Dawn L. Francis

Achalasia: Update on the Disease and Its Treatment

Epidemiology Most studies that evaluate the epidemiology of achalasia are retrospective. Studies on he incidence and prevalence of achalasia come mostly rom the United Kingdom, but there have been also tudies of diverse populations such as Northern Europe, srael, New Zealand, the United States, and Zimbabwe.1–5 hese studies indicate that the incidence is approxiately 1 in 100,000 individuals annually and the prevaence is 10 in 100,000. There is no gender predominance nd the disease can occur at any age, although diagnosis efore the second decade is rare6 and the incidence inreases with age, with the highest incidence in the sevnth decade7 and a second smaller peak of incidence at 0 – 40 years of age.8

Occurrence of and risk factors for complications after endoscopic dilation in eosinophilic esophagitis

BACKGROUND Several small series have suggested an increased risk of complications associated with esophageal dilation in patients with eosinophilic esophagitis (EoE). OBJECTIVE To quantitate the risk and identify risk factors for esophageal complications in dilation in EoE patients. DESIGN Retrospective, uncontrolled, single-center study. SETTING Tertiary referral hospital. PATIENTS A total of 161 EoE patients (mean ± standard deviation age 44.3 ± 15.3 years, 112 men, 49 women, 150 white patients, 10 unknown, 1 Asian). INTERVENTIONS Through-the-scope balloon or Savary dilation of EoE. MAIN OUTCOME MEASUREMENTS The rate of complications defined as deep mucosal tear, major bleeding, or perforation, and determination of risk factors for complications. RESULTS A total of 293 dilations were performed in 161 patients. Complications reported were deep mucosal tear in 9.2% (n = 27), major bleeding in 0.3% (n = 1), and immediate perforation in 1.0% (n = 3). All patients with perforations were successfully treated medically without surgery (mean ± standard deviation hospital stay 5.3 ± 3.2 days). Factors associated with an increased risk of complications were luminal narrowing in the upper (odds ratio [OR], 5.62; 95% CI, 2.07-15.26; P < .001) and middle third of the esophagus (OR, 4.93; 95% CI, 1.64-14.83; P < .005) compared with lower third, luminal stricture unable to be traversed with a standard upper endoscope (OR, 2.48; 95% CI, 1.06-5.83; P = .037), and use of Savary dilator (OR, 2.63; 95% CI, 1.18-5.83; P = .018). LIMITATIONS Retrospective design, uncontrolled study. CONCLUSIONS Deep mucosal tears are common after dilation (9%), but the risk of immediate transluminal perforation with EoE is approximately 1%. The risk of severe complications is increased in patients with more proximal stricture and strictures that initially prevent endoscope passage.

Symptoms Have Modest Accuracy in Detecting Endoscopic and Histologic Remission in Adults With Eosinophilic Esophagitis

BACKGROUND & AIMS It is not clear whether symptoms alone can be used to estimate the biologic activity of eosinophilic esophagitis (EoE). We aimed to evaluate whether symptoms can be used to identify patients with endoscopic and histologic features of remission. METHODS Between April 2011 and June 2014, we performed a prospective, observational study and recruited 269 consecutive adults with EoE (67% male; median age, 39 years old) in Switzerland and the United States. Patients first completed the validated symptom-based EoE activity index patient-reported outcome instrument and then underwent esophagogastroduodenoscopy with esophageal biopsy collection. Endoscopic and histologic findings were evaluated with a validated grading system and standardized instrument, respectively. Clinical remission was defined as symptom score <20 (range, 0-100); histologic remission was defined as a peak count of <20 eosinophils/mm(2) in a high-power field (corresponds to approximately <5 eosinophils/median high-power field); and endoscopic remission as absence of white exudates, moderate or severe rings, strictures, or combination of furrows and edema. We used receiver operating characteristic analysis to determine the best symptom score cutoff values for detection of remission. RESULTS Of the study subjects, 111 were in clinical remission (41.3%), 79 were in endoscopic remission (29.7%), and 75 were in histologic remission (27.9%). When the symptom score was used as a continuous variable, patients in endoscopic, histologic, and combined (endoscopic and histologic remission) remission were detected with area under the curve values of 0.67, 0.60, and 0.67, respectively. A symptom score of 20 identified patients in endoscopic remission with 65.1% accuracy and histologic remission with 62.1% accuracy; a symptom score of 15 identified patients with both types of remission with 67.7% accuracy. CONCLUSIONS In patients with EoE, endoscopic or histologic remission can be identified with only modest accuracy based on symptoms alone. At any given time, physicians cannot rely on lack of symptoms to make assumptions about lack of biologic disease activity in adults with EoE. ClinicalTrials.gov, Number: NCT00939263.

Results of ambulatory pH monitoring do not reliably predict response to therapy in patients with eosinophilic oesophagitis

Aliment Pharmacol Ther 2012; 35: #–#

Diagnosis and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical, atypical and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms, these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations, further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis, peptic stricture, Barretts esophagus, esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification, medical therapy and surgical therapy. Lifestyle modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids, histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy, others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gastroesophageal reflux disease.

A Quality Initiative to Decrease Pathology Specimen–Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center

OBJECTIVES:Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen-labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site and correct patient by both the endoscopy nursing staff and the endoscopist for each specimen bottle.METHODS:We reviewed the number of specimen-labeling errors from our endoscopy unit for the first 3 months of 2007, before the implementation of the initiative, and for the first 3 months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two-provider confirmation of correct site, correct patient specimen labeling. The RFID system we used was an off-the-shelf 3M (St. Paul, MN) Library Sciences RFID system modified and installed for our purposes. Specimen-labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) or Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischers exact test was used to compare the rate of specimen-bottle labeling errors before and after the initiation of this new system.RESULTS:In the first 3 months of 2007, our endoscopy unit sent 8,231 specimen bottles to our pathology laboratory for evaluation; 8,539 bottles were sent in the first 3 months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P<0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and 10 (0.12%) in the first quarter of 2008 (P<0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected before the processing of the specimens in the pathology laboratory (P=0.001).CONCLUSIONS:These data confirm that the initiation of a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by two health-care providers significantly decreased specimen-labeling errors at every level in a high-volume endoscopy center.

Time of day variation in polyp detection rate for colonoscopies performed on a 3-hour shift schedule

BACKGROUND Recent research suggests that the colonoscopy polyp detection rate (PDR) varies by time of day, possibly because of endoscopist fatigue. Mayo Clinic Rochester (MCR) schedules colonoscopies on 3-hour shifts, which should minimize fatigue. OBJECTIVE To examine PDR variation with the MCR shift schedule. DESIGN Retrospective cohort. SETTING Outpatient tertiary-care center. PATIENTS This study involved completed outpatient colonoscopies in 2008. Procedures were excluded for lack of withdrawal time stamps, indications other than average-risk screening, inadequate bowel preparation, fellow participation, or performance by endoscopists with a low number of endoscopies performed. INTERVENTION None. MAIN OUTCOME MEASUREMENTS PDR (colonoscopies with ≥1 polyp divided by total number of colonoscopies) by shift of day. RESULTS We analyzed 3846 colonoscopies. PDR varied significantly by shift (P = .008) on univariate analysis; results for shifts 1 and 3 were similar (39.0% vs 38.7%, respectively) whereas shift 2 had the highest PDR (44.7%). Mean withdrawal times were stable (P = .92). PDR also varied significantly (P < .0001) by month of year on univariate analysis. On multivariate analysis, patient age (P < .0001), patient gender (P < .0001), endoscopist mean withdrawal time (P < .0001), month of year (P = .0002), endoscopist experience (P = .04), and shift of day (P = .048) significantly predicted PDR. LIMITATIONS Retrospective study. CONCLUSION MCRs 3-hour shift schedule does not show a decrease in PDR as the day progresses, as seen in other recent studies. Intervention trials at other institutions could determine whether alterations in shift length lead to PDR improvements.

Inter-observer agreement for multichannel intraluminal impedance-pH testing

Twenty-four-hour ambulatory multichannel intraluminal impedance (MII)-pH detects both acid and nonacid reflux (NAR). A computer-based program (Autoscan™, Sandhill Scientific, Highlands Ranch, CO, USA) automates the detection of reflux episodes, increasing the ease of study interpretation. Inter-observer agreement between multiple reviewers and with Autoscan™ for the evaluation of significant NAR with MII-pH has not been studied in the adult population. Twenty MII-pH studies on patients taking a proton pump inhibitor twice daily were randomly selected. Autoscan™ analyzed all studies using the same pre-programmed parameters. Four reviewers interpreted the MII-pH studies, adding or deleting reflux episodes detected by Autoscan™. Positive studies for NAR and total reflux episodes were based on published criteria. Cohens kappa statistic (κ) evaluated inter-observer agreement between reviewers and Autoscan™ analysis. The average κ for pathologic NAR between reviewers was 0.57 (0.47-0.70), and between reviewers and Autoscan™ was 0.56 (0.4-0.8). When using the total reflux episode number as a marker for pathologic reflux (acid and NAR), the κ score was 0.72 (0.61-0.89) between reviewers, and 0.74 (0.53-0.9) when evaluating total reflux episodes. Two reviewers agreed more often with each other and with Autoscan™ on the number of NAR episodes, while the other two reviewers agreed with each other, but did not agree with either Autoscan™ or the first two reviewers. Inter-observer agreement between reviewers and Autoscan™ for detecting pathologic NAR is moderate, with reviewers either excluding more of the Autoscan™-defined events or excluding fewer events and therefore agreeing with Autoscan™.

Prevalence of Esophageal Eosinophils in Patients With Barrett ' s Esophagus

OBJECTIVES:Recent studies have demonstrated high esophageal eosinophil counts in patients with GERD similar to eosinophilic esophagitis (EoE) yet the frequency of esophageal eosinophilia in GERD is unknown. Our aim was to determine the prevalence of dense esophageal eosinophilia in patients with Barretts esophagus as a manifestation of GERD.METHODS:The Mayo Clinic pathology database was reviewed for patients diagnosed with Barretts esophagus from January to December 2008 with squamous mucosa obtained during endoscopic surveillance. Clinical, endoscopic, and histologic findings were reviewed. Patients with ≥15 eosinophils per high powered field were identified and compared to those without esophageal eosinophilia.RESULTS:Two hundred patients with Barretts esophagus and squamous tissue obtained at the time of biopsy were identified. Fourteen of the 200 patients (7%) had ≥15 eosinophils per high powered field. Demographics, symptoms, and proton pump inhibitor therapies were similar between those with and without esophageal eosinophilia. Endoscopic features suggestive of EoE were found in the squamous mucosa of 2 patients with and 7 patients without esophageal eosinophilia. Use of photodynamic, radiofrequency ablation, or monopolar electrocoagulation therapy for ablation of Barretts mucosa was not associated with a higher rate of esophageal eosinophilia. Basal cell hyperplasia, papillary elongation, and spongiosis occurred frequently in association with esophageal eosinophilic infiltration.CONCLUSIONS:High esophageal eosinophil counts were found in 7% of this cohort of 200 patients with Barretts esophagus and likely underestimates prevalence. The finding of esophageal eosinophilia in this cohort was independent of proton pump inhibitor use, features of EoE, or endoscopic therapy for Barretts esophagus. Further studies are needed to assess if these findings are applicable to all patients with GERD.

Proximal black esophagus: a case report and review of the literature

A 79-year-old man presented to an outside hospital with retrosternal chest pain associated with lightheadedness, diaphoresis, and dyspnea. He had a medical history of coronary artery disease, diabetes mellitus, hypertension, and chronic renal insufficiency. Home medications included pioglitazone, metoprolol, furosemide, calcitriol, allopurinol, and cetirizine. At presentation, his blood pressure was 81/53 mm Hg (normal 90-119/60-79 mm Hg), with a heart rate in the range of 30 beats/min (60-100 beats/min), and was treated with intravenous fluids and atropine. An electrocardiogram showed changes consistent with an inferior myocardial infarction. He was given aspirin, heparin, metoprolol, and reteplase, and was transferred to our facility. On admission to our hospital, the patient was asymptomatic and hemodynamically stable. Repeat electrocardiogram showed resolving STelevation in the inferior leads and continuous ST depression over the anterior leads. Coronary catheterization revealed an 80% obstructing circumflex lesion and a 100% proximal right coronary occlusion. Coronary angioplasty was performed, and a drug-eluting stent was deployed into the distal circumflex artery. Clopidogrel was then initiated. Several hours later, the patient experienced a single episode of hematemesis. There was no associated melena or abdominal pain. He had no history of alcohol use, liver disease, varices, peptic ulcer disease, abdominal aortic surgery, nonsteroidal anti-inflammatory drug use, gastroparesis, or previous GI bleeding. Physical examination was unremarkable. Pertinent laboratory studies included a hemoglobin level of 11.3 g/dL (13.5-17.5 g/dL), platelet count of 121 10/L (150-450 10/L), blood urea nitrogen of 44 mg/dL (8-24 mg/dL), and a creatinine level of 5.1 mg/dL (0.8-1.3 mg/dL). An upper endoscopy showed a 5-cm–long circumferential area of black macerated tissue with adherent clot located 22 cm from the central incisors (Fig. 1). The clot was removed, revealing only macerated mucosa underlying it. Biopsy specimens were not taken because the patient was immunocompetent and did not report a history of odynophagia. Review of the patient’s admission medications revealed no medications commonly associated with pill esophagitis. The patient was started on pantoprazole, given twice daily, and continued on aspirin, clopidogrel, metopro-