Endoscopic findings and outcomes of gastric mucosal changes relating to potassium-competitive acid blocker and proton pump inhibitor therapy.

Gastric mucosal changes associated with long-term potassium-competitive acid blocker and proton pump inhibitor (PPI) therapy may raise concern. In contrast to that for PPIs, the evidence concerning the safety of long-term potassium-competitive acid blocker use is scant. Vonoprazan (VPZ) is a representative potassium-competitive acid blocker released in Japan in 2015. In order to shed some comparative light regarding the outcomes of gastric mucosal lesions associated with a long-term acid blockade, we have reviewed six representative gastric mucosal lesions: fundic gland polyps, gastric hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like gastric mucosal changes, gastric black spots, and stardust gastric mucosal changes. For these mucosal lesions, we have evaluated the association with the type of acid blockade, patient gender, Helicobacter pylori infection status, the degree of gastric atrophy, and serum gastrin levels. There is no concrete evidence to support a significant relationship between VPZ/PPI use and the development of neuroendocrine tumors. Current data also shows that the risk of gastric mucosal changes is similar for long-term VPZ and PPI use. Serum hypergastrinemia is not correlated with the development of some gastric mucosal lesions. Therefore, serum gastrin level is unhelpful for risk estimation and for decision-making relating to the cessation of these drugs in routine clinical practice. Given the confounding potential neoplastic risk relating to H. pylori infection, this should be eradicated before VPZ/PPI therapy is commenced. The evidence to date does not support the cessation of clinically appropriate VPZ/PPI therapy solely because of the presence of these associated gastric mucosal lesions.

A Study of Omentum Reduction on the Improvement of Nausea and vomiting and Gastroesophageal Reflux Symptoms After Laparoscopic Gastric Sleeve Resection.

OBJECTIVE: To investigate the effect of omentum reduction in laparoscopic sleeve gastrectomy (LSG) on the improvement of postoperative nausea and vomiting and gastroesophageal reflux symptoms. METHODS: A retrospective study was performed on the case data of 198 obese patients who underwent LSG in the Department of Obesity and Metabolic Diseases of Xiaolan People's Hospital of Zhongshan from March 2021 to March 2022 and were divided into omentum reduction group and control group, with 99 cases in each group, and the preoperative body mass index (BMI) of the patients was recorded. Age, gender, comorbidities, and comparative analysis of operation time, blood loss, length of hospital stay, postoperative nausea and vomiting score, gastroesophageal reflux GerdQ score, postoperative pain score, weight, and postoperative complications were analyzed. RESULTS: There were no significant differences in preoperative BMI, age, gender and comorbidities between the two groups (P > 0.05), but there were significant differences in intraoperative blood loss and operation time (P < 0.05). There were differences in postoperative nausea and vomiting scores and VAS pain scores between the two groups (P < 0.05). The GerdQ scores of the omental reduction group were 8.11 ± 2.84 points at 1 year, and those in the control group were 7.56 ± 2.67 points, which were 3.97 ± 4.09 points higher than those in the preoperative omentum reduction group and 3.42 ± 3.41 in the control group, with no significant difference (P > 0.05). There was no significant difference in the postoperative excess weight loss rate %EWL and postoperative complications (p > 0.05). CONCLUSION: Omentum reduction can improve short-term nausea and vomiting after LSG, but it cannot significantly improve long-term reflux symptoms.

pHoenix score: development and validation of a novel approach to decrease the number of inconclusive GERD diagnoses.

BACKGROUND: The Johnson-DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes. METHODS: This single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET. RESULTS: We identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001). CONCLUSION: Total AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS.

Assessment of gastroesophageal reflux disease signs, symptoms, and food behaviors concerning mental health in Herat, Afghanistan: A descriptive study.

Background and Aims: Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder with modifiable risk factors that are associated with considerable health and economic burdens. The current study was conducted to assess the signs and symptoms, food behaviors, depression, anxiety, and stress related to GERD in Herat, Afghanistan. Methods: A descriptive study was conducted between August 29 and October 20, 2020, among patients with GERD symptoms, who provided informed verbal consent at the Mowaffaq Clinic and Sehat Hospital in Herat, Afghanistan. The minimum sample size was 384. Data were collected using a three-domain questionnaire and Depression, Anxiety, and Stress Scale 42 standard questionnaire. SPSS version 27 was used to perform descriptive statistics and χ 2 tests. Results: The sample consisted of 396 patients, with the majority being female (67.9%), married (78.5%), and illiterate (34.8%). Heartburn (88.1%) and regurgitation (84.3%) were the most common symptoms reported by participants. Tomato consumption (60.1%) was the most frequent type of eating behavior. Most patients reported severe anxiety (45.9%) and showed statistically significant differences in age, sex, education level, and cigarette usage. This study also found that certain demographic status, eating behaviors, and symptoms were associated with significantly different depression, anxiety, and stress scores among patients with GERD. Conclusion: Our study demonstrates the association between GERD and various modifiable risk factors in Herat, Afghanistan. Public health initiatives focusing on preventive measures and raising awareness can potentially alleviate the burden of GERD. Moreover, further research and targeted interventions are essential to improve health outcomes, particularly among patients with GERD, who may experience psychological comorbidities.

Spectrum of esophageal manometry and 24-h pH impedance findings in non-erosive gastroesophageal reflux disease and response to phenotype-based treatment-A prospective observational study.

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is classified into erosive reflux disease (ERD) and non-erosive reflux disease (NERD). NERD includes three phenotypes: true NERD, functional heartburn (FH) and reflux hypersensitivity (RH). The management of these NERD phenotypes differs. We aimed at studying the spectrum of high-resolution manometry (HRM) and 24-hour impedance-pH findings in Indian patients with NERD, classifying the phenotypes and assessing the response to phenotype-based treatment. METHODS: We prospectively studied the clinical characteristics, endoscopy, HRM, 24-hour impedance-pH findings, symptom association and response to phenotype-specific treatment in patients with NERD. RESULTS: Of 53 patients with NERD, the following phenotypes were diagnosed namely: 35 (66%) true NERD, 12 (22.7%) RH and six (11.3%) FH. The esophagogastric junction-contractile integral (EGJ-CI) was low in 60.4% and ineffective esophageal motility (IEM) was present in 53% of patients. The respective median values for true NERD, RH and FH groups were as follows: proximal mean nocturnal baseline impedance (P-MNBI) 2250Ω, 2241Ω, 2550Ω, (p = 0.592), distal (D-MNBI) 1431Ω, 2887.5Ω, 2516Ω (p < 0.001), post-reflux swallow-induced peristaltic wave index (PSPWI) 11.1%, 16%, 18.7% (p = 0.127). Receiver operating characteristic (ROC) curve analyses showed that D-MNBI and PSPWI discriminated FH and RH from true NERD, respectively, with a cut-off of 2376.5Ω (area under curve [AUC]:0.919, p < 0.001), 22.6% (AUC:0.671, p = 0.184) and 2318Ω (AUC:0.919, p = < 0.001), 16.2% (AUC:0.671, p = 0.079). The median P-MNBI was lower in patients with GERD-associated cough than other symptoms 1325 (1250, -). Fifty (94.3%) patients showed significant improvement in symptom severity scores (p < 0.001) following phenotype-specific treatment. CONCLUSIONS: In NERD patients, EGJ-CI and IEM were low. D-MNBI and PSPWI could effectively discriminate true NERD from FH and RH, whereas P-MNBI could help diagnose GERD-associated cough. The phenotype-specific treatment provides better symptom relief for patients.

Mechanochemical chemically assisted ablation of varicose veins for venous insufficiency: American vein and lymphatic society position statement.

Background: Mechanical occlusion chemically assisted ablation (MOCA) of incompetent saphenous veins has been utilized since its FDA approval in 2008. However, only recently have longer-term three and 5 year clinical follow up data become available. This updated information necessitates a societal update to guide treatment and ensure optimal patient outcomes. Method: The American Vein and Lymphatic Society convened an expert panel to write a Position Statement with explanations and recommendations for the appropriate use of MOCA for patients with venous insufficiency. Result: This Position Statement was produced by the expert panel with recommendations for appropriate use, treatment technique, outcomes review, and potential adverse events. These recommendations were reviewed, edited, and approved by the Guidelines Committee of the Society. Conclusions: MOCA is effective in alleviating symptoms and a safe treatment option for venous insufficiency. It obviates the need for tumescent anesthesia, has less procedural discomfort and lower risk of thermal nerve or skin injury. It may be used in both the below knee distal GSV as well as the SSV. However, it is associated with significantly lower rates of vessel closure and higher recanalization rates compared to both RFA and EVLA and is less cost effective than thermal techniques. It is an available option for those in whom thermal ablation is not suitable.

Robotic Repair of a Paraesophageal Hernia After an Open Nissen Fundoplication: Case Presentation and Clinical Discussion.

We present a female in her sixties with a recurrent paraesophageal hernia status post open Nissen fundoplication and multiple esophageal dilations who underwent a robotic paraesophageal hernia repair, with extensive lysis of adhesions. The stomach and esophagus were dissected off the crura and the previous wrap was undone. Once the entirety of the stomach and esophagus were freed from their surrounding structures, the hernia sac was able to be excised. The crural defect was closed and gastropexy was performed. The patient had an uneventful postoperative course and was discharged home. This case is presented to provide evidence that robotic repair presents a viable option in the reoperation of patients following an open Nissen fundoplication as well as provide an overview of the types of hiatal hernias and the indications and options for surgical intervention.

A Comprehensive Review on the Efficacy and Safety of Vonoprazan in the Management of Gastric Acid-Related Diseases.

Gastric acid-related diseases, including gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and Helicobacter pylori (H. pylori) infection, present significant clinical challenges due to their prevalence and potential for severe complications. Effective management of these conditions is essential for symptom relief, mucosal healing, and prevention of complications. This review aims to evaluate the efficacy and safety of vonoprazan, a novel potassium-competitive acid blocker (P-CAB), in the treatment of gastric acid-related diseases and to compare it with traditional proton pump inhibitors (PPIs). A comprehensive analysis of clinical trials and studies was conducted to assess the effectiveness of vonoprazan in managing GERD, PUD, and H. pylori infection. The safety profile of vonoprazan was also reviewed, and comparisons were made to PPIs and other gastric acid suppressants. Vonoprazan demonstrates superior and more consistent acid suppression than PPIs, resulting in rapid and sustained symptom relief and mucosal healing. Clinical trials have shown its efficacy in treating GERD, PUD, and H. pylori infection, with higher eradication rates for H. pylori when used in combination therapies. The safety profile of vonoprazan is favorable, with fewer adverse effects and drug interactions compared to PPIs. Vonoprazan offers a promising alternative to traditional PPIs for the management of gastric acid-related diseases. Its unique mechanism of action and superior efficacy make it a valuable option for patients requiring effective and reliable acid suppression. Further research is warranted to explore its potential in broader clinical applications and to establish long-term safety data.

Gastroesophageal reflux following peroral endoscopic myotomy for achalasia: Bumps in the road to success.

Achalasia can significantly impair the quality of life. The clinical presentation typically includes dysphagia to both solids and liquids, chest pain, and regurgitation. Diagnosis can be delayed in patients with atypical presentations, and they might receive a wrong diagnosis, such as gastroesophageal reflux disease (GERD), owing to overlapping symptoms of both disorders. Although the cause of achalasia is poorly understood, its impact on the motility of the esophagus and gastroesophageal junction is well established. Several treatment modalities have been utilized, with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation. Recently, peroral endoscopic myotomy (POEM) has gained popularity as an effective treatment for achalasia, despite a relatively high incidence of GERD occurring after treatment compared to other modalities. The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors. The long-term sequelae of post-POEM GERD are yet to be determined, but it appears to have a benign course and is usually manageable with clinically available modalities. Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.

Gastroesophageal Reflux Disease and Preterm Birth: Univariate and Multivariate Mendelian Randomization.

Background: Observational studies have established a connection between Gastroesophageal reflux disease (GERD) and preterm birth (PTB). Nevertheless, these correlations can be affected by residual confounding or reverse causality, resulting in ambiguity regarding the connection. The objective of this study was to assess the relationship between genetically predicted GERD and PTB. Methods: Initially, we performed bidirectional univariate Mendelian randomization (UVMR) analysis utilizing publicly accessible genome-wide association studies (GWAS) data. The primary analytical approach employed to determine the causal impact between GERD and PTB is the inverse variance weighted technique (IVW). Subsequently, we utilized multivariate Mendelian randomization (MVMR) to adjust for potential factors that could influence the results, such as body mass index (BMI), maternal smoking around birth, educational attainment, household income, and Townsend deprivation index (TDI). Furthermore, we performed a sequence of comprehensive sensitivity analyses to assess the reliability of our MR findings. Results: The UVMR analysis results showed a significant correlation between GERD and PTB (odds ratio [OR]: 1.810; 95% confidence interval [CI]: 1.344-2.439; P=9.60E-05) in the IVW model, and the Weighted median method (OR=1.591, 95% CI=1.094-2.315, P=0.015) revealed consistent results. The inverse MR findings suggest no causal link between PTB and the incidence of GERD. In addition, the sensitivity analysis did not detect heterogeneity or horizontal pleiotropy, and the "leave-one-out" examination confirmed that the causal estimation is unlikely to be influenced by the single nucleotide polymorphisms (SNPs) effect. The MVMR analysis demonstrated that the causal association between GERD and PTB still existed after considering BMI, maternal smoking around birth, educational attainment, household income, and TDI (OR=1.921, 95% CI=1.401-2.634, P=5.08E-05). Conclusion: This study presents evidence indicating that genetically predicted GERD can heighten the risk of PTB. Therefore, it is advisable to perform focused screening for pregnant women with GERD in order to find the initial signs of PTB and promptly apply intervention strategies to extend the duration of pregnancy.

An evaluation of ureteral diameter ratio and vesicoureteral reflux index in the treatment of primary vesicoureteral reflux.

Objective: Vesicoureteral reflux (VUR) index is a simple, validated tool that reliably predicts significant improvement and spontaneous resolution of primary reflux in children. The aim of this study was to evaluate and compare the ureter diameter ratio (UDR) and VUR index (VURx) of patients treated with endoscopic injection (EI) and ureteroneocystostomy (UNC) methods in the pediatric age group due to primary VUR. Methods: Patients under the age of 18 years old who underwent EI and UNC with the diagnosis of primary VUR between January 2011 and September 2021 were determined as the participants. The UDR was assessed using voiding cystourethrography, and the VURx score was determined prior to treatment based on hospital records included in the study. Results: A total of 255 patients, 60 (23.5%) boys and 195 (76.5%) girls, with a mean age of 76.5 (range 13.0-204.0) months, were included in the study. EI was applied to 130 (51.0%) patients and UNC was applied to 125 (49.0%) patients due to primary VUR. The optimum cut-off for the distal UDR was obtained as 0.17 with sensitivity and specificity of 73.0% and 63.0%, respectively. The positive and negative predictive values were 66.0% and 70.0%, respectively. Conclusion: When the UDR and VURx score are evaluated together for the surgical treatment of primary VUR in the pediatric age group, it is thought that it may be useful in predicting the clinical course of the disease and evaluating surgical treatment options.

Treating acid reflux without compressing the food passageway: 4-year safety and clinical outcomes with the RefluxStop device in a prospective multicenter study.

INTRODUCTION: RefluxStop is an implantable device for laparoscopic surgical treatment of gastroesophageal reflux disease (GERD) to restore and maintain lower esophageal sphincter and angle of His anatomy without encircling and putting pressure on the food passageway, thereby avoiding side effects such as dysphagia and bloating seen with traditional fundoplication. This study reports the clinical outcomes with RefluxStop at 4 years following implantation of the device. METHODS: A prospective, single arm, multicenter clinical investigation analyzing safety and effectiveness of the RefluxStop device in 50 patients with chronic GERD. RESULTS: Available data are presented for 44 patients at 4 years with the addition of three patients at 3 years carried forward. At 4 years, median GERD-HRQL score was 90% reduced compared to baseline. Two patients (2/44) used regular daily proton pump inhibitors (PPIs) despite subsequent 24-h pH monitoring off PPI therapy yielding normal results. There were no device-related adverse events (AEs), esophageal dilations, migrations, or explants during the entire study period. AEs reported between 1 and 4 years were as follows: one subject with heartburn and a pathologic pH result with device positioned too low at surgery; one subject with dysphagia, thus, 46/47 patients reported no dysphagia-related AEs between years 1 and 4. Two patients (2/47) were dissatisfied with treatment despite normal 24-h pH monitoring, of whom one had manometry-verified dysmotility at 6 months, indicating dissatisfaction for reasons other than acid reflux. CONCLUSION: These results confirm the excellent and already published 1-year results as stable in the long-term, supporting the safety and effectiveness of the RefluxStop device in treating GERD for over 4 years. GERD-HRQL score, pH testing, and PPI usage indicate treatment success without dysphagia or gas-bloating and only minimal incidence of other AEs. This favorably low rate of AEs is likely attributable to RefluxStop's dynamic physiologic interaction and non-encircling nature.

The Impact of a Twice-daily vs Once-daily Proton Pump Inhibitor Dosing Regimen on Laryngopharyngeal Reflux Symptoms: A Prospective Randomized Controlled Trial.

Background/Aims: Proton pump inhibitors (PPIs) play a crucial role in managing laryngopharyngeal reflux (LPR), but the optimal dosing regimen remains unclear. We aim to compare the effectiveness of the same total PPI dose administered twice daily versus once daily in LPR patients. Methods: We conducted a prospective randomized controlled trial at a tertiary referral hospital, enrolling a total of 132 patients aged 19-79 with LPR. These patients were randomly assigned to receive either a 10 mg twice daily (BID) or a 20 mg once daily (QD) dose of ilaprazole for 12 weeks. The Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) were assessed at 8 weeks and 16 weeks. The primary endpoint was the RSI response, defined as a reduction of 50% or more in the total RSI score from the baseline. We also analyzed the efficacy of the dosing regimens and the impact of dosing and duration on treatment outcomes. Results: The BID group did not display a higher response rate for RSI than the QD group. The changes in total RSI scores at the 8-week and 16-week visits showed no significant differences between the 2 groups. Total RFS alterations were also comparable between both groups. Each dosing regimen demonstrated significant decreases in RSI and RFS. Conclusions: Both BID and QD PPI dosing regimens improved subjective symptom scores and objective laryngoscopic findings. There was no significant difference in RSI improvement between the 2 dosing regimens, indicating that either dosing regimen could be considered a viable treatment option.

Magnetic sphincter augmentation vs subtotal gastrectomy with Roux-en-Y reconstruction for the treatment of postsleeve gastrectomy gastroesophageal reflux disease.

BACKGROUND: Obesity affects more than one-third of Americans and can be treated with bariatric surgery, most commonly sleeve gastrectomy (SG). SG has been shown to increase the incidence of gastroesophageal reflux disease (GERD) in some patients, which can be refractory to medical management. Surgical options for post-SG GERD include magnetic sphincter augmentation (MSA) and subtotal gastrectomy with Roux-en-Y reconstruction (SGRY). A comparative analysis of MSA and SGRY for post-SG GERD was performed to evaluate postoperative outcomes. METHODS: A retrospectively maintained prospectively gathered database from 2018 to 2023 was used to identify patients who underwent MSA or SGRY for the indication of GERD after SG. Differences among patient characteristics; GERD assessments, including the health-related quality of life (HRQL) questionnaire and the reflux symptom index (RSI); and procedure outcomes were collected and analyzed according to surgery type. RESULTS: A total of 92 patients (85 females and 7 males) met the inclusion criteria. The study included 17 patients in the MSA group, 71 patients in the SGRY group, and 4 patients who underwent both procedures. The average preoperative body mass index (BMI) of all patients was 33.3. Compared with patients who underwent MSA, those who underwent SGRY presented with higher BMI (29.4 vs 34.2, respectively; P = .013), preoperative GERD-HRQL (35 vs 52, respectively; P = .046), and RSI (14 vs 28, respectively; P = .017). Postoperatively, patients who underwent SGRY demonstrated a higher decrease in mean postoperative DeMeester score than those who underwent MSA (44.2 vs 13.9, respectively; P = .040), with 22 patients (50%) in the SGRY group vs 10 patients (20%) in the MSA group achieving normalization. CONCLUSION: Although MSA remains a viable surgical alternative, our study indicated that SGRY can produce better symptom control and decrease acid exposure compared with MSA in patients with post-SG GERD.

A Study of Clinical Profile of Congenital Anomalies of Kidney and Urinary Tract (CAKUT) in a Tertiary Care Center.

Background  Congenital anomalies of the kidney and urinary tract (CAKUT) encompass a diverse array of disorders arising from developmental irregularities in the renal parenchymal development, disrupted embryonic migration of the kidneys, and the urinary collecting system. This study aimed to investigate the clinical presentations, patterns of obstructive and non-obstructive CAKUT, and associated extrarenal manifestations in affected children. Methods This observational study was conducted in the Department of Pediatrics, Acharya Vinoba Bhave Rural Hospital, Wardha. Ethical clearance was obtained, and the study included 105 diagnosed CAKUT patients aged from birth to 18 years. Data collection spanned from June 2022 to May 2024. Clinical features, antenatal findings, associated anomalies, estimated glomerular filtration rate (eGFR), and serum creatinine levels were recorded. Descriptive and inferential statistical analyses were performed using Stata software. Results Among the 105 participants, 81 (77.14%) were males, with a male-to-female ratio of 3.37:1. The mean age was 42.49 months. Forty-two individuals (40%) were asymptomatic, while the most common symptomatic presentation was the ventral opening of the urethra (24.76%). Extrarenal malformations were present in 35 subjects (33.33%), with undescended testis (25.71%) and congenital heart disease (CHD) (20%) being the most common. The antenatal diagnosis was made in 63.8% of cases. Obstructive uropathy was present in 42.86% of subjects, with a significant association between antenatal diagnosis and bilateral hydronephrosis. Medical management was provided to 41.9% of subjects, while 58.1% underwent surgical interventions. Conclusion The study highlights the clinical variability and diverse presentations of CAKUT in children, with a substantial proportion being asymptomatic. Early detection through antenatal screening and prompt intervention can potentially prevent or delay the progression to ESRD. The findings underscore the importance of comprehensive evaluation and targeted management strategies to address both renal and extrarenal manifestations of CAKUT.

The foregut in cystic fibrosis.

The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple "reflux" as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called "GI-related aspiration" or "GRASP." Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomach to the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes-GERD and gastroparesis-that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post-lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF-related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.

Mean nocturnal baseline impedance in gastro-esophageal reflux disease diagnosis: Should we strictly follow the Lyon 2 Consensus?

Clinical practice guidelines drive clinical practice and clinicians rely to them when trying to answer their most common questions. One of the most important position papers in the field of gastro-esophageal reflux disease (GERD) is the one produced by the Lyon Consensus. Recently an updated second version has been released. Mean nocturnal baseline impedance (MNBI) was proposed by the first Consensus to act as supportive evidence for GERD diagnosis. Originally a cut-off of 2292 Ohms was proposed, a value revised in the second edition. The updated Consensus recommended that an MNBI < 1500 Ohms strongly suggests GERD while a value > 2500 Ohms can be used to refute GERD. The proposed cut-offs move in the correct direction by diminishing the original cut-off, nevertheless they arise from a study of normal subjects where cut-offs were provided by measuring the mean value ± 2SD and not in symptomatic patients. However, data exist that even symptomatic patients with inconclusive disease or reflux hypersensitivity (RH) show lower MNBI values in comparison to normal subjects or patients with functional heartburn (FH). Moreover, according to the data, MNBI, even among symptomatic patients, is affected by age and body mass index. Also, various studies have proposed different cut-offs by using receiver operating characteristic curve analysis even lower than the one proposed. Finally, no information is given for patients submitted to on-proton pump inhibitors pH-impedance studies even if new and extremely important data now exist. Therefore, even if MNBI is an extremely important tool when trying to approach patients with reflux symptoms and could distinguish conclusive GERD from RH or FH, its values should be interpreted with caution.

Cholelithiasis and cholecystectomy increase the risk of gastroesophageal reflux disease and Barrett's esophagus.

Background: Cholelithiasis or cholecystectomy may contribute to the development of gastroesophageal reflux disease (GERD), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) through bile reflux; however, current observational studies yield inconsistent findings. We utilized a novel approach combining meta-analysis and Mendelian randomization (MR) analysis, to assess the association between them. Methods: The literature search was done using PubMed, Web of Science, and Embase databases, up to 3 November 2023. A meta-analysis of observational studies assessing the correlations between cholelithiasis or cholecystectomy, and the risk factors for GERD, BE, and EACwas conducted. In addition, the MR analysis was employed to assess the causative impact of genetic pre-disposition for cholelithiasis or cholecystectomy on these esophageal diseases. Results: The results of the meta-analysis indicated that cholelithiasis was significantly linked to an elevated risk in the incidence of BE (RR, 1.77; 95% CI, 1.37-2.29; p < 0.001) and cholecystectomy was a risk factor for GERD (RR, 1.37; 95%CI, 1.09-1.72; p = 0.008). We observed significant genetic associations between cholelithiasis and both GERD (OR, 1.06; 95% CI, 1.02-1.10; p < 0.001) and BE (OR, 1.21; 95% CI, 1.11-1.32; p < 0.001), and a correlation between cholecystectomy and both GERD (OR, 1.04; 95% CI, 1.02-1.06; p < 0.001) and BE (OR, 1.13; 95% CI, 1.06-1.19; p < 0.001). After adjusting for common risk factors, such as smoking, alcohol consumption, and BMI in multivariate analysis, the risk of GERD and BE still persisted. Conclusion: Our study revealed that both cholelithiasis and cholecystectomy elevate the risk of GERD and BE. However, there is no observed increase in the risk of EAC, despite GERD and BE being the primary pathophysiological pathways leading to EAC. Therefore, patients with cholelithiasis and cholecystectomy should be vigilant regarding esophageal symptoms; however, invasive EAC cytology may not be necessary.

Hiatal Hernia With Ulcer at the Gastroesophageal Junction Presenting With Progressive Dysphagia and Epigastric Pain: A Case Report.

A hiatal hernia occurs when the contents of the abdominal cavity, most often the stomach, protrude into the chest cavity through the esophageal hiatus. The hiatus is an elliptical-shaped outlet, typically formed by parts of the right diaphragmatic crus surrounding the distal esophagus. This ailment can transpire due to either the broadening of the specific diaphragmatic opening or a shortening in the overall length of the esophagus, leading to herniation of the stomach into the thoracic region. Raised pressure in the abdominal region may also be one of the culprits. Patients with a hiatal hernia usually remain asymptomatic, but patients might have difficulty swallowing both liquids and solids in the advanced stages of the disease. The disease is rarely accompanied by reflux of gastric acid into the esophagus due to decreased activity of the lower esophageal sphincter, leading to increased complaints of epigastric pain and ulceration near the gastroesophageal junction. Long-standing cases can increase the risk of developing Barrett's esophagus with dysplasia, which may advance to esophageal carcinoma in later stages. Advanced age and obesity are significant risk factors for hiatal hernia. Obese individuals, in particular, experience higher intra-abdominal pressure, which significantly raises the likelihood of developing a hiatal hernia. The hernia may be diagnosed through an upper gastrointestinal endoscopy or radiologically through a chest X-ray in the posterior-anterior view, defining the border of the esophagus. Hence, this facilitates a more seamless and precise diagnosis. Surgical fundoplication treatment improves the patient's condition better than solitary medical management. Overall, addressing the condition surgically often yields more favorable outcomes and enhances the patient's quality of life. Hiatal hernia usually presents with no or minimal clinical manifestations. Thus, this case report highlights the importance of comprehensive clinical management of such cases.