Review article: Oesophageal disorders in chronic liver disease.

BACKGROUND: Oesophageal disorders and chronic liver disease are common worldwide and significantly impact quality of life. The intricate link between these conditions, including how oesophageal disorders like GERD, Barrett's oesophagus and oesophageal cancer affect and are affected by chronic liver disease, remains poorly understood. AIMS: To review the relationship between oesophageal disorders and chronic liver disease, evaluating epidemiology, pathophysiology and therapeutic factors. METHODS: We reviewed the literature on the relationship between oesophageal disorders and chronic liver disease, including cirrhosis, using the PubMed database RESULTS: Oesophageal disorders such as gastroesophageal reflux disease, Barrett's oesophagus, oesophageal cancer, oesophageal motor disorders and oesophageal candidiasis are prevalent among individuals with cirrhosis, exacerbating the burden of liver disease. These diseases have a multifaceted symptomatology and pathogenic basis, posing a significant challenge in cirrhotic patients that necessitates careful diagnosis and management. Additionally, therapies frequently used for these diseases, such as proton pump inhibitors, require careful consideration in cirrhotic patients due to potential adverse effects and altered pharmacokinetics. Managing oesophageal disorders in cirrhotic patients requires a cautious approach due to possible interactions with medications and the risk of adverse effects. Furthermore, symptoms associated with these conditions are often exacerbated by common interventions in patients with cirrhosis, such as band ligation for oesophageal varices. CONCLUSIONS: Oesophageal disorders are common in cirrhosis and increase the disease burden. These conditions require careful management due to complex symptoms and treatment risks. Proton pump inhibitors and other therapies must be used cautiously, as cirrhosis interventions can worsen symptoms.

[ADVANCES ON ESOPHAGEAL MEASUREMENTS: HIGH RESOLUTION MANOMETRY, TIMED BARIUM SWALLOW, ENDOFLIP AND PH MONITORING].

INTRODUCTION: Upper gastrointestinal (UGI) symptoms are very common in the general adult population. Dysphagia, heartburn, regurgitation and non-cardiac chest pain are the most common signs. The clinical approach in managing these symptoms starts with upper GI endoscopy in order to exclude inflammatory, neoplastic and fibrotic disorders that involve the esophagus. Upper GI endoscopy is mandatory especially when alarm signs exist. In patients with no structural abnormalities, physiological testing might aid to better understand the origin of the symptoms and to improve management.

Retrograde cricopharyngeal dysfunction and treatment with botulinum toxin: a systematic review.

PURPOSE: Retrograde cricopharyngeal dysfunction (RCPD) is a disease first described systematically in 2019. The main symptom is inability to belch due to cricopharyngeal muscle dysfunction. Other symptoms include gurgling noises, chest pain, bloating, and excessive flatulence. This paper aims to describe RCPD, the aetiology and diagnosis, treatment options, follow-up, and treatment with botulinum toxin (BT). METHODS: A systematic review was done according to the PRISMA guidelines, using the databases PubMed, Embase, and Cochrane at 8/3/2024. The search combined BT with different descriptions of RCPD. All papers were screened by two authors. RESULTS: 120 papers were identified in the search. After screening 13 papers describing 472 patients in total were included. Mean age was 29.3 years with 51.1% men. Diagnosis was established in 82.4% of the cases by symptomatology, 2.1% by high-resolution manometry, and 15.3% by oesophagoscopy. The mean amount of BT was 66 units (U). Mean follow-up time was 13 months. After 1-4 weeks 93.7% had an effect post-treatment and 81.0% after 6 months. Common symptoms were inability to belch (99.8%), chest pain and/or bloating (95.4%), gurgling noises (84.9%), and excessive flatulence (75.9%). Common complications were mild and transient dysphagia (59.4%) and reflux (35.4%). CONCLUSION: The accumulated numbers of patients with RCPD indicates a growing attention to the plausible condition. Injection with BT is a good and safe treatment of RCPD. Most patients only experience mild and transient complications to the treatment. Much is still unknown about RCPD and conditions for setting the diagnosis needs to be evaluated and established internationally.

Esophageal Epidermoid Metaplasia: Clinical Characteristics and Risk of Esophageal Squamous Neoplasia.

INTRODUCTION: Esophageal epidermoid metaplasia (EEM) is a rare disease. METHODS: Patients with EEM diagnosed between 2014 and 2020 were reviewed. RESULTS: Forty EEM cases were identified. EEM occurred in 9 (23%) patients before, concordant, or after esophageal squamous cell carcinoma (ESCC). EEM was associated with previous esophageal lichen planus in 5 patients, Barrett's esophagus 7, and esophageal adenocarcinoma 1. EEM was focal in 28 (70%) or diffuse in 12 (30%) and not detected in 45% on recent previous endoscopy. DISCUSSION: EEM is a premalignant underrecognized condition associated with multiple conditions. Close follow-up or endoscopic treatment may be warranted because of its ESCC association.

Microbiome of the Aerodigestive Tract in Health and Esophageal Disease.

The diverse human gut microbiome is comprised of approximately 40 trillion microorganisms representing up to 1000 different bacterial species. The human microbiome plays a critical role in gut epithelial health and disease susceptibility. While the interaction between gut microbiome and gastrointestinal pathology is increasingly understood, less is known about the interaction between the microbiome and the aerodigestive tract. This review of the microbiome of the aerodigestive tract in health, and alterations in microbiome across esophageal pathologies highlights important findings and areas for future research. First, microbiome profiles are distinct along the aerodigestive tract, spanning the oral cavity to the stomach. In patients with reflux-related disease such as gastro-esophageal reflux disease, Barrett's esophagus, and esophageal adenocarcinoma, investigators have observed an overall increase in gram negative bacteria in the esophageal microbiome compared to healthy individuals. However, whether differences in microbiome promote disease development, or if these shifts are a consequence of disease remains unknown. Interestingly, use of proton pump inhibitor therapy is also associated with shifts in the microbiome, with distinct shifts and patterns along the aerodigestive tract. The relationship between the human gut microbiome and esophageal pathology is a ripe area for investigation, and further understanding of these pathways may promote development of novel targets in prevention and therapy for esophageal diseases.

Flip Technology for Assessing Esophageal Structural and Motor Disorders: a Skeptic's View.

PURPOSE OF REVIEW: Functional lumen impedance (FLIP) technology has become commercially available to assess structural and motor abnormalities of the esophagus. Increasing numbers of papers have described novel findings with this technology. This review examines the validity of the FLIP technique, how it compares with existing diagnostic modalities, and evidence to date on diagnostic accuracy. RECENT FINDINGS: FLIP studies require deep sedation at the time of endoscopy to complete. They assess a simulated state of esophageal obstruction in only a distal part of the esophagus rather than deglutitive motor function of the entire esophagus. The available normative dataset is small and not matched to the older age of patients typically being evaluated. The test-retest agreement in health and disease is unknown, as is the operator dependence on performing and interpreting findings. Studies to date have largely excluded patients with structural disorders, which FLIP cannot reliably distinguish from motor disorders. FLIP is an expensive technology that has been made clinically available without its true utility being established. For FLIP to be deemed a device ready for widespread clinical use, additional studies on validity, diagnostic accuracy, and outcomes need to be performed. Prospective clinical studies need to include all patients and assess the incremental cost-effectiveness of FLIP over more innovative use of existing technology, such as high-resolution manometry with provocative challenges.

Esophageal Functional Lumen Imaging Probe (FLIP): How Can FLIP Enhance Your Clinical Practice?

Recent innovations in esophageal diagnostic testing have enhanced gastroenterology clinical practice by facilitating more nuanced and advanced evaluation of esophageal symptoms. Among these pivotal advances is the FDA-approved functional lumen imaging probe (FLIP), which utilizes impedance planimetry via volumetric distension of a catheter-mounted balloon at the time of sedated upper endoscopy, to acquire esophageal dimensions and pressures. In real time, FLIP can display cross-sectional areas (CSA) and distensibility indices (ratios of CSA to intra-balloon pressures) throughout the esophagus, most notably at the esophagogastric junction, as well as secondary peristaltic esophageal body contractile patterns. As the use of FLIP has progressively spread and permeated into the practice of clinical gastroenterology since its introduction, increasing data on and experiences with its applications have accumulated to guide its utility in clinical practice. In this current review developed for gastroenterologists and foregut surgeons across clinical practice, we provide an introduction to FLIP technology and metrics and discuss the clinical scenarios in which performance of or referral for FLIP may be helpful in the evaluation and management of patients with commonly encountered esophageal symptoms and disorders. Specifically, we discuss the potential applications and limitations of FLIP as a complementary diagnostic modality in patients with non-obstructive dysphagia, established or suspected achalasia spectrum disorders, eosinophilic esophagitis, gastroesophageal reflux disease and those undergoing esophageal surgery.

Applying the Functional Luminal Imaging Probe to Esophageal Disorders.

PURPOSE OF REVIEW: The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. The goal of this review is to summarize the most recent advances in applying the (FLIP) to esophageal disorders. RECENT FINDINGS: The FLIP has been studied in esophageal disease states including gastroesophageal reflux disease (GERD), achalasia, and eosinophilic esophagitis. It has also been used in the investigation of dysphagia. The FLIP is a valuable tool for the diagnosis of esophageal diseases as well as guiding treatments and predicting treatment response. As further research is done, the FLIP may become the initial test for the patient with undifferentiated dysphagia at the time of their index endoscopy.

Esophageal motility patterns are altered in older adult patients. / Los patrones de motilidad esofágica están alterados en pacientes adultos mayores.

INTRODUCTION AND AIMS: Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (=60 years of age) with an esophageal disorder and compare them with adults under 60 years of age. MATERIALS AND METHODS: A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results. RESULTS: Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups. CONCLUSIONS: Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated.

Opioid-Induced Esophageal Dysfunction: Differential Effects of Type and Dose.

OBJECTIVE: Data regarding opioid effects on esophageal function are limited. We previously demonstrated an association between chronic opioid use and esophageal motor dysfunction characterized by esophagogastric junction outflow obstruction, distal esophageal spasm, achalasia type III, and possibly Jackhammer esophagus. Our aim was to characterize the influence of different opioids and doses on esophageal dysfunction. METHODS: Retrospective review of 225 patients prescribed oxycodone, hydrocodone, or tramadol for >3 months, who completed high-resolution manometry from 2012 to 2017. Demographic and manometric data were extracted from a prospectively maintained motility database. Frequency of opioid-induced esophageal dysfunction (OIED, defined as distal esophageal spasm, esophagogastric junction outflow obstruction, achalasia type III, or Jackhammer esophagus on high-resolution manometry, was compared among different opioids. The total 24-hour opioid doses for oxycodone, hydrocodone, and tramadol were converted to a morphine equivalent for dose effect analysis. RESULTS: OIED was present in 24% (55 of 225) of opioid users. OIED was significantly more prevalent with oxycodone or hydrocodone use compared with tramadol (31% vs 28% vs 12%, P = 0.0162), and for oxycodone alone vs oxycodone with acetaminophen (43% vs 21%, P = 0.0482). There was no difference in OIED for patients taking hydrocodone alone vs hydrocodone with acetaminophen. Patients with OIED were taking a higher median 24-hour opioid dose than those without OIED (45 vs 30 mg, P = 0.058). DISCUSSION: OIED is more prevalent in patients taking oxycodone or hydrocodone compared with tramadol. There is greater likelihood of OIED developing with higher doses. Reducing the opioid dose or changing to tramadol may reduce OIED in opioid users.

GI Manifestations With a Focus on the Esophagus: Recent Progress in Understanding Pathogenesis.

PURPOSE OF REVIEW: Esophageal dysfunction is common in systemic sclerosis (SSc) patients. Limited treatment options are available for scleroderma esophageal disease. Here, we discuss recent updates on the diagnosis, treatment, and characterization that have been made in patients with scleroderma esophageal disease. RECENT FINDINGS: In the past few years, novel diagnostic tools have provided insight into esophageal dysmotility in SSc patients. New drugs are being tested and might improve symptoms and quality of life in SSc patients with esophageal dysfunction. Molecular stratification methods have facilitated the identification of molecular signatures in the esophagus of SSc patients. The Friend leukemia integration 1 (Fli1) conditional knockout mouse is the first animal model to report an esophageal phenotype with SSc features. The clinical presentation in SSc patients with esophageal dysfunction is heterogeneous, complicating diagnosis and management. The improvement of diagnostic tools for esophageal symptoms and dysfunction and the use of molecular approaches in SSc mouse models and patient biopsies offer an opportunity to improve the characterization of SSc esophageal disease, which should help improve management and treatment decisions.

Diffuse Esophageal Leiomyomatosis in Pediatric Patients: A Systematic Review and Quality of Evidence Assessment.

BACKGROUND: Diffuse esophageal leiomyomatosis (DEL) is a rare disorder characterized by benign hypertrophy of esophageal smooth muscle cells. No rigorous summary of available evidence on how to best manage these patients exists. OBJECTIVE: To define the clinical features and outcomes of pediatric patients with DEL. MATERIALS AND METHODS: A systematic literature search of the PubMed and Cochrane databases was performed with respect to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (end-of-search date: October 6, 2018). The algorithm: "esophageal leiomyomatosis AND (children OR pediatric*)" was implemented. RESULTS: Thirty-five studies including a total of 58 patients were analyzed. The female:male ratio was 1.45:1. Mean patient age was 8.54 ± 4.67 years. The most common disease manifestations were dysphagia and gastrointestinal symptoms (90.0%, 95% confidence interval [CI]: 78.2-96.1), followed by failure to thrive (57.9%, 95% CI: 36.2-76.9) and pulmonary symptoms (56.4%, 95% CI: 41.0-70.7). Alport syndrome (AS) was seen in 57.7% (95% CI: 44.2-70.1) of the patients. The most commonly implemented procedure was esophagectomy (85.2%; n = 46/54; 95% CI: 73.1-92.6) with gastric transposition (37.8%; n = 17/45; 95% CI: 25.1-52.4). Postoperative complications developed in 33.3% (n = 15/45; 95% CI: 21.3-48) of the patients. All-cause mortality was 7.0% (95% CI: 2.3-17.2) and disease-specific mortality was 3.5% (95% CI: 0.3-12.6). CONCLUSION: DEL is an uncommon condition that typically occurs in the setting of AS. Esophagectomy with gastric transposition is the mainstay of treatment. Although complications develop in one-third of the patients, mortality rates are low.

The Role of Novel Functional Probes in the Evaluation and Treatment of Esophageal Disease.

The understanding of esophageal function and dysfunction in a variety of disease states has been driven largely by the introduction of a variety of measurement technologies. Included in these are contrast esophagram, computed tomography, high-resolution manometry, and 24-hour pH monitoring. Two novel measurement technologies, the functional lumen imaging probe (FLIP) and mucosal impedance (MI) catheter have recently introduced and studied. This review will discuss the technological basis of these tools and the evidence behind their application in the measurement of esophageal anatomy, physiology, and histology pertaining to a number of diseases, including gastroesophageal reflux disease, achalasia, and esosinophilic esophagitis.

The Esophageal Epithelial Barrier in Health and Disease.

Dysfunction in the esophageal epithelial barrier function is a major source for morbidity. To better understand the pathophysiologic pathways of the diseases associated with barrier dysfunction, including gastroesophageal reflux disease, eosinophilic esophagitis, Barrett's esophagus, and obesity, it is important to understand the esophageal epithelial embryologic development, microscopic anatomy with a special focus on the barrier structure and function, extraepithelial defense mechanisms, and how these change in the diseased state. In recent years, significant progress has been made in elucidating the esophageal barrier structure and function both in vitro and in vivo. This has enhanced the understanding of mechanisms of disease, and may also allow identification of therapeutic targets that can help in the management of these diseases. This review provides a detailed discussion regarding the esophageal epithelial barrier structure and function, the current and historical techniques used to study the barrier, and how it is affected by common esophageal diseases.

Utility of the Shock Index for Risk Stratification in Patients with Acute Upper Gastrointestinal Bleeding.

OBJECTIVES: Patients with upper gastrointestinal bleeding (UGIB) frequently require hospitalization, and a small but significant percentage of these patients have adverse outcomes. Risk-scoring tools can help clinicians organize care and make predictions about outcomes. The shock index (heart rate divided by systolic blood pressure) has been used in multiple acute disorders and has the potential to identify patients with UGIB who are at risk for adverse outcomes. METHODS: We retrospectively reviewed the electronic medical records of patients admitted with UGIB between January 1, 2012 and December 31, 2015. We collected information about patient demographics, presenting symptoms, underlying clinical disorders, endoscopic results, and outcomes. We calculated risk scores using the Glasgow-Blatchford score, the pre-endoscopy Rockall score, the full Rockall score, the AIMS65 (albumin, international normalized ratio, mental status, systolic blood pressure, age older than 65 years) score, and the shock index. RESULTS: This study included 214 admissions for acute UGIB. The mean age was 59.0 ± 15.9 years, 64.5% were men, the mean hemoglobin was 9.2 ± 3.1 g/dL, and the mean shock index was 0.78 ± 0.21 bpm/mm Hg. The mean shock index was significantly increased in patients requiring endoscopic therapy, admission to the intensive care unit, blood component transfusion, and red blood cell transfusion. Classification of patients by a shock index >0.7 preferentially selected patients with these adverse short-term outcomes. Among the scoring tools evaluated in this study, the shock index was the best predictor of the need for endoscopic therapy. CONCLUSIONS: The shock index is a good tool to identify patients with the potential for short-term adverse outcomes when they present with UGIB. It performs as well as other risk-scoring tools for GI bleeding and has the potential for serial use during hospitalization to identify changes in the clinical course.

Esophageal button battery ingestion in children.

BACKGROUND: Button battery lodged in the esophagus carries a high risk of morbidity and mortality. The purpose of this study was to present cases of patients with esophageal button battery ingestion treated at our clinic and to emphasize the importance of early diagnosis and treatment. METHODS: Records of patients admitted to our hospital for foreign body ingestion between January 2010 and May 2015 were retrospectively reviewed. Cases with button battery lodged in the esophagus were included in the study. Patient data regarding age, sex, length of time after ingestion until admission, presenting clinical symptoms, type and localization of the battery, management, and prognosis were analyzed. RESULTS: Among 1891 foreign body ingestions, 71 were localized in the esophagus, and 8 of those (11.2%) were cases of button battery ingestion. Mean age was 1.7 years. Admission was within 6 hours of ingestion in 5 cases, after 24 hours had elapsed in 2, and 1 month after ingestion in 1 case. All patients but 1 knew the history of ingestion. Prompt endoscopic removal was performed for all patients. Three patients developed esophageal stricture, which responded to dilatation. CONCLUSION: Early recognition and timely endoscopic removal is mandatory in esophageal button battery ingestion. It should be suspected in the differential diagnosis of patients with persistent respiratory and gastrointestinal symptoms.