Diagnostic value of the Reflux Disease Questionnaire in general practice

Characteristics and Risk Factors of Functional Dyspepsia Fulfilling the Rome IV Criteria Overlapping With Gastroesophageal Reflux Disease, Irritable Bowel Syndrome, and Functional Constipation in South China

Background/Aims

Functional dyspepsia (FD) overlapping with other gastrointestinal disorders are quite common. The characteristics of FD overlap in Chinese population with latest Rome IV criteria were unclear. This large-scale outpatient-based study assessed the characteristics of FD overlap in South China.

Methods

Consecutive FD patients visited the Gastroenterology Clinic at 2 tertiary medical centers in Hangzhou, China who fulfilled the Rome IV criteria were enrolled. Complete questionnaires related to the gastrointestinal symptoms (Rome IV criteria), Reflux Disease Questionnaire, anxiety and depression, quality of sleep and life, and demographic information were collected.

Results

Among the total of 3281 FD patients, 50.69% overlapped with gastroesophageal reflux disease, 21.46% overlapped with irritable bowel syndrome, 6.03% overlapped with functional constipation. FD overlap had higher proportion of single/divorced/widowed rate, high education level, being employed, drinking, night shift, unhealthy dietary habit than FD only (P < 0.05). They had higher frequency of consultation and economic burden, as well as lower scores in quality of life (P < 0.001). Multivariate logistic regression showed that increasing age, female, low body mass index, history of gastroenteritis, anxiety, depression, and poor sleep quality were independent risk factors for FD overlap.

Conclusions

FD overlap was quite common in China with high economic burden and poor quality of life, FD patients with history of gastroenteritis, anxiety, depression, and poor sleep quality were more likely to have overlap disorders. Awareness of the physical and psychosocial stressors in overlapping condition would help optimize the management of FD overlap in clinical practice.

Ziverel for PPI-refractory reflux symptoms: efficacy and mechanisms of action in humans

OBJECTIVES

It is thought that esophageal hypersensitivity in combination with an impaired mucosal barrier function contributes to PPI-resistant reflux symptoms. Ziverel, a bioadhesive agent that coats the esophageal wall, was shown to have a positive effect on reflux symptoms. However, the mechanisms of action are unclear. We aimed to assess the effect of Ziverel on esophageal sensitivity to acid and mucosal barrier function.

METHODS

We performed a double-blind randomized placebo-controlled crossover trial in PPI-refractory patients with reflux symptoms. Patients were assigned (1:1) to 14 days of Ziverel followed by 14 days of placebo or opposite treatment order. The effect was evaluated using acid perfusion tests, an upper endoscopy with electrical tissue impedance spectroscopy (ETIS) and esophageal biopsies. The primary outcome was the esophageal sensitivity based on perfusion sensitivity score. Secondary outcomes included mucosal barrier function and reflux symptoms and correlations between the different outcomes.

RESULTS

Perfusion sensitivity score was not significantly different during treatment with Ziverel (106 (73-115)) and placebo (102 (67-110)) (p = 0.508) along with total RDQ score (2.6 (1.9-3.3) vs 2.8 (1.6-3.5) p = 0.456). ETIS showed comparable values during treatment with Ziverel (13514 (8846-19734)Ω·m) and placebo (13217 (9127-24942)Ω·m (p = 0.650)). Comparing Ziverel and placebo no difference was seen in transepithelial electrical resistance (TEER) 203 (163-267) Ω.cm2 vs 205 (176-240) Ω.cm2 (p = 0.445) and fluorescein flux 775 (17-6964) nmol/cm2/h vs 187 (4-12209) nmol/cm2/h (p = 0.638).

CONCLUSION

Ziverel did not show a benefit on acid sensitivity, reflux symptoms or esophageal mucosal integrity compared to placebo in PPI-refractory patients with reflux symptoms.Trial registration: Netherlands Trial Register number: NL7670.

Prevalence and associated factors of worry for cancer in patients with a Barrett's esophagus

Although the risk of cancer progression in a Barrett's esophagus (BE) is very low, worrying about cancer is known as an important factor affecting HRQoL. The aim of this study was to determine the proportion of BE patients with high levels of worry for cancer, to compare outcomes of patients endoscopically treated for BE neoplasia (DBE), non-dysplastic BE patients (NDBE) and patients with reflux symptoms, and to examine associated factors. We performed a cross sectional, exploratory, self-administered questionnaire study using the cancer worry scale, and the reflux disease questionnaire. A total of 192 DBE patients, 213 NDBE patients and 111 refractory reflux symptom patients were included from October 2019 until July 2021, 76.8% of BE participants were male and aged 66.9 years. High cancer worry was reported in 40.6% of the DBE patients and 36.2% of NDBE patient. Reflux patients scored statistically significant worse with 56.6% stated high cancer worry. Positive correlations were found between reflux symptoms and cancer worry in NDBE patients and reflux patients. In DBE patients' negative correlations were found between higher cancer worry and younger age as well as a family history of esophageal carcinoma. A clinically significant group of BE patients reported high cancer worry, which was associated with reflux symptoms in NDBE patients and a younger age and a (family) history of esophageal carcinoma diagnosis in BE patients treated for (early) neoplasia. Physicians should communicate about the actual cancer risk, which leads to greater patient understanding and therefore may have a positive impact on health outcomes.

The effect of sleep positional therapy on nocturnal gastroesophageal reflux measured by esophageal pH-impedance monitoring

BACKGROUND & AIMS

The aim of the study was to evaluate the effect of an electronic positional therapy wearable device on nocturnal gastroesophageal reflux measured by pH-impedance reflux monitoring.

METHODS

We performed a single-center, prospective, interventional study in 30 patients with nocturnal reflux symptoms and a nocturnal esophageal acid exposure time (AET) ≥1.5% measured off acid-suppressive medication by ambulatory pH-impedance reflux monitoring. Patients were treated with an electronic positional therapy wearable device for 2 weeks. The device vibrates in the right lateral decubitus position so it conditions patients to avoid that sleep position. After 2 weeks treatment, the pH-impedance study was repeated. Primary outcome was the change in nocturnal AET. Secondary outcomes include change in number of reflux episodes and reflux symptoms.

RESULTS

Complete data were available for 27 patients (13 females, mean age 49.8 years). The median nocturnal AET decreased from 6.0% (IQR, 2.3-15.3) to 3.1% (0.1-10.8) after 2 weeks of treatment (p = 0.079). The number of reflux episodes was significantly reduced after 2 weeks of treatment (baseline: 8.0 (3.0-12.3) vs. end: 3.0 (1.0-8.0); p = 0.041). Treatment led to a statistically significant decrease in time spent in right lateral decubitus position (baseline: mean 36.9% ± 15.2% vs. end: 2.7% ± 8.2%; p = <0.001) and an increase in the left lateral decubitus position (baseline 29.2% ± 14.8% vs. end: 63.3% ± 21.9%; p = <0.001). Symptom improvement was reported by 70.4% of the patients.

CONCLUSIONS

Sleep positional therapy using an electronic wearable device promotes sleeping in the left lateral decubitus position and improves reflux parameters measured by pH-impedance reflux monitoring.

Medical treatment of eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated eosinophilic inflammatory disease isolated to the esophagus. As a clinicopathologic disorder, a diagnosis of EoE requires a constellation of clinical symptoms of esophageal dysfunction and histologic findings (at least 15 eosinophils/high-powered microscope field (eos/hpf)). Current guidelines no longer require the failure of response to proton pump inhibitor medications to establish a diagnosis of EoE, but continue to suggest the exclusion of other etiologies of esophageal eosinophilia. The treatment goals for EoE are improvement in clinical symptoms, resolution of esophageal eosinophilia and other histologic abnormalities, endoscopic improvement, improved quality of life, improved esophageal function, minimized adverse effects of treatment, and prevention of disease progression and subsequent complications. Currently, there is no cure for EoE, making long-term treatment necessary. Standard treatment modalities include dietary modifications, esophageal dilation, and pharmacologic therapy. Effective pharmacologic therapies include corticosteroids, rapidly emerging biological therapies, and proton pump inhibitor medications.

OBJECTIVES

To evaluate the efficacy and safety of medical interventions for people with eosinophilic esophagitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP to 3 March 2023.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any medical intervention or food elimination diet for the treatment of eosinophilic esophagitis, either alone or in combination, to any other intervention (including placebo).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently selected studies and conducted data extraction and risk of bias assessment. We expressed outcomes as a risk ratio (RR) and as the mean or standardized mean difference (MD/SMD) with 95% confidence interval (CI). We assessed the certainty of the evidence using GRADE. Our primary outcomes were: clinical, histological, and endoscopic improvement, and withdrawals due to adverse events. Secondary outcomes were: serious and total adverse events, and quality of life.

MAIN RESULTS

We included 41 RCTs with 3253 participants. Eleven studies included pediatric patients while the rest recruited both children and adults. Four studies were in patients with inactive disease while the rest were in patients with active disease. We identified 19 intervention comparisons. In this abstract we present the results of the primary outcomes for the two main comparisons: corticosteroids versus placebo and biologics versus placebo, based on the prespecified outcomes defined of the primary studies. Fourteen studies compared corticosteroids to placebo for induction of remission and the risk of bias for these studies was mostly low. Corticosteroids may lead to slightly better clinical improvement (20% higher), measured dichotomously (risk ratio (RR) 1.74, 95% CI 1.08 to 2.80; 6 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNTB) = 4; low certainty), and may lead to slightly better clinical improvement, measured continuously (standard mean difference (SMD) 0.51, 95% CI 0.17 to 0.85; 5 studies, 475 participants; low certainty). Corticosteroids lead to a large histological improvement (63% higher), measured dichotomously (RR 11.94, 95% CI 6.56 to 21.75; 12 studies, 978 participants; NNTB = 3; high certainty), and may lead to histological improvement, measured continuously (SMD 1.42, 95% CI 1.02 to 1.82; 5 studies, 449 participants; low certainty). Corticosteroids may lead to little to no endoscopic improvement, measured dichotomously (RR 2.60, 95% CI 0.82 to 8.19; 5 studies, 596 participants; low certainty), and may lead to endoscopic improvement, measured continuously (SMD 1.33, 95% CI 0.59 to 2.08; 5 studies, 596 participants; low certainty). Corticosteroids may lead to slightly fewer withdrawals due to adverse events (RR 0.64, 95% CI 0.43 to 0.96; 14 studies, 1032 participants; low certainty). Nine studies compared biologics to placebo for induction of remission. Biologics may result in little to no difference in clinical improvement, measured dichotomously (RR 1.14, 95% CI 0.85 to 1.52; 5 studies, 410 participants; low certainty), and may result in better clinical improvement, measured continuously (SMD 0.50, 95% CI 0.22 to 0.78; 7 studies, 387 participants; moderate certainty). Biologics result in better histological improvement (55% higher), measured dichotomously (RR 6.73, 95% CI 2.58 to 17.52; 8 studies, 925 participants; NNTB = 2; moderate certainty). We could not draw conclusions for this outcome when measured continuously (SMD 1.01, 95% CI 0.36 to 1.66; 6 studies, 370 participants; very low certainty). Biologics may result in little to no difference in endoscopic improvement, measured dichotomously (effect not estimable, low certainty). We cannot draw conclusions for this outcome when measured continuously (SMD 2.79, 95% CI 0.36 to 5.22; 1 study, 11 participants; very low certainty). There may be no difference in withdrawals due to adverse events (RR 1.55, 95% CI 0.88 to 2.74; 8 studies, 792 participants; low certainty).

AUTHORS' CONCLUSIONS

Corticosteroids (as compared to placebo) may lead to clinical symptom improvement when reported both as dichotomous and continuous outcomes, from the primary study definitions. Corticosteroids lead to a large increase in histological improvement (dichotomous outcome) and may increase histological improvement (continuous outcome) when compared to placebo. Corticosteroids may or may not increase endoscopic improvement (depending on whether the outcome is measured dichotomously or continuously). Withdrawals due to adverse events (dichotomous outcome) may occur less frequently when corticosteroids are compared to placebo. Biologics (as compared to placebo) may not lead to clinical symptom improvement when reported as a dichotomous outcome and may lead to an increase in clinical symptom improvement (as a continuous outcome), from the primary study definitions. Biologics lead to a large increase in histological improvement when reported as a dichotomous outcome, but this is uncertain when reported as a continuous outcome, as compared to placebo. Biologics may not increase endoscopic improvement (dichotomous outcome), but this is uncertain when measured as a continuous outcome. Withdrawals due to adverse events as a dichotomous outcome may occur as frequently when biologics are compared to placebo.

Heartburn relief with bicarbonate-rich mineral water: results of the randomised, placebo-controlled phase-III trial STOMACH STILL

OBJECTIVE

We assessed whether the bicarbonate-rich mineral water Staatl. Fachingen STILL is superior over conventional mineral water in relieving heartburn.

DESIGN

Multicentre, double-blind, randomised, placebo-controlled trial STOMACH STILL in adult patients with frequent heartburn episodes since ≥6 months and without moderate/severe reflux oesophagitis. Patients drank 1.5 L/day verum or placebo over the course of the day for 6 weeks. Primary endpoint was the percentage of patients with reduction of ≥5 points in the Reflux Disease Questionnaire (RDQ) score for 'heartburn'. Secondary endpoints included symptom reduction (RDQ), health-related quality of life (HRQOL, Quality of Life in Reflux and Dyspepsia (QOLRAD)), intake of rescue medication and safety/tolerability.

RESULTS

Of 148 randomised patients (verum: n=73, placebo: n=75), 143 completed the trial. Responder rates were 84.72% in the verum and 63.51% in the placebo group (p=0.0035, number needed to treat=5). Symptoms improved under verum compared with placebo for the dimension 'heartburn' (p=0.0003) and the RDQ total score (p=0.0050). HRQOL improvements under verum compared with placebo were reported for 3 of 5 QOLRAD domains, that is, 'food/drink problems' (p=0.0125), 'emotional distress' (p=0.0147) and 'vitality' (p=0.0393). Mean intake of rescue medication decreased from 0.73 tablets/day at baseline to 0.47 tablets/day in week 6 in the verum group, whereas in the placebo group it remained constant during the trial. Only three patients had treatment-related adverse events (verum: n=1, placebo: n=2).

CONCLUSION

STOMACH STILL is the first controlled clinical trial demonstrating superiority of a mineral water over placebo in relieving heartburn, accompanied by an improved HRQOL.

TRIAL REGISTRATION NUMBER

EudraCT 2017-001100-30.

Barrett Esophagus: Quality of life and factors associated with illness perception

Background

Health‐related Quality of life (HRQoL) in patients with Barrett's esophagus (BE), a premalignant condition, may be influenced by gastroesophageal reflux disease (GERD) symptoms and the risk of developing esophageal adenocarcinoma.

Methods

We aim to investigate HRQoL in non‐dysplastic Barrett Esophagus (NDBE) patients, identify factors associated with a negative illness perception of the diagnosis BE and compare outcomes between patients treated in a specialized BE center with non‐expert centers. In this multi‐center cross‐sectional study, HRQoL of NDBE patients were assessed using the Short Form 36, Hospital Anxiety and Depression Scale, Cancer worry Scale, and Reflux Disease Questionnaire. A multivariable, linear regression analysis was conducted to assess factors associated with illness perception (Illness perception scale) of the BE diagnosis. Outcome parameters of patients from expert centers were compared to non‐expert centers.

Results

A total of 859 NDBE patients (mean age 63.6% and 74.5% male), of which 640 from BE expert centers were included. BE patients scored similar or higher means (i.e. better) on generic HRQoL in comparison with a Dutch norm population. The multivariable regression model showed that cancer worry, GERD symptoms, signs of anxiety and depression, and female gender were associated with a negative illness perception of BE. GERD symptoms were reported in the minority (22.4%) of BE patients. Levels of anxiety symptoms were comparable to a Dutch norm population (mean 3.7 vs. 3.9 p 0.183) and lower for depression symptoms (mean 6.8 vs. 7.6 p < 0.001). Overall, there were no differences found on outcomes between expert centers and non‐expert centers.

Conclusion

NDBE patients scored similar or better on generic HRQoL, anxiety and depression than an age and gender matched norm population. The presence of cancer worry, gastrointestinal symptoms, anxiety and depression, and female gender are factors associated with a negative illness perception of the diagnosis BE.

Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders

PURPOSE OF REVIEW

To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD).

RECENT FINDINGS

Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.

Childhood outcome after correction of long-gap esophageal atresia by thoracoscopic external traction technique

BACKGROUND

Thoracoscopic external traction technique (TTT) is a relatively new surgical intervention for patients with long-gap esophageal atresia (LGEA) that preserves the native esophagus. The major accomplishment with TTT is that esophageal repair can be achieved within days after birth. This study evaluates the childhood outcome in LGEA patients treated with TTT, including gastrointestinal outcome, nutritional status and Health-Related Quality of Life (HRQoL).

METHODS

A cohort study including all LGEA patients that underwent TTT between 2006-2017 was conducted. Patients and/or their parents were invited to fill out questionnaires regarding reflux symptoms and HRQoL.

RESULTS

TTT was successful in 11/13 patients (85%). Esophageal anastomosis was accomplished at a median age of 12 days (range 7-138), first oral feeding was started at a median of 16 days postoperatively (range 5-37). All patients required multiple dilatations and 10 patients required anti-reflux surgery. At median follow-up of seven years, five patients reported mild and one moderate reflux complaints. All patients but one reached age-appropriate oral diet. Most patients (80%) were within normal growth range. Overall HRQoL was comparable to healthy controls.

CONCLUSION

TTT provides acceptable results in childhood. Oral feeding can be started as soon as two weeks postoperatively. Almost all patients are able to eat an age-appropriate oral diet. Overall HRQoL was comparable to healthy controls.

Atomic force microscopy analysis of the surface alterations of enamel, dentin, composite and ceramic materials exposed to low oral pH in GERD

Dental erosion is a significant topic in medical literature, both for gastroenterology and dental medicine. Dental structure loss has a psychosocial and functional significance. The pathogenesis of dental erosion in patients diagnosed with gastroesophageal reflux disease (GERD) characterized by the presence of an acidic oral environment after reflux episodes, is not well understood. The present study was designed to observe the effect of low oral pH in time on natural surfaces including enamel and dentine, but also on materials used in treating these dental destructions such as composites and ceramics. The acidic oral environment was estimated in relation to salivary pH. In the dental laboratory, 5-mm2 and 1-mm composite pieces of thick enamel, dentine, Emax Ceramic and Nexco Ivoclar were cut in order to be analyzed using atomic force microscopy (AFM) and to observe the surface alterations. Gastric acid was collected and mixed with saliva until a pH value of 6.0 was obtained, in which the pieces were immersed for 24, 120, 240 h. Roughness of each surface was calculated at a microstructure and nanostructure level. The results showed significant alterations in enamel and dentine exposed to a lower pH level beginning even at a short immersion time, in comparison with composites and ceramics which had no alterations. In conclusion, multidisciplinary attention should be given to detect and manage acidity of the oral cavity caused by GERD, in order to prevent dental erosion.

Types and applications of cough-related questionnaires

Cough is a normal protective reflex that can effectively remove foreign bodies and secretions from the airway. However, excessive cough adversely affects a patient's physiological, psychological and social functions. Thus, it is important to effectively evaluate the severity of cough to determine its diagnosis and treatment. Cough severity can be assessed with subjective or objective tools. Herein, we summarize the subjective evaluation of cough severity with questionnaires.

Persistent gastro-oesophageal reflux symptoms despite proton pump inhibitor therapy

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.

Mucosal integrity and sensitivity to acid in the proximal esophagus in patients with gastroesophageal reflux disease

Acid reflux episodes that extend to the proximal esophagus are more likely to be perceived. This suggests that the proximal esophagus is more sensitive to acid than the distal esophagus, which could be caused by impaired mucosal integrity in the proximal esophagus. Our aim was to explore sensitivity to acid and mucosal integrity in different segments of the esophagus. We used a prospective observational study, including 12 patients with gastroesophageal reflux disease (GERD). After stopping acid secretion-inhibiting medication, two procedures were performed: an acid perfusion test and an upper endoscopy with electrical tissue impedance spectroscopy and esophageal biopsies. Proximal and distal sensitivity to acid and tissue impedance were measured in vivo, and mucosal permeability and epithelial intercellular spaces at different esophageal levels were measured in vitro. Mean lag time to heartburn perception was much shorter after proximal acid perfusion (0.8 min) than after distal acid perfusion (3.9 min) (P = 0.02). Median in vivo tissue impedance was significantly lower in the distal esophagus (4,563 Ω·m) compared with the proximal esophagus (8,170 Ω·m) (P = 0.002). Transepithelial permeability, as measured by the median fluorescein flux was significantly higher in the distal (2,051 nmol·cm(-2)·h(-1)) than in the proximal segment (368 nmol·cm(-2)·h(-1)) (P = 0.033). Intercellular space ratio and maximum heartburn intensity were not significantly different between the proximal and distal esophagus. In GERD patients off acid secretion-inhibiting medication, acid exposure in the proximal segment of the esophagus provokes symptoms earlier than acid exposure in the distal esophagus, whereas mucosal integrity is impaired more in the distal esophagus. These findings indicate that the enhanced sensitivity to proximal reflux episodes is not explained by increased mucosal permeability.

Long-term effects of anti-reflux surgery on the physiology of the esophagogastric junction

BACKGROUND

Studies performed shortly after anti-reflux surgery have demonstrated that the reduction of reflux episodes is caused by a decrease in the rate of transient lower esophageal sphincter relaxations (TLESRs) and a decrease in the distensibility of the esophagogastric junction (EGJ). We aimed to assess the long-term effects of surgical fundoplication on the physiology of the EGJ.

METHODS

We included 18 patients who underwent surgical fundoplication >5 years before and 10 GERD patients who did not have surgery. Patients underwent 90-min combined high-resolution manometry and pH-impedance monitoring, and EGJ distensibility was assessed.

RESULTS

Post-fundoplication patients exhibited a lower frequency of reflux events than GERD patients (2.0 ± 0.5 vs 15.1 ± 4.3, p < 0.05). The rate of TLESRs (6.1 ± 0.9 vs 12.6 ± 1.0, p < 0.05) and their association with reflux (28.3 ± 9.0 vs 74.9 ± 6.9 %, p < 0.05) was lower in post-fundoplication patients than in GERD patients. EGJ distensibility was significantly lower in post-fundoplication patients than in GERD patients. Recurrence of GERD symptoms after fundoplication was not associated with an increased number of reflux episodes, nor was it associated with an increased distensibility of the EGJ or an increase in the number of TLESRs.

CONCLUSION

More than 5 years after anti-reflux surgery, patients still exhibit a lower rate of TLESRs and a reduced distensibility of the EGJ compared with medically treated GERD patients. These data suggest that the effects of surgical fundoplication on EGJ physiology persist at the long term and underlie the persistent reduction of reflux events.

Endoscopic appearance and location dictate diagnostic yield of biopsies in eosinophilic oesophagitis

BACKGROUND

Acknowledging that eosinophilic esophagitis (EoE) is a disease with variable involvement throughout the oesophagus, studies have suggested a minimum of five biopsies to diagnose EoE. Although it is accepted that furrows and exudates appear to represent areas of inflammation, no research to date has looked specifically at EoE endoscopic findings to see if eosinophilic infiltrate correlates with specific endoscopic findings.

AIM

To evaluate the distribution of eosinophils in EoE and determine whether endoscopic appearances predict the degree of eosinophilia at various locations of the oesophagus.

METHODS

We performed a prospective cross sectional study of EoE (treated and untreated) patients to study the distribution of eosinophils according to endoscopic findings. The oesophagus of 10 EoE patients were biopsied up to 32 times in a circumferential manner. The mucosal changes were documented at the site of each biopsy. Histological determination of eosinophil counts and related histopathology of the oesophagus were then correlated with endoscopic findings. Similar biopsy assessments were made in treated (resolved) EoE patients (n = 6) to determine the permanence of specific endoscopic appearances.

RESULTS

A total of 16 patients were biopsied (10 EoE, 6 treated EoE). A total of 432 biopsies were obtained in all with 294 biopsies from 10 EoE subjects. Eosinophil density was increased distally in the majority of EoE patients. Biopsies performed in areas of exudates and furrows demonstrated higher eosinophil counts. Lines and normal-appearing oesophagi in EoE subjects were not commonly associated with elevated eosinophil counts (>15 eos/HPF). Rings alone without associated furrows or plaques did not demonstrate elevated eosinophil counts and were seen in resolved EoE (Rx-EoE) as well as in active EoE patients.

CONCLUSIONS

Eosinophilic esophagitis remains a variable disease with some patients manifesting extensive disease throughout the oesophagus. Characteristics of furrows and exudates found during endoscopy are associated with higher peak eosinophil counts, requiring fewer biopsies to make a diagnosis. Lines and otherwise normal appearances of the oesophagus suggest a milder mucosal eosinophilia, requiring substantial biopsies to adequately identify fields with diagnostic eosinophil counts.

Effects of anxiety and depression in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Increased levels of anxiety and depression have been associated with esophageal hyperalgesia and an increased risk of gastroesophageal reflux disease (GERD). We investigated the effects of anxiety and depression on GERD symptoms and the perception of reflux episodes in a well-characterized group of patients.

METHODS

We performed a prospective study of 225 consecutive patients who had symptoms of GERD evaluated. Patients underwent ambulatory 24-hour pH impedance monitoring, and levels of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale.

RESULTS

GERD was diagnosed in 147 patients (78 patients had functional heartburn); 36 patients were hypersensitive to gastroesophageal reflux. Among patients with GERD, increased levels of anxiety were associated with more severe retrosternal pain and retrosternal burning. Furthermore, increased levels of anxiety and depression each were associated with lower scores of the mental component of quality of life questionnaire. Levels of anxiety or depression were not associated with the number of reflux symptoms reported during 24-hour pH impedance monitoring or with the number of symptoms associated with a reflux event. Among GERD patients with hypersensitivity to reflux, levels of anxiety and depression and decreases in quality of life were similar to those of other patients with GERD. Patients with functional heartburn had higher levels of anxiety than patients with GERD.

CONCLUSIONS

In patients with GERD, increased levels of anxiety are associated with increased severity of retrosternal pain and heartburn and reduced quality of life. Patients with GERD with hypersensitivity to gastroesophageal reflux have similar levels of anxiety and similar quality-of-life scores as other patients with GERD.

Gastro-oesophageal reflux is common in oligosymptomatic patients with dental erosion: A pH-impedance and endoscopic study

BACKGROUND

Dental erosion is a complication of gastro-oesophageal reflux disease (GORD) according to the Montreal consensus statement. However, GORD has not been comprehensively characterized in patients with dental erosions and pH-impedance measures have not been reported.

OBJECTIVES

Characterize GORD in patients with dental erosions using 24-h multichannel intraluminal pH-impedance measurements (pH-MII) and endoscopy.

METHODS

This single-centre study investigated reflux in successive patients presenting to dentists with dental erosion using pH-MII and endoscopy.

RESULTS

Of the 374 patients, 298 (80%) reported GORD symptoms <2 per week, 72 (19%) had oesophagitis and 59 (16%) had a hiatal hernia. In the 349 with pH-MII the mean percentage time with a pH <4 (95% CI) was 11.0 (9.3-12.7), and 34.4% (31.9-36.9) for a pH <5.5, a critical threshold for dental tissue. The mean numbers of total, acidic and weakly acidic reflux episodes were 71 (63-79), 43 (38-49) and 31 (26-35), respectively. Of the reflux episodes, 19% (17-21) reached the proximal oesophagus. In 241 (69%) patients reflux was abnormal using published normal values for acid exposure time and reflux episodes. No significant associations between the severity of dental erosions and any reflux variables were found. The presence of GORD symptoms and of oesophagitis or a hiatal hernia was associated with greater reflux, but not with increased dental erosion scores.

CONCLUSIONS

Significant oligosymptomatic gastro-oesophageal reflux occurs in the majority of patients with dental erosion. The degree of dental erosion did not correlate with any of the accepted quantitative reflux indicators. Definition of clinically relevant reflux parameters by pH-MII for dental erosion and of treatment guidelines are outstanding. Gastroenterologists and dentists need to be aware of the widely prevalent association between dental erosion and atypical GORD.

Laparoscopic Thal fundoplication in children: a prospective 10- to 15-year follow-up study

OBJECTIVE

To study long-term (10-15 years) efficacy of antireflux surgery (ARS) in a prospectively followed cohort of pediatric patients with gastroesophageal reflux disease, using 24-hour pH monitoring and reflux-specific questionnaires.

BACKGROUND

Studies on short-term outcome of ARS in pediatric patients with gastroesophageal reflux disease have shown good to excellent results; however, long-term follow-up studies are scarce, retrospective, and have not used objective measurements.

METHODS

Between 1993 and 1998, a cohort of 57 pediatric patients (ages 1 month to 18 years; 46% with neurological impairment) underwent laparoscopic anterior partial fundoplication (Thal). Preoperatively and postoperatively (at 3-4 months and at 1-5 and 10-15 years), reflux-specific questionnaires were filled out, and 24-hour pH monitoring was performed.

RESULTS

At 3 to 4 months, at 1 to 5 years, and at 10 to 15 years after ARS, 81%, 80%, and 73% of patients, respectively, were completely free of reflux symptoms. Disease-free survival analysis, however, demonstrated that only 57% of patients were symptom free at 10 to 15 years after ARS. Total acid exposure time significantly decreased from 13.4% before ARS to 0.7% (P < 0.001) at 3 to 4 months after ARS; however, at 3 to 4 months after ARS, pH monitoring was still pathological in 18% of patients. At 10 to 15 years after ARS, the number of patients with pathological reflux had even significantly increased to 43% (P = 0.008). No significant differences were found comparing neurologically impaired and normally developed patients.

CONCLUSIONS

As gastroesophageal reflux persists or recurs in 43% of children 10 to 15 years after laparoscopic Thal fundoplication, it is crucial to implement routine long-term follow-up after ARS in pediatric patients with gastroesophageal reflux disease.

Systematic review: questionnaires for assessment of gastroesophageal reflux disease

Numerous questionnaires with a wide variety of characteristics have been developed for the assessment of gastroesophageal reflux disease (GERD). Four well-defined dimensions are noticeable in these GERD questionnaires, which are symptoms, response to treatment, diagnosis, and burden on the quality of life of GERD patients. The aim of this review is to develop a complete overview of all available questionnaires, categorized per dimension of the assessment of GERD. A systematic search of the literature up to January 2013 using the Pubmed database and the Embase database, and search of references and conference abstract books were conducted. A total number of 65 questionnaires were extracted and evaluated. Thirty-nine questionnaires were found applicable for the assessment of GERD symptoms, three of which are generic gastrointestinal questionnaires. For the assessment of response to treatment, 14 questionnaires were considered applicable. Seven questionnaires with diagnostic purposes were found. In the assessment of quality of life in GERD patients, 18 questionnaires were found and evaluated. Twenty questionnaires were found to be used for more than one assessment dimension, and eight questionnaires were found for GERD assessment in infants and/or children. A wide variety of GERD questionnaires is available, of which the majority is used for assessment of GERD symptoms. Questionnaires differ in aspects such as design, validation and translations. Also, numerous multidimensional questionnaires are available, of which the Reflux Disease Questionnaire is widely applicable. We provided an overview of GERD questionnaires to aid investigators and clinicians in their search for the most appropriate questionnaire for their specific purposes.

Long-term follow up in patients with gastroesophageal reflux disease with specific emphasis on reflux symptoms, use of anti-reflux medication and anti-reflux surgery outcome: a retrospective study

BACKGROUND

Various treatment modalities are currently being used in patients with gastroesophageal reflux disease (GERD); however, long-term outcome is not clear. The aim is to evaluate long-term results of GERD treatments with regard to reflux symptoms, use of anti-reflux medication and anti-reflux surgery outcome.

METHODS

Patients who had undergone 24-h pH monitoring for reflux symptoms between January 2002 and March 2012 were invited to fill out the Reflux Disease Questionnaire (RDQ) and a general questionnaire. Patients with and without anti-reflux surgery were compared using multiple linear and logistic regression models.

RESULTS

In total, 1027 of 2190 included patients (47%) returned the questionnaires. After exclusion due to predefined criteria, 477 patients were analyzed. Median total RDQ score was 18 points (10.2% symptom-free) in the conservative group (n = 304) and 10 points (31.2% symptom-free) in the surgical group (n = 173) after a mean follow up of 5.1 years. Daily proton pomp inhibitor (PPI) use was higher in the conservative group than in the surgical group (80.9% vs. 51.4%, p = 0.000). Linear regression analysis showed an association between RDQ scores and anti-reflux surgery (β = -5.477, p = 0.001) and male gender (β = -4.306, p = 0.006). Logistic regression analyses showed that daily PPI use was lower in patients who underwent anti-reflux surgery (odds ratio [OR] = 0.24, p = 0.000), while it increased with age (OR = 1.03, p = 0.000).

CONCLUSIONS

There is still a high prevalence of typical reflux symptoms and daily PPI use in GERD patients after >5 years of follow up. Male patients and patients who had undergone anti-reflux surgery were more often asymptomatic. Daily PPI use was lower after anti-reflux surgery, while it increased with age.

Management of the patient with incomplete response to PPI therapy

Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.

Gastroesophageal reflux, esophageal function, gastric emptying, and the relationship to dysphagia before and after antireflux surgery in children

OBJECTIVES

To assess gastroesophageal reflux (GER), esophageal motility, and gastric emptying in children before and after laparoscopic fundoplication and to identify functional measures associated with postoperative dysphagia.

STUDY DESIGN

Combined impedance-manometry, 24-hour pH-impedance, and gastric-emptying breath tests were performed before and after laparoscopic anterior partial fundoplication. Impedance-manometry studies were analyzed with the use of conventional analysis methods and a novel automated impedance manometry (AIM) analysis.

RESULTS

Children with therapy resistent GER disease (n = 25) were assessed before fundoplication, of whom 10 (median age 6.4 years; range, 1.1-17.1 years; 7 male; 4 with neurologic impairment) underwent fundoplication. GER episodes reduced from 97 (69-172) to 66 (18-87)/24 hours (P = .012). Peristaltic contractions were unaltered. Complete lower esophageal sphincter relaxations decreased after fundoplication (92% [76%-100%] vs 65% [29%-91%], P = .038). Four (40%) patients developed postoperative dysphagia, which was transient in 2. In those patients, preoperative gastric emptying was delayed compared with patients without postoperative dysphagia, 96 minutes (71-104 minutes) versus 48 minutes (26-68 minutes), P = .032, and AIM analysis derived dysphagia risk index was greater (56 [15-105] vs 2 [2-6] P = .016). Two patients underwent a repeat fundoplication.

DISCUSSION

Fundoplication in children reduced GER without altering esophageal motility. Four patients who developed dysphagia demonstrated slower gastric emptying and greater dysplasia risk index preoperatively. AIM analysis may allow detection of subtle esophageal abnormalities potentially leading to postoperative dysphagia.

Clinical features distinguish eosinophilic and reflux-induced esophagitis

BACKGROUND AND OBJECTIVES

Diagnosing eosinophilic esophagitis (EoE) depends on intraepithelial eosinophil count of ≥15 eosinophils per high-power field (HPF); however, differentiating EoE from gastroesophageal reflux disease (GERD) continues to be a challenge because no true "criterion standard" criteria exist. Identifying clinical and endoscopic characteristics that distinguish EoE could provide a more comprehensive diagnostic strategy than the present criteria. The aim of the study was to determine symptoms and signs that can be used to distinguish EoE from reflux esophagitis.

METHODS

Adult and pediatric patients with EoE were identified by present diagnostic guidelines including an esophageal biopsy finding of ≥15 eosinophils/HPF. Patients with GERD were age-matched one to one with patients with EoE. Clinical, endoscopic, and histologic information at the time of diagnosis was obtained from the medical record and compared between pairs by McNemar test. A conditional logistic regression model was created using 6 distinguishing disease characteristics. This model was used to create a nomogram to differentiate EoE from reflux-induced esophagitis.

RESULTS

Patients with EoE were 75% men and 68% had a history of atopy. Many aspects of EoE were statistically distinct from GERD when controlling for age. Male sex, dysphagia, history of food impaction, absence of pain/heartburn, linear furrowing, and white papules were the distinguishing variables used to create the logistic regression model and scoring system based on odds ratios. The area under the curve of the receiver-operator characteristic curve for this model was 0.858.

CONCLUSIONS

EoE can be distinguished from GERD using a scoring system of clinical and endoscopic features. Prospective studies will be needed to validate this model.

Dysphagia in Duchenne muscular dystrophy assessed by validated questionnaire

BACKGROUND

Duchenne muscular dystrophy (DMD) leads to progressive muscular weakness and death, most typically from respiratory complications. Dysphagia is common in DMD; however, the most appropriate swallowing assessments have not been universally agreed and the symptoms of dysphagia remain under-reported.

AIMS

To investigate symptoms of dysphagia in DMD and to determine the potential of the validated Sydney Swallow Questionnaire (SSQ) to diagnose dysphagia in this patient group.

METHODS & PROCEDURES

Three participant groups completed the SSQ and the results were compared: nine DMD participants with dysphagia, six DMD participants without dysphagia and 12 healthy controls.

OUTCOMES & RESULTS

The questionnaire scores for dysphagic DMD participants were significantly higher than for non-dysphagic DMD participants (p = 0.039) and for healthy controls (p ≤ 0.001). The diagnostic ability of the questionnaire was good for detecting dysphagia in participants with DMD (receiver operating characteristic (ROC) area under the curve = 0.89, p = 0.013), with a cut-off score of 224.5 (13.2%) giving a sensitivity of 0.78 and a specificity of 0.83 for determining dysphagia. Dysphagic participants rated time to eat a meal, swallowing hard food, swallowing thick liquids and needing to cough up or spit during meals with the highest severity of all questionnaire items. Results of the questionnaire by item are presented to inform the clinician of the symptoms of dysphagia in DMD.

CONCLUSIONS & IMPLICATIONS

DMD leads to pervasive symptoms of dysphagia. The simple SSQ is a clinically informative assessment tool for patients with DMD.

Supragastric belches are the main determinants of troublesome belching symptoms in patients with gastro-oesophageal reflux disease

BACKGROUND

Patients with gastro-oesophageal reflux disease (GERD) frequently report excessive belching but it is not known what determines the severity of these complaints.

AIM

To determine what causes troublesome belching symptoms in GERD patients.

METHODS

We included 90 consecutive patients who were referred for ambulatory 24-h pH-impedance measurement as part of the analysis of reflux symptoms. Overall severity of belching was reported by the patients using a 3-point scale. Furthermore, each belch perceived during the ambulatory measurement was reported by the patients using a symptom diary.

RESULTS

No significant differences in frequency of gastric belches or combined liquid reflux and gastric belches were observed. However, the number of supragastric belches was significantly higher in patients with severe belching complaints compared to patients with moderate and none to mild complaints. Moreover, the number of supragastric belches which coincided with a liquid reflux episode was significantly higher in patients with severe complaints than in those with moderate and none to mild complaints. Per-patient analysis showed that belches coinciding with a liquid reflux event were more often symptomatic than isolated belches.

CONCLUSIONS

The type of belch determines the burden of belching complaints in patients with GERD. Supragastric belches, not gastric belches determine the severity of belching complaints.

Distension of the esophagogastric junction augments triggering of transient lower esophageal sphincter relaxation

Patients with gastroesophageal reflux disease show an increase in esophagogastric junction (EGJ) distensibility and in frequency of transient lower esophageal sphincter relaxations (TLESR) induced by gastric distension. The objective was to study the effect of localized EGJ distension on triggering of TLESR in healthy volunteers. An esophageal manometric catheter incorporating an 8-cm internal balloon adjacent to a sleeve sensor was developed to enable continuous recording of EGJ pressure during distension of the EGJ. Inflation of the balloon doubled the cross-section of the trans-sphincteric portion of the catheter from 5 mm OD (round) to 5 × 11 mm (oval). Ten healthy subjects were included. After catheter placement and a 30-min adaptation period, the EGJ was randomly distended or not, followed by a 45-min baseline recording. Subjects consumed a refluxogenic meal, and recordings were made for 3 h postprandially. A repeat study was performed on another day with EGJ distension status reversed. Additionally, in one subject MRI was performed to establish the exact position of the balloon in the inflated state. The number of TLESR increased during periods of EGJ distension with the effect being greater after a meal [baseline: 2.0(0.0-4.0) vs. 4.0(1.0-11.0), P=0.04; postprandial: 15.5(10.0-33.0) vs. 22.0(17.0-58.0), P=0.007 for undistended and distended, respectively]. EGJ distension augments meal-induced triggering of TLESR in healthy volunteers. Our data suggest the existence of a population of vagal afferents located at sites in/around the EGJ that may influence triggering of TLESR.

Epidemiology and symptom profile of gastroesophageal reflux in the Indian population: report of the Indian Society of Gastroenterology Task Force

BACKGROUND

Gastroesophageal reflux disease (GERD) and its complications are thought to be infrequent in India; there are no data from India on the prevalence of and risk factors for GERD. The Indian Society of Gastroenterology formed a task force aiming to study: (a) the frequency and profile of GERD in India, (b) factors including diet associated with GERD.

METHODS

In this prospective, multi-center (12 centers) study, data were obtained using a questionnaire from 3224 subjects regarding the frequency, severity and duration of heartburn, regurgitation and other symptoms of GERD. Data were also obtained regarding their dietary habits, addictions, and lifestyle, and whether any of these were related or had been altered because of symptoms. Data were analyzed using univariate and multivariate methods.

RESULTS

Two hundred and forty-five (7.6%) of 3224 subjects had heartburn and/or regurgitation at least once a week. On univariate analysis, older age (OR 1.012; 95% CI 1.003-1.021), consumption of non-vegetarian and fried foods, aerated drinks, tea/coffee were associated with GERD. Frequency of smoking was similar among subjects with or without GERD. Body mass index (BMI) was similar in subjects with and without GERD. On multivariate analysis, consumption of non-vegetarian food was independently associated with GERD symptoms. Overlap with symptoms of irritable bowel syndrome was not uncommon; 21% reported difficulty in passage of stool and 9% had mucus in stools. About 25% of patients had consulted a doctor previously for their gastrointestinal symptoms.

CONCLUSION

7.6% of Indian subjects have significant GERD symptoms. Consumption of non-vegetarian foods was an independent predictor of GERD. BMI was comparable among subjects with or without GERD.

Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis

BACKGROUND

Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids.

OBJECTIVE

To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone.

DESIGN

Prospective randomized controlled trial.

SETTING

Academic medical center.

PARTICIPANTS

Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf.

INTERVENTIONS

Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks.

MAIN OUTCOME MEASUREMENTS

Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study.

RESULTS

About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70).

LIMITATIONS

Small sample size, unexpectedly high drop-out rate.

CONCLUSIONS

Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

Quantification of dental erosions in patients with GERD using optical coherence tomography before and after double-blind, randomized treatment with esomeprazole or placebo

OBJECTIVES

Dental erosion, the chemical dissolution of enamel without bacterial involvement, is a rarely reported manifestation of gastroesophageal reflux disease (GERD), as well as of recurrent vomiting and dietary habits. It leads to loss of tooth substance, hypersensitivity, functional impairment, and even tooth fracture. To date, dental erosions have been assessed using only very basic visual methods, and no evidence-based guidelines or studies exist regarding the prevention or treatment of GERD-related dental erosions.

METHODS

In this randomized, double-blind study, we used optical coherence tomography (OCT) to quantify dental tissue demineralization and enamel loss before and after 3 weeks of acid-suppressive treatment with esomeprazole 20 mg b.i.d. or placebo in 30 patients presenting to the Berne University Dental Clinic with advanced dental erosions and abnormal acid exposure by 24-h esophageal pH manometry (defined as >4% of the 24-h period with pH<4). Enamel thickness, reflectivity, and absorbance as measures of demineralization were quantified by OCT before and after therapy at identical localizations on teeth with most severe visible erosions as well as several other predefined changes in teeth.

RESULTS

The mean+/-s.e.m. decrease of enamel thickness of all teeth before and after treatment at the site of maximum exposure was 7.2+/-0.16 black trianglem with esomeprazole and 15.25+/-0.17black trianglem with placebo (P=0.013), representing a loss of 0.3% and 0.8% of the total enamel thickness, respectively. The change in optical reflectivity to a depth of 25 black trianglem after treatment was-1.122 +/-0.769 dB with esomeprazole and +2.059+/-0.534 dB with placebo (P 0.012), with increased reflectivity signifying demineralization.

CONCLUSIONS

OCT non-invasively detected and quantified significantly diminished progression of dental tissue demineralization and enamel loss after only 3 weeks of treatment with esomeprazole 20 mg b.i.d. vs. placebo. This suggests that esomeprazole may be useful in counteracting progression of GERD-related dental erosions. Further validation of preventative treatment regimens using this sensitive detection method is required, including longer follow-up and correlation with quantitative reflux measures.

Eosinophilic oesophagitis in patients presenting with dysphagia--a prospective analysis

BACKGROUND

Eosinophilic oesophagitis (EoO) may be a common finding in adults presenting with dysphagia.

AIM

To identify the risk factors and prevalence of EoO in an adult population with dysphagia.

METHODS

All patients with dysphagia referred for an upper endoscopy (EGD) were asked to participate. Patients completed a detailed questionnaire followed by EGD with four quadrant biopsies in the distal and mid-oesophagus. Primary endpoint was the prevalence of EoO; secondary endpoints included age, gender, asthma, food allergies, gastro-oesophageal reflux disease/dysphagia score and endoscopic findings.

RESULTS

Two hundred and sixty-one patients enrolled between December 2005 and January 2007. Thirty-one patients (12%) met pathological criteria for EoO. There was no difference in EoO prevalence within each gender. Mean age of EoO patients was 42 +/- 15 vs. 61 +/- 15 for non-EoO patients (P < 0.001). EoO was diagnosed in 35% of patients <50 years of age. EoO was present in 22% of asthmatics vs. 9% non-asthmatics (P < 0.01). EoO was present in 36.8% of patients with self-reported food allergies vs. 9.3% those without allergy (P < 0.001). A 13/31(42%) of EoO patients did not have the classic EGD findings (rings +/- furrows) and would have been missed without oesophageal biopsies.

CONCLUSIONS

Eosinophilic oesophagitis was diagnosed in 12% of the patients presenting with dysphagia with relative risk of 9.5 if age <50 years. Oesophageal biopsies are warranted in patients presenting with dysphagia especially in the younger population. Patients may not present with classic endoscopic findings and EoO can be missed without biopsies.