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Walsh E, Krause AJ, Greytak M, Kaizer AM, Weissbrod PA, Liu K, Taft T, Yadlapati R. Laryngeal Recalibration Therapy Improves Laryngopharyngeal Symptoms in Patients with Suspected Laryngopharyngeal Reflux Disease. Am J Gastroenterol 2024:00000434-990000000-01134. [PMID: 38656937 DOI: 10.14309/ajg.0000000000002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Laryngopharyngeal symptoms such as cough, throat clearing, voice change, paradoxic vocal fold movement or laryngospasm are hyper-responsive behaviors resulting from local irritation (e.g., refluxate) and heightened sympathetic tone. Laryngeal recalibration therapy (LRT) guided by a speech-language pathologist (SLP) provides mechanical desensitization and cognitive recalibration to suppress hyper-responsive laryngeal patterns. This study aimed to assess symptom response to LRT among patients with chronic laryngopharyngeal symptoms symptoms undergoing evaluation of gastroesophageal reflux disease (GERD). METHODS Adults with chronic laryngopharyngeal symptoms referred for evaluation of GERD to a single center were prospectively followed. Inclusion criteria included >2 SLP directed LRT sessions. Data from endoscopy, ambulatory reflux monitoring, and patient reported outcomes were collected when available. The primary outcome was symptom response. RESULTS Sixty-five participants completed LRT: mean age 55.4 years (SD 17.2), 46 (71%) female, mean body mass index 25.6kg/m2 (6.8), mean of 3.7 (1.9) LRT sessions. Overall, 55 (85%) participants met criteria for symptom response. Specifically, symptom response was similar between those with isolated laryngopharyngeal symptoms (13/15 (87%)) and concomitant laryngopharyngeal/esophageal symptoms (42/50 (84%)). Among participants that underwent reflux monitoring, symptom response was similar between those with proven, inconclusive for, and no GERD (18/21 (86%), 8/9 (89%), 10/13 (77%)). CONCLUSION 85% of patients with chronic laryngopharyngeal symptoms referred for GERD evaluation that underwent LRT experienced laryngeal symptom response. Rates of symptom response were maintained across patients with or without proven GERD as well as patients with or without concomitant esophageal reflux symptoms. SLP directed LRT is an effective approach to incorporate into multi-disciplinary management of chronic laryngopharyngeal symptoms/laryngopharyngeal reflux disease.
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Affiliation(s)
- Erin Walsh
- . Department of Otolaryngology, University of California San Diego, La Jolla, California
| | - Amanda J Krause
- . Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
| | - Madeline Greytak
- . Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
| | - Alexander M Kaizer
- . Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Philip A Weissbrod
- . Department of Otolaryngology, University of California San Diego, La Jolla, California
| | - Kelli Liu
- . Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
| | - Tiffany Taft
- . The Rome Foundation Research Institute. Chapel Hill, NC, USA
| | - Rena Yadlapati
- . Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
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Salvador R, Pandolfino JE, Costantini M, Gyawali CP, Keller J, Mittal S, Roman S, Savarino EV, Tatum R, Tolone S, Zerbib F, Capovilla G, Jain A, Kathpalia P, Provenzano L, Yadlapati R. The Role of High-Resolution Manometry Prior to and Following Antireflux Surgery: The Padova Consensus. Ann Surg 2024:00000658-990000000-00840. [PMID: 38606560 DOI: 10.1097/sla.0000000000006297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BACKGROUND In the last two decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiologic information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision making. METHOD A multi-disciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre- and post- ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM prior to ARS and the role of HRM following ARS. CONCLUSION This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre- and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.
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Affiliation(s)
- Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - John E Pandolfino
- Division of Gastroenterology, Northwestern University, Chicago, IL, USA
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jutta Keller
- Israelitic Hospital, Academic Hospital University of Hamburg, Orchideenstieg 14, 22297 Hamburg, Germany
| | - Sumeet Mittal
- Foregut Program, Norton Thoracic Institute, Phoenix, AZ, USA
| | - Sabine Roman
- Division of Gastroenterology, Lyon University and Hospices Civils de Lyon, Lyon, France
| | - Edoardo Vincenzo Savarino
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Roger Tatum
- Department of Surgery, University of Washington and VA Puget Sound Health Care System, Seattle, WA, USA
| | - Salvatore Tolone
- Medicine & Surgery, Universita degli Studi della Campania, School of Medicine Naples, Italy
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology department; Université de Bordeaux; INSERM CIC 1401; Bordeaux, France
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Anand Jain
- Division of Gastroenterology, Emory University, Atlanta, GA, USA
| | - Priya Kathpalia
- Division of Gastroenterology, University of California San Francisco, San Francisco, CA USA
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, CA USA
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Yousef A, Krause A, Yadlapati R, Sharma P, Weissbrod PA. Upper Esophageal Sphincter and Esophageal Motility Pathology on Manometry in Retrograde Cricopharyngeal Dysfunction. Otolaryngol Head Neck Surg 2024. [PMID: 38587015 DOI: 10.1002/ohn.735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/13/2024] [Accepted: 02/29/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE There exists a paucity of data regarding the mechanism and manometric findings in retrograde cricopharyngeal dysfunction (RCPD). In this study, we aimed to compare esophageal physiologic findings between patients with RCPD compared to an asymptomatic cohort. STUDY DESIGN Case-control study. SETTING Tertiary Care Center. METHODS Esophageal high-resolution impedance manometry was completed preoperatively in patients diagnosed with RCPD. Manometric data were compared between the RCPD and asymptomatic cohorts. A 2:1 age-sex-matched asymptomatic cohort was used as the control group. Treatment response was assessed among the RCPD cohort. RESULTS Thirty-nine patients are included: 13 RCPD [mean age: 31.1 (SD: 12.6) years, female sex: 11 (85%)] and 26 asymptomatic [mean age: 32.1 (SD: 1.5) years, female sex: 22 (85%)]. The RCPD cohort, compared to the asymptomatic cohort, exhibited significantly greater upper esophageal sphincter (UES) length [4.5 (SD: 0.7) vs 3.7 (0.9) cm, P = .01] and higher UES basal pressures [91.9 (35.0) vs 49.7 (25.5) mm Hg, P = .002]. Patients with RCPD demonstrated higher rates of ineffective swallows [70.0% (31.6%) vs 15.4% (21.6%), P < .001] and incomplete bolus clearance [81% (22.0%) vs 21.8% (30.0%), P < .001]. All patients who underwent cricopharyngeal botulinum injections experienced initial improvement of symptoms with 3 patients requiring repeat intervention. CONCLUSION RCPD is associated with a longer UES, elevated UES basal pressures, and an increased incidence of ineffective esophageal motility. This study is the first to compare preoperative manometry results among patients with RCPD to those of an asymptomatic cohort, providing insights into the mechanism of RCPD.
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Affiliation(s)
- Andrew Yousef
- Department of Otolaryngology, University of California San Diego, La Jolla, California, USA
| | - Amanda Krause
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Priya Sharma
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Philip A Weissbrod
- Department of Otolaryngology, University of California San Diego, La Jolla, California, USA
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Krause AJ, Greytak M, Kaizer AM, Carlson DA, Chan WW, Chen CL, Gyawali CP, Jenkins A, Pandolfino JE, Polamraju V, Wong MW, Yadlapati R. Diagnostic Yield of Ambulatory Reflux Monitoring Systems for Evaluation of Chronic Laryngeal Symptoms. Am J Gastroenterol 2024; 119:627-634. [PMID: 37830520 PMCID: PMC10994771 DOI: 10.14309/ajg.0000000000002557] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Among patients with chronic laryngeal symptoms, ambulatory reflux monitoring off acid suppression is recommended to evaluate for laryngopharyngeal reflux (LPR). However, reflux monitoring systems are diverse in configuration and monitoring capabilities, which present a challenge in creating a diagnostic reference standard in these patients. This study aimed to compare diagnostic yield and performance between reflux monitoring systems in patients with chronic laryngeal symptoms. METHODS This multicenter, international study of adult patients referred for evaluation of LPR over a 5-year period (March 2018-May 2023) assessed and compared diagnostic yield of pathologic gastroesophageal reflux (GER+) on ambulatory reflux monitoring off acid suppression. RESULTS Of 813 patients, 296 (36%) underwent prolonged wireless pH, 532 (65%) underwent 24-hour pH-impedance monitoring, and 15 (2%) underwent both tests. Overall diagnostic yield for GER+ was 36% and greater for prolonged wireless pH compared with that for 24-hour pH-impedance monitoring (50% vs 27%; P < 0.01). Among 15 patients who underwent both prolonged wireless pH and 24-h pH-impedance monitoring, concordance between systems for GER+ was 40%. The most common source of discordance was strong evidence of GER+ across multiple days on prolonged wireless pH compared with no evidence of GER+ on pH-impedance. DISCUSSION In this multicenter international study of patients with chronic laryngeal symptoms referred for LPR evaluation, diagnostic yield of ambulatory reflux monitoring off acid suppression was 36% and rose to 50% when using wireless pH monitoring. In patients referred for chronic laryngeal symptoms, 24-hour pH-impedance monitoring may risk a low negative predictive value in patients with unproven GER+ disease.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
| | - Madeline Greytak
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Walter W Chan
- Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chien-Lin Chen
- Department of Medicine, Division of Gastroenterology and Hepatology, Tzu Chi University, Hualien County, Taiwan
| | - C Prakash Gyawali
- Department of Medicine, Division of Gastroenterology, Washington University, St. Louis, Missouri, USA
| | - Andrew Jenkins
- Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Vinathi Polamraju
- Department of Medicine, Division of Gastroenterology, Washington University, St. Louis, Missouri, USA
| | - Ming-Wun Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Tzu Chi University, Hualien County, Taiwan
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
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Low EE, Demb J, Shah SC, Liu L, Bustamante R, Yadlapati R, Gupta S. Risk of Esophageal Cancer in Achalasia: A Matched Cohort Study Using the Nationwide Veterans Affairs Achalasia Cohort. Am J Gastroenterol 2024; 119:635-645. [PMID: 37975607 PMCID: PMC10994742 DOI: 10.14309/ajg.0000000000002591] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Achalasia is a postulated risk factor of esophageal cancer (EC); however, EC-associated risk in achalasia is understudied. We aimed to evaluate EC risk among individuals within the nationwide Veterans Affairs Achalasia Cohort. METHODS We conducted a matched cohort study among US veterans aged 18 years or older from 1999 to 2019. Individuals with achalasia were age matched and sex matched 1:4 to individuals without achalasia. Follow-up continued from study entry until diagnosis with incident/fatal EC (primary outcome), death from non-EC-related causes, or end of the study follow-up (December 31, 2019). Association between achalasia and EC risk was examined using Cox regression models. RESULTS We included 9,315 individuals in the analytic cohort (median age 55 years; 92% male): 1,863 with achalasia matched to 7,452 without achalasia. During a median 5.5 years of follow-up, 17 EC occurred (3 esophageal adenocarcinoma, 12 squamous cell carcinoma, and 2 unknown type) among individuals with achalasia, compared with 15 EC (11 esophageal adenocarcinoma, 1 squamous cell carcinoma, and 3 unknown type) among those without achalasia. EC incidence for those with achalasia was 1.4 per 1,000 person-years, and the median time from achalasia diagnosis to EC development was 3.0 years (Q1-Q3: 1.3-9.1). Individuals with achalasia had higher cumulative EC incidence at 5, 10, and 15 years of follow-up compared with individuals without achalasia, and EC risk was 5-fold higher (hazard ratio 4.6, 95% confidence interval: 2.3-9.2). DISCUSSION Based on substantial EC risk, individuals with achalasia may benefit from a high index of suspicion and endoscopic surveillance for EC.
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Affiliation(s)
- Eric E Low
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California, USA
- Division of Gastroenterology, University of California, La Jolla, California, USA
| | - Joshua Demb
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California, USA
- Division of Gastroenterology, University of California, La Jolla, California, USA
| | - Shailja C Shah
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California, USA
- Division of Gastroenterology, University of California, La Jolla, California, USA
| | - Lin Liu
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California, USA
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, USA
| | - Ranier Bustamante
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, La Jolla, California, USA
| | - Samir Gupta
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California, USA
- Division of Gastroenterology, University of California, La Jolla, California, USA
- University of California, San Diego Moores Cancer Center, La Jolla, California, USA
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Krause AJ, Greytak M, Kessler M, Yadlapati R. Pilot study evaluating salivary bile acids as a diagnostic biomarker of laryngopharyngeal reflux. Dis Esophagus 2024:doae021. [PMID: 38525936 DOI: 10.1093/dote/doae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/16/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
Bile acids in refluxate contribute to esophageal and laryngeal symptoms and are quantifiable. The aim of this study was to compare salivary bile acid concentrations across healthy controls and symptomatic patients (esophageal or laryngeal) with or without objective gastroesophageal reflux disease (GERD). This prospective study enrolled adults into three groups: esophageal symptoms (heartburn, regurgitation, chest pain); laryngeal symptoms (cough, throat clearing, sore throat, dysphonia); and controls. Symptomatic patients primarily underwent prolonged wireless reflux monitoring off acid suppression and were categorized as symptomatic no GERD (acid exposure time <4%) or esophageal/laryngeal symptoms with GERD (acid exposure time ≥4%). Controls did not undergo reflux monitoring nor upper endoscopy. Saliva samples were provided for bile acid analysis via ultraperformance liquid chromatography tandem mass spectrometry. Thirty-five participants were enrolled (mean age 47.4 years [SD 18.9], 16 [46%] male), including 10 controls and 25 symptomatic: 9 no GERD, 5 esophageal symptoms + GERD, and 11 laryngeal symptoms + GERD. Total salivary bile acids were highest in the laryngeal symptoms + GERD group (24.2 nM [SD 24.7]) compared to other groups (controls: 5.8 [6.0], P = 0.03; symptomatic no GERD: 3.1 [4.4]; P < 0.01; esophageal symptoms + GERD: 7.1 [7.1], P = 0.10). Bile acids were elevated in 45% (5/11) of the laryngeal symptoms + GERD group compared to 0% of the other three groups (P < 0.01). Salivary bile acids were higher among patients with laryngeal symptoms and objective GERD versus other groups. Salivary bile acids are a quantifiable biomarker with diagnostic potential for laryngopharyngeal reflux.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
| | - Madeline Greytak
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
| | - Marco Kessler
- Clinical Development Department, Ironwood Pharmaceuticals, Boston, MA, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
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Kahrilas P, Anastasiou F, Bredenoord AJ, El Serag HB, Labenz J, Mendive J, Savarino EV, Sifrim D, Udrescu M, Yadlapati R, Hungin AP. Proton pump inhibitors: rational use and use-reduction. The Windsor Workshop. Dig Dis 2024:000538399. [PMID: 38513623 DOI: 10.1159/000538399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Despite deprescribing initiatives to curb overutilisation of proton pump inhibitors (PPIs), achieving meaningful reductions in PPI use is proving a challenge. SUMMARY An international group of primary care doctors and gastroenterologists examined the literature surrounding PPI use and use-reduction to clarify: (i) what constitutes rational PPI prescribing; (ii) when and in whom PPI use-reduction should be attempted; and (iii) what strategies to use when attempting PPI use-reduction. KEY MESSAGES • Before starting a PPI for reflux-like symptoms, patients should be educated on potential causes and alternative approaches including dietary and lifestyle modification, weight loss, and relaxation strategies. • When commencing a PPI, patients should understand the reason for treatment, planned duration and review date. • PPI use at hospital discharge should not be continued without a recognised indication for long-term treatment. • Long-term PPI therapy should be reviewed at least annually. • PPI use-reduction should be based on the lack of a rational indication for long-term PPI use, not concern for PPI-associated adverse events. • PPI use-reduction strategies involving switching to on-demand PPI or dose tapering, with rescue therapy for rebound symptoms, are more likely to succeed than abrupt cessation.
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Guadagnoli L, Yadlapati R, Pandolfino J, Bedell A, Pandit AU, Dunbar KB, Fass R, Gevirtz R, Gyawali CP, Lupe SE, Petrik M, Riehl ME, Salwen-Deremer J, Simons M, Tomasino KN, Taft T. Behavioral Therapy for Functional Heartburn: Recommendation Statements. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00285-4. [PMID: 38518891 DOI: 10.1016/j.cgh.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 12/18/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND & AIMS Brain-gut behavior therapies (BGBT) are increasingly recognized as effective therapeutic interventions for functional heartburn. However, recommendations regarding candidacy for treatment, initial treatment selection, and navigating treatment non-response have not been established for functional heartburn specifically. The aim of this study was to establish expert-based recommendations for behavioral treatment in patients with functional heartburn. METHODS The validated RAND/University of California, Los Angeles Appropriateness Method was applied to develop recommendations. A 15-member panel composed of 10 gastrointestinal psychologists and 5 esophageal specialists ranked the appropriateness of a series of statements on a 9-point interval scale over 2 ranking periods. Statements were within the following domains: pre-therapy evaluation, candidacy criteria for BGBT, selection of initial BGBT, role of additional therapy for initial non-response to BGBT, and role of pharmacologic neuromodulation. The primary outcome was appropriateness of each intervention based on the recommendation statements. RESULTS Recommendations for psychosocial assessment (eg, hypervigilance, symptom-specific anxiety, health-related quality of life), candidacy criteria (eg, motivated for BGBT, acknowledges the role of stress in symptoms), and treatment were established. Gut-directed hypnotherapy or cognitive behavioral therapy were considered appropriate BGBT for functional heartburn. Neuromodulation and/or additional BGBT were considered appropriate in the context of non-response. CONCLUSIONS Gut-directed hypnotherapy and/or cognitive behavioral therapy are recommended as appropriate behavioral interventions for heartburn symptoms, depending on clinical indication, specific gut-brain targets, and preferred treatment modality (pharmacologic vs non-pharmacologic). Pre-therapy evaluation of psychosocial processes and candidacy for BGBT are important to determine eligibility for referral to psychogastroenterology services.
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Affiliation(s)
- Livia Guadagnoli
- Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium.
| | - Rena Yadlapati
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California
| | - John Pandolfino
- Kenneth C. Griffin Esophageal Center, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alyse Bedell
- Departments of Psychiatry & Behavioral Neuroscience and Medicine (Section of Gastroenterology, Hepatology, and Nutrition), The University of Chicago, Chicago, Illinois
| | - Anjali U Pandit
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kerry B Dunbar
- Division of Digestive Diseases, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Case Western Reserve University, Cleveland, Ohio
| | - Richard Gevirtz
- Clinical PhD Program, CSPP@Alliant International University, San Diego, California
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Stephen E Lupe
- Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio
| | - Megan Petrik
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Megan E Riehl
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jessica Salwen-Deremer
- Departments of Psychiatry and Medicine (Section of Gastroenterology & Hepatology), Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Madison Simons
- Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio
| | - Kathryn N Tomasino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tiffany Taft
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kamboj AK, Patel DA, Yadlapati R. Long-Term Proton Pump Inhibitor Use: Review of Indications and Special Considerations. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00195-2. [PMID: 38471653 DOI: 10.1016/j.cgh.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Dhyanesh A Patel
- Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville, Tennessee
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
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Krause AJ, Yadlapati R. Review article: Diagnosis and management of laryngopharyngeal reflux. Aliment Pharmacol Ther 2024; 59:616-631. [PMID: 38192086 PMCID: PMC10997336 DOI: 10.1111/apt.17858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/17/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Laryngopharyngeal reflux has classically referred to gastroesophageal reflux leading to chronic laryngeal symptoms such as throat clearing, dysphonia, cough, globus sensation, sore throat or mucus in the throat. Current lack of clear diagnostic criteria significantly impairs practitioners' ability to identify and manage laryngopharyngeal reflux. AIMS To discuss current evidence-based diagnostic and management strategies in patients with laryngopharyngeal reflux. METHODS We selected studies primarily based on current guidelines for gastroesophageal reflux disease and laryngopharyngeal reflux, and through PubMed searches. RESULTS We assess the current diagnostic modalities that can be used to determine if laryngopharyngeal reflux is the cause of a patient's laryngeal symptoms, as well as review some of the common treatments that have been used for these patients. In addition, we note that the lack of a clear diagnostic gold-standard, as well as specific diagnostic criteria, significantly limit clinicians' ability to determine adequate therapies for these patients. Finally, we identify areas of future research that are needed to better manage these patients. CONCLUSIONS Patients with chronic laryngeal symptoms are complex due to the heterogenous nature of symptom pathology, inconsistent definitions and variable response to therapies. Further outcomes data are critically needed to help elucidate ideal diagnostic workup and therapeutic management for these challenging patients.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
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11
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Yadlapati R. Incidence of Esophageal Adenocarcinoma Among Symptomatic Reflux Patients Without Erosive Disease on Endoscopy is Similar to the General Population. Gastroenterology 2024; 166:533-534. [PMID: 37977311 PMCID: PMC10922406 DOI: 10.1053/j.gastro.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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12
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Samo S, Hamo F, Hamza A, Yadlapati R, Kahrilas PJ, Wozniak A. Rapid Development of Achalasia After SARS-CoV-2 Infection: Polymerase Chain Reaction Analysis of Esophageal Muscle Tissue. Am J Gastroenterol 2024:00000434-990000000-00990. [PMID: 38265043 DOI: 10.14309/ajg.0000000000002669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Achalasia has been linked to viruses. We have observed cases of rapid-developing achalasia post-coronavirus disease 2019 (COVID-19). METHODS We aimed to prospectively evaluate esophageal muscle for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) from patients with rapid-onset achalasia post-COVID-19 and compare them with achalasia predating COVID-19 and achalasia with no COVID-19. RESULTS Compared with long-standing achalasia predating COVID-19 and long-standing achalasia with no COVID-19, the subjects with achalasia post-COVID-19 had significantly higher levels of messenger RNA for the SARS-CoV-2 nucleocapsid (N) protein, which correlated with a significant increase in the inflammatory markers NOD-like receptor family pyrin domain-containing 3 and tumor necrosis factor. DISCUSSION SARS-CoV-2, the virus responsible for COVID-19, is a possible trigger for achalasia.
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Affiliation(s)
- Salih Samo
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Falak Hamo
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Ameer Hamza
- Department of Pathology, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ann Wozniak
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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13
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Yadlapati R. Esophageal Food Impaction-Cola Can't Beat the Real Thing. Gastroenterology 2024:S0016-5085(24)00182-3. [PMID: 38373635 DOI: 10.1053/j.gastro.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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14
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Krause AJ, Kaizer AM, Carlson DA, Chan WW, Chen CL, Gyawali CP, Jenkins A, Pandolfino JE, Polamraju V, Wong MW, Greytak M, Yadlapati R. Validated Clinical Score to Predict Gastroesophageal Reflux in Patients With Chronic Laryngeal Symptoms: COuGH RefluX. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00098-3. [PMID: 38309491 DOI: 10.1016/j.cgh.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/04/2024] [Accepted: 01/16/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND & AIMS Discerning whether laryngeal symptoms result from gastroesophageal reflux is clinically challenging and a reliable tool to stratify patients is needed. We aimed to develop and validate a model to predict the likelihood of gastroesophageal reflux disease (GERD) among patients with chronic laryngeal symptoms. METHODS This multicenter international study collected data from adults with chronic laryngeal symptoms who underwent objective testing (upper gastrointestinal endoscopy and/or ambulatory reflux monitoring) between March 2018 and May 2023. The training phase identified a model with optimal receiver operating characteristic curves, and β coefficients informed a weighted model. The validation phase assessed performance characteristics of the weighted model. RESULTS A total of 856 adults, 304 in the training cohort and 552 in the validation cohort, were included. In the training phase, the optimal predictive model (area under the curve, 0.68; 95% CI, 0.62-0.74), was the Cough, Overweight/obesity, Globus, Hiatal Hernia, Regurgitation, and male seX (COuGH RefluX) score, with a lower threshold of 2.5 and an upper threshold of 5.0 to predict proven GERD. In the validation phase, the COuGH RefluX score had an area under the curve of 0.67 (95% CI, 0.62-0.71), with 79% sensitivity and 81% specificity for proven GERD. CONCLUSIONS The externally validated COuGH RefluX score is a clinically practical model to predict the likelihood of proven GERD. The score classifies most patients with chronic laryngeal symptoms as low/high likelihood of proven GERD, with only 38% remaining as indeterminate. Thus, the COuGH RefluX score can guide diagnostic strategies and reduce inappropriate proton pump inhibitor use or testing for patients referred for evaluation of chronic laryngeal symptoms.
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Affiliation(s)
- Amanda J Krause
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Chien-Lin Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University, St. Louis, Missouri
| | - Andrew Jenkins
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Vinathi Polamraju
- Division of Gastroenterology, Department of Medicine, Washington University, St. Louis, Missouri
| | - Ming-Wun Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Madeline Greytak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California.
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15
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Lee Lynch K, Chen J, Jain A, Yadlapati R. Esophagogastric Junction Outflow Obstruction: A Diagnosis in Evolution. Gastroenterol Hepatol (N Y) 2024; 20:108-114. [PMID: 38414912 PMCID: PMC10895913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Esophagogastric junction outflow obstruction (EGJOO) is a rapidly evolving diagnosis that can represent early or variant achalasia. Since the publication of the Chicago Classification version 4.0, the criteria for this diagnosis have been more stringent. Currently, the criteria include an elevated median integrated relaxation pressure (IRP) in both the supine and upright positions, elevated intrabolus pressure in at least 20% of supine swallows, dysphagia and/or chest pain, as well as an abnormal timed barium esophagram and/or impedance planimetry testing. Additionally, other secondary causes may result in an elevated IRP and must be excluded. The management of conclusive EGJOO is targeted therapy to the lower esophageal sphincter (LES), although treatment is not straightforward. Overall, adjuvant testing and data should be scrutinized for appropriateness of LES disruption. The spectrum of treatment options includes simple monitoring as well as more invasive therapies such as endoscopic dilation and myotomy. This article explores the newest criteria and management options for clinically relevant EGJOO.
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Affiliation(s)
- Kristle Lee Lynch
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joan Chen
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Anand Jain
- Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
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16
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Krause AJ, Taft T, Greytak M, Burger ZC, Walsh E, Weissbrod P, Pandolfino JE, Yadlapati R. Validation of the Laryngeal Cognitive-Affective Tool. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00100-9. [PMID: 38309495 DOI: 10.1016/j.cgh.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/19/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND & AIMS Cognitive-affective processes, including hypervigilance and symptom-specific anxiety, may contribute to chronic laryngeal symptoms and are potentially modifiable; however, a validated instrument to assess these constructs is lacking. The aims of this study were to develop and validate the Laryngeal Cognitive-Affective Tool (LCAT) instrument. METHODS This 2-phase single-center prospective study enrolled participants from November 2021 to June 2023. In the initial phase 1:1 patient cognitive interviews and multidisciplinary team consensus were conducted to develop the LCAT. In the second phase asymptomatic and symptomatic participants completed a series of questionnaires to examine psychometric properties of the LCAT. RESULTS A total of 268 participants were included: 8 in the initial phase and 260 in the validation phase (56 asymptomatic; 204 symptomatic). A 15-item LCAT was developed. In the validation phase, mean total LCAT and hypervigilance/anxiety subscores were significantly higher in symptomatic versus asymptomatic participants (P < .01). The LCAT had excellent internal consistency (α = 0.942) and split-half reliability (Guttman = 0.853). Using a median split, a score of 33 or greater was defined as elevated. CONCLUSIONS The 15-item LCAT evaluates laryngeal hypervigilance and symptom-specific anxiety among patients with laryngeal symptoms. It has excellent reliability and construct validity. The LCAT highlights burdensome cognitive-affective processes that can accordingly help tailor treatments.
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Affiliation(s)
- Amanda J Krause
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Tiffany Taft
- Division of Gastroenterology & Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Madeline Greytak
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Zoe C Burger
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Erin Walsh
- Department of Otolaryngology, University of California San Diego, La Jolla, California
| | - Philip Weissbrod
- Department of Otolaryngology, University of California San Diego, La Jolla, California
| | - John E Pandolfino
- Division of Gastroenterology & Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California.
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17
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Vahedi F, Low EE, Kaizer AM, Fehmi SA, Hasan A, Chang MA, Kwong W, Krinsky ML, Anand G, Greytak M, Yadlapati R. Esophageal anatomy and physiology vary across spastic and non-spastic phenotypes of disorders of esophagogastric junction outflow. Neurogastroenterol Motil 2024; 36:e14709. [PMID: 38009826 PMCID: PMC10843578 DOI: 10.1111/nmo.14709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/13/2023] [Revised: 10/06/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pathophysiologic mechanisms of disorders of esophagogastric junction (EGJ) outflow are poorly understood. We aimed to compare anatomic and physiologic characteristics among patients with disorders of EGJ outflow and normal motility. METHODS We retrospectively evaluated adult patients with achalasia types 1, 2, 3, EGJ outflow obstruction (EGJOO) or normal motility on high-resolution manometry who underwent endoscopic ultrasound (EUS) from January 2019 to August 2022. Thickened circular muscle was defined as ≥1.6 mm. Characteristics from barium esophagram (BE) and functional lumen imaging probe (FLIP) were additionally assessed. KEY RESULTS Of 71 patients (mean age 56.2 years; 49% male), there were 8 (11%) normal motility, 58 (82%) had achalasia (5 (7%) type 1, 32 (45%) classic type 2, 21 (30%) type 3 [including 12 type 2 with FEPs]), and 7 (7%) had EGJOO. A significantly greater proportion of type 3 achalasia had thickened distal circular muscle (76.2%) versus normal motility (0%; p < 0.001) or type 2 achalasia (25%; p < 0.001). Type 1 achalasia had significantly wider mean maximum esophageal diameter on BE (57.8 mm) compared to type 2 achalasia (32.8 mm), type 3 achalasia (23.4 mm), EGJOO (15.9 mm), and normal motility (13.5 mm). 100% type 3 achalasia versus 0% type 1 achalasia/normal motility had tertiary contractions on BE. Mean EGJ distensibility index on FLIP was lower for type 3 achalasia (1.2 mmHg/mm2 ) and EGJOO (1.2 mmHg/mm2 ) versus type 2 (2.3 mmHg/mm2 ) and type 1 achalasia (2.9 mmHg/mm2 ). CONCLUSIONS Our findings suggest distinct pathologic pathways may exist: type 3 achalasia and EGJOO may represent a spastic outflow phenotype consisting of a thickened, spastic circular muscle, which is distinct from type 1 and 2 achalasia consisting of a thin caliber circular muscle layer with more prominent esophageal dilation.
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Affiliation(s)
- Farnoosh Vahedi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Eric E Low
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Michael A Chang
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Mary L Krinsky
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
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18
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Krause AJ, Carlson DA, Chan WW, Chen CL, Gyawali CP, Yadlapati R. High Diagnostic Yield of Abnormal Endoscopic Findings in the Evaluation of Laryngopharyngeal Reflux. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00087-9. [PMID: 38278193 DOI: 10.1016/j.cgh.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/07/2023] [Accepted: 01/08/2024] [Indexed: 01/28/2024]
Abstract
Esophagogastroduodenoscopy (EGD) is recommended in patients with typical gastroesophageal reflux disease (GERD) symptoms (heartburn, regurgitation, chest pain) in the setting of proton pump inhibitor (PPI) nonresponse. EGD evaluates for erosive disease, assesses antireflux barrier integrity, excludes non-GERD conditions, and, in the absence of erosive findings, is followed by reflux testing.1,2 The diagnostic utility of EGD is less clear in the evaluation for laryngopharyngeal reflux (LPR), and the current reference standard is ambulatory reflux monitoring.1,3,4 This study of patients referred for evaluation of chronic laryngeal symptoms had the following aims: (1) to characterize endoscopic findings, (2) to discern whether findings differed between patients with or without concomitant esophageal reflux symptoms, and (3) to measure the association between endoscopic findings and objective GERD on ambulatory reflux monitoring.
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Affiliation(s)
- Amanda J Krause
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Chien-Lin Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University, St. Louis, Missouri
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California.
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19
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Gyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E, Sifrim D, Spechler S, Zerbib F, Fox MR, Bhatia S, de Bortoli N, Cho YK, Cisternas D, Chen CL, Cock C, Hani A, Remes Troche JM, Xiao Y, Vaezi MF, Roman S. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut 2024; 73:361-371. [PMID: 37734911 PMCID: PMC10846564 DOI: 10.1136/gutjnl-2023-330616] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
The Lyon Consensus provides conclusive criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD), and adjunctive metrics that consolidate or refute GERD diagnosis when primary criteria are borderline or inconclusive. An international core and working group was assembled to evaluate research since publication of the original Lyon Consensus, and to vote on statements collaboratively developed to update criteria. The Lyon Consensus 2.0 provides a modern definition of actionable GERD, where evidence from oesophageal testing supports revising, escalating or personalising GERD management for the symptomatic patient. Symptoms that have a high versus low likelihood of relationship to reflux episodes are described. Unproven versus proven GERD define diagnostic strategies and testing options. Patients with no prior GERD evidence (unproven GERD) are studied using prolonged wireless pH monitoring or catheter-based pH or pH-monitoring off antisecretory medication, while patients with conclusive GERD evidence (proven GERD) and persisting symptoms are evaluated using pH-impedance monitoring while on optimised antisecretory therapy. The major changes from the original Lyon Consensus criteria include establishment of Los Angeles grade B oesophagitis as conclusive GERD evidence, description of metrics and thresholds to be used with prolonged wireless pH monitoring, and inclusion of parameters useful in diagnosis of refractory GERD when testing is performed on antisecretory therapy in proven GERD. Criteria that have not performed well in the diagnosis of actionable GERD have been retired. Personalisation of investigation and management to each patient's unique presentation will optimise GERD diagnosis and management.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California in San Diego, La Jolla, California, USA
| | - Ronnie Fass
- Medicine/Section of Gastroenterology, Case Western Reserve University, Cleveland, Ohio, USA
| | - David Katzka
- Gastroenterology and Hepatology, Columbia University, New York, New York, USA
| | - John Pandolfino
- Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Department of Medical and Surgical Specialties, University of Padua, Padova, Italy
| | - Daniel Sifrim
- Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Stuart Spechler
- Division of Gastroenterology, Baylor Scott and White North Texas, Dallas, Texas, USA
| | - Frank Zerbib
- Gastroenterology, CHU de Bordeaux, Bordeaux, France
| | - Mark R Fox
- Gastroenterology, University of Zurich, Zurich, Switzerland
| | | | | | - Yu Kyung Cho
- Gastroenterology, Catholic University of Korea - Songsin Campus, Seoul, Korea (the Republic of)
| | - Daniel Cisternas
- Digestive System Research Unit, Universidad del Desarrollo Facultad de Medicina Clínica Alemana, Las Condes, Chile
| | - Chien-Lin Chen
- Department of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Charles Cock
- Department of Gastroenterology and Hepatology, Flinders University, Adelaide, South Australia, Australia
| | - Albis Hani
- Gastroenterology Unit, Department of Medicine, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | - Yinglian Xiao
- Department of Gastroenterology, Sun Yan-sen University of Medical Sciences, Guangzhou, China
| | - Michael F Vaezi
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sabine Roman
- Department of Digestive Physiology, Universite de Lyon, Lyon, France
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20
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Hungin AP, Yadlapati R, Anastasiou F, Bredenoord AJ, El Serag H, Fracasso P, Mendive JM, Savarino EV, Sifrim D, Udrescu M, Kahrilas PJ. Management advice for patients with reflux-like symptoms: an evidence-based consensus. Eur J Gastroenterol Hepatol 2024; 36:13-25. [PMID: 38006602 PMCID: PMC10695341 DOI: 10.1097/meg.0000000000002682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/11/2023] [Indexed: 11/27/2023]
Abstract
Patients with reflux-like symptoms (heartburn and regurgitation) are often not well advised on implementing individualised strategies to help control their symptoms using dietary changes, lifestyle modifications, behavioural changes or fast-acting rescue therapies. One reason for this may be the lack of emphasis in management guidelines owing to 'low-quality' evidence and a paucity of interventional studies. Thus, a panel of 11 gastroenterologists and primary care doctors used the Delphi method to develop consolidated advice for patients based on expert consensus. A steering committee selected topics for literature searches using the PubMed database, and a modified Delphi process including two online meetings and two rounds of voting was conducted to generate consensus statements based on prespecified criteria (67% voting 'strongly agree' or 'agree with minor reservation'). After expert discussion and two rounds of voting, 21 consensus statements were generated, and assigned strength of evidence and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) rating. Eleven statements achieved the strongest (100%) agreement: five are related to diet and include identification and avoidance of dietary triggers, limiting alcohol, coffee and carbonated beverages, and advising patients troubled by postprandial symptoms not to overeat; the remaining six statements concern advice around smoking cessation, weight loss, raising the head-of-the-bed, avoiding recumbency after meals, stress reduction and alginate use. The aim of developing the consensus statements is that they may serve as a foundation for tools and advice that can routinely help patients with reflux-like symptoms better understand the causes of their symptoms and manage their individual risk factors and triggers.
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Affiliation(s)
- A. Pali Hungin
- Professor Emeritus, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Foteini Anastasiou
- 4th Local Primary Care Team, Municipality Practice and Academic Practice of Heraklion; University of Crete, Crete, Greece
| | - Albert J. Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Hashem El Serag
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Pierluigi Fracasso
- Department of Gastroenterology and Digestive Endoscopy, Ospedale Sandro Pertini, Local Health Agency Roma 2, Rome, Italy
| | - Juan M Mendive
- La Mina Primary Care Academic Centre, Catalan Health Institute, University of Barcelona, Spain
| | - Edoardo V. Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | | | - Peter J Kahrilas
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Shah ED, Yadlapati R, Chan WW. Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and Cost-Minimization Analysis. Am J Gastroenterol 2024; 119:97-106. [PMID: 37883488 PMCID: PMC10841887 DOI: 10.14309/ajg.0000000000002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/20/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Guidelines advise esophageal motility testing for dysphagia when structural disorders are ruled out, but cost concerns impede adoption. We evaluated cost-effective positioning of esophageal motility testing in the algorithm to evaluate esophageal dysphagia. METHODS We developed a decision analytic model comparing 3 strategies: (i) esophageal manometry, (ii) screening impedance planimetry followed by esophageal manometry if needed, or (iii) nonalgorithmic usual care. Diagnostic test accuracy was adapted to expected rates of esophageal motility disorders in general gastroenterology populations. We modeled routine testing for all patients with nonstructural/mechanical dysphagia compared with selective testing with strong suspicion for achalasia. Cost outcomes were defined on national commercial and Medicare datasets stratified on age and sex. Health outcomes were modeled on populations with achalasia. The time horizon was 1 year. RESULTS Motility testing was preferred over nonalgorithmic usual care due to cost savings rather than health gains. To commercial insurers, routine esophageal manometry for nonstructural/mechanical dysphagia would be cost-saving below a reimbursed cost of $2,415. Screening impedance planimetry would be cost saving below a reimbursed cost of $1,130. The limit for reimbursed costs would be lower for patients older than 65 years to achieve cost savings mainly due to insurance. Sex did not significantly influence cost-effectiveness. Patients and insurers preferred routine screening impedance planimetry before manometry when the index of suspicion for achalasia was below 6%. DISCUSSION Aligning with practice guidelines, routine esophageal motility testing seems cost saving to patients and insurers compared with nonalgorithmic usual care to evaluate nonstructural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.
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22
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Low EE, Yadlapati R. Utility of Functional Lumen Imaging Probe in the Evaluation of Esophageal Conditions. Am J Gastroenterol 2024; 119:15-20. [PMID: 37450632 PMCID: PMC10841715 DOI: 10.14309/ajg.0000000000002387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Eric E. Low
- Division of Gastroenterology and Hepatology, University of California, San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California, San Diego, San Diego, California, USA
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23
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Low EE, Hasan A, Fehmi SA, Chang MA, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Yadlapati R. Diagnostic methods to measure spastic segment and guide tailored myotomy length in type 3 achalasia. Neurogastroenterol Motil 2023; 35:e14625. [PMID: 37288617 PMCID: PMC10726676 DOI: 10.1111/nmo.14625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/17/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Myotomy length in type 3 achalasia is generally tailored based on segment of spasticity on high-resolution manometry (HRM). Potential of length of tertiary contractions on barium esophagram (BE) or length of thickened circular muscle on endoscopic ultrasound (EUS) to guide tailored myotomy is less understood. This study aimed to assess agreement between spastic segments lengths on HRM, BE, and EUS among patients with type 3 achalasia. METHODS This retrospective study included adults with type 3 achalasia on HRM between November 2019 and August 2022 who underwent evaluation with EUS and/or BE. Spastic segments were defined as HRM-distance between proximal borders of lower esophageal sphincter and high-pressure area (isobaric contour ≥70 mmHg); EUS-length of thickened circular muscle (≥1.2 mm) from proximal border of esophagogastric junction (EGJ) to the transition to a non-thickened circular muscle; BE-distance between EGJ to proximal border of tertiary contractions. Pairwise comparisons assessed for correlation (Pearson's) and intraclass correlation classification (ICC) agreement. KEY RESULTS Twenty-six patients were included: mean age 66.9 years (SD 13.8), 15 (57.7%) male. Spastic segments were positively correlated on HRM and BE with good agreement (ICC 0.751, [95% CI 0.51, 0.88]). Spastic segments were negatively correlated with poor agreement on HRM and EUS (ICC -0.04, [-0.45, 0.39]) as well as BE and EUS (ICC -0.03, [-0.47, 0.42]). CONCLUSIONS & INFERENCES Length of spastic segment was positively correlated on HRM and BE while negatively correlated when compared to EUS, supporting the common use of HRM and highlighting the uncertain role for EUS in tailoring myotomy length for type 3 achalasia.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Michael A. Chang
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Denver, Colorado, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
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24
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Yadlapati R, Cappell K, Sedgley R, Pelletier C, Jacob R, Bonafede M, Shah SC. A Linked Electronic Medical Record-Claims Analysis of the Clinical and Economic Outcomes of Patients Coded for Erosive Esophagitis in the United States. Adv Ther 2023; 40:5489-5501. [PMID: 37837526 PMCID: PMC10611850 DOI: 10.1007/s12325-023-02688-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Erosive esophagitis (EE) is a severe form of gastroesophageal reflux disease commonly treated with proton pump inhibitors (PPIs). The aim of this retrospective, observational cohort study was to describe the characteristics and healthcare burden of patients with EE. METHODS We identified adults in the USA with an EE diagnosis between January 1, 2016 and February 28, 2019 in a linked dataset containing electronic health records (EHR) from the Veradigm Network EHR and claims data from Komodo Health. Patients were required to have 1 year of baseline data and 3 years of follow-up data. Patients were stratified by the number of PPI lines of therapy (LOT) during the 4-year study period. We descriptively captured patient characteristics and treatment patterns, along with all-cause and EE-related healthcare utilization and costs. RESULTS Among the 158,347 qualifying adults with EE, 71,958 (45.4%) had 1 PPI LOT, 14,985 (9.5%) had 2 LOTs, 15,129 (9.6%) had 3+ LOTs, and 56,275 (35.5%) did not fill a PPI prescription. Omeprazole and pantoprazole comprised more than 70% of any LOT, with patients commonly switching between the two. Mean (standard deviation) annualized all-cause and EE-related healthcare costs in the follow-up period were $16,853 ($70,507) and $523 ($3659), respectively. Both all-cause and EE-related healthcare costs increased with LOTs. CONCLUSIONS Patients with EE are commonly treated with prescription PPIs; however, 19.0% of patients cycled through multiple PPIs. Higher PPI use was associated with a higher comorbidity burden and higher healthcare costs compared to 0 PPI use.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, 9500 Gilman Drive, MC 0956, La Jolla, CA, 92093, USA.
| | | | | | - Corey Pelletier
- Medical Affairs, Phathom Pharmaceuticals, Florham Park, NJ, USA
| | - Rinu Jacob
- Medical Affairs, Phathom Pharmaceuticals, Florham Park, NJ, USA
| | | | - Shailja C Shah
- Division of Gastroenterology, University of California San Diego, 9500 Gilman Drive, MC 0956, La Jolla, CA, 92093, USA
- GI Section, VA San Diego Healthcare System, San Diego, CA, USA
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25
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Fass R, Vaezi M, Sharma P, Yadlapati R, Hunt B, Harris T, Smith N, Leifke E, Armstrong D. Randomised clinical trial: Efficacy and safety of on-demand vonoprazan versus placebo for non-erosive reflux disease. Aliment Pharmacol Ther 2023; 58:1016-1027. [PMID: 37750406 DOI: 10.1111/apt.17728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/10/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Non-erosive reflux disease (NERD) symptoms are often episodic, making on-demand treatment an attractive treatment approach. AIMS We compared the efficacy and safety of on-demand vonoprazan versus placebo in patients with NERD. METHODS Patients with NERD, defined as heartburn for ≥6 months and for ≥4/7 consecutive days with normal endoscopy, received once-daily vonoprazan 20 mg during a 4-week run-in period. Patients without heartburn during the last 7 days and with ≥80% study drug and diary compliance were randomised 1:1:1:1 to vonoprazan 10, 20, 40 mg or placebo on-demand for 6 weeks. The primary endpoint was the percentage of evaluable heartburn episodes completely relieved within 3 h of on-demand dosing and sustained for 24 h. RESULTS Of 458 patients in the run-in period, 207 entered the on-demand period. In the vonoprazan 10 mg group, 56.0% (201/359) of evaluable heartburn episodes met the criteria for complete and sustained relief; 60.6% (198/327) in the 20 mg group; and 70.0% (226/323) in the 40 mg group, compared with 27.3% (101/370) in the placebo group (p < 0.0001 versus placebo for each vonoprazan group). By 1 h post-dose, vonoprazan was associated with complete relief of significantly more heartburn episodes compared with placebo. No serious treatment-emergent adverse events were reported. CONCLUSION On-demand vonoprazan may be a potential alternative to continued daily acid suppression therapy for the relief of episodic heartburn in patients with NERD. CLINICALTRIALS gov: NCT04799158.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michael Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri, USA
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Rena Yadlapati
- Division of Gastroenterology, Center for Esophageal Diseases, University of California, San Diego, California, USA
| | - Barbara Hunt
- Phathom Pharmaceuticals, Research and Development, Buffalo Grove, Illinois, USA
| | - Tom Harris
- Phathom Pharmaceuticals, Research and Development, Buffalo Grove, Illinois, USA
| | - Neila Smith
- Phathom Pharmaceuticals, Research and Development, Buffalo Grove, Illinois, USA
| | - Eckhard Leifke
- Phathom Pharmaceuticals, Research and Development, Buffalo Grove, Illinois, USA
| | - David Armstrong
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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26
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Low EE, Fehmi SA, Yadlapati R. Tailored myotomy for the treatment of type 3 achalasia: Is there a role for the functional lumen imaging probe? Neurogastroenterol Motil 2023; 35:e14670. [PMID: 37691561 PMCID: PMC10759927 DOI: 10.1111/nmo.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Eric E Low
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Syed A Fehmi
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
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27
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Low EE, Song Q, Yadlapati R, Dellon ES, Aceves S, Liu L, Gupta S, Choksi YA, Shah SC. Development and Validation of the Veterans Affairs Eosinophilic Esophagitis Cohort. Clin Gastroenterol Hepatol 2023; 21:3030-3040.e4. [PMID: 37031716 PMCID: PMC10558623 DOI: 10.1016/j.cgh.2023.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/17/2023] [Revised: 03/08/2023] [Accepted: 03/23/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND & AIMS Gaps remain in understanding the epidemiology of eosinophilic esophagitis (EoE). Our aim was to identify and validate a national cohort of individuals with EoE using Veterans Health Administration (VHA) data. METHODS We used 2 validation strategies to develop algorithms that identified adults with EoE between 1999 and 2020. The first validation strategy applied International Classification of Diseases (ICD) code algorithms to a base cohort of individuals who underwent esophagogastroduodenoscopy with esophageal biopsy specimens. The second applied ICD code algorithms to a base cohort of all individuals in the VHA. For each ICD algorithm applied, a random sample of candidate EoE cases and non-EoE controls were selected and the charts were reviewed manually by a blinded reviewer. Each algorithm was modified iteratively until the prespecified diagnostic accuracy end point (95% confidence lower bound for a positive predictive value [PPV], >88%) was achieved. We compiled individuals from each strategy's maximum performance algorithm to construct the Veterans Affairs Eosinophilic Esophagitis Cohort. RESULTS The maximum performance algorithm from the first validation strategy included 2 or more ICD code encounters for EoE separated by more than 30 days and achieved a 93.3% PPV (lower bound, 88.1%) for identifying true EoE cases. The maximum performance algorithm from the second validation strategy included 4 or more ICD code encounters for EoE in which 2 codes were separated by at least 30 days, and similarly achieved a 93.3% PPV (lower bound, 88.1%). Combining both strategies yielded 6637 individuals, which comprised the Veterans Affairs Eosinophilic Esophagitis Cohort. CONCLUSIONS We developed and validated 2 highly accurate coding algorithms for EoE and established a nationwide VHA cohort of adults with EoE for future studies.
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Affiliation(s)
- Eric E Low
- Jennifer Moreno Department of Veteran Affairs Medical Center, San Diego Healthcare System, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Qingyuan Song
- Veterans Affairs Tennessee Valley Health Care System, Nashville, Tennessee
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Seema Aceves
- Division of Allergy and Immunology, Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, California
| | - Lin Liu
- Jennifer Moreno Department of Veteran Affairs Medical Center, San Diego Healthcare System, San Diego, California; Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California
| | - Samir Gupta
- Jennifer Moreno Department of Veteran Affairs Medical Center, San Diego Healthcare System, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Yash A Choksi
- Veterans Affairs Tennessee Valley Health Care System, Nashville, Tennessee; Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University, Nashville, Tennessee
| | - Shailja C Shah
- Jennifer Moreno Department of Veteran Affairs Medical Center, San Diego Healthcare System, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California.
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28
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Krause AJ, Greytak M, Burger ZC, Taft T, Yadlapati R. Hypervigilance and Anxiety are Elevated Among Patients With Laryngeal Symptoms With and Without Laryngopharyngeal Reflux. Clin Gastroenterol Hepatol 2023; 21:2965-2967.e2. [PMID: 36309340 PMCID: PMC10130229 DOI: 10.1016/j.cgh.2022.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/07/2022] [Accepted: 10/11/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Amanda Jayne Krause
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California.
| | - Madeline Greytak
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Zoe C Burger
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Tiffany Taft
- Division of Gastroenterology & Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
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29
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Kolb JM, Pessorrusso F, Pisipati S, Han S, Menard-Katcher P, Yadlapati R, Wagh MS. Role of short interval FLIP panometry in predicting long-term outcomes after per-oral endoscopic myotomy. Surg Endosc 2023; 37:7767-7773. [PMID: 37580583 PMCID: PMC10771858 DOI: 10.1007/s00464-023-10319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The Eckardt score (ES) is used to assess symptom response to Per-Oral Endoscopic Myotomy (POEM), but reliable methods to assess physiologic success are needed. Functional lumen imaging probe (FLIP) panometry has a potential role in post-POEM follow-up to predict long-term outcomes. The aim of this study was to assess the correlation between clinical success and FLIP parameters following POEM to determine if short interval FLIP could predict long-term outcomes. METHODS This was a prospective study of adult patients who underwent POEM with short interval follow-up FLIP between 11/2017 and 3/2020. Clinical success was defined as post-procedure ES ≤ 3. Physiologic success was based on an esophago-gastric junction distensibility index (EGJ-DI) > 2.8 mm2/mmHg on FLIP. RESULTS 47 patients (55% female, mean age 55 years) were included in the study. Clinical success after POEM was seen in 45 (96%) patients (mean ES 6.5 ± 2.2 pre and 0.83 ± 1.0 post-POEM, p < 0.001). Physiologic success was noted in 43 (91.5%) patients (mean EGJ-DI 6.1 mm2/mmHg ± 2.5). Among 4 patients not meeting criteria for physiologic success, EGJ-DI was 2.5-2.6. There was no correlation between post-POEM EGJ-DI and ES in the short term or long term. Significant reflux esophagitis was seen in 6 (12.8%) patients with no difference in mean EGJ-DI with vs without esophagitis (5.9 vs 6.1, p = 0.44). CONCLUSION Post-POEM endoscopy with FLIP is useful to both assess EGJ physiology and to examine for reflux esophagitis. Short interval FLIP has limited utility to predict long-term patient outcomes or risk of acid reflux.
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Affiliation(s)
- Jennifer M Kolb
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Fernanda Pessorrusso
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sailaja Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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30
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Pandolfino JE, Spechler SJ, Yadlapati R. Updates in the Management of Erosive Esophagitis. J Fam Pract 2023; 72:S1-S12. [PMID: 37862630 DOI: 10.12788/jfp.0666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Upon completion of this activity, participants will:Have increased knowledge regarding the Mechanistic differences between proton pump inhibitors (PPIs) and potassium-competitive acid blockers (PCABs) Evidence comparing PPIs with PCABs for the treatment of GERD and EE Have greater competence related to Selecting evidence-based treatments for EE.
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31
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Shah ED, Chan WW, Jodorkovsky D, Lee Lynch K, Patel A, Patel D, Yadlapati R. Optimizing the Management Algorithm for Heartburn in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis. Clin Gastroenterol Hepatol 2023:S1542-3565(23)00676-6. [PMID: 37683879 PMCID: PMC10918040 DOI: 10.1016/j.cgh.2023.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND AIMS Heartburn is the most common symptom seen in gastroenterology practice. We aimed to optimize cost-effective evaluation and management of heartburn. METHODS We developed a decision analytic model from insurer and patient perspectives comparing 4 strategies for patients failing empiric proton pump inhibitors (PPIs): (1) PPI optimization without testing, (2) endoscopy with PPI optimization for all patients, (3) endoscopy with PPI discontinuation when erosive findings are absent, and (4) endoscopy/ambulatory reflux monitoring with PPI discontinuation as appropriate for phenotypic management. Health outcomes were respectively defined on systematic reviews of clinical trials. Cost outcomes were defined on Centers for Medicare and Medicaid Services databases and commercial multipliers for direct healthcare costs, and national observational studies evaluating healthcare utilization. The time horizon was 1 year. All testing was performed off PPI. RESULTS PPI optimization without testing cost $3784/y to insurers and $3128 to patients due to lower work productivity and suboptimal symptom relief. Endoscopy with PPI optimization lowered insurer costs by $1020/y and added 11 healthy days/y by identifying erosive reflux disease. Endoscopy with PPI discontinuation added 11 additional healthy days/y by identifying patients without erosive reflux disease that did not need PPI. By optimizing phenotype-guided treatment, endoscopy/ambulatory reflux monitoring with a trial of PPI discontinuation was the most effective of all strategies (gaining 22 healthy days/y) and saved $2183 to insurers and $2396 to patients. CONCLUSIONS Among patients with heartburn, endoscopy with ambulatory reflux monitoring (off PPI) optimizes cost-effective management by matching treatment to phenotype. When erosive findings are absent, trialing PPI discontinuation is more cost-effective than optimizing PPI.
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Affiliation(s)
- Eric D Shah
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan.
| | - Walter W Chan
- Division of Gastroenterology, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniela Jodorkovsky
- Division of Gastroenterology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kristle Lee Lynch
- Division of Gastroenterology, Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Patel
- Division of Gastroenterology, Department of Internal Medicine, Duke University School of Medicine and Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Dhyanesh Patel
- Division of Gastroenterology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rena Yadlapati
- Division of Gastroenterology, Department of Internal Medicine, University of California San Diego, San Diego, California
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32
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Liu K, Krause A, Yadlapati R. Quality of Life and Laryngopharyngeal Reflux. Dig Dis Sci 2023; 68:3527-3533. [PMID: 37410247 PMCID: PMC10726674 DOI: 10.1007/s10620-023-08027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/21/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
Laryngopharyngeal reflux (LPR) is characterized by the reflux of gastric contents into the pharynx or larynx and often presents with symptoms including but not limited to cough, throat clearing, sore throat, globus, and dysphonia. Unlike gastroesophageal reflux disease (GERD), LPR is a relatively understudied syndrome, and knowledge regarding the diagnostic and treatment strategies, as well as the psychosocial impact continues to evolve. No singular test or procedure currently exists as a gold standard for LPR diagnosis. While laryngoscopy or pH monitoring may be positive, this does not exclude the contribution of non-gastroenterological processes. Prior research into psychosocial impact demonstrates a significant increase in symptom burden when comparing patients with laryngeal symptoms to controls and those with isolated GERD symptoms. However, these data are limited by the absence of physiologic data to correlate with the reported symptoms and survey responses. This knowledge gap highlights the need for further research to investigate the relationship between symptom burden and pathologic acid reflux on quality of life (QOL), anxiety, and depression. Ultimately, future studies to directly analyze these variables will help to guide treatment strategies and improve QOL in these patients.
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Affiliation(s)
- Kelli Liu
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Amanda Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, 9500 Gilman Drive MC0956, La Jolla, CA, 92093, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, 9500 Gilman Drive MC0956, La Jolla, CA, 92093, USA.
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Chen JW, Khan A, Chokshi RV, Clarke JO, Fass R, Garza JM, Gupta M, Gyawali CP, Jain AS, Katz P, Konda V, Lazarescu A, Lynch KL, Schnoll-Sussman F, Spechler SJ, Vela MF, Yadlapati R, Schauer JM, Kahrilas PJ, Pandolfino JE, Carlson DA. Interrater Reliability of Functional Lumen Imaging Probe Panometry and High-Resolution Manometry for the Assessment of Esophageal Motility Disorders. Am J Gastroenterol 2023; 118:1334-1343. [PMID: 37042784 PMCID: PMC10523887 DOI: 10.14309/ajg.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/07/2022] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION High-resolution manometry (HRM) and functional lumen imaging probe (FLIP) are primary and/or complementary diagnostic tools for the evaluation of esophageal motility. We aimed to assess the interrater agreement and accuracy of HRM and FLIP interpretations. METHODS Esophageal motility specialists from multiple institutions completed the interpretation of 40 consecutive HRM and 40 FLIP studies. Interrater agreement was assessed using intraclass correlation coefficient (ICC) for continuous variables and Fleiss' κ statistics for nominal variables. Accuracies of rater interpretation were assessed using the consensus of 3 experienced raters as the reference standard. RESULTS Fifteen raters completed the HRM and FLIP studies. An excellent interrater agreement was seen in supine median integral relaxation pressure (ICC 0.96, 95% confidence interval 0.95-0.98), and a good agreement was seen with the assessment of esophagogastric junction (EGJ) outflow, peristalsis, and assignment of a Chicago Classification version 4.0 diagnosis using HRM (κ = 0.71, 0.75, and 0.70, respectively). An excellent interrater agreement for EGJ distensibility index and maximum diameter (0.91 [0.90-0.94], 0.92 [0.89-0.95]) was seen, and a moderate-to-good agreement was seen in the assignment of EGJ opening classification, contractile response pattern, and motility classification (κ = 0.68, 0.56, and 0.59, respectively) on FLIP. Rater accuracy for Chicago Classification version 4.0 diagnosis on HRM was 82% (95% confidence interval 78%-84%) and for motility diagnosis on FLIP Panometry was 78% (95% confidence interval 72%-81%). DISCUSSION Our study demonstrates high levels of interrater agreement and accuracy in the interpretation of HRM and FLIP metrics and moderate-to-high levels for motility classification in FLIP, supporting the use of these approaches for primary or complementary evaluation of esophageal motility disorders.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Abraham Khan
- Center for Esophageal Health, Division of Gastroenterology & Hepatology, NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
| | - Reena V Chokshi
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - John O Clarke
- Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Ronnie Fass
- Division of Gastroenterology & Hepatology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Jose M Garza
- GI Care for Kids, Neurogastroenterology and Motility Program Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Milli Gupta
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anand S Jain
- Division of Digestive Diseases, Emory University Department of Medicine, Atlanta, Georgia, USA
| | - Philip Katz
- Department of Gastroenterology Weill Cornell Medical Center, New York, New York, USA
| | - Vani Konda
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Kristle L Lynch
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Stuart J Spechler
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Jacob M Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Yadlapati R. Approach to Management of Refractory Gastroesophageal Reflux Disease. Gastroenterol Hepatol (N Y) 2023; 19:499-502. [PMID: 37772155 PMCID: PMC10524426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Affiliation(s)
- Rena Yadlapati
- Professor of Clinical Medicine Division of Gastroenterology Director, UCSD Center for Esophageal Diseases University of California San Diego La Jolla, California
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Yadlapati R. Dupilumab: The New Kid on the Block for Management of Eosinophilic Esophagitis. Gastroenterology 2023; 165:302-303. [PMID: 36801387 PMCID: PMC10785045 DOI: 10.1053/j.gastro.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Rena Yadlapati
- University of California San Diego, La Jolla, California
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Le KHN, Low EE, Yadlapati R. Evaluation of Esophageal Dysphagia in Elderly Patients. Curr Gastroenterol Rep 2023; 25:146-159. [PMID: 37312002 PMCID: PMC10726678 DOI: 10.1007/s11894-023-00876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence. RECENT FINDINGS In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.
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Affiliation(s)
| | - Eric E Low
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA
| | - Rena Yadlapati
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA.
- , La Jolla, CA, USA.
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Chandar AK, Low EE, Singer ME, Yadlapati R, Singh S. Estimated Burden of Screening for Barrett's Esophagus in the United States. Gastroenterology 2023; 165:283-285.e2. [PMID: 37001765 PMCID: PMC10683979 DOI: 10.1053/j.gastro.2023.03.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 04/19/2023]
Affiliation(s)
- Apoorva K Chandar
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Eric E Low
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Mendel E Singer
- Department of Population & Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, California.
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Affiliation(s)
- Rena Yadlapati
- Center for Esophageal Disorders, Division of Gastroenterology, University of California San Diego, La Jolla, California.
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Leiman DA, Kamal AN, Otaki F, Bredenoord AJ, Dellon ES, Falk GW, Fernandez-Becker NQ, Gonsalves N, Hirano I, Katzka DA, Peterson K, Yadlapati R, Kathpalia P. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol 2023; 118:1091-1095. [PMID: 36599135 PMCID: PMC10392038 DOI: 10.14309/ajg.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/03/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Despite best practice recommendations for managing eosinophilic esophagitis (EoE), variation in care exists. METHODS We used established methodology for quality indicator development to identify metrics to define quality for the treatment of EoE. RESULTS Among 29 proposed quality indicator statements, 9 (31%) were adopted as highly valid across all categories. Two (22%) of these statements were identified as having existing or suspected quality gaps. DISCUSSION We identified highly valid EoE quality indicators for adult gastroenterologists, which can be used for quality improvement with resulting benefits for patient outcomes.
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Affiliation(s)
- David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Nielsen Q. Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David A. Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
| | | | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
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Low EE, Yadlapati R, Liu L, Bustamante R, Gupta S. Development and Validation of a National US Achalasia Cohort: The Veterans Affairs Achalasia Cohort (VA-AC). Clin Gastroenterol Hepatol 2023; 21:1178-1187.e1. [PMID: 36075504 PMCID: PMC9986341 DOI: 10.1016/j.cgh.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/10/2022] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Achalasia is an esophageal motility disorder associated with significant morbidity, yet achalasia-associated risk factors and outcomes are not well-characterized. Our aim was to establish a national cohort of individuals with achalasia, utilizing Veterans Health Administration (VHA) data. METHODS We iteratively developed combinations of International Classification of Diseases and Current Procedural Terminology code algorithms to validate an approach for identifying achalasia cases. We assessed algorithm accuracy for achalasia diagnosis through manual chart review of candidate achalasia cases and candidate non-achalasia controls. The prespecified end point chosen to establish algorithm performance success was achieving a 1-sided 95% confidence lower bound for a positive predictive value >85% for a random sample of 100 candidate achalasia cases. Once adequate performance was validated, we queried national VHA data to establish and characterize a cohort of individuals diagnosed with achalasia between 1999 and 2020. RESULTS Three rounds of algorithm modification and validation were conducted to achieve the prespecified performance endpoint. In the final round, a combination of 3 or more International Classification of Diseases codes for achalasia in the subject's lifetime and a Current Procedural Terminology code for esophageal manometry achieved an observed 94% positive predictive value (1-sided 95% confidence lower bound of 88.5%) for identifying achalasia. Applying the algorithm to national VHA data identified a cohort of 2100 individuals with achalasia, with a median age 65 years and who were 93% male. CONCLUSIONS Using a rigorous validation approach, we established a national cohort of 2100 individuals with achalasia within the VHA, one of the largest established to date. This cohort can be utilized to study risk factors for achalasia and outcomes over time.
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Affiliation(s)
- Eric E Low
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Lin Liu
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California; Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California
| | - Ranier Bustamante
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California
| | - Samir Gupta
- Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California.
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Yadlapati R. Impact of Helicobacter pylori Eradication on Incidence of Peptic Ulcer Bleeding in Patients Taking Regular Aspirin. Gastroenterology 2023; 164:1017. [PMID: 36502864 PMCID: PMC10786320 DOI: 10.1053/j.gastro.2022.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Rena Yadlapati
- Department of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
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Low EE, Yadlapati R. Chagas' disease achalasia may represent a sub-group of type 2 achalasia without focal elevated pressures. Neurogastroenterol Motil 2023; 35:e14537. [PMID: 36688493 PMCID: PMC10762682 DOI: 10.1111/nmo.14537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023]
Affiliation(s)
- Eric E Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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Yadlapati R, Gyawali CP, Carlson DA, Pandolfino JE, Fass R, Khan A, Lin H, Richter JE, Vela MF, Vaezi M, Clarke JO. Inter- and intra-rater agreement of interpretation of functional lumen imaging probe in healthy subjects. Neurogastroenterol Motil 2023; 35:e14505. [PMID: 36480408 PMCID: PMC10726675 DOI: 10.1111/nmo.14505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/18/2022] [Revised: 11/03/2022] [Accepted: 11/15/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The functional lumen imaging probe (FLIP) evaluates esophagogastric junction (EGJ) opening and esophageal contractility. Both post hoc and real-time analyses are possible, but reproducibility and reliability of analysis remain undefined. This study assesses inter- and intra-rater agreement of normative FLIP measurements among novice and experienced users. METHODS Eight motility experts from different institutions independently evaluated de-identified video recordings from 27 asymptomatic healthy subjects using FLIP. Interpretation methods simulating a post-procedure and a live procedure setting were tested. Novice FLIP users (n = 3) received training prior to post-procedure interpretation. Experienced FLIP users (n = 5) interpreted using both methods. Users recorded maximum EGJ and distal esophageal body diameter, distensive pressure, and EGJ distensibility index (EGJ-DI), at balloon fill volumes of 50-, 60-, and 70 ml, as well as repetitive antegrade contractions (RACs). Inter- and intra-rater agreements of diameters, distensive pressure and EGJ-DI were assessed by intra-class correlation coefficient (ICC) and Pearson's correlation coefficient (PCC). Percentage agreement evaluated inter- and intra-rater reliability for RACs. KEY RESULTS Novice and experienced users acquired normative FLIP metrics. Good-to-excellent inter- and intra-rater reliability were achieved for all variables at 60 ml balloon fill volumes. Median parameters at 60 ml balloon fill volume were as follows: EGJ-DI 5.5 mm2 /mmHg, maximum EGJ diameter 18.6 mm, distensive pressure at maximum EGJ diameter 48.1 mmHg, and distal esophageal body diameter 19.5 mm. CONCLUSIONS AND INFERENCES Normative FLIP parameters can be reliably extracted from FLIP videos using both real-time and post hoc analyses, with high reliability between experienced and novice users.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, California, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Abraham Khan
- Center for Esophageal Health, Division of Gastroenterology & Hepatology, NYU Langone Health, New York, New York, USA
| | | | - Joel E. Richter
- Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Marcelo F. Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John O. Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Vespa E, Farina DA, Kahrilas PJ, Kou W, Low EE, Yadlapati R, Pandolfino JE, Carlson DA. Identifying spastic variant of type II achalasia after treatment with high-resolution manometry and FLIP Panometry. Neurogastroenterol Motil 2023:e14552. [PMID: 36807659 DOI: 10.1111/nmo.14552] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/03/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Panesophageal pressurization (PEP) defines type II achalasia on high-resolution-manometry (HRM) but some patients exhibit spasm after treatment. The Chicago Classification (CC) v4.0 proposed high PEP values as predictor of embedded spasm, yet supportive evidence is lacking. METHODS Fifty seven type II achalasia patients (47 ± 18 years, 54% males) with HRM and LIP Panometry before and after treatment were retrospectively identified. Baseline HRM and FLIP studies were analyzed to identify factors associated with post-treatment spasm, defined on HRM per CC v4.0. RESULTS Seven patients (12%) had spasm following treatment (peroral endoscopic myotomy 47%; pneumatic dilation [PD] 37%; laparoscopic Heller myotomy 16%). At baseline, greater median maximum PEP pressure (MaxPEP) values on HRM (77 vs 55 mmHg, p = 0.045) and spastic-reactive contractile response pattern on FLIP (43% vs 8%, p = 0.033) were more common in patients with post-treatment spasm while absent contractile response on FLIP was more common in patients without spasm (14% vs 66%, p = 0.014). The strongest predictor of post-treatment spasm was the percentage of swallows with MaxPEP ≥70 mmHg (best cut-off: ≥30%), with AUROC of 0.78. A combination of MaxPEP <70 mmHg and FLIP 60 mL pressure < 40 mmHg identified patients with lower rates of post-treatment spasm (3% overall, 0% post-PD) compared to those with values above these thresholds (33% overall, 83% post-PD). CONCLUSIONS High maximum PEP values, high FLIP 60 mL pressures and contractile response pattern on FLIP Panometry prior to treatment identified type II achalasia patients more likely to exhibit post-treatment spasm. Evaluating these features may guide personalized patient management.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy.,Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eric E Low
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Cai JX, Low EE, Yadlapati R. Narrowing the Quality Chasm in Achalasia. Dig Dis Sci 2023; 68:341-343. [PMID: 36242687 PMCID: PMC10766075 DOI: 10.1007/s10620-022-07662-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Jennifer X Cai
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Eric E Low
- Division of Gastroenterology, University of California, San Diego, 9500 Gilman Drive, MC 0956, La Jolla, CA, 92093, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, 9500 Gilman Drive, MC 0956, La Jolla, CA, 92093, USA
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Shah S, Cappell K, Sedgley R, Pelletier C, Jacob R, Bonafede M, Yadlapati R. Diagnosis and treatment patterns among patients with newly diagnosed Helicobacter pylori infection in the United States 2016-2019. Sci Rep 2023; 13:1375. [PMID: 36697470 PMCID: PMC9876904 DOI: 10.1038/s41598-023-28200-3] [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] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/13/2023] [Indexed: 01/27/2023] Open
Abstract
Approximately 36% of the United States (US) population is infected with Helicobacter pylori (HP), a known major risk factor for peptic ulcer disease and gastric cancer. HP eradication reduces the rate of complications; however, the benefits are undermined by rising rates of HP eradication treatment failure. This real-world observational cohort analysis aims to describe HP diagnostic and treatment patterns among insured patients in the US. Using diagnoses, lab results, and treatment patterns, we identified adults (18+) with new diagnoses of HP in the Veradigm Health Insights EHR Database linked to Komodo claims data (1/1/2016-12/31/2019). Patients were required to have ≥ 12 months of data pre-/post-index. We captured patient characteristics, HP-related diagnostic testing, and the use of US guideline-recommended HP eradication regimens. HP eradication rates following first-line eradication treatment were measured among patients with available lab results. Overall, 31.8% of the 60,593 included patients did not receive guideline-recommended treatment. Among the 68.2% (41,340) with first-line treatment, 80.2% received clarithromycin-based triple therapy, and 6.6% received bismuth quadruple therapy. Of the 4569 patients with a repeated course of eradication therapy, 53.4% received the same regimen as their first-line, the majority (90.7%) of whom received two rounds of clarithromycin-based triple therapy. Among the 2455 patients with results of HP non-serology testing following first-line treatment, the 180-day eradication rate was 80.2% overall, with differences based on treatments and demographics. This study highlights gaps between guideline-recommended HP management and real-world patterns, underscoring the need to improve HP testing, treatment, and follow-up practices.
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Affiliation(s)
- Shailja Shah
- University of California, San Diego, CA, USA. .,VA San Diego Healthcare System, San Diego, CA, USA.
| | | | | | | | - Rinu Jacob
- Phathom Pharmaceuticals, Florham Park, NJ, USA
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Shah S, Cappell K, Sedgley R, Pelletier C, Jacob R, Bonafede M, Yadlapati R. Healthcare costs among patients with newly diagnosed helicobacter pylori infection in the United States: a linked claims-EHR study. J Med Econ 2023; 26:1227-1236. [PMID: 37748019 DOI: 10.1080/13696998.2023.2263252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/03/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023]
Abstract
AIMS The study objectives were to 1) characterize the cost drivers of patients with Helicobacter pylori (HP) and 2) estimate HP-related cost savings following lab-confirmed HP eradication with US guideline-recommended treatment compared to failed eradication. METHODS We identified adults newly diagnosed with HP between 1/1/2016-12/31/2019 in the Veradigm Electronic Health Record Database linked to claims data (earliest HP diagnosis = index date). For the overall costs analysis, we required patients to have data available for ≥12 months before and after the index date. Then, we used multivariable modeling to assess the marginal effects of comorbidities on all cause-healthcare costs in the 12 months following HP diagnosis. For the eradication savings analysis, we identified patients with ≥1 HP eradication regimen, a subsequent HP lab test result, and ≥1 year of data after the test result. Then we used multivariable modeling to estimate HP-related cost while adjusting for eradication status, demographics, post-testing HP-related clinical variables, and the interactions between eradication status and each HP-related clinical variable. RESULTS The overall cost analysis included 60,593 patients with HP (mean age 54.2 years, 65.5% female). Mean (SD) 12-month unadjusted all-cause costs were $23,693 ($78,089). Rare comorbidities demonstrated the highest marginal effect. The marginal effects of gastric cancer and PUD were $15,705 and $7,323, respectively. In the eradication savings analysis, 1,835 (80.0%) of the 2295 patients had lab test-confirmed HP eradication. Compared to failed eradication, there were significant one-year cost savings among patients with successful HP eradication and select conditions: $1,770 for PUD, $518 for atrophic gastritis, $494 for functional dyspepsia, and $352 for gastritis. CONCLUSIONS The healthcare costs of patients with HP are partially confounded by their burden of high-cost comorbidities. In the subset of patients with available results, confirmed vs. failed eradication of HP was associated with short-term cost offsets among those with specific to HP-related sequelae.
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Affiliation(s)
- Shailja Shah
- Division of Gastroenterology, University of California, San Diego, CA, USA
- Gastroenterology Section, VA San Diego Healthcare System, San Diego, CA, USA
| | | | | | | | - Rinu Jacob
- Medical Affairs, Phathom Pharmaceuticals, NJ, USA
| | | | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, CA, USA
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Carlson DA, Yadlapati R, Pandolfino JE. The Tailored Approach to Manometric Esophagogastric Junction Outflow Obstruction: Treat the Clinical Diagnosis, Not the Manometry Pattern. Am J Gastroenterol 2023; 118:5-9. [PMID: 36602829 PMCID: PMC9830561 DOI: 10.14309/ajg.0000000000001938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/27/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Low EE, Fehmi SA, Hasan A, Chang M, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Carlson DA, Pandolfino JE, Yadlapati R. Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub-group. Neurogastroenterol Motil 2022; 34:e14449. [PMID: 35972282 PMCID: PMC9722506 DOI: 10.1111/nmo.14449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 05/11/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Type II achalasia (Ach2) is distinguished from other achalasia sub-types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high-resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub-groups of Ach2. METHODS This retrospective single center study performed over 3 years (1/2019-1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub-groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub-groups utilizing unpaired univariate analyses. KEY RESULTS Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub-group without FEPs, the Ach2 sub-group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p = 0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p = 0.0006), lower esophagogastric junction distensibility index (2.2mm2 /mmHg [0.9] vs 0.9 [0.4]; p = 0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p = 0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p = 0.03). CONCLUSIONS AND INFERENCES We identified a distinct sub-group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub-group uniquely exhibits spastic features and may benefit from personalized treatment approaches.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Michael Chang
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics & Informatics, University of Colorado, Denver, Colorado, USA
| | - Dustin A. Carlson
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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Facciorusso A, Ramai D, Ichkhanian Y, Yadlapati R, Annese V, Wani S, Khashab MA. Peroral Endoscopic Myotomy for the Treatment of Esophageal Diverticula: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2022; 56:853-862. [PMID: 34608024 PMCID: PMC8977395 DOI: 10.1097/mcg.0000000000001622] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 04/03/2021] [Accepted: 09/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula. AIMS This meta-analysis aimed to assess the efficacy and safety profile of POEM in patients with Zenker (ZD) and epiphrenic diverticula. METHODS With a literature search through August 2020, we identified 12 studies (300 patients) assessing POEM in patients with esophageal diverticula. The primary outcome was treatment success. Results were expressed as pooled rates and 95% confidence intervals. RESULTS Pooled rate of technical success was 95.9% (93.4%-98.3%) in ZD patients and 95.1% (88.8%-100%) in patients with epiphrenic diverticula. Pooled rate of treatment success was similar for ZD (90.6%, 87.1%-94.1%) and epiphrenic diverticula (94.2%, 87.3%-100%). Rates of treatment success were maintained at 1 year (90%, 86.4%-97.4%) and 2 years (89.6%, 82.2%-96.9%) in ZD patients. Pooled rate of symptom recurrence was 2.6% (0.9%-4.4%) in ZD patients and 0% in patients with epiphrenic diverticula. Pooled rates of adverse events and severe adverse events were 10.6% (4.6%-16.6%) and 3.5% (0%-7.4%) in ZD and 8.4% (0%-16.8%) and 8.4% (0%-16.8%) in epiphrenic diverticula, respectively. CONCLUSION POEM represents an effective and safe therapy for the treatment of esophageal diverticula.
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Affiliation(s)
| | - Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Vito Annese
- Valiant Clinic & American Hospital, Dubai, United Arab Emirates
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore
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