An analysis of 342 patients with refractory gastroesophageal reflux disease symptoms using questionnaires, high-resolution manometry, and impedance-pH monitoring.

Symptoms of refractory gastroesophageal reflux disease (GERD) are commonly encountered in clinical practice. The aim of this study was to analyze the data obtained from questionnaires, high-resolution manometry (HRM), and ambulatory impedance-pH monitoring in patients with persisting GERD symptoms and to explore the possible underlying causes for this clinical presentation. After completing the questionnaires, the selected patients underwent endoscopy, HRM, and ambulatory impedance-pH monitoring. Based on the results of these investigations, we divided the patients into 4 groups: reflux esophagitis (RE), hypersensitive esophagus (HE), functional heartburn (FH), and nonerosive gastroesophageal reflux disease (NERD). The data from 342 patients were analyzed. One hundred twenty-nine (37.72%) patients experienced refractory GERD symptoms related to acid reflux. The scores on some scales in the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire differed significantly among groups (all P < 0.05). Liquid reflux occurred more frequently in patients with GERD (RE and NERD), while gas reflux was more common in non-GERD patients (FH and HE; all P < 0.05). The RE and NERD groups showed more percent bolus exposure time (BET) when upright (all P < 0.05). Acid exposure time (AET) in the RE and NERD groups was longer than that in the HE and FH groups (all P < 0.05). Fewer than half of the patient symptoms were related to acid reflux. The GSRS questionnaire may be an optimal indicator for patients with refractory GERD symptoms. BET and AET are useful indices to distinguish GERD from other diseases. Gas reflux is probably related to persisting symptoms in FH and HE patients.

The Chicago Classification 3.0 Results in More Normal Findings and Fewer Hypotensive Findings With No Difference in Other Diagnoses.

OBJECTIVES: High-resolution manometry (HRM) is the preferred method for the evaluation of motility disorders. Recently, an update of the diagnostic criteria (Chicago 3.0) has been published. The aim of this study was to compare the performance criteria of Chicago version 2.0 (CC2.0) vs. 3.0 (CC3.0) in a cohort of healthy volunteers and symptomatic patients. METHODS: HRM studies of asymptomatic and symptomatic individuals from several centers of Spain and Latin America were analyzed using both CC2.0 and CC3.0. The final diagnosis was grouped into hierarchical categories: obstruction (achalasia and gastro-esophageal junction obstruction), major disorders (distal esophageal spasm, absent peristalsis, and jackhammer), minor disorders (failed frequent peristalsis, weak peristalsis with small or large defects, ineffective esophageal motility, fragmented peristalsis, rapid contractile with normal latency and hypertensive peristalsis) and normal. The results were compared using McNemar's and Kappa tests. RESULTS: HRM was analyzed in 107 healthy volunteers (53.3% female; 18-69 years) and 400 symptomatic patients (58.5% female; 18-90 years). In healthy volunteers, using CC2.0 and CC3.0, obstructive disorders were diagnosed in 7.5% and 5.6%, respectively, major disorders in 1% and 2.8%, respectively, minor disorders in 25.2% and 15%, respectively, and normal in 66.4% and 76.6%, respectively. In symptomatic individuals, using CC2.0 and CC3.0, obstructive disorders were diagnosed in 11% and 11.3%, respectively, major disorders in 14% and 14%, respectively, minor disorders in 33.3% and 24.5%, respectively, and normal in 41.8% and 50.3%, respectively. In both groups of individuals, only an increase in normal and a decrease in minor findings using CC3.0 were statistically significant using McNemar's test. DISCUSSIONS: CC3.0 increases the number of normal studies when compared with CC2.0, essentially at the expense of fewer minor disorders, with no significant differences in major or obstructive disorders. As the relevance of minor disorders is questionable, our data suggest that CC3.0 increases the relevance of abnormal results.

Diagnosis and Treatment Strategy of Achalasia Subtypes and Esophagogastric Junction Outflow Obstruction Based on High-Resolution Manometry.

BACKGROUND: Based on Chicago Classification version 3.0, the disorders of esophagogastric junction outflow obstruction (EGJOO) include achalasia (types I, II and III) and EGJOO. Although no curative treatments are currently available for the treatment of the disorders of EGJOO, medical treatments, endoscopic pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and per-oral endoscopic myotomy (POEM) are usually the sought-after modes of treatment. Since the etiology and pathogenesis might vary depending on the types of EGJOO disorders, treatment strategies should be considered based on those subtypes. SUMMARY: Based on the accumulated evidences, the treatment strategies of our institution are as follows: effects of medical treatments on achalasia are limited. Either PD or LHM/POEM can be considered a first-line in achalasia type I, according to the patient's wish. PD and POEM can be considered first-line in achalasia types II and III, respectively. Conversely, In EGJOO, medical treatments including drugs like acotiamide and/or diltiazem can be tested as a first-line, and PD and POEM will be considered second and third-line treatments, respectively. Key Messages: The classification of subtypes based on high-resolution manometry will help us consider which treatment option can be selected as a first-line treatment depending upon the subtypes of disorders of EGJOO. Acotiamide has the potential to cure patients with EGJOO.

Classification for esophagogastric junction (EGJ) complex based on physiology.

We propose a new classification for esophagogastric junction (EGJ) incorporating both physiologic and morphologic characteristics. Additionally, we contrast it with the Chicago v 3.0 EGJ classification. With Institutional Review Board (IRB) approval, prospectively maintained database was queried to identify patients who underwent high-resolution manometry (HRM) and pH-study between October 2011 and October 2015. Patients with prior foregut intervention, pH study on acid suppression, esophageal dysmotility, or lower esophageal sphincter-crural diaphragm separation of >5 cm were excluded. We classified patients into three groups-Type-A: Complete overlap of lower esophageal sphincter-crural diaphragm (single high-pressure zone); Type-B: Double high-pressure zone with pressure inversion point (PIP) at or above lower esophageal sphincter; Type-C: Double high-pressure zone with PIP below lower esophageal sphincter. A total of 214 included patients were divided into Type-A (n = 101), Type-B (n = 32), and Type-C (n = 81). Abdominal lower esophageal sphincter length (AL), lower esophageal sphincter pressure (LESP), and lower esophageal sphincter pressure integral (LESPI) were significantly lower in Type-C than both Type-A and Type-B [AL(cm): 0.2 vs. 2(P < 0.001) vs. 1.6(P <0.001); LESP(mmHg): 20.1 vs. 32.1(P < 0.001) vs. 29.2(P < 0.001); LESPI(mmHg.cm.s): 187 vs. 412(P < 0.001) vs. 343(P < 0.05)] while overall lower esophageal sphincter length(OL) and Integrated Relaxation Pressure (IRP) were significantly lower in Type-C than Type-A [OL(cm): 2.9 vs. 3.6(P < 0.001); IRP(mmHg): 8.2 vs. 9.6(P < 0.05)]. Type-C patients had significantly higher positive pH score (>14.7) than Type-A and Type-B [72% vs. 47% (P < 0.05) vs. 41% (P < 0.001)]. In Type-C morphology, there is both anatomical and physiological deterioration, weakest lower esophageal sphincter function (abdominal length, lower esophageal sphincter pressure, and lower esophageal sphincter pressure integral) and is most likely to be associated with pathological reflux. This proposed classification incorporates both physiological and morphological derangements in a graded fashion.

[Endoscopic surgery for benign diseases and injuries of the esophagus (with commentary)]. / Endokhirurgiya dobrokachestvennykh zabolevanii i povrezhdenii pishchevoda (s kommentariem).

AIM: To analyze the results of surgical treatment of patients with benign diseases and injuries of the esophagus. MATERIAL AND METHODS: We summarized the experience of different endoscopic interventions in 159 patients with various benign diseases and perforation of the esophagus. Patients with achalasia (72 cases) underwent videolaparoscopic Geller's esophagomyotomy with anterior hemiesophagofundoplication by Dor. Video-assisted thoracoscopic extirpation of the esophagus with simultaneous or delayed esophagocolo/gastroplasty was performed in 56 patients with post-ambustial cicatricial stenosis of the esophagus. Patients with esophageal perforation (14 cases) underwent videolaparoscopic transhiatal mediastinal drainage. Esophageal leiomyoma has been excised through thoracoscopic (9 cases) or laparoscopic access (4 cases). Removal of esophageal diverticulum was made via VATS-access in 4 patients. RESULTS: Satisfactory early and remote results were achieved in all patients with achalasia. Mortality rate was 5.4% (3 out of 56 patients) and 14.3% (2 out of 14 patients) in groups of cicatricial esophageal stenosis and esophageal perforation respectively. Sutures failure after removal of the diverticulum and leiomyoma occurred in 2 and 1 patient respectively and has been successfully cured. CONCLUSION: Endoscopic technologies allow to perform successfully complex reconstructive interventions for dysphagia in patients with cicatricial esophageal stenosis and achalasia even at late stages, to remove benign tumors and diverticula of thoracic esophagus and provide adequate drainage of posterior mediastinum in case of esophageal perforation.

Proton pump inhibitor responsive esophageal eosinophilia, a distinct disease entity?

Recent studies have suggested the existence of a patient population with esophageal eosinophilia that responds to proton pump inhibitor therapy. These patients are being referred to as having proton pump inhibitor responsive esophageal eosinophilia (PPI-REE), which is currently classified as a distinct and separate disease entity from both gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE). The therapeutic effect of proton pump inhibitor (PPI) on PPI-REE is thought to act directly at the level of the esophageal mucosa with an anti-inflammatory capacity, and completely independent of gastric acid suppression. The purpose of this manuscript is to review the mechanistic data of the proposed immune modulation/anti-inflammatory role of the PPI at the esophageal mucosa, and the existence of PPI-REE as a distinct disease entity from GERD and EoE.

[Efficacy of the use of remnant stomach in esophagoplasty].

In the period from 2001 till 2010 there were 117 extirpations of the oesophagus with single-stage plasty of the stomach in 94 patients and plasty of the large intestine--in 23 cases. Gastric resections were performed earlier in 50 (42.7%) patients, though gastrectomy took place in 39 (78%) patients. The accumulated experience allowed making an assessment of immediate and long-term results of esophagoplasty to patients, who had earlier the gastric resection. The incompetence of oesophagogastric anastomosis was noted in 2 times more frequent and the formation of stenosis of given anastomosis in 3 times more often. I order to improve the results of esophagoplasty, the method of serousmyotomy was applied in the cases of remnant stomach.

[Surgical treatment of the benign diseases of the esophagus].

Treatment results of 207 patients with the benign diseases of the esophagus, operated on during 2009-2012 yy, were analyzed. The diseases included the burn stricture of esophagus, cardiospasm, esophageal achalasia, hiatal hernias and diverticles. Indications to different treatment algorithms were substantiated. Postoperative complications were registered in 22 (10.6%) patients; the postoperative lethality was 1.6%. The authors concluded the high efficacy of the used methods of treatment.

Risk of perforation using rigid oesophagoscopy in the distal part of oesophagus.

INTRODUCTION: Endoscopic examination and treatment of disorders in the oesophagus have been a part of the otolaryngological specialty since the introduction of the rigid endoscope. Today, both flexible and rigid oesophagoscopy (RO) is used to that end. The aim of this study was to evaluate the safety of the RO. MATERIAL AND METHODS: We conducted a retrospective cohort study of all ROs performed at a head & neck department in a Danish hospital in the 2003-2011-period. Perforation of the oesophageal wall was the primary endpoint. Secondary endpoints included: dental injury, mortality and, in case of a foreign body: location and successful removal. RESULTS: A total of 483 ROs were performed. Four patients (0.8%) suffered perforation; three during removal of a foreign body in the lower part of the oesophagus and one as part of investigation for cancer. 46.2% of the procedures were performed to remove a foreign body and 32.7% as investigation for cancer. The majority of the foreign bodies were located in the superior part of the oesophagus and the objects were successfully removed in all but one case. CONCLUSION: Our results are well within the range of previously published material. We recommend that the risk of serious complications is taken into consideration when choosing this modality. Furthermore, we believe that this risk increases in the distal part of the oesophagus and recommend that the use of the RO in this area is reserved as a last resort option. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[The value of esophageal intrapapillary capillary loop visualized by magnifying narrow-band imaging endoscopy in diagnosing esophageal mucosal pathology].

OBJECTIVE: To investigate the diagnostic potential of magnifying narrow-band imaging endoscopy (NBI-ME) for different intrapapillary capillary loop (IPCL) for the diagnosis of esophageal lesion. METHODS: Patients with abnormal esophageal mucosa found by white light gastroscopy in digestive endoscopy center, Chinese PLA General Hospital during the period of November 2009 to November 2010 were enrolled in this study. IPCL was observed and divided into different types by NBI-ME. Histopathology of biopsy or endoscopic submucosal dissection (ESD) specimens was evaluated and used as the gold standard to evaluate the diagnostic value of NBI-ME for IPCL. RESULTS: A total of 146 lesions from 145 subjects with esophageal mucosa abnormal were collected. Among them, 88 were pathology-proven inflammation, 5 were pathology-proven esophageal cancers, 20 were pathology-proven low intraepithelial neoplasia (LIN) and 33 were pathology-proven high intraepithelial neoplasia (HIN) detected with NBI-ME. By a per-lesion analysis, the accuracy of inflammation and cancer were 100% (88/88) and 7/7. For the sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio of LIN and HIN were 7/10, 69.8% (30/43), 69.8% (37/53), 35.0% (7/20), 90.9% (30/33), 12.5% (70/559), 2.3% (30/1290) and 87.1% (27/31), 72.7% (16/22), 81.1% (43/53), 81.8% (27/33), 80.0% (16/20), 634.1% (837/132) and 35.2% (124/352), respectively. CONCLUSIONS: NBI-ME can classify the different esophageal IPCL. Higher diagnostic accuracy of IPCL indicates the feasibility of NBI-ME for the efficacious diagnosis of esophageal inflammation and cancer. There is the higher diagnostic accuracy of HIN than LIN.

Candidiasis esofágica / Esophageal candidiasis

La Candidiasis esofágica es una entidad frecuente en pacientes con VIH, cáncer, usuarios de corticoides, algorra orofaringea. La Candida es un organismo comensal y puede infectar al ser humano. Existe una serie de factores locales y sistémicos del huésped que favorecen la infección por Candida. El cuadro clínico se presenta frecuentemente con odinofagia, disfagia y dolor retroesternal. El diagnóstico de certeza es histológico. El estudio endoscópico entrega un estudio de alta calidad, altamente sensible y permite diferenciar distintas causas de esofagitis. La candidiasis esofágica debe ser tratada con terapia sistémica. El fármaco más recomendado es el fluconazol.

Esophageal candidiasis is a frequently occurring entity in corticoid users, patients with HIV and oropharyngeal involvement. Candida is a commensal organism, and it can infect humans. There are many local and systemic factors of the host that favor Candida infection. Frequently clinical manifestations are odynophagia, dysphagia and retrosternal pain. Diagnostic certainty reached by histological assays. Endoscopic studies provide high-quality and highly-sensitive results that allow to differentiate esophagitis causes. Esophageal Candidiasis must receive systemic treatment. The most recommended drug is Fluconazol.

[A modified classification of chemical esophageal burn and its consequences].

A modified classification of esophageal chemical burn and its consequences, based on the now existing classifications summary and the clinic experience analysis is presented.

Development of a rating system for digestive system impairments: Korean Academy of Medical Sciences Guideline.

A systematic and effective welfare system for people with digestive system impairments is required. In Korea, an objective and scientific rating guideline does not exist to judge the digestive system impairments. Whether the impairments exist or not and the degree of it need to be examined. Thus, with these considerations we need a scientific rating guideline for digestive system impairments to fit our cultural and social background. In 2007, a research team, for the development of rating impairment guidelines, was organized under the supervision of Korean Academy of Medical Sciences. The rating guidelines for digestive system impairments was classified into upper and lower gastrointestinal tracts impairments and liver impairment. We developed objective rating guidelines for the upper gastrointestinal tract, the impairment generated after surgery for the stomach, duodenum, esophagus, and for the lower gastrointestinal tract, the impairment generated after construction and surgery for colon, rectum, anus, and intestinal stomas. We tried to make the rating impairment guidelines to include science, objectivity, convenience, rationality, and actuality. We especially emphasized objectivity as the most important value. We worked to make it easy and convenient to use for both the subjects who received the impairment ratings and the doctors who will give the ratings.

Development of a Rating System for Digestive System Impairments: Korean Academy of Medical Sciences Guideline

A systematic and effective welfare system for people with digestive system impairments is required. In Korea, an objective and scientific rating guideline does not exist to judge the digestive system impairments. Whether the impairments exist or not and the degree of it need to be examined. Thus, with these considerations we need a scientific rating guideline for digestive system impairments to fit our cultural and social background. In 2007, a research team, for the development of rating impairment guidelines, was organized under the supervision of Korean Academy of Medical Sciences. The rating guidelines for digestive system impairments was classified into upper and lower gastrointestinal tracts impairments and liver impairment. We developed objective rating guidelines for the upper gastrointestinal tract, the impairment generated after surgery for the stomach, duodenum, esophagus, and for the lower gastrointestinal tract, the impairment generated after construction and surgery for colon, rectum, anus, and intestinal stomas. We tried to make the rating impairment guidelines to include science, objectivity, convenience, rationality, and actuality. We especially emphasized objectivity as the most important value. We worked to make it easy and convenient to use for both the subjects who received the impairment ratings and the doctors who will give the ratings.

Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls.

AIM: This study aimed to devise a scheme for the systematic analysis of esophageal high-resolution manometry (HRM) studies displayed using topographic plotting. METHODS: A total of 400 patients and 75 control subjects were studied with a 36-channel HRM assembly. Studies were analyzed in a stepwise fashion for: (a) the adequacy of deglutitive esophagogastric junction (EGJ) relaxation, (b) the presence and propagation characteristics of distal esophageal persitalsis, and (c) an integral of the magnitude and span of the distal esophageal contraction. RESULTS: Two strengths of pressure topography plots compared to conventional manometric recordings were: (a) the ability to delineate the spatial limits, vigor, and integrity of individual contractile segments along the esophagus, and (b) the ability to distinguish between loci of compartmentalized intraesophageal pressurization and rapidly propagated contractions. Making these distinctions objectified the identification of distal esophageal spasm (DES), vigorous achalasia, functional obstruction, and nutcracker esophagus subtypes. Applying these distinctions made the diagnosis of spastic disorders quite rare: (a) DES in 1.5% patients, (b) vigorous achalasia in 1.5%, and (c) a newly defined entity, spastic nutcracker, in 1.5%. CONCLUSIONS: We developed a systematic approach to analyzing esophageal motility using HRM and pressure topography plots. The resultant scheme is consistent with conventional classifications with the caveats that: (a) hypercontractile conditions are more specifically defined, (b) distinctions are made between rapidly propagated contractions and compartmentalized esophageal pressurization, and (c) there is no "nonspecific esophageal motor disorder" classification. We expect that pressure topography analysis, with its well-defined functional implications, will prove valuable in the clinical management of esophageal motility disorders.

Heterotopic gastric mucosa of the esophagus: literature-review and proposal of a clinicopathologic classification.

The prevalence of heterotopic gastric mucosa (HGM) in the cervical esophagus is frequently underestimated. Tiny microscopic foci have to be distinguished from a macroscopically visible patch, also called "inlet patch." Symptoms as well as morphologic changes associated with HGM are regarded as a result of the damaging effect of acid, produced by parietal cells in the mostly fundic type of HGM. We herein review the literature and propose a new clinicopathologic classification of esophageal HGM: Most of the carriers of esophageal HGM are asymptomatic (HGM I). Some individuals with HGM in the esophagus complain of dysphagia, odynophagia, or "extraesophageal manifestations" (hoarseness and coughing), without further morphologic findings (HGM II). Still fewer patients are symptomatic due to morphologic changes, i.e., esophageal strictures, webs, or esophagotracheal fistula (HGM III). Malignant transformation via dysplasia (intraepithelial neoplasia, HGM IV) to cervical esophageal adenocarcinoma (HGM V) is exceedingly rare (only 24 reported cases). In contrast to Barrett's esophagus, HGM should not be regarded as a precancerous lesion. Symptoms are more likely to occur in patients with inlet patch, whereas malignant transformation and adenocarcinogenesis can also occur in microscopic HGM foci. Asymptomatic HGM requires neither specific therapy nor endoscopic surveillance. Only in symptomatic cases treatment, i.e., dilatation for (benign) strictures or acid suppression for reflux symptoms, can be recommended. Patients with low-grade dysplasia in HGM might be candidates for surveillance strategies, whereas in cases of high-grade dysplasia and invasive adenocarcinoma oncological treatment strategies must be employed.