PPI Therapy Research Articles

EoE Recurrence on PPI Maintenance Therapy: You Do Not Know if You Do Not Look!

Data regarding histologic recurrence of EoE on PPI maintenance therapy are lacking. Retrospective review of 101 patients with histologic PPI-responsive EoE. 52/101 (51%) patients underwent follow-up EGD with biopsies. Of the 52 patients, 29 (56%) maintained histologic remission and 23 (44%) had histologic recurrence. 21 (40%) patients maintained BID PPI, 20 (39%) tapered to QD, and 11 (21%) had discontinued PPI. Of the 21 patients on BID PPI, 7 (33%) had histologic recurrence, of which 6 (86%) were asymptomatic. Patients on PPI therapy for EoE benefit from serial clinical, endoscopic, and histologic surveillance.

S650 Reassessing the Need for Continued PPI Therapy in Chronic GERD

S650 Reassessing the Need for Continued PPI Therapy in Chronic GERD

461. BARRETT'S ESOPHAGUS POST-ABLATION TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) WITH OR WITHOUT HIATAL HERNIA REPAIR (CTIF):A PROSPECTIVE FEASIBILITY TRIAL

Abstract Transoral incisionless fundoplication without (TIF) or with concomitant hiatal hernia repair(cTIF) are treatment options for GERD. Lifelong PPI therapy is recommended for BE patients, even after endoscopic eradication therapy (EET), but concern for adverse effects of chronic PPI use has increased. Full barrier surgical therapy (Nissen fundoplication, magnetic sphincter augmentation) is a highly effective treatment for GERD but is associated with dysphagia and gas-bloat. We hypothesized that TIF/cTIF may be reasonable alternatives. AIM: We studied the safety and efficacy of TIF/cTIF in post-EET BE patients with refractory GERD symptoms or esophagitis despite PPI, and those averse to chronic PPI. METHODS: We prospectively enrolled BE patients with BMI <35 after successful EET (EMR, RFA, cryoablation) who underwent TIF (HH < 2cm, Hill grade ≤2) from Nov 2017-2020 or cTIF (HH ≥2cm, Hill grade ≥3) from Nov 2020-2022. Preoperative evaluation included baseline standardized GERD questionnaires, EGD, and selective pH testing and manometry. The primary outcome was GERD/LPRD symptom control. Secondary outcomes were presence of esophagitis, PPI use, patient satisfaction (rated as satisfied/neutral/dissatisfied), average duration of symptom control off PPI, failure rate, BE recurrence, and adverse events. RESULTS: To date, 30 patients have had TIF or cTIF (Table 1) after EET for LGD/HGD/ImCA (n=19) or no dysplasia + family history of BE/ECA, n=11). Median follow-up to date is 3 years (IQR 2-4, range 0.5-6). 22/30(76%) were asymptomatic on once/twice daily PPI at baseline but PPI averse. All TIFs/cTIFs were completed without serious adverse events. At 6 months post TIF/cTIF, GERD/LPRD symptom control was 86% (GERD-HRQL score) and 93% (Reflux Symptom Index score) (Fig 1B), esophagitis was absent in all patients, PPI discontinued or reduced to occasional use in 83% (Fig 1B), and acid exposure time was normal in 74%. At last follow-up, GERD and LPRD symptoms remained controlled in 93% and 96%, respectively, esophagitis absent in 95%, PPI discontinued or reduced in 71% (Fig 1D). Overall, the mean duration off PPI from TIF/cTIF was 30.4 months (range 4.4-72.5). Patient satisfaction improved from 43% at baseline, to 69% at 6 months, to 79% at last follow-up (Fig 1C). TIF/cTIF failure (defined as resumption of daily/twice daily PPI, symptom recurrence, and/or abnormal AET) was 9(32%), greater in TIF (50%) than cTIF (8%) (p=0.039). Median recurrent hiatal hernia length was 1(IQR 0-1.5). Nondysplastic BE recurrence noted in 1 patient treated with APC and TIF (3.3%). Dysphagia (10%) and gas bloat (7%) improved from baseline (37% and 20%, respectively). CONCLUSION: Transoral partial fundoplication is a safe and effective alternative to chronic PPI or full barrier surgical therapy in BE patients after EET. Surgical hiatal hernia repair (cTIF) provides added durability.

381. MULTICENTER PAN-CANADIAN EXPERIENCE OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) FOR THE TREATMENT OF ACHALASIA: A RETROSPECTIVE STUDY

Abstract Background Per oral endoscopic myotomy (POEM) has emerged as a modality for the surgical treatment of achalasia using a minimally invasive approach with similar clinical efficacy to laparoscopic Heller myotomy. Japanese, European, American and International clinical practice guidelines now cite POEM as a first line treatment for achalasia. In Canada, single-centre experiences with POEM have shown promising results. This study aims to capture the pan-Canadian national experience with POEM for the treatment of achalasia across multiple institutions. Methods This was a retrospective study of patients who underwent POEM for achalasia across four Canadian institutions (St. Joseph's Healthcare Hamilton, Kingston Health Sciences Centre, Surrey Memorial Hospital and Montreal Sacred Heart Hospital) between 2012 to 2022. Pre-operative, procedural and post-operative data was collected. Our primary outcome was the proportion of patients with normal Eckhardt score (≤ 3) at 4 weeks. Secondary outcomes included procedure related adverse events, length of stay in hospital, post-procedure lower esophageal sphincter pressures, post-procedure gastroesophageal reflux disease (GERD) and response rate at further timepoints. Outcomes are reported as either proportions (%) or medians (IQR). Results POEM was attempted in 369 patients with a success rate of 99%. The median duration of surgery was 64 (47 – 89) minutes and length of stay was ≤1 day in 88% of patients. Peri-operative complications occurred in 11% of patients, all of which were Clavien-Dindo Grade ≤III. The post-operative response rate (Eckhardt score ≤3) was 100%, 98% and 95% at 1, 6 and 12 months, respectively. Additional interventions for achalasia following POEM were required in 6% of patients. High DeMeester scores, endoscopic esophagitis and symptomatic GERD were reported in 36%, 43% and 44%, respectively. 93% of GERD was treated with PPI therapy. Conclusions POEM is safe and feasible in Canadian institutions with efficacy in keeping with current international literature.

Mucosal impedance as a diagnostic tool for gastroesophageal reflux disease: an update for clinicians.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett's esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett's esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

Co-Administration of Proton Pump Inhibitors May Negatively Affect the Outcome in Inflammatory Bowel Disease Treated with Vedolizumab.

Concomitant medications may alter the effect of biological therapy in inflammatory bowel disease. The aim was to investigate the effect of proton pump inhibitors on remission rates in patients with inflammatory bowel disease treated with the gut-selective vedolizumab. Patients from the Hungarian nationwide, multicenter vedolizumab cohort were selected for post hoc analysis. Primary outcomes were the assessment of clinical response and endoscopic and clinical remission at weeks 14 and 54. Secondary outcomes were the evaluation of the combined effect of concomitant steroid therapy and other factors, such as smoking, on remission. A total of 108 patients were identified with proton pump inhibitor data from 240 patients in the original cohort. Patients on steroids without proton pump inhibitors were more likely to have a clinical response at week 14 than patients on concomitant PPI (95% vs. 67%, p = 0.005). Non-smokers with IBD treated with VDZ were more likely to develop a clinical response at week 14 than smokers, particularly those not receiving PPI compared with patients on co-administered PPI therapy (81% vs. 53%, p = 0.041, and 92% vs. 74%, p = 0.029, respectively). We found that the use of PPIs in patients treated with VDZ may impair the achievement of response in certain subgroups. Unnecessary PPI prescriptions should be avoided.

Eosinophilic esophagitis and duodenal food challenge - evaluation through endoscopic confocal laser endomicroscopy.

Endoscopic confocal laser endomicroscopy (eCLE) is an established technique that allows clinical evaluation of mucosal integrity by fluorescein leaking through the mucosa upon duodenal food challenge (DFC). Analysis of eCLE with DFC in eosinophilic esophagitis (EoE) would be interesting to evaluate epithelial barrier dysfunction also in other regions of the gastrointestinal tract and to characterize potential individual food allergens that trigger the esophageal inflammation. In an observational and proof of concept study we evaluated 9 patients with histologically proven EoE by eCLE and DFC. Severity of symptoms were graduated according to the validated symptom-based EoE activity index. The endoscopic appearance of the esophagus was described according to the Endoscopic Reference Score System (ERERS). Spontaneous and food induced transfer of fluorescein into duodenal lumen were detected 10 minutes following intravenously application of fluorescein and 10 minutes after DFC. Food allergens were yeast, egg, soy, milk, and wheat, respectively. Local application of sodium chloride solution 10 % to the duodenal mucosa before DFC served as a control. Patients responding to DFC received a dietary exclusion therapy according to the results of DFC. We investigated 9 patients with EoE (8 men, 49.7±13.8, 36-76 years). Symptom-based EoE activity index was 79±27.4, 33-100. In all patients EoE was confirmed by histology with number of esophageal mucosal eosinophilic granulocytes > 15/HPF, (91.4±77.4, 42-263). Mean ERERS score was 4.5±1.3, 3-7. None of the patients was aware of any food intolerance. eCLE revealed one patient with spontaneous transfer of i. v. fluorescein into duodenal lumen before DFC ("leaky gut"). 40 DFC were performed in the remaining 8 patients of whom 5 patients (61 %) responded to DFC. Rank order of fluorescein leakage upon DFC was wheat and milk in 37.5 % each, soy in 25 %, and egg in 12.5 %. The patients were treated by PPI (n=9), esophageal bouginage (n=5) and/or local corticoid therapy (n=3). The 5 patients responding to DFC received an additional food exclusion dietary advice focussed on the results of DFC. All patients reported a reduction of their symptoms. EoE activity indexes of patients with positive DFC were 73.7+28.6, 33-100 before and 22.7+37.9, 0-79 four weeks after food exclusion. The findings of our proof of concept study suggest that eCLE with DFC may be an interesting tool to further evaluate patients with EoE. This technique has the potential to identify patients who may benefit from an additional individual dietary therapy.

S800 Intermittent vs Continuous PPI Therapy and EGD Timing: A Retrospective Study

S800 Intermittent vs Continuous PPI Therapy and EGD Timing: A Retrospective Study

Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years

IntroductionHaving performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication.ObjectivesWe report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation.ResultsThe operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery.ConclusionBoth the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

Depression Events Associated with Proton-Pump Inhibitors in Postmarketing Drug Surveillance Data

Proton-pump inhibitors, PPIs, are widely prescribed and are available over the counter for prolonged reduction of stomach acid production and related disorders. PPIs irreversibly inhibit the hydrogen/potassium ATPase in gastric parietal cells. Recent retrospective studies have described an association between PPI use and depression. However, there is conflicting evidence that PPI therapy improves depressive symptoms. Considering the widespread use and over-the-counter availability of these drugs, further investigation into depression adverse event was warranted with a larger-scale postmarketing set of reports. Here we analyzed over 125,923 reports from the FDA Adverse Event Reporting System consisting of PPI and histamine-2 receptor antagonist monotherapy records and found a statistically significant association between use of PPIs and depression. Additionally, we analyzed each of the six currently marketed PPIs individually and observed the association with the depression adverse reaction for all of them.

Nitazoxanide Based New Regimens versus Metronidazole Standard Quardable Regimen as Rescue Therapy in Treatment of Resistant H. Pylori gastritis

Abstract Background Helicobacter pylori (H. pylori) is a small, Gram-negative spirochete inhabiting the mucous layer overlying the gastric epithelial cells in humans. It is the most common prevalent chronic human bacterial infection estimated in 50% of the global population Aim of the Work This study aimed to evaluate the efficacy of nitazoxanide and doxycycline as a new regimen in treatment of H.pylori Patients and Methods A Prospective observational cohort study for each patient the time for antibiotic therapy for two weeks and continue PPI therapy for three months. Results In this study we found that there is insignificant difference between both studied groups as regards demographic data. This table shows that there is insignificant difference between both studied groups as regards smoking, chronic illness, main complaint and pelvic-abd US. In this study we demonstrated that there is significant difference between both studied groups as regards PLT and INR. In study in our hands, the eradication rates were found to be higher in LOAD therapy group compared to Concomitant therapy group (83.3% vs. 71.4%), Also there is insignificant difference between both studied groups as regards outcome (P = 0.03) In this thesis we found that increased age is independently associated with higher probability of cure (negative Ag in stool). Conclusion We concluded that LOAD therapy is preferable to clarithromycin-contained triple therapy in H. pylori infection eradication particularly in countries like Egypt with great clarithromycin resistance. This is at least until we can get the bismuth in our country. Recently, the increasing concepts about levofloxacin resistance and decreasing efficacy as a second line treatment directed us towards thinking in levofloxacin contained quadruple therapy including doxycycline and NTZ as alternative line of regimen therapy for better H. pylori eradication in our country. Further studies are needed on larger scale of patients, and culture and sensitivity tests are frequently required to evaluate the resistant emergent bacteria. Although culture and sensitivity might not be carried out, the detection of mutations by molecular methods provides an alternative way in which we can relay in the future.

Endoscopic measurement of hiatal hernias: is it reliable and does it have a clinical impact? Results from a large prospective database

ABSTRACT Objectives The aim of our study was to compare the results of endoscopy and manometry with regard to the presence and longitudinal size of hiatal hernias using a cohort of patients with PPI-refractory reflux symptoms. In addition, we aimed to investigate the clinical relevance of hiatal hernias and their size in relation to the occurrence of GERD. Methods Five hundred patients with suspected GERD due to typical reflux symptoms (heartburn and regurgitation) and inadequate response to PPI therapy underwent standardized screening at a reflux center. After 2 weeks of PPI withdrawal, all patients underwent endoscopy, 24-h pH impedance measurement, and high-resolution manometry (HRM). Both endoscopy and HRM results were available for 487 patients. Results There was a high correlation between the endoscopic and manometric measured longitudinal size of hernias (rho = .768 (p < .001)). Absolute differences differ on a small effect basis (Cohen’s d = 0.23). The presence of hernias increases significantly with the severity of GERD, regardless of whether the hernia was diagnosed by endoscopy or manometry. Conclusion In summary, endoscopically and manometrically measured hiatal hernia size are highly significantly correlated. Patients with refractory reflux symptoms and a hernia size of 4 cm are very likely to have GERD. In the future, this finding could greatly simplify the diagnosis of GERD.

PPIs and gastric cancer: any causal relationship?

Hydrochloric acid is crucial in gastric physiology. In 1978 cimetidine, the first H2 antagonist of histamine receptors on the gastric parietal cell was introduced into therapy, inducing acid. Lasting the years, several studies focused on the potential relationship between inducing hypo-achlorhydria and risk of developing gastric cancer. In 1988 omeprazole, the first proton pump inhibitor, entered therapy. In 1996, Kuipers underlined the danger of progression of chronic atrophic gastritis in subjects taking PPIs. In 2018, one paper from Korea and an another on from Sweden suggested a possible relationship between long-term PPI therapy and the development of gastric cancer. Over the years, several articles, meta-analyzes and population based focused on relationship between long-term of PPI use and the onset of gastric cancer, with conflicting results. As reported, the presence of bias in the collection of cases, in particular concerning the evaluation of the H.p. status and presence of atrophic gastritis and intestinal metaplasia in subjects treated with PPI, can lead to noticeable errors in the results and conclusions, as demonstrated in the literature by exhaustive methodological studies of pharmacoepidemiology. A possible bias in the collection of case histories is due to the fact that PPIs are often administered to dyspeptic patients, among which there are patients already carriers of gastric neoplasia: the so-called inverse causality. Literature data, amended by methodological bias (sampling errors, lack of comparative assessment of Hp status and atrophic gastritis) NOT support a causal relationship between long-term PPIs therapy and the onset of gastric cancer.

Treatment of GERD Irrespective of Symptoms and Severity in COPD: To be or not to be!

COPD and GERD more commonly diagnosed and frequently reported health issues due to overlapping pathophysiological mechanisms and now considered as ‘two sides of same coin’. COPD related anatomical changes and medications will alter the course of existing GERD and increase the risk of new onset GERD. Proximal and distal anatomical locations of GERD have variable presentations such as worsening of COPD, acute non-infective exacerbations, recurrent cough, and respiratory failure. Proximal pathways involve direct lung injury by means of microaspiration of gastric contents and microbiological colonization. Distal pathway involves indirect mechanisms by sharing common anatomical and embryological developments with involvement of vagus nerve mediated noradrenergic cholinergic mediator’s related effects on bronchi and bronchioles. Both proximal and distal pathways have effects on lung functions. GERD has negative impact on natural course of COPD and exists in asymptomatic and symptomatic types. Prevalence of GERD should be actively sought in all COPD cases to prevent exacerbations, decrease lung functions decline, lower the risk of clinical and physiological worsening, and overall cost of care because of these high index issues. PPI therapy has significant effects on patients with COPD in reducing the number of acute attacks, adverse reactions, and mortality. Recurrent exacerbations need GERD to be ruled out in all cases of COPD to have successful treatment outcome. Only symptomatic cases treatment has shown positive outcome in GERD with COPD. Hence, ‘to be or not to be is the real question’ and no treatment is recommended for asymptomatic GERD cases with COPD irrespective of disease severity.

Refractory Gastroesophageal Reflux Disease: Scopes Beyond PPI

Gastroesophageal reflux disease (GERD) is a very common GI disorder where the reflux of gastric contents into the esophagus causes symptom generation. PPI is the principal weapon to fight against GERD. An empiric course of PPI therapy is a cost-effective strategy for managing GERD. But sometimes, PPI can only do so much if taken correctly. As PPI does not reduce the number of reflux, other measures, including lifestyle modification, are required to get relief of GERD symptoms. Most patients respond to 8 weeks of PPI therapy, but 20-40% do not respond or respond partially. While these patients are labeled as having refractory heartburn, many do not have GERD or have not been treated adequately. So, alternative etiology must be considered when patients are refractory to PPI. Endoscopy of upper GIT should be done initially in case of the presence of alarm symptoms and when considered refractory to exclude other conditions. If endoscopy reveals no abnormality, then esophageal function tests like esophageal manometry, 24 hrs ambulatory pH monitoring, and mucosal impedance test can be considered to exclude other related conditions. Endoscopic and surgical treatment options can also be considered in particular cases. J Dhaka Med Coll. 2022; 31(1) : 148-157

A282 RISK FACTORS ASSOCIATED WITH UNSUCCESSFUL HIGH-RESOLUTION MANOMETRY: FAILURE IS COMMON BUT WHAT CAN WE CHANGE

Abstract Background High-resolution manometry (HRM) is a diagnostic tool used to evaluate esophageal motor function and diagnose motility disorders. A standardized protocol is used to make an accurate diagnosis based on the Chicago Classification. Some existing literature suggests that incomplete or imperfect manometry tests are common, however; there remains a paucity of data to evaluate risk factors for failure to help clinicians determine when a study may be difficult to perform. Purpose Our goal was to quantify how often failed tests occurred and determine specific factors that may be associated with failed HRM. Method We retrospectively evaluated records for HRM tests performed over 1 year at our academic centre. Based on clinical experience, we identified several factors that may be associated with the success of HRM testing including the following: indications and symptoms leading to testing, patient’s age and biological sex, previous esophageal manometry history, previous esophageal/gastric surgery, previous septal repair/deviated septum, history of significant nausea/vomiting, history of anxiety/depression, history of irritable bowel syndrome, and medication use (opioids, proton pump inhibitors, calcium channel blockers, nitrates). We then compared patients with successful HRM vs. unsuccessful HRM with regard to our pre-specified risk factors. Result(s) 29 HRM tests were unsuccessful from a total of 152 that were performed (19% failure rate). Reasons for failure included the inability to pass the probe through LES (55%) and the inability to tolerate the manometry probe for a minimum of 10 saline swallows (45%). After separating the failed cases from successful tests, both groups had a similar distribution of age and sex. Specific symptoms and indications did not have a significant association with unsuccessful tests. A previous history of failed manometry was associated with unsuccessful HRM (OR: 15, 95% CI 1.88 to 183.8, p=0.0156). Conversely, PPI usage was associated with fewer failed HRM tests (OR: 0.37, 95% CI 0.16 to 0.90, p=0.0343). Other medical history or medication use was not found to be associated with testing failure in our study. Conclusion(s) HRM is useful for diagnosing esophageal motility disorders, but incomplete tests are common. Although this study did not identify any factors in a patient’s medical history that could be used to predict failure in patients who have never had testing, further investigations may identify if PPI therapy can make HRM testing more tolerable. Additionally, the association between previous failed HRM and repeat failures suggests that endoscopic probe placement techniques should be considered instead of retrying conventional probe placement. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A144 BLACK ESOPHAGUS: A PEDIATRIC PRESENTATION OF ACUTE ESOPHAGEAL NECROSIS AND MANAGEMENT OF ITS COMPLICATIONS

Abstract Background Acute esophageal necrosis (AEN), or "Black Esophagus", is a rare diagnosis in children with adult literature citing high mortality. We present a pediatric case of this unusual condition. Purpose To report the rare presentation of AEN in a child and the response to intensive endoscopic management. Method Chart and literature review of AEN presentation and management. Result(s) A 13-year-old male who presented with a one-day history of severe chest pain, worsened with swallowing, followed by coffee ground emesis. No caustic ingestion. A nasogastric (NG) tube was placed and 2L of coffee-ground aspirate drained. The patient was an ex-preterm infant (25 weeks) who presented at age 2 years with an antral ulcer that developed into an antral stricture. This resolved with successive endoscopic dilatation with no recurrence after 5 years, off acid suppression. Physical exam showed BMI 99th %ile and palpated epigastric tenderness. CT-angiogram showed diffuse circumferential thickening of the esophagus and impressive gastric dilatation. A contrast study showed stasis of contrast in the esophageal lumen. Upper endoscopy revealed a thick, white membrane followed by circumferential black mucosa in the mid to distal esophagus. Previous antral stricture was noted with easy scope passage. Biopsies were negative for fungus, bacteria, HSV, CMV and parvovirus. Inflammatory infiltrate (mainly neutrophils and scattered histocytes with occasional lymphocytes) was noted in the esophagus. Necrotic tissue was identified and a diagnosis of AEN was made. The patient remained NPO, on TPN, and morphine was used for pain control. He responded well to this, along with high dose PPI. He tolerated clear fluids and oral sucralfate. Repeat scope one week later showed resolved necrosis with remaining oedematous white plaques and an unchanged antral stricture. 10 days later he developed severe dysphagia and a 15.5 cm long 6 mm diameter distal esophageal stricture was identified. This was managed by serial balloon dilatations. Due to frequent need for dilatations, endoscopic triamcinolone injections were used in several procedures as an adjunct therapy. A total of 80 mg of triamcinolone per session was injected along the length of the stricture in 4 aliquots in five out of nine endoscopic dilations in the last seven months. The most recent procedure successfully dilated the esophagus to 18mm. Currently, the patient is now tolerating a soft oral diet and remains on PPI therapy. Image Conclusion(s) AEN is very rare in children with no literature describing the endoscopic management of AEN related stenotic complications. We report the case of this unique presentation in a teenager, resulting in severe, long-segment esophageal stenosis. Intensive endoscopic therapeutic management has resulted in a positive clinical outcome allowing oral nutrition without any stenting or surgical interventions. Early recognition and active endoscopic management likely contributed to the positive outcome. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Presence of refractory GERD-like symptoms following laparoscopic fundoplication is rarely indicative of true recurrent GERD.

Laparoscopic fundoplication (LF) is the gold standard for gastroesophageal reflux disease (GERD). Recurrent GERD is a known complication; however, the incidence of recurrent GERD-like symptoms and long-term fundoplication failure is rarely reported. Our objective was to identify the rate of recurrent pathologic GERD in patients with GERD-like symptoms following fundoplication. We hypothesized that patients with recurrent GERD-like symptoms refractory to medical management do not have evidence of fundoplication failure as indicated by a positive ambulatory pH study. This is a retrospective cohort study of 353 consecutive patients undergoing LF for GERD between 2011 and 2017. Baseline demographics, objective testing, GERD-HRQL scores, and follow-up data were collected in a prospective database. Patients with return visits to clinic following routine post-operative visits were identified (n = 136, 38.5%), and those with a primary complaint of GERD-like symptoms (n = 56, 16%) were included. The primary outcome was the proportion of patients with a positive post-operative ambulatory pH study. Secondary outcomes included proportion of patients with symptoms managed with acid-reducing medications, time to return to clinic, and need for reoperation. P values < 0.05 were considered significant. Fifty-six (16%) patients returned during the study period for an evaluation of recurrent GERD-like symptoms with a median interval of 51.2 (26.2-74.7) months. Twenty-four patients (42.9%) were successfully managed expectantly or with acid-reducing medications. Thirty two (57.1%) presented with GERD-like symptoms and failure of management with medical acid suppression and underwent repeat ambulatory pH testing. Of these, only 5 (9%) were found to have a DeMeester score of > 14.7, and three (5%) underwent recurrent fundoplication. Following LF, the incidence of GERD-like symptoms refractory to PPI therapy is much higher than the incidence of recurrent pathologic acid reflux. Few patients with recurrent GI symptoms require surgical revision. Evaluation, including objective reflux testing, is critical to evaluating these symptoms.

Fractures in CKD Patients—Risk Analysis in RRT Lombardy Patients

The increase in the number of patients with CKD starting dialysis treatment has become a major health problem in recent years. Osteoporosis is a typical feature of advanced age, which, in the dialysis population, is almost always accompanied by uremic osteodystrophy (CKD-MBD). These two factors are involved in the pathogenesis of fractures, which represent an important risk factor for the outcome of patients. The real consistency of fractures in CKD patients on kidney replacement therapy (KRT) requiring hospitalization in the Lombardy region (over 9,000,000 inhabitants) was analyzed using data from the regional administrative databases in the years 2011–2012. Among 8109 prevalent patients, 251 (45.8% women), with fractures after 1 January 2011, entered the analysis. A follow-up of two years (2011–2012) was considered to evaluate the incidence of more frequent fractures (femur, pelvis, hip, and spine) using ICD-9-CM codes. The most frequent sites of fractures were the femur (68.5%), hip and pelvis (47.4%), and vertebrae (12%). The patients on hemodialysis (HD) had more events than PD (3.3% vs. 1.4%; p = 0.03), while patients undergoing kidney transplantation (KTx) had a significantly lower percentage of fractures (0.6% vs. 3.3%; p &lt; 0.001). Observed mortality was very high: the estimated gross mortality rate for any cause was 25.9% at 90 days and 34.7% at 180 days. Diabetes, peripheral vasculopathy, and heart failure were associated with a numerical increase in fractures, although this was not significant. Proton pump inhibitor drugs (PPI), vitamin K antagonists, and diphosphonates were more frequently associated with fracture occurrence. The average total cost of fractured patients was 11.4% higher than that of non-fractured patients. On multivariate analysis, age &gt;65 years, female gender, PPI therapy, and cerebrovascular disease were found to be strongly associated with fractures in dialysis patients, whereas undergoing renal transplantation presented a reduced risk.

Anxiety correlates with excessive air swallowing and PPI refractoriness in patients with concomitant symptoms of GERD and functional dyspepsia.

Anxiety may exacerbate GERD and FD symptoms perception and reduce quality of life. As many as 50% of patients with GERD symptoms have incomplete relief with PPI therapy, and psychological factors may influence PPI responsiveness. The potential relationship between anxiety, excessive air swallowing, and PPI responsiveness was evaluated. GERD patients with concomitant FD were prospectively evaluated. Validated structured questionnaires were used to evaluate anxiety, GERD, and FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard dose PPI therapy. One hundred sixty-one patients were included. Frequency of non-responders in patients with moderate/severe anxiety was significantly higher compared to patients with mild anxiety (62.7% vs. 37.3%, p < 0.01). Patients with moderate/severe anxiety displayed a significantly higher mean FD symptoms score value compared to patients with mild anxiety. A significantly higher mean number of air swallows were observed in patients with moderate/severe anxiety. At ROC analysis, air swallows and mixed reflux episodes were significantly associated with the presence of PPI refractoriness (AUC: 0.725, 95% CI: 0.645-0.805 and 0.768, 0.692-0.843). According to univariate analysis, an abnormal number of air swallows, mixed reflux episodes and presence of moderate/severe anxiety was significantly associated with PPI refractoriness. Our results, if confirmed in in a larger, prospective clinical and therapeutic study, demonstrate the usefulness of an up-front evaluation with anxiety questionnaire and esophageal testing in patients with a broad spectrum of upper gastrointestinal symptoms who fail to respond to PPI treatment, supporting the option of alternative treatment modalities.