bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.