Abraham Khan

Potentially reversible pseudoachalasia after laparoscopic adjustable gastric banding.

Background Although esophageal dilation after laparoscopic adjustable gastric banding (LAGB) has been reported, the effect of banding on esophageal peristalsis, including the development of aperistalsis and its potential reversibility, have received only little attention. Goals Our aim was to report our experience with 6 patients who developed manometric evidence of esophageal aperistalsis after LAGB. Study We retrospectively reviewed the clinical, manometric, and radiologic data of 6 patients referred between September 2005 and June 2007 to our Center for Esophageal Disease for evaluation of dysphagia or heartburn that developed after LAGB, and in whom manometric studies showed aperistalsis. Patients had the fluid in the band completely removed (N=5) or had the band removed (N=1). Reversibility of esophageal aperistalsis was then assessed. Clinical follow-up was obtained from 2009 to early 2010. Results Six patients (all female, age range, 37 to 55 y old) were evaluated because of dysphagia or heartburn after LAGB and had complete aperistalsis on manometry. Five of the 6 patients had manometry after removal of all the fluid from the band (N=4) or after surgical removal of the band (N=1). Two patients had partial return of peristalsis, 1 had normal peristalsis, and 2 others had continued aperistalsis but did show clinical improvement. Another patient had improvement of radiologic esophageal dilation but declined repeat manometry. Conclusions LAGB can cause an achalasia-like esophageal aperistalsis that may be reversible. Gastroenterologists caring for bariatric patients need be aware of this pseudoachalasia, as the treatment of such patients differs from those with primary achalasia.

Dysphagia in the Elderly

Dysphagia, or difficulty swallowing, is a common problem in the elderly. Based on the initial clinical history and physical examination, the dysphagia is assessed as either primarily oropharyngeal or esophageal in origin. Most oropharyngeal dysphagia is of neurologic origin, and management is coordinated with a clinical swallow specialist in conjunction with an ear, nose, and throat (ENT) physician if warning signs imply malignancy. Several structural and functional esophageal disorders can cause dysphagia. If a patient has likely esophageal dysphagia, a video barium esophagram is a good initial test, and referral to a gastroenterologist is generally warranted leading to appropriate treatment.

Impact of obesity treatment on gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.

Patients with Throat Symptoms on Acid Suppressive Therapy: Do They Have Reflux?

Purpose The aim of this study was to characterize the reflux events in patients with laryngeal symptoms unresponsive to proton pump inhibitor (PPI) therapy. Background Gastroesophageal reflux disease (GERD) is commonly implicated as the cause of laryngeal symptoms. Methods We retrospectively reviewed the pH/impedance records of 21 patients evaluated for persistent throat symptoms despite PPI therapy. They were compared to 30 others with typical reflux symptoms despite medication. Results Five of 21 (24%) patients in the “throat group” had normal reflux values, 13 (62%) continued to have abnormal acid reflux, and three (14%) had abnormal nonacid reflux but normal acid reflux while on medication. These results did not differ from those with typical symptoms unresponsive to medication. Conclusion In patients with chronic laryngeal symptoms despite PPI therapy, a substantial minority have no reflux at all, but the majority have abnormal amounts of acid reflux despite their taking PPI medication.

Making the Cut: An Isolated Filiform Polyp

75-year-old woman with a remote history of sigAmoidectomy for perforated diverticulitis, as well as benign colonic polyps found during colonoscopy 4 years prior, presented for surveillance colonoscopy. During colonoscopy, an isolated, 3 cm in length, pedunculated, worm-like polyp was discovered at 40 cm proximal to the anus (Figure A). Initial hot snare polypectomy, set at 25 W, cut through the outermost layer of stalk tissue but failed to cut through the central fibrous-appearing core. Of note, the stalk of the polyp was noted to contract with application of current. By using the autocut function set at 180 W, the central core was successfully cut (Figure B). The polyp was retrieved, and hemostatic clips were placed to prevent post-polypectomy bleeding. Pathologic examination revealed a finger-like polyp lined by benign reactive colonic epithelium and containing a central fibrovascular core, which was negative for dysplasia (Figure C). There were no post-procedural adverse events. Filiform polyps are most commonly associated with inflammatory bowel disease but may also be seen with diverticulitis and malignancy. Differing from this case, filiform polyps more commonly are found as a group of polyps or even as mass-like agglomerations. Histologic examination of filiform polyps reveals nonspecific inflammation of colonic mucosa with a core that is often fibrovascular but can also contain disordered smooth muscle fascicles and nerves. These muscle fascicles are believed to be the cause of polyp contraction with application of current during this case. Filiform polyps generally are not thought to have malignant potential. However, endoscopists should consider polypectomy or biopsy if the polyp is of uncertain histology. This was an atypical, isolated filiform polyp found during colonoscopy, and thus the endoscopists chose to proceed with polypectomy. A previous report suggested a snare and cautery technique for removal of suspected filiform polyps. However, because of the fibrovascular and muscular core of these polyps, autocut may be more successful for polypectomy of a suspected filiform polyp.

Tu1806 A Burning Issue: Defining GERD in Non-Erosive Disease

BACKGROUND: GERD is a prevalent condition that encompasses bothersome symptoms or mucosal injury. It remains challenging to diagnose the condition in individuals with the most common presentation of non-erosive reflux disease. The current diagnostic tools include symptom assessment, endoscopy, and pH-metry. Few studies have evaluated the utility of combining these factors with histology to diagnose GERD in the general population. This study aimed to assess the diagnostic yield of a model with predefined criteria in diagnosing GERD among those with non-erosive disease. METHODS: Individuals presenting for upper endoscopy were prospectively enrolled, and the presence of upper GI symptoms was assessed via a standardized questionnaire. All subjects underwent EGD with lower esophageal biopsies 2 cm above the squamocolumnar junction. A blinded GI pathologist reviewed all biopsies. Esophageal acid exposure and symptom association were assessed off acid suppression therapy via 48-hour pH-metry. Subjects were categorized as GERD if at least two of the following criteria in this model were present: 1) positive symptoms reported on presentation 2) any endoscopically identified LA grade esophagitis 3) histologic pathology 4) esophageal pH ,4 for more than 4.5% of the time. RESULTS: Among the 292 subjects enrolled 26% were women and 74% were men, while the majority were either Caucasian (43%) or African American (27%). Mean age (59 ± 9 years) did not differ according to gender or race/ethnicity. The prevalence of GERD symptoms was 62% and erosive esophagitis was 20%. Data for all diagnostic criteria was complete for 113 subjects and as expected, the prevalence of positive pH studies (pH+) was highest for those with endoscopic esophagitis compared to those without endoscopic esophagitis (65% vs. 41%, p=0.03). However the sensitivity of EGD alone for pH+ was 29% with a specificity of 87%. Regardless of endoscopic findings, no difference in pH+ studies was found based on symptoms or histology alone. Among the 90 subjects with a normal endoscopy who still met the predefined criteria the prevalence of pH+ was significantly higher compared to those who did not meet the criteria (71% vs. 15%, p,0.001). The positive likelihood ratio for this diagnostic approach among individuals with non-erosive disease was 3. In multivariate logistic regression analysis, the model remained significant for GERD with pH+ after controlling for age, gender, BMI, tobacco and alcohol (OR 11, 95% CI 3.0-39; p,0.001). CONCLUSIONS: Among individuals presenting for general endoscopic evaluation the prevalence of erosive disease is low. A predictive model that includes histology allows for a clinically useful approach in diagnosing GERD in non-erosive disease and can help predict and potentially obviate the need for pH testing. Further assessment should be conducted in diverse populations.

Gastroesophageal Reflux Disease: Molecular Predictors in Neoplastic Progression of Barrett's Esophagus

Barrett’s esophagus (BE) represents a metaplastic change from squamous epithelium to intestinal epithelium as a result of chronic gastroesophagheal reflux. Since the development of esophageal adenocarcinoma (EAC) is not universal among patients with BE, it is important to understand and to gauge the factors that influence risk of progression to dysplasia and cancer. While heartburn symptoms have been reported to be associated with BE (Eisen et al., 1997; Lagergren et al., 1999a), the severity of gastroesophageal reflux symptoms is not a reliable indicator for the presence of BE (Eloubeidi and Provenzale, 2001). There is a vital need to explore factors other than symptoms that not only may elucidate the pathophysiology of BE development but also that may be predictive of progression to EAC. Significant advances have been made along key areas such as cell cycle abnormalities, growth factors, adiposity, and the gut microbiome. This chapter aims to review some of these elements as well as the prognostic value of biomarkers for progression from BE to EAC. The importance of fulfilling the promise that these biomarkers hold is underscored by the notable increase in the risk of progression to cancer from 0.5% per year in non-dysplastic BE, to 13% in the setting of low-grade dysplasia, and to 40% in high-grade dysplasia (Curvers et al., 2010; Wani et al., 2009).