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Desai M, Rex DK, Bohm ME, Davitkov P, DeWitt JM, Fischer M, Faulx G, Heath R, Imler TD, James-Stevenson TN, Kahi CJ, Kessler WR, Kohli DR, McHenry L, Rai T, Rogers NA, Sagi SV, Sathyamurthy A, Vennalaganti P, Sundaram S, Patel H, Higbee A, Kennedy K, Lahr R, Stojadinovikj G, Campbell C, Dasari C, Parasa S, Faulx A, Sharma P. Impact of withdrawal time on adenoma detection rate: results from a prospective multicenter trial. Gastrointest Endosc 2023; 97:537-543.e2. [PMID: 36228700 DOI: 10.1016/j.gie.2022.09.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/07/2022] [Accepted: 09/23/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Performing a high-quality colonoscopy is critical for optimizing the adenoma detection rate (ADR). Colonoscopy withdrawal time (a surrogate measure) of ≥6 minutes is recommended; however, a threshold of a high-quality withdrawal and its impact on ADR are not known. METHODS We examined withdrawal time (excluding polyp resection and bowel cleaning time) of subjects undergoing screening and/or surveillance colonoscopy in a prospective, multicenter, randomized controlled trial. We examined the relationship of withdrawal time in 1-minute increments on ADR and reported odds ratio (OR) with 95% confidence intervals. Linear regression analysis was performed to assess the maximal inspection time threshold that impacts the ADR. RESULTS A total of 1142 subjects (age, 62.3 ± 8.9 years; 80.5% men) underwent screening (45.9%) or surveillance (53.6%) colonoscopy. The screening group had a median withdrawal time of 9.0 minutes (interquartile range [IQR], 3.3) with an ADR of 49.6%, whereas the surveillance group had a median withdrawal time of 9.3 minutes (IQR, 4.3) with an ADR of 63.9%. ADR correspondingly increased for a withdrawal time of 6 minutes to 13 minutes, beyond which ADR did not increase (50.4% vs 76.6%, P < .01). For every 1-minute increase in withdrawal time, there was 6% higher odds of detecting an additional subject with an adenoma (OR, 1.06; 95% confidence interval, 1.02-1.10; P = .004). CONCLUSIONS Results from this multicenter, randomized controlled trial underscore the importance of a high-quality examination and efforts required to achieve this with an incremental yield in ADR based on withdrawal time. (Clinical trial registration number: NCT03952611.).
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Affiliation(s)
- Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA; Division of Gastroenterology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Douglas K Rex
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Matthew E Bohm
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Perica Davitkov
- Department of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monika Fischer
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Ryan Heath
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Timothy D Imler
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Toyia N James-Stevenson
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Charles J Kahi
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - William R Kessler
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Divyanshoo R Kohli
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Lee McHenry
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tarun Rai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Nicholas A Rogers
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sashidhar V Sagi
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Anjana Sathyamurthy
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Prashanth Vennalaganti
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Suneha Sundaram
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Harsh Patel
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - April Higbee
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Kevin Kennedy
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Rachel Lahr
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gjorgie Stojadinovikj
- Department of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Carlissa Campbell
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Chandra Dasari
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sravanthi Parasa
- Department of Gastroenterology, Swedish Medical Center, Seattle, Washington, USA
| | - Ashley Faulx
- Department of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA; Division of Gastroenterology, University of Kansas School of Medicine, Kansas City, Kansas, USA
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Desai M, Srinivasan S, Sundaram S, Dasari C, Andraws N, Mathur S, Higbee A, Miller J, Beg S, Fateen W, Sami SS, Repici A, Ragunath K, Sharma P. Narrow-band imaging for the diagnosis of nonerosive reflux disease: an international, multicenter, randomized controlled trial. Gastrointest Endosc 2022; 96:457-466.e3. [PMID: 35487299 DOI: 10.1016/j.gie.2022.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We examined the accuracy of narrow-band imaging (NBI) findings in nonerosive reflux disease (NERD) patients compared with control subjects and the impact of proton pump inhibitor (PPI) therapy on these mucosal changes in a multicenter, double-blind, randomized controlled trial. METHODS NERD patients (typical symptoms using a validated GERD questionnaire, absence of erosive esophagitis, and abnormal 48-hour pH study) and control subjects underwent high-definition white-light endoscopy followed by NBI and biopsy sampling of the distal esophagus. Then, NERD patients were randomized to esomeprazole 40 mg/day or placebo for 8 weeks, followed by repeat endoscopy. The presence of distal esophageal mucosal changes on NBI were recorded at baseline and after treatment: intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions, increased vascularity, columnar islands, and ridge/villous pattern (RVP) above the squamocolumnar junction. RESULTS Of 122 screened, 21 NERD and 21 control subjects were identified (mean age, 49.5 ± 14.6 years; 62% men; and 85% white). The combination of IPCL tortuosity, RVP, and microerosions (62% vs 19%, P < .05) had a high specificity (86%) and moderate sensitivity (60%) for NERD with an area under the curve of .74. In 10 NERD patients treated with PPIs, resolution of microerosions was most significant (P = .047) compared with placebo (n = 11). RVP resolved in all NERD patients after therapy (P = .02) and correlated with acid exposure time (P = .004). Papillary length (P = .02) and basal cell thickness (P = .02) significantly correlated with a combination of IPCL tortuosity, RVP, and microerosions. CONCLUSIONS In this randomized controlled trial, RVP on NBI demonstrated a high specificity, correlated with acid exposure time, and improved with PPI therapy, suggesting that it could be used as a surrogate marker for diagnosis of NERD. (Clinical trial registration number: NCT02081404.).
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Affiliation(s)
- Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sachin Srinivasan
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Suneha Sundaram
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Chadra Dasari
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Nevene Andraws
- Department of Pathology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sharad Mathur
- Department of Pathology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - April Higbee
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Jennifer Miller
- Pharmacy Services, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sabina Beg
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Waleed Fateen
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sarmed S Sami
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alessandro Repici
- Department of Endoscopy, Humanitas Research Hospital, IRCCS, 20089 Rozzano, Italy
| | - Krish Ragunath
- NIHR Nottingham Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA; Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
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Duvvuri A, Desai M, Vennelaganti S, Higbee A, Gorrepati VS, Dasari C, Chandrasekar VT, Vennalaganti P, Kohli D, Sathyamurthy A, Rai T, Sharma P. Diagnostic accuracy of a novel third generation esophageal capsule as a non-invasive detection method for Barrett's esophagus: A pilot study. J Gastroenterol Hepatol 2021; 36:1222-1225. [PMID: 32996655 DOI: 10.1111/jgh.15283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/20/2020] [Accepted: 09/25/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Previous two generations of esophageal capsule did not show adequate detection rates for Barrett's esophagus (BE). We assessed the diagnostic accuracy of a novel third generation capsule with an improved frame rate of 35 frames per second for the detection of BE in a pilot study. METHODS This was a blinded prospective pilot study conducted at a tertiary medical center. Patients with known BE (at least C0M > 1) who presented for endoscopic surveillance (May to October 2017) were included. All patients underwent novel esophageal capsule (PillCam™ UGI; Medtronic) ingestion using the simplified ingestion protocol followed by standard high-definition upper endoscopy (esophagogastroduodenoscopy [EGD]). Capsule endoscopy findings were interpreted by examiners blinded to endoscopy results and compared with endoscopic findings (gold standard). Following completion of both tests, a subjective questionnaire was provided to all patients regarding their experience. RESULTS Twenty patients (95%males, mean age 66.3 [±7.9] years) with BE undergoing surveillance EGD were eligible. The mean BE length was 3.5 (±2.7) cm. Novel esophageal capsule detected BE in 75% patients when images were compared with endoscopy. Novel capsule detected BE in 82% patients when the BE length was ≥2 cm. The mean esophageal transit time was 0.59 s. On a subjective questionnaire, all 20 patients reported novel capsule as being more convenient compared with EGD. CONCLUSIONS In this pilot, single-center study, novel esophageal capsule was shown to be not ready for population screening of BE. Studies integrating artificial intelligence into improved quality novel esophageal capsule should be performed for BE screening.
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Affiliation(s)
- Abhiram Duvvuri
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Sreekar Vennelaganti
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - April Higbee
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | | | - Chandra Dasari
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | | | - Prashanth Vennalaganti
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Divyanshoo Kohli
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Anjana Sathyamurthy
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Tarun Rai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
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Saligram S, Tofteland N, Wani S, Gupta N, Mathur S, Vennalaganti P, Kanakadandi V, Giacchino M, Higbee A, Lim D, Rastogi A, Bansal A, Sharma P. Long-term results of the mucosal ablation of Barrett's esophagus: efficacy and recurrence. Endosc Int Open 2015; 3:E189-94. [PMID: 26171429 PMCID: PMC4486038 DOI: 10.1055/s-0034-1391669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 10/31/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS It has been postulated that the endoscopic ablation of Barrett's esophagus can lead to complete eradication of the disease. This study was undertaken to evaluate the efficacy of endoscopic eradication therapy for Barrett's esophagus and the rates of recurrence of intestinal metaplasia. PATIENTS AND METHODS As part of an initial randomized controlled trial, patients with nondysplastic or low grade dysplastic Barrett's esophagus underwent mucosal ablation. Following ablation, the patients had annual surveillance endoscopies. Recurrence was defined as the presence of intestinal metaplasia after initial complete eradication had been achieved. RESULTS A total of 28 patients with Barrett's esophagus were followed for a mean of 6.4 years after ablation therapy. At baseline, the majority of the patients had nondysplastic Barrett's esophagus (79 %). Initial complete eradication of intestinal metaplasia was achieved at a mean of 4.1 months. During long-term follow-up, initial recurrence of intestinal metaplasia was seen in 14 of the 28 of patients (50 %) at a mean of 40 months, and further maintenance ablation therapy was applied. At the final follow-up, 36 % of the patients had complete eradication of intestinal metaplasia, 18 % of the patients had intestinal metaplasia, and 21 % had died of unrelated causes; invasive esophageal adenocarcinoma had developed in 1 patient. CONCLUSIONS The long-term results of this study demonstrate a recurrence rate of 50 % after complete eradication of Barrett's esophagus with endoscopic eradication therapy. In addition, re-recurrence (in 36 %), even after further maintenance endoscopic eradication therapy, and deaths unrelated to the disease (21 %) occurred. Complete remission of Barrett's esophagus appears to be a difficult goal to achieve. These results call into question the role of ablation in patients with low risk Barrett's esophagus.
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Affiliation(s)
- Shreyas Saligram
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Nathan Tofteland
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Sachin Wani
- University of Colorado and Veterans Affairs Medical Center, Denver, Colorado, USA
| | - Neil Gupta
- Loyola University Health System, Maywood, Illinois, USA
| | - Sharath Mathur
- Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | | | - Vijay Kanakadandi
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | | | - April Higbee
- Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Diego Lim
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Amit Rastogi
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Ajay Bansal
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Prateek Sharma
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA,Corresponding author Prateek Sharma, MD Department of Gastroenterology (111)Veterans Affairs Medical Center4801 East Linwood BoulevardKansas City, Missouri 64128-2295+1-412-708-5548
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5
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Wani S, Abrams J, Edmundowicz SA, Gaddam S, Hovis CE, Green D, Gupta N, Higbee A, Bansal A, Rastogi A, Early D, Lightdale CJ, Sharma P. Endoscopic mucosal resection results in change of histologic diagnosis in Barrett's esophagus patients with visible and flat neoplasia: a multicenter cohort study. Dig Dis Sci 2013; 58:1703-9. [PMID: 23633158 PMCID: PMC4309270 DOI: 10.1007/s10620-013-2689-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 04/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are limited data on the effect of endoscopic mucosal resection (EMR) on changes of histopathologic diagnosis for Barrett's esophagus (BE) patients undergoing endoscopic eradication therapy (EET); especially those without visible lesions. AIM To compare the frequency of changes of diagnosis by EMR compared with pre-EMR biopsy diagnosis for patients with and without visible lesions. METHODS In this multicenter outcomes project, patients with Barrett's-related neoplasia undergoing EET at three tertiary-care centers were included. Patients undergoing biopsies followed by EMR within six months were included. The main outcome measures were frequency of overall change of histopathologic diagnosis, change based on pre-EMR biopsy diagnosis, and change based on the presence of visible lesions. RESULTS One-hundred and thirty-eight BE patients (low-grade dysplasia (LGD) 15 (10.9 %), high-grade dysplasia (HGD) 87 (63 %), esophageal adenocarcinoma (EAC) 36 (26.1 %)) were included; 114 (82.6 %) patients had visible lesions. EMR resulted in a change of diagnosis for 43 (31.1 %) patients (upgrade 14 (10.1 %); downgrade 29 (21 %)). For HGD patients, EMR downstaged dysplasia grade for 17 (19.5 %) cases and upstaged it to EAC for nine (10.3 %) cases. There was a change of diagnosis for 26 (29.9 %) HGD patients, irrespective of the presence or absence of visible lesions (p = 0.76). For EAC patients, EMR downstaged dysplasia grade in 10 (27.8 %) cases. There was a change of diagnosis for 10 (27.8 %) EAC patients, irrespective of the presence or absence of endoscopically visible lesions (p = 0.48). CONCLUSIONS EMR results in a change of diagnosis for approximately 30 % of BE patients with early neoplasia (with and without visible lesions) referred for EET.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, CO, USA
| | - Julian Abrams
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christine E. Hovis
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Green
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gupta
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - April Higbee
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Ajay Bansal
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Dayna Early
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles J. Lightdale
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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Lynch CR, Wani S, Rastogi A, Keighley J, Mathur S, Higbee A, Bansal A, Gaddam S, Sharma P. Effect of acid-suppressive therapy on narrow band imaging findings in gastroesophageal reflux disease: a pilot study. Dis Esophagus 2012; 26:124-9. [PMID: 22404535 DOI: 10.1111/j.1442-2050.2012.01335.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Standard endoscopy is an insensitive test for gastroesophageal reflux disease (GERD). Narrow band imaging (NBI) endoscopy enhances visualization of the distal esophagus. NBI patterns like intrapapillary capillary loop (IPCL) dilatation, tortuosity, and increased number; microerosions; increased vascularity at the squamocolumnar junction (SCJ); ridge-villous pattern below the SCJ; and presence of columnar islands in the distal esophagus have been suggested as features of GERD. We evaluated the effect of proton pump inhibitor (PPI) therapy on NBI findings in GERD patients. Patients prospectively underwent NBI upper endoscopy before and after PPI therapy. NBI findings were recorded at each endoscopy. Twenty-one patients with GERD symptoms (mean age 60.0 years; males 90.5%; white 90.5%) were studied. After PPI therapy, there was a significant reduction in the proportion of patients with the following NBI features: IPCL tortuosity (90% vs. 4.8%, P < 0.0001), dilated IPCLs (86% vs. 9.5%, P < 0.0001), and increased vascularity at the SCJ (43% vs. 9.5%, P= 0.0082). PPI led to healing of all microerosions (71% vs. 0%, P < 0.0001) and disappearance of ridge-villous patterns below the SCJ (14% vs. 0%, P < 0.0001). There was no significant change in the proportion of patients with increased numbers of IPCLs pre- and post-PPI therapy (71% vs. 48%, P= 0.09) or columnar islands in the distal esophagus (38% vs. 29%, P= 0.31). In patients with GERD symptoms, NBI features suggestive of GERD respond to PPI; suggesting these features are truly acid-mediated. These findings need to be confirmed by randomized controlled trials.
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Affiliation(s)
- C R Lynch
- Division of Gastroenterology and Hepatology, Department Veterans Affairs Medical Center, University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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Tadiparthi RA, Bansal A, Wani S, Mathur S, Hall SB, Rastogi A, Higbee A, Gaddam S, Sharma P. Dilated intercellular spaces and lymphocytes on biopsy relate to symptoms in erosive GERD but not NERD. Aliment Pharmacol Ther 2011; 33:1202-8. [PMID: 21453401 DOI: 10.1111/j.1365-2036.2011.04643.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mechanisms of symptom perception among patients with gastro-oesophageal reflux disease (GERD) remain to be fully elucidated. AIM To correlate quantitative reflux symptom scores with microscopic oesophageal histopathology. METHODS Prior to endoscopy, patients with reflux symptoms completed a validated reflux disease questionnaire (score 0-36). Erosive oesophagitis (EO) was graded using the LA classification. Oesophageal biopsies were graded 0-2 for basal cell hyperplasia, papillary elongation, dilated intercellular spaces (DIS), necrosis or erosion, eosinophils and neutrophils by a blinded gastrointestinal pathologist as previously described. Additionally, lymphocyte density was also evaluated. Pearson's correlation coefficients were computed. RESULTS Thirty-two EO and 21 non-erosive reflux disease (NERD) patients were prospectively enrolled. For EO vs. NERD, mean reflux symptom scores (10.7 vs. 8.8, P=0.35) and histology scores were similar (4.29 vs. 4.25; P=0.9). However, when symptom scores were compared with histology scores, a correlation was found in the EO group, but not in the NERD group (r=0.34, P=0.05 vs. r=0.22, P=0.36). On further analysis, DIS was associated with symptom scores in the EO group (P≤0.001), but not in the NERD group (P=N.S.). Similarly, lymphocyte density was associated with symptom scores in the EO group (r=0.56, P=0.0009), but not in the NERD group (r=0.002, P=0.9). CONCLUSIONS Although mean symptom and histology scores were similar in the EO and NERD groups, a significant correlation of symptom scores with histology scores, DIS and lymphocytes was found in the former, but not in the latter. EO and NERD patients may have different symptom perception mechanisms and thus, dissimilar symptom resolution rates with acid suppression.
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Affiliation(s)
- R A Tadiparthi
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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8
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Gaddam S, Wani S, Ahmed H, Maddur P, Hall SB, Gupta N, Puli SR, Higbee A, Rastogi A, Bansal A, Sharma P. The impact of pre-endoscopy proton pump inhibitor use on the classification of non-erosive reflux disease and erosive oesophagitis. Aliment Pharmacol Ther 2010; 32:1266-74. [PMID: 20955446 DOI: 10.1111/j.1365-2036.2010.04468.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Factors associated with non-erosive reflux disease (NERD) and erosive oesophagitis (EO) are incompletely understood and the overlap between the two entities is debated. AIM To compare clinical, demographic, and endoscopic findings in a large cohort of NERD and EO patients. METHODS After they completed a validated GERD questionnaire, patients who presented for index endoscopy were enrolled and categorized as NERD or EO. Analysis was performed using Chi-square, Mann-Whitney U-test and multivariate logistic regression. RESULTS A total of 696 GERD patients [455 (65.4%) NERD; 241 (34.6%) EO]; mean age 57 years; 92% men and 82% Caucasian were prospectively enrolled. Using logistic regression, patients on PPI were more likely to be classified as NERD (OR: 3.2; P < 0.001). NERD patients were older (OR: 1.50; P = 0.05), less likely to have nocturnal symptoms (OR: 0.63; P = 0.04) and hiatal hernia (OR: 0.32; P < 0.001). Compared with PPI-naïve NERD patients, those on PPI were more likely to have nocturnal symptoms (69% vs. 29%, P = 0.048) and less likely to have mild-moderate symptoms (63% vs. 79%, P < 0.001) - similar to the EO group. CONCLUSIONS Pre-endoscopy PPI usage contributes significantly to the classification of GERD patients into the NERD-phenotype. NERD patients on PPI therapy demonstrate some features that are significantly different from PPI-naïve patients, but similar to EO patients. This observation supports the notion that some PPI NERD patients are actually healed EO patients, and that an overlap does exist between the GERD phenotypes.
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Affiliation(s)
- S Gaddam
- Veterans Affairs Medical Center, Kansas City, MO 64128-2295, USA
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Sharma P, Wani S, Rastogi A, Bansal A, Higbee A, Mathur S, Esquivel R, Camargo L, Sampliner RE. The diagnostic accuracy of esophageal capsule endoscopy in patients with gastroesophageal reflux disease and Barrett's esophagus: a blinded, prospective study. Am J Gastroenterol 2008; 103:525-32. [PMID: 17459025 DOI: 10.1111/j.1572-0241.2007.01233.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophageal capsule endoscopy (ECE) is a novel technique that offers noninvasive evaluation of esophageal pathology in gastroesophageal reflux disease (GERD) patients. OBJECTIVE To assess the diagnostic accuracy of ECE for Barrett's esophagus (BE), erosive esophagitis, and hiatal hernia and to assess the safety profile of ECE. METHODS Patients with GERD symptoms and those undergoing BE surveillance were prospectively enrolled. All patients underwent ECE followed by standard upper endoscopy. ECE findings were interpreted by examiners blinded to endoscopy results. The gold standard was the findings at endoscopy and ECE results were compared with those at endoscopy. RESULTS One hundred patients were enrolled of which 94 completed the study. At upper endoscopy, BE was suspected in 53 (mean length 3.1 cm) and confirmed in 45 patients. Erosive esophagitis and hiatal hernia were identified in 18 and 70 patients, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ECE for BE in GERD patients were 67%, 87%, 60%, and 90%, respectively. The sensitivity, specificity, PPV, and NPV of ECE for BE patients undergoing surveillance were 79%, 78%, 94%, and 44%, respectively. The sensitivity, specificity, PPV, and NPV for erosive esophagitis were 50%, 90%, 56%, and 88% and for hiatal hernia were 54%, 67%, 83%, and 33%, respectively. CONCLUSIONS Current diagnostic rates of ECE for BE are not yet accurate enough for application in clinical practice. An improvement in technology and learning curve assessments are required, until then standard upper endoscopy remains the gold standard.
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Affiliation(s)
- Prateek Sharma
- Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA
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Sharma P, Bansal A, Mathur S, Wani S, Cherian R, McGregor D, Higbee A, Hall S, Weston A. The utility of a novel narrow band imaging endoscopy system in patients with Barrett's esophagus. Gastrointest Endosc 2006; 64:167-75. [PMID: 16860063 DOI: 10.1016/j.gie.2005.10.044] [Citation(s) in RCA: 223] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Accepted: 10/17/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND A narrow band imaging (NBI) endoscopy system has been developed that allows superficial surface imaging of esophageal tissue in vivo. OBJECTIVE The objective was to assess the potential of NBI for prediction of histology during screening and surveillance endoscopy in patients with Barrett's esophagus (BE). DESIGN A prospective cohort study. SETTING Veterans Affairs Medical Center. PATIENTS Fifty-one patients with known or suspected BE. METHODS NBI images were graded according to mucosal pattern (ridge/villous, circular and irregular/distorted) and vascular pattern (normal and abnormal), and correlated with histology in a prospective, blinded manner. MAIN OUTCOME MEASUREMENTS Biopsy-confirmed intestinal metaplasia (IM) and dysplasia were used as the outcome measures. RESULTS Of 51 patients (mean BE length 3.5 cm), 28 had IM without dysplasia, 8 had low-grade dysplasia (LGD), 7 had high-grade dysplasia (HGD), and 8 had cardiac-type mucosa. The sensitivity, specificity, and positive predictive value of ridge/villous pattern for diagnosis of IM without HGD were 93.5%, 86.7%, and 94.7%, respectively. The sensitivity, specificity, and positive predictive value of irregular/distorted pattern for HGD were 100%, 98.7%, and 95.3%, respectively. If biopsies were limited to areas with irregular/distorted pattern, no patient with HGD would have been missed. However, NBI was unable to distinguish areas of IM from those with LGD. LIMITATIONS The open study design without a control group was the main limitation. CONCLUSIONS NBI is a novel diagnostic tool with a high degree of accuracy for the detection of metaplastic and dysplastic tissue within the BE segment.
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Affiliation(s)
- Prateek Sharma
- Division of Gastroenterology and Hepatology, Department of Pathology, and Kansas Cancer Institute, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA
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Abstract
BACKGROUND Barrett's oesophagus patients may continue to have abnormal oesophageal acid exposure on proton pump inhibitor therapy. The effect of factors such as Barrett's oesophagus length, hiatal hernia size and Helicobacter pylori infection on intra-oesophageal pH in Barrett's oesophagus patients has not been adequately studied. AIM To evaluate oesophageal acid exposure in a large Barrett's oesophagus population on b.d. proton pump inhibitor therapy and determine clinical factors predicting normalization of intra-oesophageal pH on therapy. METHODS Barrett's oesophagus patients were studied using 24 h pH monitoring to evaluate intra-oesophageal acid suppression on b.d. dosing of rabeprazole. RESULTS Forty-six Barrett's oesophagus patients completed the study. Median total percentage time pH < 4 was 1.05% (range: 0-29.9%) in the entire group and respective values for upright and supine percentage time pH < 4 were 1.15% and 0%. However, 34 of the Barrett's oesophagus patients (73.9%) had a normal pH study (median total percentage time pH < 4: 0.2%) and 12 patients (26.1%) had an abnormal result (median total percentage time pH < 4: 9.3%). There were no significant differences between patients with a normal and abnormal 24 h pH result with respect to age, Barrett's oesophagus length, hiatal hernia size and presence of H. pylori infection. CONCLUSIONS Approximately 25% of Barrett's oesophagus patients continue to have abnormal total intra-oesophageal pH profiles despite b.d. proton pump inhibitor therapy. Factors such as age, Barrett's oesophagus length and hiatal hernia size cannot be used to predict persistent abnormal intra-oesophageal pH on proton pump inhibitor.
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Affiliation(s)
- S Wani
- University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MO 64128-2295, USA
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