April D. Higbee

The diagnostic accuracy of esophageal capsule endoscopy in patients with gastroesophageal reflux disease and Barrett's esophagus: a blinded, prospective study.

BACKGROUND:Esophageal capsule endoscopy (ECE) is a novel technique that offers noninvasive evaluation of esophageal pathology in gastroesophageal reflux disease (GERD) patients.OBJECTIVE:To assess the diagnostic accuracy of ECE for Barretts esophagus (BE), erosive esophagitis, and hiatal hernia and to assess the safety profile of ECE.METHODS:Patients with GERD symptoms and those undergoing BE surveillance were prospectively enrolled. All patients underwent ECE followed by standard upper endoscopy. ECE findings were interpreted by examiners blinded to endoscopy results. The gold standard was the findings at endoscopy and ECE results were compared with those at endoscopy.RESULTS:One hundred patients were enrolled of which 94 completed the study. At upper endoscopy, BE was suspected in 53 (mean length 3.1 cm) and confirmed in 45 patients. Erosive esophagitis and hiatal hernia were identified in 18 and 70 patients, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ECE for BE in GERD patients were 67%, 87%, 60%, and 90%, respectively. The sensitivity, specificity, PPV, and NPV of ECE for BE patients undergoing surveillance were 79%, 78%, 94%, and 44%, respectively. The sensitivity, specificity, PPV, and NPV for erosive esophagitis were 50%, 90%, 56%, and 88% and for hiatal hernia were 54%, 67%, 83%, and 33%, respectively.CONCLUSIONS:Current diagnostic rates of ECE for BE are not yet accurate enough for application in clinical practice. An improvement in technology and learning curve assessments are required, until then standard upper endoscopy remains the gold standard.

Prevalence and Predictors of Columnar Lined Esophagus in Gastroesophageal Reflux Disease (GERD) Patients undergoing upper endoscopy

OBJECTIVES:Chronic gastroesophageal reflux disease (GERD) is a risk factor for Barretts esophagus (BE), the most important surrogate marker for the development of esophageal adenocarcinoma (EAC). The need to document the presence of intestinal metaplasia in esophageal biopsies from a columnar lined esophagus (CLE) to diagnose BE is debated. The objective of this study was to prospectively evaluate the prevalence and risk factors of CLE in a large cohort of GERD patients undergoing upper endoscopy.METHODS:Consecutive patients presenting to the endoscopy unit at a tertiary referral center for their index upper endoscopy for evaluation of GERD symptoms were enrolled in this prospective cohort study. Patients were asked to complete a validated GERD questionnaire that documents the onset of GERD symptoms (heartburn and acid regurgitation) and grades the frequency and severity of symptoms experienced over the past year. Demographic information, body mass index, and use of aspirin/nonsteroidal antiinflammatory drugs were recorded. Endoscopic details including length of CLE, presence and size of hiatal hernia were noted. Patients with CLE (cases) were compared with those without CLE (controls) using Fischers exact test and t-test. All factors that were statistically significant (P<0.05) were then entered into stepwise logistic regression to evaluate for independent predictors of CLE.RESULTS:A total of 1058 patients with GERD symptoms were prospectively enrolled. On index endoscopy, the prevalence of CLE was 23.3%, whereas of CLE with documented intestinal metaplasia was 14.1%. On univariate analysis, male gender, Caucasian race, heartburn duration of >5 years, presence and size of hiatal hernia were significantly associated with the presence of CLE compared with controls (P<0.05). On multivariate analysis, heartburn duration >5 years (odds ratio (OR): 1.50, 95% confidence interval (CI): 1.07–2.09, P=0.01), Caucasian race (OR: 2.40, 95% CI: 1.42–4.03, P=0.001), and hiatal hernia (OR: 2.07, 95% CI: 1.50–2.87, P<0.01) were found to be independent predictors for CLE. CLE length was significantly associated with the presence of intestinal metaplasia (P<0.001).CONCLUSIONS:If BE is defined by the presence of CLE alone on upper endoscopy, up to 25% of GERD patients are diagnosed with this lesion. Enrolling all these patients in surveillance programs would have significant ramifications on health-care resources.

Lack of predictors of normalization of oesophageal acid exposure in Barrett's oesophagus

Background : Barretts oesophagus patients may continue to have abnormal oesophageal acid exposure on proton pump inhibitor therapy. The effect of factors such as Barretts oesophagus length, hiatal hernia size and Helicobacter pylori infection on intra‐oesophageal pH in Barretts oesophagus patients has not been adequately studied.

Dilated intercellular spaces and lymphocytes on biopsy relate to symptoms in erosive GERD but not NERD

Aliment Pharmacol Ther 2011; 33: 1202–1208

Impact of Measurement of Esophageal Acid Exposure Close to the Gastroesophageal Junction on Diagnostic Accuracy and Event–Symptom Correlation: A Prospective Study Using Wireless Dual pH Monitoring

OBJECTIVES:Ambulatory esophageal pH monitoring has limited diagnostic accuracy in patients with gastroesophageal reflux disease (GERD), especially in those with non-erosive reflux disease (NERD). In addition, there is lack of symptom–reflux association in the majority of GERD patients. The aim of this study was to evaluate the impact of measuring acid exposure 1 cm above the gastroesophageal junction (GEJ) on diagnostic accuracy and symptom correlation in GERD patients compared with conventional pH measurements (6 cm above the GEJ) using the wireless pH system.METHODS:GERD patients and controls as defined by two validated questionnaires (Gastroesophageal Reflux Questionnaire and Reflux Disease Questionnaire) were prospectively enrolled. Under direct endoscopic vision, two wireless pH capsules (BRAVO, Given Imaging, Yokneam, Israel) were placed 6 and 1 cm, respectively, above the GEJ. Receiver operator characteristic curves were constructed, and symptom indexes were calculated separately for pH measurements at 6-cm (proximal) and 1-cm (distal) locations.RESULTS:A total of 40 GERD patients (20 erosive esophagitis (EE) and 20 NERD) and 16 controls were analyzed. Sensitivity and specificity of abnormal acid exposure times in GERD were as follows: proximal: 67 and 66%, distal: 60 and 88%; in EE proximal: 75 and 81%, distal: 84 and 92%; and in NERD proximal: 61 and 67%, distal: 58 and 66%, respectively. The proportion of patients with a positive symptom–reflux correlation in GERD was as follows: symptom index (SI): proximal: 35%, distal: 50%; symptom sensitivity index (SSI): proximal: 25%, distal: 5%; and symptom-associated probability (SAP): proximal: 30% and distal: 35%. The higher proportion of patients with a positive SI distally was due to the EE group (EE, proximal: 35% and distal: 65%; NERD, proximal: 35% and distal: 35%).CONCLUSIONS:Compared with the traditional location, measurement of acid reflux 1 cm above the GEJ improved the diagnostic accuracy as well as symptom correlation in EE, but not in NERD patients. Thus, pH monitoring 1 cm above the GEJ for improving the diagnosis of NERD cannot be recommended in clinical practice at this time.

The impact of pre‐endoscopy proton pump inhibitor use on the classification of non‐erosive reflux disease and erosive oesophagitis

Aliment Pharmacol Ther 2010; 32: 1266–1274

Effect of acid-suppressive therapy on narrow band imaging findings in gastroesophageal reflux disease: a pilot study

Standard endoscopy is an insensitive test for gastroesophageal reflux disease (GERD). Narrow band imaging (NBI) endoscopy enhances visualization of the distal esophagus. NBI patterns like intrapapillary capillary loop (IPCL) dilatation, tortuosity, and increased number; microerosions; increased vascularity at the squamocolumnar junction (SCJ); ridge-villous pattern below the SCJ; and presence of columnar islands in the distal esophagus have been suggested as features of GERD. We evaluated the effect of proton pump inhibitor (PPI) therapy on NBI findings in GERD patients. Patients prospectively underwent NBI upper endoscopy before and after PPI therapy. NBI findings were recorded at each endoscopy. Twenty-one patients with GERD symptoms (mean age 60.0 years; males 90.5%; white 90.5%) were studied. After PPI therapy, there was a significant reduction in the proportion of patients with the following NBI features: IPCL tortuosity (90% vs. 4.8%, P < 0.0001), dilated IPCLs (86% vs. 9.5%, P < 0.0001), and increased vascularity at the SCJ (43% vs. 9.5%, P= 0.0082). PPI led to healing of all microerosions (71% vs. 0%, P < 0.0001) and disappearance of ridge-villous patterns below the SCJ (14% vs. 0%, P < 0.0001). There was no significant change in the proportion of patients with increased numbers of IPCLs pre- and post-PPI therapy (71% vs. 48%, P= 0.09) or columnar islands in the distal esophagus (38% vs. 29%, P= 0.31). In patients with GERD symptoms, NBI features suggestive of GERD respond to PPI; suggesting these features are truly acid-mediated. These findings need to be confirmed by randomized controlled trials.

Cigarette smoking is a modifiable risk factor for Barrett's oesophagus.

Background Cigarette smoking has been associated with an increased risk of oesophageal adenocarcinoma (OAC). However, the impact of smoking and more importantly smoking cessation on Barrett’s oesophagus (BO) is unclear. Objective The aim of the study is to evaluate the association between cigarette smoking and presence of BO in a large prospective cohort of patients with gastro-oesophageal reflux disease (GORD). Methods Patients presenting to the endoscopy unit for upper endoscopy completed a validated GORD questionnaire and information on demographics (age, gender, and ethnicity), cigarette smoking [status (current/past), amount (pack years) and duration of smoking cessation], clinical data [medication history, body mass index (BMI), and family history] and endoscopic findings [BO and hiatal hernia] were recorded. Cigarette smokers (current and past) and nonsmokers were compared using Fisher’s Exact test for categorical variables and Mann–Whitney test for continuous variables. Effects of cigarette smoking and smoking cessation on BO risk was assessed by stepwise logistic regression analysis. Results A total of 1056 patients were included in the analysis [mean age: 57.2 ± 12.7years, Caucasian 880 (83.3%), male 985 (93.3%), and mean BMI 29.6 (SD: ± 5.6)]. 827 (78.3%) were smokers and 229 (21.6%) were nonsmokers. 474 subjects (44.9%) had a previous history of smoking. Anytime smokers were more likely to have BO (adjusted OR: 3.3; 95 CI: 1.7–6.3; p < 0.01). Higher smoking burden (pack years) was associated with higher risk of BO in this GORD cohort (p for trend < 0.01). Duration of smoking cessation was inversely associated with risk of BO (p for trend: 0.01). Conclusion This study shows that smokers with reflux symptoms have about threefold higher risk of BO compared with nonsmokers, whereas discontinuing smoking is associated with a significant reduced risk. Smoking cessation appears to be a viable option to reduce BO risk in patients with reflux disease.

M1104 Predicting High-Grade Dysplasia (HGD) and Esophageal Adenocarcinoma (EAC) in Patients With Non-Dysplastic Barrett's Esophagus (BE): Results From a Large, Multicenter Cohort Study

Predicting High-Grade Dysplasia (HGD) and Esophageal Adenocarcinoma (EAC) in Patients With Non-Dysplastic Barretts Esophagus (BE): Results From a Large, Multicenter Cohort Study Srinivas Gaddam, Patrick E. Young, Amy Wang, Ajay Bansal, Neil Gupta, Sachin B. Wani, Mandeep Singh, Vikas Singh, Keng-Yu Chuang, Vikram Boolchand, Hemanth Gavini, Priti Sud, John Kuczynski, April D. Higbee, Amit Rastogi, Sharad C. Mathur, Brooks D. Cash, Gary W. Falk, Richard E. Sampliner, Prateek Sharma

M1107 Durability of Ablative Therapies in Barrett's Esophagus (BE): Long Term Results of a Randomized Controlled Trial (RCT) of Ablation With Argon Plasma Coagulation (APC) and Multipolar Electrocoagulation (MPEC)

Predicting High-Grade Dysplasia (HGD) and Esophageal Adenocarcinoma (EAC) in Patients With Non-Dysplastic Barretts Esophagus (BE): Results From a Large, Multicenter Cohort Study Srinivas Gaddam, Patrick E. Young, Amy Wang, Ajay Bansal, Neil Gupta, Sachin B. Wani, Mandeep Singh, Vikas Singh, Keng-Yu Chuang, Vikram Boolchand, Hemanth Gavini, Priti Sud, John Kuczynski, April D. Higbee, Amit Rastogi, Sharad C. Mathur, Brooks D. Cash, Gary W. Falk, Richard E. Sampliner, Prateek Sharma