Jenna Craft

High-Resolution Impedance Manometry Metrics of the Esophagogastric Junction for the Assessment of Treatment Response in Achalasia

OBJECTIVES:We aimed to evaluate the value of novel high-resolution impedance manometry (HRIM) metrics, bolus flow time (BFT), and esophagogastric junction (EGJ) contractile integral (CI), as well as EGJ pressure (EGJP) and the integrated relaxation pressure (IRP), as indicators of treatment response in achalasia.METHODS:We prospectively evaluated 75 patients (ages 19–81, 32 female) with achalasia during follow-up after pneumatic dilation or myotomy with Eckardt score (ES), timed-barium esophagram (TBE), and HRIM. Receiver-operating characteristic (ROC) curves for good symptomatic outcome (ES≤3) and good radiographic outcome (TBE column height at 5 min<5 cm) were generated for each potential predictor of treatment response (EGJP, IRP, BFT, and EGJ-CI).RESULTS:Follow-up occurred at a median (range) 12 (3–291) months following treatment. A total of 49 patients had good symptomatic outcome and 46 had good radiographic outcome. The area-under-the-curves (AUCs) on the ROC curve for symptomatic outcome were 0.55 (EGJP), 0.62 (IRP), 0.77 (BFT) and 0.56 (EGJ-CI). The AUCs for radiographic outcome were 0.64 (EGJP), 0.48 (IRP), 0.73 (BFT), and 0.65 (EGJ-CI). Optimal cut-points were determined as 11 mm Hg (EGJP), 12 mm Hg (IRP), 0 s (BFT), and 30 mm Hg•cm (EGJ-CI) that provided sensitivities/specificities of 57%/46% (EGJP), 65%/58% (IRP), 78%/77% (BFT), and 53%/62% (EGJ-CI) to predict symptomatic outcome and 57%/66% (EGJP), 57%/41% (IRP), 76%/69% (BFT), and 57%/66% (EGJ-CI) to predict radiographic outcome.CONCLUSIONS:BFT, a novel HRIM metric, provided an improved functional assessment over manometric measures of EGJP, IRP, and EGJ-CI at follow-up after achalasia treatment and may help direct clinical management.

Evaluating the reliability and construct validity of the Eckardt symptom score as a measure of achalasia severity

Achalasia is a disease of mechanical esophageal dysfunction characterized by dysphagia, chest pain, regurgitation, and malnutrition. The Eckardt symptom score (ESS) is the gold standard self‐report assessment tool. Current guidelines outline a three‐step approach to patient reported outcomes measure design. Developed prior to these policies, the ESS has not undergone rigorous testing of its reliability and validity.

765 Symptom Reporting Among PPI Non Responders May Be Driven by Esophageal Hypervigilance and Not Reflux Phenotype

Background: Patients with persistent troublesome heartburn symptoms on at least a standard FDA approved dose of PPI therapy are a heterogenous group referred to as PPI nonresponders (PPINR). These patients are routinely referred for ambulatory reflux monitoring to determine the physiologic mechanism of their refractory GERD and classified into 1 of 4 phenotypes in order to determine next steps for treatment: P1(+symptom; +reflux); P2(-symptom; +reflux); P3 (+symptom, -reflux); P4(symptom, reflux). Unfortunately, research from our group has demonstrated that typical reflux parameters (symptom index, symptom associated probability, acid exposure, symptom reflux correlation) are of limited value in explaining PPINR and do not really inform treatment. We hypothesized that while mechanisms for persistent reflux despite PPI use may differ physiologically, PPINR may share features of esophageal hypersensitivity and hypervigilance, which independently drive symptom experience. Methods: PPINRs were taken off PPIs for 10 days prior to undergoing upper endoscopy with 96h Bravo ph capsule placement at an academic Esophageal Center. Patients were categorized into reflux phenotypes based on results of pH testing. Patients also completed the GERDQ and other questionnaires focused on hypersensitivity, hypervigilance, and psychological distress. Data was analyzed in SPSSv21 using oneway ANOVA and linear regression. Descriptive data is reported as means and standard deviation. Results: 66 patients participated [mean age = 50.0(13.7)yrs, 44%male]. Phenotypes (P) did not statistically differ from each other on any questionnaire variables. Psychological distress parameters (depression, anxiety, somatization) were within normal limits for all groups. Heartburn catastrophizing was elevated but not different in P3 (+,-). Visceral hypersensitivity was elevated but not

The Reflux Improvement and Monitoring (TRIM) Program Is Associated With Symptom Improvement and Weight Reduction for Patients With Obesity and Gastroesophageal Reflux Disease.

Objectives:Current healthcare systems do not effectively promote weight reduction in patients with obesity and gastroesophageal reflux disease (GERD). The Reflux Improvement and Monitoring (TRIM) program provides personalized, multidisciplinary, health education and monitoring over 6 months. In this study we aimed to (i) measure the effectiveness of TRIM on GERD symptoms, quality of life, and weight, and (ii) examine patient health beliefs related to TRIM.Methods:This prospective mixed methods feasibility study was performed at a single center between September 2015 and February 2017, and included adult patients with GERD and a body mass index ≥30 kg/m2. Quantitative analysis consisted of a pre- to post-intervention analysis of TRIM participants (+TRIM Cohort) and a multivariable longitudinal mixed model analysis of +TRIM vs. patients who declined TRIM (−TRIM Cohort). Primary outcomes were change in patient-reported GERD symptom severity (GerdQ) and quality of life (GerdQ-DI), and change in percent excess body weight (%EBW). Qualitative analysis was based on two focus groups of TRIM participants.Results:Among the +TRIM cohort (n=52), mean baseline GerdQ scores (8.7±2.9) decreased at 3 months (7.5±2.2; P<0.01) and 6 months (7.4±1.9; P=0.02). Mean GerdQ-DI scores decreased, but did not reach statistical significance. Compared with the −TRIM cohort (n=89), reduction in %EBW was significantly greater at 3, 6, and 12 months among the +TRIM cohort (n=52). In qualitative analysis, patients unanimously appreciated the multidisciplinary approach and utilized weight loss effectively to improve GERD symptoms.Conclusions:In this mixed methods feasibility study, participation in TRIM was associated with symptom improvement, weight reduction, and patient engagement.

The relationship between esophageal acid exposure and the esophageal response to volumetric distention

Increased esophagogastric junction (EGJ) distensibility is thought to contribute to gastroesophageal reflux disease (GERD). Using the functional lumen imaging probe (FLIP), we aimed to assess the esophageal response to distension among patients undergoing esophageal pH monitoring.

The Upper Esophageal Sphincter Assist Device is Associated with Symptom Response in Reflux Associated Laryngeal Symptoms

&NA; Reflux‐associated laryngeal symptoms (RALS) is the process in which chronic laryngeal symptoms are related to gastroesophagopharyngeal reflux.1 Impairment of upper esophageal sphincter (UES) reflexes may predispose to esophagopharyngeal reflux.1 The novel noninvasive nonpharmacologic UES assist device (UESAD) applies external cricoid pressure to augment intraluminal UES pressure by 20 to 30 mm Hg and reduce esophagopharyngeal reflux events.2 This study aimed to assess the therapeutic efficacy of the UESAD in a pragmatic clinical setting, and to identify factors associated with symptom response among patients with suspected RALS.