Presence Of Esophagitis Research Articles

Long-term effect of Roux-en-Y gastric bypass versus sleeve gastrectomy on reflux and Barrett's oesophagus: a randomized controlled trial.

Laparoscopic sleeve gastrectomy (LSG) is a potentially refluxogenic operation while Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is regarded as an anti-reflux procedure. The aim of this study is to compare long-term incidence of Barrett's Oesophagus (BO) and gastroesophageal reflux disease (GORD) following LSG and LRYGB. Participants of a double-blinded randomized controlled trial comparing banded LRYGB and LSG for remission of type 2 diabetes were contacted to take part. A gastroscopy was performed. Primary outcome was endoscopic and histologic evidence of BO. Secondary outcomes included reflux and regurgitation scores, presence of oesophagitis, proton-pump inhibitor (PPI) usage, Body Mass Index (BMI), and percentage excess weight loss (%EWL). Forty-eight of 109 patients were enrolled into the study (LSG 26 vs. LRYGB 22). Mean follow-up was 7.5 years for the LSG group, and 7.4 years for the RYGB group (P = 0.22). 8 LSG patients had BO while 3 LRYGB patients had BO (30.8%vs13.6%, P = 0.19). There was no significant difference in the mean reflux (8.1 ± 9.4(0-36) vs. 9.3 ± 8.8(0-34), P = 0.47) and regurgitation scores (7.7 ± 6.9(0-22) vs. 11.5 ± 10.5(0-44), P = 0.23) for LSG versus LRYGB patients or between those with and without BO. PPI usage before and after surgery was 6/26 (23.1%) versus 13/26 (50.0%) and 8/22 (36.4%) versus 12/22 (54.5%) for LSG and LRYGB patients respectively. PPI usage in patients with and without BO was 7/11 versus 18/37. EWL was significantly greater (P = 0.0013) in the LRYGB group (74.8 ± 28.1%) compared to LSG group (49.7 ± 18.7%). Long-term incidence of BO trended towards but was not significantly higher for LSG compared to LRYGB group. We support routine endoscopic surveillance for bariatric patients.

BN O01 - Hiatus hernia and gastro-oesophageal reflux disease. Does size matter?

Abstract Background Hiatus hernia occurs when part of the stomach bulges into the thoracic cavity through the hiatal opening of the diaphragm. In our study, we aimed to assess the impact of the hiatal hernia size on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. The study also looked at the impact of various characteristics including age, smoking, alcohol consumption, body mass index (BMI), and presence of oesophagitis and/or dysmotility on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. Method The study was conducted in an Upper Gastrointestinal surgery unit located in the North West of England. All patients aged over 18 who underwent laparoscopic fundoplication for gastro-oesophageal reflux disease between January 2017 and June 2023 were included. Patients who underwent fundoplication for para-oesophageal hiatus hernia, those who had fundoplication as a complementary step to Heller’s cardio-myotomy, or those who underwent revisional surgery were excluded. Results A total of 115 patients with a median age of 54 were included. Patients’ age was found to have a statistically significant association with hiatus hernia size above 2 cm, DeMeester score, and Symptom Association Probability with a P value of 0.011, 0.021, and 0.030 respectively. Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux (P=0.017). Smoking association with DeMeester score was found to be significant (P=0.027). Hiatus hernia size was not found to have a statistically significant association with DeMeester score, Symptom Index, or Symptom Association Probability (P=0.115, 0.315, 0.904) respectively. Conclusion Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux on PH studies but not statistically associated with elevated DeMeester score above 14.72 or symptom correlation indices. Thorough endoscopic assessment in addition to detailed oesophageal physiological studies are mandatory to evaluate patients with gastro-oesophageal reflux disease prior to considering surgery.

743. HIATUS HERNIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE. DOES SIZE MATTER?

Abstract Background Hiatus hernia occurs when part of the stomach bulges into the thoracic cavity through the hiatal opening of the diaphragm. In our study, we aimed to assess the impact of the hiatal hernia size on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. The study also looked at the impact of various characteristics including age, smoking, alcohol consumption, body mass index (BMI), and presence of oesophagitis and/or dysmotility on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. Methods The study was conducted in an Upper Gastrointestinal surgery unit located in the North West of England. All patients aged over 18 who underwent laparoscopic fundoplication for gastro-oesophageal reflux disease between January 2017 and June 2023 were included. Patients who underwent fundoplication for para-oesophageal hiatus hernia, those who had fundoplication as a complementary step to Heller’s cardio-myotomy, or those who underwent revisional surgery were excluded. Results A total of 115 patients with a median age of 54 were included. Patients’ age was found to have a statistically significant association with hiatus hernia size above 2 cm, DeMeester score, and Symptom Association Probability with a P value of 0.011, 0.021, and 0.030 respectively. Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux (P=0.017). Smoking association with DeMeester score was found to be significant (P=0.027). Hiatus hernia size was not found to have a statistically significant association with DeMeester score, Symptom Index, or Symptom Association Probability (P=0.115, 0.315, 0.904) respectively. Conclusion Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux on PH studies but not statistically associated with elevated DeMeester score above 14.72 or symptom correlation indices. Thorough endoscopic assessment in addition to detailed oesophageal physiological studies are mandatory to evaluate patients with gastro-oesophageal reflux disease prior to considering surgery.

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.

Predictors of Pathological Gastroesophageal Reflux among Emirati Patients with Reflux Symptoms Who Undergo Wireless pH Monitoring.

Background: Diagnosis of gastroesophageal reflux disease (GERD) relies on recognizing symptoms of reflux and mucosal changes during esophagogastroduodenoscopy. The desired response to acid suppression therapy is reliable resolution of GERD symptoms; however, these are not always reliable, hence the need for pH testing in unclear cases. Our objective was to identify potential predictors of a high DeMeester score among patients with potential GERD symptoms to identify patients most likely to have pathological GERD. Methods: We conducted a retrospective case-control study on patients who underwent wireless pH monitoring from January 2020 to April 2022. Cases were patients with a high DeMeester score (more than 14.7), indicating pathological reflux, and controls were those without. We collected clinical and demographic data, including age, sex, body mass index (BMI), smoking status, non-steroidal anti-inflammatory drugs (NSAIDs) use, and presence of atypical symptoms. Results: 86 patients were enrolled in the study. 46 patients with high DeMeester scores were considered cases, and 40 patients with DeMeester scores less than 14.7 were considered controls. Esophagitis (grade A) was found in 41.1% of the cases and in 22.5% of the control group. In our study, age of more than 50 years compared with age of 20-29 years and being overweight appeared to be predictors of true pathological reflux among patients with reflux symptoms who underwent wireless pH monitoring. Conclusion: Age above 50 years compared with age between 20-29 years and being overweight appeared to be predictors of true pathological reflux among patients with reflux symptoms who underwent wireless oesophageal pH monitoring. The presence of oesophagitis was approximately four times more likely to be associated with true pathological reflux.

Non-erosive gastro-oesophageal reflux disease and incidence of oesophageal adenocarcinoma in three Nordic countries: population based cohort study

ObjectiveTo assess the incidence rate of oesophageal adenocarcinoma among patients with non-erosive gastro-oesophageal reflux disease compared with the general population.DesignPopulation based cohort study.SettingAll patients in hospital and specialised outpatient healthcare...

12. NEUROKININ A AND SUBSTANCE P SERUM CONCENTRATIONS CORRELATE WITH MOTILITY METRICS PREDISPOSING TO REFLUX, BUT NOT WITH ESOPHAGITIS PRESENCE IN GERD

Abstract Background Neurokinin A (NKA) and substance P (SP) may be responsible for airway hyper-reactivity and hypersensitization. Animal studies showed an increase of their blood concentration in response to acid installation into the esophagus, suggesting the presence of neurogenic inflammation in pathogenesis of asthma and chronic cough. Association between serum concentration of these cytokines and esophageal function testing parameters in patients with gastroesophageal reflux disease (GERD) is poorly studied. Aim of the study was to assess serum concentration of neurokinin A and substance P in patients with erosive esophagitis and non-erosive form of GERD and perform correlation analysis between concentrations of these substances and data of multichannel esophageal pH-impedance (MII-pH) and high-resolution esophageal manometry (HREM). Methods The data of examination of 88 subjects (31 with erosive esophagitis (EE); 57 with non-erosive form of GERD (NERD)) served as a source for the study. Diagnosis of GERD was established per Lyon criteria. Subjects with autoimmune disorders, receiving some medications able to affect esophageal motility were not eligible. Patients underwent HREM with the use of 36-channel solid-state catheters and MII-pH with 2-pH, 6-impedandce sensors. Serum concentrations of NKA and SP were measured with ELISA kits and biochemistry analyzer. Results Acid exposure time (AET), and number of high gastroesophageal refluxes were higher in EE compared to NERD, while number of refluxes and concentrations of NKA and SP were similar. Mean, minimal and residual lower esophageal sphincter resting pressures were lower in EE compared to NERD. There was direct correlation between serum concentration of SP and number of gastroesophageal refluxes (Spearman rank R = 0.26), AET (R = 0.25), and number of refluxes lasting >5 min (R = 0.35). NKA concentration correlated directly with number of refluxes >5 min long (R = 0.28), and inversely with levels of integrated relaxation pressure (R = –0.32), and contractile front velocity (R = –0.38). Conclusions In patients with GERD, serum concentrations of Neurokinin A and Substance P do not depend on the presence of esophagitis and probably are not caused by the influence of reflux content to sensory neurons of esophageal mucosa. Established correlations may support the involvement of Neurokinin A and Substance P in pathogenesis of gastroesophageal reflux disease.

Pediatric Gastroesophageal Reflux Disease (GERD): A Literature Review

Background: Gastroesophageal reflux disease (GERD) is a condition where stomach contents reflux into the esophagus, causing discomfort and complications. It is most prevalent in infants (26.9%) and lesser in children under 10 (3.2%) and over 10 years old (10.1%). Discussion: GERD is caused by frequent relaxations of the lower esophageal sphincter (LES), allowing stomach contents to escape into the esophagus. Symptoms vary with age, with infants experiencing regurgitation and irritability, while older children may have heartburn and nausea. Diagnosis requires differentiating GERD from similar conditions and may involve various tests, though their primary use lacks sufficient evidence. Nonpharmacological treatments include thickened feeding, reducing feeding volume but increasing frequency and possibly eliminating cow's milk protein. Pharmacological treatments include Proton Pump Inhibitors (PPIs), and Histamine Receptor Antagonists (H2RAs), though their efficacy varies. Prokinetics are generally not recommended due to lack of evidence. If all these treatments fail, anti-reflux surgery such as fundoplication can be considered. Conclusion: The hallmark of GERD is the presence of esophagitis during endoscopy. However, Barrett’s esophagus is rare in pediatric GERD patients. Factors indicating a worse prognosis include early onset age, an initial GERD diagnosis, and the need for PPI or combination of H2RA and PPI treatment.

The possibilities of transabdominal sonographic diagnosis of liver and intestinal lesions in comorbid gastroesophageal reflux disease

Introduction. The spread of gastroesophageal reflux disease (GERD), comorbid with non-alcoholic fatty liver disease, requires modification of methods for non-invasive diagnosis of liver steatosis and fibrosis and concomitant gastrointestinal syndromes. Aim. Substantiation of a modified complex outpatient transabdominal sonographic diagnosis of combined lesions of the liver and intestines in comorbid GERD. Materials and methods. 165 outpatients with GERD (mean age 40.4 ± 2.9 years) underwent clinical and laboratory examinations, ultrasound examination (UE) of the gastrointestinal tract (GIT), liver shear wave elastometry (SWE), esophagogastroduodenoscopy, colonoscopy (CS). Results and discussion. In patients with GERD, a pronounced transsyndromic comorbidity was observed. The degrees of steatosis and fibrosis of the liver according to SWE positively correlated with the biochemical indices APRI and FORNS. ST-index of liver steatosis was statistically significantly associated with the presence of esophagitis, bile sludge, gallbladder polyps and thickening of the colon wall according to ultrasound criteria, sigmoiditis according to CS. Steatosis on ultrasound was associated with male sex, increased waist circumference, lactase deficiency and deficiency of cholecalciferol in the blood, the presence of yeast-like fungi in feces. Liver fibrosis according to the FORNS index directly correlated with the volume of HE-reflux, duodenitis and intestinal damage according to the results of ultrasound, and according to the APRI index, it inversely correlated with the concentration of vitamin D3 in the blood. Fibrosis according to the ESP criteria directly correlated with the presence of hiatal hernia, bile sludge, and the volume of HE-refluxate according to ultrasound criteria; with lactase deficiency, as well as esophagitis and colitis on endoscopic signs. Conclusions. To identify steatosis and liver fibrosis, the SWE methodology can be considered priority, and serum panels of biomarkers – alternative. Ultrasound of the gastrointestinal tract and SWE allow you to identify the degree of steatosis and fibrosis of the liver, the pathology of the esophagus, colon and the biliary system.

Management of Gastroesophageal Reflux Disease in Esophageal Atresia Patients: A Cross-Sectional Survey amongst International Clinicians.

Objectives:After surgical repair, up to 70% of esophageal atresia (EA) patients suffer from gastroesophageal reflux disease (GERD). The ESPGHAN/NASPGHAN guidelines on management of gastrointestinal complications in EA patients were published in 2016. Yet, the implementation of recommendations on GERD management remains poor.We aimed to assess GERD management in EA patients in more detail, to identify management inconsistencies, gaps in current knowledge, and future directions for research.Methods:A digital questionnaire on GERD management in EA patients was sent to all members of the ESPGHAN EA working group and members of the International network of esophageal atresia (INoEA).Results:Forty responses were received. Thirty-five (87.5%) clinicians routinely prescribed acid suppressive therapy for 1–24 (median 12) months. A fundoplication was considered by 90.0% of clinicians in case of refractory GERD with persistent symptoms despite maximal acid suppressive therapy and in 92.5% of clinicians in case of GERD with presence of esophagitis on EGD. Half of clinicians referred patients with recurrent strictures or dependence on transpyloric feeds. Up to 25.0% of clinicians also referred all long-gap EA patients for fundoplication, those with long-term need of acid suppressants, recurrent chest infections and feedings difficulties.Conclusions:Respondents’ opinions on the optimal duration for routine acid suppressive therapy and indications for fundoplication in EA patients varied widely. To improve evidence-based care for EA patients, future prospective multicenter outcome studies should compare different diagnostic and treatment regimes for GERD in patients with EA. Complications of therapy should be one of the main outcome measures in such trials.

Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) for gastroesophageal reflux disease: a systematic review and meta-analysis.

Background and study aims Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) are new endoscopic procedures for patients with gastroesophageal reflux disease (GERD). We conducted a meta-analysis to systematically assess the feasibility, clinical success, and safety of these procedures. Patients and methods We searched Embase, PubMed, and Cochrane Central from inception to October 2020. Overlapping reports, animal studies, and case reports were excluded. Our primary outcomes were clinical success and adverse events (AEs). Secondary outcomes included technical success, endoscopic esophagitis, 24-hour pH monitoring, and proton pump inhibitor (PPI) use. A random effects model was used to pool data. Results In total, 15 nonrandomized studies (12 ARMS, n = 331; 3 ARMA, n = 130) were included; 10 were conducted in patients with refractory GERD. The technical success rate was 100 %. The pooled short-term (first assessment within the first 6 months), 1-year, and 3-year clinical success rates were 78 % (95 % confidence interval [95 %CI] 70 %–85 %), 72% (95 %CI 47 %–92 %), and 73 % (95 %CI 65 %–81 %), respectively. ARMS and ARMA yielded similar clinical success. The proportion of patients off PPIs at 1 year was 64 % (95 %CI 52 %–75 %). There were significant drops ( P < 0.01) in validated clinical questionnaires scores, presence of esophagitis, and acid exposure time. The most common AE (11 %, 95 %CI 8 %–15 %) was dysphagia requiring dilation (7%, 95 %CI 5 %–11 %). Four cases of perforation were recorded, all in patients undergoing ARMS. Conclusions Our meta-analysis of nonrandomized studies suggests that ARMS and ARMA are safe and effective for patients with GERD.

633 CONVERSION TO TOUPET FUNDOPLICATION WITH DISTAL GASTRECTOMY AND ROUX-EN-Y GASTROJEJUNOSTOMY AFTER FAILED NISSEN FUNDOPLICATION

Abstract Laparoscopic Nissen Fundoplication fails in almost 15% of patients and most of them must be re-operated in order to improve reflux symptoms, esophagitis, or hiatal hernia. Surgical options are to redo LNF, distal gastrectomy alone or combination of both procedures. Redoing LNF, is associated with high rate of postoperative complications and re-failure. Purpose To present the early and medium-term postoperative outcomes of patients submitted to Laparoscopic Toupet Fundoplication combined with Distal Gastrectomy with Roux-en-Y gastrojejunostomy. Methods prospective study including 23 patients submitted to Laparoscopic Nissen Fundoplication who presented recurrence of gastroesophageal reflux after the operation. They were studied with endoscopy, barium swallow, manometry and 24 h pH monitoring in order to determine presence of esophagitis, anatomical deformities, defective Lower Esophageal Sphincter and pathologic acid reflux. Surgical process consisted on re-establishing the anatomy of the esophago-gastric junction, and then perform laparoscopic Toupet fundoplication combined with distal gastrecvtomy and Roux Y gastrojejunostomy. Results After surgery statistically significant improvement regarding heartburn (p &amp;lt; 0.0001), dysphagia (p &amp;lt; 0.0001) and retrosternal chest pain (p &amp;lt; 0.0001) as well as in the endoscopic esophagitis was observed. No significant LES pressure increase after the operation was observed. (from 7.88 + 2.7 to 10.5 + 3.36) (p = 0.15), but the abnormal acid reflux improved significantly after the reoperation, %time pH &amp;lt; 4 decreases from 12.00 + 6.62 to 4.3 + 4.04 (0.0004) and DeMeester score from 44.82 + 21.8 to 11.95 + 5.14 (0.0008) respectively. Conclusion The proposed procedure is safe option to treat successfully patients after failed Nissen fundoplication. Reflux symptoms, esophagitis, presence oh hiatal hernia and reflux score improved after the procedure.

Antireflux surgery leads to durable improvement in laryngopharyngeal reflux symptoms.

Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery. Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2weeks, 8weeks, and 1year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and > 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores. One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI > 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p > 0.05). The RSI > 13 group had more female patients (80 vs 52%, p = < 0.001), higher mean GERD-HRQL score, lower rates of PPI use, and normal esophageal motility. The RSI of all patients improved from a mean preoperative value of 19.2 to 7.8 (2weeks), 6.1 (8weeks), and 10.9 (1year). Those with the highest preoperative scores (RSI > 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking. In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.

Reflux symptoms and oesophageal acidification in treated achalasia patients are often not reflux related

ObjectiveAfter treatment, achalasia patients often develop reflux symptoms. Aim of this case–control study was to investigate mechanisms underlying reflux symptoms in treated achalasia patients by analysing oesophageal function, acidification patterns...

Is Malignant Potential of Barrett's Esophagus Predictable by Endoscopy Findings?

Given that endoscopic findings can be used to predict the potential of neoplastic progression in Barrett’s esophagus (BE) cases, the detection rate of dysplastic Barrett’s lesions may become higher even in laborious endoscopic surveillance because a special attention is consequently paid. However, endoscopic findings for effective detection of the risk of neoplastic progression to esophageal adenocarcinoma (EAC) have not been confirmed, though some typical appearances are suggestive. In the present review, endoscopic findings that can be used predict malignant potential to EAC in BE cases are discussed. Conventional results obtained with white light endoscopy, such as length of BE, presence of esophagitis, ulceration, hiatal hernia, and nodularity, are used as indicators of a higher risk of neoplastic progression. However, there are controversies in some of those findings. Absence of palisade vessels may be also a new candidate predictor, as that reveals degree of intense inflammation and of cyclooxygenase-2 protein expression with accelerated cellular proliferation. Furthermore, an open type of mucosal pattern and enriched stromal blood vessels, which can be observed by image-enhanced endoscopy, including narrow band imaging, have been confirmed as factors useful for prediction of neoplastic progression of BE because they indicate more frequent cyclooxygenase-2 protein expression along with accelerated cellular proliferation. Should the malignant potential of BE be shown predictable by these endoscopic findings, that would simplify methods used for an effective surveillance, because patients requiring careful monitoring would be more easily identified. Development in the near future of a comprehensive scoring system for BE based on clinical factors, biomarkers and endoscopic predictors is required.

S0353 The Addition of Provocation Testing Enhances the Accuracy of Barium Esophagography Testing for Gastroesophageal Reflux Disease

INTRODUCTION: Gastroesophageal Reflux (GER) is a common digestive disorder that affects one-third of the population. The main confirmatory method for detecting pathologic acid reflux is pH monitoring with 24-hour pH impedance or 96-hour wireless pH testing, which may not be readily accessible. We studied the accuracy of barium esophagram (Cine) to detect GER using pH testing as the reference standard. METHODS: We analyzed data on patients from The Johns Hopkins Heartburn Center prospectively enrolled from 2017-2019 evaluated with Cine, Esophagogastroduodenoscopy (EGD) and 24 hour pH impedance or 96-hour wireless pH testing. Patients on acid reflux therapy at the time of pH study or history of anti-reflux procedure were excluded. Subjects were observed for unprovoked spontaneous GER on Cine. If GER was not seen, positional maneuvers were done by turning the patient from supine to lateral positions. If no GER, the water siphon test (WST) was performed with the patient drinking water through a straw while lying supine then rolling to right posterior oblique position. Cine maneuvers were completed in this order and stopped once GER was seen. The test was positive if barium was noted at minimum 2 cm above the gastroesophageal junction. Total acid exposure time > 6% during pH testing was considered abnormal and corresponded to GER as the reference standard. The presence of esophagitis on EGD based on LA grade classification and/or Barrett’s esophagus on biopsy were considered positive for reflux disease. RESULTS: 98 patients were selected (40 male, 58 female, mean age 55.2). 60 (61%) had GER based on pH testing, 44 (45%) had reflux during Cine. The overall sensitivity, specificity, and accuracy of the Cine for GER were 64.2%, 74.2%, and 67.3%, respectively. WST showed sensitivity of 55.2%, specificity of 90.3%, and accuracy of 67.5% (Table 1). Receiver operating characteristic (ROC) curve analyses showed that the area under the curve (AUC) for Cine is equivalent to EGD showing Barrett’s esophagus or esophagitis for all GERD, LPRD, and regurgitation-predominant GERD/LPRD (Table 2). In 29 of 70 (41%) patients with EGD inconclusive or negative for GERD, Cine with provocation testing showed GER. CONCLUSION: Esophagram with provocative maneuvers is an inexpensive, simple test that might act as an initial diagnostic tool in the workup of GER. WST improves specificity, positive predictive value, and accuracy for the diagnosis of GER compared to unprovoked observation or position change alone.Table 1Table 2

Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis.

BackgroundHeller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM.MethodsWe searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM.ResultsWe included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM.ConclusionsPOEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.

The relationship between Helicobacter pylori infection in the stomach and reflux esophagitis in patients referring to Khorramabad Shohada Hospital, Lorestan province, southwest Iran between 2014 and 2018

IntroductionGastroesophageal reflux disease is a common disorder of the digestive tract. Esophageal mucosa exposure to gastric acid can lead to mucosal damage such as esophagitis.ObjectiveThe aim of this study was to determine the relationship between Helicobacter pylori infection in the stomach and reflux esophagitis in patients referring to the endoscopy units of hospitals in Khorramabad between 2014 and 2018.Materials and MethodsIn this cross-sectional study, all patients who referred for endoscopy to the Endoscopy Units of Shohadaye Ashayer and Shahid Rahimi Hospitals of Khorramabad during 2014-2018 were studied. H. pylori infection was diagnosed based on pathological specimens. All patientschr('39') information including age, sex, presence of esophagitis (its grade), and H. pylori infection were recorded in the questionnaires and their relationship with esophagitis and its grade as well as H. pylori infection was statistically analyzed. Tables and charts were used to describe the data. t-test and Chi-squared test were used to investigate the relationship between variables.ResultsThe frequency of esophagitis in our patients was 52.8%, with the highest frequency obtained for grade B esophagitis (48%). In this study, the prevalence of H. pylori infection was 57.5%. This rate was 55.4% in patients with esophagitis, with a statistically significant difference to the group without esophagitis (P=0.0009). There was a significant relationship between grade A esophagitis and H. pylori infection (P=0.0002).ConclusionThis study suggests a significant relationship between H. pylori infection and esophagitis in affected patients.

Impact of Chronic Statins Use on the Development of Esophagitis in Patients with Gastroesophageal Reflux Disease.

Background and Aims We aimed to assess whether chronic statins used (> 6 months) were protective of the development of esophagitis in patients with gastroesophageal reflux disease. In the presence of esophagitis, complications such as strictures, Barrett's esophagus, and adenocarcinoma were the most common. Statins, lipid lowering drugs with a pleiotropic effect, are recently implicated in various pathologies. Nevertheless, the possible impact of statins in esophagitis development has never been assessed. Methods We performed a retrospective, cross-sectional, single center study that included 4148 gastroesophageal reflux disease patients from 2014 and 2018 at EMMS Nazareth Hospital. We divided the patients into 5 groups. The groups were split into positive control group, which was the nonesophagitis group, and the other 4 groups were A-D (as per Los Angeles classification). Results Overall, out of the 4148 patients included, 48% were males and 2840 patients were in the control group. In groups A, B, C, and D there were 818, 402, 72, and 16 patients, respectively. Logistic regression analysis revealed that chronic statins usage is protective by preventing development esophagitis (OR 0.463 [95%CI 0.370–0.579], p < 0.0001). NSAIDS use, Hiatus hernia, and H. pylori were promoting factors (OR, 1.362, 1.779, and 1.811; 95% CI, 1.183-1.569, 1.551-2.040, and 1.428-2.298; P<0.0001, P<0.0001, and P<0.0001, respectively). Conclusion Using chronic statins was protective to the development of esophagitis among GERD patients. Our findings of potential clinical application mandate further randomized controlled trials to better assess the impact of statins on esophagitis.

The prevalence of upper respiratory symptoms in a cohort of adults presenting with symptoms of gastro-oesophageal reflux disease.

Gastro-oesophageal reflux disease (GORD) is the pathological reflux of gastric contents into the oesophagus. The oesophagus and the upper respiratory tract have a common origin from the foregut. There is increasing evidence for multiple associations of GORD with the upper respiratory tract. To study the presence of and association of upper respiratory symptoms (URS) with GORD. Seventy adults scoring ≥12.5 on a previously validated GORD symptom score (GORD patients) and 70 healthy controls who had infrequent GORD symptoms or no upper gastro-intestinal complaints completed a pre-tested URS questionnaire on the frequency of 14 URS in 5 categories (laryngeal, nasal, pharyngeal, sinusal and aural). All GORD patients underwent upper gastro-intestinal endoscopy. The calculated URS score was correlated against the GORD symptom score and endoscopy findings. URS scores and individual symptom scores were higher in GORD patients compared to controls (mean ± SE, 4.7 ± 4.0; 1.9 ± 2.3). Individuals with higher GORD symptom scores reported more frequent URS. Pharyngeal symptoms had the highest correlation with the GORD symptom score (r=0.507, p<0.001). The presence of oeso-phagitis did not seem to influence the frequency of reporting URS. Upper respiratory symptoms are common in individuals with GORD symptoms though there appears to be no association with oesophageal mucosal damage.