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Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
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Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, 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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3
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Blonski W, Kumar A, Jacobs J, Feldman J, Richter JE. Impact of opioids on treatment response among idiopathic esophagogastric junction outflow obstruction patients: A retrospective cohort study. Indian J Gastroenterol 2023; 42:136-142. [PMID: 36781814 DOI: 10.1007/s12664-022-01311-x] [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: 03/27/2022] [Accepted: 11/07/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Esophageal dysmotility has been attributed to opioid use. The goal was to assess the differences in pre- and post-treatment timed-barium esophagram (TBE) barium heights at 1 and 5 minutes and symptomatic response to treatment in esophagogastric junction outflow obstruction (EGJOO) patients according to opioid use status. METHODS We performed a retrospective cohort study. Consecutive patients with EGJOO were eligible for inclusion. Data were collected on demographics, pre and post-treatment 1 and 5 minutes TBE barium heights and symptom outcomes. Groups were compared according to opioid use. RESULTS Thirty-one EGJOO patients met the inclusion criteria. All patients were treated with pneumatic dilation. Of the 31 patients, 11 (35%) had opioid exposure and 20 (65%) did not. The median follow-up post-treatment was two months (range 1-47 months). There was no statistically significant difference in post-treatment outcomes for opioid exposed vs. unexposed groups. The median per cent decrease in the TBE barium height at 1 minute was 100% for the opioid exposed vs. 71% for the unexposed group (p = 0.92). The median per cent decrease in the TBE barium height at 5 minutes was zero % for the opioid exposed and unexposed groups (p = 0.67). The incidence of symptomatic improvement was 82% (9/11) for the opioid exposed group vs 95% (19/20) for the unexposed group (p = 0.28). CONCLUSIONS Patients with EGJOO seem to respond to treatment similarly regardless of being on opioids.
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Affiliation(s)
- Wojciech Blonski
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Health Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA
- Department of Gastroenterology, James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - John Jacobs
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Health Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA
| | - John Feldman
- Department of Radiology, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Health Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA.
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4
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Dellon ES, Gonsalves N, Abonia JP, Alexander JA, Arva NC, Atkins D, Attwood SE, Auth MKH, Bailey DD, Biederman L, Blanchard C, Bonis PA, Bose P, Bredenoord AJ, Chang JW, Chehade M, Collins MH, Di Lorenzo C, Dias JA, Dohil R, Dupont C, Falk GW, Ferreira CT, Fox AT, Genta RM, Greuter T, Gupta SK, Hirano I, Hiremath GS, Horsley-Silva JL, Ishihara S, Ishimura N, Jensen ET, Gutiérrez-Junquera C, Katzka DA, Khoury P, Kinoshita Y, Kliewer KL, Koletzko S, Leung J, Liacouras CA, Lucendo AJ, Martin LJ, McGowan EC, Menard-Katcher C, Metz DC, Miller TL, Moawad FJ, Muir AB, Mukkada VA, Murch S, Nhu QM, Nomura I, Nurko S, Ohtsuka Y, Oliva S, Orel R, Papadopoulou A, Patel DA, Pesek RD, Peterson KA, Philpott H, Putnam PE, Richter JE, Rosen R, Ruffner MA, Safroneeva E, Schreiner P, Schoepfer A, Schroeder SR, Shah N, Souza RF, Spechler SJ, Spergel JM, Straumann A, Talley NJ, Thapar N, Vandenplas Y, Venkatesh RD, Vieira MC, von Arnim U, Walker MM, Wechsler JB, Wershil BK, Wright BL, Yamada Y, Yang GY, Zevit N, Rothenberg ME, Furuta GT, Aceves SS. International Consensus Recommendations for Eosinophilic Gastrointestinal Disease Nomenclature. Clin Gastroenterol Hepatol 2022; 20:2474-2484.e3. [PMID: 35181570 PMCID: PMC9378753 DOI: 10.1016/j.cgh.2022.02.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [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: 12/21/2021] [Revised: 01/28/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Substantial heterogeneity in terminology used for eosinophilic gastrointestinal diseases (EGIDs), particularly the catchall term "eosinophilic gastroenteritis," limits clinical and research advances. We aimed to achieve an international consensus for standardized EGID nomenclature. METHODS This consensus process utilized Delphi methodology. An initial naming framework was proposed and refined in iterative fashion, then assessed in a first round of Delphi voting. Results were discussed in 2 consensus meetings, and the framework was updated and reassessed in a second Delphi vote, with a 70% threshold set for agreement. RESULTS Of 91 experts participating, 85 (93%) completed the first and 82 (90%) completed the second Delphi surveys. Consensus was reached on all but 2 statements. "EGID" was the preferred umbrella term for disorders of gastrointestinal (GI) tract eosinophilic inflammation in the absence of secondary causes (100% agreement). Involved GI tract segments will be named specifically and use an "Eo" abbreviation convention: eosinophilic gastritis (now abbreviated EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The term "eosinophilic gastroenteritis" is no longer preferred as the overall name (96% agreement). When >2 GI tract areas are involved, the name should reflect all of the involved areas. CONCLUSIONS This international process resulted in consensus for updated EGID nomenclature for both clinical and research use. EGID will be the umbrella term, rather than "eosinophilic gastroenteritis," and specific naming conventions by location of GI tract involvement are recommended. As more data are developed, this framework can be updated to reflect best practices and the underlying science.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Nicoleta C Arva
- Department of Pathology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dan Atkins
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Stephen E Attwood
- Department of Health Services Research, Durham University, Durham, United Kingdom
| | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, United Kingdom
| | - Dominique D Bailey
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York; Division of Digestive and Liver Disease, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Columbia Center for Human Development, Columbia University Irving Medical Center, New York, New York
| | - Luc Biederman
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Carine Blanchard
- Department of Gastro-Intestinal Health, Immunology group, Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Lausanne, Switzerland
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Paroma Bose
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children and Community Health Network, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MichiganI
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Ranjan Dohil
- Division on Pediatric Gastroenterology, Rady's Children's Hospital, University of California, San Diego, San Diego, California
| | - Christophe Dupont
- Ramsay Group, Marcel Sembat Clinic, Paris Descartes University, Paris, France
| | - Gary W Falk
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania
| | - Cristina T Ferreira
- Hospital Santo Antônio, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Adam T Fox
- Paediatric Allergy, Guy's & St. Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Robert M Genta
- Division of Gastroenterology, Department of Pathology and Medicine, Baylor College of Medicine, Houston, Texas; Inform Diagnostics, Irving, Texas
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland; Division of Gastroenterology and Hepatology, University Hospital Lausanne, Lausanne, Switzerland
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children and Community Health Network, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Girish S Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Shunji Ishihara
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Shimane, Japan
| | - Norihisa Ishimura
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Shimane, Japan
| | - Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, University Hospital Puerta de Hierro Majadahonda, Autonomous University of Madrid, Majadahonda, Spain
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic Rochester, Minnesota
| | - Paneez Khoury
- Human Eosinophil Section, National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, Maryland
| | | | - Kara L Kliewer
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany; Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - John Leung
- Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Chris A Liacouras
- Center for Pediatric Eosinophilic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Tomelloso, Spain
| | - Lisa J Martin
- Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Emily C McGowan
- Division of Allergy and Immunology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - David C Metz
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania
| | | | - Fouad J Moawad
- Division of Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California
| | - Amanda B Muir
- Center for Pediatric Eosinophilic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Simon Murch
- Warwick University Medical School, Coventry, United Kingdom
| | - Quan M Nhu
- Division of Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California; Department of Molecular Medicine, Scripps Research Institute, San Diego, California; Division of Allergy and Immunology, University of California, San Diego, La Jolla, California
| | - Ichiro Nomura
- Division of Eosinophilic Gastrointestinal Disorders, Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts
| | - Yoshikazu Ohtsuka
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Salvatore Oliva
- Pediatric Digestive Endoscopy, Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, University Hospital, University of Rome, Rome, Italy
| | - Rok Orel
- University Children's Hospital Ljubljana, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, Children's Hospital Agia Sofia, First Department of Pediatrics, University of Athens, Athens, Greece
| | - Dhyanesh A Patel
- Center for Esophageal Disorders, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert D Pesek
- Division of Allergy and Immunology, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Hamish Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, University of Adelaide, Adelaide, Australia
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joel E Richter
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Rachel Rosen
- Aerodigestive Center, Boston Children's Hospital, Boston, Massachusetts
| | - Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, University Hospital Lausanne, Lausanne, Switzerland
| | - Shauna R Schroeder
- Division of Gastroenterology, Hepatology, and Nutrition, Phoenix Children's Hospital, Phoenix, Arizona
| | - Neil Shah
- Portland Hospital, London, United Kingdom; Reckitt Healthcare, Slough, United Kingdom
| | - Rhonda F Souza
- Division of Gastroenterology and Center for Esophageal Diseases, Baylor Scott & White Center for Esophageal Research, Baylor University Medical Center, Baylor Scott & White Research Institute, Dallas, Texas
| | - Stuart J Spechler
- Division of Gastroenterology and Center for Esophageal Diseases, Baylor Scott & White Center for Esophageal Research, Baylor University Medical Center, Baylor Scott & White Research Institute, Dallas, Texas
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Nicholas J Talley
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia; National Health and Medical Research Council Centre of Research Excellence on Digestive Health, Newcastle, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, School of Medicine, University of Queensland, Brisbane, Australia; Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Yvan Vandenplas
- KidZ Health Castle, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rajitha D Venkatesh
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio
| | - Mario C Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Marjorie M Walker
- Department of Pathology, College of Health, Medicine and Wellbeing, Faculty of Health and Medicine, University of Newcastle Callaghan, Australia
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Barry K Wershil
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona; Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Yoshiyuki Yamada
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noam Zevit
- Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel-Aviv University, Petah-Tikva, Israel
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy, Immunology, and Rheumatology, Departments of Pediatrics and Medicine, Rady Children's Hospital, University of California San Diego, San Diego, California
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5
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Kamal AN, Kathpalia P, Otaki F, Bredenoord AJ, Castell DO, Clarke JO, Falk GW, Fass R, Gyawali CP, Kahrilas PJ, Katz PO, Katzka DA, Pandolfino JE, Penagini R, Richter JE, Roman S, Savarino E, Triadafilopoulos G, Vaezi MF, Vela MF, Leiman DA. Development of quality indicators for the diagnosis and management of achalasia. Neurogastroenterol Motil 2021; 33:e14118. [PMID: 33720448 PMCID: PMC9380030 DOI: 10.1111/nmo.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/04/2020] [Revised: 01/21/2021] [Accepted: 02/14/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The management of achalasia has improved due to diagnostic and therapeutic innovations. However, variability in care delivery remains and no established measures defining quality of care for this population exist. We aimed to use formal methodology to establish quality indicators for achalasia patients. METHODS Quality indicator concepts were identified from the literature, consensus guidelines and clinical experts. Using RAND/University of California, Los Angeles (UCLA) Appropriateness Method, experts in achalasia independently ranked proposed concepts in a two-round modified Delphi process based on 1) importance, 2) scientific acceptability, 3) usability, and 4) feasibility. Highly valid measures required strict agreement (≧ 80% of panelists) in the range of 7-9 for across all four categories. KEY RESULTS There were 17 experts who rated 26 proposed quality indicator topics. In round one, 2 (8%) quality measures were rated valid. In round two, 19 measures were modified based on panel suggestions, and experts rated 10 (53%) of these measures as valid, resulting in a total of 12 quality indicators. Two measures pertained to patient education and five to diagnosis, including discussing treatment options with risk and benefits and using the most recent version of the Chicago Classification to define achalasia phenotypes, respectively. Other indicators pertained to treatment options, such as the use of botulinum toxin for those not considered surgical candidates and management of reflux following achalasia treatment. CONCLUSIONS & INFERENCES Using a robust methodology, achalasia quality indicators were identified, which can form the basis for establishing quality gaps and generating fully specified quality measures.
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Affiliation(s)
- Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, 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
| | - Donald O. Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John O. Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Department of Medicine, The MetroHealth Medical Center and Case Western Reserve, Cleveland, Ohio, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Philip O. Katz
- Division of Gastroenterology, Weill Cornell School of Medicine, New York, NY, USA
| | - David A. Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, Milan, Italy,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Joel E. Richter
- Division of Digestive Diseases & Nutrition, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hospital E Herriot and Lyon I University, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcelo F. Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
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6
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Richter JE. Chicago Classification Version 4.0 and Its Impact on Current Clinical Practice. Gastroenterol Hepatol (N Y) 2021; 17:468-475. [PMID: 35462733 PMCID: PMC9021169] [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: 06/14/2023]
Abstract
High-resolution manometry (HRM) has revolutionized esophageal motility testing, and the evolving Chicago Classification has been critical in codifying HRM metrics and definitions of old and new motility disorders. The latest Chicago Classification (version 4.0) is the result of a working group of 52 members (10 women) from 20 countries. Two critical new elements are the expansion of the normal database from 75 to 469 healthy volunteers and the recommendation of ancillary function tests (timed barium esophagram, functional lumen imaging planimetry, and/or impedance) to help with inconclusive HRM metrics, especially in cases of suspected achalasia, esophagogastric junction outflow obstruction (EGJOO), and ineffective esophageal motility (IEM). Important changes relevant to clinical practice include (1) refinement of the diagnosis criteria for EGJOO, which now require elevated integrated relaxation pressure in an upright position along with primary symptoms of dysphagia/noncardiac chest pain and obstruction at the esophago-gastric junction; (2) exclusion of mechanical obstruction in cases of suspected distal esophageal spasm and hypercontractile esophagus; and (3) a shift to a more restrictive metric (>70% ineffective peristalsis) for a diagnosis of IEM. In addition, the working group urged caution in using treatments such as pneumatic dilation or myotomy, which can irreversibly destroy lower esophageal sphincter competency and peristalsis, as the natural history of EGJOO/hypercontractile esophagus is poorly understood and spontaneous symptom resolution is common. Future versions should address the routine use of impedance with HRM, the role of HRM in pharyngeal/upper esophageal sphincter diseases, and the need for better criteria to determine which subsets of spastic disorders warrant aggressive treatment, as is done with achalasia.
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Affiliation(s)
- Joel E Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
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7
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Jacobs JW, Richter JE. Functional lumen imaging probe and Heller myotomy: solves the dysphagia issue, but the resulting GERD is still a mystery. Gastrointest Endosc 2021; 94:515-516. [PMID: 34412826 DOI: 10.1016/j.gie.2021.03.931] [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: 03/17/2021] [Accepted: 03/27/2021] [Indexed: 02/08/2023]
Affiliation(s)
- John W Jacobs
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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8
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DeSantis AJ, Barry T, Saad AR, DuCoin C, Jacobs JW, Richter JE, Velanovich V. Etiology and Reoperative Management of Postoperative Recalcitrant Dysphagia after Nissen Fundoplication: Skipping the Ounce of Prevention Resulting in a Pound of Cure. J Gastrointest Surg 2021; 25:1559-1561. [PMID: 33169319 DOI: 10.1007/s11605-020-04856-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/01/2020] [Accepted: 10/31/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Anthony J DeSantis
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Tara Barry
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Christopher DuCoin
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - John W Jacobs
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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9
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Blonski W, Kumar A, Feldman J, Richter JE. Timed barium swallow for assessing long-term treatment response in patients with achalasia: Absolute cutoff versus percent change - A cross-sectional analytic study. Neurogastroenterol Motil 2021; 33:e14005. [PMID: 32996266 DOI: 10.1111/nmo.14005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 07/30/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Timed barium swallow (TBS) assesses esophageal emptying before and after therapy in patients with achalasia. Our aim was to compare the accuracy of percent change in barium height with traditional absolute cutoff of <5 cm on post-treatment TBS. MATERIALS AND METHODS Consecutive patients with treatment naïve achalasia treated with either PD, HM, or POEM between 1/2012 and 7/2017 were eligible for inclusion. The accuracy of percent change in pre- and post-treatment barium height at 5 minutes versus an absolute <5 cm cutoff for assessing treatment response was assessed using the receiver operating curve analysis (ROC). RESULTS Eighty-one patients met the inclusion criteria. The median percent change in barium heights at five minutes in patients who did not improve was 6 percent increase (n = 10; mean 10.6) versus 78 percent decrease (n = 71; mean 64) in patients who improved (P = 0.0001). The AUC for percent change in TBS 5 minutes height was 76% (95% CI 48% to 90%), and a 3% decrease from baseline as a cutoff had a sensitivity of 60% and specificity of 99%. The AUC for post-treatment TBS 5 minutes height was 79% (95% CI 53% to 91%), and the 5 cm cutoff had a sensitivity of 70% and specificity of 75%. CONCLUSIONS The results show that 3% percent improvement in pre- and post-treatment barium height at 5 minutes rather than absolute cutoff value of <5 cm on post-treatment TBS is a better indicator of treatment success in achalasia patients. These findings indicate the need for reassessment of tools to identify treatment response.
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Affiliation(s)
- Wojciech Blonski
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - John Feldman
- Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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10
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Slone S, Kumar A, Jacobs J, Velanovich V, Richter JE. Accuracy of Achalasia Quality of Life and Eckardt scores for assessment of clinical improvement post treatment for achalasia. Dis Esophagus 2021; 34:5900199. [PMID: 32875315 DOI: 10.1093/dote/doaa080] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 02/06/2020] [Revised: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023]
Abstract
Achalasia Quality of Life (ASQ) and Eckardt scores are two patient-reported instruments widely used to assess symptom severity in achalasia patients. ASQ is validated and reliable. Although Eckardt is commonly used, it has not been rigorously assessed for validity or reliability. This study aims to evaluate (i) the accuracy of Eckardt and ASQ for assessing improvement post-treatment (predictive validity), (ii) accuracy of Eckardt and ASQ for assessing improvement post-treatment with pneumatic dilatation (PD) versus surgical myotomy (predictive validity), and (iii) convergent validity of Eckardt and ASQ tools. Patients with achalasia treated between 2011 and 2018 were eligible. Both instruments were administered by telephone. Treatment failure was determined by the review of medical records by two clinicians. The predictive ability of ASQ and Eckardt instruments in identifying treatment successes and failures was determined using receiver operating characteristics analysis and summarized as area under the curve (AUC). A total of 106 patients met inclusion criteria with 39 PD, 51 Heller myotomy, and 16 per-oral endoscopic myotomy. A review of medical records and esophageal testing revealed 13 failures (12%). AUC for Eckardt was 0.96 (95% confidence interval [CI] 0.87-0.99] and ASQ 0.97 (95% CI 0.92-0.99). The Eckardt cutoff 4, and ASQ, cutoff 15, were 94% and 87% accurate in identifying treatment successes versus failures, respectively. The correlation coefficient between the two tools was 0.85. In conclusions, (i) ASQ and Eckardt scores are valid and reliable tools to assess symptom severity in achalasia patients, (ii) both instruments accurately classify treatment successes versus failures, and (iii) the choice of tool should be informed by the physicians and patients' values and preferences and repeat physiologic testing may be reserved for treatment failures with either instrument and patients classified, as treatment successes may be spared routine physiologic testing in the long term.
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Affiliation(s)
| | | | - John Jacobs
- Division of Digestive Diseases and Nutrition.,Joy McCann Culverhouse Center for Swallowing Disorders
| | - Vic Velanovich
- Joy McCann Culverhouse Center for Swallowing Disorders.,Division of General Surgery, Morsani College of Medicine University of South Florida, Tampa, Florida, USA
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition.,Joy McCann Culverhouse Center for Swallowing Disorders
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11
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Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Gyawali CP, Roman S, Babaei A, Mittal RK, Rommel N, Savarino E, Sifrim D, Smout A, Vaezi MF, Zerbib F, Akiyama J, Bhatia S, Bor S, Carlson DA, Chen JW, Cisternas D, Cock C, Coss-Adame E, de Bortoli N, Defilippi C, Fass R, Ghoshal UC, Gonlachanvit S, Hani A, Hebbard GS, Jung KW, Katz P, Katzka DA, Khan A, Kohn GP, Lazarescu A, Lengliner J, Mittal SK, Omari T, In Park M, Penagini R, Pohl D, Richter JE, Serra J, Sweis R, Tack J, Tatum RP, Tutuian R, Vela MF, Wong RK, Wu JC, Xiao Y, Pandolfino JE. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 ©. Neurogastroenterol Motil 2021; 33:e14058. [PMID: 33373111 PMCID: PMC8034247 DOI: 10.1111/nmo.14058] [Citation(s) in RCA: 359] [Impact Index Per Article: 119.7] [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: 11/11/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
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Affiliation(s)
- Rena Yadlapati
- Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark R. Fox
- University of Zürich, CH-8091 Zürich & Department of Gastroenterology, Klinik Arlesheim, CH-4144 Arlesheim
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - C. Prakash Gyawali
- Division of Gastroenterology & Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sabine Roman
- Univ Lyon, Université Lyon I, Hospices Civils de Lyon, Digestive Physiology, F-69003, Lyon, France,Univ Lyon, Université Lyon I, Hospices Civils de Lyon, INSERM, LabTAU, F-69003, Lyon, France
| | | | - Ravinder K. Mittal
- Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA,Veteran Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Nathalie Rommel
- University of Leuven, Neurosciences, Experimental ORL, Deglutology - University Hospitals Leuven Dept Gastroenterology, Neurogastroenterology & Motility
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate institute of Neurogastroenterology, Queen Mary University of London
| | - André Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology department; Université de Bordeaux; INSERM CIC 1401; Bordeaux, France
| | | | | | - Serhat Bor
- Ege University School of Medicine, Div. Gastroenterology, Turkey
| | - Dustin A. Carlson
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo. Santiago, Chile
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa
| | | | - Ronnie Fass
- MetroHealth System and case Western Reserve University
| | - Uday C. Ghoshal
- Dept. of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sutep Gonlachanvit
- Excellence Center on Neurogastroenterology and Motility, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Thailand
| | - Albis Hani
- Pontificia Universidad Javeriana-Hospital San Ignacio, Colombia
| | | | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Abraham Khan
- New York University, Langone Health, New York, NY, USA
| | | | | | | | | | - Taher Omari
- College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Roberto Penagini
- Gastroenterology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Joel E. Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jordi Serra
- University Hospital Germans Trias i Pujol. Badalona. CIBERehd
| | - Rami Sweis
- University College London Hospital, United Kingdom
| | - Jan Tack
- TARGID, University of Leuven, Belgium
| | - Roger P. Tatum
- University of Washington Department of Surgery/VA Puget Sound HCS
| | - Radu Tutuian
- Bürgerspital Solothurn, University of Bern, University of Zurich, Switzerland
| | | | - Reuben K. Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore
| | - Justin C. Wu
- The Chinese University of Hong Kong, Hong Kong SAR
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-sen University, China
| | - John E. Pandolfino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Richter JE. Laparoscopic Magnetic Sphincter Augmentation: Potential Applications and Safety Are Becoming More Clear-But the Story Is Not Over. Clin Gastroenterol Hepatol 2020; 18:1685-1687. [PMID: 31678603 DOI: 10.1016/j.cgh.2019.10.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 10/10/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, Morsani College of Medicine, University of South Florida, Tampa, Florida
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13
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Smith KE, Saad AR, Hanna JP, Tran T, Jacobs J, Richter JE, Velanovich V. Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy. J Gastrointest Surg 2020; 24:991-999. [PMID: 31147973 DOI: 10.1007/s11605-019-04264-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 02/25/2019] [Accepted: 05/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. METHODS All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. DATA COLLECTED demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. RESULTS A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. CONCLUSION There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.
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Affiliation(s)
- Kaylee E Smith
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA
| | - John P Hanna
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Thanh Tran
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - John Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.
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14
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Richter JE. Tailoring Therapy for Achalasia. Gastroenterol Hepatol (N Y) 2020; 16:249-257. [PMID: 34035727 PMCID: PMC8132639] [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: 06/12/2023]
Abstract
Achalasia is a rare esophageal motility disorder with impaired lower esophageal sphincter (LES) opening and aperistalsis. The disease cannot be cured and aperistalsis cannot be corrected, but good long-term symptom relief results from some degree of destruction to the obstruction of the LES. The presence of multiple treatment options with excellent scientific efficacy now offers the opportunity to tailor therapy for patients with achalasia. Drug therapy, especially botulinum toxin A, should be reserved for elderly patients with short life expectancy. Pneumatic dilation and surgical myotomy are equally effective for patients with types I and II achalasia. Pneumatic dilation offers a less morbid, cheaper outpatient procedure, especially for older patients and women, but redilation may be needed. Surgical myotomy is effective across all groups, especially young men. Laparoscopic Heller myotomy with fundoplication is preferred in patients with megaesophagus, diverticulum, or hiatal hernia. Peroral endoscopic myotomy is the treatment of choice for patients with type III achalasia, but requires advanced endoscopic skills, and the risk of gastroesophageal reflux disease is high. This article reviews the various treatments currently available for achalasia and discusses how to tailor therapy for patients.
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Affiliation(s)
- Joel E Richter
- Dr Richter is a professor of medicine, Hugh F. Culverhouse Chair for Esophageal Disorders, director of the Division of Digestive Diseases and Nutrition, and director of the Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders at the University of South Florida Morsani College of Medicine in Tampa, Florida
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15
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Richter JE. Editorial: fluticasone propionate orally disintegrating tablets-interesting concept but is it going anywhere? Aliment Pharmacol Ther 2020; 51:989-990. [PMID: 32338782 DOI: 10.1111/apt.15694] [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] [Indexed: 12/09/2022]
Affiliation(s)
- Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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16
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Weche M, Saad AR, Richter JE, Jacobs JJ, Velanovich V. Revisional Procedures for Recurrent Symptoms After Heller Myotomy and Per-Oral Endoscopic Myotomy. J Laparoendosc Adv Surg Tech A 2020; 30:110-116. [DOI: 10.1089/lap.2019.0277] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- McWayne Weche
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Adham R. Saad
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joel E. Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
- Division of Gastroenterology, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - John J. Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
- Division of Gastroenterology, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
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17
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Thélin CS, Richter JE. Review article: the management of heartburn during pregnancy and lactation. Aliment Pharmacol Ther 2020; 51:421-434. [PMID: 31950535 DOI: 10.1111/apt.15611] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/15/2019] [Accepted: 11/24/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Gestational reflux is common, affecting up to 80% of pregnant women. Most symptoms will abate during lactation. During both of these periods, interventions used to relieve symptoms focus on a "step-up" methodology with progressive intensification of treatment. This begins with lifestyle modifications. AIM To provide guidance in the treatment of reflux in pregnancy and lactation, as well as briefly summarising the pathogenesis, clinical presentation and diagnostic workup. METHODS A comprehensive search, using online databases PubMed and MEDLINE, along with relevant manuscripts published in English between 1966 and 2019 was used. All abstracts were screened, potentially relevant articles were researched, and bibliographies were reviewed. RESULTS Only a small percentage of relevant drugs are contraindicated for use in pregnancy or while breastfeeding. However, not all drug agents have been extensively evaluated in pregnant women or during the breastfeeding period. Antacids, alginates, and sucralfate are the first-line therapeutic agents. If symptoms persist, any of the H2 RAs can be used except for nizatidine (due to foetal teratogenicity or harm in animal studies). PPIs are reserved for women with intractable symptoms or complicated GERD; all are FDA category B drugs, except for omeprazole, which is a category C drug. CONCLUSIONS The management of heartburn during pregnancy and lactation begins with lifestyle modifications. In situations where disease severity increases, medical providers must discuss risks and benefits of these medicines with the patient in detail.
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Affiliation(s)
- Camille S Thélin
- Division of Digestive Diseases & Nutrition, Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- Joy Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases & Nutrition, Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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McDonald JD, Jacobs J, Saad A, Richter JE, Velanovich V. Heller Myotomy for Epiphrenic Diverticula Compared to Nondiverticula Esophageal Motility Disorders, A Single Institution Experience and Appraisal of Patient Characteristics, High-Resolution Manometry and Outcomes. Dig Surg 2019; 37:72-80. [PMID: 30721906 DOI: 10.1159/000496804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to compare demographics, symptoms, prior interventions, operation, and outcomes of patients who underwent Heller myotomy for esophageal motility disorders and epiphrenic diverticulectomy with Heller myotomy. METHODS We identified all patients who underwent Heller myotomy for esophageal motility disorders with and without esophageal diverticulectomy over an 80-month period. Primary data points included patient demographics, presenting symptoms, prior intervention, high-resolution manometry, surgery performed with rate of laparoscopic, conversion to open, and open procedures; postoperative complications, and symptom resolution. RESULTS Over the study period, 308 Heller esophagomyotomy operations were performed on 301 patients. Of these, 277 cases were without epiphrenic diverticula and 31 included diverticula. One patient with an asymptomatic epiphrenic diverticulum did not undergo surgery was included, for a total of 32 diverticula patients. Six patients in the non-diverticula group and 1 in the diverticula group required a second operation for recurrent symptoms or residual diverticulum. The diverticula group was significantly older, had different manometry findings, required more open operations, and had longer length of stay. The diverticula group had a lower frequency of patients with prior interventions, but similar postoperative leaks, higher overall postoperative complications, and no difference in reported symptomatic improvement. CONCLUSIONS Esophageal diverticula patients have a unique profile compare to patients with non-diverticula motility disorders. Operations are more complex, with increased complication rate and a longer length of stay. In spite of this, there is no statistically significant difference in symptomatic outcomes between the groups.
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Affiliation(s)
- James D McDonald
- Division of General Surgery, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - John Jacobs
- Division of Gastroenterology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.,Joy McCann Culverhouse Swallowing Center, University of South Florida, Tampa, Florida, USA
| | - Adham Saad
- Division of Gastroenterology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.,Joy McCann Culverhouse Swallowing Center, University of South Florida, Tampa, Florida, USA
| | - Joel E Richter
- Division of Gastroenterology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.,Joy McCann Culverhouse Swallowing Center, University of South Florida, Tampa, Florida, USA
| | - Vic Velanovich
- Division of General Surgery, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA, .,Joy McCann Culverhouse Swallowing Center, University of South Florida, Tampa, Florida, USA,
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19
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Dellon ES, Liacouras CA, Molina-Infante J, Furuta GT, Spergel JM, Zevit N, Spechler SJ, Attwood SE, Straumann A, Aceves SS, Alexander JA, Atkins D, Arva NC, Blanchard C, Bonis PA, Book WM, Capocelli KE, Chehade M, Cheng E, Collins MH, Davis CM, Dias JA, Di Lorenzo C, Dohil R, Dupont C, Falk GW, Ferreira CT, Fox A, Gonsalves NP, Gupta SK, Katzka DA, Kinoshita Y, Menard-Katcher C, Kodroff E, Metz DC, Miehlke S, Muir AB, Mukkada VA, Murch S, Nurko S, Ohtsuka Y, Orel R, Papadopoulou A, Peterson KA, Philpott H, Putnam PE, Richter JE, Rosen R, Rothenberg ME, Schoepfer A, Scott MM, Shah N, Sheikh J, Souza RF, Strobel MJ, Talley NJ, Vaezi MF, Vandenplas Y, Vieira MC, Walker MM, Wechsler JB, Wershil BK, Wen T, Yang GY, Hirano I, Bredenoord AJ. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology 2018; 155:1022-1033.e10. [PMID: 30009819 PMCID: PMC6174113 DOI: 10.1053/j.gastro.2018.07.009] [Citation(s) in RCA: 642] [Impact Index Per Article: 107.0] [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: 03/06/2018] [Revised: 06/21/2018] [Accepted: 07/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis. METHODS A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences. RESULTS Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement. CONCLUSIONS EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm2) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.
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Affiliation(s)
- 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.
| | - Chris A Liacouras
- Center for Pediatric Eosinophilic Diseases, Division of Gastroenterology and Hepatology & Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Javier Molina-Infante
- Department of Gastroenterology, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain and Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Center for Pediatric Eosinophilic Diseases, Division of Allergy-Immunology, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Stuart J Spechler
- Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Stephen E Attwood
- Department of Health Services Research, Durham University, Durham, UK
| | | | - Seema S Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California-San Diego and Rady Children's Hospital, San Diego, La Jolla, California
| | | | - Dan Atkins
- Allergy & Immunology Section, Children's Hospital Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Carine Blanchard
- Institute of Nutritional Science, Nestlé Research Center, Vevey, Switzerland
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Wendy M Book
- American Partnership for Eosinophilic Disorders, Atlanta, Georgia
| | - Kelley E Capocelli
- Department of Pediatric Pathology, Children's Hospital Colorado, Aurora, Colorado
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edaire Cheng
- Departments of Pediatrics and Internal Medicine, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carla M Davis
- Allergy and Immunology Section of the Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jorge A Dias
- Pediatric Gastroenterology, Centro Hospitalar S. João, Porto, Portugal
| | - Carlo Di Lorenzo
- Division of Gastroenterology and Hepatology & Nutrition, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Ranjan Dohil
- Division of Gastroenterology and Hepatology, University of California-San Diego, Rady Children's Hospital, San Diego, California
| | | | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Cristina T Ferreira
- Federal University of Health Sciences of Porto Alegre, Hospital Santo Antônio, Porto Alegre, RS, Brazil
| | - Adam Fox
- Department of Paediatric Allergy, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Nirmala P Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Illinois, University of Illinois, Peoria, Illinois
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Yoshikazu Kinoshita
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, Illinois
| | - David C Metz
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Center, Eppendorf, Hamburg, Germany
| | - Amanda B Muir
- Center for Pediatric Eosinophilic Diseases, Division of Gastroenterology and Hepatology & Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Simon Murch
- Department of Paediatrics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts
| | - Yoshikazu Ohtsuka
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Rok Orel
- University of Ljubljana, Faculty of Medicine, University Children's Hospital, Ljubljana, Slovenia
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, University of Athens, Children's Hospital Agia Sofia, Athens, Greece
| | | | - Hamish Philpott
- Northern Adelaide Local Health Network, Department of Gastroenterology, University of Adelaide, South Australia
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joel E Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Rachel Rosen
- Aerodigestive Center, Boston Children's Hospital, Boston, Massachusetts
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alain Schoepfer
- Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | | | - Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Javed Sheikh
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Rhonda F Souza
- Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Mary J Strobel
- American Partnership for Eosinophilic Disorders, Atlanta, Georgia
| | | | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mario C Vieira
- Department of Pediatrics, Pontifical University of Paraná and Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Marjorie M Walker
- Anatomical Pathology University of Newcastle Faculty of Health and Medicine School of Medicine and Public Health Callaghan, New South Wales, Australia
| | - Joshua B Wechsler
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Barry K Wershil
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Albert J Bredenoord
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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Chae S, Richter JE. Wireless 24, 48, and 96 Hour or Impedance or Oropharyngeal Prolonged pH Monitoring: Which Test, When, and Why for GERD? Curr Gastroenterol Rep 2018; 20:52. [PMID: 30259210 DOI: 10.1007/s11894-018-0659-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW pH monitoring technologies are routinely utilized in practice to further evaluate symptoms of gastro-esophageal reflux disease and laryngopharyngeal reflux (LPR). This is a review of the recent literature of the available pH monitoring technology and creates an algorithm in the diagnostic work up of a patient with GERD or LPR. RECENT FINDINGS The catheter-free wireless pH monitor traditionally collects data for 48 h. Recent studies have found that extending to 96 h can be helpful in patients with conflicting results on the first 2 days of the study. In addition, 96 h can allow for testing both on and off of PPI therapy. The oropharyngeal monitoring device is a newer technology that is designed to aid in the diagnoses of LPR. There are limitations with this technology as there is no universal abnormal cutoff and some studies have suggested a poor correlation between multichannel intraluminal impedance-pH (MII-pH) and the oropharyngeal monitoring device. MII-pH has recently developed two additional parameters, the measurement of three 10-min nighttime periods and the post-reflux swallow-induced peristaltic wave (PSPW) index, both of which may increase accuracy of testing. Each of these technologies can provide unique data regarding acid reflux exposure in the esophagus and oropharynx. The wireless pH monitor performed off of PPI therapy can help to establish or exclude the diagnosis of GERD. For those patients with refractory symptoms on PPI, MII-pH study can be performed while on therapy and provides data regarding the response to treatment. Oropharyngeal pH monitoring is being utilized in some practices to aid in diagnosis of LPR, but the scientific validity is controversial.
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Affiliation(s)
- Soojong Chae
- The Joy McCann Culverhouse Center for Esophageal Diseases, Division of Digestive Diseases and Nutrition, University of South Florida, Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC 72, Tampa, FL, 3361, USA
| | - Joel E Richter
- The Joy McCann Culverhouse Center for Esophageal Diseases, Division of Digestive Diseases and Nutrition, University of South Florida, Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC 72, Tampa, FL, 3361, USA.
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21
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Richter JE. Per-oral endoscopic myotomy short-term outcomes are good-but the long-term results are what count. Gastrointest Endosc 2018; 87:1421-1422. [PMID: 29759157 DOI: 10.1016/j.gie.2018.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/07/2018] [Accepted: 02/25/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Joel E Richter
- Joy McCann Culverhouse, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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22
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Richter JE, Kumar A, Lipka S, Miladinovic B, Velanovich V. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis. Gastroenterology 2018; 154:1298-1308.e7. [PMID: 29305934 DOI: 10.1053/j.gastro.2017.12.021] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [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: 10/19/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The effects of transoral incisionless fundoplication (TIF) and laparoscopic Nissen fundoplication (LNF) have been compared with those of proton pump inhibitors (PPIs) or a sham procedure in patients with gastroesophageal reflux disease (GERD), but there has been no direct comparison of TIF vs LNF. We performed a systematic review and network meta-analysis of randomized controlled trials to compare the relative efficacies of TIF vs LNF in patients with GERD. METHODS We searched publication databases and conference abstracts through May 10, 2017 for randomized controlled trials that compared the efficacy of TIF or LNF with that of a sham procedure or PPIs in patients with GERD. We performed a network meta-analysis using Bayesian methods under random-effects multiple treatment comparisons. We assessed ranking probability by surface under the cumulative ranking curve. RESULTS Our search identified 7 trials comprising 1128 patients. Surface under the cumulative ranking curve ranking indicated TIF had highest probability of increasing patients' health-related quality of life (0.96), followed by LNF (0.66), a sham procedure (0.35), and PPIs (0.042). LNF had the highest probability of increasing percent time at pH <4 (0.99), followed by PPIs (0.64), TIF (0.32), and the sham procedure (0.05). LNF also had the highest probability of increasing LES pressure (0.78), followed by TIF (0.72) and PPIs (0.01). Patients who underwent the sham procedure had the highest probability for persistent esophagitis (0.74), followed by those receiving TIF (0.69), LNF (0.38), and PPIs (0.19). Meta-regression showed a shorter follow-up time as a significant confounder for the outcome of health-related quality of life in studies of TIF. CONCLUSIONS In a systematic review and network meta-analysis of trials of patients with GERD, we found LNF to have the greatest ability to improve physiologic parameters of GERD, including increased LES pressure and decreased percent time pH <4. Although TIF produced the largest increase in health-related quality of life, this could be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs. TIF is a minimally invasive endoscopic procedure, yet based on evaluation of benefits vs risks, we do not recommend it as a long-term alternative to PPI or LNF treatment of GERD.
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Affiliation(s)
- Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Morsani College of Medicine, Tampa, Florida.
| | - Ambuj Kumar
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Branko Miladinovic
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Abstract
Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the United States, and leads to substantial morbidity, though associated mortality is rare. The prevalence of GERD symptoms appeared to increase until 1999. Risk factors for complications of GERD include advanced age, male sex, white race, abdominal obesity, and tobacco use. Most patients with GERD present with heartburn and effortless regurgitation. Coexistent dysphagia is considered an alarm symptom, prompting evaluation. There is substantial overlap between symptoms of GERD and those of eosinophilic esophagitis, functional dyspepsia, and gastroparesis, posing a challenge for patient management.
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Affiliation(s)
- Joel E. Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases & Nutrition, University of South Florida College of Medicine, Tampa FL
| | - Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI,Barrett’s Esophagus Program, Division of Gastroenterology & Hepatology, University of Michigan Medical School, Ann Arbor, MI
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Kahrilas PJ, Katzka D, Richter JE. Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute. Gastroenterology 2017; 153:1205-1211. [PMID: 28989059 PMCID: PMC5670013 DOI: 10.1053/j.gastro.2017.10.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The purpose of this review is to describe a place for per-oral endoscopic myotomy (POEM) among the currently available robust treatments for achalasia. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: 1) in determining the need for achalasia therapy, patient-specific parameters (Chicago Classification subtype, comorbidities, early vs late disease, primary or secondary causes) should be considered along with published efficacy data; 2) given the complexity of this procedure, POEM should be performed by experienced physicians in high-volume centers because an estimated 20-40 procedures are needed to achieve competence; 3) if the expertise is available, POEM should be considered as primary therapy for type III achalasia; 4) if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes; and 5) post-POEM patients should be considered high risk to develop reflux esophagitis and advised of the management considerations (potential indefinite proton pump inhibitor therapy and/or surveillance endoscopy) of this before undergoing the procedure.
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Richter JE. Esophageal dilation for eosinophilic esophagitis: it's safe! Why aren't we doing more dilations? Gastrointest Endosc 2017; 86:592-594. [PMID: 28917340 DOI: 10.1016/j.gie.2017.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Joel E Richter
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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Benedict JJ, Golas AA, Richter JE, Velanovich V. Health-Related Quality of Life and Physiological Outcomes of Peroral Endoscopic Myotomy for Achalasia. J Laparoendosc Adv Surg Tech A 2017; 27:778-783. [PMID: 28657822 DOI: 10.1089/lap.2017.0087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has gained acceptance as a treatment for achalasia. The aim of this study was to assess symptomatic, quality of life (QoL), and physiological outcomes of POEM using standardized methods. MATERIALS AND METHODS Patients who were planned to undergo POEM were evaluated pre- and postoperatively with timed barium esophagogram (TBE), high-resolution manometry (HRM), the achalasia symptom questionnaire (ASQ) (best score 10, worst score 31), and the short form (SF)-36 (best score 100, worst score 0). Nine patients completed postoperative HRM, TBE, and 48 hours esophageal pH monitoring. A P-value of <.05 was considered statistically significant. RESULTS A total of 34 of 37 patients completed the POEM procedure. There was improvement in the ASQ scores and in QoL. HRM integrated relaxation pressures (IRPs) improved from 31.4 ± 10.8 mmHg preoperatively to 12.3 ± 6.7 mmHg postoperatively, and lower esophageal sphincter pressure (LESP) improved from 49.1 ± 16.9 mmHg preoperatively to 23.1 ± 9.4 mmHg postoperatively. Of the 7 patients who were evaluated with 48-hour pH monitoring postoperatively, 5 patients (71%) demonstrated pathological reflux with an average Demeester score of 23.1 ± 19.1. There was a negative linear correlation between LESP change and Demeester scores (r = -0.7, P = .03). CONCLUSION The POEM procedure significantly improves achalasia-related symptoms and improves social functioning. Physiologically, there is reduction in both IRP and LESP. Postoperative pathological reflux is correlated with LESP reduction.
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Affiliation(s)
- Jacob J Benedict
- 1 Division of General Surgery, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Adam A Golas
- 1 Division of General Surgery, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Joel E Richter
- 2 Division of Gastroenterology, University of South Florida Morsani College of Medicine , Tampa, Florida.,3 Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Vic Velanovich
- 1 Division of General Surgery, University of South Florida Morsani College of Medicine , Tampa, Florida.,3 Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine , Tampa, Florida
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Affiliation(s)
- J E Richter
- Division of Digestive Diseases & Nutrition, Joy McCann Culverhouse, Center for Esophageal and Swallowing Disorders, University of South Florida, Tampa, FL, USA
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Richter JE. Rule of three for esophageal dilation: like the tortoise versus the rabbit, low and slow is our friend and our patients' win. Gastrointest Endosc 2017; 85:338-339. [PMID: 28089032 DOI: 10.1016/j.gie.2016.08.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 08/17/2016] [Accepted: 08/27/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Joel E Richter
- University of South Florida Morsani College of Medicine, Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, Tampa, Florida
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Davis-Yadley AH, Keshishian J, Champeaux A, Richter JE. Multinucleated histiocytes in esophageal squamous mucosa secondary to gastroesophageal reflux disease in a patient with esophageal stricture. Dis Esophagus 2016; 29:1159-1161. [PMID: 25715818 DOI: 10.1111/dote.12342] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We present a novel finding of multinucleated histiocytes associated with acute and chronic inflammation secondary to gastroesophageal reflux in a patient with a history of esophageal stricture, representing the first documented case after a review of the literature. Multinucleated squamous cells, while rare, are a more common finding in association with reactive and inflammatory conditions and have been reported in other areas of the body, such as the vulva, skin, and colon. Esophageal involvement with multinucleated epithelial giant cells appears to be a much less frequently encountered occurrence with only one previous report in the literature. We add to this series an interesting case of esophageal multinucleated giant cells that are histiocytes rather than epithelial cells, supported with positive CD68 immunohistochemical staining. Our patient had severe esophageal dysphagia with stricture with history of food impaction, requiring several dilation sessions to achieve an esophageal luminal diameter of 17 mm. There was marked clinical and endoscopic improvement with proton pump inhibitor and endoscopic therapy. The multinucleated mucosal histiocytes at the time of biopsy were likely due to reactive changes from chronic injury due to food stasis and reflux.
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Affiliation(s)
- A H Davis-Yadley
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - J Keshishian
- Department of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - A Champeaux
- Department of Pathology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - J E Richter
- Department of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.,Joy Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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Lipka S, Muhammad A, Champeaux A, Richter JE. Case report of proton pump inhibitor responsive esophageal eosinophilia: why 2 months of proton pump inhibitors is required. Dis Esophagus 2016; 29:700-3. [PMID: 24842729 DOI: 10.1111/dote.12237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease defined by the 2nd EoE consensus panel as: 'symptoms related to esophageal dysfunction, ≥15 eosinophils per high-power field, eosinophilia that persists after a trial of proton pump inhibitor (PPI) therapy, and exclusion of other secondary causes of esophageal eosinophilia'. After Ngo et al. first reported a case series of 3 patients initially diagnosed with eosinophilic esophagitis responding endoscopically and histologically to PPI therapy, the term PPI-responsive esophageal eosinophilia has evolved. Several studies have since confirmed the existence of this entity. Although recent ACG guidelines call for a 2-month course of PPI followed by endoscopy biopsies this recommendation is classified as a strong recommendation with 'low evidence', and has not been proven in the literature. We present a case of PPI-REE treated with rabeprazole 20 mg BID for 2 months, and describe simultaneous symptom resolution with histological and endoscopic remission of disease. This unique case with serial endoscopy and histology at baseline and monthly suggests the current recommendation of at least two months therapy with PPIs dosed twice daily is appropriate. Future studies will need to address duration of high dose therapy, whether patients can be stepped down to once a day PPI, and therapeutic strategy for transient responders.
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Affiliation(s)
- S Lipka
- Department of Medicine, Tampa, Florida, USA
| | - A Muhammad
- Department of Medicine, Division of Gastroenterology, University of South Florida, Tampa, Florida, USA
| | - A Champeaux
- Department of Pathology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - J E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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Colizzo JM, Clayton SB, Richter JE. Intrabolus pressure on high-resolution manometry distinguishes fibrostenotic and inflammatory phenotypes of eosinophilic esophagitis. Dis Esophagus 2016; 29:551-7. [PMID: 25913144 DOI: 10.1111/dote.12360] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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] [Indexed: 12/11/2022]
Abstract
The aim of this investigation was to determine the motility patterns of inflammatory and fibrostenotic phenotypes of eosinophilic esophagitis (EoE) utilizing high-resolution manometry (HRM). Twenty-nine patients with a confirmed diagnosis of EoE according to clinicopathological criteria currently being managed at the Joy McCann Culverhouse Swallowing Center at the University of South Florida were included in the retrospective analysis. Only patients who completed HRM studies were included in the analysis. Patients were classified into inflammatory or fibrostenotic subtypes based on baseline endoscopic evidence. Their baseline HRM studies prior to therapy were analyzed. Manometric data including distal contractile integral, integrated relaxation pressure, and intrabolus pressure (IBP) values were recorded. HRM results were interpreted according to the Chicago Classification system. Statistical analysis was performed with SPSS software (Version 22, IBM Co., Armonk, NY, USA). Data were compared utilizing Student's t-test, χ(2) test, Pearson correlation, and Spearman correlation tests. Statistical significance was set at P < 0.05. A total of 29 patients with EoE were included into the retrospective analysis. The overall average age among patients was 40 years. Male patients comprised 62% of the overall population. Both groups were similar in age, gender, and overall clinical presentation. Seventeen patients (58%) had fibrostenotic disease, and 12 (42%) displayed inflammatory disease. The average IBP for the fibrostenotic and inflammatory groups were 18.6 ± 6.0 mmHg and 12.6 ± 3.5 mmHg, respectively (P < 0.05). Strictures were only seen in the fibrostenotic group. Of the fibrostenotic group, 6 (35%) demonstrated proximal esophageal strictures, 7 (41%) had distal strictures, 3 (18%) had mid-esophageal strictures, and 1 (6%) patient had pan-esophageal strictures. There was no statistically significant correlation between the level of esophageal stricture and degree of IBP. Integrated relaxation pressure, distal contractile integral, and other HRM metrics did not demonstrate statistical significance between the two subtypes. There also appeared no statistically significant correlation between patient demographics and esophageal metrics. Patients with the fibrostenotic phenotype of EoE demonstrated an IBP that was significantly higher than that of the inflammatory group.
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Affiliation(s)
- J M Colizzo
- Department of Internal Medicine, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
| | - S B Clayton
- Department of Internal Medicine, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
| | - J E Richter
- Department of Internal Medicine, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
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Richter JE. Editorial: unravelling the mystery of the aetiology of eosinophilic oesophagitis. Aliment Pharmacol Ther 2016; 43:1232-3. [PMID: 27137722 DOI: 10.1111/apt.13593] [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] [Indexed: 12/08/2022]
Affiliation(s)
- J E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Center, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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Clayton SB, Patel R, Richter JE. Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes. Clin Gastroenterol Hepatol 2016; 14:907-911. [PMID: 26792374 DOI: 10.1016/j.cgh.2015.12.041] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [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: 07/01/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 02/07/2023]
Abstract
Little is known about the clinical features, radiology and manometry findings, and treatment outcomes of patients with functional and mechanical esophagogastic junction outflow obstruction (EGJOO). Between November 2011 and February 2015, a total of 1443 high-resolution manometries were reviewed and 49 patients (3.4%) met the manometric criteria for EGJOO. Then, we performed a retrospective chart review, collecting data from manometric studies, timed barium esophagram findings (TBEs), endoscopic reports, and clinical records. Twenty-seven patients had functional EGJOO and 22 patients had an anatomic esophageal obstruction. Common causes of anatomic EGJOO included strictures (36% of patients) and hiatal hernias (31% of patients). There were no differences between groups in manometric or radiographic metrics. Each group had increased basal lower esophageal sphincter and intrabolus pressures, compared with individuals without EGJOO, and most patients had abnormal findings on TBE analysis. Two patients with functional EGJOO progressed to type 3 achalasia. We conclude that patients diagnosed with EGJOO based on manometry findings can have anatomic obstruction or functional EGJOO; high-resolution manometry and TBE do not distinguish between disease causes.
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Affiliation(s)
- Steven B Clayton
- University of South Carolina School of Medicine, Greenville, Greenville Health System Gastroenterology and Liver Center, Greenville, South Carolina.
| | - Rupal Patel
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida
| | - Joel E Richter
- Department of Internal Medicine, Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida
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Patti MG, Vela MF, Odell DD, Richter JE, Fisichella PM, Vaezi MF. The Intersection of GERD, Aspiration, and Lung Transplantation. J Laparoendosc Adv Surg Tech A 2016; 26:501-5. [PMID: 27218671 DOI: 10.1089/lap.2016.0170] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Lung transplantation is a radical but life-saving treatment option for patients with end-stage lung diseases, such as idiopathic pulmonary fibrosis (IPF) and scleroderma. In light of the proposed association and controversy linking gastroesophageal reflux disease (GERD) to IPF and lung transplant outcome, the American Gastroenterological Association convened during the DDW in Washington in May 2015 a multidisciplinary group of experts in the field of GERD and lung transplantation to make considerations about the care of these patients based on available data and subsequent expert panel discussion at this symposium. The following topics were discussed: (1) pathophysiology of GERD-induced pulmonary symptoms, (2) GERD evaluation before and after lung transplantation, (3) outcome of lung transplantation for IPF and scleroderma, and (4) role of laparoscopic fundoplication before or after lung transplantation.
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Affiliation(s)
- Marco G Patti
- 1 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
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Yadlapati R, Gawron AJ, Keswani RN, Bilimoria K, Castell DO, Dunbar KB, Gyawali CP, Jobe BA, Katz PO, Katzka DA, Lacy BE, Massey BT, Richter JE, Schnoll-Sussman F, Spechler SJ, Tatum R, Vela MF, Pandolfino JE. Identification of Quality Measures for Performance of and Interpretation of Data From Esophageal Manometry. Clin Gastroenterol Hepatol 2016; 14:526-534.e1. [PMID: 26499925 PMCID: PMC4993017 DOI: 10.1016/j.cgh.2015.10.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 07/10/2015] [Revised: 09/01/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal manometry is the standard for the diagnosis of esophageal motility disorders. Variations in the performance and interpretation of esophageal manometry result in discrepant diagnoses and unnecessary repeated procedures, and could have negative effects on patient outcomes. We need a method to benchmark the procedural quality of esophageal manometry; as such, our objective was to formally develop quality measures for the performance and interpretation of data from esophageal manometry. METHODS We used the RAND University of California Los Angeles Appropriateness Method (RAM) to develop validated quality measures for performing and interpreting esophageal manometry. The research team identified potential quality measures through a literature search and interviews with experts. Fourteen experts in esophageal manometry ranked the proposed quality measures for appropriateness via a 2-round process on the basis of RAM. RESULTS The experts considered a total of 29 measures; 17 were ranked as appropriate and were as follows: related to competency (2), assessment before the esophageal manometry procedure (2), the esophageal manometry procedure itself (3), and interpretation of data (10). The data interpretation measures were integrated into a single composite measure. Eight measures therefore were found to be appropriate quality measures for esophageal manometry . Five other factors also were endorsed by the experts, although these were not ranked as appropriate quality measures. CONCLUSIONS We identified 8 formally validated quality measures for the performance and interpretation of data from esophageal manometry on the basis of RAM. These measures represent key aspects of a high-quality esophageal manometry study and should be adopted uniformly. These measures should be evaluated in clinical practice to determine how they affect patient outcomes.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Andrew J. Gawron
- Division of Gastroenterology, University of Utah, Salt Lake City, IL, USA
| | - Rajesh N. Keswani
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Karl Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Donald O. Castell
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - Kerry B. Dunbar
- University of Texas Southwestern Medical Center and the Dallas VA Medical Center, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Dallas, TX, USA
| | - Chandra P. Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Blair A. Jobe
- Esophageal and Thoracic Institute, Allegheny Health Network, Pittsburgh, PN, USA
| | - Philip O. Katz
- Thomas Jefferson University, Philadelphia, Pennsylvania; Division of Gastroenterology, Albert Einstein Medical Center, Philadelphia, PN, USA
| | - David A. Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Brian E. Lacy
- Division of Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Benson T. Massey
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joel E. Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Felice Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Stuart J. Spechler
- University of Texas Southwestern Medical Center and the Dallas VA Medical Center, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Dallas, TX, USA
| | - Roger Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Marcelo F. Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Lipka S, Kumar A, Miladinovic B, Richter JE. Systematic review with network meta-analysis: comparative effectiveness of topical steroids vs. PPIs for the treatment of the spectrum of eosinophilic oesophagitis. Aliment Pharmacol Ther 2016; 43:663-73. [PMID: 26834077 DOI: 10.1111/apt.13537] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/23/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Controversy surrounds the clinical and histological response to topical steroids in patients with eosinophilic oesophagitis (EoE). AIM To perform a systematic review and network meta-analysis of randomised controlled trials to assess the efficacy of topical steroids compared with placebo or proton pump inhibitor (PPIs) for the management of eosinophilic oesophagitis. METHODS Cochrane Central Register of Controlled Trials and MEDLINE from inception to 1 July 2015 was searched. Data were extracted independently by two authors. Methodological quality was assessed using the Cochrane risk of bias tool. A network meta-analysis was performed using the Bayesian methods under random-effects multiple treatment comparisons. Results were summarised as odds ratio along with credibility intervals. We also calculated the ranking probability for each treatment based on surface under the cumulative ranking curve (SUCRA). RESULTS The overall methodological quality of included studies was low. SUCRA ranking probability indicated that PPI had the highest probability of being the best treatment for achieving histological remission and mean change in eosinophils (0.81 and 0.85, respectively), followed by budesonide (0.74 and 0.63, respectively) and fluticasone (0.5 and 0.5, respectively). None of the comparisons indicated a statistically signicant difference. CONCLUSIONS The results from network meta-analysis show that there is no statistically significant difference between PPI, budesonide and fluticasone for the treatment of EoE as assessed by the histological and clinical response. The evidence is limited by serious risk of bias and imprecision, which emphasises the urgent need for large RCTs with adequate sample size and methodological rigour to provide conclusive evidence.
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Affiliation(s)
- S Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - A Kumar
- Division of Evidence Based Medicine and Outcomes Research, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - B Miladinovic
- Division of Evidence Based Medicine and Outcomes Research, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - J E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Affiliation(s)
- John Jacobs
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal Disease, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal Disease, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Lipka S, Boyce HW, Kumar A, Richter JE. The changing faces of eosinophilic esophagitis: the impact of consensus guidelines at the University of South Florida. Dig Dis Sci 2015; 60:1572-8. [PMID: 25618310 DOI: 10.1007/s10620-014-3517-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/29/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Prior to the consensus guideline conference in 2007, eosinophilic esophagitis (EoE) was uncommon dominated by the fibrostenotic phenotype, but over the past decade has become a common cause of dysphagia with more inflammatory phenotypes diagnosed. We assessed the impact of guideline definitions on the characteristics of EoE phenotypes over the past 26 years at our institution. METHODS We reviewed the electronic health record of 75 consecutive patients meeting guideline definition EoE from 1/1988 to 5/2014. We separated groups based on 5-year intervals of diagnosis and phenotype. For continuous data, results were summarized as mean difference and standard deviation with 95 % confidence intervals. RESULTS Five groups based on 5-year intervals of diagnosis were identified: group 1-1988-1993 (n = 7), group 2-1994-1999 (n = 7), group 3-2000-2005 (n = 4), group 4-2006-2011 (n = 35), and group 5-2012-2014 (n = 22). Prior to 2000, all patients were diagnosed with fibrostenotic EoE. After the initial 2007 guideline conference, inflammatory EoE has predominated with only one-third diagnosed with fibrostenotic EoE. Prior to 2011, only two were diagnosed with PPI-REE. In the last 3 years, 8 out of 22 patients (32 %) had PPI-REE. Overall, 8 out of 10 (80 %) PPI-REE were the inflammatory phenotype. When comparing pre- (n = 18) and post (n = 57)-consensus definitions, there was a significant difference between age of diagnosis (30.710.2 vs. 41.3 ± 14.3; p = 0.001), age of symptom onset (18.4 +/15.2 vs. 32.4 ± 15.5), and initial esophageal diameter (10.5 ± 2.7 vs. 14.3 ± 4.2; p < 0.0001), respectively. CONCLUSIONS Fibrostenotic EoE has steadily decreased, and inflammatory EoE is now the most recognized form. Across our 26-year experience, there was a decrease in delay in diagnosis and severity of esophageal stricture. The pivotal change occurred around 2007 corresponding to the first EoE guideline emphasizing the impact and importance of early detection of disease.
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Affiliation(s)
- Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Lipka S, Kumar A, Richter JE. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2015; 13:1058-67.e1. [PMID: 25459556 DOI: 10.1016/j.cgh.2014.10.013] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [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: 08/06/2014] [Revised: 09/26/2014] [Accepted: 10/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A radiofrequency ablation technique known as Stretta was recommended by the Society of American Gastrointestinal and Endoscopic Surgeons as an alternative treatment for gastroesophageal reflux disease (GERD). However, randomized controlled trials of the efficacy of Stretta have produced conflicting findings, and those from previous systematic reviews were compromised as a result of deficiencies in study conduct and reporting of findings. We performed a systematic review to evaluate all evidence on the efficacy of Stretta for the management of GERD. METHODS We searched MEDLINE and the Cochrane Central Register of Controlled Trials (The Cochrane Library) from inception until February 28, 2014, along with other databases, for randomized controlled trials of Stretta in patients with GERD. Primary outcomes were physiologic parameters of GERD, including normalization of esophageal pH values and augmentation of lower esophageal sphincter pressure (LESP). Secondary outcomes were health-related quality of life (HRQOL) and ability to stop the use of proton pump inhibitors (PPIs). For quality assurance purposes, 2 investigators were involved throughout the study. Data were pooled under a random-effects model. The systematic review was performed as per the standards of the Cochrane collaboration. RESULTS We collected data from 4 trials and a total of 165 patients (153 patients were analyzed). Three trials compared Stretta vs sham, and 1 trial compared Stretta with PPI therapy. The overall quality of evidence was very low. The pooled results showed no difference between Stretta and sham or management with PPI in patients with GERD for the outcomes of mean (%) time the pH was less than 4 over a 24-hour time course, LESP, ability to stop PPIs, or HRQOL. CONCLUSIONS In a meta-analysis of trials, we found that Stretta for patients with GERD does not produce significant changes, compared with sham therapy, in physiologic parameters, including time spent at a pH less than 4, LESP, ability to stop PPIs, or HRQOL.
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Affiliation(s)
- Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Ambuj Kumar
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida.
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Kolkhorst KS, Richter JE. Images of the month. Achalasia with an elbow. Am J Gastroenterol 2014; 109:1860. [PMID: 25621338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
High-resolution manometry (HRM) with 36 pressure transducers spanning the esophagus has revolutionized the diagnosis and treatment of esophageal motility disorders, especially with respect to achalasia. The three major contributions of HRM are as follows: (a) Integrated relaxation pressure (IRP) at the esophagus gastric junction (EGJ) >15 mmHg has a sensitivity of 97 % for the diagnosis of achalasia; (b) there are three distinct subtypes of achalasia - type 1 (no distal pressurization), type II (panesophageal pressurization), and type III (spastic contractions); and (c) subtypes predict the success of treatment with type II patients doing the best and type III being the most difficult to treat. Recent studies also suggest that HRM is superior to conventional manometry for diagnosis of achalasia. Other useful observation from HRM is the recognition of EGJ outflow obstruction (type IV achalasia) with normal peristalsis which may be due to mechanical or functional impairment at the EGJ. Finally, after successful treatment of achalasia, the IRP falls to less than 15 mmHg and the achalasia pressurization pattern resolves sometimes with the return of weak peristalsis. This complements well with the information obtained by the timed barium esophagram.
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Patel R, Clayton S, Kulkarni P, Kolkhorst KS, Richter JE. Images of the month. Distal esophageal calcific mass. Am J Gastroenterol 2014; 109:1860. [PMID: 25470580 DOI: 10.1038/ajg.2014.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Lipka S, Keshishian J, Boyce HW, Estores D, Richter JE. The natural history of steroid-naïve eosinophilic esophagitis in adults treated with endoscopic dilation and proton pump inhibitor therapy over a mean duration of nearly 14 years. Gastrointest Endosc 2014; 80:592-598. [PMID: 24703087 DOI: 10.1016/j.gie.2014.02.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/06/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite the vast focus of research in eosinophilic esophagitis (EoE), the natural history of untreated EoE remains undefined. Current expert consensus panels are calling for natural history studies to define long-term risks, adverse events, and progression of the disease. OBJECTIVE To address the natural course and long-term adverse events of EoE. DESIGN Retrospective, single-center study. SETTING Tertiary-care center. A cohort of patients from the year 1988 initially diagnosed as having congenital esophageal stenosis who were later reclassified as having EoE. PATIENTS Ninety-five patients, with 13 meeting entrance criteria for idiopathic EoE with follow-up >5 years. INTERVENTIONS Anti-acids and esophageal dilation. MAIN OUTCOME MEASUREMENTS Clinical response, adverse events, long-term clinical outcomes, and progression of disease. RESULTS Thirteen patients (mean age at diagnosis 30.3 years, 10 male) were evaluated over a 13.6-year mean follow-up (range 5-24 years). All patients experienced daily dysphagia, with 12 presenting with food impactions. Patients were treated with esophageal dilation (64% Maloney, 34% Savary, 2.5% through-the-scope balloon) and daily anti-acids. Patients were initially treated with an average of 3.2 dilations over the first year (range 1-6) to achieve a luminal size of 15.8 mm (range 14-18 mm). They were maintained successfully with dilations every 2 years, on average, based on symptoms. Two patients not adhering to recommended dilation schedules experienced repeat impactions. One adverse event from a mucosal tear required hospitalization (1 of 157, 0.6%). Seven of 13 had Barrett's esophagus, average length 2.4 cm (range 1-4 cm), 3 on initial EGD and 4 identified over a mean duration of 9.4 years. No patient developed dysplasia or malignancy. LIMITATIONS Retrospective, small sample. CONCLUSION The course of EoE over a 13.6-year mean duration, although persistent, appears benign and not associated with cancer risk. A program of regular esophageal dilations based on symptom recurrence appears to be a safe, long-term treatment.
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Affiliation(s)
- Seth Lipka
- Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jonathan Keshishian
- Department of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - H Worth Boyce
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - David Estores
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida
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Richter JE. Current Diagnosis and Management of Suspected Reflux Symptoms Refractory to Proton Pump Inhibitor Therapy. Gastroenterol Hepatol (N Y) 2014; 10:547-555. [PMID: 27551249 PMCID: PMC4991531] [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: 06/06/2023]
Abstract
Suspected reflux symptoms that are refractory to proton pump inhibitors (PPIs) are rapidly becoming the most common presentation of gastroesophageal reflux disease (GERD) in patients seen in gastroenterology clinics. These patients are a heterogeneous group, differing in symptom frequency and severity, PPI dosing regimens, and responses to therapy (from partial to absent). Before testing, the physician needs to question the patient carefully about PPI compliance and the timing of drug intake in relation to meals. Switching PPIs or doubling the dose is the next step, but only 20% to 25% of the group refractory to PPIs will respond. The first diagnostic test should be upper gastrointestinal endoscopy. In more than 90% of cases, the results will be normal, but persistent esophagitis may suggest pill esophagitis, eosinophilic esophagitis, or rarer diseases, such as lichen planus, Zollinger-Ellison syndrome, or genotype variants of PPI metabolism. If the endoscopy results are normal, esophageal manometry and especially reflux testing should follow. Whether patients should be tested on or off PPI therapy is controversial. Most physicians prefer to test patients off PPIs to identify whether abnormal acid reflux is even present; if it is not, PPIs can be stopped and other diagnoses sought. Testing patients on PPI therapy allows nonacid reflux to be identified, but more than 50% of patients have a normal test result, leaving the clinician with a conundrum-whether to stop PPIs or continue them because the GERD is being treated adequately. Alternative diagnoses in patients with refractory GERD and normal reflux testing include achalasia, eosinophilic esophagitis, gastroparesis, rumination, and aerophagia. However, more than 50% will be given the diagnosis of functional heartburn, a visceral hypersensitivity syndrome. Treating patients with PPI-refractory GERD-like symptoms can be difficult and frustrating. Any of the following may help: a histamine-2 receptor antagonist at night, baclofen to decrease transient lower esophageal sphincter relaxations, pain modulators, acupuncture, or hypnotherapy. At this time, antireflux surgery should be limited to patients with abnormal acid reflux defined by pH testing and a good correlation of symptoms with acid reflux.
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Affiliation(s)
- Joel E Richter
- Dr Richter is a professor of medicine, the Hugh F. Culverhouse Chair for Esophagology, director of the Division of Digestive Diseases and Nutrition, and director of the Joy McCann Culverhouse Center for Swallowing Disorders at the University of South Florida Morsani College of Medicine in Tampa, Florida
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Affiliation(s)
- Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA.
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Abstract
Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
| | - Giovanni Zaninotto
- Department of Surgical and Gastroenterological Sciences, University of Padova, UOC General Surgery, Sts Giovanni e Paolo Hospital, Venice, Italy
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Abstract
Management of eosinophilic esophagitis (EoE) centers around the 3 Ds: diet, drug therapy, and dilation. Unfortunately, there is not a consistent relationship between symptom relief and resolution of mucosal eosinophilia. Elemental diets are very successful in children, but poorly tolerated by adults. The 6-food elimination diet is more attractive to adults, especially for those individuals with multiple food allergies. Steroids are the preferred anti-eosinophil drug for EoE. Oral prednisone is infrequently used because of side effects. Topical swallowed preparations (fluticasone, budesonide) are preferred for acute and possibly maintenance therapy. Relapses off steroids are frequent and dysphagia does not predictably improve. Esophageal dilation is key treatment for patients with the fibrostenotic phenotype of EoE. Long-term symptom relief for 1-2 years is common. Post-procedure chest pain is to be expected but perforation is very rare. A suggested algorithm for the treatment of EoE based on endoscopic phenotypes is outlined.
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Affiliation(s)
- Ricardo Prieto
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC 72, Tampa, FL 33612, USA
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Jobe BA, Richter JE, Hoppo T, Peters JH, Bell R, Dengler WC, DeVault K, Fass R, Gyawali CP, Kahrilas PJ, Lacy BE, Pandolfino JE, Patti MG, Swanstrom LL, Kurian AA, Vela MF, Vaezi M, DeMeester TR. Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel. J Am Coll Surg 2013; 217:586-97. [PMID: 23973101 DOI: 10.1016/j.jamcollsurg.2013.05.023] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [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: 03/12/2013] [Revised: 05/01/2013] [Accepted: 05/28/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes. STUDY DESIGN A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application. RESULTS The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. CONCLUSIONS Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.
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Affiliation(s)
- Blair A Jobe
- Department of Surgery, The Western Pennsylvania Hospital, West Penn Allegheny Health System, Pittsburgh, PA.
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