Severe Reflux Esophagitis Research Articles

Zollinger–Ellison Syndrome

BackgroundZollinger–Ellison (ZE) syndrome is characterized by gastric acid hypersecretion and ulcer disease from autologous gastrin secretion by a gastrinoma. Patient and methodsA 43 year old man underwent upper endoscopy for a 6 week history of recurrent nausea, vomiting, heartburn, weight loss, and watery diarrhea. ResultsEndoscopic findings included severe reflux esophagitis with multiple linear esophageal ulcerations, thickened gastric folds with mosaic pattern mucosa, distinctive gastric corpus and antrum junction, numerous antral erosions with traces of coffee ground substance, bulbar erosions and ulcerations, and post-bulbar erosions and ulcerations. Based on these symptoms and endoscopic findings, a gastrinoma work-up was instituted and the diagnosis was confirmed. ConclusionsEndoscopists need to be aware of the classical symptoms and clinical findings associated with ZE syndrome in order to appropriately diagnose and manage affected patients.

Novel fundoplication for esophagogastrostomy after proximal gastrectomy.

Stapled esophagogastrostomy is simple and safe reconstruction after proximal gastrectomy. However, this reconstruction is often concomitant with severe reflux esophagitis because of the loss of cardiac function; simple esophagogastrostomy is not preferred reconstruction after proximal gastrectomy. To prevent reflux esophagitis, we established the fundoplication under the endoscopic stent after proximal gastrectomy. After proximal gastrectomy with lymph node dissection, end-to-side esophago-gastrostomy was done with circular suturing instrument. To prevent gastric juice reflux from the remnant stomach, the stomach was rolling around the abdominal esophagus and tightly under the endoscopical stenting. To make renewal His angle and fornix, the stump of greater curvature was fixed to the left side of diaphragmatic crus with some sutures. We performed this type of fudplication for 18 patients with early gastric cancers and gastric submucosal tumors. Almost all patients postoperative course was uneventful. Three patients needed an endoscopic dilatation for the stricture of esophago-gastrostomy. One case revealed asymptomatic reflux esophagitis because of the looseness of the anastomosis. Weight loss was limited, almost all patients recovered preoperative weight. Simple esophagogastrostomy plus this fundoplication with endoscopic stent is safe and satisfactory reconstruction procedure after proximal gastrectomy.

Laparoscopic antireflux surgery improves esophageal body motility in patients with severe reflux esophagitis

This study was designed to clarify whether laparoscopic antireflux surgery (LARS) improves the esophageal body motility (EBM) in patients with reflux esophagitis. Thirty-five patients with gastroesophageal reflux disease (GERD) scheduled to undergo LARS were divided into a mild esophagitis group (ME; n = 18, Grade O:A:B = 7:10:1) and a severe esophagitis group (SE; n = 17, Grade C:D = 13:4), according to the Los Angeles classification of reflux esophagitis. The types of fundoplication (Nissen/Toupet) were 6/12 in the ME group and 4/13 in the SE group. Esophageal pH monitoring and manometry were performed before and 1 year after surgery. The fraction time of a pH below 4 significantly decreased after surgery in both groups. The LES pressures did not change significantly after surgery in the ME group, but significantly increased in the SE group. The peristaltic amplitudes 18 and 13 cm above the LES did not change significantly after surgery in either group. The peristaltic amplitudes 8 and 3 cm above the LES did not change significantly after surgery in the ME group, but significantly increased after surgery in the SE group. The preoperative EBM was not improved by LARS in patients with GERD and mild mucosal breaks in the esophagus, but the preoperative middle to distal EBM was improved by LARS in patients with GERD and severe mucosal breaks.

Berberine protects against esophageal mucosal damage in reflux esophagitis by suppressing proinflammatory cytokines

This study was performed to investigate the effects of berberine (BB) in a rat model of gastroesophageal reflux disease (GERD), induced by pylorus and forestomach ligation. We evaluated cytotoxicity and proinflammatory biomarkers (nitric oxide, interleukin (IL)-1β and prostaglandin E2) in RAW 264.7 cells in vitro and anti-inflammatory effects in vivo. A total of 54 Sprague Dawley rats were divided into six groups: intact control rats; reflux esophagitis (RE) control rats; RE rats treated with 20 mg/kg omeprazole and RE rats treated with BB at doses of 20, 40 and 60 mg/kg, respectively. All rats were fasted. RE was induced by pylorus and forestomach ligation one hour subsequent to the oral treatment. Six hours subsequent to the surgery, the rats were sacrificed, blood was collected from the abdominal vein and the esophagus and stomach were dissected. The gastric volume and the pH of the gastric juice were evaluated, prior to the esophagus being cut longitudinally and an inner mucosal area being imaged, to analyze mucosal damage indices. Proinflammatory biomarkers in the serum, including tumor necrosis factor (TNF)-α, IL-1β, IL-6 and monocyte chemoattractant protein (MCP)-1 were analyzed using an enzyme-linked immunosorbent assay (ELISA) kit, while the mRNA expression of TNF-α, IL-1β, IL-6 and plasminogen activator inhibitor (PAI)-1 was analyzed using a quantitative polymerase chain reaction (qPCR). Esophagic tissue damage in the BB groups was dose-dependently decreased compared with that in the RE control group. This result was consistent with significant reductions in the levels of proinflammatory biomarkers in the serum and in the expression of proinflammatory mRNA, specifically, TNF-α, IL-1β, IL-6 and PAI-1. The results suggest that the anti-inflammatory and protective effects of BB may attenuate the severity of RE and prevent esophageal mucosal damage, in addition to validating the use of BB as a pharmacological treatment for esophageal reflux disease.

Risk Factors for Resistance to Proton Pump Inhibitor Maintenance Therapy for Reflux Esophagitis in Japanese Women over 60 Years

Aim: The aim of this study was to evaluate risk factors for proton pump inhibitor (PPI) resistance in older Japanese female patients with reflux esophagitis evaluated by physicians. Methods: The study included 462 Japanese female patients aged over 60 years with reflux esophagitis who received PPI maintenance therapy for more than 6 months. Results: The characteristics of all 462 patients were: age: 76.4 ± 7.6 years, height: 147.2 ± 6.1 cm, weight: 49.9 ± 8.4 kg and body mass index: 24.0 ± 3.5. The reflux esophagitis grades were A in 69.5%, B in 15.8%, C in 9.1% and D in 5.6%. Helicobacter pylori was positive in 60.6%. Regarding PPI maintenance therapy for clinical symptoms evaluated by the attending physicians, 66.7% were ‘good control’, 26.8% were ‘reasonable control’ and 6.5% were ‘bad control: resistant’. PPI maintenance therapy was less effective in patients with more severe reflux esophagitis of grades C and D (OR: 0.027; 95% CI: 0.010–0.077) and negative H. pylori infection status (OR: 4.470; 95% CI: 1.631–12.247). Lumbar kyphosis and hiatus hernia were risk factors for severity grading of reflux esophagitis. Conclusions: PPI maintenance therapy evaluated by attending physicians indicated that reflux esophagitis severity and negative H. pylori status were risk factors for treatment resistance.

Clinical feature of asymptomatic reflux esophagitis in patients who underwent upper gastrointestinal endoscopy

Prevalence of gastroesophageal reflux disease (GERD) varies in regions, but few reports on clinical features and quality of life (QOL) of asymptomatic GERD exist in Japan. Endoscopy was performed in our department between April 2008 and September 2010. Among 6409 cases answering Frequency of Scale for the Symptoms of GERD (FSSG) and SF8 QOL (PCS: physical component summary; MCS: mental component summary), proton pump inhibitor or histamine 2 receptor antagonist users were excluded, and 388 cases diagnosed as reflux esophagitis (RE) (Los Angeles Classification grade A, B, C, D) were analyzed. Asymptomatic cases with FSSG total score = 0 were defined as asymptomatic RE (AsymRE) and FSSG total score ≥ 1 as symptomatic RE (SymRE). Each clinical feature was analyzed. The frequency of AsymRE was 11.6% of RE (AsymRE, n = 45; SymRE, n = 343). Patient characteristics in AsymRE, SymRE were male/female = 35/10; 239/104 (not significant), mean age (year) = 63.5 ± 14.3; 58.3 ± 12.7 (P < 0.01), body mass index = 23.9 ± 4.3; 23.5 ± 3.7 (ns), respectively. Regarding the grade of RE, grade A 80.0%, B 17.8%, C 2.2% and D 0% in AsymRE, and grade A 72.6%, B 24.8%, C 2.0% and D 0.6% in SymRE (ns). PCS in SF8 was AsymRE; SymRE = 51.8 ± 9.8; 49.0 ± 7.7 (P < 0.01) and MCS in SF8 was AsymRE; SymRE = 51.4 ± 9.4; 48.2 ± 7.6 (P < 0.01), respectively. The prevalence of asymptomatic RE was high, particularly in elderly subjects. Unlike symptomatic RE, QOL was not impaired at all with asymptomatic RE. No differences were seen between groups in clinical features such as endoscopic severity of RE, indicating that asymptomatic RE is a condition that should not be overlooked clinically.

CYP2C19 genotypes determine the efficacy of on‐demand therapy of pantoprazole for reflux esophagitis as Los‐Angeles grades C and D

The present study determined whether the genotypes of S-mephenytoin 4'-hydroxylase (CYP2C19) could serve as an indicator to assess the success of long-term on-demand therapy (ODT) with pantoprazole for the patients with severe reflux esophagitis as Los Angles grade C or D (RE-CD). A total of 240 patients with RE-CD were prospectively enrolled to receive continuous pantoprazole, 40 mg daily for 6 months. The patients, who achieved complete healing and were free from acid reflux-related symptoms during follow up, were included to receive ODT with a 40 mg pantoprazole tablet up to 1 year. Each patient was followed to assess the monthly tablet number of 40 mg pantoprazole and the cumulative rate of failure of ODT. The CYP2C19 genotype of each included patient was defined as homologous extensive metabolizer (HomoEM), heterologous extensive metabolizer (HeteroEM), and poor metabolizer (PM). Two-hundred patients were included to receive ODT, including 51 as HomoEM, 108 as HeteroEM, and 41 as PM. There were no differences in demographic and endoscopic features among patients with different CYP2C19 genotypes (P > 0.05). The 1-year cumulative failure rate of ODT was significantly higher in HomoEM than in HeteroEM and PM (P < 0.05, by log-rank test). For those with successful ODT during the 1-year follow up, the mean monthly tablet number of pantoprazole was lower in PM than in HeteroEM and HomoEM (11.5 vs 16.3 and 18.6, P < 0.05). For RE-CD with complete healing after continuous pantoprazole, the successful shift to ODT is determined by the CYP2C19 genotypes of the patients.

High-Resolution Manometry for Assessing Hiatal Hernia in a Patient With Severe Reflux Esophagitis

A 58 year-old man visited the hospital complaining heartburn, acid regurgitation and dysphagia, especially in the postprandial period and in the supine position. Los Angeles grade C reflux esophagitis and sliding hiatal hernia (HH) were identified from upper gastrointestinal endoscopy (Fig. 1). Barium esophagogram also showed reducible sliding hiatal hernia and normal barium transit to the stomach (Fig. 2). He underwent high-resolution manometry (HRM; version 2.1, Manoscan, Sierra Scientific Instruments Inc, Los Angeles, CA, USA) to evaluate the other causes of dysphagia. Figure 3 shows the HRM findings. The HRM diagnosis was intermittent hypotensive peristalsis. Mean distal esophageal amplitudes was 29.3 mmHg, the intergrated relaxation pressure was 9 mmHg and intrabolus pressure was 2 mmHg. During inspiration, HRM plot showed minimal separation of lower esophageal sphincter (LES) and crural diaphragm (CD), making double peak high pressure zone which is the typical finding of HH. Figure 1 The retroflexed endoscopic view shows sliding hiatal hernia. The gastroesophageal area is stayed open and squamous epithelium of distal esophagus is seen. Figure 2 Esophagogram also shows reducible sliding hiatal hernia. Figure 3 (A) A swallow shows hypotensive contraction. Two arrows point 2 high pressure zone. (B) During inspiration, the separation between the crural diaphragm and the lower esophageal sphincter (LES) was augmented making double pressure peak at esophagogastric ... HH presents with widening of the diaphragmatic hiatus and axial displacement between the LES and CD of sufficient magnitude that a pouch of stomach is sandwiched between two.1 Using HRM with pressure topography, the LES and CD elements of the esophagogastric junction (EGJ) can be selectively localized and their contractility quantified. HRM examples of EGJ pressure morphology subtypes are primarily distinguished by the extent of LES-CD separation.2 Type I HH is characterized by complete overlap of the CD and LES with a single pressure peak in the spatial pressure variation plots during both inspiration and expiration, which means normal finding. Type II HH is characterized by minimal, 1-2 cm LES-CD separation presenting a double peaked spatial pressure variation plot. Type III HH with greater than 2 cm separation is an overt hiatal hernia, a frequent finding in patients with gastroesophageal reflux disease whereas it is rarely found in asymptomatic controls or functional heartburn.2 Comprehensive evaluation on EGJ morphology or impaired EGJ components is possible by using HRM. This case is a patient with severe reflux esophagitis combined with low grade disruption of the EGJ (type II HH). There is quantifiable separation between the CD and the LES, but the magnitude of this separation is insufficient to constitute a overt sliding hernia. HRM is the only method capable of reliably detecting this condition, the intermediate stage between normal and overt sliding hiatus hernia.1

Helicobacter pylori Has an Inverse Relationship With Severity of Reflux Esophagitis

The association between Helicobacter pylori infection and gastroesophageal reflux disease (GERD) remains controversial, with geographical location being a strong contributor to the heterogeneity of results in different studies.1,2 Studies from Western countries have shown an inconsistent association between GERD and H. pylori.3-5 In contrast, a negative association between reflux esophagitis and H. pylori has been shown in most of the studies from East Asia.6-8 A prospective cohort study with large scale in Korea showed that H. pylori infection had a strong negative association with reflux esophagitis and eradication of H. pylori increased the risk of reflux esophagitis.9 However, there are few reports about the relationship between the severity of reflux esophagitis and H. pylori. Presence of H. pylori was associated with reduced severity across the spectrum of GERD, especially in Indians.8 In the current issue of the Journal, Chung et al9 assessed the effect of H. pylori infection on the risk of reflux esophagitis in general population. They found that H. pylori seropositivity reduced the risk of reflux esophagitis (adjusted OR, 0.44; 95% CI, 0.39-0.49) after adjusting for potential confounders. This OR is similar with OR (adjusted OR 0.42; 95% CI, 0.34-0.51) from the previous Korean study.10 Epidemiological evidence for the association between H. pylori infection and reflux esophagitis has been inconsistent, according to the study places.2 In a study from a population-based setting in Northern Europe, H. pylori infection, irrespective of cytotoxin associated gene A (cagA) status, did not affect reflux symptoms.3 However, the results of recent population-based studies performed in Western countries showed an inverse relation between H. pylori seropositivity and reflux esophagitis.4,11 In contrast, the negative association between reflux esophagitis and H. pylori has been shown in most of the studies from East Asia.6-8,10 H. pylori seems to have a protective effect against GERD mainly through the development of atrophic gastritis and thereby decreased gastric acid secretion.6,7 The more virulent type of H. pylori such as cagA-positive strain was postulated to promote the more intense gastric inflammation, exemplifying the risk of atrophy and thereby the further reduction in GERD risk.12,13 However, H. pylori had a negative association with GERD even in atrophy-negative subjects, suggesting that H. pylori might protect GERD not only by atrophy-related low acid production but also by other mechanisms.4 Intragastric urease, which is produced by H. pylori, increases the gastric pH.14 Ammonia, which serves as an acid neutralizer, is one of the products of H. pylori. The development of reflux esophagitis was significantly inhibited by ammonia in a dose-dependent manner in the rat experiments.15 That study indicates that ammonia protects against development of reflux esophagitis. A decreased amount of ammonia in the stomach might be related to the development of reflux esophagitis after H. pylori eradication. Actually, compared with the prevalence of reflux esophagitis in the persistent infection group, the prevalence of reflux esophagitis increased after a successful H. pylori eradication (OR, 2.34; 95% CI, 1.45-3.76; P < 0.001), which was comparable to that of the H. pylori-negative group (OR, 2.42; 95% CI, 1.73-3.36; P < 0.001) in a previous Korean study.10 In the large case-control study from Chung et al,9 H. pylori seropositivity was inversely associated with the severity of reflux esophagitis with adjusted ORs of 0.63 in Los Angeles-M (LA-M), 0.36 in LA-A or B and 0.20 in LA-C or D (P < 0.001). Although there are many evidences about the inverse relationship between reflux esophagitis and H. pylori, there are few reports about the association between severity of GERD and H. pylori. Presence of H. pylori was associated with reduced severity across the spectrum of GERD, especially in Indians, who had the highest H. pylori prevalence among multiethnic Asian populations.8 In a small case-control study, compared with the prevalence of H. pylori infection in the non-reflux group, the prevalence in the mild and severe reflux groups was significantly lower (60.7%, 47.8% and 14.8%, respectively; P < 0.05).7 was significantly lower.7 Barrett's esophagus, which has been considered as an advanced form of GERD, had a strong negative association with H. pylori.4 H. pylori seropositivity was inversely associated with Barrett's esophagus and reflux esophagitis with adjusted ORs (95% CIs) of 0.35 (0.22 to 0.56) and 0.42 (0.27 to 0.65), respectively.4 In conclusion, the study by Chung et al9 has contributed to a better understanding of a protective role of H. pylori against GERD by assessing the inverse relationship between H. pylori and severity of reflux esophagitis.

Helicobacter pylori Serology Inversely Correlated With the Risk and Severity of Reflux Esophagitis in Helicobacter pylori Endemic Area: A Matched Case-Control Study of 5,616 Health Check-Up Koreans.

Background/AimsThe role of Helicobacter pylori in gastroesophageal reflux disease remains still controversial and the effect of the organism on severity of reflux esophagitis have been rarely issued. The aim of this study was to investigate the relationship between H. pylori infection and reflux esophagitis, and especially the severity of reflux esophagitis.MethodsWe performed a cross-sectional case-control study of 5,616 subjects undergoing both upper endoscopy and H. pylori serology during health Check-up (2,808 cases vs age- and sex-matched controls). Smoking, alcohol, body mass index and waist circum - ference were added to a multiple regression model.ResultsPrevalence of H. pylori infection was lower in cases with reflux esophagitis than in controls (38.4% vs 58.2%, P < 0.001) and negative associations with H. pylori infection continued across the grade of esophagitis (46.7% in Los Angeles classification M [LA-M], 34.3% in LA-A or LA-B and 22.4% in LA-C or LA-D, P < 0.001). Positive serology for H. pylori independently reduced the risk of reflux esophagitis (adjusted OR, 0.44; 95% CI, 0.39-0.49). Notably, the negative associations continued across the grade of esophagitis with adjusted ORs of 0.63 in LA-M, 0.36 in LA-A or LA-B and 0.20 in LA-C or LA-D (P < 0.001).ConclusionsIn a age-sex matched Korean, H. pylori seropositivity was independently and inversely associated with the risk and severity of reflux esophagitis, suggesting the organism may have a protective role against gastroesophageal reflux disease.

Pouch Roux-en-Y vs No Pouch Roux-en-Y following total gastrectomy: a meta-analysis based on 12 studies

After a total resection of the stomach, the continuity of the gastrointestinal tract can be restored either by Rouxen-Y esophagojejunostomy with or without a pouch. There is still no consensus on the best reconstruction technique. The aim of this report was to derive a more precise estimation of Roux-en-Y esophagojejunostomy with a pouch compared with Roux-en-Y esophagojejunostomy without a pouch. Studies were identified by PubMed and Embase searches, and the inclusion criteria were randomized controlled trials (RCTs) comparing reconstruction techniques between Roux-en-Y with and without a pouch. A total of 12 studies including 1,018 patients were included. The meta-analysis shows that pouch Roux-en-Y does not significantly increase total postoperative complications, anastomotic leakage or mortality. Importantly, there is no significant difference in 5-year survival rates between the two groups. Patients with Roux-en-Y esophagojejunostomy complained significantly less of reflux symptoms and dumping syndrome, and had significantly less severe reflux esophagitis. Quality of life was significantly improved in patients with Roux-en-Y esophagojejunostomy with a pouch compared with patients who received Roux-en-Y reconstruction without a pouch. The results indicate the need for Roux-en-Y esophagojejunostomy with a pouch is a gastric substitute after total gastrectomy by comparison with Roux-en-Y esophagojejunostomy without a pouch.

残胃全摘B-II再建後の高度逆流性食道炎が輸入脚切除で治癒した１例

胃全摘Billroth-II法（B-II）再建後の高度逆流性食道炎に対し，輸入脚を部分切除しRoux-Y再建に変更することで食道炎を治癒せしめた１例を報告する． 症例は73歳，男性．2005年９月，幽門側胃切除B-I再建後の残胃の癌に対し，他院にて残胃全摘B-II再建がなされた．術直後より高度逆流性食道炎が発生し，保存的治療で改善なく，2008年11月当科に紹介された．上部消化管造影検査では，造影剤は食道へ容易に逆流し，輸出脚と輸入脚の間をBraun吻合を介して循環していた．輸出脚の食道空腸吻合，Braun吻合間の距離が約40cmと長かったため，輸入脚のBraun吻合口側直上と食道空腸吻合間を切除し，Roux-Y再建に変更し食道炎の著明な改善を得た.

Etiological difference between ultrashort- and short-segment Barrett’s esophagus

Barrett's esophagus has been divided into three categories based on the extent of the metaplasia: long-segment (LSBE), short-segment (SSBE), and ultrashort-segment Barrett's esophagus (USBE). While both LSBE and SSBE are thought to be induced by gastroesophageal reflux, the etiology of USBE is still unclear. We conducted a case-control study to identify the differences in the pathogenesis between SSBE and USBE in a hospital-based population. The endoscopic findings and clinical factors of 199 patients with short-segment endoscopically suspected esophageal metaplasia (SS-ESEM) and 317 patients with ultrashort-segment ESEM (US-ESEM) were compared with those of 199 and 317 age- and gender-matched patients without ESEM. The severity of gastric mucosal atrophy was marginally associated with the presence of US-ESEM [odds ratio (OR) 1.20, 95% confidence interval (CI) 0.98-1.46, p = 0.08], but not with that of SS-ESEM. On the other hand, the presence of gallstones and that of severe reflux esophagitis were associated with the presence of SS-ESEM (OR 2.19, 95% CI 1.21-3.98; OR 1.72, 95% CI 1.08-2.75), but not with that of US-ESEM. Presence of gastric corpus atrophy without gallstones was associated with the presence of US-ESEM, but not with that of SS-ESEM. Presence of gastric corpus atrophy was associated with an increased likelihood of the presence of US-ESEM, whereas the presence of gallstones was associated with an increased likelihood of the presence of SS-ESEM, suggesting difference in etiology between US- and SS-ESEM.

Randomized Open-label Trial to Assess the Impact of Dosage Timing of Omeprazole/Sodium Bicarbonate (Zegerid 40 mg) on Healing of Severe Reflux Esophagitis: A Progress Report: 2010 Presidential Poster

Purpose: Twice daily proton pump inhibitor (PPI) therapy is commonly recommended to heal severe reflux esophagitis. For optimal efficacy, patients are currently advised to take their PPI on an empty stomach 20 to 60 minutes before a meal - which can be a cumbersome process. Administration of a single nightly PPI regardless of meal time might increase adherence, and hence efficacy in healing esophagitis. Aim: To compare the efficacy of 8 weeks immediate-release omeprazole/sodium bicarbonate (IR-OME), taken either before breakfast or before bedtime, on healing severe esophagitis. Methods: Prospective open-label single-blinded cohort study of outpatients with LA Grade C or D reflux esophagitis randomized to IR-OME 40 mg taken 20 to 60 minutes before breakfast or before bedtime. Esophagogastroduodenoscopy (EGD) was performed at baseline and after 8 weeks of study medication. A 24-hour pH study was offered at the time of the follow-up EGD regardless of endoscopic findings. Results: To date, 88 subjects have been recruited of which 77 have completed the study [53 (69%) male, mean age 58 (SD 13, range 22 to 86), LA grades C=49, D=28]. Forty-one subjects were allocated to the morning dose and 47 to the bedtime dose (with 2 and 6 dropping out of each arm, respectively). Of 38 completed subjects (C=23, D=15) randomized to morning PPI, 32 (84%) had healed at 8 weeks. The 6 with persistent esophagitis all showed improvement in severity by one or two grades. Of 39 completed subjects (C=26, D=13) randomized to bedtime PPI, 33 (85%) healed. Four of 6 improved, one had the same grade, and one worsened in severity. 18 of 77 (23%) underwent pH testing while on study medication. Six discontinued study medication prior to pH probe placement and were excluded from subgroup analysis. Of the 12 subjects who underwent pH testing while on IR-OME (8 with standard probe, 4 with Bravo), 7 were on the morning dose of whom 6 (86%) showed normalization of their pH parameters. One subject on morning PPI demonstrated acid reflux (5.5% overall, 1.9% upright, 9.9% supine). Five subjects on bedtime PPI consented to pH testing; three (60%) with normalization of pH parameters. Amongst 4 subjects on morning vs. 4 on bedtime PPI each with gastric pH measurement obtained, there was no obvious difference for PPI effect on pH < 4 (mean 19.5, range 11.4-32% vs. 17.5, 0.2-52%). Conclusion: Both morning and bedtime dosing of IR-OME are highly and similarly effective in resolving severe LA grade C and D erosive reflux esophagitis at 8 weeks. Bedtime dosing was just as effective as morning dosing in controlling gastric acid production. Too few esophageal pH observations have been collected to comment on differences in nocturnal supine reflux between morning and bedtime dosing schedules. Disclosure: Dr Romero - Consultant: Santarus, and grant support for this project from Santarus. Dr Jung - won a travel award to attend DDW 2010 from Santarus. This research was supported by an industry grant from Santarus, Inc.

Impact of upper gastrointestinal lesions in patients on low‐dose aspirin therapy: Preliminary study

We investigated the incidence of upper gastrointestinal lesions in the esophagus, stomach and duodenum in patients on low-dose aspirin (LDA) therapy. The subjects were 101 consecutive outpatients who had been on LDA therapy (average age 67.2 +/- 8.3 years; male : female ratio 3.8:1). All subjects underwent endoscopy without ceasing their antiplatelet or anticoagulant therapy. We investigated the rates of endoscopic peptic ulcer, reflux esophagitis (RE) and malignant lesion. RE was detected in eight subjects and esophageal ulcer in one subject. The severity of RE, according to the Los Angeles classification, was grade A in one subject, B in four, C in two and D in one. All nine subjects (8.9%) with RE and esophageal ulcer were negative for Helicobacter pylori infection. Gastric ulcer was detected in 12 subjects (six H. pylori positive, six negative) and duodenal ulcer in four (one H. pylori positive, three negative). The incidence of gastroduodenal ulcer was 15.8% (16/101). The incidence of esophageal and gastric cancers was high at 5.9% (6/101). Subjects were surveyed using the gastrointestinal symptom rating scale, with no differences in scores for acid reflux, abdominal pain or indigestion according to the presence or absence of RE, gastric ulceration or duodenal ulceration. Upper gastrointestinal mucosal injuries and neoplasm were found in not only the stomach, but also the esophagus and duodenum in LDA taking subjects. These results emphasize the importance of endoscopic surveillance in patients on LDA therapy.

Helicobacter pylori infection and reflux esophagitis in young and middle‐aged Japanese subjects

Helicobacter pylori infection rates are reported to be high in people over the age of 40 years, but are decreasing in younger age groups. A negative correlation has been reported between H. pylori infection and reflux esophagitis (RE). The subjects were 418 patients who underwent esophagogastroduodenoscopy and measurement of serum immunoglobulin G H. pylori antibodies examined as part of their routine health checks. Their mean age was 39.2 +/- 8.3 years (range 22-58). We analyzed the RE findings (Los Angeles classification: A, B, C, D). The total H. pylori infection rate was 33.7% (141/418). By age group, infection rates were 15.7% in the 20-29 years group, 28.0% in the 30-39 group, 34.3% in the 40-49 group and 69.1% in the 50-59 group. The proportion of H. pylori-negative subjects with RE was 23.5% (20-29, 22.9%; 30-39, 31.7%; 40-49, 32.4%; 50-59, 41.7%), significantly higher than that (12.1%) in H. pylori-positive subjects (20-29, 0%; 30-39, 16.7%; 40-49, 12.2%; 50-59, 10.5%). The severity of RE increased with advancing age in H. pylori-positive subjects, but not in H. pylori-negative subjects. In this study, higher rates of RE were seen in H. pylori-negative subjects. It may be, however, that the presence of H. pylori infection influences the progression of RE.

The Risk Factors of Reflux Complication after Gastrectomy for Proximal Gastric Cancer

Purpose: The aim of this study was to investigate the risk factors of reflux associated complications (reflux symptoms, reflux esophagitis, and esophageal stricture) after gastrectomy for proximal gastric cancer. Methods: 150 patients with proximal gastric cancer were included from January 2005 to December 2008. Their medical and surgical records were retrospectively analyzed concerning clinical and pathologic characteristics, operation methods, morbidity, reflux associated complications and nutritional states. Results: Tumor sizes and operation methods were statistically significant in univariate analysis of risk factors for reflux associated complications (P＜0.05). However, only operation methods were statistically significant in multivariate analysis (P=0.00). We, thus, compared operation methods. There were no significant differences in morbidity, body weight, hemoglobin, serum cholesterol, protein and albumin between total gastrectomy groups and proximal gastrectomy groups (P＞0.05). However, reflux complications were significantly more common in proximal gastrectomy groups (72.4%) than in total gastrectomy groups (29.5%). Severe reflux esophagitis (LA classification C or D) was found in only proximal gastrectomy groups. Conclusion: Total gastrectomy is favorable for proximal early gastric cancer in terms of reduced esophageal reflux complications.

ROLE of Ultrasound Guided Transversus Abdominis Plane (ustap) Block in Analgesic Supplementation for Laparoscopic Radical Prostatectomy. Preliminary Findings

ROLE of Ultrasound Guided Transversus Abdominis Plane (ustap) Block in Analgesic Supplementation for Laparoscopic Radical Prostatectomy. Preliminary Findings

Verrucous Squamous Cell Carcinoma: A Rare Esophageal Malignancy

A 63-year-old woman with a history of osteoporosis presented with dysphagia, cough, and chest pain. She had never used tobacco. She had a distant history of odynophagia after swallowing several medications without water. She felt well until early 2008 when she developed a paroxysmal cough so violent that she broke ribs and occasionally vomited, including hematemesis. Five esophagogastroduodenoscopies (EGDs) between August 2008 and May 2009 for worsening symptoms showed severe reflux esophagitis; a Mallory–Weiss tear; and thickened, friable mucosa in the mid- and/or distal esophagus.

Should Patients with Severe Reflux Esophagitis Undergo Repeat Endoscopy After 8 to 12 Weeks of Proton Pump Inhibitor (PPI) Therapy to Exclude Underlying Barrettʼs Esophagus (BE)? Preliminary Results from Two Prospective Trials

Purpose: Retrospective reports have suggested that 5-25% of patients with reflux esophagitis (RE) at baseline, who undergo repeat esophagogastroduodenoscopy (EGD) following PPI therapy, have concomitant BE—most short in segment length. Given the retrospective nature of these reports, it is not clear how many patients had intestinal metaplasia of the cardia misdiagnosed as BE. We are recruiting subjects with RE into 2 prospective studies, each with different primary aims. A uniting secondary aim is to assess the prevalence of suspected and unsuspected BE in patients with RE treated with PPI therapy for 8-12 weeks. Methods: Subjects from two studies were pooled for this analysis. Study A's primary aim is to assess the role of compliance in GERD symptom resolution in subjects with Los Angeles (LA) grades B, C and D RE. Follow-up EGD was left to the discretion of the primary physician. Study B's primary aim is to compare the percent of subjects with LA grades C and D RE who achieve resolution after 8 weeks PPI treatment (morning vs. bedtime dosing). Follow-up EGD was mandatory. Endoscopists were not informed of the subject's participation in a research study. Subjects previously diagnosed with BE were excluded from this analysis. Results: Study A recruited 50 subjects [25 (50%) male, mean age 56 (SD 15), B=40, C=5, D=5], of whom 10 [4 (40%) male, mean age 58 (SD 15), B=7, C=1, D=2] had a follow-up EGD. To date, Study B has recruited 57 subjects of which 45 [31 (69%) male, mean age 56.8 (SD 13), C=27, D=18] have undergone a follow-up EGD. Thus, 55 subjects (B=7, C=28, D=20, BMI 31.5) have undergone baseline and follow-up EGD after 8-12 weeks PPI therapy and are the subjects of this analysis. Five (C=3, D=2) of 55 (9%) subjects were newly diagnosed with biopsy-proven BE at follow-up EGD [overall 2 (40%) male; mean age 55 (SD 11); BMI 35.3, short (< 3 cm) N=4 (2 male, lengths ranging from islands to 2 cm); long (>3 cm) N=1 (0 male, 5 cm). In 5 (100%) cases, BE was unexpected. The BMI of the 50 RE subjects who did not have BE at follow up EGD was 31.3 (p=0.16). Conclusion: In this prospective study, 10% of subjects with LA grade C or D RE had concomitant BE that could not be recognized during the initial endoscopy in the setting of diffuse inflammation. Unsuspected BE was not found in subjects with LA grade B RE. Subjects with RE and BE tended to be more obese than subjects with RE alone, although this finding did not achieve statistical significance. These prospective results suggest that patients with severe LA grade C or D disease undergo repeat EGD after 8 to 12 weeks of PPI therapy to exclude underlying BE. Disclosure: Dr Alexander - Consulting Meritigae Pharmacia and Wyeth; Research Funding - Merck, Novartis, and Glaxo Smith Kline. Dr Howden - Consultant - Santarus and Takeda, Speakers Bureau - Santarus and Takeda. Dr Romero - Grant/Research Support and Consultant, Santarus, makers of omeprazole/sodium bicarbonate (Zegerid), and Grant/Research Support and Consultant, AstraZeneca, makers of esomeprazole (Nexium). No disclosures for: Drs Jung, Francis, Arora, Grothe, Enders, Dabade, Murray, Farrugia, Kane, Buttar, Crowell, Locke, Wong Kee Song, Wang, Prasad, Sharma, Namasivayam, and Achem, and Mrs Geno, Fredericksen, and Diehl. This research was supported by an industry grant from AstraZeneca funded Study A in this abstract. They supplied esomeprazole. Santarus funded Study B in this abstract. They supplied omeprazole/sodium bicarbonate. Note, they are both referred to as PPI therapy. The names of their products are not described in the abstract.