred in unexplained iron deficiency anaemia.

Clinical spectrum and presentation of patients with absent contractility

BackgroundPrimary absent contractility is an uncommon finding on high-resolution manometry (HRM). The goal of this study was to describe the clinical spectrum and presentation of patients with primary absent contractility.MethodsWe queried a prospectively maintained esophageal testing registry to identify patients with absent contractility who presented between August 2016 and September 2018. Patients with poor quality studies and patients with insufficient clinical records as well as those with a history of previous foregut surgery or esophagram consistent with achalasia were excluded.ResultsA total of 2068 patients underwent HRM during the study period. Of these, 66 patients (3.2%) met the inclusion criteria and formed the study cohort; 52 patients in the cohort had an upper gastrointestinal contrast study, 50 had endoscopy, and 51 completed a foregut symptom questionnaire. Thirty-eight patients (57.6%) were women. The mean age was 56.6±13.86 years, and the mean body mass index was 26.37±5.7 kg/m2. Almost half of the patients (29/66, 43.9%) were undergoing lung transplant evaluation, and 22 patients (37.3%) had a history of autoimmune immune-mediated or myopathic diseases. On the symptom questionnaire, 42 of 51 patients (82.3%) reported heartburn, 24 of 51 (47.1%) reported dysphagia, and 23 of 51 patients (45.1%) reported both. On ambulatory pH monitoring, 23 of 37 patients (62.2%) had pathological esophageal acid exposure (acid exposure time >6%).ConclusionsAbsent contractility on HRM is uncommon and is frequently associated with connective tissue, myopathic or autoimmune disorders. The usual clinical presentation is reflux, dysphagia or both.

374 VIDEO ESOPHAGOGRAM CORRELATES OF DYSPHAGIA IN PATIENTS WITH NORMAL LOWER ESOPHAGEAL SPHINCTER

Abstract Dysphagia is a common foregut symptom. However, there is poor association between non-obstructive dysphagia and esophageal body peristaltic parameters in patients with normal lower esophageal sphincters (LES). The objective of this retrospective study was to study bolus transit patterns noted on barium esophagogram in patients experiencing dysphagia. Methods After IRB approval, we queried our esophageal database for patients with normal manometric LES. Jackhammer esophagus, esophageal spasm, previous foregut surgery, and unavailable foregut symptom questionnaires were exclusion criteria. Patients were grouped based on reported dysphagia: 0 = None; 1 = Mild; 2 = Moderate; 3 = Severe/very severe. All barium esophagograms were re-evaluated. Bolus esophageal transit time was studied with patients in both upright and prone positions, using live time stamps at bolus entry/exit. “Barium residue” was defined as persistent contrast on the esophageal wall after bolus exit. “Retrograde escape” referred to barium escaping proximally from the bolus into previously cleared esophagus. ANOVA and χ2 were used. Results In all, 150 patients met inclusion criteria. 76 (50.1%) were women. Mean age and body mass index were 58.4 ± 14.7 years and 22.9 ± 10.4 kg/m2, respectively. The number of patients in each dysphagia group (0, 1, 2, and 3) were 82(54.7%), 29(19.3%), 25(16.7%) and 14(9.3%), respectively. The difference in mean bolus transit time among dysphagia groups was statistically significant in prone-position swallows (39.3 ± 36.7, 75 ± 74.8, 98.8 ± 85 and 69.6 ± 43.7 seconds; p &amp;lt; 0.001) but not in upright-position swallows (14.6 ± 22, 12.4 ± 8.1, 14.3 ± 8.8 and 12.6 ± 8.2 seconds; p = 0.929; Fig. 1). The prevalence of residual contrast and retrograde escape in prone swallows were comparable among patients reporting dysphagia (p = 0.444, p = 0.173). Conclusion Bolus transit time in prone-position barium swallows is simple to assess, and correlates with dysphagia reported by patients with normal lower esophageal sphincters. However, further studies with comprehensive dysphagia score are needed.

573 PER-ORAL ENDOSCOPIC MYOTOMY FOR RECURRENT KILLIAN-JAMESON DIVERTICULUM

Abstract Killian-Jameson Diverticulum (KGD) is similar to Zenker's diverticulum(ZD) in respect to underlying pathology of protrusion of esophageal mucosa and vague foregut symptoms including dysphagia. However, KGD is distinctly different from ZD due to location of diverticulum, incidence, and preferred surgical approach. Methods We present a case of a patient who had previously undergone a transcervical diverticulectomy for JKD. He initially had symptomatic relief but eight months later developed a recurrence of his diverticulum with dysphagia. A per-oral endoscopic myotomy (POEM) was then performed. A video of this endoscopic intervention can be seen in this submission, along with appropriate commentary. Results The patient had resolution of his dysphagia and he recovered without complication. Conclusion This novel approach to recurrent Killian-Jameson Diverticulum after the more standard open transcervical approach should be considered for this challenging clinical scenario. The basic principles of an endoscopic myotomy can be applied similarly to such a diverticulum. Video https://www.dropbox.com/s/dlne8d08tp3rskb/KJ%20Diverticula%203%20min%20Edit%20%28edited%20-%20WeVideo%29.mp4?dl=0

Number of reflux episodes on pH-impedance monitoring associates with improved symptom outcome and treatment satisfaction in gastro-oesophageal reflux disease (GERD) patients with regurgitation

ObjectiveNumber of reflux episodes, an adjunctive metric on pH-impedance monitoring, is incompletely studied. We aimed to determine if number of reflux episodes associates with therapeutic outcome in regurgitation predominant gastro-oesophageal...

Combined pharmacologic antireflux therapy after esophagectomy: effect on symptoms and endoscopic findings at 1-year follow-up

Heartburn, regurgitation, pulmonary aspiration, and remnant esophagitis represent common sequelae of esophagectomy and gastric conduit reconstruction. Proton pump inhibitors are the mainstay of treatment. The aim of the study was to focus on the efficacy of combination therapy with mucosal surface protection. Patients undergoing esophagectomy were followed up to 1 year. Patients in group A received 60 mg/day lansoprazole and those in group B received combination therapy. During follow-up, the dosage of lansoprazole was reduced to 30 mg/day in asymptomatic patients with or without grade A–B esophagitis. The Gastro-Esophageal Reflux Disease – Health-Related Quality of Life (GERD-HRQL) and the Short-Form 36 (SF-36) were used to assess postoperative quality of life, and the foregut symptom questionnaire to assess the prevalence of regurgitation, respiratory symptoms, and sleep disorders. Between August 2017 and August 2018, 56 patients were enrolled in the study. Over follow-up, the incidence of refractory symptoms and/or esophagitis grade C–D was 35.7% in group A and 21.4% in group B (p = 0.024). At 1 year, 18 (64.2%) patients in group A and 22 (78.5%) in group B remained symptom free and without severe esophagitis under treatment with 30 mg of lansoprazole (p = 0.076). The GERD-HRQL score was similar at 3 and 6 months (p = 0.790 and p = 0.812, respectively); at 12 months, patients in group B had a lower score although the difference was not significant (p = 0.216). There were no statistically significant differences in terms of SF-36 scores at 1‑year follow-up. Concerning the foregut symptom questionnaire, group B experienced less respiratory symptoms (p = 0.045) and sleep disorders (p = 0.039). At 1‑year after esophagectomy, combination therapy with 30 mg lansoprazole and Esoxx® appears to be an effective antireflux strategy.

353 Multi-Center Randomized Trial Comparing Standard Forceps Biopsies to Wide-Area Transepithelial Sampling Brush for Finding Intestinal Metaplasia and Dysplasia in the Esophagus and Gastroesophageal Junction

INTRODUCTION: Intestinal metaplasia (IM) in the esophagus is a potentially pre-malignant mucosal change. The aim of this study was to compare the frequency of IM detection during upper endoscopy by biopsy forceps versus wide-area transepithelial sampling (WATS) brush. METHODS: Patients presenting for upper endoscopy for foregut symptoms or Barrett’s surveillance were prospectively enrolled and randomized to either biopsies or WATS brush from October1, 2017 to December 31, 2018. Patients with a history of malignancy were excluded. This study was IRB approved and funded by CDx Diagnositics. RESULTS: There were 1002 patients enrolled at 9 centers. Patient demographics and indications for endoscopy are shown in Table 1. A total of 509 patients had biopsies and 493 had WATS. A columnar-lined esophagus (CLE) of any length was seen in 282 patients, while in 720 patients there was no CLE and the biopsy or WATS was from a normal or irregular appearing gastroesophageal junction (GEJ). The median length of CLE when present was 3 cm. The overall frequency of finding IM by biopsy was 19.45% and by WATS 22.72%, P = 0.2. Table 2 shows the frequency of finding IM in the 817 patients that had upper endoscopy with no prior history of IM, compared to the frequency of finding IM in patients undergoing endoscopy for Barrett’s surveillance or follow-up after ablation (n = 185). In patients without a prior history of IM, biopsy and WATS found IM with similar frequency overall, but WATS found significantly more IM in patients with any endoscopically visible length of CLE. Biopsy found one cancer, and low-grade dysplasia was found in one patient each with biopsy and WATS. In the 185 patients that had their endoscopy for follow-up of Barrett’s or ablation there was no difference in the frequency of IM detection for biopsy vs WATS, and was similar in patients with &lt; 3 cm CLE and in those with ≥ 3 cm CLE. Dysplasia or cancer was found in 5 patients in this group, 2 by WATS and 3 by biopsy. CONCLUSION/DISCUSSION: Both biopsy and WATS detect a similar frequency of IM overall; however, WATS was over twice as likely as biopsies to find IM in patients without a history of IM who had a CLE on endoscopy. In patients undergoing surveillance for Barrett’s or follow-up after ablation both WATS and biopsy showed IM and dysplasia with similar frequency. These findings suggest that WATS can be used instead of biopsies of the GEJ and esophagus with similar or improved efficacy at detecting IM and dysplasia.

490 High-Resolution Electrogastrogram Identifies Disturbed Gastric Slow Waves and Dysautonomia in Subjects With Dumping Syndrome

INTRODUCTION: Rapid gastric emptying is the sine qua non of Dumping Syndrome (DS), which can arise from multiple etiologies including gastric surgery and diabetes mellitus. The relationship between DS and gastric myoelectric activity is unknown, but dysautonomia may play a role. We sought to characterize features of gastric slow waves and autonomic indices among subjects with DS using the ambulatory high-resolution electrogastrogram (HR-EGG). METHODS: Eleven subjects completed 24-hour ambulatory HR-EGG. Fasting abdominal computed tomography scan was utilized for stomach localization and placement of the ambulatory HR-EGG array, consisting of 10 skin mounted electrodes. Subjects were divided into two groups: DS (4F, age 53.2 ± 9.3, BMI 31.7 ± 11, 79-93% gastric emptying at 1 hour on scintigraphy, two diabetics, one prior gastric surgery, one gastrointestinal amyloidosis) and healthy age-matched controls (4M/3F, age 47.6 ± 28, BMI 24.5 ± 3.7). All subjects completed the PAGI-SYM foregut symptom questionnaire and a diary capturing all meals and sleep/wake times. RESULTS: Subjects with DS had significantly higher mean PAGI-SYM foregut symptom severity scores (1.9 ± 1.0 vs 0.1 ± 0.1; P = 0.0007). HR-EGG showed that DS subjects had a significantly lower slow wave speed (4.6 vs 5.9 ± 0.4; P = 0.0003) and higher post-prandial power change (11 vs 3.5 ± 3.6; P = 0.002) compared to healthy controls. The global percent stomach activity throughout the 24-hour ambulatory recordings was not different between groups. DS subjects trended towards higher post-prandial area under the curve EGG activity at both the 1-hour (261.9 ± 360.7 vs 172.9 ± 137.5) and 4-hour marks (1108.8 ± 1589.4 vs 656.3 ± 442.2). In addition, subjects with DS had significantly lower heart rate variability than controls: RMSDD (39.9 ± 9.7 vs 58.1 ± 7.8) and SDNN (12.6 ± 4.2 vs 23.7 ± 3.2); no differences were noted in mean heart rate (Table 1). CONCLUSION: Ambulatory HR-EGG clearly identifies that there are spatial abnormalities of the gastric slow wave present among subjects with DS. Moreover, reduced heart rate variability - a marker of autonomic dysfunction - was observed among subjects with DS. These findings suggest that gastric dysrhythmias and autonomic disturbances should be given important consideration in the pathogenesis of Dumping Syndrome.

Clinical Presentation of Gastroesophageal Reflux Disease: A Prospective Study on Symptom Diversity and Modification of Questionnaire Application

Introduction: Symptoms occurring in gastroesophageal reflux disease (GERD) such as heartburn, regurgitation, thoracic pain, epigastric pain, respiratory symptoms, and others can show a broad overlap with symptoms from other foregut disorders. The goal of this study is the accurate assessment of symptom presentation in GERD. Methods: Patients with foregut symptoms were investigated for symptoms as well as endoscopy and gastrointestinal-functional studies for presence of GERD and symptom evaluation by standardized questionnaire. Questionnaire included a graded evaluation of foregut symptoms documenting severity and frequency of each symptom. The three types of questionnaires include study nurse solicitated, self-reported, and free-form self-reported by the patient. Results: For this analysis, 1,031 GERD patients (572 males and 459 females) were enrolled. Heartburn was the most frequently reported chief complaint, seen in 61% of patients. Heartburn and regurgitation are the most common (82.4/58.8%, respectively) in overall symptom prevalence. With regard to modification in questionnaire technique, if patients fill in responses without prompting, there is a trend toward more frequent documentation of respiratory symptoms (up to 54.5% [p < 0.01]), fullness (up to 93.9%), and gas-related symptoms (p < 0.001). Self-reported symptoms are more diverse (e.g., throat-burning [12%], mouth-burning [9%], globus [6%], dyspnea [9%], and fatigue [7%]). Conclusions: GERD symptoms are commonly heartburn and regurgitation, but overall symptom profile for patients may change depending on the type of questionnaire.

Magnetic Sphincter Augmentation Superior to Proton Pump Inhibitors for Regurgitation in a 1-Year Randomized Trial

Regurgitative gastroesophageal reflux disease (GERD) refractive to medical treatment is common and caused by mechanical failure of the anti-reflux barrier. We compared the effects of magnetic sphincter augmentation (MSA) with those of proton-pump inhibitors (PPIs) in a randomized trial. Patients with moderate to severe regurgitation (assessed by the foregut symptom questionnaire) despite once-daily PPI therapy (n= 152) were randomly assigned to groups given twice-daily PPIs (n= 102) or laparoscopic MSA (n= 50) at 20 sites, from July 2015 through February 2017. Patients answered questions from the foregut-specific reflux disease questionnaire and GERD health-related quality of life survey about regurgitation, heartburn, dysphagia, bloating, diarrhea, flatulence, and medication use, at baseline and 6 and 12 months after treatment. Six months after PPI therapy, MSA was offered to patients with persistent moderate to severe regurgitation and excess reflux episodes during impedance or pH testing on medication. Regurgitation, foregut scores, esophageal acid exposure, and adverse events were evaluated at 1 year. Patients in the MSA group and those who crossed over to the MSA group after PPI therapy (n= 75) had similar outcomes. MSA resulted in control of regurgitation in 72/75 patients (96%); regurgitation control was independent of preoperative response to PPIs. Only 8/43 patients receiving PPIs (19%) reported control of regurgitation. Among the 75 patients who received MSA, 61 (81%) had improvements in GERD health-related quality of life improvement scores (greater than 50%) and 68 patients (91%) discontinued daily PPI use. Proportions of patients with dysphagia decreased from 15% to 7% (P <.005), bloating decreased from 55% to 25%, and esophageal acid exposure time decreased from 10.7% to 1.3% (P < .001) from study entry to 1-year after MSA (Combined P<.001). Seventy percent (48/69) of patients had pH normalization at study completion. MSA was not associated with any peri-operative events, device explants, erosions, or migrations. In a prospective study, we found MSA to reduce regurgitation in 95% of patients with moderate to severe regurgitation despite once-daily PPI therapy. MSA is superior to twice-daily PPIs therapy in reducing regurgitation. Relief of regurgitation is sustained over 12 months. ClinicalTrials.gov no: NCT02505945.