Aurelio Mauro

Inconsistency in the Diagnosis of Functional Heartburn: Usefulness of Prolonged Wireless pH Monitoring in Patients With Proton Pump Inhibitor Refractory Gastroesophageal Reflux Disease.

Background/Aims The diagnosis of functional heartburn is important for management, however it stands on fragile pH monitoring variables, ie, acid exposure time varies from day to day and symptoms are often few or absent. Aim of this study was to investigate consistency of the diagnosis of functional heartburn in subsequent days using prolonged wireless pH monitoring and its impact on patients’ outcome. Methods Fifty proton pump inhibitotor refractory patients (11 male, 48 years [range, 38–57 years]) with a diagnosis of functional heart-burn according to Rome III in the first 24 hours of wireless pH monitoring were reviewed. pH variables were analysed in the following 24-hour periods to determine if tracings were indicative of diagnosis of non-erosive reflux disease (either acid exposure time > 5% or normal acid exposure time and symptom index ≥ 50%). Outcome was assessed by review of hospital files and/or telephone interview. Results Fifteen out of 50 patients had a pathological acid exposure time after the first day of monitoring (10 in the second day and 5 in subsequent days), which changed their diagnosis from functional heartburn to non-erosive reflux disease. Fifty-four percent of non-erosive reflux disease vs 11% of functional heartburn patients (P < 0.003) increased the dose of proton pump inhibitors or underwent fundoplication after the pH test. Outcome was positive in 77% of non-erosive reflux disease vs 43% of functional heartburn patients (P < 0.05). Conclusions One-third of patients classified as functional heartburn at 24-hour pH-monitoring can be re-classified as non-erosive reflux disease after a more prolonged pH recording period. This observation has a positive impact on patients’ management.

Usefulness of low- and high-volume multiple rapid swallowing during high-resolution manometry.

BACKGROUND It has been suggested that multiple rapid swallowing should be added to oesophageal manometry. AIM To prospectively evaluate whether 10 and 200 mL multiple rapid swallowing provide different information concerning motor function. METHODS 30 consecutive patients with oesophageal symptoms, 13 achalasia patients after successful pneumatic dilation and 19 healthy subjects performed eight 5 mL single swallows, two 10 mL and one 200 mL multiple rapid swallowing. RESULTS Almost all of the healthy subjects and two-thirds of the patients with oesophageal symptoms showed motor inhibition during both 10 and 200 mL multiple rapid swallowing. The oesophago-gastric pressure gradient was significantly higher during 200 mL multiple rapid swallowing within each group (p < 0.01), and significantly higher in the achalasia patients than in the other two groups (p < 0.0001). Presence of a contraction and increased contraction strength in comparison with single swallows were both more frequent after 10 mL than after 200 mL multiple rapid swallowing in the healthy subjects and the patients (p<0.05). CONCLUSION Motor inhibition could be similarly evaluated by means of 10 and 200 mL multiple rapid swallowing; 10 mL evaluated the after-contraction, whereas 200 mL multiple rapid swallowing was more valuable in identifying increased resistance to outflow.

Achalasia: from diagnosis to management

Achalasia is an esophageal motility disorder associated with abnormalities in peristalsis and lower esophageal sphincter (LES) relaxation. The etiology of the disease remains elusive. It is often misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia to solids and liquids but may focus on regurgitation as the primary symptom, leading to the early misdiagnosis. Chest pain, weight loss, and occasional vomiting may be additional symptoms encountered in those with achalasia. The disease may be suspected on the basis of clinical presentation, but diagnosis depends on classic findings using high‐resolution manometry, showing either failed or simultaneous contractions with associated normal or high LES pressures with no or incomplete relaxation with swallows. There are no cures for achalasia, and, in most patients, treatments have to be repeated over time. Definitive treatment options in achalasia include pneumatic dilation, surgical myotomy, and the new technique of per‐oral endoscopic myotomy. Botulinum toxin (Botox) or other medical therapies are often reserved for those who cannot have definitive therapies owing to comorbid conditions.

Optimal number of multiple rapid swallows needed during high-resolution esophageal manometry for accurate prediction of contraction reserve

Multiple rapid swallows (MRS) is a provocative test for assessment of contraction reserve, however reproducibility on repetitive MRS is incompletely understood. Our aim was to determine the optimal number of MRS sequences for consistent assessment of contraction reserve.

Gastro-esophageal reflux and antisecretory drugs use among patients with chronic autoimmune atrophic gastritis: a study with pH-impedance monitoring

Patients with chronic autoimmune atrophic gastritis (CAAG) often refer digestive symptoms and are prescribed antisecretory medications. Aims were to investigate: (i) gastro‐esophageal reflux (GER), (ii) psychopathological profile, (iii) frequency of use and clinical benefit of antisecretory drugs.

Helicobacter pylori infection does not protect against eosinophilic esophagitis: results from a large multicenter case-control study

OBJECTIVES: Rising trends in eosinophilic esophagitis (EoE) have been repeatedly linked to declining Helicobacter pylori (H. pylori) infection, mostly in retrospective studies. We aimed to prospectively evaluate this inverse association. METHODS: Prospective case‐control study conducted in 23 centers. Children and adults naïve to eradication therapy for H. pylori were included. Cases were EoE patients, whereas controls were defined by esophageal symptoms and <5 eos/HPF on esophageal biopsies. H. pylori status was diagnosed by non‐invasive (excluding serology) or invasive testing off proton pump inhibitor (PPI) therapy for 2 weeks. Atopy was defined by the presence of IgE‐mediated conditions diagnosed by an allergist. RESULTS: 808 individuals, including 404 cases and 404 controls (170 children) were enrolled. Overall H. pylori prevalence was 38% (45% children vs. 37% adults, p 0.009) and was not different between cases and controls (37% vs. 40%, p 0.3; odds ratio (OR) 0.97; 95% confidence interval (CI) 0.73‐1.30), neither in children (42% vs. 46%, p 0.1) nor in adults (36% vs. 38%, p 0.4). Atopy (OR 0.85; 95%CI 0.75‐0.98) and allergic rhinitis (OR 0.81; 95%CI 0.68‐0.98) showed a borderline inverse association with H. pylori infection in EoE patients. This trend was not confirmed for asthma or food allergy. CONCLUSIONS: H. pylori infection was not inversely associated with EoE, neither in children nor in adults. A borderline inverse association was confirmed for atopy and allergic rhinitis, but not asthma of food allergy. Our findings question a true protective role of H. pylori infection against allergic disorders, including EoE.

Traditional vs wireless intragastric pH monitoring: are the two techniques comparable?

Background  Few data are available comparing intragastric pH measured with the traditional catheter‐based and the more recent wireless system (Bravo), and also comparing intraesophageal and intragastric pH during reflux events. Aims of our study were to elucidate these points.

Eosinophilic esophagitis: latest insights from diagnosis to therapy

Eosinophilic esophagitis (EoE) represents a chronic, local immune‐mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil‐predominant inflammation. Other systemic and local causes of esophageal eosinophilia should be excluded. Clinical manifestations or pathologic data should not be interpreted in isolation. EoE was first described as a distinct disease entity in 1993. Most patients are diagnosed with underlying food allergies. The first diagnostic and therapeutic guidelines were published in 2007 with a first update in 2011. In 2017, new international guidelines were published based on the GRADE methodology. These guidelines provide, among many other topics, insights on the role of proton pump inhibitor‐responsive esophageal eosinophilia. Over the last two decades, considerable progress was made by stakeholders regarding the understanding of EoEs pathogenesis, genetic background, natural history, allergy workup, standardization of assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. This brief review provides further insights into latest diagnostic and therapeutic advances.

Rapid air infusion into the oesophagus: Motor response in patients with achalasia and nonobstructive dysphagia assessed with high-resolution manometry

Background Achalasia is a neurodegenerative disorder of the oesophagus. Alteration of motor activity induced by oesophageal distension has not been explored. Objectives To investigate this function, using high-resolution Manometry. Methods This study enrolled 15 healthy subjects, 15 nonobstructive dysphagia (NOD), and 18 achalasia patients successfully treated with pneumatic dilation (six with restored peristalsis). The three groups underwent five rapid (<1 s) intraoesophageal infusions of 20-ml air boluses, followed by eight 5-ml water swallows. Results Whereas the response rate to water swallows was similar in the three groups, air infusion induced a lower response rate in achalasia (median, interquartile range: 70%, 40–100%) and, to a lesser extent, in NOD patients (100%, 60–100%) than in healthy subjects (100%, 100–100%; p < 0.001 and p = 0.06, respectively). However, the response rate was highly variable in achalasia patients irrespective of presence of peristalsis. Furthermore, the strength of motor response to air infusion when compared to water swallows was diminished in achalasia patients but not in healthy subjects and NOD. Conclusions Motor response to rapid air infusion was variably impaired in achalasia. The role of this alteration in the long-term outcome deserves evaluation.

Effect of Cold Water on Esophageal Motility in Patients With Achalasia and Non-obstructive Dysphagia: A High-resolution Manometry Study

Background/Aims Swallowing of cold liquids decreases amplitude and velocity of peristalsis in healthy subjects, using standard manometry. Patients with achalasia and non obstructive dysphagia may have degeneration of sensory neural pathways, affecting motor response to cooling. To elucidate this point, we used high-resolution manometry. Methods Fifteen healthy subjects, 15 non-obstructive dysphagia and 15 achalasia patients, after pneumatic dilation, were studied. The 3 groups underwent eight 5 mL single swallows, two 20 mL multiple rapid swallows and 50 mL intraesophageal water infusion (1 mL/sec), using both water at room temperature and cold water, in a randomized order. Results In healthy subjects, cold water reduced distal contractile integral in comparison with water at room temperature during single swallows, multiple rapid swallows and intraesophageal infusion (ratio cold/room temperature being 0.67 [95% CI, 0.48-0.85], 0.56 [95% CI, 0.19-0.92] and 0.24 [95% CI, 0.12-0.37], respectively). A similar effect was seen in non-obstructive dysphagia patients (0.68 [95% CI, 0.51-0.84], 0.69 [95% CI, 0.40-0.97] and 0.48 [95% CI, 0.20-0.76], respectively), whereas no changes occurred in achalasia patients (1.06 [95% CI, 0.83-1.29], 1.05 [95% CI, 0.77-1.33] and 1.41 [95% CI, 0.84-2.00], respectively). Conclusions Our data suggest impairment of esophageal reflexes induced by cold water in patients with achalasia, but not in those with non obstructive dysphagia.