Severe Erosive Esophagitis Research Articles

The prevalence, severity, and risk factors of erosive esophagitis in a Middle Eastern population.

Erosive esophagitis (EE) is frequently present in patients with gastroesophageal reflux disease (GERD), some of which may not have GERD symptoms. The prevalence of EE in the Saudi population is unknown. In this study, we aimed to determine the prevalence and risk factors of EE among patients undergoing esophagogastroduodenoscopy (EGD). We retrospectively reviewed consecutive adults who underwent EGD at an academic tertiary care center. Clinical and endoscopic data were collected. The prevalence and severity of EE were determined. Multivariate regression analysis was used to identify risk factors for EE. Records for 3230 patients were reviewed, of which 2805 were included in this study. The mean age was 48.6 ±18.6 years, and 1088 (38.7%) were male. Two hundred and twenty six (8%) patients underwent EGD for GERD-related indications. EE was noted in 309 (11%) patients and 58 (25.6%) with GERD-related indications. For patients with EE, the mean age was 49.2 ± 18.7 years, and 132 (42.7%) were males. LA Grade A esophagitis was the most common (53.9%), followed by grade B (29.6%). Among all patients, only EGD for GERD-related indications and hiatal hernia were significantly associated with EE on multivariate analysis [(aOR = 3.1, 95% CI 2.2-4.4, P < 0.01) and (aOR = 1.4, 95% CI 1.1-1.9, P < 0.01), respectively]. Age, gender, and body mass index were not associated with EE. In this large cohort, EE was present in 11% of patients who underwent EGD and in 25% of patients with GERD. EGD for GERD-related indications and hiatal hernia are independent risk factors for the presence of EE.

Comparison of Los Angeles Grades of Erosive Esophagitis Scored by Local Investigators vs Central Adjudicators in a Clinical Trial

Approximately 30% of patients with typical gastroesophageal reflux disease (GERD) symptoms have endoscopic evidence of erosive esophagitis (EE).1 The severity of EE is commonly graded using the Los Angeles (LA) classification system as grade A (minimal) to D (very severe), depending on the extent of endoscopically visible mucosal breaks (Supplementary Figure1).2 Accurate grading of EE severity is crucial in clinical trials of medical EE treatments, as EE severity strongly influences both initial rates of healing and the likelihood of recurrence during maintenance treatment.3,4 Almost all EE treatment studies have relied exclusively on local investigators' grading of EE severity to determine study eligibility and response to treatment. Those few studies that included central adjudication did not assess the reliability of grading by local investigators.5 Unlike typical studies of EE treatment, the phase III clinical trial of vonoprazan versus lansoprazole for the treatment of EE (NCT04124926) mandated central adjudication of endoscopic grading for study participation.6 The aim of the present investigation was to evaluate the rate of agreement between local investigators and central adjudicators for EE grading during screening for entrance into that clinical trial.

Vonoprazan is superior to lansoprazole for healing of severe but not mild erosive esophagitis: A systematic review with meta-analysis of randomized controlled trials.

Healing rates of severe erosive esophagitis (EE; Los Angeles [LA] Grade C/D) in patients treated with a proton pump inhibitor (PPI) is suboptimal (~60-70%). Vonoprazan, a potassium-competitive acid blocker, is suggested to have better healing rates in patients with severe EE. This meta-analysis compares the efficacy and safety of vonoprazan 20mg versus lansoprazole 30mg daily in healing EE, specifically in those with LA Grade C/D. We searched MEDLINE, Embase, and CENTRAL on May 24, 2023. Studies that randomized EE patients to vonoprazan 20mg daily or lansoprazole 30mg daily and compared healing rates were included. The risk of bias was assessed using Cochrane's Risk of Bias 2 tool. The fixed-effect model was used to obtain the pooled efficacy and safety outcomes. Subgroup analysis was done to compare healing rates in mild (LA Grade A/B) versus severe EE and based on study location. Four randomized controlled trials (RCTs) with low risks of bias comprising 2208 participants were included. Vonoprazan 20mg was superior to lansoprazole 30mg daily in healing severe EE at all weeks (Week 2 RR 1.294 [95% CI 1.169-1.433], Week 4 1.160 [1.059-1.270], and Week 8 1.175 [95% CI 1.107-1.247]), but was similar for mild EE at all weeks (P-interaction<0.01). Vonoprazan 20mg was more efficacious than lansoprazole 30mg at Week 8 in Western versus Asian studies (P-interaction<0.01). Any, serious, and drug-related treatment-emergent adverse events were comparable between groups. Vonoprazan 20mg is superior to lansoprazole 30mg for healing severe EE but not mild EE. Vonoprazan 20mg daily has a similar safety profile to lansoprazole 30mg daily.

Latin American consensus on diagnosis of gastroesophageal reflux disease.

Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts. This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard. A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination. Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.

Oral Disintegrating Tablets of Proton Pump Inhibitors for Chronic Gastroesophageal Reflux Disease: An Update.

Oral disintegrating tablets (ODT) offer an attractive choice for Gastroesophageal Reflux Disease (GERD) patients suffering from dysphagia. In chronic condition, GERD patient suffers from severe erosive esophagitis. Thus patients feel difficulty and pain during swallowing, which results in patient in-compliance toward medication of tablets or capsules- especially in geriatrics and pediatric patients. These symptoms of GERD patients have attracted the formulation scientists in improving the formulation methodology for such patients. Orally disintegrating tablets could increase the therapeutic impact and drug compliance in these patients. The aim of this compilation is to provide a more convenient way to develop an oral disintegrating drug delivery system of proton pump inhibitors in patients suffering from odynophagia, associated with chronic Gastroesophageal Reflux Disease (GERD). Oral disintegrating tablets (ODT), when placed on the tongue, can quickly disintegrate and release the medicament. It later dissolves or disperses in saliva without any additional water. The saliva containing drug can easily be swallowed and descends into the stomach leading to maximum absorption from the mouth, throat, and upper esophagus. The patient compliance and bio-availability of Oral disintegrating tablets (ODT) are high compared to other conventional tablets.

S561 Vonoprazan Is Superior to a Proton Pump Inhibitor in Healing Severe Erosive Esophagitis: A Meta-Analysis of Randomized Controlled Trials

S561 Vonoprazan Is Superior to a Proton Pump Inhibitor in Healing Severe Erosive Esophagitis: A Meta-Analysis of Randomized Controlled Trials

Validity and Reliability of the Reflux Symptoms Index Translated into Indonesian: The Role of Upper Endoscopy in Assessing Extra-Esophageal Gastroesophageal Reflux Disease Symptoms.

The Reflux Symptom Index (RSI) is a questionnaire that evaluates the severity of extra-esophageal symptoms and is one of the most widely used measures to evaluate LPR. This study assessed the validity and reliability of the RSI questionnaire in Bahasa Indonesia and investigated the association between each extra-esophageal symptom reported in the questionnaire and the severity of erosive esophagitis as determined by endoscopic findings. 85 adult patients with GERD symptoms had an upper endoscopy examination and were asked to complete the translated RSI. The validity and reliability of the questionnaire were assessed. The construct validity of the RSI translated into Bahasa Indonesia was verified with the r value of each question being higher than the crucial table value (r>0.213, p<0.05). Our questionnaire had a Cronbach alpha value of 0.81, which indicates an acceptable level of internal consistency. At least one extra-esophageal symptom was seen in 91.7% of patients with Los Angeles (LA) grade B or higher-grade esophagitis. In addition, the presence of extra-esophageal symptoms was associated with significant mucosal erosion (p=0.20). The symptoms of cough after eating or lying down and chronic cough were associated with the severity of esophageal mucosal erosion (p<0.05). The version of RSI translated into Bahasa Indonesia is a valid and reliable tool for assessing extra-esophageal GERD symptoms. The occurrence of extra-esophageal symptoms in patients with typical GERD symptoms is associated with endoscopic findings of LA grade B or erosive esophagitis of higher severity.

Vonoprazan Versus Lansoprazole for Healing and Maintenance of Healing of Erosive Esophagitis: A Randomized Trial

For decades, proton pump inhibitors (PPIs) have been the mainstay of treatment for erosive esophagitis. The potassium-competitive acid blocker vonoprazan provides more potent acid inhibition than PPIs, but data on its efficacy for erosive esophagitis are limited. Adults with erosive esophagitis were randomized to once-daily vonoprazan, 20 mg, or lansoprazole, 30 mg, for up to 8 weeks. Patients with healing were rerandomized to once-daily vonoprazan, 10 mg, vonoprazan, 20 mg, or lansoprazole, 15 mg, for 24 weeks. Primary end points, percentage with healing by week 8 endoscopy, and maintenance of healing at week 24 endoscopy, were assessed in noninferiority comparisons (noninferiority margins, 10%), with superiority analyses prespecified if noninferiority was demonstrated. Analyses of primary and secondary end points were performed using fixed-sequence testing procedures. Among 1024 patients in the healing phase, vonoprazan was noninferior to lansoprazole in the primary analysis and superior on the exploratory analysis of healing (92.9 vs 84.6%; difference, 8.3%; 95% confidence interval [CI], 4.5%-12.2%). Secondary analyses showed vonoprazan was noninferior in heartburn-free days (difference, 2.7%; 95% CI,-1.6% to 7.0%), and superior in healing Los Angeles Classification Grade C/D esophagitis at week 2 (difference, 17.6%; 95% CI, 7.4%-27.4%). Among 878 patients in the maintenance phase, vonoprazan was noninferior to lansoprazole in the primary analysis and superior on the secondary analysis of maintenance of healing (20 mg vs lansoprazole: difference, 8.7%; 95% CI, 1.8%-15.5%; 10 mg vs lansoprazole: difference, 7.2%; 95% CI, 0.2%-14.1%) and secondary analysis of maintenance of healing Grade C/D esophagitis (20 mg vs lansoprazole: difference, 15.7%; 95% CI, 2.5%-28.4%; 10 mg vs lansoprazole: difference, 13.3%; 95% CI, 0.02%-26.1%). Vonoprazan was noninferior and superior to the PPI lansoprazole in healing and maintenance of healing of erosive esophagitis. This benefit was seen predominantly in more severe erosive esophagitis. (ClinicalTrials.gov: NCT04124926).

S2303 Endoscopic Balloon Dilation of Recurrent Peptic Stricture in a Patient With Portal Hypertension

Introduction: Variceal hemorrhage is a devastating complication and a major cause of mortality in patients with portal hypertension. Unfortunately, one third of patients with varices develop bleeding in their lifetime. This case depicts a rarely reported intervention that physicians may be hesitant to pursue. Case Description/Methods: A 61-year-old male with history significant for atrial fibrillation (afib), alcoholic cirrhosis complicated by gastric and esophageal varices, and GERD presented with dysphagia. He previously underwent endoscopic variceal band ligation (EVL) in 2009 for primary prevention of esophageal varices and placed on daily nadolol. His GERD was controlled with twice daily PPI and as-needed H2 antagonist. Despite this, he developed strictures secondary to severe erosive esophagitis. He was then started on apixaban for afib and transitioned from nadolol to carvedilol. His MELD-Na is 8 and had a reported distant history of hepatic encephalopathy. He presented to the esophageal motility clinic with progressive dysphagia to both solids and liquids. An EGD was scheduled which revealed a partially obstructive ulcerative stricture spanning 29 - 34 cm from incisors. The stricture was injected with 4 ml of triamcinolone acetonide distributed in 1 cm increments across 4 quadrants. Then the stricture was dilated with a 10-12 mm cre balloon under fluoroscopic guidance. Dilation caused shallow mucosal tears with scant blood but otherwise no significant bleeding or complication. The scope was traversed into the stomach with retroflexion revealing moderate gastric varices in the cardia. After the procedure was completed, the patient had complete resolvent of symptoms and tolerated oral nutrition (Figure). Discussion: This case describes a cirrhotic patient with portal hypertension requiring frequent endoscopic balloon dilations for severe dysphagia secondary to recurrent peptic strictures. Extensive literature review did not reveal any documented cases describing this scenario. The presence of gastric varices in this patient is indicative of active portal hypertension. This in combination with the patient’s anticoagulation places a theoretical high risk of bleeding during the procedure. Although this case demonstrates that it is safe to perform serial dilations in patients with portal hypertension if they have undergone EVL and do not have active esophageal varices.Figure 1.: A) EGD showed ulcerative peptic stricture located in the mid-esophagus. (B) There was scant bleeding after dilation, otherwise no significant bleeding or complication. (C) Retroflexion was performed in the stomach and revealed moderate gastric varies in the cardia.

Esophageal Complications in Patients with Ankylosing Spondylitis: Endoscopic and Histomorphological Features

On the basis of clinical and endoscopic examination of 31 patients with ankylosing spondylitis (AS) with clinical signs of esophageal lesions, we have found that in these patients erosive lesions of the esophagus occur much more often than in simple gastroesophageal reflux disease (GERD). Esophageal lesions in patients with AS are more severe than in simple GERD — severe erosive esophagitis (of C and D grade) is detected in 43.8 % of patients with erosive and ulcerative lesions of the esophagus against AS. Microscopic examination of biopsy material taken from esophageal mucosa suggests multifactorial mechanism of esophageal lesions in AS, including systemic and local immune inflammation, abnormal microvasculature, excessive proliferation of connective tissue, disseminated sclerotic processes in the wall of the esophagus, reduced number of esophageal glands.

High prevalence of esophagitis in patients with severe ineffective esophageal motility: need for a new diagnostic cutoff.

BackgroundA new classification criterion for diagnosing ineffective esophageal motility (IEM) was proposed at the 2018 Stanford symposium, but limited data exists about the utility of this criterion.MethodsWe conducted a cross-sectional study among 3826 patients treated at the Institute of Gastroenterology and Hepatology, Hanoi, Vietnam, between March 2018 and May 2020. Patients were classified as having normal motility, mild IEM, severe IEM, or absent contractility based on the Chicago classification version 3.0 and the new IEM criterion (severe IEM was defined as having >70% ineffective swallows). We examined the association between these 4 motility subgroups and the presence of erosive esophagitis and Barrett’s esophagus, using multivariate logistic regression analysis.ResultsThe mean age of the study sample was 44.7 years and 66.3% were women. The prevalence of symptoms, hiatal hernia, and Helicobacter pylori-positive patients was similar in the 4 study groups. The 4-second integrated relaxation pressures and lower esophageal sphincter resting pressures were lower in patients with severe IEM and absent contractility. Severe IEM and absent contractility, but not mild IEM, were significantly associated with Los Angeles (LA) grade B-D esophagitis (relative risk ratio [RRR] for severe IEM 1.81, 95% confidence interval [CI] 1.17-2.80; and RRR for absent contractility 2.37, 95%CI 1.12-5.04). None of the hypomotility subgroups were associated with LA grade A esophagitis and Barrett’s esophagus.ConclusionsPatients with severe IEM have a high prevalence of severe erosive esophagitis. These findings suggest the need for a more meaningful classification criterion for IEM.

CHARACTERISTICS AND SUBSTANTIATION OF THE USE OF PELLETS AS A MODERN DOSAGE FORM ON THE MARKET OF UKRAINE

currently, omeprazole pellets are one of the most common pellet formulations on the pharmaceutical market of Ukraine (Gorobets, Matyash, Pekhenko &amp; Barna, 2019). This medication is available in capsule form. Pellets are multi particular dosage forms that have several advantages over monoparticular dosage forms; therefore, pellets are promising oral delivery systems for active pharmaceutical ingredients (APIs). Pellets are used when the stability of the active substance changes with fluctuations in the pH of the environment, when irritation of the gastric mucosa is possible, to facilitate swallowing (especially important for patients with dysphagia, elderly patients, and children). When using polymers in the shell, it is possible to regulate the release in a certain part of the gastrointestinal tract, this allows you to get a point pharmacological effect. In addition, pellets can be of different sizes (from 0.1 to 2 mm), because of their shape, pellets exhibit abrasion resistance and are more fluid. Omeprazole is a synthetic substance. The active ingredient suppresses gastric acid secretion. In refers to the pharmaceutical group of proton pump inhibitors, it prescribes drugs in this group to treat active duodenal ulcers, gastric ulcers, gastro-oesophageal reflux disease (GERD), severe erosive esophagitis, pathological hypersecretory conditions, for example, Zollinger Ellison syndrome. Among the most commonly used methods for the production of pellets are: stage-by-stage spraying of solutions or suspensions (the second name is stage-by-stage layering); direct pelletization (the second name is extrusion-spheronization); spray drying and spray cooling of melts; agglomeration-spheronization. Unfortunately, at the moment, none of the Ukrainian manufacturers is manufactured enteric pellets on their own (they buy ready-made pellets), while there are medicines of both foreign and Ukrainian origin on the domestic market. The article contains an overview of pharmaceutical preparations as pellets, systematization of information on production methods, a review of omeprazole drugs as pellets, presented on the pharmaceutical market of Ukraine. The purpose of this study was to summarize the cases when the use of such a form as pellets is the most reasonable; make an overview of medicines in Ukraine containing pellets; summarize modern methods of pellet production.

Safety and effectiveness of sling fiber preservation POEM to reduce severe post-procedural erosive esophagitis.

Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been an important challenge since the early days of POEM implementation. The esophagogastric junction anti-reflux barrier consists of internal lower esophageal sphincter (LES) (i.e., intrinsic muscles of distal esophagus with sling fibers) and external LES (crural diaphragm and phrenoesophageal ligament anchors the distal esophagus to the crural diaphragm). During conventional POEM, the entire internal LES is unintentionally dissected. Preservation of the sling fiber may reduce post-POEM GERD, but its safety and effectiveness have been unclear. In this study, we investigated the safety and effectiveness of sling fiber preservation POEM (SP-POEM) for reducing severe post-procedural erosive esophagitis. We analyzed data of 236 patients who underwent POEM; of these, 203 patients underwent posterior myotomy without (Group 1) or with attempted (Group 2) sling fiber preservation. Group 1 (N = 79; sling fiber excision, N = 68) and Group 2 (N = 90; sling fiber preservation, N = 81) were compared. Post-procedural erosive esophagitis (Los Angeles classification) were assessed and the area (direction and length) of mucosal break was also investigated. The gastroesophageal flap valve was evaluated by Hill's classification. Severe erosive esophagitis exceeding grade C (Los Angeles classification) occurred in 44.1% of patients (30/68) in Group 1 and in 18.5% of patients (15/81) in Group 2. In mapping of erosive esophagitis, mucosal breaks appeared widely in all directions in Group 1; they tended to be limited in Group 2 (especially in the 2 o'clock direction). Assessment using the Hill's classification showed that the gastroesophageal flap valve was preserved after SP-POEM. SP-POEM is safe and effective, with a success rate of 90%. The rate of severe erosive esophagitis can be decreased by preserving sling fibers.

S3584 Endoscopic Evaluation in a Patient with Post-Bulbar Duodenal Ulcer and Stricture

Introduction: Gastric outlet obstruction (GOO) is the least frequent complication of peptic ulcer disease (PUD) in the US after bleeding and perforation. Ulcers located in the pyloric region and duodenum are most causative of GOO. PUD has decreased since the advent of PPI and eradication of Helicobacter pylori. Although most patients have typical ulcer symptoms prior to the development of complications, asymptomatic ulcers necessitate the need for endoscopic evaluation. Early suspicion and endoscopic evaluation can assist with the prompt management of this complication. Case Description/Methods: 71 year-old white male evaluated for a 5 week history of abdominal pain, nausea, post-prandial vomiting, 35 pound weight loss. Denied the use of non-steroidal anti-inflammatory drugs. Medical history is significant for type 2 diabetes mellitus current tobacco use and hypertension. No prior history of PUD. Physical exam was notable for epigastric tenderness and muscle wasting. Contrasted Abdominopelvic CT showed questionable diverticulum in the second portion of the duodenum and no evidence of pancreatic mass. Endoscopic evaluation showed severe erosive esophagitis, a pinhole stricture in the duodenal bulb with the appearance of a benign peptic stricture. The duodenal stricture was unable to be traversed with a standard gastroscope. With fluoroscopic guidance, the stricture was dilated progressively with a balloon to 6mm, 8mm and 10mm. Biopsies were obtained and the stricture was then traversed with a pediatric scope. After endoscopic evaluation, it was determined that the duodenal stricture was not amenable to durable endoscopic intervention. Pathology, negative for Helicobacter pylori and malignancy. Patient subsequently underwent an exploratory laparotomy and gastrojejunostomy with gastro-jejunal tube placement. Patient continued to improve and was discharged to continue tube feeding at home, outpatient follow up with gastroenterology and surgery. Discussion: Endoscopy plays a critical role in the evaluation and management of patients with symptoms concerning for post bulbar duodenal ulcer, stricture and gastric outlet obstruction. Silent ulcers and complications are more prevalent in older patients. Early detection, evaluation and treatment of GOO could improve disease related morbidity and mortality. Risk modification which consists of tobacco cessation, treating post bulbar ulcers, duodenal ulcers and Helicobacter pylori infection could improve the GOO trends.Figure 1.: Severe Duodenal Stenosis.

675 FUNDOPLICATION VERSUS ORAL PROTON PUMP INHIBITORS FOR GASTROESOPHAGEAL REFLUX DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS

Abstract Gastroesophageal reflux disease (GERD) is a widely studied and highly prevalent condition. However, few is reported about the exact efficacy and safety of fundoplication (FPT) compared to oral intake proton-pump inhibitors (PPI). This systematic review and meta-analysis of randomized clinical trials (RCT) aims to compare PPI and FPT in relation to the efficacy, as well as the adverse events associated with these therapies. Methods This systematic review was guided by PRISMA statement. Search carried out in June 2020 was conducted on Medline, Cochrane, EMBASE and LILACS. The inclusion criteria were (I) patients with GERD; (II) Randomized clinical trials, comparing oral intake PPI with FPT; (III) relevant outcomes for this review. The exclusion criteria were (I) reviews, case reports, editorials and letters (II) transoral or endoscopic FPT (III) studies with no full text. No restrictions were set for language or period. Certainty of evidence and risk of bias were assessed with GRADE Pro and with Review Manager Version 5.4 bias assessment tool. Results Ten RCT were included. Meta-analysis showed that heartburn (RD = −0.19; 95% CI = −0.29, −0.09) was less frequently reported by patients that underwent FPT. Furthermore, patients undergoing surgery had greater pressure on the lower esophageal sphincter than those who used PPI (MD = 7.81; 95% CI 4.79, 10.83). There was no significant difference between groups in the percentage of time with pH less than 4 in 24 hours, sustained remission and Gastrointestinal Symptom Rating Scale. Finally, FPT did not increase significantly the risk for adverse events such as postoperative dysphagia and impaired belching. Conclusion FPT is a more effective therapy than PPI treatment for GERD, without significantly increasing the risk for adverse events. However, before indicating a possible surgical approach, it is extremely important to correctly assess and select the patients who would benefit from FPT, such as those with severe erosive esophagitis, severe respiratory symptoms, low adherence to continuous drug treatment and patients with non-acid reflux, to ensure better results.

Gastroesophageal reflux after per-oral endoscopic myotomy is frequently asymptomatic, but leads to more severe esophagitis: A case-control study.

Background and aimThe incidence of gastroesophageal reflux disease (GERD) is high after per‐oral endoscopic myotomy (POEM). GERD after POEM may be qualitatively different from GERD in patients without motility disorders. In this study, we aimed to analyze and compare different aspects of GERD between patients with post‐POEM GERD and nonachalasia GERD.MethodsThe data of patients with GERD after POEM (January 2018 to June 2019) were compared with that of a control group (nonachalasia GERD group), which included patients presenting with typical reflux symptoms without associated major motility disorders. Patients with lower esophageal sphincter pressure lower than 10 mmHg were excluded from the study. GERD was evaluated at 3 months after POEM. Esophageal acid exposure time higher than 4.2% was used to define GERD. The primary outcome of the study was comparison of GERD‐related quality of life and reflux symptom severity between the two groups. In addition, the severity of erosive esophagitis and reflux‐symptom association were also recorded in the two groups.ResultsA total of 100 patients were included in the study, with 50 patients in each group (post‐POEM GERD vs. controls). The baseline parameters were comparable between the two groups. Median interquartile range of GERD‐related quality of life score was significantly lower in the post‐POEM group (11 [0–23.3] versus 34 [24–44]; p < 0.001). The post‐POEM GERD group had significantly lower median heartburn (6.0 [0–16.3] versus 15.5 [7.5–24.8]; p = 0.001) and regurgitation scores (0 [0–6.0] versus 20.0 [12.3–25.0]; p < 0.001). Erosive esophagitis was more frequent in the post‐POEM group (28 [56%] versus 10 [20.4%], p = 0.001). Only three (6%) patients in the post‐POEM group had a positive reflux‐symptom association as compared with 28 (56%) patients in the control group (p < 0.001).ConclusionIn selected patients with pH positive GERD after POEM, the symptoms are milder and reflux‐symptom association is poor in spite of more severe esophagitis as compared with controls.

Gastroesophageal reflux disease and autoimmune thyroiditis: features of pathomorphological manifestation in young people

The aim of the work. To study the effect of concomitant autoimmune thyroiditis (AIT) on the pathomorphological features of lesions of the esophageal mucosa in young patients with gastroesophageal reflux disease (GERD).&#x0D; Material and research methods. The study included 165 individuals. The contingent of the surveyed was students of Kharkov higher educational institutions. The main group consisted of 120 patients with a combined course of GERD and AIT, the comparison group included 65 individuals with an isolated GERD. The morphological form of the GERD was revealed during esophagogastroduodenoscopy (“Fuginon” system). A histomorphological study of the obtained biopsy material from the mucous membrane of the esophagus was carried out. Samples were studied on an Olympus BX-41 microscope. Morphometric study of the esophageal mucosa was performed using the Olympus DP-Soft.&#x0D; Research results. Histological examination of biopsy specimens revealed that the main pathomorphological signs of GERD in both groups were hyperplasia of the basal zone, lengthening of epithelial papillae, leukocyte infiltration, intercellular edema, expansion of the intercellular space, dystrophic changes, submucous fibrosis, the presence of severe inflammatory infiltration in the submucosal layer. Presence of concomitant AIT was associated with a statistically higher frequency of occurrence of certain signs: hyperplasia of the basal layer of the epithelium, elongation of the papillae, epithelial edema, expansion of the intercellular space, dystrophic changes in the epithelium (p&lt;0.05).&#x0D; Conclusions. The presence of concomitant AIT in young patients with GERD does not affect the incidence of erosive GERD, but is associated with a significant increase in the severity of erosive esophagitis. The comorbid course of GERD and AIT in the student population is accompanied by a significant increase in the incidence and statistically significant intensification of the severity of hyperplasia of the basal layer of the epithelium, elongation of connective tissue papillae and leukocyte infiltration compared with isolated GERD

S3598 L.A Grade D Erosive Esophagitis With Incidental Ectopic Pancreas

INTRODUCTION: Grade D erosive esophagitis and ectopic pancreas are both rare findings. We describe a patient that presented for an upper GI bleed with several risk factors for esophagitis. On endoscopy, L.A grade D erosive esophagitis was found along with an asymptomatic ectopic pancreas within the antrum of the stomach. CASE DESCRIPTION/METHODS: 58-year-old male with a history of tobacco usage, alcohol abuse, and GERD presented with alcoholic intoxication, black stools, and coffee-ground emesis for one day. He was found to have a hemoglobin of 7.7 from 13.5, hematocrit 21.3, elevated BUN and ALT. He was tachycardic and hypotensive. His skin showed pallor, abdomen was soft and tender to palpation in the epigastrium. Rectal exam was positive for black stool. He was given fluids and started on a PPI drip. The patient was admitted to the MICU for hemorrhagic shock. He received 2 unit’s FFP and 2 units PRBC prior to Endoscopy. EGD showed LA Grade D erosive esophagitis, a single lesion of aberrant pancreas in the stomach and gastritis. His hospital stay was uncomplicated and he was discharged with follow up. DISCUSSION: We describe a patient with L.A. grade D erosive esophagitis and ectopic pancreas. Both are rare conditions and present as a source of bleeding. Ectopic pancreas has an incidence of 0.2%, while grade C and D erosive esophagitis combined are 1% of all erosive esophagitis cases. The severity of erosive esophagitis in our patient is due to several factors, one being the patient’s 40 pack-year smoking history of which causes the LES pressures to be significantly lower. He had a hiatal hernia. The GE junction becomes both dilated and shorter, allowing for LES relaxation and increased acid reflux. His excessive alcohol drinking history can also reduce the LES tone and cause pyroptosis.On EGD our patient also had ectopic pancreas finding. This usually presents asymptomatically. This finding can pose a problem, as it can cause asymptomatic bleeding and can later develop into pancreatitis. Being a ETOH abuser, he is at risk for pancreatitis by both his ETOH usage and his ectopic pancreas.Periodic upper endoscopy must be done to monitor for cancer transformation, as ectopic pancreas can turn malignant at a rate of .7% to 1.8%. The extensive bleeding in our patient could have been due to the erosive esophagitis, aberrant pancreatitis or a combination of both. While both are rare findings, they can independently cause life-threatening complications and it is crucial to be aware that they can coexist together.Figure 1.: Aberrant pancreas in the Antrum of the Stomach.Figure 2.: Esophagitis.

S1877 Treatment Refractory Esophageal Ulceration and Stricture: An Interesting Presentation of Zollinger-Ellison Syndrome

INTRODUCTION: Esophageal symptoms are common in patients with Zollinger Ellison syndrome, however, esophageal stricture is found in only a small percentage of patients. We present a case of severe erosive esophagitis with recurrent esophageal stricture refractory to standard medical therapy due to Zollinger Ellison syndrome. CASE DESCRIPTION/METHODS: A 72-year-old male with a medical history significant for HIV on HAART, GERD, hypertension, H. pylori treated with quadruple therapy in 2017, and chronic pancreatitis secondary to remote alcohol abuse presented to the ED with worsening epigastric pain associated with nausea, vomiting, and diarrhea. Stool testing was positive for campylobacter and enteropathogenic E. coli, and H. pylori stool antigen was positive. EGD showed severe erosive esophagitis and multiple duodenal ulcers. Gastrin level was 437 pg/mL, however, the patient was not fasting and was on proton pump inhibitor therapy. The patient completed quadruple therapy for H. pylori and supportive care for presumed infectious diarrhea. He was continued on twice daily PPI therapy after completing treatment for H. pylori. The patient presented back to the ED approximately one month later with dysphagia. EGD showed severe erosive esophagitis and luminal narrowing in the mid-esophagus (approximately 2–3 mm). Repeat gastrin level was 927 pg/mL. PET scan demonstrated a DOTATE avid mass in the first portion of the duodenum consistent with a gastrinoma. The patient was placed on maximal medical therapy (pantoprazole 240 mg/day, famotidine 80 mg/day); however, required serial dilation every 1–2 weeks for recurrent esophageal stricture. He eventually underwent distal gastrectomy and duodenal resection for removal of the gastrin secreting tumor. The final pathology report noted a grade 1 well-differentiated neuroendocrine tumor in the duodenum. DISCUSSION: Zollinger Ellison syndrome is caused by the secretion of gastrin by neuroendocrine tumors (i.e., gastrinomas) most commonly found in the duodenum and pancreas. It most often presents with peptic ulcer disease, heartburn, and diarrhea. Although 31–56% of patients present with esophageal symptoms, esophageal stricture is found in only 4–10% of patients. Our patient was found to have Zollinger Ellison syndrome after presenting with treatment refractory esophageal ulceration and stricture. Medical therapy is the current standard of care, however, surgical resection and other systemic therapy is sometimes required to control symptoms and tumor growth.Figure 1.: Endoscopic images showing severe erosive esophagitis in the proximal esophagus.Figure 2.: Endoscopic images showing luminal narrowing in the mid-esophagus.Figure 3.: Barium esophagram demonstrating severe, long segment stricture of the mid to distal esophagus.

Comparative efficacy of first-line therapeutic interventions for achalasia: a systematic review and network meta-analysis

BackgroundSeveral interventions with variable efficacy are available as first-line therapy for patients with achalasia. We assessed the comparative efficacy of different strategies for management of achalasia, through a network meta-analysis combining direct and indirect treatment comparisons.MethodsWe identified six randomized controlled trials in adults with achalasia that compared the efficacy of pneumatic dilation (PD; n = 260), laparoscopic Heller myotomy (LHM; n = 309), and peroral endoscopic myotomy (POEM; n = 176). Primary efficacy outcome was 1-year treatment success (patient-reported improvement in symptoms based on validated scores); secondary efficacy outcomes were 2-year treatment success and physiologic improvement; safety outcomes were risk of gastroesophageal reflux disease (GERD), severe erosive esophagitis, and procedure-related serious adverse events. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence.ResultsLow-quality evidence, based primarily on direct evidence, supports the use of POEM (RR [risk ratio], 1.29; 95% confidence intervals [CI], 0.99–1.69), and LHM (RR, 1.18 [0.96–1.44]) over PD for treatment success at 1 year; no significant difference was observed between LHM and POEM (RR 1.09 [0.86–1.39]). The incidence of severe esophagitis after POEM, LHM, and PD was 5.3%, 3.7%, and 1.5%, respectively. Procedure-related serious adverse event rate after POEM, LHM, and PD was 1.4%, 6.7%, and 4.2%, respectively.ConclusionsPOEM and LHM have comparable efficacy, and may increase treatment success as compared to PD with low confidence in estimates. POEM may have lower rate of serious adverse events compared to LHM and PD, but higher rate of GERD.