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Aceves SS, Alexander JA, Baron TH, Bredenoord AJ, Day L, Dellon ES, Falk GW, Furuta GT, Gonsalves N, Hirano I, Konda VJA, Lucendo AJ, Moawad F, Peterson KA, Putnam PE, Richter J, Schoepfer AM, Straumann A, McBride DL, Sharma P, Katzka DA. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc 2022; 96:576-592.e1. [PMID: 35965102 DOI: 10.1016/j.gie.2022.05.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
Endoscopy plays a critical role in caring for and evaluating the patient with eosinophilic esophagitis (EoE). Endoscopy is essential for diagnosis, assessment of response to therapy, treatment of esophageal strictures, and ongoing monitoring of patients in histologic remission. To date, less-invasive testing for identifying or grading EoE severity has not been established, whereas diagnostic endoscopy as integral to both remains the criterion standard. Therapeutic endoscopy in patients with adverse events of EoE may also be required. In particular, dilation may be essential to treat and attenuate progression of the disease in select patients to minimize further fibrosis and stricture formation. Using a modified Delphi consensus process, a group of 20 expert clinicians and investigators in EoE were assembled to provide guidance for the use of endoscopy in EoE. Through an iterative process, the group achieved consensus on 20 statements yielding comprehensive advice on tissue-sampling standards, gross assessment of disease activity, use and performance of endoscopic dilation, and monitoring of disease, despite an absence of high-quality evidence. Key areas of controversy were identified when discussions yielded an inability to reach agreement on the merit of a statement. We expect that with ongoing research, higher-quality evidence will be obtained to enable creation of a guideline for these issues. We further anticipate that forthcoming expert-generated and agreed-on statements will provide valuable practice advice on the role and use of endoscopy in patients with EoE.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Jeffrey A Alexander
- Departments of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Arjan J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Lukejohn Day
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Gary W Falk
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Fouad Moawad
- Scripps Health Uniformed Services, La Jolla, California, USA
| | - Kathryn A Peterson
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah Health, Salt Lake City, Utah, USA
| | - Philip E Putnam
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joel Richter
- University of South Florida Health, Tampa, Florida, USA
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausannel, Lausanne, Switzerland
| | - Alex Straumann
- Facharzt FMH fur Gastroenterologie u Innere Medizin, Olten, Switzerland
| | | | - Prateek Sharma
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - David A Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
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Parasa S, Vennalaganti S, Gaddam S, Vennalaganti P, Young P, Gupta N, Thota P, Cash B, Mathur S, Sampliner R, Moawad F, Lieberman D, Bansal A, Kennedy KF, Vargo J, Falk G, Spaander M, Bruno M, Sharma P. Development and Validation of a Model to Determine Risk of Progression of Barrett's Esophagus to Neoplasia. Gastroenterology 2018; 154:1282-1289.e2. [PMID: 29273452 DOI: 10.1053/j.gastro.2017.12.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [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: 09/13/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS A system is needed to determine the risk of patients with Barrett's esophagus for progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). We developed and validated a model to determine of progression to HGD or EAC in patients with BE, based on demographic data and endoscopic and histologic findings at the time of index endoscopy. METHODS We performed a longitudinal study of patients with BE at 5 centers in United States and 1 center in Netherlands enrolled in the Barrett's Esophagus Study database from 1985 through 2014. Patients were excluded from the analysis if they had less than 1 year of follow-up, were diagnosed with HGD or EAC within the past year, were missing baseline histologic data, or had no intestinal metaplasia. Seventy percent of the patients were used to derive the model and 30% were used for the validation study. The primary outcome was development of HGD or EAC during the follow-up period (median, 5.9 years). Survival analysis was performed using the Kaplan-Meier method. We assigned a specific number of points to each BE risk factor, and point totals (scores) were used to create categories of low, intermediate, and high risk. We used Cox regression to compute hazard ratios and 95% confidence intervals to determine associations between risk of progression and scores. RESULTS Of 4584 patients in the database, 2697 were included in our analysis (84.1% men; 87.6% Caucasian; mean age, 55.4 ± 20.1 years; mean body mass index, 27.9 ± 5.5 kg/m2; mean length of BE, 3.7 ± 3.2 cm). During the follow-up period, 154 patients (5.7%) developed HGD or EAC, with an annual rate of progression of 0.95%. Male sex, smoking, length of BE, and baseline-confirmed low-grade dysplasia were significantly associated with progression. Scores assigned identified patients with BE that progressed to HGD or EAC with a c-statistic of 0.76 (95% confidence interval, 0.72-0.80; P < .001). The calibration slope was 0.9966 (P = .99), determined from the validation cohort. CONCLUSIONS We developed a scoring system (Progression in Barrett's Esophagus score) based on male sex, smoking, length of BE, and baseline low-grade dysplasia that identified patients with BE at low, intermediate, and high risk for HGD or EAC. This scoring system might be used in management of patients.
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Affiliation(s)
- Sravanthi Parasa
- Division of Gastroenterology, Swedish Medical Group, Seattle, Washington
| | - Sreekar Vennalaganti
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Srinivas Gaddam
- Division of Gastroenterology, Cedar-Sinai Medical Center, Los Angeles, California
| | - Prashanth Vennalaganti
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Patrick Young
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Neil Gupta
- Division of Gastroenterology, Loyola University Medical Center, Maywood, Illinois
| | - Prashanthi Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Brooks Cash
- University of South Alabama, Mobile, Alabama; American Gastroenterological Association
| | - Sharad Mathur
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Richard Sampliner
- Department of Gastroenterology and Hepatology, University of Arizona, Tucson, Arizona
| | - Fouad Moawad
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Ajay Bansal
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Kevin F Kennedy
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - John Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Gary Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Manon Spaander
- Department of Gastroenterology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Marco Bruno
- Department of Gastroenterology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Prateek Sharma
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri; Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas.
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Thota PN, Vennalaganti P, Vennelaganti S, Young P, Gaddam S, Gupta N, Lieberman D, Sampliner R, Falk GW, Mathur S, Kennedy K, Cash BD, Moawad F, Bansal A, Spaander MC, Bruno MJ, Vargo J, Sharma P. Low Risk of High-Grade Dysplasia or Esophageal Adenocarcinoma Among Patients With Barrett's Esophagus Less Than 1 cm (Irregular Z Line) Within 5 Years of Index Endoscopy. Gastroenterology 2017; 152:987-992. [PMID: 27988383 DOI: 10.1053/j.gastro.2016.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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: 09/19/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Many patients with a < 1 cm segment of columnar metaplasia in the distal esophagus, also called an irregular Z line, are encountered. These patients, often referred to as patients with Barrett's esophagus (BE), are enrolled in surveillance programs. However, little is known about their risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). We aimed to determine the incidence of HGD and EAC in patients with irregular Z line with intestinal metaplasia. METHODS We performed a prospective, multicenter cohort study of patients who underwent endoscopic examination for BE at tertiary care referral centers in the United States and Europe. We analyzed data from 1791 patients (mean age, 56 ± 17 years) found to have non-dysplastic BE at the index endoscopy and after 1 year or more of follow-up. Patients were followed for a median of 5.9 years (interquartile range, 3.1-8.3 years). We calculated rates of progression to HGD or EAC between groups of patients with irregular Z line (n = 167) and those with BE of ≥ 1 cm (n = 1624). RESULTS A higher proportion of patients in the irregular Z-line group were female (26.3%) than in the BE group (14.8% female BE) (P <.001). A lower proportion of patients in the irregular Z-line group were smokers (33.5%) than in the BE group (52.6% smokers). None of the patients with irregular Z line developed HGD or EAC during a median follow-up period of 4.8 years (interquartile range, 3.2-8.3 years). All 71 incident cases of HGD or EAC developed in patients with BE of ≥1 cm in length. On multivariate analysis, patients with irregular Z line and patients with BE of ≥ 1 cm did not differ significantly in age, race, or duration of follow-up. CONCLUSIONS In a prospective, multicenter cohort study, we found that patients with irregular Z line do not develop HGD or esophageal cancer within 5 years after index endoscopy.
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Affiliation(s)
- Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio.
| | - Prashanth Vennalaganti
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Sreekar Vennelaganti
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Patrick Young
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Srinivas Gaddam
- Department of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Neil Gupta
- Department of Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, Illinois
| | - David Lieberman
- Department of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Richard Sampliner
- Department of Gastroenterology and Hepatology, University of Arizona, Tucson, Arizona
| | - Gary W Falk
- Department of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sharad Mathur
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Kevin Kennedy
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Brooks D Cash
- Department of Gastroenterology and Hepatology, University of South Alabama, Mobile, Alabama
| | - Fouad Moawad
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Ajay Bansal
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Manon C Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - John Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas; Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri
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Locke GR, Horwhat J, Mashimo H, Savarino E, Zentilin P, Savarino V, Zerbib F, Armbruster SP, Wong RK, Moawad F. Endotherapy for and tailored approaches to treating GERD, and refractory GERD. Ann N Y Acad Sci 2013; 1300:166-186. [PMID: 24117641 DOI: 10.1111/nyas.12240] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This paper presents commentaries on how endoluminal antireflux procedures compare to laparoscopic fundoplication; new endoscopic procedures being studied to treat refractory gastroesophageal reflux disease (GERD); the new Stretta; the relationship between obesity and proton pump inhibitor (PPI) resistance; data concerning acid hypersensitivity and sensory receptors (vallinoid, TRPV1) causing refractory GERD; whether microscopic esophagitis is relevant in determining symptoms of non-erosive reflux disease (NERD); how concomitant functional gastrointestinal disorders affect the PPI response in NERD; the evidence that a functional esophagus is associated with inflammatory bowel syndrome (IBS); the role of GABA agonists in the treatment of refractory GERD; the role of biofeedback and antidepressants in refractory GERD; and endoluminal fundoplication using the EsophyX device.
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Affiliation(s)
- G Richard Locke
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John Horwhat
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Hiroshi Mashimo
- VA Boston Healthcare System/Harvard Medical School, Boston, Massachusetts
| | - Edoardo Savarino
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | | | | | - Frank Zerbib
- Department of Gastroenterology, CHU Bordeaux, Saint Andre Hospital, Bordeaux, France
| | - Steven P Armbruster
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Roy K Wong
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Fouad Moawad
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Moawad F, Truesdell A, Mulhall B. A "fishy" cough: hepatobronchial fistula due to a pyogenic liver abscess. N Z Med J 2006; 119:U1906. [PMID: 16582969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
A hepatobronchial fistula is an anatomic communication between the liver parenchyma and the bronchial tree. Major causes of such fistulae include inflammatory conditions resulting from obstruction of the biliary tract and infectious processes, such as pyogenic liver abscesses, amoebiasis, and hydatid cysts. We report a rare case of a patient (with a chronic, recurrent hepatic abscess) who suffered a persistent, productive cough resulting from a hepatobronchial fistula.
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Affiliation(s)
- Fouad Moawad
- Department of Medicine, Walter Reed Army Medical Center, 6900 Georgia Ave., NW Washington, DC 20307, USA.
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