George E. Burdick

Opioid-Induced Esophageal Dysfunction (OIED) in Patients on Chronic Opioids

OBJECTIVES:Bowel dysfunction has been recognized as a predominant side effect of opioid use. Even though the effects of opioids on the stomach and small and large intestines have been well studied, there are limited data on opioid effects on esophageal function. The aim of this study was to compare esophageal pressure topography (EPT) of patients taking opioids at the time of the EPT (≤24 h) with chronic opioid users who were studied off opioid medications for at least 24 h using the Chicago classification v3.0.METHODS:A retrospective review identified 121 chronic opioid users who completed EPT between March 2010 and August 2012. Demographic and manometric data were compared between the two groups using general linear models or χ2.RESULTS:Of the 121 chronic opioid users, 66 were studied on opioid medications (≤24 h) and 55 were studied off opioid medications for at least 24 h. Esophagogastric junction (EGJ) outflow obstruction was significantly more prevalent in patients using opioids within 24 h compared with those who did not (27% vs. 7%, P=0.004). Mean 4 s integrated relaxation pressure was also significantly higher in patients studied on opioids (10.71 vs. 6.6 mm Hg, P=0.025). Resting lower esophageal sphincter pressures tended to be higher on opioids (31.61 vs. 26.98 mm Hg, P=0.25). Distal latency was significantly lower in patients studied on opioids (6.15 vs. 6.74 s, P=0.044).CONCLUSIONS:Opioid use within 24 h of EPT is associated with more frequent EGJ outflow obstruction and spastic peristalsis compared with when opioid use is stopped for at least 24 h before the study.

Interrater and Intrarater Agreement of the Chicago Classification of Achalasia Subtypes Using High-Resolution Esophageal Manometry

OBJECTIVES:Subclassification of achalasia based on high-resolution manometry (HRM) may be clinically relevant because response to therapy may vary by subtype. However, the consistency and reliability of subtyping achalasia patients based on HRM remains undefined. The objectives of this study were to assess interrater and intrarater agreement (reliability) of achalasia subtyping using the Chicago classification, and to evaluate the diagnostic consistency between clinicians interpreting HRM.METHODS:After receiving training on the classification criteria, five raters classified 20 achalasia and 10 non-achalasia cases in separate sessions 1 week apart. To further assess agreement, two raters classified all 101 available achalasia HRMs. Agreement for the classification of subtypes of achalasia was calculated using Cohens κ and Krippendorffs α-reliability estimate.RESULTS:Estimates of agreement among raters was good during both sessions (α=0.75; 95% confidence interval=0.69, 0.81 and α=0.75; 95% confidence interval=0.68, 0.81). Both interrater (κ=0.86–1.0) and intrarater (κ=0.86–1.0) agreement were very good for type III achalasia. Agreement between types I and II was more variable. Reliability was improved when type I and type II were combined (α=0.84; 95% confidence interval=0.78, 0.89). When all available cases were classified by two experienced raters, agreement was very good (κ=0.81; 95% confidence interval=0.71, 0.91).CONCLUSIONS:Interobserver and intraobserver agreement for differentiating achalasia from non-achalasia patients using HRM and the Chicago classification was very good to excellent. More variability was seen in agreement when classifying achalasia subtypes. The most variation was observed in classification between type I and type II achalasia, which have similar characteristics. Clearly, differentiating between panesophageal pressurization and compartmentalization should improve discrimination between these subtypes.

Comparison of the impact of wireless versus catheter-based pH-metry on daily activities and study-related symptoms

Aims To evaluate the variation in tolerance to wireless pH-metry compared with catheter-based pH-metry, and to determine clinical characteristics that might predict reduced tolerance to wireless pH-metry. Methods Consecutive outpatients (n=341) completing wireless (n=234) or catheter-based pH-metry (n=106) were evaluated. All patients completed the pH-Metry Impact Scale and the pH-Metry Symptoms Scale to assess the impact of the pH-metry on activities of daily living and pH-metry associated changes in study-related symptoms. All data are presented as mean (SD) or odds ratios (95% confidence interval). Results The impact of pH-metry on activities of daily living were modest, but wireless pH-metry had less impact than catheter-based pH-metry (P=0.01). A sense of foreign body in the chest, chest discomfort, and chest pain were reported more frequently during wireless pH-metry. Difficulty swallowing and painful swallowing were more common during catheter-based pH-metry. Noncardiac chest pain was associated with increased symptom severity. Patients with poor tolerance were twice as likely to have a diagnosis of noncardiac chest pain (odds ratio=2. 53; 95% confidence interval, 1.4-4.6). Conclusions Wireless pH-metry has less of an impact on activities of daily living but is not associated with fewer study-related symptoms compared with catheter-based pH-metry. The prevalence of specific study-related symptoms does differ between the 2 groups and noncardiac chest pain seems to be the primary risk factor for more severe study-related symptoms and reduced tolerance for wireless pH-metry. This information may be useful in helping to decide which patients should undergo the wireless pH-metry or receive additional counseling on procedural expectations.

Gastroscopic demonstration of a jejunogastric intussusception

Another case of retrograde jejunogastric intussusception is added to the worlds sparse literature. An endoscopic technique is described for demonstrating the transient form of this entity. With this technique, more suspected cases may be confirmed endoscopically.

996 Achalasia Subtypes: an Assessment of Inter- And Intra-Rater Reproducibility

of the c-kit gene in a case control-study of achalasia. Method: Eighty eight achalasia patients diagnosed by esophageal manometry and 101 healthy controls were included in the study. Genomic DNA was isolated from the peripheral blood, amplified and the results were analyzed using melting curve analysis. Results: The T allele at the rs6554199 locus was significantly associated with achalasia (p=0.03 OR: 1.55; 95%CI, 1.03-2.34). In a T dominant model, TT+GT genotype was significantly more frequent in achalasia patients (80.7%) than controls (65.3%) (p=0.02; OR: 2.21; %95CI, 1.13-4.32). Within the achalasia group, the presence of the G allele (GG+GT) increases the occurrence of regurgitation (p=0.008; OR: 5.09; 95% CI 1.56-16.58). The polymorphism at rs2237025 was not associated with achalasia. Conclusion: The T allele at rs6554199 of the c-kit gene is significantly associated with achalasia in this population. The functional consequences of this variant in achalasia remain to be determined. The distribution of rs6554199 polymorphism