Normal pH Monitoring Research Articles

Acid Reflux Management with the RefluxStop Implant: A Prospective Multicenter Trial with 3-Year Outcomes.

RefluxStop is a unique implant for laparoscopic treatment of gastroesophageal reflux disease (GERD). It restores normal function of the gastroesophageal junction without the unwanted effects of encircling the esophagus, circumventing adverse events (AEs) associated with conventional anti-reflux surgeries. Three-year follow-up of 50 patients with chronic GERD treated by RefluxStop was achieved in a prospective, single-arm, multicentric clinical trial analyzing safety and effectiveness of the procedure. The 3-year results included 47 of 50 patients. No cases of device-related AEs, erosion, device migration, or explantation occurred during the entire study period. Two AEs were reported between the 1- and 3-year results (1-year results previously published), including mild dysphagia (n = 1) and heartburn (n = 1). No subjects (n = 0/47) required regular daily proton pump inhibitor (PPI) therapy at 3-year follow-up. Subjects experienced a 93.1% reduction in median total GERD-HRQL score at 3years (2.0) from baseline (29.5). One subject (n = 1) was dissatisfied with treatment but demonstrated normal 24-h pH monitoring results. Daily regurgitation improved by 97.9% from a baseline of 86% (n = 43/50) to 2.1% (n = 1/47) at follow-up. Dysphagia GERD-HRQL subscore of > 2 (i.e., bothersome everyday) decreased from 22% at baseline to 2% at 3years. Baseline odynophagia (16%) completely resolved at 3years. RefluxStop surgery treats GERD without encircling and applying pressure on the esophagus. Three-year follow-up demonstrates that the device is safe and effective in treating GERD with substantial improvements in quality of life via GERD-HRQL (median improvement 93%), PPI usage (0%), and 98% without dysphagia.

Treating acid reflux without compressing the food passageway: 4-year safety and clinical outcomes with the RefluxStop device in a prospective multicenter study

IntroductionRefluxStop is an implantable device for laparoscopic surgical treatment of gastroesophageal reflux disease (GERD) to restore and maintain lower esophageal sphincter and angle of His anatomy without encircling and putting pressure on the food passageway, thereby avoiding side effects such as dysphagia and bloating seen with traditional fundoplication. This study reports the clinical outcomes with RefluxStop at 4 years following implantation of the device.MethodsA prospective, single arm, multicenter clinical investigation analyzing safety and effectiveness of the RefluxStop device in 50 patients with chronic GERD.ResultsAvailable data are presented for 44 patients at 4 years with the addition of three patients at 3 years carried forward. At 4 years, median GERD-HRQL score was 90% reduced compared to baseline. Two patients (2/44) used regular daily proton pump inhibitors (PPIs) despite subsequent 24-h pH monitoring off PPI therapy yielding normal results. There were no device-related adverse events (AEs), esophageal dilations, migrations, or explants during the entire study period. AEs reported between 1 and 4 years were as follows: one subject with heartburn and a pathologic pH result with device positioned too low at surgery; one subject with dysphagia, thus, 46/47 patients reported no dysphagia-related AEs between years 1 and 4. Two patients (2/47) were dissatisfied with treatment despite normal 24-h pH monitoring, of whom one had manometry-verified dysmotility at 6 months, indicating dissatisfaction for reasons other than acid reflux.ConclusionThese results confirm the excellent and already published 1-year results as stable in the long-term, supporting the safety and effectiveness of the RefluxStop device in treating GERD for over 4 years. GERD-HRQL score, pH testing, and PPI usage indicate treatment success without dysphagia or gas-bloating and only minimal incidence of other AEs. This favorably low rate of AEs is likely attributable to RefluxStop’s dynamic physiologic interaction and non-encircling nature.

474. MANOMETRIC IDENTIKIT OF A FUNCTIONING AND EFFECTIVE FUNDOPLICATION IN THE HIGH-RESOLUTION MANOMETRY ERA

Abstract Background Assessing patients following Laparoscopic Fundoplication (LF) can be challenging. Functional information provided by pathophysiological testing—which can shed light on the cause of recurrent symptoms—could be key to clinical decision making. The value of performing High-Resolution Manometry (HRM) after LF is still unclear and debated. We sought to establish the HRM parameters indicative of a functioning fundoplication, and whether HRM could distinguish it from a tight or defective one. Methods We studied patients with gastroesophageal reflux disease (GERD) who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010–2022. HRM and pH monitoring were performed before and 6 months after surgery. LF failure was defined as GerdQ score ≥ 8 and abnormal 24 h-pH study or just abnormal 24 h-pH study. The study population was divided into 5 groups: LN and LT patients with normal pH monitoring (LNpH- and LTpH-, respectively); LN and LT patients with pathological pH monitoring (LNpH+ and LTpH+ groups, respectively); and patients with postoperative severe dysphagia (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 subtypes: HM1 (normal morphology); HM2 (intrathoracic fundoplication); and HM3 (slipped fundoplication). Results We recruited 132 patients: 46 in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH+ group, 7 in the LTpH+ group, and 5 in the Dysphagia group (Figure 1). Eight patients with GerdQ score ≥ 8 and normal 24 h-pH findings were excluded. At univariate analysis, postoperative lower esophageal sphincter (LES) basal pressure (p = 0.011), total and abdominal LES length (p = 0.014, p < 0.001) were correlated with LF failure. At multivariate analysis, postoperative abdominal LES length (p = 0.001) and HM2 (p < 0.001) were independently associated with surgical failure. Integrated relaxation pressure (IRP) was significantly higher in the Dysphagia group than in the LNpH- group. Conclusion This study generated reference HRM values for an effective LF and confirms that using HRM to assess the abdominal portion of the neo-sphincter and abnormal hiatal morphology (HM2) improves the clinical assessment of recurrent symptoms. HRM can distinguish patients with a well-functioning wrap from those developing recurrent GERD due to an ineffective wrap. Postoperative IRP also correlated significantly with the onset of dysphagia after surgery.

Routine Reflux Testing Guides Timely Antireflux Treatment to Reduce Acute and Chronic Rejection After Lung Transplantation.

Gastroesophageal reflux has been associated with poorer lung transplantation outcomes, although no standard approach to evaluation/management has been adopted. We aimed to evaluate the effect of timely antireflux treatment as guided by routine reflux testing on postlung transplant rejection outcomes. This was a retrospective cohort study of lung transplant recipients at a tertiary center. All patients underwent pretransplant ambulatory pH monitoring. Timely antireflux treatment was defined as proton pump inhibitor initiation or antireflux surgery within 6 months of transplantation. Patients were separated into 3 groups: normal pH monitoring (-pH), increased reflux (+pH) with timely treatment, and +pH with delayed treatment. Rejection outcomes included acute rejection, bronchiolitis obliterans syndrome, and chronic lung allograft dysfunction per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses using Cox proportional hazard models were applied. Patients not meeting outcomes were censored at death or last clinic visit. One hundred seventy-five patients (59% men/mean 56.3 yr/follow-up: 496 person-years) were included. On multivariable analyses, +pH/delayed treatment patients had higher risks of acute rejection (adjust hazard ratio [aHR]:3.81 [95% confidence interval [CI]: 1.90-7.64], P = 0.0002), bronchiolitis obliterans syndrome (aHR: 2.22 [95% CI: 1.07-4.58], P = 0.03), and chronic lung allograft dysfunction (aHR: 2.97 [95% CI: 1.40-6.32], P = 0.005) than +pH/timely treatment patients. Similarly, rejection risks were increased among +pH/delayed treatment patients vs -pH patients (all P < 0.05). No significant differences in rejection risks were noted between +pH/timely treatment patients and -pH patients. Failure/complications of antireflux treatment were rare and similar among groups. Timely antireflux treatment, as directed by pretransplant reflux testing, was associated with reduced allograft rejection risks and demonstrated noninferiority to patients without reflux. A standardized peri-transplant test-and-treat algorithm may guide timely reflux management to improve lung transplant outcomes.

Indications of 24-h esophageal pH monitoring, capsule pH monitoring, combined pH monitoring with multichannel impedance, esophageal manometry, radiology and scintigraphy in gastroesophageal reflux disease?

Ambulatory esophageal pH monitoring is an essential method in patients exhibiting signs of non-erosive reflux disease (NERD) to make an objective diagnosis. Intra-esophageal pH monitoring is important in patients who are non-responsive to medications and in those with extraesophageal symptoms, particularly in NERD, before surgical interventions. With the help of the wireless capsule pH monitoring, measurements can be made under more physiological conditions as well as longer recordings can be performed because the investigation can be better tolerated by patients. Ambulatory esophageal pH monitoring can be detected within normal limits in 17%-31.4% of the patients with endoscopic esophagitis; therefore, normal pH monitoring cannot exclude the diagnosis of gastroesophageal reflux disease (GERD). Multi-channel intraluminal impedance pH (MII-pH) technology have been developed and currently the most sensitive tool to evaluate patients with both typical and atypical reflux symptoms. The sensitivity of a pH catheter test is 58% for the detection of acid reflux compared with MII-pH monitoring; further, its sensitivity is 28% for the detection of weak acid reflux compared with MII-pH monitoring. By adding impedance to pH catheter in patients with reflux symptoms, particularly in those receiving PPIs, it has been demonstrated that higher rates of diagnoses and symptom analyses can be obtained than those using only pH catheter. Esophageal manometry is used in the evaluation of patients with functional dysphagia and unexplained noncardiac chest pain and prior to antireflux surgery. The use of esophageal manometry is suitable for the detection of esophageal motor patterns and extreme motor abnormalities (e.g., achalasia and extreme hypomotility). Esophageal manometry and ambulatory pH monitoring are often used in assessments prior to laparoscopic antireflux surgery and in patients with reflux symptoms refractory to medical treatment. Although the esophageal motility is predominantly normal in patients with non-acid reflux, ineffective esophageal motility is often monitored in patients with acid reflux. In the literature, there are contradictory and an insufficient number of studies regarding radiological methods for the diagnosis of GERD. There are inconsistent values for sensitivity and specificity among the barium studies. There are inadequate studies in the literature involving scintigraphic examinations in the diagnosis of GERD, and a majority of existing studies have been conducted in the pediatric group. The results of a few studies do not provide sufficient contribution toward the implementation in clinical practice.

Non-acid gastro-oesophageal reflux is associated with squamous cell carcinoma of the oesophagus

IntroductionSquamous cell carcinoma of the oesophagus is a common cancer among South Africans. Due to the absence of effective screening and surveillance programme for early detection and late presentation, squamous...

Proton Pump Inhibitor Therapy in Eosinophilic Esophagitis: Current Role and Future Perspectives

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms related to esophageal dysfunction, eosinophil-predominant inflammation, and lack of response to high-dose proton pump inhibitor (PPI) therapy. Responsiveness to PPI therapy in patients with suspected EoE has been historically assumed as evidence of gastroesophageal reflux disease (GERD), but this concept has rapidly changed over the past few years. A novel phenotype, termed PPI-responsive esophageal eosinophilia (PPI-REE), was described in 2011. PPI-REE refers to patients who appear to have EoE, but who achieve complete remission after PPI therapy. Currently, a PPI trial is mandatory before diagnosing EoE since 30–40 % of EoE patients will be eventually diagnosed with PPI-REE. Evolving evidence on PPI-REE suggests it is not simply GERD but actually a subphenotype of EoE, given the fact PPI-REE and EoE remain genetically and phenotypically indistinguishable. Instead of PPI-REE, the term PPI-responsive EoE might be more accurate to name this entity. PPI-REE might occur with either normal or pathological esophageal pH monitoring. PPI therapy can partially restore epithelial integrity and reverse allergic inflammation gene expression in PPI-REE. Whether esophageal barrier impairment is the cause of the effect of esophageal eosinophilia and whether PPI therapy primarily targets barrier or inflammation healing in PPI-REE have not been yet elucidated. The natural history of the disease, long-term doses, and duration of PPI therapy, as well as factors influencing symptom and/or inflammation relapse remain yet unknown. The mechanism as to why among identical patients, some respond to PPI therapy (PPI-REE) while others do not (EoE), warrants further research.

Can we swallow the idea of azathioprine as the next treatment option for pediatric eosinophilic esophagitis?

This article was originally published online on 8 April 2015 Eosinophilic esophagitis (EoE) is a burgeoning health concern impacting a growing proportion of the population. Experts advise utilization of either dietary modifications, swallowing of topical steroids or a combination for management. We present a child with EoE refractory to diet and topical corticosteroids who improved with oral azathioprine (AZA). We have a case of a 6 year old boy diagnosed with EOE after presenting with dysphagia to solids more so than liquids associated with severe odynophagia and vomiting. While on a PPI, the esophageal biopsy results revealed micro-abscesses, a thickened squamous basal layer and >150 Eos/hpf with normal esophageal pH monitoring. There was no evidence of increased eosinophils in the gastric and duodenal biopsies and no peripheral blood eosinphilia. Skin prick testing was negative to a panel of 70 foods including cow’s milk. Food patch testing revealed no evidence of delayed hypersensitivity. He failed to respond to several months swallowed topical fluticasone propionate or swallowed topical budesonide. A trial of ciclesonide swallowed was initiated but his clinical symptoms persisted. Due to his prior failure with swallowed topical corticosteroids, prednisone 5mg every other day was started in addition to budesonide 1mg inhalation suspension. During follow-up one month later, he had worsening symptoms consisting of increased vomiting, dysphagia with soft foods and generalized abdominal pain. The prednisone dose was discontinued and he was started on AZA. Follow-up four months later revealed significant improvement in his clinical symptoms. He had no symptoms of solid food dysphagia, odynophagia, impaction, abdominal pain or vomiting. His follow-up EGD still demonstrated hyperplastic basal cell layer but a tenfold reduction in intraepithelial eosinophils with a peak count of 15 Eos/hpf in his esophagus and no other histologic findings consistent with EoE. 18 months after starting AZA, his peak esophageal biopsy intraepithelial count remained at 15 Eos/hpf and his duodenum and stomach remained normal. To date he continues to tolerate AZA and has not manifested any drug adverse side effects. His growth has actually improved while on AZA. AZA has previously been used as monotherapy to induce long term remission in adults with refractory corticosteroid-dependent EoE. Current review of the literature yielded no prior reports of safely using AZA in the pediatric EoE population to successfully reduce clinical symptoms and tissue eosinophilia as observed in our case. This index case report suggests that AZA can be considered as a safe adjuvant therapy in recalcitrant pediatric EoE cases.

Gut Motility Alterations in Neonates and Young Infants

C olic usually affects babies in the first few weeks of their lives and persists for about 4 months. Crying can be intense and furious and it may last for several hours per day for several weeks. Although crying can occur at any time, it is usually worse in the late afternoon and evening, and occasionally affects the baby’s sleep. Infantile colic is not considered a disease, fulfilling instead criteria for a functional disorder. Research shows that babies with colic continue to eat and gain weight appropriately, despite the crying (1). The main risk for these babies relates to the stress and anxiety that the condition creates at home, especially when it affects the first child. The cause of colic is not known. Painful flatus may contribute to colic, but there is little evidence to prove that it is linked to digestive problems (2). Another theory is that while the digestive system is maturing, some babies are more sensitive to substances such as lactose ingested through breast-feeding and formula milk; however, evidence to support this hypothesis also is limited. Other possible causes relate to the baby’s behavior and temperament. Among the gastrointestinal (GI) factors, we focus on non-nutritive pathophysiology such as the relation of colic to gastroesophageal reflux (GER), GI motility disorders, the role of gut hormones, and intestinal microflora.

Results of Multichannel Intraluminal Impedance pH Metry in Symptomathic Children with Normal pH Metry Findings

A retrospective study was performed to evaluate the results of multichannel intraluminal impedance (MII) pH metry in symptomatic children with normal pH monitoring (PM) findings. Children who have reflux index (RI) less than 4% in PM and recurrent symptoms were included. All children underwent MII. Children who received antireflux treatment with normal PM findings were excluded from the study. MII results were evaluated for RI, content of reflux (acid, weak acid, and alkaline) number and type of impedance events, esophageal bolus clearance time and proximal extent of reflux (PER). Eight patients (age range: 5-13 years) were included to the study. The male female ratio was 5:3. The recurrent symptoms were related with gastrointestinal (n = 5) and upper respiratory system (n = 3). One of the patients was operated for esophageal atresia and one was followed for corrosive esophageal disease. Four of the patients had RI higher than 4% in MII. Patients with normal RI in MII, had weak acid reflux (n: 1), alkaline reflux (n = 1) and no reflux (n = 2). When number of impedance events evaluated, four patients had abnormal reflux episodes (70 or more reflux episodes). Impedance event recordings were correlated in 75% of PM findings. The content of impedance events were mixed and gas in nature. Prolonged esophageal clearance time and PER were detected in patients with chest pain and operated esophageal atresia. MII can be considered as a superior diagnostic tool to detect weak acid and alkaline reflux in patients who had recurrent symptoms with normal PM studies. MII also provides information about bolus clearance time and extent of reflux.

Lung Transplantation Triggered "Jackhammer Esophagus": A Case Report and Review of Literature

A 19-years-old girl was referred for lung transplant due to end stage lung disease secondary to idiopathic bilateral bronchiectasis. Her routine pre lung transplant evaluation showed normal esophageal high-resolution manometry (HRM) and 24-hours impedance pH monitoring. Four weeks after the bilateral sequential lung transplantation (LTx), she developed dysphagia, chest pain and regurgitation, complicated by aspiration pneumonia. Repeated HRM showed Jackhammer esophagus, delayed gastric emptying and abnormal 24-hour pH impedance monitoring consistent with the diagnosis of gastroesophageal reflux disease. Twelve weeks after LTx, she was symptom free, HRM and 24-hour impedance pH monitoring returned to normal. To the best of our knowledge, this rare transient esophageal hypercontractility episode occurred after LTx and recovered without any specific treatment was never reported in literature. The etiopathogenesis of Jackhammer esophagus in general and LTx induced dysmotility in particular is discussed and reviewed.

Laryngeal and voice disorders in patients with gastroesophageal symptoms. Correlation with pH-monitoring

To investigate laryngeal and voice disorders in patients with gastroesophageal symptoms and their correlation with pH-monitoring. A prospective study was carried out in patients attended at the Voice Disorder Outpatient Clinics of Botucatu Medical School in a five-year period and had vocal and gastroesophagic symptoms. Patients underwent videolaryngoscopy, auditory-perceptual vocal analyses, computerized acoustic vocal analysis and dual probe pH-monitoring for 24 hours. Fifty-seven patients were included (aged between 21 and 65 years; 45 women and 12 men), 18 had normal (31.6%) and 39 had abnormal pH-monitoring results (68.4%). Videolaryngoscopy recorded several laryngeal lesions for both patients with normal and abnormal pH-monitoring, but mostly for the latter group, highlighting posterior pachyderma. Auditory-perceptual vocal assessments identified vocal changes of several intensities for both groups but especially for patients with abnormal pH-monitoring results. All acoustic parameters, except f0, were abnormal for both groups, compared to the control population. Acoustic and perceptual vocal changes and laryngeal lesions were recorded for both patients with normal pH-monitoring results and patients with abnormal pH-monitoring results, evidencing the importance of clinical history and videolaryngoscopic findings for diagnosing acid laryngitis.

Eosinophilic Esophagitis Without Abundant Eosinophils? The Expanding Spectrum of a Disease That Is Difficult to Define

In 2007, the American Gastroenterological Association (AGA) provided a systematic review and consensus recommendations for the diagnosis and treatment of eosinophilic esophagitis (EoE) [1]. At that time, EoE was defined as a distinct clinical and pathologic entity characterized by the presence of clinical symptoms of esophageal dysfunction, an absence of gastroesophageal reflux disease (GERD) by either lack of response to proton pump inhibitor (PPI) therapy or normal pH monitoring values of the distal esophagus, and documentation of C15 eosinophils per high power field (Eos/HPF) in mucosal biopsies of the esophagus. Since its original description in children, EoE is now recognized as a disorder of adults as well. EoE is believed to represent an immune mediated disease for a variety reasons, but primarily because of its known association with other hypersensitivity or allergic disorders, the beneficial effect to steroid therapy in many patients, and by an abundance of studies that have shown an association with T-helper 2 mediated immunity via the action of eotaxin-3 and cytokines IL-13 and IL-5 [2–4]. Although EoE likely represents an allergic disorder, ultimately, the underlying initiating and perpetuating pathogenetic mechanisms remain unknown, which is partly the reason why it is difficult to establish definitive clinical and pathologic diagnostic criteria. In fact, the number of patients diagnosed with EoE is steadily increasing, and although this may be partly due to increasing awareness of this entity among clinicians, unfortunately, due to the lack of standardized diagnostic criteria prior to 2007, interpretation and comparison of data from prior studies (pre 2007) is difficult. There is a growing body of data, mainly related to the pathology, pathogenesis, natural history, and effect of certain forms of treatment, to suggest that the diagnostic criteria put forth in 2007 for EoE was in need of revision. For instance, there is evidence to suggest that there is a potential pathogenetic (or synergistic) relationship between EoE and GERD, as exemplified by the recent identification of patients who have overlapping clinical and pathologic features. Several studies have shown that eosinophil counts in patients with GERD may reach, or even exceed, the levels often associated with EoE [5–8]. Conversely, it is now being increasingly recognized that some patients with clinical and endoscopic features of EoE, but without GERD, contain lower than the normal threshold numbers of peak Eos/HPF in their esophageal biopsies. Also interesting is the recent identification of a subgroup of patients with esophageal eosinophilia and with clinical/endoscopic symptoms of EoE who respond positively to PPI therapy, termed ‘‘PPI-responsive EoE.’’ For instance, Ngo et al. described three patients with dysphagia and food impaction and [20 Eos/HPF in their esophageal biopsies who, following treatment with PPI, became clinically asymptomatic, achieved normal endoscopic findings, and normal, or near normal, intraepithelial eosinophil counts [9]. A recent prospective study by Molina-Infante et al. [8] of 35 patients with C15 Eos/HPF also provided evidence that a subgroup of patients with EoE may respond to PPI therapy. This and other clinical and pathologic data suggest that there may be a pathogenetic link between EoE and GERD, and that the original criteria used to diagnose EoE was in need of revision. As a result, the 2011 updated consensus recommendations for EoE in children and adults has altered the definition of EoE as ‘‘a disorder that represents a L. A. Doyle R. D. Odze (&) Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA e-mail: rodze@partners.org

Diagnosis of Eosinophilic Esophagitis: Current Approach and Future Directions

Eosinophilic esophagitis (EoE), a chronic inflammatory condition with a rapidly evolving epidemiology, is now a major cause of esophageal disease. Current guidelines emphasize that EoE is a clinicopathologic condition with the following criteria: clinical symptoms of esophageal dysfunction; at least 15 eosinophils in one high-power field on esophageal biopsy; and lack of responsiveness to high-dose proton-pump inhibition or normal pH monitoring of the distal esophagus. Challenges in diagnosis include lack of standardized esophageal biopsy protocols, variability in how eosinophil counts are determined, variability in the size of microscope high-power fields, and the need to evaluate the differential diagnosis of esophageal eosinophilia. In particular, the complex interplay between esophageal eosinophilia, EoE, and reflux disease remains an area both of controversy and active study. In the future, diagnostic strategies could include symptom scores, tissue or noninvasive biomarkers, and/or genetic expression profiles.

Eosinophilic Esophagitis Should Not Be Diagnosed by Histology Alone

Eosinophilic esophagitis (EoE) is often diagnosed solely on the basis of esophageal eosinophilic infiltration (EEI) with a count of ≥15 eosinophils per high-power field (eos/hpf). This practice is counter to consensus recommendations for diagnostic criteria, one of which is the exclusion of gastroesophageal reflux disease (GERD) through response to high-dose proton-pump inhibitors (PPIs) or normal pH monitoring. Nevertheless, many clinicians have observed that a subset of patients with …

Diagnosis and Treatment of Eosinophilic Gastrointestinal Disorders

Eosinophilic gastrointestinal disorders are a heterogeneous group of disorders defined primarily by an eosinophil-rich inflammatory infiltration of the gastrointestinal mucosa in the absence of other known causes for eosinophilia. In this review, the pathogenesis, clinical symptoms, diagnosis, and treatment of eosinophilic esophagitis (EE) are discussed. As the most common eosinophilic gastrointestinal disorder, EE is associated with food or inhalant hypersensitivity in up to 80% of EE patients. CD4 T cell production of Th2 cytokines interleukin-5 (IL-5) and IL-13 are important in the pathogenesis of these disorders. Clinical characteristics of patients with EE include nausea, vomiting, abdominal pain, dysphagia, food impaction, and feeding disorders. Diagnostic criteria include presence of symptoms consistent with esophageal dysfunction and peak eosinophil count of >15 eosinophils per one high powered field. Gastroesophageal reflux disease must be eliminated diagnostically by the absence of responsiveness to proton pump inhibitors or normal pH monitoring of the distal esophagus. The most common treatment modalities for EE include dietary elimination and oral or topical steroids to decrease esophageal inflammatory responses. Treatment interventions typically require 4–12 weeks to determine efficacy. Leukotriene inhibitors are not as efficacious as steroid therapy. Mepolizumab (anti-IL-5) and omalizumab (anti-IgE) are newer therapies currently under investigation. Future therapeutic agents may target the proinflammatory cytokines involved in the pathogenesis of disease, but more randomized controlled studies are needed to evaluate the benefits and harms of various therapeutic approaches.

Esophageal Eosinophilic Infiltration Responds to Proton Pump Inhibition in Most Adults

Despite consensus recommendations, eosinophilic esophagitis (EoE) is commonly diagnosed upon esophageal eosinophilic infiltration (EEI; based on ≥ 15 eosinophils per high power field; eo/HPF). We evaluated the prevalence of EEI before and after proton pump inhibitor (PPI) therapy and assessed the accuracy of EEI and pH monitoring analyses. Biopsies were taken from the upper-middle esophagus of 712 adults with upper gastrointestinal symptoms who were referred for endoscopy due to upper gastrointestinal symptoms. Patients with EEI were treated with rabeprazole (20 mg, twice daily) for 2 months. EoE was defined by persistent symptoms and >15 eo/HPF following PPI therapy. Thirty-five patients (4.9%) had EEI, of whom 55% had a history of allergies, and 70% had food impaction or dysphagia as their primary complaint. Twenty-six EEI patients (75%) achieved clinicopathological remission with PPI therapy; of these, 17 had GERD-like profile (EEI <35 eo/HPF and objective evidence of reflux, based on endoscopy or pH monitoring), and 9 had EoE-like profile (EEI 35-165 eo/HPF, typical EoE symptoms and endoscopic findings). The PPI response was 50% in the EoE-like profile patients. The PPI-response was 50% in EoE-like profile patients. Likewise, PPI-responsive EEI occurred with normal (33%) and pathologic (80%) pH monitoring. Higher histologic cut-off values improved specificity and positive predictive for EoE (35%-35% for >20 eo/HPF; 46%-39% for >24 eo/HPF; 65%-50% for 35 eo/HPF). In adults with EEI, 75% of unselected patients and 50% with an EoE phenotype respond to PPI therapy; pH monitoring is poorly predictive of response. Patients with PPI-responsive EEI >35 eo/HPF are phenotypically undistinguishable from EoE patients. EoE might be overestimated without clinical and pathologic follow-up of patient response to PPI.

Esophageal Motility in Children With Suspected Gastroesophageal Reflux Disease

Motility abnormalities in adults with gastroesophageal reflux disease (GERD) include nontransmitted contractions, reduced distal esophageal contraction amplitude, and simultaneous contractions. Information on esophageal body motility in children with GERD is scarce. Our aim was to study esophageal motility patterns in children with GERD, taking into account the presence of anatomical abnormalities and neurological impairment, the effect of age on esophageal motility in GERD, and the relation between esophageal manometry and GERD severity parameters (acid exposure and presence of esophagitis). Consecutive children referred for severe GER(D) symptoms underwent a barium swallow, upper endoscopy, pH monitoring, and stationary water-perfused esophageal manometry. Mean lower esophageal sphincter (LES) pressure and velocity of propagation in the proximal and distal esophagus decreased with age in this group of children with GERD (all P < 0.01). Severely disturbed esophageal motility was found in children with previous esophageal atresia. Patients with psychomotor retardation had significantly lower occurrence of peristaltic waves (94% +/- 21% vs 79% +/- 38%; P = 0.001), distal propagation velocity (0.8 +/- 0.4 vs 0.6 +/- 0.5 cm/s; P = 0.05), and distal contraction duration (3.1 +/- 0.8 vs 3.4 +/- 1 seconds; P = 0.05). None of the manometric characteristics differed between patients with normal or abnormal esophageal pH monitoring or with or without erosive esophagitis. LES pressure and esophageal velocity decreased with increasing age. Esophageal manometry is severely impaired in children with esophageal atresia and psychomotor retardation. No specific esophageal motor abnormalities related to the presence of endoscopic esophagitis or abnormal pH monitoring were found.

S1074 Differences Between Blacks and Whites With Eosinophilic Esophagitis

BACKGROUND & AIMS Eosinophilic esophagitis (EoE) can be currently diagnosed upon histopathology and a normal pH monitoring. We aimed to evaluate the prevalence of EoE before and after proton pump inhibitors (PPI) therapy and the accuracy of the aforementioned tests compared to systematic clinicopathologic follow-up on PPIs METHODS Biopsies of upper-mid esophagus were taken in 712 symptomatic adults referred for endoscopy, regardless of endoscopic findings. Patients with ≥ 15 eosinophils per high power field (eo/HPF) were treated with rabeprazole 20 mg b.i.d for two months. Gastroesophageal reflux disease (GERD) was defined by clinicopathologic remission on PPIs. RESULTS 35 patients (4,9%) had ≥ 15 eo/HPF, 55% had allergic history and 70% had food impaction or dysphagia as primary complaint. 26 patients (75%) were diagnosed of GERD after PPI treatment, including 2 with normal pH monitoring. The prevalence of ≥ 15 eo/HPF in 20 eo/HPF, 46% and 39% for > 24 eo/HPF, 64% and 50% for 35 eo/HPF). Clinical remission without histological response occurred in 5 out of 9 EoE patients after PPIs. CONCLUSIONS 75% of symptomatic adults with≥ 15 eo/HPF are responsive to acid suppression, irrespective of acid exposure time, eosinophil count or histopathologic features. EoEmay be overestimated without systematic clinicopathologic reevaluation on PPI therapy.

S1073 Systematic Clinicopathological Follow-up on High-Dose Acid Suppression is Mandatory to Avoid Eosinophilic Esophagitis Overestimation in Adults

BACKGROUND & AIMS Eosinophilic esophagitis (EoE) can be currently diagnosed upon histopathology and a normal pH monitoring. We aimed to evaluate the prevalence of EoE before and after proton pump inhibitors (PPI) therapy and the accuracy of the aforementioned tests compared to systematic clinicopathologic follow-up on PPIs METHODS Biopsies of upper-mid esophagus were taken in 712 symptomatic adults referred for endoscopy, regardless of endoscopic findings. Patients with ≥ 15 eosinophils per high power field (eo/HPF) were treated with rabeprazole 20 mg b.i.d for two months. Gastroesophageal reflux disease (GERD) was defined by clinicopathologic remission on PPIs. RESULTS 35 patients (4,9%) had ≥ 15 eo/HPF, 55% had allergic history and 70% had food impaction or dysphagia as primary complaint. 26 patients (75%) were diagnosed of GERD after PPI treatment, including 2 with normal pH monitoring. The prevalence of ≥ 15 eo/HPF in 20 eo/HPF, 46% and 39% for > 24 eo/HPF, 64% and 50% for 35 eo/HPF). Clinical remission without histological response occurred in 5 out of 9 EoE patients after PPIs. CONCLUSIONS 75% of symptomatic adults with≥ 15 eo/HPF are responsive to acid suppression, irrespective of acid exposure time, eosinophil count or histopathologic features. EoEmay be overestimated without systematic clinicopathologic reevaluation on PPI therapy.