PPI Trial Research Articles

The practical management of patients with gastroesophageal reflux: an Italian survey

BACKGROUND: Gastroesophageal reflux disease (GERD) is a prevalent medical condition in clinical practice. However, its management is still controversial and debated. An Italian survey involved a group of gastroenterologists in describing their clinical approach.METHODS: A panel of Italian gastroenterologists participated in the survey. The survey included questions concerning professional characteristics and patient management in clinical practice.RESULTS: Sixty-five gastroenterologists completed the questionnaire. GERD diagnosis is usually established by history and PPI Test (commonly for 4 or 8 weeks with a single dose). After reassessment, PPI is usually associated with mucosal protectors, alginates, and antacids. Gastroenterologists were particularly satisfied (88.4%) with the combination of PPI (single dose) plus mucosal protectors, while 43.5 preferred the single PPI approach.CONCLUSIONS: The present Italian survey showed that the work-up in GERD patients is essentially based on history and PPI Trial. After reassessment, PPIs are commonly prescribed, but they are frequently associated with mucosal protectors, alginates, and antacids, preferring the former.

S3726 A Silent Gastric Adenocarcinoma With Peritoneal Carcinomatosis: A Case of a Newly Diagnosed Decompensated Cirrhosis Leading to a Fatal Diagnosis of a Silent Metastatic Malignancy

Introduction: Gastric carcinoma (GC) with peritoneal carcinomatosis is an advanced cancer with a median survival of less than 6 months. It is the third leading cause of cancer-related death. We present a case of an advanced Gastric Signet-ring cell carcinoma (GSRCC) with peritoneal carcinomatosis that presented as decompensated liver cirrhosis. Case Description/Methods: A 62-years-old African American male with HTN and DM type II presented with 4 week of worsening abdominal distension with pressure and worsening acid reflux. He denied alcohol, smoking and has no family history of gastrointestinal malignancy. Physical exam revealed a non tender but distended abdomen with dullness to percussion. CT scan of abdomen and pelvis (CT A/P) revealed liver cirrhosis and moderate ascites with mesenteric edema. EGD revealed small varices and poor distensibility of the stomach with diffuse mucosal congestion, granularity, and ulceration in the gastric body and antrum. Biopsy uncovered poorly differentiated GC with signet ring cells. Ascitic fluid cytology also confirmed adenocarcinoma with positive CK7 and CDX-2 markers. Repeat CT A/P with contract revealed nodular densities in the omentum with ascites. With the aforementioned test results, diagnosis of GSRCC stage P3 was made and he was started on palliative chemotherapy with mFOLFOX6 (modified folinic acid, fluorouracil, and oxaliplatin). He is doing well after 9 months of mFOLFOX6 initiation. Discussion: Most GC are diagnosed at advanced and incurable stage with a median survival of 6 months hence early diagnosis is key to increased survival. The only potential curative therapy is surgical resection for GC in situ whereas palliative chemotherapy is the probable therapeutic option for intraperitoneally-disseminated GC. Based on multiple retrospective studies, gastrectomy with systemic palliative chemotherapy did not significantly improve survival when compared to chemotherapy alone in intraperitoneally-disseminated GC. With rising in GSRCC cases, general population should be educated about its early signs and should seek medical attention sooner. Physicians likewise should have a low threshold for referring to gastroenterologist for endoscopy in a high-risk patient with any alarm symptoms or for persistent acid reflux or epigastric pain that is not relieved with a trial of PPI. Our patient had acid reflux for more than a year which was mildly controlled with antacid. Had he sought appropriate medical attention, his diagnosis could have been made at an earlier stage.

S2272 Inlet Patch Polyp Mimicking Esophageal Cancer

Introduction: Heterotopic gastric mucosa (HGM) in the proximal esophagus also known as cervical inlet patch is a prevalent accidental finding during EGD. Case Description/Methods: 56 y.o. female with no prior PMH presented with a 4-year history of constipation, heartburn, epigastric pain, and weight loss. Symptoms were not controlled with the PPI trial. EGD showed 2 areas of gastric mucosa heterotopy in the duodenal bulb, sized up to 5 mm. In the cervical esophagus, an area of HGM sized 15x20 mm with protruding lesion Paris 0-Is sized 5x7mm was visualized. In the narrow-band imaging, the vessel pattern was irregular, with dilated interpupillary loops, and an irregular surface pattern. Malignancy was suspected with biopsies obtained. Pathology showed gastric-type epithelium with active inflammation, erosion, and hyperplastic polyp in HGM. On repeat EGD lesion was completely removed with hot snare polypectomy. Final pathology showed inflammatory (granulation) polyp without dysphasia or neoplastic process. The patient’s dyspeptic symptoms improved on follow-up with double dose PPI (Figure). Discussion: HGM is found in up to 10% of the general population. Some studies consider that HGM is a common benign finding which can be used as a surrogate marker for thorough esophagus examination. Other data suggest that inlet patches can be associated with reflux and dysphagia symptoms, dysplasia, and malignancy in rare cases. Quick insertion and withdrawal of the scope can lead to missed diagnoses of HGM and its complications. HGM detection rate can serve as an EGD quality indicator. Narrow band imaging can be used to improve the HGM detection rate. Various classifications of surface and vessel patterns are used to identify squamous cell malignancy in the upper esophagus, but they are inapplicable in HGM. Careful examination with histopathological examination of biopsies is recommended for mucosal abnormalities in HGM.Figure 1.: Narrow-band image of the HGM polyp.

S2422 A Lichen for the Esophagus: A Rare Case of Esophageal Lichen Planus

Introduction: Lichen planus is an inflammatory condition of the skin and mucosal membranes. Sites of disease are variable and esophageal involvement is uncommon. We highlight a case of esophageal lichen planus masquerading as eosinophilic esophagitis. Case Description/Methods: A 59-year-old female with a past medical history of hypothyroidism status post thyroidectomy presents with progressive dysphagia and odynophagia to solids for 3 years. Symptoms initially began after thyroidectomy. Evaluation by ENT was notable for inflammatory changes of the oropharynx for which PPI trial was given for clinical features of silent reflux. Despite a 2-month course of therapy, symptoms persisted. Videofluoroscopic swallow study was unremarkable without evidence of aspiration or penetration. Subsequent EGD was notable for exudates, linear furrowing, and rings to suggest the diagnosis of eosinophilic esophagitis. Esophageal biopsy pathology features, however, showed band-like lymphocytic infiltration of the lamina propria and civatte bodies within the squamous epithelium consistent with esophageal lichen planus. Unfortunately, the patient was lost to follow up and subsequent treatment was unable to be initiated. Discussion: Esophageal lichen planus is an exceedingly rare entity with less than 100 documented case reports. It is likely underdiagnosed given that it can mimic other esophageal entities, such as eosinophilic esophagitis as seen in our patient. As such, histologic examination is necessary to identify key features of esophageal lichen planus which include lymphocytic infiltrates of the lamina propria as well as civatte bodies, which represent necrotic keratinocytes. Esophageal lichen planus has a tendency to be chronic and require topical or systemic therapy with steroids. Stricture development will typically require dilatation. Clinicians should consider esophageal lichen planus as part of their differential for dysphagia especially given the potential for malignant transformation to squamous cell carcinoma, which has been reported in 1-2% of cases.

Assessing the Merits of a PPI Trial-Based Diagnosis for Gastroesophageal Reflux Disease: Speculations on Efficacy and Pitfalls

Gastroesophageal reflux disease is a highly prevalent condition which can lead to complications in affected individuals. Given the economic implications of widespread testing, there has been interest in a symptom-based approach to diagnosis and use of short-term empiric acid suppressive therapy as a diagnostic modality. This review will highlight the background with regards to these clinical questions, the data regarding performance characteristics of establishing a symptom-based reflux diagnosis (focusing on typical, atypical, and extra-esophageal symptoms), the merits of the so-called “PPI Trial” and potential pitfalls to consider when seeing patients with suspected reflux symptoms.

Surgical referral for cholecystectomy in patients with atypical symptoms

BackgroundCholelithiasis referrals often present with concomitant or isolated atypical symptoms such as reflux, bloating, or epigastric pain. We sought to identify the impact of preoperative symptomatology of atypical or dyspepsia-type biliary colic on operative and non-operative clinical outcomes. MethodsA retrospective review of patients referred for gallstone disease from 2014 to 2018 at a single institution in Los Angeles County was performed. ResultsOf 746 patients evaluated for gallstone disease, 87.4% (n = 652) underwent cholecystectomy – 90.8% (n = 592) had symptom resolution postoperatively whereas 9.2% (n = 60) did not. Over half presented with concomitant atypical and/or dyspepsia symptoms (n = 411). Heartburn/reflux was significantly associated with unresolved symptoms postoperatively (OR 2.1,1.0–4.4, p = 0.04). Overall, 11.1% (n = 83) of all 746 patients and 20.2% of patients with atypical and/or dyspepsia symptoms improved with medical management of gastritis or Helicobacter pylori triple therapy pre/post-operatively. ConclusionAtypical biliary colic and/or dyspepsia is associated with unresolved symptoms following cholecystectomy. Such patients may benefit from H. pylori testing or PPI trial prior to cholecystectomy.

Proton Pump Inhibitor Therapy in Eosinophilic Esophagitis: Predictors of Nonresponse.

Identification of clinical predictors of response to first-line therapies for EoE is needed to guide initial medical management. A retrospective analysis of patients diagnosed with EoE from 2011 to 2018 was conducted. Clinical and diagnostic variables including demographics, endoscopic, and esophagram findings were compared between PPI responders and PPI nonresponders. All patients underwent a standard 8-week twice-daily PPI trial, with PPI responsiveness defined as < 15 eos/hpf on repeat EGD. Univariate and multivariable analyses were conducted to identify risk factors for nonresponse, and ROC curves were created to identify cutoff values. A total of 223 EoE patients (135 male, median age 39 (29-51)) were identified, with PPI nonresponse (PPI-NR) in 71% of patients. PPI-NR was seen in all 10 patients with failure of scope passage, with an OR of 9.06 by univariate analysis (P = 0.1485). In a multivariable model, age per 10years (OR 0.71; P = 0.007), BMI per 1kg/m2 (OR 0.94; P = 0.03), and peripheral eosinophil count per 100 per mm3 (OR 1.37; P = 0.003) were independent risk factors. Dichotomization to maximize sensitivity and specificity identified age ≤ 36years old, BMI ≤ 25.2kg/m2, and peripheral eos > 460 per mm3 as predictive thresholds for PPI-NR. The probability of PPI-NR was 72.4-84.5% with 1 risk factor, 87.9-93.8% with 2 risk factors, and 97.2% with all 3 risk factors. Young age, reduced BMI, elevated peripheral eosinophil count, and likely inability to pass an endoscope predict lack of response to PPIs in patients with EoE.

EoE Down Under Is Still EoE: Variability in Provider Practice Patterns in Australia and New Zealand Among Pediatric Gastroenterologists.

There is likely variation in approach and management of patient with EoE due to lack of standardized care and variation in guidelines. We aimed to identify current practices regarding diagnosis and treatment in children with eosinophillic esophagitis (EoE) in Australia and New Zealand (ANZ). Information on current diagnostic and management approaches for pediatric EoE was collected via an online survey sent to pediatric gastroenterologists (pGE) in ANZ. We performed a cross-sectional study of pGE using a 49-question instrument regarding evaluation, diagnostic, and therapeutic aspects of EoE between October 2019 and December 2019. Eighty-five percent of the survey responders were from Australia, and 66% were academic. 30% pGE perform > 3 esophageal biopsies for diagnosis of EoE, 40% involve an allergist, 30% use a twice daily PPI trial, and 70% do not exclude other cause of esophageal eosinophilia. For management, only 3% use dietary elimination as an initial therapy, and 24% use less than the recommended doses of swallowed fluticasone. Forty-nine percent were likely to stop treatment in after remission is achieved for 12months. The EoE endoscopic reference score (EREFS) was not routinely used (49%). Two-thirds of pGE are concerned about long-term effects of recurrent need of general anesthesia. Diagnostic and management strategies for EoE differed widely among pGE in ANZ, including in diagnostic biopsies, assessing competing causes of esophageal eosinophilia, initials selection of treatments, and maintenance strategies. This variability likely reflects continued uncertainty regarding optimal management strategies and stresses the need for pediatric-specific ANZ guidelines to standardize EoE care.

Eosinophilic Esophagitis in Children: Clinical Findings and Diagnostic Approach.

Eosinophilic esophagitis (EoE) is an emerging chronic immune and antigen-mediated clinicopathologic disease. During the last 2 decades, the incidence of this condition in children has increased significantly, thanks to practitioners for creating the awareness and higher use of diagnostic endoscopy. We have analysed paediatric literature on EoE focusing on the epidemiology, pathophysiology, clinical findings and diagnostic approach.EoE is pathogenically related to a Th2 inflammation characterized by a mixed IgE and non-IgE-mediated reaction to food and/or environmental agents. This leads to esophageal dysfunction and remodeling accompanied by subepithelial fibrosis. EoE can be presented with several range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infants and toddlers, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnostic suspicion is based on the presence of chronic symptoms of esophgeal dysfunction and esophageal eosinophilia characterised histologically by a significant eosinophilic infiltration of the oesophageal mucosa (>15 eosinophils per high powered field). In this review, we will provide an update on clinical presentation and diagnostic approach to EoE in children. We emphasized on the relevant aspects of the new clinical condition termed “PPI responsive esophageal eosinophilia”, as entities distinct from EoE and the role of PPI trial in the diagnostic workup, therefore we proposed a new diagnostic algorithm.

2738 A Rare Cause of Dyspepsia: Gastric Sarcoidosis

INTRODUCTION: Dyspepsia is one of the most commonly addressed gastrointestinal problems in the outpatient settings, globally thought to affect 7-45% of the population. The majority of cases with dyspepsia are functional, as defined by the Rome Criteria, and have no organic cause. A rare cause of organic dyspepsia is gastric sarcoidosis, with only 40-60 cases described in literature so far. We present a case of new onset dyspepsia secondary to sarcoidosis. CASE DESCRIPTION/METHODS: Our patient was a 48 year-old African American female with a history of pulmonary sarcoidosis, which had been treated with systemic steroids and methotrexate and had been stable off medications. During a routine healthcare visit, she reported new onset of nausea and heartburn for one month, failed trial of PPI and then was referred for an EGD. Endoscopy showed grade A gastro-esophageal junction esophagitis and erosive gastritis. Biopsies of gastric antrum and body showed severe active chronic gastritis with non-necrotizing granulomatous inflammation, with negative staining for fungi, mycobacteria and H pylori, diagnosed as gastric sarcoidosis. DISCUSSION: Dyspepsia is a constellation of upper GI symptoms, including the presence of upper abdominal pain or discomfort with or without other symptoms such as nausea, belching and vomiting. Less than 30% of cases of dyspepsia are found to have an organic cause, the most common of which are chronic peptic ulcer disease, gastroesophageal reflux (with or without esophagitis) and malignancy. Among the rarer causes is sarcoidosis. Sarcoidosis is a multi-systemic disease characterized by the histological presence of non-caseating granulomas, which commonly has pulmonary manifestations. Gastrointestinal involvement is extremely uncommon in sarcoidosis and usually asymptomatic, with only 0.1-0.9% of all cases of GI sarcoidosis displaying symptoms. The mainstay of diagnosis is endoscopy with biopsy showing the characteristic non-caseating lesions, after ruling out infections and other etiology. Management consists of immunosuppressive therapy, including corticosteroids. Although rare, it remains the second most common cause of granulomatous gastritis in developed countries and should be kept in mind investigating GI symptoms especially in patients with preexisting disease. Our case also highlights the importance of appropriate upper endoscopy evaluation in cases of new-onset dyspepsia.

Eosinophilic Esophagitis (EoE) - Successful Treatment With PPI Therapy in a Single-Center - Education and Engagement Are Key

Introduction: Recently, the international EoE consensus eliminated the cumbersome terminology of PPI-responsive esophageal eosinophilia. This supports our practice over the last 7 years of using PPI’s as first line therapy for EoE patients because of convenience, cost, and ease of administration. Here we present our single-center experience in treating EoE. Keys to success involve intense education on appropriate drug dosing, the mechanism of PPIs being anti-eosinophilic, and the key role of strict adherence to a proper PPI trial. Methods: From 2011 to 2017, patients at our institution with confirmed EoE were enrolled sequentially into a database. EoE diagnosis required the combination of clinical symptoms, endoscopic features, and histologic confirmation. In a retrospective manner, data was analyzed as outlined in Figure 1.379 Figure 1 No Caption available.Results: 77 patients (mean age 37, range 17-71, 69% male) with confirmed EoE were treated at our center. A PPI trial was completed on 71/77 (92%) patients with 50/71 (70%) patients having response. Complete response was seen in 44/50 (88%) and partial response in 6/50 (12%). Of those with a complete response, 27/32 (84%) were able to be reduced to once daily PPI maintenance therapy, but 5/32 (16%) relapsed. Of 33 patients with fibrostenotic EoE, an average of 2.3 dilatations were needed to reach a final average esophageal diameter of 17mm. Symptom relief was achieved in 85%; no perforations occurred. Ten patients (13%) were treated with topical steroids. Overall, 7/10 (70%) were steroid responsive. Selective diet elimination based on food allergy testing was successful in 7/8 (88%). Six-food elimination diet as primary therapy in one patient received a complete response. Conclusion: Our 70% response to PPI therapy in our EoE population over 7 years is on the high end of the reported range of 33-80%. The reason for our success in this unselected population may be due to intense education and engagement fostered in our patients. Our patients understand the drug mechanism of action/dosing, are very compliant with the PPI trial, and often rewarded by not needing topical steroids or diet restriction. In addition, the 85% with complete response were decreased to once daily PPIs, thereby lessening concern over potential side effects of long term high dose PPIs. Conclusion In our practice, PPIs have a 70% response rate in unselected EoE patients. Our excellent success may be related to intense education and engagement with our patients.

A Case of Low Grade Astrocytoma Induced Progressive Episodic Intractable Nausea and Vomiting

Chronic nausea and emesis, which may serve a protective function, pose a diagnostic challenge with a broad differential and contribute to numerous health care visits each year. We present a case of chronic intermittent nausea/emesis due to a brain mass without classic neurologic findings. A 36 year-old male presented with 3 months of intermittent episodes consisting of: relentless nausea, up to 10 bouts of forceful emesis a day, and PO intolerance. Episodes would last 2-3 days and occur once every 6 to 8 weeks with asymptomatic intervals between episodes. He denied preceding events, food triggers, and other related symptoms. He was taking lisinopril and aspirin and denied over the counter supplements. He remained afebrile and hemodynamically stable. Physical exam noted active emesis and non-peritoneal left quadrant pain. CBC, CMP, TSH, lipase were within normal limits. Urine drug screen and EtOH level were negative. CT abdomen/pelvis and right upper quadrant ultrasound were unremarkable. EGD revealed a small hiatal hernia with LA grade B esophagitis, chronic active gastritis, no food retention, and no evidence of obstruction. A trial of high dose PPI was unsuccessful. Subsequent imaging of the brain revealed a 1.6cm right posterior high frontal cortical mass without mass effect that was suspected to be benign; therefore, plan was for conservative management. However, in the following months, the patient had progression of symptoms with episodes increasing to once every 4 weeks and lasting 1-2 weeks. An elective sub-total resection of the mass was performed. Pathology demonstrated a diffuse grade II astrocytoma. The patient reported complete symptom resolutions at his 3-month follow up exam. The most common symptoms associated with brain masses are headache and neurologic deficits. However, nausea/vomiting are the initial presenting symptoms in up to 13% of cases. Nausea/emesis are typically the result of increased intracranial pressure, mass effect, involvement of the posterior fossa leading to gastroparesis, or involvement of the area postrema at the chemoreceptor trigger zone. However, lesions involving the higher cortical centers (such as the frontal lobe) can also lead to nausea and emesis. We highlight a rare case of a frontal astrocytoma initially presenting with unexplained nausea/emesis with resolution of symptoms following resection. It is important to consider the extra-intestinal etiologies for common gastrointestinal symptoms.3085_A Figure 1. MRI Brain Horizontal3085_B Figure 2. MRI Brain Sagittal

Implementation of guidelines in eosinophilic esophagitis at an academic pediatric practice.

Guidelines for eosinophilic esophagitis (EoE) require high-dose PPI (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. This study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. Retrospective review of new patients treated with HD-PPI after an index EGD showing>15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of>15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. Adherence to guidelines improves with time. Patients are vested in care.

A Tough Pill to Swallow: A Case of Rituximab-associated Esophageal Ulcers

Idiopathic giant esophageal ulcers were initially reported in patients with acquired immunodeficiency syndrome (AIDS), and later in other immunocompromised patients such as transplant recipients. However, there are no reported cases of esophageal ulcers associated with rituximab in lymphoma patients to our knowledge. A 44-year old male with history of Stage IV B-cell Lymphoma diagnosed 2 years ago, initially treated with Rituximab-Bendamustine, currently on rituximab maintenance therapy presented to the clinic for 2-week history of odynophagia and dysphagia. Physical exam was unremarkable. Labs showed WBC count of 2900 cells/uL with mild neutropenia of 1500 cells/uL and lymphopenia of 400 cells/uL (normal 0.7-4 k cells/uL). Esophagogastroduodenoscopy (EGD) showed multiple large ulcers in the mid-esophagus measuring 5-6 cm. Biopsies demonstrated reactive squamous epithelial changes and granulation tissue with no evidence of viral infection or malignancy. Testing for CMV, HSV, AFB, bacterial and fungal cultures, were negative. The patient was initially given a trial of PPI and empiric antiviral therapy with Valganciclovir for a week with no subjective improvement in symptoms. Repeat EGD showed mid-esophageal ulcers, unchanged from prior exam with negative biopsies. Repeat labs showed normal white count with Lymphopenia of 400 cells/uL. At this juncture, the patient was thought to have esophageal ulcers secondary to immunosuppression and rituximab was stopped. He was started on prednisone 20mg twice a day. He reported symptomatic relief within a week. EGD after 4 weeks showed healing ulcers. The patient is currently being tapered off the steroids. Idiopathic giant esophageal ulcers are rare and occur in the distal half of esophagus. Pathogenesis of these ulcers is unclear. Literature review shows few cases of idiopathic ulcers in AIDS and transplant patients that respond to steroid therapy with endoscopically documented healing. Alterations in the immune system leading to leukopenia may be the underlying mechanism for these ulcers. Even though our patient did not have a significant leukopenia, he did have lymphopenia. Rituximab may have induced an imbalance between various lymphocyte subpopulations and played a role in the pathogenesis of these ulcers. Steroid therapy and discontinuation of rituximab may have restored the immune balance. In conclusion, rituximab was the likely cause of multiple esophageal ulcers in our patient, and they responded to steroids.

Causes and Outcomes of Esophageal Perforation in Eosinophilic Esophagitis.

To characterize patients who suffer perforation in the context of eosinophilic esophagitis (EoE) and to identify predictors of perforation. Esophageal perforation is a serious complication of EoE. We conducted a retrospective cohort study of the University of North Carolina EoE clinicopathologic database from 2001 to 2014. Subjects were included if they had an incident diagnosis of EoE and met consensus guidelines, including nonresponse to a PPI trial. Patients with EoE who had suffered perforation at any point during their course were identified, and compared with EoE cases without perforation. Multiple logistic regression was performed to determine predictors of perforation. Out of 511 subjects with EoE, 10 (2.0%) had experienced an esophageal perforation. Although those who perforated tended to have a longer duration of symptoms before diagnosis (11.4 vs. 7.0 y, P=0.13), a history of food impaction (odds ratio, 14.9; 95% confidence interval, 1.7-129.2) and the presence of a focal stricture (odds ratio, 4.6; 95% confidence interval, 1.1-19.7) were the only factors independently associated with perforation. Most perforations (80%) occurred after a prolonged food bolus impaction, and only half of individuals (5/10) carried a diagnosis of EoE at the time of perforation; none occurred after dilation. Six patients (60%) were treated with nonoperative management, and 4 (40%) required surgical repair. Esophageal perforation is a rare but serious complication of eosinophilic esophagitis, occurring in ∼2% of cases. Most episodes are due to food bolus impaction or strictures, suggesting that patients with fibrostenotic disease due to longer duration of symptoms are at increased risk.

Management of refractory eosinophilic oesophagitis.

The goal of this Review is to discuss the clinical approach to patients who do not respond to treatment for eosinophilic oesophagitis (EoE). Refractory EoE is challenging to manage as there are limited data to guide decision-making. In this Review, refractory EoE is defined as persistent eosinophilia in the setting of incomplete resolution of the primary presenting symptoms and incomplete resolution of endoscopic findings following a PPI trial, and after treatment with either topical steroids or dietary elimination. However, this definition is controversial. This Review will examine these controversies, explore how frequently non-response is observed, and highlight potential explanations and predictors of non-response. Non-response is common and affects a large proportion of patients with EoE. It is important to systematically assess multiple possible causes of non-response, as well as consider treatment complications and an incorrect diagnosis of EoE. If non-response is confirmed, second-line treatments are required. Although the overall response rate for second-line therapy is disappointing, with only half of patients eventually responding, there are several promising agents that are currently under investigation, and the future is bright for new treatment modalities for refractory EoE.

The GerdQ questionnaire and high resolution manometry support the hypothesis that proton pump inhibitor-responsive oesophageal eosinophilia is a GERD-related phenomenon.

Little is known about the relationship between proton pump inhibitor-responsive oesophageal eosinophilia (PPI-REE), eosinophilic esophagitis (EoE) and gastro-oesophageal reflux disease (GERD). To compare high resolution manometry features and symptom profiles of patients with EoE, PPI-REE and GERD. Consecutive patients diagnosed with EoE or PPI-REE according to international criteria (presence of at least one typical symptom of oesophageal dysfunction; at least 15 eosinophils per high-power field at mid/proximal oesophagus, persistence or resolution of eosinophils after an 8-week PPI trial), and a group of patients with proven GERD and oesophageal eosinophilia, prospectively completed the GerdQ questionnaire and underwent high resolution manometry. Thirty-five patients with EoE, 17 with PPI-REE and 27 with GERD were enrolled. When compared to GERD, both EoE and PPI-REE had higher rates of dysphagia (15% vs. 94% vs. 88%, P<0.0001), patients with EoE reported heartburn and regurgitation less frequently (26% vs. 85%, and 17% vs. 74%, respectively; P < 0.001 for each and had lower GerdQ score [1 (0-6) vs. 8 (6-12), P<0.001] than GERD patients. There was no significant difference comparing PPI-REE and GERD patients. Patients with PPI-REE had a higher prevalence of erosive oesophagitis than patients with EoE (35% vs. 9%, P=0.04), which was similar to that of GERD (48%, P=0.54). Patients with EoE had a lower frequency of high resolution manometry features associated with GERD than patients with PPI-REE. There was no significant difference between PPI-REE and GERD patients. GERD, as assessed by GerdQ and high resolution manometry is common in patients with PPI-REE, which may share similar pathogenic mechanisms.

Mo1197 Does Endoscopic Appearance Correlate With Esophageal Eosinphilia After PPI Trial in EoE?

Mo1197 Does Endoscopic Appearance Correlate With Esophageal Eosinphilia After PPI Trial in EoE?

Mo1192 Lack of PPI Trial Prior to Commencing Therapy for Eosinophilic Esophagitis Is Common

Mo1192 Lack of PPI Trial Prior to Commencing Therapy for Eosinophilic Esophagitis Is Common

Safety and Efficacy of Esophageal Dilation in a Large Cohort of Patients With Eosinophilic Esophagitis

Introduction: Little is known about the long-term safety and efficacy of esophageal dilation for eosinophilic esophagitis (EoE). We sought to report outcomes of esophageal dilation for EoE at a large academic referral center. To determine predictors of esophageal dilation in a large cohort, and to assess the safety and efficacy of dilation in this cohort. Methods: We conducted a retrospective cohort study of the UNC EoE clinicopathologic database from 2001-2014. Subjects were included if they had an incident diagnosis of EoE and met consensus guideline criteria for EoE, including non-response to a PPI trial. Patients who had undergone dilation at our center were identified. Chi-square test was performed for categorical variables, and Student's T-test was used for continuous variables. Multiple variable logistic regression was used to assess predictors of dilation. Results: In this cohort of 509 EoE cases, we identified a total of 486 dilations performed in 164 individuals (32%; mean 2.97 ± 3.7 dilations/per person). Those requiring dilation were more likely to have symptoms of food impaction (49% vs 27%; p < 0.001) or dysphagia (96% vs 55%; p < 0.001), and have a significantly longer duration of symptoms (11.1 vs 5.4 yrs; p < 0.001) (Table). However, eosinophil counts did not differ between those who required dilation and those who did not. Adjusting for clinical and demographic variables, the presence of dysphagia was the strongest clinical predictor of needing dilation (OR 8.4, 95% CI: 3.4, 20.7). Those who underwent dilation required a mean of 3 procedures (SD 3.7), and esophageal diameter improved by a mean of 4.2mm. Dilation was associated with few complications. There were no deaths or perforations as a result of dilation. There was one hospitalization and one episode of bleeding post-dilation; three individuals were seen in the ER following dilation and did not require admission. Conclusion: Esophageal dilation is a safe and effective treatment in patients with EoE. Individuals requiring dilation often require multiple dilations. The presence of dysphagia is the strongest predictor for ultimately requiring dilation. Those who receive dilation have had a significant increase in their esophageal diameter.Table 1: Characteristics of patients with eosinophilic esophagitis, comparing those requiring dilation to those not requiring dilation