bluuebunny/crossref_metadata_2025_split huggingface dataset:
390 Opioids Interfere With Deglutitive Inhibition Assessed by Response to Multiple Rapid Swallows During High Resolution Esophageal Manometry
Authors: Snyder Diana L. , Valdovinos-Garcia Luis R. , Horsley-Silva Jennifer L. , Crowell Michael D. , Valdovinos-Diaz Miguel A. , Vela Marcelo F. 
Published: October 2019

INTRODUCTION:
We previously showed an association between chronic opioid use and esophageal motor dysfunction characterized by esophagogastric junction outflow obstruction, distal esophageal spasm, achalasia type III, and Jackhammer esophagus. Assessment of response to multiple rapid swallows (MRS) during high-resolution esophageal manometry (HRM) enables detection of impaired inhibition during MRS. Healthy subjects respond to MRS by deglutitive inhibition during MRS followed by an augmented contraction with higher vigor than single swallows. Hypothesis: during MRS, opioids may interfere with deglutitive inhibition and may enhance post MRS contraction. Aim: compare response to MRS in opioid users, non-users and healthy controls.

METHODS:
Response to MRS was evaluated in 200 patients with esophageal symptoms (100 chronic opioid users on oxycodone, hydrocodone, or tramadol for ≥3 months, 100 not on opioids), and 19 asymptomatic healthy controls that underwent HRM. Patients with prior gastroesophageal surgery, pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, esophageal stricture, achalasia type I or II, and scleroderma were excluded. Demographic and symptom data were extracted from a prospectively maintained motility database. Response to MRS was evaluated for complete versus incomplete inhibition (contractility with DCI >100 mmHg-sec-cm during MRS), and presence of post MRS contraction augmentation (DCI post MRS greater than mean DCI for single swallows). Categorical variables were analyzed by chi square.

RESULTS:
Patients were older than controls (Table 1). HRM indications are shown in Table 2. Incomplete inhibition during MRS was significantly more frequent in chronic opioid users compared to patients not on opioids and healthy controls (26% vs 11% vs 0% P = 0.002; Figure 1). There was a significant difference in the rate of incomplete MRS inhibition for patients on oxycodone, hydrocodone, and tramadol (27% vs 34% vs 22% P = 0.002). The proportion of patients with augmentation post MRS was similar for opioid users, non-opioid users and healthy controls (P = 0.05).

CONCLUSION:
Impaired deglutitive inhibition during MRS was significantly more frequent among opioid users compared to non-opioid users and healthy controls. This was more common with stronger opioids (oxycodone and hydrocodone) compared to tramadol. These findings support our hypothesis that opioids interfere with inhibitory signals in the esophagus.
394 Esophageal Food Impaction - A Retrospective Chart Review
Authors: Gurala Dhineshreddy , Philipose Jobin , Polavarapu Abhishek , Gumaste Vivek 
Published: October 2019

INTRODUCTION:
Esophageal Food Impaction (EFI) is the third most common non-biliary emergency in gastroenterology with an estimated annual incidence rate of 13 episodes per 100,000 person-year and resulting in 1500 deaths per year. Patient’s presenting with food impaction often have underlying esophageal pathology. Esophageal dysmotility is one of them which can be seen in diabetics and 60% of these patients have manometric abnormalities which may be associated with increased risk of food impaction but limited studies have been done to evaluate these correlations. The possible risk factors and association with diabetes in EFI was evaluated in our study.

METHODS:
Retrospective chart review of 455 patients who presented to the Staten Island University Hospital with symptoms of food impaction from 1999 to 2017. A retrospective analysis was undertaken on relevant clinical data such as age, risk factors, type of bolus, location, administration of glucagon, endoscopic technique, complications, and outcome.

RESULTS:
Overall, 174 patients had endoscopically confirmed FI with males 102/174 (58%). Esophageal pathology found in endoscopy includes esophagitis in 58/174 (33%), stricture in 43/174 (24%), hiatal hernia in 29/174 (17%), Schatzki ring in 15/174 (9%), normal endoscopy in 32/174 (19%) (Figure 1). Diabetes was reported in 20/174 (11%) (Figure 2). Type of food was meat in 73/174 (41%). Location of EFI mainly in the lower one-third of the esophagus in 94/174 (61%). Endoscopic push technique was used in 95/174 (55%), pull technique in 83/174 (48%). Endoscopy was successful for the first time in 165/174 (96%) patients. Complications were reported in only 5/174 (3%) including perforation and tear. Glucagon was given to 74/174 (43%) and mean door to endoscopy time (time of presentation to the emergency department to endoscopy procedure) was 10 hours in patients received glucagon, 13 hours in patients who didn’t receive glucagon (Figure 3).

CONCLUSION:
EFI is more common in males. Esophageal stricture and hiatal hernia were the most common pathologies found in endoscopy. Esophagitis is found in 33% of patients but whether it is the culprit for FI or consequence of FI is not clear. Diabetes is associated with food impaction in only 11% of patients but more studies are needed to find out the true association. Administration of glucagon resulted in the decreased door to scope time. Endoscopy is a safe and effective method for food impaction and complications reported were minimal.
395 Determining the Necessity for Separate Histologic Evaluations of Proximal and Distal Biopsies in Adult Eosinophilic Esophagitis
Authors: Yazdian Aaron , Choksi Yash , Willey Jade , Patel Dhyanesh , Slaughter Christopher , Higginbotham Tina , Vaezi Michael 
Published: October 2019

INTRODUCTION:
Proton Pump Inhibitors (PPIs) can induce remission in up to 1/2 of patients with EoE. Understanding clinical or pathologic features of EoE that are associated with PPI-responsiveness could inform choice of PPI for therapy, rather than diet or topical steroids. The aim of this study was to determine if evaluation of mid esophageal biopsies separately from distal esophageal biopsies could reveal information important in predicting PPI response.

METHODS:
We utilized a de-identified database containing information derived from our institution’s electronic medical record between 2000-2017. We queried this database for patients with an ICD9 or ICD10 code for Eosinophilic Esophagitis. A total of 1,198 patients resulted. These records were manually reviewed, and an EoE diagnosis was confirmed in 749/1198 by a pathology report showing an esophageal biopsy containing an eosinophil count with ≥ 15 eosinophils/high power field. Patients with ≥ 15 eosinophils/high power field in both mid and distal esophageal biopsies (separately reported) with ≤ 15 eosinophils/high power field in both mid and distal biopsies following PPI therapy were considered to be PPI-responsive, while those with ≥ 15 eosinophils/high power field in either biopsy after PPI therapy were considered to be not responsive to PPI. 564/749 patients were excluded due to interventions other than PPI or lack of pre-EGD or post-EGD data.

RESULTS:
Our study constituted 43 PPI-responsive and 142 non-responsive patients (median age 23 vs.18 years, respectively; male 67% vs 68%, respectively). Dysphagia was the most common indication for EGD (56%, refer to Table 1). Patients non-responsive to PPI demonstrated a trend towards a longer duration of symptoms prior to EoE diagnosis (24 vs. 12 months, P = 0.14). In PPI-responsive patients, pre-EGD eosinophils/high power field were significantly lower in number in the mid (21 vs. 44, Figure 1, P < 0.001) and distal (30 vs. 50, P < 0.001) esophageal biopsies.

CONCLUSION:
Biopsies in the mid and distal esophagus had significantly fewer eosinophils in EoE patients that respond to PPI versus those that do not. Perhaps this information can be used in conjunction with other data to predict PPI response. In the future, we plan to validate these findings in other populations and examine the differences of other EoE histologic features in mid and distal esophageal biopsies.
401 EGJ Outflow Obstruction in Setting of Opiate Use Is Associated With Esophageal Spasticity and Hypercontractility
Authors: Jonas Daniel , Foromera Joshua , Ross Kristina , Menard-Katcher Paul , Kaizer Alexander , Yadlapati Rena 
Published: October 2019

INTRODUCTION:
Esophagogastric junction outflow obstruction (EGJOO) is an increasingly diagnosed motility disorder defined by an elevated integrated relaxation pressure without meeting criteria for achalasia subtypes per the Chicago Classification v3.0. Various mechanisms may contribute to an EGJOO motility pattern such as effect from opiates, hiatal hernia, or normal physiology. We hypothesize that esophageal motility patterns differ across mechanisms of EGJOO. The aim of this study was to compare physiologic factors across sub-groups of patients with EGJOO.

METHODS:
This was a retrospective study of adult patients who underwent high-resolution manometry at a single academic center over 59 months (1/2014-11/2018). Demographics, medical/surgical history, medications, and manometry results were collected from the electronic health record. Patients diagnosed with EGJOO and without prior foregut surgery were included in the analysis. Patients were further classified according to whether they had a hiatal hernia and/or opiate use. Fisher’s exact test and a Wald test from linear regression was used to compare EGJOO sub-groups for categorical and continuous variables, respectively.

RESULTS:
Of 912 patients who underwent manometry over 59 months, 114 (13%) had EGJOO; 26 were excluded due to history of foregut disease. Therefore, 88 patients with EGJOO are included in this analysis: 29 (33%) male, mean age 59.1 years (SD 13.6), mean body mass index 26.4 kg/m2 (SD 5.7) [Table 1]. The 88 patients were sub-grouped as: EGJOO + Hernia 25 (28%), EGJOO + Opiate 18 (21%), and EGJOO without hernia or opiate use 45 (51%). Patients with EGJOO + Opiate had a significantly higher distal contractile integral than EGJOO + Hernia (4132 (SD 2079) vs 2147 (SD 2166) mmHg-s-cm; P = 0.03) and a greater proportion of hypercontractile swallows than those with EGJOO + Hernia or EGJOO without hernia or opiate use (P = 0.06). Additionally, EGJOO + Opiate use had a shorter mean distal latency than those with EGJOO + Hernia or EGJOO without hernia or opiate use (P = 0.17) [Table 2].

CONCLUSION:
In this study of 88 patients with EGJOO, patients with EGJOO and opiate use exhibited increased esophageal contractility and spasticity compared to those without opiate use. These results support the notion that mechanisms of EGJOO vary, and that spasticity may explain EGJOO in patients using opiates. Further research should assess the efficacy of treatments targeting esophageal spasticity in patients with EGJOO that are unable to stop opiates.
417 Lack of Peristaltic Reserve as Detected by Multiple Rapid Swallows on HRM Predicts Development of Dysphagia Following Magnetic Sphincter Augmentation for GERD
Authors: Dominguez-Profeta Rebeca , Horgan Santiago , Cheverie Joslin , Cubas Robert , Kunkel David C. 
Published: October 2019

INTRODUCTION:
Magnetic Sphincter Augmentation (MSA) is an antireflux procedure that can be performed on patients with normal esophageal motor function. The most common side-effect of MSA is dysphagia, which occurs in 34-38% of patients and may require dilation (Lipham JC et al, 2015). Multiple rapid swallows (MRS) is a provocative maneuver during high resolution esophageal manometry (HRM) that assesses peristaltic reserve; impaired MRS has previously been shown to predict the development of dysphagia following fundoplication (Shaker A et al, 2013). We hypothesized that impaired MRS may predict which patients experience dysphagia following laparoscopic MSA.

METHODS:
Retrospective review of all patients who underwent MSA at a tertiary academic center from May 2015 to May 2018. All patients completed a standardized esophageal questionnaire and pre-operative HRM which included MRS. Peristaltic augmentation with MRS was defined as a ratio >1 of the distal contractile integral (DCI) following MRS and the median DCI of the 10 baseline wet swallows. Demographics, MSA implant size, and symptom data from post-operative follow-up of at least 6 months was gathered on all patients.

RESULTS:
29 patients (age 52 ± 17 years, 59% female, BMI 25 ± 4.2 kg/m2) were identified. Postoperatively, 15 patients developed dysphagia, 9 of them within the first 2 weeks. 5 patients required balloon dilatation for symptom relief. Among the patients that did not develop dysphagia, peristaltic augmentation with MRS was present in 42.9% compared to 6.7% of patients who developed dysphagia (P-value 0.03). 40% of the patients that required balloon dilatation exhibited complete absence of any smooth muscle contraction following MRS (DCI = 0). Having a small MSA implant (13 or 14 beads) versus a large MSA implant (15, 16 or 17 beads) trended towards an association with developing dysphagia (47% versus 29%, P-value 0.18). The DCI ratio of MRS/wet swallows that predicted development of dysphagia following MSA was 0.59.

CONCLUSION:
Intact peristaltic reserve, as assessed by augmented contraction following MRS, was protective of developing dysphagia following MSA. MRS should be given important consideration in the evaluation of patients under consideration for antireflux surgery specifically with regards to counseling patients on their individual risk of developing dysphagia and the potential need for additional procedures such as dilation.
434 Response to Multiple Rapid Swallows Shows Impairment of Inhibitory Pathways in Patients With Distal Esophageal Spasm
Authors: Hernandez Patricia V. , Valdovinos-Garcia Luis R. , Horsley-Silva Jennifer L. , Valdovinos-Diaz Miguel A. , Crowell Michael D. , Vela Marcelo F. 
Published: October 2019

INTRODUCTION:
Distal esophageal spasm (DES) is a motility disorder characterized by premature contraction of the esophageal body during single swallows. It is thought to be due to impairment of esophageal inhibitory pathways, but studies to support this are limited. Assessment of response to multiple rapid swallows (MRS) during high-resolution esophageal manometry (HRM) enables detection of impaired inhibition during MRS. Healthy subjects respond to MRS by deglutitive inhibition during the MRS sequence. We hypothesize that deglutitive inhibition is impaired in DES patients. Aim: compare response to MRS in DES patients and healthy controls.

METHODS:
Response to MRS was evaluated in 19 DES patients and 24 asymptomatic healthy controls. Demographic and symptom data were extracted from a prospectively maintained motility database. Patients with history of prior gastroesophageal surgery, endoscopic myotomy (POEM), pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, and esophageal stricture were excluded. HRM was performed with a solid state catheter with 36 circumferential pressure sensors 1-cm apart; ten 5-ml liquid swallows were given followed by MRS sequence, analyzed with Manoview software (Medtronic). Esophagogastric junction integrated relaxation pressure (IRP), distal contractile integral (DCI), and distal latency (DL) were calculated, and Chicago Classification v3.0 was applied to diagnose DES (defined by ≥ 2 swallows with DL ≤ 4.5 sec). Response to MRS was evaluated for complete versus impaired inhibition (contractility with DCI > 100 mmHg-sec-cm during MRS), and presence of post MRS contraction augmentation (DCI post MRS greater than single-swallow mean DCI). Chi-Square and Fisher’s exact test were used for statistical analysis.

RESULTS:
Demographics and symptom data are shown in Table 1. Patients with DES were older and more symptomatic than controls. Impaired inhibition of peristalsis during MRS was significantly more frequent in DES compared to controls (89% vs 0%, P < 0.001, Figure 1). The proportion of subjects with augmentation post MRS was similar for both groups (37% vs 38%, P = 1.00), but mean DCI post MRS was higher in DES than controls (3788 vs 1239, P = 0.013).

CONCLUSION:
Impaired deglutitive inhibition during MRS is present in the majority of patients with DES, supporting impaired inhibitory pathways in the esophagus as a mechanism of action in this disorder.
438 Seasonal Variations in Eosinophilic Esophagitis Related Hospitalizations: A Multiyear Analysis From the Largest Inpatient United States Database
Authors: Gupta Kamesh , Khan Ahamd , Sohail Abdullah , Bansal Pardeep , Goyal Hemant 
Published: October 2019

INTRODUCTION:
Seasonal variations have been reported in the exacerbation of the eosinophilic esophagitis (EE), but there is conflicting data with no clear consensus. The pathogenesis of EE is believed to be immune/allergen mediated, including aeroallergens. This would support the theory of seasonal variations as other allergic conditions like asthma have been also shown to peak in Autumn. The purpose of our study is to analyze the seasonal variations in EE-related hospitalizations and hospital charges.

METHODS:
We conducted a cross-sectional study using the National Inpatient Sample (2008 to 2014), which is the largest US inpatient database. We used ICD-9-CM code (K200) to identify cases with a primary diagnosis of EE. Seasons were defined as follows: Winter (December-February); Spring (March-May); Summer (June–August); Autumn (September–November). The number and proportion of hospitalizations along with other outcome variables like mortality, length of stay (LOS) and hospitalization charges were compared and adjusted odds ratio for the outcome variables with regression analysis accounting for these confounders: age, gender, race, comorbidities, LOS, admission status and hospital factors including location and teaching status. All statistical analyses were performed with STATA.

RESULTS:
A total of 10,856 hospitalizations with a primary diagnosis of EE were reported between 2008 and 2014. Mean age of the population was 25.76 ± 0.78 years, and 34% were females. The highest number of EE-related hospitalizations were reported in summer (N = 2775; 25.5%) followed by winter (N = 2766; 25.4%), Autumn (N = 2749; 25.32%) and the least in spring season (N = 2565; 23.6%). In-hospital death was recorded in only 5 cases (0.04%). Mean length of stay was highest in the Spring as compared to the mean LOS for all seasons (3.73 vs. 3.30 days; P = 0.004). Hospitalization charges were highest in spring ($26403) versus a mean of $24826 over all four seasons (P = 0.336).

CONCLUSION:
We did not observe any statistically significant seasonal pattern in the number of EE-related hospitalizations. However, patients admitted during Spring (March, April, May) had significantly longer LOS. Economic costs per hospitalization were also highest in spring but were not statistically significant. This study is limited in that the analysis is based on the accuracy of diagnostic codes reported at the time of hospitalization.
443 Adjunctive Yield of Wide-Area Trans-Epithelial Sampling With Computer-Assisted Three-Dimensional Analysis in Detection of Dysplasia After Advanced Imaging and Random Biopsies in Barrett’s Esophagus
Authors: Raphael Kara L. , Stewart Molly , Sejpal Divyesh , Cheung Mary , Whitson Matthew , Han Dennis , Benias Petros , Lee Calvin , Miller Larry , Trindade Arvind 
Published: October 2019

INTRODUCTION:
Wide-area trans-epithelial sampling with computer-assisted three-dimensional analysis (WATS-3D) has been used for dysplasia detection in endoscopic surveillance of Barrett’s esophagus (BE). Little is known about the additive yield of WATS after a thorough exam with advanced imaging that consists of high definition white light endoscopy (HDWLE), narrow band imaging (NBI), volumetric laser endomicroscopy (VLE) with laser marking, and Seattle protocol biopsies (collectively termed HDWLE-NBI-VLE-SP exam). The aim of this study was to evaluate the adjunctive yield of WATS-3D after an HDWLE-NBI-VLE-SP exam.

METHODS:
This is a single center observational cohort study from January 2017 to December 2018. Charts were abstracted for consecutive patients that underwent an advanced imaging exam. Raised lesions were removed by endoscopic resection. Areas suspicious for dysplasia on NBI and VLE were biopsied or resected. This was followed by random biopsies. Finally WATS-3D brush biopsies were performed.

RESULTS:
One hundred and thirty eight cases were included in this study. Thirty-five cases (25% of the total ) were identified as some degree of dysplasia on the HDWLE-NBI-VLE-SP exam. Of these, 14 were reported as indefinite for dysplasia, 11 low-grade dysplasia (LGD), 8 high-grade dysplasia (HGD) or intramucosal cancer, and 2 T1b cancers. Adjunctive use of WATS-3D yielded an additional 12 new cases of dysplasia (9 with crypt dysplasia and 3 with LGD), for added yield of 34.3% (=12/35, 95% CI 14.6-62.2%). In addition, 8 cases of dysplasia found on the HDWLE-NBI-VLE-SP exam were upgraded by WATS-3D to a higher grade of dysplasia (5 with crypt dysplasia and 3 with HGD). Thus the absolute increase provided by WATS was 8.7% (=12/138) for a new diagnosis of dysplasia and was 14.5% (=20/138) when combining both new and upgraded diagnosis of dysplasia grade.

CONCLUSION:
The addition of WATS-3D to an already thorough exam with HDWLE-NBI-VLE-SP can increase the yield of dysplasia detection.
445 A Comparative Study of Proton Pump Inhibitor’s Prescription According to Clinical Practice Guidelines Between a Private Clinic and a Public Hospital in Lima, Peru
Authors: Granda Camila , Martel Mariana , Ticse Ray , Pinto Jose , Espinoza-Ríos Jorge 
Published: October 2019

INTRODUCTION:
The use of proton pump inhibitors (PPI) for the treatment of the upper digestive system diseases, had exponentially grown by 456% globally since the 1990’s. They lower the gastric acid production by inhibiting the H+/K+/ATPase from the gastric parietal cells. Despite being considered relatively safe, studies have arised associating them with nutrient malabsorption, gastroenteritis, diarrhea caused by Clostridium difficile, fractures and renal failure. The objective of this study is to determine the frequency of adequate prescription of PPIs comparing a public hospital and a private clinic in Lima, Peru.

METHODS:
A descriptive cross-sectional study was developed in which data was collected from the clinical files of hospitalized patients and was registered on a checklist created by the guidelines from the FDA, AGA, ACG and ASHP, and categorized on whether they were adequately prescribed by following the guidelines or not. The study included patients older than 18 years old who had received at least one PPI while hospitalized in the services of internal medicine and general surgery of a public hospital and a private clinic in Lima, Perú. The exclusion criteria are patients who consumed PPIs within 2 weeks of the hospitalization or patients who had been in critical care units.

RESULTS:
A total of 128 patients, 46% from the hospital and 54% patients from the clinic. An average age of 52 years and 25% of patients were older than 65 years with a male female ratio of 3:2. Comparing the service of internal medicine within both establishments the public hospital had better adherence to the guidelines (68.18%, 27.28%; P = 0.019) and comparing general surgery, the private clinic was more adequate (63.64%, 35.14%; P = 0.078).Within the hospital, medicine had a better adherence to the guidelines than surgery (68.18%; 35.14%). On the other hand, within the clinic the surgery presented a better adherence (63.64%; 27.28%).

CONCLUSION:
The high percentage of inadequate PPI prescription found in this study is similar to those found on other studies between public hospitals.The main reason for a prescription according to the guidelines was for gastric ulcer prophylaxis in patients older than 65 years old who were taking NSAIDs. The main reasons to not follow the clinical guidelines was polypharmacy (3 or more drugs) mainly on surgery in the hospital and on medicine in the clinic. The clinic has a more adequate prescription of PPI in surgery and lower in medicine compared to the hospital.