Kornilia Nikaki

Adult and paediatric GERD: diagnosis, phenotypes and avoidance of excess treatments.

Detailed investigations and objective measurements in patients with symptoms of gastro-oesophageal reflux should be performed with the intent of making the correct diagnosis, thus enabling choice of appropriate therapy. Establishing the most effective therapy is particularly important in adults who do not respond to standard treatment and in children. The use of PPIs for suspected GERD has increased substantially over the past decade, providing great relief in patients with acid-related symptoms, but also leading to adverse effects and a considerable economic burden. Adults with functional heartburn do not benefit from PPIs, while prolonged PPI use in patients with extraoesophageal symptoms remains a controversial area. Moreover, PPIs are not indicated in infants with GERD unless symptoms are proven to be acid-related. With regard to antireflux surgery, patients must be carefully selected to avoid the need for ongoing PPI treatment postoperatively. Correct diagnosis and phenotyping of patients with symptoms attributed to gastro-oesophageal reflux through detailed investigations is therefore imperative, leading to improved patient outcomes and rationalized use of available treatment options. In this Review, we outline currently available diagnostic tests and discuss approaches to limit any unnecessary medical or surgical interventions.

Assessment of intestinal malabsorption.

Significant efforts have been made in the last decade to either standardize the available tests for intestinal malabsorption or to develop new, more simple and reliable techniques. The quest is still on and, unfortunately, clinical practice has not dramatically changed. The investigation of intestinal malabsorption is directed by the patients history and baseline tests. Endoscopy and small bowel biopsies play a major role although non-invasive tests are favored and often performed early on the diagnostic algorithm, especially in paediatric and fragile elderly patients. The current clinically available methods and research tools are summarized in this review article.

Chronic recurrent multifocal osteomyelitis and inflammatory bowel disease.

ABSTRACT Chronic recurrent multifocal osteomyelitis (CRMO) has been reported in association with inflammatory bowel disease (IBD), mostly in children. We describe the UK paediatric experience of CRMO and IBD and review the global literature. Three cases of CRMO and IBD were identified in UK children during the last 10 years. This adds to the previously published 24 cases worldwide (15 children). We provide further evidence for the true association of CRMO and IBD, and a greater understanding of disease course. CRMO may be considered a rare extraintestinal complication of IBD.

200ml Rapid Drink Challenge During High Resolution Manometry Predicts Oesophago-Gastric-JunctionObstruction Detected by Timed Barium Oesophagogram with High Sensitivity and Specificity

Introduction In patients with dysphagia, confirmation of obstruction at the oesophago-gastric junction (OGJ) is used to decide further endoscopic or surgical therapy. This is true for both untreated and treated patients with persistent dysphagia. A 200 ml rapid drink challenge (RDC) during high resolution manometry (HRM) may aid diagnosis of oesophageal motility disorders (Marin &Serra NGM 2016). Timed barium oesophagogram (TBO) detects impaired oesophageal emptying of liquids. We hypothesised that O-G pressure parameters during RDC could predict pathologic barium column in TBO. We aimed to assess the ability of RDC to diagnose obstruction at the OGJ in a group of untreated and treated patients with dysphagia. Method 30 patients with dysphagia (mean age 50y) were prospectively included. All patients underwent HRM (Medtronic; Sandhill) with standard protocol plus RDC followed by TBO. HRM analysis was in accordance with the Chicago Classification v3.0. Analysis of RDC included all parameters described by Marin & Serra 2016; cutoff points for each were determined using a ROC curve analysis. During TBO, oesophageal emptying was assessed at minutes 1, 3 and 5. Persistent barium column at 5 min was diagnostic of OGJ obstruction. Results Of 30 patients, 19 patients were untreated; 11 patients were previously treated (5 dilation, 6 myotomy). HRM diagnoses: 3 normal, 23 achalasia (type I=4, II=18, III=1), 1 aperistalsis, 1 distal oesophageal spasm. Overall, the RDC parameter that best predicted OGJ obstruction during TBO was IRP/200 ml (cutoff >17mmHg: sensitivity=75%, specificity=90%). Subgroup analysis: Prediction of obstruction during TBO by the RDC test further improved in the untreated group (sensitivity 100%; specificity 85.5%) but not for the treated group (sensitivity 50%; sensitivity 66%). Abstract PTH-138 Table 1 All patients (n=30) Abstract PTH-138 Table 2a Untreated population (n=19) Abstract PTH-138 Table 2b Treated population (n=11) Conclusion RDC during HRM is a useful adjuvant to improve diagnosis of OGJ obstruction, particularly in untreated dysphagia. Disclosure of Interest S. Sonmez: None Declared, J Arguero: None Declared, J Ooi: None Declared, K Nakagawa: None Declared, E Glasinovic: None Declared, P Woodland: None Declared, E Yazaki: None Declared, D Sifrim Conflict with: Reckitt Benckiser (Hull, UK); Sandhill Scientific (CO, USA)

Measurement of Salivary Pepsin to Detect Gastroesophageal Reflux Disease Is Not Ready for Clinical Application

&NA; A noninvasive test for gastroesophageal reflux disease (GERD) is desirable for adults and children. Salivary pepsin measurement has been proposed as such a test.1–3 A previous study from our group demonstrated that a maximal salivary pepsin cutoff of >210 ng/mL using the PepTest device (RD Biomed, Hull, United Kingdom) had excellent specificity of 96% but modest sensitivity of 44% to diagnose GERD,4 leading to optimism about its potential use. In this study, we aimed to confirm the previously reported sensitivity and specificity in healthy volunteers and patients with heartburn, evaluate the association between a positive PepTest and response to proton pump inhibitor (PPI) therapy, assess if test‐sensitivity can be improved for GERD when samples are taken over a 72‐hour sampling period, and establish normal values of salivary pepsin in infants.

Effect of Cognitive Behavioural Therapy On Supragastric Belching and Acid Reflux

Introduction Supragastric belching (SGB) is considered a behavioural disorder. SGB can manifest as a large number of belch episodes during daytime, or can be associated with reflux symptoms or rumination. Supragastric belches can be immediately followed by acid reflux and in some GORD patients, SGB-associated reflux can contribute to up to 1/3 of the total acid exposure (AET) (Koukias, 2015). Current treatments for SGB are cognitive behavioural therapy (CBT) and Baclofen. We hypothesised that reducing SGB might improve QOL and reduce acid GOR. The aim of our study was to assess the effectiveness of CBT on subjective and objective outcomes in patients with pathological SGB. Method Patients were recruited from the upper GI Physiology Unit after performance of pH-impedance (Sandill Sci, USA). Visual analysis of tracing was performed to identify SGB and patients with more than 13 SGB/day were invited to participate. Patients attended a total of 5 CBT sessions. The CBT protocol was adapted from Katzka et al (2013) and consisted of teaching 1. diaphragmatic breathing, 2. mouth opening/tongue position and 3. recognition of a warning signal/feeling pre-belching. Patients exercised these manoeuvres daily and tried to apply them to prevent belching. Before and after CBT, subjective evaluation included a 4-item visual analogue scale (VAS) regarding severity of belching. Objective evaluation included pH-impedance at baseline and after CBT. Parameters were number of SGB, the acid exposure time, and proportion of AET associated with SGB. Results 45 patients were recruited since March 2016. So far, 21 patients completed the protocol (age: 44, (21-72), 10 females) of which 17 had a second pH-impedance study. Subjective evaluation: VAS scores decreased after CBT in 20/21 patients [before: 250 (210-310) mm vs. after: 130(80-200) mm, p 50%. Objective evaluation: Number of SGB decreased significantly after CBT in 15/17 patients [before: 90 (51-228) vs. after 45 (24-149), p=0.0041]. 8/17 patients had reduction of SGB by more than 50%. Ten patients had increased AET pre-treatment, [AET: 8.6 (SEM 0.93). In these patients SGB contributed to 32% of the AET. Overall, AET after CBT was: 6.08 (SEM 0.82), p=0.06). In 5/10 patients with baseline increased AET, we observed after CBT a reduction of number of reflux episodes driven by SGB and AET (by 31.5%). Conclusion Cognitive behavioural therapy ameliorates supragastric belching. It reduces the number of belches and improves social and daily activities in 50% of patients. Careful analysis of pH-impedance allows identification of a subgroup of GORD patients with acid reflux predominantly driven by SGB. In these patients, CBT can reduce daytime esophageal acid exposure. Disclosure of Interest E. Glasinovic: None Declared, E. Wynter: None Declared, J. Arguero: None Declared, J. Ooi: None Declared, P. Hajek: None Declared, D. Sifrim Conflict with: Reckitt Benckiser (Hull, UK); Sandhill Scientific (CO, USA)

The Diagnostic Yield of Gastric pH-Metry During Ambulatory Gastro-Oesophageal Reflux Monitoring

Introduction Catheter-based ambulatory monitoring to study gastro-oesophageal reflux (GER) is conventionally performed using a single pH sensor to detect intra-oesophageal acid. A less-often used system is a dual pH catheter, allowing simultaneous measurement of oesophageal and gastric pH. In our tertiary referral GI Physiology Unit, we routinely perform pHmetry or impedance-pHmetry using dual-pH sensor probes for concurrent oesophageal and gastric pH monitoring. Aim: To evaluate the additional diagnostic yield associated with using gastric pHmetry analysis during gastro-oesophageal reflux pH monitoring. Method We retrospectively evaluated 2916 dual pH reflux studies done in our unit between 2009 and 2016 (pH-only or combined pH-impedance). In patients having ‘off’ PPI studies we looked for evidence of prolonged gastric pH buffering by meals that provoked further investigation with gastric emptying study, and for evidence of gastric achlorhydria. In patients having ‘on’ PPI studies (for investigation of reflux refractory to PPI therapy) we evaluated whether inadequate gastric acid suppression (defined as gastric pH >4 for>50% of study period1) could be seen on gastric pH monitoring. Results 271 patients (9.4%) had studies performed ‘on’ the patient’s current proton pump inhibitor therapy (PPI) to investigate refractory GORD symptoms. 150/271 patients (55% of ‘on PPI’ studies) were shown to require escalation of treatment, due to inadequacy of gastric acid suppression (defined as gastric pH >4 for>50% of 1) The gastric pH profile further contributed to the diagnostic workup in 135 patients studied ‘off’ acid suppressive therapy (5% of ‘off PPI’ cohort). 111 patients with overlapping symptoms of reflux and dyspepsia had prolonged postprandial elevation of gastric pH period study2, prompting suspicion of gastroparesis. 72/111 underwent formal gastric emptying testing on 13C-octanoic acid breath test or scintigraphy, and 59/72 were confirmed to have delayed gastric emptying. Finally, latent gastric achlorhydria (gastric pH >4 for the entire study period) was discovered in 24 patients, thus explaining PPI failure and obviating the need to continue PPI for presumed acid reflux. Conclusion For small extra cost (£5 per study in the UK) and no additional labour (automated gastric pH analysis), intragastric pH profiling in routine GER monitoring contributes to diagnostic yield and subsequent clinical management in three ways: 1) assessing adequacy of gastric acid suppression ‘on PPI’ in the event of persistent symptoms; 2) suggesting underlying gastroparesis in reflux-dyspepsia overlap syndromes; 3) revealing latent gastric achlorhydria. References . Bonapace ES, et al. Dig Dis Sci. 2000Jan;45(1):34–9. . Ooi & Glasinovic, et al. UEG Journal 2016;4(5S):A157–A720.A497.[P0991] Disclosure of Interest J. Ooi: None Declared, P Woodland Conflict with: Reckitt Benckiser (Hull, UK), E Glasinovic: None Declared, K Nikaki: None Declared, S Sonmez: None Declared, E Yazaki: None Declared, D Sifrim Conflict with: Reckitt Benckiser (Hull, UK); Sandhill Scientific (CO, USA)

PTU-129 Ambulatory High Resolution Oesophageal Manometry: A Novel Tool to Investigate Non-Cardiac Chest Pain

Introduction Non-cardiac chest pain can present a clinical challenge to the gastroenterologist. Many causes remain undiagnosed and untreated. Oesophageal spasm is frequently considered a cause of non-cardiac chest pain, but current diagnostic tools are often poor at making this diagnosis. High resolution oesophageal manometry is now the gold standard oesophageal motility test, and is a swallow-based assessment. Unfortunately most episodes of chest pain in this context are not swallow-related, and are usually sporadic and unpredictable. Thus most manometry assessments occur in the absence of a symptom event. We propose that prolonged, ambulatory high resolution may be a tool that can detect these sporadic chest pain events and allow correlation to symptom episodes. We aimed to test the diagnostic yield of a novel, ambulatory high resolution oesophageal manometry device in the diagnosis of non-cardiac chest pain. Methods We studied 17 patients (7 male, 10 female, age range 14 to 66) with chest pain. All had cardiac pain excluded by cardiology review, and all had been studied with normal upper GI endoscopy. All had also had major oesophageal motor disorder (including spasm) excluded by swallow-based high resolution manometry (with liquid and solid swallows). An ultra-thin high resolution solid-state catheter was inserted transnasally into the oesophagus. This was connected to a small laptop and battery pack carried in a backpack. Patients were sent home and encouraged to mobilise. Patients were asked to keep the catheter in place at least until a symptomatic pain event was perceived. Symptom events were self-marked on a recorder device that was subsequently synchronised with the manometry output. Manometry tracings were read manually, and motor events at the time of symptoms were examined in detail. Results The median duration of recording with the system was 12 hours, 13 minutes (range 5 hours, 30 minutes to 26 hours, 40 minutes). 12 of the 17 patients perceived typical chest pain symptom during recording. Of the 12 with typical symptoms, 3 (25%) had clinically important findings that changed management. They had significant oesophageal spasm, pressurisation and shortening associated with pain events. These have been treated successfully with oesophageal body Botox injections (2 patients) and with long laparoscopic myotomy (1 patient). The remaining 9 patients either had no abnormalities, or minor abnormalities that did not correspond to symptoms. Conclusion Ambulatory high-resolution manometry is a novel tool for investigation of non-cardiac chest pain. In our series, we identified management-altering abnormalities in 3 of 17 patients who had previously been investigated with normal cardiac, endoscopic and stationary manometric evaluation. Disclosure of Interest J. Ooi: None Declared, E. Yazaki: None Declared, K. Nikaki: None Declared, D. Sifrim Grant/research support from: Research grant from Sandhill Scientific, P. Woodland: None Declared