bluuebunny/crossref_metadata_2025 huggingface dataset:
351 Intrinsic Sex-Specific Differences in Inflammatory and Fibrotic Gene Expression and Remodeling Contribute to Male Disease Predisposition in Eosinophilic Esophagitis
Authors: Nhu Quan M. , Duong Loan D. , Rawson Renee M. , Newbury Robert O. , Kurten Richard C. , Dohil Ranjan , Aceves Seema S.
Published: October 2019

INTRODUCTION:

Eosinophilic esophagitis (EoE) is a chronic allergic disease characterized by esophageal inflammation and fibrosis with a higher disease prevalence in males than females (3:1). The underlying mechanisms behind this sexual dimorphism remain unclear.

METHODS:

Primary human fibroblasts from males and females with active EoE were isolated from esophageal biopsies. Normal fibroblasts were isolated from donor esophageal explants. Fibroblasts were treated with recombinant IL-4, IL-13, or TGFβ1 and analyzed for inflammatory and fibrotic gene expression by qPCR. Esophageal biopsy specimens from active disease patients were scored using a standardized histology score.

RESULTS:

IL-4 or IL-13 induced significantly more eotaxin-3/ccl26 mRNA expression in esophageal fibroblasts from males as compared with females (P < 0.001). This trend was observed in fibroblasts derived from adults or children, consistent with increased EoE onset in males of all ages. TGFβ1 induced significantly higher levels of collagen-1, α-smooth muscle actin, fibronectin, and serpinE1 (P < 0.03) mRNA in male (n = 5) EoE esophageal fibroblasts as compared with females (n = 3). Hematoxylin and eosin staining of EoE esophageal biopsies (n = 153, 125 males and 28 females) revealed that while overall eosinophil count correlated with epithelial remodeling score (r = 0.3550, P < 0.0001) within the distal esophagus, this correlation was distinctly stronger in the male patients (r = 0.4062, P < 0.0001) than within the female patients (r = 0.1546, P = 0.4323). The same pattern was found in the middle (male r = 0.6080, P < 0.0001; female r = 0.4723, P = 0.013) and proximal esophageal levels (male r = 0.8504, P < 0.0001; female r = 0.5235, P = 0.006). Immunohistochemical staining of EoE esophageal biopsies showed significantly more TGFβ1-positive cells in female than male patients (P < 0.001) but no differences in Smad2/3 phosphorylation.

CONCLUSION:

Male esophageal fibroblasts have a more robust response to Th2 interleukins and TGFβ1 as compared with female fibroblasts in adults and children and during the normal and active disease states, suggesting an intrinsic sexual dimorphism in esophageal cells. Epithelial histologic disease severity in males also correlates more strongly with elevated eosinophil counts than in females, suggesting that the male esophagus may have more profound responses to cytokines or antigens as compared to females. These data support a potential mechanism for the sex biased disease expression of EoE.
357 Trends and Per-Patient Expenditures Associated With Proton Pump Inhibitor Use Among the Elderly in the United States: A 10-Year Analysis of the Medical Expenditure Panel Survey
Authors: Alayo Quazim A. , Akanbi Olalekan , Nnanna Onyema , Adejumo Adeyinka C. , Okafor Philip N.
Published: October 2019

INTRODUCTION:

Multiple observational studies have reported associations between long-term PPI use and adverse events particularly in the elderly leading to increased morbidity and healthcare utilization. We examined the trend, per-patient expenditures and healthcare resource utilization associated with PPI use in non-institutionalized elderly in the United States (US).

METHODS:

We conducted a cross-sectional study using data from the Medical Expenditure Panel Survey (MEPS) from 2006 to 2015. A Cochrane Armitage trend analysis was performed on elderly (>65 years old) participants in the US self-reporting PPI use during this period. Trend in PPI use were compared by race, socioeconomic, and educational status of participants. Weighted logistic regression was used to explore the association between PPI use, healthcare utilization and expenditures, adjusted for relevant sociodemographic factors and comorbidities.

RESULTS:

We identified 32 790 elderly participants with data on PPI use representing ≅38.8 million US elderly population. Trend in PPI use increased from 20.6% (95% CI, 19.2%-22.1%) in the 2006-07 cohort to 22.7% (95% CI, 20.7%-24.4%) in the 2014-15 cohort (P = 0.07, Figure 1). Women reported higher rates of PPI use compared to men (22.5% vs 19.8%, P < 0.001). Interestingly, PPI use significantly increased in Hispanics in the study period (Figure 1). Hispanic participants had the highest rates of PPI use (22.9%), followed by non-Hispanic Whites (21.7%), African-Americans (19.7%) and lowest in Asians (16.7%) (P < 0.001). PPI use was most prevalent in elderly residing in the Southern US (P = 0.006), and significantly higher in very low-income earners (P < 0.001), and those with less than high school education (P < 0001) [Table 1]. Over the 10-year period, we found an increasing trend in PPI use among these subpopulations (Figure 1). Participants reporting PPI use were more likely to have ER visits (AOR: 1.76; 95% CI, 1.55-2.01) and hospitalizations (AOR: 1.86; 95% CI, 1.49-1.77) compared to non-PPI users even after adjusting for potential confounders (Table 2). Expectedly, this increased resource utilization among PPI users resulted in higher health-related costs with an excess of $3,483 (95% CI, $2815-$4151) in mean total annual healthcare expenditures compared to non-PPI user.

CONCLUSION:

Despite reports of adverse events associated with PPI use especially in the elderly, trend in PPI use is increasing particularly among elderly Hispanic patients, low-income earners, and those with less than a high school education.
358 Clinical Features of Reflux Esophagitis in a Predominantly Hispanic Population at a Large Safety-Net Hospital
Authors: Haghighat Shida , Horwich Brian H. , Liu Yao , Idos Gregory , Shaker Anisa
Published: October 2019

INTRODUCTION:

There are many variables whose role remains undefined in predicting esophagitis severity. This is particularly true for female and non-white populations for whom existing data is limited. Our aim was to determine clinical and endoscopic characteristics of reflux esophagitis in the predominantly Hispanic population of a large, safety-net hospital.

METHODS:

We performed a retrospective electronic medical record review of patients identified with mild (Los Angeles Grade A/B) and severe (Los Angeles Grade C/D) esophagitis between January 2017 to December 2018. Demographic, clinical, and endoscopic data were recorded. Continuous and categorical data was analyzed using a two tailed T-test and/or chi-square test or Fisher’s Exact test.

RESULTS:

Reflux esophagitis was identified in 382 patients; 56.5% (n = 216) males, 79.8% (n = 305) Hispanic, 8.4% (n = 32) Caucasian, 5.8% (n = 22) African American, and 6.0% (n = 23) other. Among the cohort, 59% (n = 225) had mild esophagitis and 41% (n = 157) had severe esophagitis with median ages 56 and 58 years, respectively (P = 0.05). Patients with mild esophagitis had a higher body mass index (BMI) as compared to those with severe esophagitis [median 28.4 (25.5, 33.7) vs. 26.3 (21.9, 29.6); P < 0.01], were more frequently female (P = 0.03), diagnosed in the outpatient setting vs. inpatient (P < 0.01), and had higher rates of cirrhosis (P = 0.03). Gastroparesis (P = 0.02) and immunosuppression (P = 0.01) were more common in severe vs. mild esophagitis. Hiatal hernia (P < 0.01) and esophageal strictures (P = 0.01) were more frequent in severe esophagitis. Gastrointestinal bleed (P < 0.01), dysphagia (P < 0.01) and nausea/vomiting (P = 0.02) were more frequently the indication for endoscopy in severe vs. mild esophagitis. Esophagitis severity was not associated with tobacco or alcohol use.

CONCLUSION:

In this predominantly Hispanic cohort, patients with severe esophagitis were more frequently male, hospitalized, and had lower BMI compared to those with mild esophagitis. Ongoing multivariate analysis is underway to determine whether these variables are independent risk factors for severity of esophagitis in this unique population after adjustment for age, BMI, and hospitalization status.
360 Gender and Racial Disparities in Incidence Rates of Esophageal Adenocarcinoma
Authors: Bhagat Vicky , Kahaleh Michel
Published: October 2019

INTRODUCTION:

Adenocarcinoma is more common in the US than squamous cell cancer of the esophagus. The purpose of this study is to investigate the impact of gender, and race/ethnicity on the incidence of esophageal adenocarcinoma cancer from 2000-2016 using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS:

Patients diagnosed with esophageal adenocarcinoma from 2000-2016 were identified from the SEER Registry. We retrospectively evaluated gender-specific, and race/ethnicity variations in age-adjusted annual percent changes in incidence rates during 2000-2016 for people above the age above 20. A secondary analysis was also done in regards to stage distribution for disease from 2007-2016.

RESULTS:

Based on the SEER 21 areas data sets, the annual percent change of incidence for esophageal adenocarcinoma was 2.3% from 2000-2007 and -0.8% from 2007-2016 for both males and females. The annual percent change for females was 2.0% from 2000-2008, -5.7% from 2008-2011, and 3.5% from 2011-2016. For males, the annual percent change was 2.3 from 2000-2007 and -1.1 from 2007-2016. There was an increase in the annual percent change incidence for females from 2011-2016. Annual percentage of incidence rates by race/ethnicity can be seen in Table 1. Percent of incidence of cases of esophageal adenocarcinoma from 2007-2016 by stage distribution was evaluated by gender. Males had the highest percent of incidence cases for distant spread at 39.4, and regional spread at 32.5. Females had the highest percent of incidence cases for localized spread at 23.8. Percent of incidence of cases of esophageal adenocarcinoma from 2007-2016 by stage distribution for race/ethnicity can be seen in Table 2. For distant spread, the highest percent of cases was seen with American Indian/Alaska Natives at 46.5.

CONCLUSION:

Esophageal adenocarcinoma can be prevented. Our study shows that there has been an increase in the annual percent change of incidence for females in the last decade. In addition, males had the highest incidence cases for distant spread and regional spread. This study shows that American Indian/Alaskan Native and Non-Hispanic White and White (including Hispanics) had the highest percentage of cases for distant and regional spread, respectively. This may support interventions to inform certain gender and race/ethnic populations about the importance of screening for esophageal adenocarcinoma.
364 Shorter Esophageal Length Is Associated With Increased Proximal Reflux and Symptom Severity in Patients Presenting With Laryngopharyngeal Reflux (LPR) Symptoms
Authors: Sikavi Daniel R. , Cai Jennifer X. , Carroll Thomas L. , Chan Walter W.
Published: October 2019

INTRODUCTION:

Laryngopharyngeal reflux (LPR) is a heterogeneous condition with various underlying pathologies. The effect of esophageal anatomy on LPR is unclear. Shorter distance between lower esophageal sphincter (LES) and upper esophageal sphincter (UES) may allow refluxate to more easily reach the pharynx. We aimed to examine the effect of esophageal length on reflux parameters and symptoms.

METHODS:

115 consecutive patients (64% female, mean age 53.9 yrs) with suspected LPR referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMII-pH) at a tertiary center in 3/2018-5/2019 were enrolled. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index (RSI) and 12-item short-form health survey (SF-12) for health-related quality of life (HRQOL). Esophageal length was measured from the distal margin of UES to the proximal margin of LES on HRM. Univariate analyses were performed with Pearson correlation or Student’s t-test. Generalized linear regression was used for multivariate analysis.

RESULTS:

Mean esophageal length on HRM was 20.4 cm (SD = 2.2). Esophageal length was significantly shorter among patients with a hiatal hernia ≥2 cm (19.2 cm vs 20.6 cm, P = 0.01), but did not correlate with any primary motility disorder per Chicago classification v3.0. Shorter esophageal length was significantly associated with higher acid exposure time and proximal reflux events on impedance, with a trend toward more total reflux events (Table 1). Esophageal length was also shorter among patients with pharyngeal reflux events on HEMII-pH compared to those without (20.0 cm vs 20.9 cm, P = 0.04). Even after controlling for hiatal hernia size, esophageal length remained independently predictive of reflux severity and pharyngeal reflux events. There was a correlation between shorter esophageal length and more severe symptoms on the heartburn/chest pain/indigestion subscore of RSI, but not total RSI or throat symptom subscores (Table 2). Shorter esophageal length was associated with lower physical health scores on SF-12 for HRQOL (Figure 1).

CONCLUSION:

Shorter esophageal length is independently associated with increased reflux severity, proximal reflux, and pharyngeal reflux, even after controlling for hiatal hernia size. It also correlates with more severe typical reflux symptoms and physical HRQOL. Decreased esophageal length may play a role in the pathophysiology of reflux in patients with LPR symptoms.
365 The Prevalence and Clinical Significance of Esophageal Motility Disorders in Patients Presenting With Laryngopharyngeal Reflux (LPR) Symptoms
Authors: Sikavi Daniel R. , Cai Jennifer X. , Carroll Thomas L. , Chan Walter W.
Published: October 2019

INTRODUCTION:

Esophageal motor dysfunction may underlie impaired bolus and refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of co-existing esophageal dysmotility and correlation with reflux parameters and symptoms in LPR is unknown.

METHODS:

We conducted a retrospective study of consecutive patients with suspected LPR referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing (HEMII-pH) at a tertiary center in 3/2018-5/2019. Validated symptom surveys were prospectively collected at the time of testing, including Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Questionnaire (GERD-Q), and 12-item short-form health survey (SF-12). HRM findings were categorized using the Chicago Classification v3.0. Statistical analyses were performed using ANOVA or Fisher’s exact test.

RESULTS:

113 patients (64% female, mean age 54.9 years) were included, with 52 (46%) having abnormal findings on HRM. The most common diagnosis was ineffective esophageal motility (IEM) [n = 37 (32.7%)]. 19 (16.8%) patients were found to have either a disorder of esophagogastric junction (EGJ) outflow or a major disorder of peristalsis, of which EGJ outflow obstruction (EGJOO) was the most prevalent diagnosis [n = 11 (9.7%)] (Table 1). With the exception of increased distal acid exposure time (AET) among patients with hypercontractile motility disorders (9% vs 2% in patients with normal HRM, P = 0.03), there were no differences in pharyngeal bolus reflux events, total bolus reflux events on impedance, and AET across HRM findings. Reporting throat symptoms as a primary complaint on presentation was associated with greater odds of having abnormal HRM compared to esophageal symptoms alone (OR 5.5, P = 0.005) (Figure 1). However, the presence and specific type of motility disorder were not associated with symptom severity as measured on RSI, GERD-Q, or health-related quality of life on the SF-12.

CONCLUSION:

Esophageal motility disorders are prevalent among patients with suspected LPR symptoms, including up to one of six with either a disorder of EGJ outflow or major disorder of peristalsis. Patients with these conditions are more likely to report throat symptoms as a primary complaint. However, there was no correlation between HRM findings and symptom severity. The role of esophageal motor dysfunction in patients with LPR symptoms remains to be further defined.
366 Safety and Efficacy of Cryoablation Balloon for the Treatment of Barrett’s Associated Neoplasia: A Meta-Analysis
Authors: Westerveld Donevan , Nguyen Khaai , Banerjee Debdeep , Jacobs Chelsea , Kadle Nikhil , Draganov Peter V. , Yang Dennis
Published: October 2019

INTRODUCTION:

The Cryoballoon Focal Ablation System (CbFAS) (CryoBalloon; Pentax Medical, Redwood City, California, USA), a novel device that permits the conversion of liquid nitrous oxide into its gaseous form within a contact balloon system, was recently introduced for the endoscopic ablation of Barrett’s esophagus (BE) associated neoplasia. We performed a meta-analysis to assess the feasibility, efficacy, and safety of the CbFAS for the treatment of BE neoplasia.

METHODS:

Several databases were searched for relevant articles (PubMed, Web of Science, Google Scholar, EMBASE) as well as abstracts of recent gastroenterology meetings. Studies included at least 5 patients with BE treated with cryotherapy via cryoballoon device and data extraction, which was performed by two investigators using standardized forms, included age, gender, length of BE segment, treatments prior to CbFAS, procedural time and number ablation sessions, technical feasibility, adverse events, and eradication rates of intestinal metaplasia (CE-IM) and dysplasia (CE-D) at follow-up. Quality of the studies was performed using a modified Newcastle Ottawa Scale. Random effects model was used in the presence of heterogeneity.

RESULTS:

Seven studies (4 full-length publications, 3 abstracts) met inclusion criteria for a total of 548 ablation sessions in 272 patients. In aggregate, the most common histopathology reported prior to cryoballoon ablation was high-grade dysplasia (n = 131), followed by low-grade dysplasia (n = 75), and intramucosal adenocarcinoma (n = 52). The pooled rate for technical feasibility, defined as completion of cryoablation as intended was 95.8% (95% CI: 93.6-97.5%; I2 = 13.2%; P = 0.3) (Figure 1a). The pooled rates of CE-IM and CE-D were 85.8% (95% CI: 77.8-92.2%, I2 = 55.5%; P = 0.04) and 93.8% (95% CI: 85.5-98.7%, I2 = 74.2%; P = 0.001) (Figure 1b,c), respectively. Funnel plots did not show substantial publication bias (Figure 2). The overall adverse event rate was 12.5% (34 out of 272 patients), of which stricture formation was the most common (5.8%), followed by mucosal laceration (0.7%), perforation (0.4%), and bleeding (0.4%). All adverse events were successfully managed endoscopically.

CONCLUSION:

This meta-analysis suggests that CbFAS has a comparable safety profile to radiofrequency ablation with a 12.5% adverse event rate. Furthermore, this study demonstrated that CbFAS is associated with high rates of CE-IM (88%) and CE-D (94%). Future prospective comparative trials are needed to corroborate these initial findings.
368 Comparison of Budesonide and Fluticasone in the Treatment of Patients With Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis
Authors: Numan Laith , Hamdeh Shadi , Kalot Mohamad , Jajeh Muhammad Omar , Tarakji Ahmad G. , Olyaee Mojtaba
Published: October 2019

INTRODUCTION:

Steroids are the first line treatment of choice in patients with eosinophilic esophagitis (EOE) who failed proton pump inhibitors (PPIs). Fluticasone and budesonide are the two main steroid medications used in EOE treatment, but current guidelines do not recommend one agent over the other. In our study, we aim to conduct a meta-analysis to compare both agents and determine whether if one agent is associated with better outcomes.

METHODS:

A comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus was performed from each database’s inception to June, 1st, 2019. Two independent reviewers systematically identified trials that compared the effect of budesonide versus fluticasone in the management of EOE. A meta-analysis was performed using a fixed effects model. The main outcome was the histologic response (defined as eosinophils count < 15/HPF), and therefore response to treatment.

RESULTS:

Three studies met our inclusion criteria and included in the analysis, with a total of 272 patients. All studies were done in the United States, with one RCT. Our meta-analysis showed no statistically significant difference with the use of budesonide compared to fluticasone in achieving histologic response (total of eosionphils count < 15/hpf) (OR: 1.29, 95% CI: 0.77-2.14, P = 0.34, heterogeneity I2: 0%).

CONCLUSION:

Our systematic review and meta-analysis indicated no difference in budesonide and fluticasone in achieving histologic response in patients with eosinophilic esophagitis.
369 Impact of Selective Criteria for Esophageal Acid Exposure in Patient on PPI Therapy
Authors: Javed Abid T. , Khalaf Mohamed , Elias Puja S. , Castell Donald
Published: October 2019

INTRODUCTION:

The Lyon consensus defined diagnostic guidelines and criteria for GERD and NERD. pH impedance testing is a mainstay of diagnostic confirmation of GERD, but use of PPI prior to pH impedance testing can confound results if esophageal acid exposure (EAE) interpretation is not adjusted for this variable. We sought to demonstrate the necessity of selective EAE criteria in those on PPIs to improve diagnostic accuracy of pH impedance testing.

METHODS:

117 consecutive adult patients referred for medication (H2RA, PPI) refractory GERD-symptoms were included. Patients completed RSI, GERDQ, and then 24 hour pH impedance. Patients were divided into 2 groups, those on PPI (n = 82) and those off PPI (n = 35). EAE was interpreted first with uniform off therapy criteria; then the PPI group was re-interpreted with selective on therapy cutoffs. On therapy cutoffs for normal acid exposure were < 1.5% upright and < 0.5% recumbent; off therapy cutoffs were < 6.3% upright and < 1.2% recumbent.

RESULTS:

In group 1 (on PPI), when on-therapy criteria were applied, 37% (31/82) of patients had abnormal EAE, while with the uniform criteria 25.6% (21/82) had abnormal EAE. In group 2 (off PPI), 13/35 (37%) had abnormal pH-impedance results. There was a significant difference between the two groups (P = 0.02). Those on PPI did not have significantly improved abnormal upright EAE (23% vs 11%, P = 0.44), recumbent EAE (16% vs 11%, P = 0.53). Those on PPI therapy had a greater number of abnormal GERDQ (56.1% vs 45.7%, P = 0.30) and RSI (74.4% vs 60.0%, P = 0.12).

CONCLUSION:

Application of selective criteria for EAE interpretation improves diagnostic accuracy of pH impedance testing, though those with abnormal EAE are not significantly more likely to have positive GERDQ or RSI results. PPI use does not decrease individual abnormal upright or recumbent esophageal acid exposure when selective criteria for PPI use are applied.
370 Can Subjective GERD Questionnaires Predict Abnormal Findings in pH Impedance Testing?
Authors: Javed Abid T. , Khalaf Mohamed , Batte Kevin , Elias Puja S. , Castell Donald
Published: October 2019

INTRODUCTION:

Subjective and objective tools are used to diagnose GERD, including questionnaires and 24 hour pH impedance. We examined correlations between the GERD questionnaire (GERDQ) and Reflux Symptom Index (RSI) questionnaires against component metrics of 24-hour pH impedance testing (number of reflux events, esophageal acid exposure, and symptom association).

METHODS:

117 consecutive adult patients referred for PPI refractory GERD symptoms were included. All patients completed GERDQ and RSI, which are validated questionnaires for predicting GERD based on typical and atypical reflux symptoms, respectively. Patients then underwent 24 hour pH impedance testing. RSI score, GERDQ grade, pH impedance results (positive, negative), esophageal acid exposure (EAE), number of reflux events, and symptom association were variables of interest analyzed using Chi-square tests.

RESULTS:

A positive GERDQ result (grade C or D) was not significantly associated with abnormal pH impedance (P = 0.08). There was no correlation between positive GERDQ and abnormal EAE (P = 0.79) or number of reflux events (P = 0.26). However, positive symptom association was associated with an abnormal GERDQ (P = 0.01). Similarly, there was no significant correlation between positive RSI and abnormal pH-Imp (P = 0.06), abnormal EAE (P = 0.19), or number of reflux events (P = 0.09). Positive RSI was significantly associated with positive symptom association (P = 0.04). 58% (52/90) of patients with positive GERDQ also had positive RSI (P = 0.001).

CONCLUSION:

Our data suggest that positive subjective GERD assessment tools (GERDQ and RSI) are associated with positive symptom association component of pH impedance testing. However abnormal acid exposure or number of reflux episodes are more difficult to predict. Many patients report typical and atypical GERD symptoms, suggesting an overlap of symptoms. This may be exaggerated by self-report bias, and is not predictive of pH-impedance result.
378 Resting Upper Esophageal Sphincter Pressure Is Elevated in Proton Pump Inhibitor-Refractory Chronic Cough Patients and May Be a Marker for Laryngeal Hypersensitivity
Authors: Bloch John , Samo Salih , Jain Anand
Published: October 2019

INTRODUCTION:

Chronic cough is difficult to treat when unresponsive to proton-pump inhibitor (PPI) and sinus therapy. In this setting it is presumed to be neurogenic in etiology. Despite the role of the upper esophageal sphincter (UES) as a barrier to laryngopharyngeal reflux disease, it has not been well characterized in chronic cough patients. We aim to assess UES tonicity in patients with PPI-refractory chronic cough and otherwise intact esophageal motor function.

METHODS:

Patients with a Chicago Classification diagnosis of normal esophageal motility on high-resolution esophageal manometry (HRM) on studies performed for the indication of chronic cough were retrospectively studied. All studies were performed at a GI motility lab at a tertiary care center from January 2013 to August 2018. Patients with prior cervical spinal surgery, foregut surgery, gastroparesis, severe pulmonary disease or manometric hiatal hernia were excluded. All HRM were performed with a solid-state assembly with a 4.2 mm outer diameter catheter. Upper esophageal resting pressure and residual pressure (mmHg) were recorded from HRM studies and compared to a control group of patients with normal esophageal motility on studies performed for an indication of non-cardiac chest pain. Available pH-metry tests in chronic cough patients were also reviewed for acid exposure time.

RESULTS:

Fourteen patients with chronic cough (mean age 63 ± 25, 71% female) and twenty patients with non-cardiac chest pain (mean age 55 ± 14, 60% female) were included. Median resting UES pressure (mmHg) was higher in the chronic cough group (80) vs the chest pain group (50.8) with a p value of 0.004 (Figure 1). There was no difference in residual UES pressure (3.5 in chronic cough vs 3.15 in chest pain). A total of 12 pH studies were performed in chronic cough patients; 9 of these were on PPI. Median distal acid exposure time % was 1.35 [IQR 0.5-6].

CONCLUSION:

UES hypertonicity found in PPI-refractory chronic cough patients may be a marker of laryngeal hypersensitivity. A second possibility is that primary UES dysfunction is the cause of cough in this subgroup.
381 Measuring Differences in GEJ Compliance Using Functional Luminal Impedence Planimetry (FLIP) in a Large Series of Patients Undergoing POEM
Authors: Abadir Alexander , Moosvi Zain , Cao Vicky , Samarasena Jason , Chang Kenneth J.
Published: October 2019

INTRODUCTION:

Peroral endoscopic myotomy (POEM) is a promising novel treatment modality for achalasia. Treatment success is usually determined by the patient's improvement in symptoms. A diagnostic tool during the POEM to evaluate effectiveness of the myotomy may aid in performing the POEM procedure optimally. One such diagnostic tool is the Endoluminal Functional Lumen Imaging Probe (FLIP), which uses impedance planimetry for real-time, intraoperative measurement of gastroesophageal junction diameter, compliance, distension, and surface area. Here we evaluate the efficacy of POEM using FLIP and compare changes in FLIP with those in Eckhardt scores.

METHODS:

This studied was performed at our tertiary care referral center. A total of 72 patients underwent POEM in this study. FLIP data was collected during the procedure with respect to the following variables: diameter, circumferential area, distention, and compliance. Eckhardt scores were assessed before and after POEM. Mean follow-up time was 2.96 months.

RESULTS:

Mean age was 57 years. 57% of patients were female. Mean diameter pre-POEM was 5.61 (SD = 2.20) mm and post-POEM was 10.57 (SD = 13.36) mm (n = 66). Mean circumferential area pre-POEM was 23.25 (SD = 10.67) mm2 and post-POEM was 61.89 (SD = 30.09) mm2 (n = 64). Mean distention pre-POEM was 1.31 (SD = 0.83) mm2/mmHg and post-POEM was 3.49 (SD = 1.85) mm2/mmHg (n = 63). Mean compliance pre-POEM was 84.99 (SD-83.33) mm3/mmHg and post-POEM was 117.76 (SD = 79.05) mm3/mmHg (n = 59). All P values were less than 0.01. There was a negative correlation between the changes in all FLIP measurements and Eckhardt scores before and after POEM.

CONCLUSION:

This study is one of the largest on patients undergoing POEM examined with FLIP. FLIP measurements may serve as an intraprocedural measurement of POEM efficacy. The fact that a negative correlation between FLIP and Eckhardt scores was achieved indicates that FLIP may be a prognostic indicator for POEM patients, although further follow up data will be needed to establish this.
383 High-Resolution Esophageal Manometry in the Inpatient Setting: Is There a Role?
Authors: Antunes Catiele , Zhou Elinor , Abi Mansour Jad P. , Assis Daniella , Gutierrez Olaya Brewer , Fain Christopher , Stein Ellen , Sloan Joshua
Published: October 2019

INTRODUCTION:

High-resolution esophageal manometry (HReM) is used by gastroenterologists to evaluate a variety of symptoms including dysphagia, heartburn, and non-cardiac chest pain (NCCP). Traditionally, evaluation of those non-urgent conditions is done on outpatient basis; however, depending on practice and availability, HReM may be performed in the inpatient setting. In this study, we aim to characterize the population undergoing inpatient versus outpatient HReM. In addition, we aim to identify whether those inpatient studies resulted in any immediate action during the hospitalization in a specific subgroup.

METHODS:

This was a single-center retrospective study. Patients eighteen-years or older who underwent either inpatient or outpatient HReM between March 1st, 2015 and September 1st, 2018 were included. Demographic and clinical information were obtained from medical records.

RESULTS:

A total of 263 patients were included in this study: 76 patients who underwent inpatient HReM and 177 who underwent outpatient HReM. Demographic characteristics were similar between groups. Patients who underwent inpatient HReM had lower mean BMI (26 (±7.5) vs. 28 (±6), P = 0.022) and were more likely to have diabetes (27.6% vs. 14.7%, P = 0.021), chronic obstructive lung disease (COPD) (10.5% vs. 3.4%, P = 0.034), heart failure (21% vs. 2.8%, P < 0.001) and history of aspiration (25% vs. 6.8%, P < 0.001) (Table 1). Symptoms reported by patients were similar among groups with exception of weight loss (52.5% vs. 22%, p < 0.001, inpatient vs. outpatient respectively). Dysphagia, gastroesophageal reflux disease (GERD) and NCCP were the main indication for HReM. The inpatient group had more dysphagia (67% vs. 54.2%, P = 0.003) and less GERD as an indication (15.8% vs. 40.7%, p < 0.001). From the 76 inpatients, 23 (30.3%) underwent further intervention while inpatient (Table 2). On multivariate analysis, need for alternative diet/nutrition prior to HReM had a strong association with inpatient intervention, with an odds ratio (ORs) of 5.99 (95% confidence interval (CI) 1.53-23.39; P = 0.01).

CONCLUSION:

There appear to be discrete differences between the inpatient and outpatient manometry groups. When performed in the inpatient setting HReM resulted in additional procedures in a small percentage of patients and need for alternative diet/nutrition was a predictor for further procedures. These findings indicate that inpatient manometry may be suitable in a selected group of patients.
385 Functional Lumen Imagin Probe Topography (FLIP) as a Screening Tool for Esophageal Dysmotility: Comparison to High-Resolution Manometry (HRM) in Patient’s Whit Esophageal Symptoms
Authors: Valdovinos-Garcia Luis R. , Horsley-Silva Jennifer L. , Crowell Michael D. , Vela Marcelo F.
Published: October 2019

INTRODUCTION:

High resolution manometry (HRM) is the gold standard to assess esophageal motility. Functional lumen imaging probe topography (FLIP) performed during EGD assesses esophagogastric junction (EGJ) distensibility and esophageal peristalsis.

AIM:

Evaluate FLIP-HRM agreement and value of FLIP as screening for dysmotility.

METHODS:

Patients with esophageal symptoms underwent FLIP and HRM. FLIP performed with 16-cm balloon; peristaltic response assessed at 30-40-50-60 ml and classified as repetitive antegrade contractions-RACs, repetitive retrograde contractions-RRCs, diminished/disordered contractility, or absent contractility; median EGJ distensibility index (DI) measured at 60 ml was deemed abnormal (<2 mm2/mmHg), indeterminate (2-3 mm2/mmHg), normal (> 3 mm2/mmHg). Normal FLIP defined by normal EGJ DI and RACs without RRCs. HRM Chicago classification v3.0 diagnosis was dichotomized as normal/minor disorder (normal, ineffective esophageal motility-IEM, or fragmented peristalsis-FP) or abnormal (achalasia, jackhammer esophagus-JE, distal esophageal spasm-DES, EGJ outflow obstruction-EJGOO, absent contractility). FLIP sensitivity/specificity calculated with HRM as gold standard.

RESULTS:

HRM and FLIP performed a median 18 days apart in 75 patients, 17-92 yo, 65% F. HRM diagnoses: normal/minor disorder 45% (28% normal, 16% IEM, 1% FP), abnormal 55% (17% absent contractility, 16% achalasia, 15 % EGJOO, 4% JE, 3% DES). FLIP diagnoses: 33% normal, 77% abnormal. When FLIP was normal, HRM showed normal/minor disorder in 58% (53% normal, 5% IEM), absent contractility 26%, JE 11%, EGJOO 5% (no achalasia or DES). Normal FLIP had 80% specificity for normal/minor HRM disorder. When FLIP was abnormal, HRM showed achalasia 21%, normal 20%, IEM 19%, EGOO 18%, absent contractility 14%, DES 4%, JE 2%, FP 2%. FLIP had 80% sensitivity for major motility disorder on HRM and was abnormal in 100% patients with achalasia or DES. A normal EGJ DI by itself had a negative predictive value of 90% for normal/minor HRM disorder.

CONCLUSION:

FLIP topography performed during EGD is promising as a screening tool for esophageal dysmotility, with 80% specificity for normal/minor HRM disorder, and 80% sensitivity for major HRM disorder. Normal FLIP during EGD for evaluation of esophageal symptoms may obviate the need for manometry. Likewise, HRM is clearly indicated in patients with abnormal FLIP, with high likelihood of major motility disorder on HRM in these patients.
387 Nationwide Estimate of Emergency Department Visits in the U.S. Related to Caustic Ingestion
Authors: Li Yiting , Xu Lan , Cai Haifeng , Langworthy James , Friedenberg Frank
Published: October 2019

INTRODUCTION:

Caustic ingestion, whether intentional or unintentional, is a potentially devastating event. In particular, highly alkaline material can result in esophageal liquefactive necrosis. Our aim was to provide an estimate of the incidence and outcomes of caustic ingestion among emergency department (ED) visits across the United States.

METHODS:

The Nationwide Emergency Department Sample (NEDS) is part of the family of databases developed for the Healthcare Cost and Utilization Project (HCUP). We analyzed NEDS for the period 2010-2014. Patients > 18 years with a diagnosis of caustic ingestion were identified by ICD-9 code. Both ICD-9 and Current Procedural Terminology codes were used to identify individuals undergoing endoscopy. All analyses were performed by SAS, Version 9.4 (SAS Institute, Cary, NC).

RESULTS:

After data weighting, from 2010 to 2014, there were 46,870 adult ED visits related to caustic ingestion among 533.8 million visits (8.78/100,000; 95% CI 8.70/100,000-8.86/100,000). Overall, 60.6% were age 18-44 years, 29.0% were 45-64, and 10.4% were > 65 years. There were 45.9% males. Disposition: 82.5% visits for caustic ingestion were discharged from the ED, 14.8% were admitted, and 2.5% were transferred to another hospital or facility. For those admitted, median length of stay was 3 days (range: < 24 hours-213 days). The majority of ingestions were intentional while 6.9% of visits were due to accidental ingestion. Co-morbid diagnoses included mood disorder (2.7%) and suicidal ideation or attempt (18.7%). The weighted estimate for requiring ventilator support was 0.2%. Estimated mortality related to caustic ingestion was 0.3%. Endoscopy was uncommon with only 1.1% undergoing this procedure in the ED and 6.1% as an inpatient. Among all ED visits related to caustic ingestion, acute and chronic complications were rarely recorded: esophagitis (2.9%), perforation of esophagus (0.02%), esophageal stricture (0.2%), esophageal hemorrhage (0.04%), and esophageal necrosis (0.3%).

CONCLUSION:

Caustic ingestion is rare among all ED visits, and most are discharged directly from the ED. The implication from NEDS is that very few caustic ingestions seen in US emergency departments involve substances at the extremes of the pH scale and in sufficient volume to cause significant injury. For those admitted for caustic ingestion, there was a significant length of stay however inpatient mortality was relatively low.
396 Endoscopic Submucosal Dissection for Resection of T1b N0 Esophageal Cancer: Retrospective Multicenter Study
Authors: Mejia Perez Lady Katherine , Alaber Omar , Jawaid Salmaan , Chua Tiffany , Kudaravalli Praneeth , Mehta Neal , Vargo John , Jang Sunguk , Dumot John , Gabr Moamen , Aihara Hiroyuki , Fukami Norio , Draganov Peter V. , Chak Amitabh , Bhatt Amit
Published: October 2019

INTRODUCTION:

While esophagectomy is the standard treatment for submucosal (T1b) esophageal adenocarcinoma (EAC) and squamous cell cancer (SCC), many elderly patients -the age group that esophageal cancer tends to affect- are not candidates for surgery. Endoscopic submucosal dissection (ESD) is a minimally invasive procedure that allows for en-bloc resection of early esophageal cancer and allows for precise histopathologic staging of the tumor. ESD could be curative in submucosal cancer without lymph node metastasis, and it allows for precise histopathologic staging. To evaluate the long-term outcomes of ESD in patients with EUS-staged T1b esophageal cancer.

METHODS:

A retrospective multicenter study was performed at three academic hospitals in the U.S. Patients who underwent ESD with a pre-procedural or post-procedural histopathologic diagnosis of T1b N0 M0 EAC or SCC were included in the study. Data was collected on demographics, tumor and procedure characteristics, procedure pathology, and follow-up. Local recurrence was confirmed by endoscopic findings and pathological analysis. Metastasis was confirmed by cross-sectional imaging. The main outcome was a composite of rate of metastasis and local recurrence. Follow-up time was defined as months from initial procedure to recurrence or last follow-up visit if recurrence-free. A time-to-event analysis was performed to evaluate recurrence.

RESULTS:

Fifty-two patients underwent ESD (mean age 69.6 years +/-9; 35 males) (Table 1). Based on available comorbidity data, 42% patients were not fit for surgery, as determined by an age-adjusted Charlson Comorbidity Index > 6. Twenty tumors (62%) were found to be HGD or T1a on post-ESD specimen analysis, while one was staged as T2. Nineteen patients were staged as T1b after ESD. Immediately after ESD, 6 patients were referred for surgery, 3 underwent chemoradiation therapy, and 6 radiation alone (Table 2). Patients were followed for a median of 18 months, and the calculated 24-month recurrence rate was 13% (Figure 1).

CONCLUSION:

This multicenter trial showed that ESD for T1b esophageal cancer can be acceptable for patients who deemed not surgical candidates. However, close follow up is necessary. ESD can also serve as a staging procedure, as our data confirms inaccurate EUS-staging of T1b cancer, with 62% of tumors being down-staged to T1a, as has been previously reported.
397 Durability of Transoral Fundoplication (TIF 2): 154 Patients Followed Up to 9 Years
Authors: Bell Reginald , Freeman Katherine , Heidrick Rachel
Published: October 2019

INTRODUCTION:

Transoral Fundoplication (TIF 2.0) has become an accepted procedure to treat GERD. Long-term data on clinical success has been limited. We report results on 154 patients followed up to 9 years.

METHODS:

IRB approved retrospective study of prospective registry patients undergoing TIF 2.0 (without hernia repair) at single institution between 1/2008 and 7/2015. Perioperative complications, need for reintervention, and clinical response measured by GERD-HRQL and Regurgitation scores used in prior TIF studies, and changes in pH parameters were primary outcome measures.

RESULTS:

154 patients with objectively documented GERD (88 F, mean age 54 (17-81), mean BMI 27 (19.6-38) underwent TIF 2.0 with the EsophyX-2 device. Using a combination of a caudal helical retractor, caudally-directed external advancement of the device to which the esophagus was adherent by suction, and a rotational movement of the tissue mold around one single helix engagement at 12 o’clock position, the fundus of the stomach was partially rotated around the distal esophagus and secured with multiple 6.5 mm H-shaped polypropylene fasteners. 131 (85%) patients were available for clinical follow-up at up to 9 years (0.7-9.7, Med 4.7, IQR 2-6.7); 75 (49%) were followed ≥ 5 years. 29 (19.3%) patients underwent laparoscopic fundoplication at median of 465 days after TIF (93-2643). QOL results were similar in this group (Figure 1). At a median of 4.7 years after TIF, GERD-HRQL and Regurgitation scores decreased by ≥50% in 70% and 78%. Figure 2 shows GERD-HRQL scores by year. Bloating by GERD-HRQL (score >2) decreased from 46% (58/126) preop to 18% (23/127) of patients postop. 89% (137/154) presented with medically refractory GERD. 72% of patients not undergoing reoperation were not using PPIs and 2 (2%) prn PPI at follow-up. 101 patients had pH testing at a mean of 20 months [1-94 R] post-procedure. Worst day DeMeester score decreased from a median of 32.7 [IQR 23.5-50] to 19.7 [IQR 7.4-35], p< 0.001, with 41/101 (41%) normalized. 3 complications required re-intervention: a GI bleed clipped endoscopically, an immediate laparoscopic repair of an esophageal leak, and an abscess at 5 days requiring laparoscopic drainage, repair, and fundoplication.

CONCLUSION:

Primary TIF 2.0 technique is durable with stable improvement in QOL and PPI use at up to 9 years, including 76/150 (51%) of patients followed ≥5 years. 72% non-reoperated TIF patients remained off PPI at up to 9 years of follow-up.
399 Safety and Efficacy of Multiband Mucosectomy in Early Barrett's Neoplasia: A Systematic Review and Meta-Analysis
Authors: Dhindsa Banreet , Mubder Mohamad I. , Dhaliwal Amaninder , Mashiana Harmeet , Choa Jacqueline , Sayles Harlan , Ohning Gordon , Singh Shailender , Bhat Ishfaq , Adler Douglas G.
Published: October 2019

INTRODUCTION:

Endoscopic mucosal resection (EMR) is treatment of choice for early Barrett’s neoplasia. Multiband mucosectomy (MBM) is a type of EMR procedure used for diagnosis and treatment of early Barrett’s neoplasia. This procedure has an advantage over cap-resection as it does not require submucosal lifting. We performed systematic review and meta-analysis to compare the overall safety and efficacy of this procedure for early Barrett’s neoplasia.

METHODS:

We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of MBM for early Barrett’s neoplasia. The primary outcome was to evaluate the technical success of the procedure which was defined as complete endoscopic resection of a delineated focal lesion. The secondary outcome was to study overall, early and delayed adverse events related to the procedure. The meta-analysis was performed using Der Simonian and Laird random effect model.

RESULTS:

15 studies reporting on 1197 patients with 1487 lesions were included. Majority of the patient population were males (80.8%), with mean age of 64 years. The pooled technical success rates were 99.1% (95% CI 96.76-100, I2 = 81.51) and the total early adverse event rates were 5.87% (95% CI 2.61-10.02, I2 = 78.26). The most common early and delayed adverse events were bleeding (5.09%; 95% CI 1.97-9.19, I2 = 79.59) and strictures (10.99%; 95% CI 5.67-17.53, I2 = 86.84) respectively. Total 5 perforations were reported in our patient population. The mean procedure time was 23.3 min reported in six studies. Significant heterogeneity was noted in in our meta-analysis.

CONCLUSION:

Multiband mucosectomy is a safe alternative procedure to endoscopic cap resection for the treatment of early Barrett’s neoplasia with high technical success and lower adverse events. Further large multicenter randomized controlled trials are needed for further validation of our findings.
400 Clinical Overlap Between Lymphocytic Esophagitis and Reflux Esophagitis With Increased Lymphocytic Infiltration
Authors: Irani Malcolm , Jones-Pauley Michelle , Gudsoorkar Vineet , Duhon Daniel , Barroso Alberto
Published: October 2019

INTRODUCTION:

Lymphocytic Esophagitis (LyE) is an increasingly recognized clinicopathologic entity with an emerging definition. A significant histologic and clinical overlap exists between LyE and reflux esophagitis (RE; however, no specific associations have been elucidated. Previous studies have shown that absence or decrease in the number of granulocytes in esophageal biopsies in patients with LyE have correlated with a different phenotypic presentation from reflux esophagitis, with more patients being predominantly older women with dysphagia. The aim of this study was to help differentiate the two entities based on their clinical characteristics.

METHODS:

A retrospective chart review was performed of all patients with a biopsy diagnosis of LyE between 2009-2018 at a large tertiary academic institution. Biopsies were then re-categorized into two groups: LyE with few granulocytes (LyE-FG), and reflux esophagitis with increased IELs (RE-IEL). Data regarding socio-epidemiologic, clinical, and histologic findings were collected.

RESULTS:

A total of 53 biopsies were reviewed (35 RE-IEL, 18 LyE-FG). Most patients were Caucasian- 78% and 75% in RE-IEL and LyE-FG groups, respectively (P = 0.559). Baseline characteristics were similar between the two groups (Table 1). Dysphagia was the most common symptom in both groups with 70.4% in RE-IEL and 75% in LyE-FG groups (P = 0.767) with heartburn being the second most common symptom (63% vs 60%; P = 0.850) respectively. More patients in the LyE-GF group had inflammatory bowel disease (17.6% vs 6.7%); however, this difference was not statistically significant (P = 0.241). A significant number of patients were on proton pump inhibitor (PPI) at the time of diagnosis (75.9% RE-IEL vs 80% LyE-IG; P = 0.756). Patients with RE-IEL were more often smokers (63.3% vs 40%); however, there was no statistical significance (P = 0.138). There was no statistical significance between rates of NSAID or alcohol use between the two groups. Site of biopsy was not statistically significant between the two groups (P = 0.306) with the majority of biopsies taken from the distal esophagus.

CONCLUSION:

Our study shows the clinical overlap between LyE-FG and RE-IEL. RE and LyE share significant histologic overlap; however, LyE is clinically characterized by dysphagia as the most predominant symptom compared to classic RE, where heartburn and regurgitation are more common.