High-dose Proton Pump Inhibitor Research Articles

1281 Duodenobiliary Fistula: A Rare Complication of Peptic Ulcer Disease

INTRODUCTION: Spontaneous biliary enteric fistulas are usually late complications of cholelithiasis or choledocholitiasis. The incidence of biliary enteric fistulas in this population ranges from 0.3 – 0.9%. Biliary enteric fistula formation is usually occurs from a gallstone ulcer perforating into the normal duodenum. However in rare circumstances (3.5-10% of cases) fistula's can form from a duodenal ulcer penetrating into the biliary tree, as is the case with biliary enteric fistula's due to peptic ulcer disease (PUD). These fistula's often present with abdominal pain, malaise and/or hematemesis. We discuss a rare case of a duodenobiliary fistula as a result of long standing peptic ulcer disease. CASE DESCRIPTION/METHODS: A 57-year-old male with long standing abdominal pain who recently immigrated to the United States from the Democratic Republic of Congo presented to the ED with acute on chronic epigastric abdominal pain. He denied previous surgery. Notably, he had tested positive for h. pylori a few months prior and was questionably compliant with prescribed antibiotics. He was admitted with hypokalemia and renal failure. Persistent symptoms prompted a computed tomography (CT) of his abdomen and pelvis. Findings from the CT demonstrated air and oral contrast material within the common bile duct and intrahepatic bile ducts with a fistulous connection to the second portion of the duodenum. Endoscopic evaluation demonstrated esophagitis, gastritis and severe pyloric stenosis likely due to long-standing PUD. The standard endoscope was unable to traverse this stenosis, but was successfully traversed with an ultrathin scope. The ampulla was briefly visualized and was grossly normal. There was no definitive fistulous tract identified. The patient was placed upon high dose proton pump inhibitor therapy. A repeat CT of the abdomen and pelvis was done 6 weeks later and was unchanged. The patient was referred to surgical oncology for definitive management. DISCUSSION: Historically, biliary enteric fistulas were often diagnosed during surgical interventions. Currently, CT can often diagnose these fistulas by detecting minimal pneumobilia. Endoscopic evaluation may or may not demonstrate a biliary enteric fistula due to duodenal narrowing or edema. Antiulcer therapy usually allows clinical improvement and fistula closure for PUD associated fistulas. Surgery is reserved for cases refractory to medical care, poorly controlled symptoms, hemorrhage or biliary obstruction.

1765 Delayed Esophageal Clearance Plays an Important Role in Reflux Symptomology in Scleroderma Patient

INTRODUCTION: We present the case of a patient with advanced scleroderma who experienced symptoms of refractory reflux despite maximum acid suppressing therapy. The use of 24-hour ambulatory esophageal pH impedance measurement led to the diagnosis of esophageal stasis, with subsequent management leading to the improvement of symptoms even with decreased proton pump inhibitor (PPI) dose. CASE DESCRIPTION/METHODS: 70-year old female with history of advanced scleroderma presented with severe retrosternal burning which she described as worst at night. She was taking 60mg Dexlansoprazole daily, an aluminum-magnesium-antacid, as well as an H2 blocker. An outside CT of the chest and abdomen showed a fluid-filled dilated esophagus and upper endoscopy was significant for a small hiatal hernia. The patient initially underwent high resolution manometry (HRM) which showed absent peristalsis. Subsequent pH impedance study identified low impedance in the esophagus with good gastric acid control (gastric acid exposure of 36%) but markedly abnormal gastric acid exposure in the distal esophagus: recumbent time acid exposure 94%, upright acid exposure 3%, and total acid exposure time of 40% despite high dose PPI. Recumbent position acid exposure at the distal esophagus was more prolonged than nocturnal gastric acidity, indicating esophageal stasis was a major factor in symptomatology. The patient was instructed to take her PPI and antacids close to bedtime, sleep with head elevation, and avoid late meals. The patient experienced significant symptom improvement and her PPI dose was successfully decreased. DISCUSSION: Scleroderma is a multiorgan connective tissue disorder affecting the gastrointestinal tract. The most commonly affected portion of the GI tract is the esophagus, with destruction of the smooth muscles of the lower esophageal sphincter and distal esophageal body. Abnormal reflux has been identified in patients with scleroderma on 24-hour pH monitoring in as many as 80% of patients. However, these study findings do not account for delayed esophageal clearance from failed or ineffective esophageal contractions. Patients with systemic sclerosis frequently have large dilated esophagi (pseudoachalasia) with subsequent stasis a major contributing factor for their symptoms. Thus, while pH studies are a useful diagnostic tool in patients with advanced scleroderma, therapeutic measures addressing esophageal stasis, such as nighttime head elevation, should be encouraged.

1144 A Prospective Study on PPI Response in Children With Eosinophilic Esophagitis

INTRODUCTION: Proton pump inhibitors (PPIs) are now considered a treatment option for eosinophilic esophagitis (EoE). High-dose PPI (HDPPI) response rates are 23-63% in pediatric studies. Our primary aim was to determine PPI response rate in children with EoE. Secondary aim was to determine clinical, endoscopic, or histologic characteristics that impact this PPI response. METHODS: A prospective cohort study of children was conducted. Demographics, clinical history, child and parent-proxy Pediatric EoE Symptom Scores version 2 (PEESSv2.0), EoE endoscopic reference scores (EREFS), and histology scores were collected at endoscopies before and after at least 8 weeks of HDPPI. EoE was defined as ≥ 15 eosinophils/high powered field (eos/hpf) on biopsy from any level of the esophagus on initial endoscopy with symptoms of esophageal dysfunction. Children with < 15 eos/hpf on repeat endoscopy were classified as PPI-responsive (PPI-R) EoE, and ≥ 15 eos/hpf were classified as PPI-nonresponsive (PPI-NR) EoE. RESULTS: 72 children were enrolled from 2015 to 2018 (58% male; mean 9.4 years). 40 children (56%) met criteria for EoE, and 25 had endoscopies before and after HDPPI. 11 refused HDPPI, and 4 were lost to follow-up. 32% (8/25) of children had PPI-R EoE. Baseline demographics, clinical history, child and parent-proxy PEESSv2.0 scores, parent-proxy dysphagia subdomain scores, EREFS, and histology scores were similar in PPI-R and PPI-NR EoE patients. Baseline child dysphagia scores were worse in PPI-NR EoE patients than in PPI-R EoE patients (17.8 v 11.0, P = 0.012). Parent-proxy PEESSv2.0 scores improved in PPI-R and PPI-NR EoE groups after HDPPI (P = 0.046, P = 0.005). Child PEESSv2.0 scores, and parent-proxy and child dysphagia scores improved significantly in the PPI-NR group after HDPPI (33.2 to 19.1, P = 0.006; 18.9 to 8.9, P = 0.004; 17.8 to 9.2, P < 0.001). EREFS improved in PPI-R and PPI-NR EoE groups (P < 0.001, P = 0.030), but had more improvement in the PPI-R group (P = 0.017). Children in the PPI-R group had improvement in degranulation and basal cell hyperplasia compared to the PPI-NR group (P = 0.016, P = 0.008). CONCLUSION: 32% of children with EoE responded to HDPPI therapy. No characteristics predicted PPI response. As anticipated, endoscopic and histologic features of EoE improved more in the PPI-R group. We did not expect to find that child and parent-proxy symptom scores would improve significantly in the PPI-NR group. The value of these symptom scores and their role in EoE management should be further studied.

1809 Gurvits Syndrome: A Rare Cause of Upper Gastrointestinal Bleed

INTRODUCTION: Acute Esophageal Necrosis (AEN), also known as Black Esophagus or Gurvit’s syndrome, is a rare disorder that can present as an acute gastrointestinal (GI) bleed. Given the high risk of perforation and mortality, a GI bleed in the correct clinical context should put AEN on the differential. We discuss clinical, endoscopic and management of AEN. CASE DESCRIPTION/METHODS: 57-year-old female with hypertension and gastroesophageal reflux disease presented after a pre-syncopal event. She was admitted for septic shock secondary to urinary tract infection. She was hypothermic with a blood pressure of 76/48 mm Hg on arrival to the ICU. She was started on broad spectrum antimicrobials, in addition to, norepinephrine and vasopressin to maintain mean atrial pressures above 60 mmHg. On ICU day two, she had multiple episodes of coffee-ground emesis and was intubated for airway protection. Her hemoglobin acutely dropped from 8 g/dl to 6.8 g/dl over 12 hours. EGD revealed circumferential ulceration of the lower esophagus with areas of necrosis. Patient was started on high-dose intravenous proton pump inhibitor and supportive therapy with treatment of septic shock. Three days later an endoscopic nasojejunal tube was placed for enteral feeding which revealed increasing amounts of viable mucosa with a decrease in the area of necrosis. There were no further GI bleed and patient was discharged 30 days later. DISCUSSION: AEN is multifactorial with a combination of an ischemic insult, corrosive injury to the mucosa from gastric contents and impaired reparative mechanism in setting of acute illness. Risk factors include male sex, older age and multiple chronic medical conditions. Men are four times more commonly affected than women. Diagnosis is made via direct visualization with findings of circumferential black discoloration of the distal esophagus that abruptly ends at the gastroesophageal junction. With comparatively less dense vasculature, the distal esophagus is the water-shed area of the esophagus. Treatment of AEN focuses on aggressive treatment of underlying disease, supportive therapy, and acid suppression. Complications of AEN include esophageal perforation, mediastinitis, and abscess formation. Long term complications include stricture formation and stenosis. Insertion of nasogastric tube should be avoided given the high risk of perforation secondary to the friability of the esophageal mucosa. In our patient, endoscopically placed nasojejunal tube was a safer alternative to restoring enteral feeding.

21 Prevalence of Potentially Inappropriate Medications (PIMs) in Older Palliative Patients, Defined by STOPPFrail Criteria

Abstract Background Polypharmacy is common in older persons with multi-morbid illness, increasing the risk of adverse drug events. Drug pharmacokinetics and pharmacodynamics are often altered in this group increasing the risk of adverse drug events and many prescribed drugs take considerable time to benefit. STOPPFrail criteria are designed to help prescribers to identify potentially inappropriate medications in older sicker patients with short life expectancy. The aim of this pilot study was to estimate the prevalence of STOPPFrail defined potentially inappropriate medications (PIMs in older patients with terminal illness at the point of admission to specialist hospice care. Methods We conducted a prospective analysis of inpatient case records and drug kardexes at a university teaching hospice over a period of one month. We recorded patients’ demographic details, principal symptoms, co-morbidities, medications at admission and at day 3-7. STOPPFrail criteria were applied to patients’ medications lists at both time points. Results Of 22 patients studied, 13 were female with a mean (+/- SD) age of 80 years (+/- 6). Eighteen patients were transferred directly from an acute hospital, 4 patients from the community. Common symptoms were pain (72%) and severe lethargy (68%). Twenty out of 22 patients had cancer as the life-limiting condition. There was a significant reduction in the mean (+/- SD) number of medications from admission (11 ± 4.1) to post palliative review (8 ± 4.7; p=0.002). 90% of patients had polypharmacy i.e. ≥ 6 daily medications, 87% had ≥ 1 STOPPFrail PIM on admission. The median number of STOPPFrail PIMs per patient was 1 (1-2, IQR), most commonly high dose proton pump inhibitors, multivitamin supplements, calcium supplements and lipid lowering therapies. Conclusion In this small study, STOPPFrail-defined PIMs were highly prevalent in older terminally ill patients. Prescribers should carefully review the medication lists of terminally ill older patients in order to minimize inappropriate polypharmacy.

150 Severe Drug Interactions (SDIs) and Potentially Inappropriate Prescriptions (PIPs) in Older Adults with Cancer

Abstract Background The objectives of this study were to identify the prevalence of severe drug interactions (SDIs) and potentially inappropriate prescriptions (PIPs) in older adults with cancer. Methods A 12-month prospective observational study of patients ≥65 years admitted to an oncology centre was conducted. SDIs were assessed using Stockley’s interaction checker; PIPs were identified using STOPP/START criteria. Logistic regression was applied to determine the influence of age, gender, co-morbidities and medication number on the likelihood of an SDI and a PIP. Results We enrolled 186 participants; mean age 72.5 (SD5.7) years, 46.2% female, mean co-morbidity number 7.5 (SD3.4), median medication number 7 (IQR4-9). Polypharmacy (≥6 medications) and major polypharmacy (≥11 medications) were identified in 60.8% and 17.7% respectively. Systemic anti-cancer therapies (SACTs) were concomitantly prescribed to 60.2%. SDIs were identified in 50.5% participants; 7.5% ≥1 SACT-SACT SDI, 41.4% ≥1 drug-drug SDI and 10.2% ≥1 drug-SACT SDI. The most common SDIs were beta-blocker/alpha-blocker (n=12), Selective serotonin re-uptake inhibitor (SSRI)/proton pump inhibitor (PPI) (n=11) and SSRI/Aspirin (n=8). A strong correlation between medication and SDI number was identified (r2=0.61, p-value <0.001). For each additional prescription, the odds of an SDI increased by 50.8% (Odds ratio 1.508, 95% CI1.288–1.764, p<0.001). PIPs were observed in 73.1%; median 2(IQR1-3). The most common PIPs were drugs prescribed beyond the recommended duration (46.8%), high-dose PPIs >8 weeks (34.9%) and regular opioids without laxatives (20.4%). Patients prescribed ≥1 PIP had more co-morbidities (8.4(SD3.4) vs 5.2(SD2.4), p< 0.001), a higher cumulative illness rating score (18(IQR12-20) vs 11(IQR10-14), p<0.001) and more prescribed medications (8(IQR6-10) vs 3(IQR1-4.25), p<0.001). For each additional prescription, the odds of receiving a PIP increased by 79.2% (Odds ratio 1.792, 95% CI1.459–2.02, p<0.001). Conclusion SDIs and PIPs are common in older adults with cancer and higher than previously reported. Comprehensive specialist medication evaluation, by a Geriatrician, may benefit patients.

CYP2C19 and STAT6 Variants Influence the Outcome of Proton Pump Inhibitor Therapy in Pediatric Eosinophilic Esophagitis.

Proton pump inhibitors (PPIs) are an effective treatment for eosinophilic esophagitis (EoE); however, only 30% to 60% of patients respond. Common genetic variants in CYP2C19 and STAT6 associate with PPI plasma concentration and magnitude of inflammatory response, respectively. Our objective was to determine if genetic variation in the genes for CYP2C19 and STAT6 influence differentiation between PPI responsive esophageal eosinophilia versus PPI nonresponsive EoE (PPI-REE, PPI-nonresponsive EoE). Genomic DNA was isolated from 92 esophageal tissue biopsies collected from participants of a prospective clinical trial of high-dose PPI therapy for esophageal eosinophilia in children. Of the 92 patients examined, 57 (62%) were PPI-REE and 35 (38%) were PPI-nonresponsive EoE. Forty-six of the 92 patients were further characterized by pH probe monitoring; there was no association between reflux index and carriage of CYP2C1917 (P = 0.35). In children who received a PPI dose between ≥1.54 and ≤2.05 mg/kg/day, binary logistic regression modeling showed that carriage of CYP2C1917 associated with PPI-nonresponsive EoE (odds ratio (OR) [95% confidence interval (CI)] = 7.71 [1.21, 49.11], P = 0.031). Carriage of STAT6 allelic variant rs1059513 predicts PPI-REE (OR [95% CI] = 6.16 [1.44, 26.4], P = 0.028), whereas carriage of STAT6 rs324011 synergizes with CYP2C1917 to predict PPI-nonresponsive EoE (rs324011 OR [95% CI] = 5.56 [1.33, 20.72], P = 0.022; CYP2C1917 OR [95% CI] = 8.19[1.42, 50.57], P = 0.023). Common variants in CYP2C19 and STAT6 associate with a PPI-nonresponsive EoE outcome of PPI therapy for esophageal eosinophilia suggesting that response rates may be improved by adopting a genotype-guided approach to PPI dosing.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry...

Potentially inappropriate prescribing in people with dementia: An Australian population-based study.

To investigate the prevalence of potentially inappropriate prescribing (PIP) using the Screening Tool of Older Person's Prescriptions (STOPP) criteria in people with dementia compared with people without dementia. A retrospective cohort study was conducted using the Pharmaceutical Benefits Scheme 10% sample of pharmacy claims. People with dementia were defined as those dispensed a medicine for dementia (cholinesterase inhibitors, memantine, or risperidone for behavioural and psychological symptoms of dementia) between 1 January 2005 and 31 December 2015, aged 65years or older at 1 January 2016 and alive at the end of 2016. An age- and gender-matched comparison cohort of people not dispensed medicines for dementia was identified. PIP prevalence was determined between 1 January 2016 and 31 December 2016. In total, 8280 people dispensed medicines for dementia and 41400 comparisons not dispensed medicines for dementia were included: 63% were female and the median age was 82years. PIP prevalence was 79% among people with dementia compared with 70% among the comparison group (P<.0001). Use of anticholinergics, long-term use of high-dose proton pump inhibitors, and use of benzodiazepines were the most common instances of PIP in people with dementia. After adjustments for age, gender, comorbidity, and number of prescribers, people with dementia were more likely to be exposed to PIP than comparisons (adjusted OR 1.44, 95% CI, 1.35-1.53, P<.0001). PIP was more common in people dispensed medicines for dementia than comparisons. These results highlight the need for effective interventions to optimize prescribing in people with dementia.

P-160 - Updated results of a phase II randomized trial with high dose proton pump inhibitors and metronomic capecitabine as salvage treatment for patients with advanced gastrointestinal tumours

P-160 - Updated results of a phase II randomized trial with high dose proton pump inhibitors and metronomic capecitabine as salvage treatment for patients with advanced gastrointestinal tumours

Patterns of High-Dose and Long-Term Proton Pump Inhibitor Use: A Cross-Sectional Study in Six South Australian Residential Aged Care Services.

AimWhile proton pump inhibitors (PPIs) are generally considered safe and well tolerated, frail older people who take PPIs long term may be susceptible to adverse events. This study characterized PPI use and determined factors associated with high-dose use among older adults in residential aged care services (RACSs).MethodsA cross-sectional study of 383 residents of six South Australian RACSs within the same organization was conducted. Clinical, diagnostic, and medication data were collected by study nurses. The proportions of residents who took a PPI for > 8 weeks and without documented indications were calculated. Factors associated with high-dose PPI use compared to standard/low doses were identified using age- and sex-adjusted logistic regression models.Results196 (51%) residents received a PPI, with 45 (23%) prescribed a high dose. Overall, 173 (88%) PPI users had documented clinical indications or received medications that can increase bleeding risk. Three-quarters of PPI users with gastroesophageal reflux disease or dyspepsia had received a PPI for > 8 weeks. High-dose PPI use was associated with increasing medication regimen complexity [odds ratio (OR) 1.02; 95% confidence interval (CI) 1.01–1.04 per one-point increase in Medication Regimen Complexity Index score] and a greater number of medications prescribed for regular use (OR 1.11; 95% CI 1.01–1.21 per additional medication).ConclusionsHalf of all residents received a PPI, of whom the majority had documented clinical indications or received medications that may increase bleeding risk. There remains an opportunity to review the continuing need for treatment and consider “step-down” approaches for high-dose PPI users.

Clinical management of eosinophilic esophagitis – a nationwide survey among gastroenterologists in Germany

Eosinophilic esophagitis (EoE) is an increasingly recognized immune-mediated esophageal disease and a common cause for dysphagia and food bolus obstruction. The aim of this study was to evaluate the current clinical management of EoE among adult gastroenterologists in Germany. We performed a cross-sectional study of 1393 adult gastroenterologists using a questionnaire containing 22 questions to general, diagnostic, and therapeutic aspects of EoE. The self-administered online survey was conducted between November 2017 and February 2018. Data capture and analysis was performed using SurveyMonkey. The overall responder rate was 29.6 %. More than half of the responders (54.9 %) felt to observe a significant increase of EoE patients. The EREFS score was mostly either unknown (44.3 %) or not routinely used (52.2 %). If EoE was suspected, most responders obtained multiple esophageal biopsies (n = 3 - 4: 35.7 %; n > 4: 61.6 %). The preferred primary treatment was proton pump inhibitors (PPI) in 37.2 % and topical steroids in 35.0 % of responders. PPI regimens were highly diverse, with only half of responders using high-dose PPI regimens. Allergy testing was often initiated (always 25.4 %, sometimes 48.9 %). The most common dietary therapy was 6-food elimination diet (52 %), followed by allergy test-directed diets (16 %) and 2-food elimination diet (16.5 %). The majority of responders indicated a need for long-term treatment (i. e., 23 % of responders in > 50 % their patients and 47.7 % of responders in 25 - 50 % of their patients). Among gastroenterologists in Germany, substantial variation in the adherence to published EoE guidelines appears to exist. This indicates the need for intensified education and national guidelines in order to optimize and harmonize the clinical management of EoE patients.

DOZ047.120: The role of proton-pump inhibitors in eosinophilic esophagitis: focus on esophageal atresia children

Abstract Introduction Since recently, after detection of eosinophilic predominant inflammation of esophagus a trial with proton-pump inhibitors (PPIs) was needed to individuate children with PPI-responsive esophageal eosinophilia (PPI-REE), only those non-responders received eosinophilic esophagitis (EoE) diagnosis. In 2018 updated international consensus suggested removing the PPI trial as a diagnostic criterion and consider PPIs as a treatment together with diets and topical steroids. The role of PPIs is evaluated in children with esophageal atresia (EA) and EoE versus EoE from general population. Method A retrospective chart review of both children with EA and EoE followed-up from at January 2005 has been performed. According to ESPGHAN guidelines published in 2014 patients showing eosinophilic inflammation received high-dose PPI trial to identified PPI-REE. Those non-responders were labeled as EoE and underwent to dietary and/or topical steroid treatment. Demographics and disease characteristics of EA patients with EoE were analyzed and compared with those with EoE from general population. Results Overall, 370 EA and 118 EoE patients were analyzed. Of them 15 EA-EoE patients were detected. Consequently, in our cohorts, 4.0% of EA patients developed EoE. Male-to-female prevalence ratio was of 2.55 with no difference in gender prevalence between groups. At diagnosis EoE-EA children were significantly younger compared to EoE group (mean: 5.1 vs 10.8 years; P &lt; 0.0001). Peak EOS/HPF at diagnosis did not differ between groups (50.1 ± 26 vs 59.8 ± 29 EOS/HPF). No difference was observed in allergy prevalence between groups (53.8 vs 68.0%). PPI-REE was significantly more prevalent in EA-EoE group that in EoE group (66.6% vs 19.4%; P = 0.0004). Conclusion Similar gender distribution and high prevalence of allergy suggest that common genetic susceptibility factors for EoE exist. However, high prevalence of PPI-REE coupled early EoE onset might also suggest that other factors (e.g. esophageal motility disorders) might play a physiopathological role in EoE development in EA children. Our study suggests that a stepwise approach with PPIs as a first-line treatment for EoE management in EA children should still be considered.

High-dose PPI-amoxicillin dual therapy with or without bismuth for first-line Helicobacter pylori therapy: A randomized trial.

A reliably highly effective high-dose proton-pump inhibitor plus amoxicillin (dual Helicobacter pylori therapy) has remained elusive. We compared whether the addition of bismuth to high-dose dual therapy would improve the efficacy of high-dose dual therapy as first-line treatment. This was an open-label, randomized single-center study of 160 treatment-naive patients with H.pylori infection who were randomly assigned to 14-day therapy with esomeprazole 40mg twice a day plus amoxicillin 1g three times a day with or without bismuth potassium citrate 600mg (elemental bismuth 220mg) twice a day. Antibiotic resistance was determined by agar dilution method and eradication by 13 C-urea breath test. The per-protocol eradication rates were 96.1%; 95% CI=88.9%-99.2% (73/76) without bismuth vs 93.3%; 95% CI=85.1%-97.8% (70/75) with bismuth (P=0.494). The intention-to-treat eradication rates were 92.5%; 95% CI=84.4%-97.2% (74/80) without bismuth and 88.8%; 95% CI=79.7%-94.7% (71/80) with bismuth (P=0.416). Resistance to amoxicillin, clarithromycin, metronidazole, and levofloxacin was 0%, 31.7%, 81.4%, and 40.7%, respectively. Smoking reduced treatment effectiveness limited to those not receiving bismuth. The per-protocol eradication rates were 70% (7/10) vs 100% (66/66) in smokers vs non-smokers without bismuth (P=0.002), and 100% (10/10) in smokers vs 92.3% (60/65) in non-smokers with bismuth (P=1.0). The adverse event rates were 7.5% (6/80) without bismuth vs 11.3% (9/80) with bismuth (P=0.416). Fourteen-day high-dose dual therapy was both effective and safe for first-line treatment in a region of high prevalence antibiotic resistance. Adding bismuth only improved treatment effectiveness among smokers.

Sa1202 – Concomitant Azithromycin and High Dose Proton Pump Inhibitors Improve Oesophageal Motility in a Proportion of Patients Under Consideration for the Linx Reflux Management System

Sa1202 – Concomitant Azithromycin and High Dose Proton Pump Inhibitors Improve Oesophageal Motility in a Proportion of Patients Under Consideration for the Linx Reflux Management System

Reconciliation of Recent Helicobacter pylori Treatment Guidelines in a Time of Increasing Resistance to Antibiotics.

Increasing resistance to antibiotics worldwide has adverse effects on the effectiveness of standard therapies to eradicate Helicobacter pylori infection. We reviewed guidelines developed by expert groups in Europe, Canada, and the United States for the treatment of H pylori infection. We compared the recommendations of these guidelines, reconciled them, and addressed the increasing resistance of H pylori to antibiotic therapy regimens. The guidelines recommend bismuth quadruple therapy for first-line treatment, replacing clarithromycin-based triple therapy. There is consensus for concomitant 4-drug therapy as an alternative, especially when bismuth is not available. When therapy is unsuccessful, it is likely due to resistance to clarithromycin, levofloxacin, and/or metronidazole; these drugs, if used previously, should be avoided in subsequent eradication attempts. Second-line therapies should be bismuth quadruple therapy or levofloxacin triple therapy, depending on suspected resistance, reserving rifabutin-based triple and high-dose dual amoxicillin proton pump inhibitor therapy for subsequent treatment attempts. The increasing resistance of H pylori to antibiotic therapy necessitates local availability of susceptibility tests for individuals, and establishment of regional and national monitoring programs to develop evidence-based locally relevant eradication strategies. Further studies into the development of more easily accessible methods of resistance testing, such as biomarker analysis of stool samples, are required. Options under investigation include substituting vonoprazan for proton pump inhibitors, adding probiotics, and vaccine development. Narrow-spectrum antibiotics and new therapeutic targets could be identified based on genomic, proteomic, and metabolomic analyses of H pylori.

Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER).

Recommendations for diagnosing and treating eosinophilic esophagitis (EoE) are evolving; however, information on real world clinical practice is lacking. To assess the practices of pediatric gastroenterologists diagnosing and treating EoE and to identify the triggering allergens in European children. Retrospective anonymized data were collected from 26 European pediatric gastroenterology centers in 13 countries. Inclusion criteria were: Patients diagnosis with EoE, completed investigations prescribed by the treating physician, and were on stable medical or dietary interventions. In total, 410 patients diagnosed between December 1999 and June 2016 were analyzed, 76.3% boys. The time from symptoms to diagnosis was 12 ± 33.5 months and age at diagnosis was 8.9 ± 4.75 years. The most frequent indications for endoscopy were: dysphagia (38%), gastroesophageal reflux (31.2%), bolus impaction (24.4%), and failure to thrive (10.5%). Approximately 70.3% had failed proton pump inhibitor treatment. The foods found to be causative of EoE by elimination and rechallenge were milk (42%), egg (21.5%), wheat/gluten (10.9%), and peanut (9.9%). Elimination diets were used exclusively in 154 of 410 (37.5%), topical steroids without elimination diets in 52 of 410 (12.6%), both diet and steroids in 183 of 410 (44.6%), systemic steroids in 22 of 410 (5.3%), and esophageal dilation in 7 of 410 (1.7%). Patient refusal, shortage of endoscopy time, and reluctance to perform multiple endoscopies per patient were noted as factors justifying deviation from guidelines. In this "real world" pediatric European cohort, milk and egg were the most common allergens triggering EoE. Although high-dose proton pump inhibitor trials have increased, attempted PPI treatment is not universal.

Refractory Peptic Ulcer Disease

The eradication of Helicobacter pylori and the widespread use of effective antisecretory therapies, including proton pump inhibitors, have improved the management of peptic ulcer disease. However, in some patients, peptic ulcer disease is refractory to 8 to 12 weeks of standard antisecretory drug treatment. For refractory peptic ulcer disease, further evaluation of the risk factors and causes of refractory peptic ulcer disease, including patient risk factors and noncompliance (smoking, nonsteroidal anti-inflammatory drug use, and noncompliance with medical treatment), persistent H. pylori infection, and non-H. pylori-related factors (giant ulcer, gastrinoma, infections other thanH. pylori, and malignancy), is essential. The treatment should focus on the cause of the refractory peptic ulcer disease, avoiding smoking and nonsteroidal anti-inflammatory drug, the treatment of persistent H. pylori, use of high-dose proton pump inhibitors, or surgical excision of gastrinomas. Surgery should be considered in patients who are at high risk for complications and recurrent peptic ulcer disease despite medical treatment. In this review, I describe the diagnosis and treatment of refractory peptic ulcer disease. Key words: Anti-inflammatory agents, non-steroidal; Helicobacter pylori; Peptic ulcer; Ulcer, refractory

STOPPFrail (Screening Tool of Older Persons' Prescriptions in Frail adults with a limited life expectancy) criteria: application to a representative population awaiting long-term nursing care.

STOPPFrail criteria highlight instances of potentially inappropriate medications (PIMs) in frailer older adults with poor 1-year survival prognosis. The objectives of this study were to (i) determine the proportion of older adults requiring long-term nursing care in whom STOPPFrail criteria are applicable, (ii) measure the prevalence of STOPPFrail PIMs, and (iii) identify risk factors for PIMs in this cohort. We retrospectively reviewed applications for long-term nursing care to nursing homes in the Cork area over a 6-month period. We recorded diagnoses, medications, functional status, cognitive ability, frailty status, and applied STOPPFrail criteria as appropriate. We reviewed 464 applications; 38 were excluded due to incomplete information and 274 patients (64.3%) met STOPPFrail eligibility criteria (median age 83years (IQR 77.25-88); 233 (54.7%) female). Those STOPPFrail eligible were prescribed 2194 medications (mean 8, (SD 4)), of which 828 (37.7%) were PIMs. At least one PIM was identified in 250 eligible patients (91.2%). The median number of PIMs was 3 (IQR 2-4), the most common being (i) medications without clear indication identified in 47.0% (n= 129) of patients, (ii) long-term high-dose proton pump inhibitors in 31.4% (n= 86), and (iii) statins in 29.6% (n= 81). For every additional medication prescribed, the odds of identifying a PIM increased by 58% (odds ratio 1.58, 95% CI 1.32-1.89, p< 0.001). Almost 65% of patients awaiting long-term care are eligible for the application of STOPPFrail criteria with over 90% prescribed at least one PIM. Transition to nursing home care represents an opportunity to review therapeutic appropriateness and goals of prescribed medications.

Rumination syndrome after esophagectomy

Gastric conduit dysfunction after esophagectomy is a disabling condition that may require revisional surgery. Rumination syndrome is an uncommon and poorly recognized functional foregut disorder of unknown etiology characterized by effortless oral regurgitation of recently ingested food. Rumination is associated with increased intragastric pressure generated by an unconscious mechanism eliciting contraction of the abdominal wall and relaxation of the diaphragm. Rumination syndrome after esophagectomy has not been previously reported in the literature. Two female patients were referred for inability to eat and weight loss due to severe food regurgitation following esophagectomy and gastric conduit replacement. Their previous medical and psychiatric history was apparently unremarkable. Symptoms occurred within the first postoperative year and progressively worsened. High-dose proton pump inhibitors, erythromycin, metoclopramide, antidepressant medications, pneumatic pyloric dilatation, and laparoscopic pyloromyotomy failed to relieve symptoms, and both patients eventually required permanent tube jejunostomy for nutritional support. Subsequently, thoracoscopic implant of a neurostimulator and a laparoscopic Roux-en-Y gastrojejunostomy were performed and failed in both patients. All medical and surgical attempts to relieve symptoms were clinically unsuccessful in these patients in whom radiological and endoscopic investigations did not demonstrate trans-diaphragmatic hernia or mechanical obstruction of the gastric conduit. Eventually, the diagnosis of rumination syndrome was made based on the Rome IV criteria. In the absence of anatomical or other functional abnormalities of the gastric conduit, revisional surgery is contraindicated; rather, the diagnosis of rumination syndrome should be considered. The role of behavioral therapy integrated with diaphragmatic breathing training and biofeedback should be investigated in these patients.