Long-term acid suppressive therapy may prevent the relapse of lower esophageal (Schatzki's) rings: a prospective, randomized, placebo-controlled study

Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023)

Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.

Gastroesophageal Reflux Disease Might Induce Certain-Supposedly Adaptive-Changes in the Esophagus: A Hypothesis

BACKGROUND

The increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration.

AIM

Our aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions.

METHODS

Based on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker's diverticulum, Schatzki's ring, esophageal web, and Barrett's esophagus).

RESULTS

Patients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki's ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett's esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett's esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium.

CONCLUSION

We believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

Achalasia following reflux disease: coincidence, consequence, or accommodation? An experience-based literature review

Achalasia is a motility disorder of the esophagus characterized by the defective peristaltic activity of the esophageal body and impaired relaxation of the lower esophageal sphincter due to the degeneration of the inhibitory neurons in the myenteric plexus of the esophageal wall. The histopathological and pathophysiological changes in achalasia have been well described. However, the exact etiological factors leading to the disease still remain unclear. Currently, achalasia is believed to be a multifactorial disease, involving both extrinsic and intrinsic factors. Based on our experience and the review of literature, we believe that gastroesophageal reflux disease (GERD) might be one of the triggering factors leading to the development of achalasia. However, it is also stated that the two diseases can simultaneously appear independently from each other. Considering the large number and routine treatment of patients with GERD and achalasia, the rare combination of the two may even remain unnoticed; thus, the analysis of larger patient groups with this entity is not feasible. In this context, we report four cases where long-standing reflux symptoms preceded the development of achalasia. A literature review of the available data is also given. We hypothesize that achalasia following the chronic acid exposure of the esophagus is not accidental but either a consequence of a chronic inflammation or a protective reaction of the organism in order to prevent aspiration and lessen reflux-related symptoms. This hypothesis awaits further clinical confirmation.

Development of quality measures for the care of patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Gastroesophageal reflux disease (GERD) is a common and costly disorder. Symptoms attributed to GERD have a wide spectrum of presentations and complications that have led to complex diagnostic and management algorithms. As such, there is considerable variation in clinical approaches to GERD. In contrast to multiple published guidelines for the management of GERD, there are few validated GERD quality measures. The objective of this study was to use a well-described, formal methodology to develop valid, physician-led quality measures for all aspects of care for patients with GERD.

METHODS

Quality measures were identified from the literature, consensus guidelines, and GERD experts. Eight clinical experts ranked potential measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology.

RESULTS

Of the 52 proposed quality measures, 24 were rated as valid, and 1 new measure was developed. These valid measures were related to initial diagnosis and management (9), monitoring (3), further diagnostic testing (4), proton pump inhibitor refractory symptoms (2), symptoms of chest pain (1), erosive esophagitis (3), esophageal stricture or ring (1), and surgical therapy (2). Fifteen of these measures were ranked with the highest validity. Twenty-seven measures were determined to be equivocal; 89% of these were extracted from guidelines that were based on low or moderate level evidence.

CONCLUSIONS

We used RAND/University of California, Los Angeles Appropriateness Methodology to develop quality measures for GERD care. By examining performance on these valid, formally developed quality measures, clinical practices and individual providers can assess their adherence with them and direct quality improvement efforts accordingly.

Obliteration of symptomatic Schatzki rings with jumbo biopsy forceps (with video)

A Schatzki ring is a submucosal, fibrotic thickening located at the gastroesophageal junction. Endoscopic treatment traditionally involves disruption of the ring. Many approaches have been described including bougies, balloons, biopsies, and diathermic monopolar incision. While all of these approaches are effective in the short-term, recurrence is common. The objective of our study was to evaluate the feasibility of complete excision of the ring using jumbo cold biopsy forceps. Our main outcome measurements were the feasibility, safety, and efficacy of complete obliteration of Schatzki rings using jumbo cold biopsy forceps. We designed an observational study using a standard protocol for patient management and data collection using a university hospital as our setting. We followed 10 patients with dysphagia due to a Schatzki's ring, six of whom had previously undergone bougienage or balloon dilation. Five patients were on maintenance therapy with a proton pump inhibitor and one with an H2 blocker. Complete endoscopic obliteration of the Schatzki rings with a cold jumbo biopsy forceps was achieved in all 10 patients requiring a mean of 9.8 biopsies (range 8-12). Omeprazole (20 mg twice daily) was prescribed after the procedure. All 10 patients demonstrated improvement in dysphagia after treatment, which persisted during a mean follow-up time of 379 days (range 63-496 days). There were no serious complications. The limitations of our study include lack of a control group, a small sample size, and being a single-institution study. We concluded that complete Schatzki ring obliteration with jumbo cold biopsy forceps is a safe, feasible, and effective endoscopic treatment.

Richard Schatzki: a familiar ring

OBJECTIVE

The Schatzki ring was named for Richard Schatzki, a renowned radiologist who described the entity with his colleague, John E. Gary. The purpose of this article is to shed more light on a man who made such a significant contribution and to chronicle developments concerning this important radiologic finding.

CONCLUSION

The Schatzki ring was described long ago, but its cause is poorly understood even today.

Is the schatzki ring a unique esophageal entity?

AIM: To study, whether the association of Schatzki rings with other esophageal disorders support one of the theories about its etiology.

METHODS: From 1987 until 2007, all patients with newly diagnosed symptomatic Schatzki rings (SRs) were prospectively registered and followed. All of them underwent structured interviews with regards to clinical symptoms, as well as endoscopic and/or radiographic examinations. Endoscopic and radiographic studies determined the presence of an SR and additional morphological abnormalities.

RESULTS: One hundred and sixty-seven patients (125 male, 42 female) with a mean age of 57.1 ± 14.6 years were studied. All patients complained of intermittent dysphagia for solid food and 113 (79.6%) patients had a history of food impaction. Patients experienced symptoms for a mean of 4.7 ± 5.2 years before diagnosis. Only in 23.4% of the 64 patients who had endoscopic and/or radiological examinations before their first presentation to our clinic, was the SR previously diagnosed. At presentation, the mean ring diameter was 13.9 ± 4.97 mm. One hundred and sixty-two (97%) patients showed a sliding hiatal hernia. Erosive reflux esophagitis was found in 47 (28.1%) patients. Twenty-six (15.6%) of 167 patients showed single or multiple esophageal webs; five (3.0%) patients exhibited eosinophilic esophagitis; and four (2.4%) had esophageal diverticula. Four (7%) of 57 patients undergoing esophageal manometry had non-specific esophageal motility disorders.

CONCLUSION: Schatzki rings are frequently associated with additional esophageal disorders, which support the assumption of a multifactorial etiology. Despite typical symptoms, SRs might be overlooked.

Long-term recurrence rates following dilation of symptomatic Schatzki rings

BACKGROUND AND AIMS

This study investigated the long-term clinical course of patients with Schatzki rings, who were treated by single bougie dilation. Furthermore, it analyzed possible predictors for the time of recurrence.

PATIENTS AND METHODS

A total of 133 patients (100 males, 33 females) with a mean age of 57 ± 14.6 years who were treated by single dilation with the use of Maloney bougies without the aid of fluoroscopy were prospectively registered and followed-up for a mean duration of 58.3 months (range 12-240 months). Duration of remission was evaluated by Kaplan-Meier estimates with regard to recurrence. Log-rank test was performed to analyze possible predictors for the time to second dilation (recurrence).

RESULTS

No complications occurred and all patients were symptom-free at the first follow-up examination 4 weeks after dilation. However, later on, 73 patients required a second dilation. The estimate remission rates were 63.8% (95% CI: 55.6-72.0%) after 2 years, 44.3% (95% CI: 35.4-53.4%) after 5 years, and 39.9% (95% CI: 30.5-49.3%) after 10 years. Neither the initial morphological findings, nor age or gender determined the need for repeated dilation. Only patients treated with a large bougie diameter (≥52 F) seemed to have a tendency for a longer time until symptomatic recurrence.

CONCLUSIONS

Single dilation of symptomatic Schatzki rings is a safe and effective therapy. However, more than half of the patients will need a second treatment. Recurrences are unrelated to initial morphological findings, age, or gender. Only the treatment with a large bougie diameter (≥52 F) showed a tendency for a longer time of remission.

Eosinophilic oesophagitis: a common cause of dysphagia in young adults?

Eosinophilic oesophagitis (EO) is an increasingly recognised chronic, relapsing inflammatory condition of the oesophagus. There has been a mini-epidemic of EO in the last decade. The incidence of this condition is higher in children and is commoner in males. There is either a family or personal history of atopic conditions present in a significant number of patients and can also be familial in up to 10%. The classical symptom in an adult is chronic, intermittent solid-food dysphagia and food impaction, often necessitating emergency endoscopic removal. Despite the history of dysphagia for a number of years, patients remain well with no weight loss, which can mislead clinicians to diagnose a functional problem with a resulting delay in the diagnosis. There are various endoscopic features of EO; commonly multiple rings and linear furrows, though these can be subtle and the mucosa may be macroscopically normal. The hallmark of this condition is the histological presence of > or =15 eosinophils/high power field (HPF) in the oesophageal mucosa. Therapeutic options include avoidance of dietary allergens, topical or systemic steroids, Montelukast, Mepolizumab (anti-IL-5 antibody) and endoscopic dilation of strictures unresponsive to medical therapy.

The many manifestations of gastroesophageal reflux disease: presentation, evaluation, and treatment

Gastroesophageal reflux disease (GERD) is a common problem that is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world, with important risk factors being obesity and the eradication of Helicobacter pylori. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory esophageal pH testing is the most sensitive test for GERD, whereas endoscopy is the most specific test. Medical treatment with proton pump inhibitors (PPIs) has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic anti-reflux surgery and PPIs have similar efficacy in the few available long-term trials. This article reviews the presentation, evaluation, and treatment of GERD.

Gastrooesophageal reflux disease

Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.

Familial dysphagia and eosinophilia

BACKGROUND

Recent reports suggest a familial predisposition to eosinophilic esophagitis (EE) and a link between Schatzki's rings and EE.

OBJECTIVE

Our objective is to present our experience with 7 families with dysphagia and eosinophilia.

DESIGN

Case series.

SETTING

One-thousand-bed community-based teaching hospital.

PATIENTS

Seventeen patients from 7 families with dysphagia and eosinophilia.

METHODS

Direct clinical and endoscopic examination with review of radiologic and pathologic data.

RESULTS

Twelve patients had EE alone, one had eosinophilic gastroenteritis (EG) alone, one had EE and EG, and 3 geriatric patients had Schatzki's rings (one with EG and peripheral eosinophilia [PE] and one with PE). EE spanned 2 generations in 4 families and involved 2 brothers in one family.

LIMITATIONS

This was a case series.

CONCLUSION

We propose a familial dysphagia syndrome characterized by eosinophilia in the form of EE, EG, or PE and Schatzki's rings in older generations.

Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis

BACKGROUND

Recently recognized as an important cause of dysphagia and food impaction in adults, eosinophilic esophagitis (EE) is diagnosed by histologic findings of increased mucosal eosinophils.

OBJECTIVE

We examined variability in histopathologic features of adults with EE to derive a recommendation on the optimal number and location of biopsies needed for diagnosis.

DESIGN

Charts were reviewed from 74 patients diagnosed with EE based on > or =15 eosinophils per high-power field (eos/hpf). Biopsy specimens were prospectively analyzed for the degree of eosinophilia and histopathologic features of EE. Subgroup analysis was performed in patients with biopsy specimens from both the proximal and the distal esophagus. The biopsy specimens from patients with EE were compared with specimens from biopsied Schatzki's ring.

SETTING

Northwestern University Feinberg School of Medicine.

PATIENTS

Charts were reviewed for 74 adult patients and biopsy specimens were available for 66 patients.

RESULTS

A total of 341 biopsy specimens from 66 patients were available for analysis and revealed marked variability within and between biopsy specimens of individual patients. The median eos/hpf was 107 (0-557 eos/hpf). By using criteria of > or =15 eos/hpf for diagnosis, we found that 1 biopsy specimen had a sensitivity of 55%, which increased to 100% after 5 biopsies. By using stricter criteria, additional biopsy specimens were needed to achieve 100% sensitivity. Despite a higher eosinophilia in distal (82 eos/hpf) compared with proximal biopsy specimens (68 eos/hpf), this difference was not statistically significant. There was marked difference between eosinophilia in mucosal biopsy specimens of patients with EE (82 eos/hpf) compared with Schatzki's ring (0.3 eos/hpf).

CONCLUSIONS

Significant histologic variability exists among biopsy specimens from individual patients with EE and necessitates multiple biopsies to improve diagnostic sensitivity. No significant difference in eosinophilia was demonstrated between proximal and distal sites.

Eosinophilic esophagitis in adults: a systematic review

BACKGROUND/AIMS

Eosinophilic esophagitis (EE) is an increasingly recognized condition both in children and adults. The aim of the present study was to review the available evidence regarding EE in adults.

METHODS

PubMed, MEDLINE and medical textbooks were searched in May-June 2005 for English-language articles published between January 1978 and June 2005 containing relevant terms. The abstracts of two major conferences from 2000 to June 2005 were also reviewed. The presence of more than 15 eosinophils per high power field on esophageal biopsies was required to establish the diagnosis.

RESULTS

Twenty-four studies with 325 patients (male/female ratio: 3/1) were found that met the review criteria. Presenting symptoms included dysphagia (93%), food impaction (62%) and heartburn (23.6%). An allergic history and peripheral eosinophilia was noted in 51.6 and 30.8% of patients, respectively. Esophageal manometry presented evidence of a motility disorder in 40% of cases. Endoscopic findings included mucosal fragility/oedema, rings, strictures, whitish pinpoint exudates and small-calibre esophagus in 59.3, 49.2, 39.7, 15.7 and 5.3% of cases, respectively, whereas 8.8% of patients had a normal endoscopy. Bougienage was performed in 64 patients, with limited efficacy and an increased complication rate. The administration of corticosteroids resulted in symptomatic improvement in more than 95% of cases.

CONCLUSIONS

An allergic history and peripheral eosinophilia is less common in adults than among children with EE. An esophageal motility disorder should be a novel indication for biopsies in adults with long-lasting dysphagia. A trial with corticosteroids before bougienage may reduce active inflammation and the complication rate.