Lisa Camargo

The omeprazole test is as sensitive as 24‐h oesophageal pH monitoring in diagnosing gastro‐oesophageal reflux disease in symptomatic patients with erosive oesophagitis

Ambulatory 24‐h oesophageal pH monitoring and a short course of high dose omeprazole can be used as diagnostic modalities for GERD. However, comparative studies of the diagnostic accuracy and reliability of both strategies have not been performed.

Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on a very high dose of proton pump inhibitor

Normalization of oesophageal acid exposure using high dose proton pump inhibitors in patients who are candidates for ablation therapy has been suggested to be essential for successful Barretts reversal. However, the success rate for achieving pH normalization has not been determined.

The diagnostic accuracy of esophageal capsule endoscopy in patients with gastroesophageal reflux disease and Barrett's esophagus: a blinded, prospective study.

BACKGROUND:Esophageal capsule endoscopy (ECE) is a novel technique that offers noninvasive evaluation of esophageal pathology in gastroesophageal reflux disease (GERD) patients.OBJECTIVE:To assess the diagnostic accuracy of ECE for Barretts esophagus (BE), erosive esophagitis, and hiatal hernia and to assess the safety profile of ECE.METHODS:Patients with GERD symptoms and those undergoing BE surveillance were prospectively enrolled. All patients underwent ECE followed by standard upper endoscopy. ECE findings were interpreted by examiners blinded to endoscopy results. The gold standard was the findings at endoscopy and ECE results were compared with those at endoscopy.RESULTS:One hundred patients were enrolled of which 94 completed the study. At upper endoscopy, BE was suspected in 53 (mean length 3.1 cm) and confirmed in 45 patients. Erosive esophagitis and hiatal hernia were identified in 18 and 70 patients, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ECE for BE in GERD patients were 67%, 87%, 60%, and 90%, respectively. The sensitivity, specificity, PPV, and NPV of ECE for BE patients undergoing surveillance were 79%, 78%, 94%, and 44%, respectively. The sensitivity, specificity, PPV, and NPV for erosive esophagitis were 50%, 90%, 56%, and 88% and for hiatal hernia were 54%, 67%, 83%, and 33%, respectively.CONCLUSIONS:Current diagnostic rates of ECE for BE are not yet accurate enough for application in clinical practice. An improvement in technology and learning curve assessments are required, until then standard upper endoscopy remains the gold standard.

Correlation of ambulatory 24-hour esophageal pH monitoring results with symptom improvement in patients with noncardiac chest pain due to gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) accounts for up to 60% of patients with noncardiac chest pain (NCCP). Twenty-four-hour esophageal pH monitoring has been considered the most sensitive test for identifying acid reflux as the probable cause for chest pain. It is unclear if there is a correlation between the degree of esophageal acid exposure as determined by 24-hour esophageal pH monitoring and symptom improvement during a short course of high-dose omeprazole (the omeprazole test) in patients with NCCP due to GERD. Twenty-three patients with GERD-related NCCP were studied. All patients were referred by a cardiologist and evaluated by upper endoscopy and 24-hour esophageal pH monitoring. Diagnosis of GERD was defined by one or both tests being abnormal. Subsequently, patients underwent baseline symptom intensity assessment during 1 week off therapy followed by 1 week on therapy with high-dose omeprazole (40 mg A.M. and 20 mg P.M.). There was a statistically significant correlation between the esophageal acid exposure by 24-hour esophageal pH monitoring and the change in symptom intensity score after treatment. However, there was no significant correlation between the pH values and symptom intensity score during baseline or during the omeprazole test. In patients with GERD-related NCCP undergoing the omeprazole test, 24-hour esophageal pH monitoring has a therapeutic predictive value in addition to its diagnostic merit. Patients with greater esophageal acid exposure appear to have a greater response to antireflux treatment.

Increased esophageal chemoreceptor sensitivity to acid in patients after successful reversal of Barrett's esophagus.

When compared to patients with erosiveesophagitis, patients with Barretts esophagus havedemonstrated reduced chemo- and mechanoreceptorsensitivity to acid infusion and balloon distension,respectively. However, anecdotal clinical experiencesuggested an increase in symptom perception in patientsafter successful elimination of Barretts epithelium,using multipolar electrocoagulation (MPEC) and high-dose proton pump inhibitor (PPI). To determineperception thresholds to acid infusion, we evaluatedeight consecutive patients after a series of MPECtreatments resulted in complete elimination of Barretts mucosa and compared them to 10 age-matchedpatients with nonreversed Barretts esophagus and 10patients with symptomatic, endoscopy-documented erosiveesophagitis (Hetzel-Dent grade 2 or greater).Chemosensitivity was determined by a modified acid perfusiontest, where acid perception thresholds were quantifiedby the lag time to initial typical symptom perception,sensory intensity rating, and an acid perfusion sensory score (APSS). While patients aftersuccessful elimination of Barretts esophagus hadsimilar sensory intensity ratings and APSS as patientswith erosive esophagitis, the lag times differedsignificantly between the groups, and both groups hadsignificantly higher sensory intensity ratings and APSSthan patients with nonreversed Barretts esophagus. Inconclusion, patients after complete reversal ofBarretts mucosa are unexpectedly as sensitive to acid assymptomatic patients with erosive esophagitis.

Impact of esophageal acid exposure on the endoscopic reversal of Barrett's esophagus.

OBJECTIVE:Normalization of esophageal acid exposure had been assumed to be necessary for the reversal of Barretts esophagus with endoscopic therapy. This assumption is examined by evaluating the esophageal pH in a group of patients undergoing reversal therapy with fixed high-dose proton pump inhibitor therapy and endoscopic multipolar electrocoagulation (MPEC).METHODS:Patients with Barretts esophagus of 2–6 cm in length were treated with omeprazole (40 mg b.i.d.). They underwent 24-h esophageal pH monitoring 5 cm above the upper margin of the lower esophageal sphincter determined by a water-perfused catheter. They then underwent MPEC therapy to an endpoint of elimination of Barretts (reversal) by both endoscopy and biopsy 6 months after the last MPEC session or failure to achieve visual (endoscopic) reversal after six treatment sessions.RESULTS:Twenty patients had 24-h pH testing and reached a reversal endpoint. Three patients had abnormal pH tests, two total and supine and one supine only. These patients had documented reversal. The remaining 17 patients had normal pH testing but five failed reversal therapy.CONCLUSION:Barretts esophagus can be completely reversed with endoscopic therapy despite abnormal esophageal acid exposure. Also, patients can fail reversal even with normal esophageal acid exposure. The necessary reduction of esophageal acid exposure for reversal therapy has yet to be defined.

M1107 Durability of Ablative Therapies in Barrett's Esophagus (BE): Long Term Results of a Randomized Controlled Trial (RCT) of Ablation With Argon Plasma Coagulation (APC) and Multipolar Electrocoagulation (MPEC)

Predicting High-Grade Dysplasia (HGD) and Esophageal Adenocarcinoma (EAC) in Patients With Non-Dysplastic Barretts Esophagus (BE): Results From a Large, Multicenter Cohort Study Srinivas Gaddam, Patrick E. Young, Amy Wang, Ajay Bansal, Neil Gupta, Sachin B. Wani, Mandeep Singh, Vikas Singh, Keng-Yu Chuang, Vikram Boolchand, Hemanth Gavini, Priti Sud, John Kuczynski, April D. Higbee, Amit Rastogi, Sharad C. Mathur, Brooks D. Cash, Gary W. Falk, Richard E. Sampliner, Prateek Sharma