Burn Pits: A Possible Trigger for Achalasia.

A 45-year-old female veteran of the United States Air Force (USAF), who was exposed to burn pits on multiple occasions while deployed in the Middle East, presented for a second opinion regarding ongoing chest pain and regurgitation after a Heller myotomy for achalasia. An esophageal X-ray showed no meaningful peristalsis, a slight diverticulum in the distal esophagus, and easy passage of liquids through the lower esophageal sphincter (LES). Esophageal manometry findings were consistent with type 3 achalasia. Based on these and endoscopic evaluation, the prior surgical intervention appeared to be successful for lower esophageal sphincter disruption, so symptoms were managed medically with a proton pump inhibitor, trazodone, and a long-acting nitrate resulting in 70% improvement. We present this case because the patient developed achalasia with a notable history of exposure to open-air burn pits during her military service. While we acknowledge that causality cannot be proven, our case is the first we are aware of that shows a temporal association between burn pit exposure and achalasia. In August of 2022, the United States Congress passed the Promise to Address Comprehensive Toxics (PACT) Act, which expanded the healthcare benefits of veterans exposed to burn pits, making identification of associated conditions a relevant and important endeavor.

Squamous Cell Carcinoma in Lichen Planus of the Esophagus.

Cancer arising in lichen planus of the esophagus (LPE) is extremely rare. We report 2 elderly female patients with LPE who developed squamous cell carcinoma. Both underwent laparoscopic ischemic gastric preconditioning followed 2 weeks later by 3-field esophagectomy. Final pathological stages were carcinoma in situ and pT3N2, respectively. No adjuvant therapy was given. The patient with in situ cancer has no evidence of recurrence at 24 months. The second patient opted to follow up locally and died 8 months later. LPE should be closely monitored for malignant degeneration. Esophagectomy should be considered when malignancy is detected.

Colonoscopy bowel preparation quality improvement for patients with decompensated cirrhosis undergoing evaluation for liver transplantation.

BACKGROUND/AIMS: Inadequate bowel preparations can necessitate early repeat of colonoscopy and increased healthcare costs. Established risk factors for suboptimal bowel preparation are known, yet data are lacking in the specific subgroup of patients with decompensated cirrhosis. The primary aim of this study was to reduce inadequate bowel preparation rates in patients with decompensated cirrhosis undergoing evaluation for liver transplant via a quality improvement initiative targeting patient education. METHODS: A total of 121 patients undergoing evaluation at our institution prior to implementation of the quality improvement initiative and 91 patients undergoing evaluation after implementation were included. The initiative was an educational intervention via a 6-minute colonoscopy and split-prep bowel preparation educational video during the initial liver transplantation evaluation visit for all patients with scheduled colonoscopy. RESULTS: Inadequate bowel preparation was observed in 36 patients (29.8%) in the pre-intervention period compared to 29 patients (31.9%) in the post-intervention period. This corresponded to a lack of a significant difference in both single-variable analysis and multivariable analysis. Of note, there was a significantly higher rate of inadequate bowel preparation as ascites worsened (P=.028). CONCLUSION: Patient educational video failed to improve bowel preparations in patients undergoing colonoscopy with decompensated cirrhosis.

Once-daily omeprazole/sodium bicarbonate heals severe refractory reflux esophagitis with morning or nighttime dosing.

BACKGROUND: Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe reflux esophagitis. AIM: Compare the effect of single dose morning (control arm) versus nighttime (experimental arm) omeprazole/sodium bicarbonate (Zegerid(®)) (IR-OME) on esophagitis and gastroesophageal reflux symptoms. METHODS: Adult outpatients with Los Angeles grade C or D esophagitis were allocated to open-label 40 mg IR-OME once a day for 8 weeks in a prospective, randomized, parallel design, single center study. Esophagogastroduodenoscopy (EGD) and validated self-report symptom questionnaires were completed at baseline and follow-up. Intention-to-treat and per-protocol analyses were performed. RESULTS: Ninety-two of 128 (72 %) eligible subjects participated [64 (70 %) male, mean age 58 (range 19-86), median BMI 29 (range 21-51), 58 C:34 D]. Overall, 81 (88 %) subjects healed [n = 70 (76 %)] or improved [n = 11 (12 %)] erosions. There was no significant difference (morning vs. night) in mucosal healing [81 vs. 71 %, (p = 0.44)] or symptom resolution [heartburn (77 vs. 65 %, p = 0.12), acid regurgitation (82 vs. 73 %, p = 0.28)]. Prevalence of newly identified Barrett's esophagus was 14 % with half diagnosed only after treatment. CONCLUSIONS: Once-daily IR-OME (taken morning or night) effectively heals severe reflux esophagitis and improves GERD symptoms. Results support the clinical practice recommendation to repeat EGD after 8 weeks PPI therapy in severe esophagitis patients to assure healing and exclude Barrett's esophagus.

Intraprocedural evaluation of comfort for sedated outpatient upper endoscopy and colonoscopy: the La Crosse (WI) intra-endoscopy sedation comfort score.

Patient comfort is often assessed during gastrointestinal procedures to guide sedation. There are, however, no validated scales appropriate for routine comfort assessment. This study validated a single-item La Crosse (WI) intra-endoscopy sedation comfort score (L-WISC) by determining interobserver agreement and correlation with patient outcomes. The study was conducted in prospective outpatient cohorts of patients undergoing outpatient esophagogastroduodenoscopy and/or colonoscopy at a regional healthcare medical center endoscopy unit. In Phase 1, independent assessments of 100 patients' intraprocedural comfort by the endoscopist and nurse determined interobserver agreement. In Phase 2, nurses assessed 200 patients, who were provided surveys to self-report their comfort 2 weeks postprocedure. In Phase 1, there was fair interobserver agreement (weighted κ = 0.36, with 95% confidence intervals [CI] [0.19, 0.53]). After L-WISC revisions, Phase 1 was repeated with moderate agreement (weighted κ = 0.45; 95% CI [0.31, 0.60]). In Phase 2, using the revised score, there was poor agreement (weighted κ = 0.098; 95% CI [-0.0020, 0.20]) between nurses' and patients' scores. The L-WISC is the first intraprocedural gastrointestinal comfort score appropriate for routine use to be validated with interobserver agreement and correlation with patient outcomes. It has reproducibility between endoscopists and nurses. It does not predict patient recollection of sedation comfort, but it remains unclear whether such prediction is possible with the use of amnestic sedatives. The L-WISC provides standardized levels of patient comfort to guide sedation titration routinely during outpatient endoscopy.

Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate.

BACKGROUND: The adenoma detection rate (ADR) is a quality benchmark for colonoscopy. Many practices find it difficult to determine the ADR because it requires a combination of endoscopic and histologic findings. It may be possible to apply a conversion factor to estimate the ADR from the polyp detection rate (PDR). OBJECTIVE: To create a conversion factor that can be used to accurately estimate the ADR from the PDR. DESIGN: This was a retrospective study of colonoscopies performed by board-certified gastroenterologists to determine the average adenoma to polyp detection rate quotient (APDRQ) for all endoscopists, individually and as a group. SETTING: Academic group practice. INTERVENTION: The group average APDRQ was used as a conversion factor for the endoscopist's PDR to estimate the ADR. MAIN OUTCOME MEASUREMENTS: The strength of the relationship between the estimated ADR and the actual ADR determined by Pearson's correlation coefficient. RESULTS: A total of 3367 colonoscopies performed by 20 staff gastroenterologists were included. The average ADR for all indications, all patient age groups, and both sexes was 0.17 (range 0.09-0.27, standard deviation 0.05). The average APDRQ was 0.64 (range 0.46-1.00, standard deviation 0.13). The correlation between the estimated ADR and the actual ADR was 0.85 (95% CI, 0.65-0.93, P = .000001). LIMITATIONS: Retrospective study in 1 practice setting with all patient types. CONCLUSIONS: The use of a conversion factor can accurately estimate the ADR from the PDR. Further study is needed to determine whether such a conversion factor can be applied to different practice settings and patient groups.