David Staff

Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features

BACKGROUND Eosinophilic esophagitis is an inflammatory condition in which there is dense eosinophilic infiltration of the surface lining of the esophagus. Reports of eosinophilic esophagitis pertain almost exclusively to pediatric populations. However, eosinophilic esophagitis is emerging as a clinical affliction of adults. This report describes the clinical and endoscopic findings of eosinophilic esophagitis in the largest cohort of adult patients reported to date. METHODS Twenty-nine patients (21 men, 8 women; mean age 35 years) with documented eosinophilic esophagitis (>/=15 eosinophils per high-power field in biopsy specimens) and a significant history of chronic dysphagia for solid food (24 patients) were evaluated clinically and endoscopically during a 3-year period (1999-2002). Fourteen patients (48%) had a history of asthma, environmental allergy, or atopy. In a subset of 15 patients, the diagnostic accuracy of endoscopy was compared with that of barium contrast esophagography. RESULTS Twenty-seven patients (93%) had abnormal endoscopic findings; 25 (86%) had unique esophageal structural changes, associated with a preserved mucosal surface, that were highly atypical for acid reflux injury. Structural alterations seen in adult patients with eosinophilic esophagitis may occur in combination or as a primary characteristic, e.g., uniform small-caliber esophagus, single or multiple corrugations (rings), proximal esophageal stenosis, or 1 to 2 mm whitish vesicles scattered over the mucosal surface. Barium contrast radiography combined with swallow of a barium-coated marshmallow identified 10 (67%) of the primary features observed endoscopically in 15 patients. However, radiography failed to detect other features noted at endoscopy (e.g., only 3/6 patients with proximal stenosis, 5/9 patients with concentric rings and none of 4 patients with small caliber esophagus). Eight of the 29 patients (20%) had a history of chronic heartburn. Twelve patients had been treated with a proton pump inhibitor and only 3 reported some improvement in the severity of dysphagia. CONCLUSIONS Relatively young age, a history of chronic dysphagia for solid food, and endoscopic detection of unique structural alterations atypical for GERD in an adult patient should prompt a suspicion of EE and subsequent biopsy confirmation. Acid reflux appears to have a secondary role in eosinophilic esophagitis. In an uncontrolled comparison, endoscopy was superior to barium contrast radiography for the diagnosis of eosinophilic esophagitis. The incidence of eosinophilic esophagitis in adults appears to be increasing.

Unsedated transnasal endoscopy accurately detects Barrett's metaplasia and dysplasia.

BACKGROUND Unsedated transnasal upper endoscopy has a diagnostic yield comparable with that of sedated conventional upper endoscopy. The ability of transnasal upper endoscopy to detect Barretts metaplasia or dysplastic change has not been systematically evaluated. The aim of this study was to assess the feasibility of transnasal upper endoscopy for surveillance of patients with Barretts esophagus and to evaluate its histopathologic yield for Barretts metaplasia and dysplasia. METHODS Thirty-two patients with Barretts esophagus were evaluated with conventional upper endoscopy and transnasal upper endoscopy. An effort was made to recruit patients known to have dysplasia. Quadrantic biopsy specimens were taken with standard (conventional upper endoscopy) and pediatric (transnasal upper endoscopy) biopsy forceps at procedures performed at least 1 week apart. Two blinded pathologists evaluated the specimens. RESULTS Transnasal upper endoscopy detected Barretts metaplasia histopathologically in 31 of 32 patients. Level of agreement for presence of dysplasia in biopsy specimens obtained between conventional upper endoscopy and transnasal upper endoscopy was excellent (k = 0.79). Interobserver agreement for dysplasia in specimens obtained by conventional upper endoscopy (k = 0.61) and by transnasal upper endoscopy (k = 0.61) were similar. Intraobserver agreement between conventional upper endoscopy and transnasal upper endoscopy biopsy specimens for dysplasia by pathologist 1 (k = 0.73) and pathologist 2 (k = 0.75) were also similar. No significant adverse effects were noted. CONCLUSIONS Transnasal upper endoscopy is feasible and accurate for identification and histopathologic confirmation of Barretts metaplasia with a histopathologic yield for dysplasia comparable with conventional upper endoscopy.

Volume and Yield Of Screening Colonoscopy at a Tertiary Medical Center After Change in Medicare Reimbursement

OBJECTIVE:Starting July 1, 2001, Medicare began to reimburse for screening colonoscopy in asymptomatic adults older than 50 yr with no risk factors for colorectal cancer. We sought to determine the short-term impact of the change in Medicare reimbursement on the demand for and yield of screening colonoscopy at our tertiary institution.METHODS:Asymptomatic patients older than 50 referred for first screening colonoscopy after the change in Medicare reimbursement from July 1, 2001 to December 31, 2001 were compared with a similar cohort screened before Medicare coverage for a family history of cancer or polyps during the same months the previous year (July 1, 2000 to December 31, 2000). Patient demographics, number, size, location, and histology of polyps/cancers for these screening colonoscopies were collected.RESULTS:A total of 1282 colonoscopies were performed in our institution from July 1, 2001 to December 31, 2001, 257 (20%) for screening. During the same months in the previous year, 121 of 938 colonoscopies (12.9%) were for screening (p < 0.01). This was a 55% increase in the percentage of colonoscopies performed for screening, and a 112% increase in the number of screening colonoscopies. Patients screened after the change in Medicare reimbursement were on average 5 yr older compared with patients of the previous year (62 ± 10 [mean ± SD] vs 56 ± 9 yr; p < 0.01). A total of 61 screening colonoscopies (24%) performed after the change in Medicare reimbursement had adenomatous lesions, compared with 25 (21%) screened for family history (p = ns). The number of adenomas 10 mm or larger or cancers did not differ significantly between the two groups (17 in 2001 vs 12 in 2000; p = ns). Age of 65 or older was associated with detection of adenomatous lesions (OR = 1.7; 95% CI = 1.01–2.9013).CONCLUSIONS:Since the change in Medicare reimbursement, there has been a significant increase in the number and proportion of colonoscopies performed for screening at our institution. Patients screened since this change are older, and the detection rate of neoplastic lesions is similar to those previously screened for a family history of colorectal cancer or polyps.

Unsedated transnasal endoscopy: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients

OBJECTIVES:Endoscopic screening of cirrhotics for large esophageal varices (EV) is advocated before initiation of prophylactic therapy for variceal bleeding. Conscious sedation for conventional endoscopy is problematic in cirrhotic patients because of risk of prolonged encephalopathy. Unsedated transnasal endoscopy (T-EGD) is a new technique, which allows for unsedated examination because it is well tolerated. The aims of this study were to determine whether T-EGD is feasible for screening of cirrhotic patients for presence of EV and to compare the diagnostic yield of T-EGD with conventional endoscopy for detecting and grading of EV.METHODS:Fifteen cirrhotics with no history of variceal bleeding, known EV, severe thrombocytopenia, or recurrent epistaxis were evaluated by unsedated T-EGD using a 5.3-mm outer diameter endoscope. Immediately afterward, a different endoscopist, blinded to T-EGD findings, performed sedated conventional endoscopy in standard fashion. The presence and size of EV, gastric varices, and other findings were recorded. Patient tolerance was also evaluated.RESULTS:Both modalities detected EV in the same 10 and gastric varices in the same two patients and completely agreed on size of EV. No stigmata of recent variceal bleeding were noted. Average time for unsedated T-EGD was 5 min 6 s. All patients found both procedures acceptable overall, with no significant difference in choking, discomfort, and sore throat. One patient developed self-limited epistaxis after T-EGD.CONCLUSIONS:1) EV are accurately detected and graded by T-EGD in cirrhotic patients. 2) T-EGD is a safe and less costly screening alternative for EV in cirrhotic patients.

ESOPHAGEAL DISORDERS IN THE ELDERLY

As the number of elderly in the population increases, decompensation of swallowing and airway protective mechanisms can create an increased health care burden. This article outlines the effect of aging on deglutitive function and esophageal and aerodigestive reflexes. Specific disorders in the elderly are discussed.

3559 T-egd: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients.

Background:Endoscopic screening of cirrhotic patients for large esophageal varices (EV) is advocated prior to initiation of prophylactic medical therapy for variceal bleeding. Conscious sedation for conventional endoscopy (CEGD), however, is problematic in cirrhotic patients due to the risk of prolonged encephalopathy. Previously, unsedated transnasal endoscopy (T-EGD) has been shown to be feasible for screening of cirrhotic patients for the presence of EV. Aims:Compare the diagnostic yield of T-EGD with C-EGD for detecting and grading of EV. Methods:Eleven cirrhotics (10 men, mean age 56)with no history of variceal bleeding, prior documentation of EV, severe thrombocytopenia or history of recurrent epistaxis were evaluated by T-EGD. Initially, unsedated T-EGD was done using a 5.3 mm endoscope. Immediately afterwards, a different endoscopist, blinded to the initial findings, performed sedated C-EGD. The presence and size of EV and gastric varices (GV) were recorded. Patient tolerance was evaluated based on a visual analogue scale. Results:Esophageal varices were detected by both modalities in six of eleven patients(table). No stigmata of variceal bleeding was noted by either modality. Average time for unsedated examination was 4.9 +/- 1.1 minutes. Patients found both procedures acceptable overall, with no significant difference in choking, discomfort, or sore throat. No untoward effects, including epistaxis, occurred. Conclusions:1) Esophageal varices are accurately detected and graded by T-EGD in cirrhotic patients. 2) T-EGD is a safe and less costly alternative for screening of cirrhotic patients for esophageal varices.