Yen-Ju Chen

Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings.

Some patients with a phenotypic appearance of eosinophilic oesophagitis (EoE) respond histologically to PPI, and are described as having PPI‐responsive oesophageal eosinophilia (PPI‐REE). It is unclear if PPI‐REE is a GERD‐related phenomenon, a subtype of EoE, or a completely unique entity.

Early Comparison of Inflammatory vs. Fibrostenotic Phenotype in Eosinophilic Esophagitis in a Multicenter Longitudinal Study

OBJECTIVES:Eosinophilic esophagitis (EoE) is a chronic inflammatory condition that causes esophageal remodeling and stricture formation. We compared the clinical course of symptoms, endoscopic findings, histology, and changes in phenotype over time in EoE patients with inflammatory and fibrostenotic phenotypes.METHODS:Data were obtained from EoE patients from three medical centers and followed prospectively. Endoscopic features and histology from index and follow-up endoscopies were recorded. Behavior was classified as inflammatory if endoscopic findings demonstrated furrows or white plaques and as fibrostenotic if endoscopic findings included fixed rings or strictures.RESULTS:Two hundred and fifty-six EoE patients were included in the analysis. The mean age was 32±18 years, 25% of patients were <18 years, 89% of patients were Caucasians, and 74% of patients were male. The mean duration of symptoms before diagnosis was 6.8±7.2 years with a follow-up of 1.7±1.9 years (maximum follow-up of 12 years). Fifty-four percent of patients presented with fibrostenotic EoE, whereas 46% presented with inflammatory EoE. Patients with inflammatory disease were younger than those with fibrostenotic disease (24±19 vs. 39±15 years, P<0.001). Patients with fibrostenotic disease had a longer duration of symptoms than those with inflammatory disease (8.1±7.7 vs. 5.3±6.3 years, P=0.002). Over the study period, 47 (18%) had remission of inflammatory EoE, 68 (27%) continued to have inflammatory disease, 74 (29%) continued to have fibrostenotic disease, 65 (25%) fibrostenotic patients had regression of fibrosis, and 2 patients (1%) progressed from inflammatory disease to fibrostenotic disease. Patients who had regression from their fibrostenosis were more likely than patients who continued to demonstrate fibrostenosis to have a decrease in proximal (54% vs. 32%, P<0.001) and distal (70% vs. 38%, P<0.001) eosinophilia.CONCLUSIONS:Most EoE patients maintained their phenotype or had an improvement with <1% progressing from inflammatory to fibrostenosis. This suggests that early therapeutic strategies aimed at controlling inflammation may interrupt, decrease, or prevent the remodeling fibrosis in EoE.

Longitudinal Evaluation of Noninvasive Biomarkers for Eosinophilic Esophagitis.

Background: The diagnosis and management of eosinophilic esophagitis (EoE) often requires multiple endoscopies. Serum biomarkers can be elevated in EoE patients, but their clinical utility in diagnosis and assessing response to treatment is not well established. Goals: To evaluate serum biomarkers in EoE subjects compared with controls and assess longitudinally in response to treatment. Study: We conducted a prospective cohort study of children and adults undergoing esophagogastroduodenoscopy for suspected EoE. After completing an 8-week course of proton-pump inhibitor therapy, esophageal mucosal biopsies were obtained, as well as, serum analysis of absolute eosinophil count (AEC), eotaxin-3, eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP) and interleukin-5. Subjects with normal endoscopic and histologic findings constituted controls. Those meeting criteria for EoE underwent repeat esophagogastroduodenoscopy and biomarker measurements following treatment with topical steroids for 8 weeks. Results: Median levels of AEC (263.50 vs. 102 cu/mm, P<0.001), ECP (26.98 vs. 5.20 ng/mL, P<0.001) and EDN (31.70 vs. 14.18 ng/mL, P=0.004) were significantly elevated in EoE subjects compared with controls and correlated with esophageal eosinophilia. Levels of AEC (odds ratio, 1.79; 95% confidence interval, 1.28-2.64) and ECP (odds ratio, 1.61; 95% confidence interval, 1.23-2.36) were associated with a diagnosis of EoE. Among the 5 biomarkers evaluated, only AEC significantly predicted esophageal eosinophilia following topical steroid therapy in EoE subjects (P=0.006). Conclusions: AEC, ECP, and EDN were higher in EoE subjects compared with controls and correlated with degree of esophageal eosinophilia. Furthermore, AEC predicted post-treatment eosinophilia, suggesting a potential role in monitoring EoE disease activity.

Reflux episodes detected by impedance in patients on and off esomeprazole: a randomised double‐blinded placebo‐controlled crossover study

Combined with 24‐h pH monitoring, the use of impedance is the most sensitive method available for detecting oesophageal reflux. Normal values for impedance have been previously established in healthy controls studied on and off proton pump inhibitors (PPI).

A Randomized Controlled Study Comparing Room Air With Carbon Dioxide for Abdominal Pain, Distention, and Recovery Time in Patients Undergoing Colonoscopy

Colonoscopy remains the gold standard for colorectal cancer screening. Many barriers to the procedure exist including the possibility of abdominal discomfort that may occur with insufflation. Carbon dioxide (CO2), which is rapidly absorbed in the blood stream, is an alternate method used to distend the lumen during colonoscopy. The goal of this study was to compare patient discomfort, abdominal girth, and recovery time in 2 groups of patients randomized to CO2 versus room air insufflation during colonoscopy. Using a Wong–Baker score, we found statistical difference in postprocedural discomfort levels (CO2 Group: 1.15 ± 2.0 vs. room air: 0.41 ± 0.31, p = .015) and a significantly greater increase in abdominal girth over CO2 immediately postprocedure (room air: 1.06 ± 1.29 inches vs. CO2: 0.56 ± 0.73 inches, p = .054) girth immediately postprocedure; however, recovery time was similar between the 2 study arms (CO2: 9.1 ± 16.2 minutes vs. room air: 10.2 ± 18.6 minutes, p = .713). Further studies are needed to determine whether CO2 is cost-effective and improves patient satisfaction with colonoscopy.

Tu1772 Comparison of Proximal and Distal Impedance Episodes in Patients With Classic Versus Extra-Esophageal Symptoms of GERD

Background: Patients are frequently referred for evaluation of extraesophageal (EXT) symptoms (cough, hoarseness, globus sensation) presumably related to gastroesophageal reflux disease (GERD). 24 hour pH/impedance is the most sensitive test for the diagnosis of GERD, however limited data exist in examining the relationship between distal and proximal impedance episodes in patients with EXT symptoms versus classic reflux symptoms. Aim: To compare the number and percentage of proximal impedance episodes in patients with EXT symptoms to those with classic GERD symptoms undergoing 24 hour pH/impedance testing. Patients & Methods: A retrospective review of adult patients undergoing esophageal manometry and 24 hour pH/impedance studies off acid suppressing therapy between 20062011 was performed. Indications for these studies included typical GERD symptoms (heartburn and regurgitation) or atypical symptoms (cough, asthma, hoarseness or globus sensation). GERD was defined using the validated Johnson-DeMeester (JD) score. The results of the esophageal manometry and 24 hour pH/impedance studies between the classic GERD and EXT groups were compared using Chi squared test and students independent t-test. Continuous data is expressed as means (sd). Results: A total of 220 patients were included in the analysis [172 GERD vs. 48 EXT]. GERD and EXT groups were similar in race and gender, however GERD patients were younger than EXT patients [46 (13) years vs. 50 (8) years, p = 0.048]. There was no significant difference between GERD and EXT in the mean number of proximal impedance episodes [33 (22) vs. 28 (22), p = 0.188], the percentage of proximal impedance episodes migrating from the distal esophagus [55 (20) % vs. 50 (17) %, p=0.178), or the mean number of distal impedance episodes [57 (33) vs. 49 (34), p = 0.157]. There was no significant difference between GERD and EXT with regards to mean lower esophageal sphincter pressures [13.3 (11) mmHg vs. 15.3 (7.8) mmHg, p = 0.251] or mean esophageal amplitude [95.4 (44.6) mmHg vs. 84.9 (41.0) mmHg, p=0.146]. Based on 24 hour pH monitoring there was no significant difference between the classic GERD and EXT groups in the JD scores [22.6 (33) vs 17.8 (22), p = 0.358] or percent total time pH ,4 [4.6 (5.3) vs. 4.2 (5.3), p = 0.642]. There was a significant correlation between the number of proximal and distal episodes between the two groups (R = 0.724, p , 0.001). Conclusion: Patients with EXT symptoms are similar to classic GERD patients in the number proximal impedance reflux episodes and percentage of distal episodes migrating to the proximal esophagus. Furthermore, both groups have a similar degree of acid reflux.

Su1887 The Role of Esophageal Manometry and 24 Hour pH With Impedance Studies in the Evaluation of Patients With Non-Cardiac Chest Pain

Background: Gastroesophageal reflux disease (GERD) is thought to be the most common cause of Non-Cardiac Chest Pain (NCCP), present in up to 60% of these patients. Esophageal manometry (EM) and 24 pH with impedance are commonly used in the evaluation of NCCP once an empiric proton pump inhibitor (PPI) trial has failed. However, the diagnostic utility of EM and 24 hour pH with impedance in NCCP patients has not been well studied. Aim: To evaluate the utility of esophageal EM and 24 hour pH with impedance in the evaluation of NCCP Methods: A retrospective chart review was performed on patients referred for the evaluation of NCCP. All patients underwent EM and 24-hour pH with impedance studies between 2006 and 2011. Esophageal manometry results were reviewed for underlying neuromuscular dysfunction and motility disorders. 24 hour pH with impedance data was reviewed for the presence or absence of acid or non-acid reflux. The validated JohnsonDeMeester (JD) score (normal , 22) was used to assess for the presence of GERD. Additionally, correlation between chest pain and reflux events was assessed. Prior endoscopic reports were reviewed for the presence of esophageal changes, such as, erosive esophagitis, salmon colored tongues, Schatzkis ring or changes suggestive of eosinophilic esophagitis. Categorical data was expressed as percentages and continuous data as means and standard deviation. Fishers exact tests and parametric statistics were used to analyze data. A p-value ≤ 0.05 was considered statistically significant. Results: Esophageal manometry and 24-hour pH with impedance studies of 112 patients were reviewed (52.3% male, 60.4% Caucasian, mean age 51 ± 13.4, mean BMI 27.8 ± 5.1). Of the cohort, 65% of EM studies were normal (mean DCI 1574 ± 1107, mean lower esophageal sphinchter (LES) pressure 14.91 ± 9.75). Of the 34.5% abnormal manometry studies, ineffective esophageal motility disorder (n=25), hypotensive LES (n=5), nutcracker esophagus (n=4), and hypertensive LES (n=1) were present. Ninety percent (n= 88) had normal 24 hour pH studies (mean JD score 9.86 ¬¬± 17.9). Eighty-six percent (n= 88) had normal impedance studies and only 6.25% of patients (n=7) had at least one episode of chest pain correlating with acid or non-acid reflux. On endoscopy, 16% of patients (n=18) had esophageal changes suggestive of reflux and 8% (n=9) had a hiatal hernia. Conclusion: The majority of patients who underwent EM and 24 hour pH with impedance examination had normal studies. The role of these studies for the evaluation of NCCP is limited.