Introduction

Patient-physician relationship (PPR) plays a center role in modern health care, especially within gastrointestinal (GI) medical practice, where patients affected by non-structural disorders (better described as disorders of gut-brain interaction or DGBI) tend to report a low satisfaction towards their medical care. In 2017 Kurlander et al. developed and validated a Patient-Physician Relationship Scale (PPRS), a questionnaire used in patients affected by Irritable Bowel Syndrome (IBS) to assess their degree of medical care-satisfaction. The original PPRS was later shortened and simplified by Drossman et al. in 2021 by creating a PPRS-SF (short form), consisting in a 12-item questionnaire.

Aims & Methods

The aims of this study were to validate the PPRS-SF in Italian and to administer it to both patients with functional and organic esophageal diseases, in order to highlight the differences in patient-physician relationship between the two categories.
The process of validation to Italian language of the PPRS-SF questionnaire was carried out following a standardized forward-backward procedure and each step was overseen by an independent clinical monitor assigned by the Rome Foundation itself. The Italian version of the PPRS SF was successfully administered to 50 Eosinophilic Esophagitis (EoE), 53 Achalasia (Ach), 48 Gastroesophageal Reflux Disease (GERD) and 44 esophageal DGBI patients (affected by functional dysphagia or functional heartburn).

Results

In esophageal DGBI and GERD, the degree of patients’ satisfaction was significantly lower, if calculated as a total summation, compared to that of EoE and Achalasia patients.. Between a minimum score of -36 and a maximum of +36, the mean PPRS-SF “Italian version” score for patients with EoE was 30.20 (±9.78), for patients with Ach 23.78 (±19.9); for patients with GERD 20.46 (±16.03); for esophageal DGBI 17.91 (±18.41). Moreover, there was a significant difference in PPR between younger patients (under 50 years old), who reported a score of 27.1 (±12.29) and older patients (over 50 years old), reporting a score of 20.16 (±19.72).

Conclusion

This study validated the Italian version of the PPRS-SF questionnaire and showed that the patients’ diagnosis together with other factors such as their age, can affect the quality of the PPR. In particular, patients with DGBI and older patients reported lower scores than the ones with organic diseases and the younger ones, respectively. Further studies are necessary to confirm these results.

Introduction

Thyroidectomy is one of the most common surgical procedures worldwide, yet its potential effects on esophageal function remain inadequately characterized. While post-thyroidectomy issues such as voice changes have been well-documented, alterations in esophageal motility following this procedure have received limited attention in scientific literature.

Aims & Methods

This study aims to evaluate the impact of thyroidectomy on esophageal motility parameters using High-resolution manometry (HRM), with particular attention to upper esophageal sphincter (UES) function. Seventeen patients (11 females), who were to undergo total thyroidectomy or hemithyroidectomy, were prospectively recruited between the months of February and May 2023. Ten of them had goiters, while seven had thyroid nodules. Exclusion criteria were having an age under 30 or over 70 years old, having to also undergo a parathyroid surgery and taking medications that could alter the esophageal sphincter. All of them underwent a pre-operative HRM and a second one thirty days after surgery. HRM were performed according to the Chicago Classification 4.0 and the data were analyzed using the online analysis platform “Swallow Gateway”. Gastrointestinal (GI) symptoms were assessed using a standardized questionnaire, before the first and the second HRM. No after procedural complication was reported.

Results

UES function significatively changed after thyroidectomy, as it is shown by HRM metrics such as Pharyngeal Contractile Integral (CI), Velopharyngeal CI, Hypopharyngeal CI, UES-CI, UES Integrated Relaxation Pressure (UES-IRP), Post-Deglutitive UES CI, Proximal Contractile Integral (PCI), which all significatively decreased (p < 0.05) at the HRM performed after surgery. Compared to Swallow Gateway normal values, there was an important increase of pathological HRM metrics after thyroidectomy. No significant HRM difference was found between the two categories of patients (goiter and thyroid nodules) and no significant correlation was registered between GI symptoms pre- and post-surgery and between GI symptoms and HRM metrics.

Conclusion

Thyroidectomy may significantly affect esophageal motility, especially the function of the upper esophageal sphincter. This finding could be useful in the diagnostic and therapeutic pathway of these patients, although further and larger studies are required to confirm this result.

Introduction

Recent studies have evaluated the upper esophageal sphincter (UES) with high-resolution manometry (HRM) in Achalasia, Esophageal-Gastric Junction Outflow Obstruction (EGJOO), and Gastroesophageal Reflux Disease (GERD). There are, however, no studies of UES metrics in Eosinophilic Esophagitis (EoE) patients.

Aims & Methods

The aim of our study was to evaluate the function of UES across EoE, GERD, and Functional Dysphagia. We also studied the relationship of UES metrics with esophageal symptoms, esophageal body contraction, and EGJ-metrics. This pilot study enrolled 30 EoE,18 GERD,and 29 Functional Dysphagia patients diagnosed according to Chicago Classification 3.0. The study data were exported to the online analysis platform Swallow Gateway. UES was assessed in terms of UES Resting Pressure (UES-RP), UES Basal Pressure (UES-BP), UES Integrated Relaxation Pressure (UES-RP), UES Relaxation Time (UES-RT), Basal UES Contractile Integral (Basal UES-CI), Post-deglutitive UES Contractile Integral (Post-deglutitive UES-CI), and Proximal Contractile Integral (PCI) through ten 5 mL wet swallows.

Results

ANOVA analysis showed significantly higher values of Post-deglutitive UES-CI in EoE patients compared with Functional Dysphagia patients (p=0.001). Basal UES-CI and UES-RP showed significantly higher values in EoE patients (p=0.002 and p=0.038) and GERD patients (p<0.001 and p=0.001) compared with Functional Dysphagia patients. A correlation between LES-CI and Post-deglutitive UES-CI, Basal UES-CI, UES-RP (p=<0.001,p=0.027,and p=0.017,respectively), and between LES-BP and Post-deglutitive UES-CI (p=0.019), independently from diagnosis, was shown. No correlations have been demonstrated between UES and EGJ metrics and esophageal symptoms.

Conclusion

These results emphasize the importance of UES analysis, which may be an additional tool to understand novel pathophysiological mechanisms underlying rare diseases such as EoE.

Introduction

Functional dyspepsia (FD) has an estimated population prevalence of 10% using the ROME IV criteria (1). Opioids have a limited therapeutic role in the management of non-malignant pain, but the opioid prescription rates for the management of non-cancer pain has increased steadily by 0.5% per year from 2006 to 2016 (2). Opioid induced hyperalgesia is thought to contribute to the development of visceral hypersensitivity in patients with disorders of gut-brain interaction (DGBIs) (3). To our knowledge, no UK study has yet addressed the clinical characteristics and healthcare outcomes of patients diagnosed with clinically confirmed ROME IV FD who are prescribed opioids.

Aims & Methods

The primary aim of this study is to determine the proportion of patients diagnosed with ROME IV FD in a tertiary care neurogastroenterology setting who are prescribed opioids. The secondary aims of the study are as follows: to determine the differences in clinical characteristics and symptomatology between patients with FD taking opioids compared to those not taking opioids; to determine the differences in healthcare utilisation (i.e., number of investigations, clinic consultations, and hospitalisations) between patients taking opioids compared to those not taking opioids; and to determine the proportion of patients who adhere to opioid cessation advice and whether their clinical symptoms improve.
This study was approved as a retrospective audit (Nottingham University Hospitals NHS Trust registration number 21-482C). Data were analysed from consecutive patients who presented to a single tertiary care neurogastroenterology unit (Queen’s Medical Centre, Nottinghamshire, UK) between January 2016 – December 2021 and diagnosed with FD according to the Rome IV clinical diagnostic criteria. Only patients aged ≥ 18 were included and pregnancy was the only exclusion factor. Phenotype and clinical outcomes were compared between FD patients taking opioids and those not taking opioids.

Results

A total of 157 patients were diagnosed with ROME IV FD. Among these 157 patients, 34 were classified in the opioid group and the remainder (n=123) in the non-opioid group. Nausea (n=28, 82.4% versus n=75, 61%; p=0.02), vomiting (n=19, 55.9% versus n=34, 27.6%; p=0.002), and constipation (n=18, 52.9% versus n=21, 23.6%; p=0.001) were most commonly seen in the opioid group. There was no intergroup difference in the number of specialist consultations (p=0.45), or number of investigations (p=0.14) that the patients underwent. In the opioid group (n=34), 32 (94.1%) patients were advised to stop opioids. Fifteen (46.8%) stopped taking opioids on advice and nine (60%) of these patients who stopped opioids reported improvement in symptoms. The most commonly reported symptom improvement was reduced constipation (n=3, 33.3%), reduced pain (n=3, 33.3%), or general feeling better (n=3, 33.3%). Approximately half of the patients who did not stop taking opioids reported that they needed the drugs for pain relief, whilst the remaining did not provide an explanation.

Conclusion

We demonstrate that opioid intake in FD is associated with more nausea, vomiting, and constipation compared to patients who are not prescribed opioids. We also show that most patients with ROME IV FD in a tertiary care setting often do not follow opioid cessation advice. Should the burden of opioids in patients diagnosed with DGBIs be as high as this study suggests, then it is possible that an appreciable part of this disease burden may be avoidable via the strict implementation of policies to reduce opioid prescriptions for chronic non-cancer pain.

References

(1) Aziz I, Palsson OS, Tornblom H, Sperber AD, Whitehead WE, Simren M. Epidemiology, clinical characteristics, and associations for symptom-based Rome IV functional dyspepsia in adults in the USA, Canada, and the UK: a cross-sectional population-based study. Lancet Gastroenterol Hepatol. 2018;3(4):252-62.
(2) LeBrett WG, Chen FW, Yang L, Chang L. Increasing Rates of Opioid Prescriptions for Gastrointestinal Diseases in the United States. The American journal of gastroenterology. 2021;116(4).
(3) Farmer AD, Gallagher J, Bruckner-Holt C, Aziz Q. Narcotic bowel syndrome. The lancet Gastroenterology & hepatology. 2017;2(5).

Introduction

Based on the Chicago classification, HREM diagnosis is classically based on metrics obtained with wet swallows carried out in the supine position. However, both patients and physicians often feel that this is not a physiological position to conduct the test as it may not translate to the real world experience. With the patient in the upright/sitting position, the test would more closely simulate real-life behaviour and may be safer for elderly patients at risk of aspiration.

Aims & Methods

In an Asian tertiary centre, a total of 104 patients had undergone high resolution esophageal manometry (HREM) with retrospective data analysis comparing both conventional supine position with the upright position. The latter is generally favoured by all patients as this represents the physiological posture during meals.

Results

Using 2-tailed paired sample T-test, comparison across all cases showed a consistently lower median Integrated Relaxation Pressure (IRP) [6.0 mmHg vs to 8.7 mmHg; p <0.01] and lower mean Distal Contractile Integral (DCI) [1463 mmHg/cm/sec vs 1864 mmHg/cm/sec; p =0.014] in the upright posture compared to supine position although the mean Distal Latency (DL) difference was not significant [6.21secs vs 6.27 secs; p =0.491]. During upright and supine position comparison respectively, subgroup analysis on subjects with normal HREM diagnosis showed even lower median IRP [4.9 mmHg vs 7.5 mmHg; p <0.01] and lower mean DCI results [1436 mmHg/cm/sec vs 1695 mmHg/cm/sec; p <0.01] with mean DL in this subgroup showing no significant statistical difference [6.29 secs vs 6.38secs; p=0.545]. The final HREM diagnosis in upright position is concordant with the conventional supine position up to 81.7% and showed an even higher concordance in terms of management similarity up to 98.1%. Only 2 cases (2/104) showed a significant discordance between supine and upright HREM diagnosis [normal HREM vs esophagogastric juntion –outflow obstruction(EGJ-OO) and hypercontractile esophagus vs normal HREM]. Minor diagnostic discordance [normal HREM vs ineffective esophageal motility (IEM)] was noted in 17/104 cases which had no major clinical impact on patients and may be overcome by adopting a lower cut-off for mean DCI for upright group.

Conclusion

In patients who are unable to perform HREM in supine position, adopting the upright position shows a high clinical concordance and may be considered a more physiological approach in the HREM protocol.

References

Riva CG, Siboni S, Ferrari D, Sozzi M, Capuzzo M, Asti E, Ogliari C, Bonavina L. Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis. J Neurogastroenterol Motil. 2020 Jul 30;26(3):335-343. doi: 10.5056/jnm20010. PMID: 32606256; PMCID: PMC7329148.

Introduction

For many patients with restrictive and obstructive lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx (1,2). Which, if any patients, should be excluded from transplantation due to GER remains unclear.

Aims & Methods

Aim: To examine the changes in esophageal motor function (Chicago Classification v4.0) and association with GER following LTx in patients based on pre-LTx restrictive or obstructive lung disease.
Methods: High-resolution impedance esophageal manometry (HRIM) and 24hr impedance-pH (MII-pH) were performed in 57 respiratory patients (40 restrictive disease, 17 obstructive disease) before and after LTx (mean age 60 yrs (range 33-75 yrs), 39 males) between November 2016 and October 2022.

Results

Restrictive disease: Before LTx, 15 (38%) patients exhibited abnormal motility, with the majority presenting with either ineffective esophageal motility (IEM) (8, 53%) or esophagogastric junction outflow obstruction (EGJOO) (6, 40%). One patient had distal esophageal spasm and the rest (25, 63%) normal motility. Following LTx, approximately half of patients (21, 53%) retained the same diagnosis as pre-LTx. Patients with normal motility pre-LTx were more likely to retain the same diagnosis (i.e. normal) post-LTx (17/25, 68%) than those with an abnormal motility diagnoses (4/15, 27%)(p=0.021), particularly those with EGJOO(1/6, 17%)(p=0.059). Nine of 15 (60%) patients with abnormal motility pre-LTx changed to normal motility post-LTx.
Obstructive disease: Before LTx, 8 (47%) patients exhibited abnormal motility, with the majority exhibiting EGJOO (4, 50%). The rest exhibited either IEM (2, 25%), absent motility (1, 12.5%) or hypercontractility (1, 12.5%). Nine (53%) exhibited normal motility. Following LTx, about half (10, 59%) retained the same diagnoses, but patients with normal motility (5/9, 56%) were no more likely to retain the same diagnoses as those with abnormal motility (5/8, 63%). Only one of eight (12.5%) patients with abnormal motility changed to normal motility post-LTx, which is lower than that seen in patients with restrictive disease (p=0.07). Examination of the pH findings revealed that although acid exposure time (AET) was similar pre-LTx (restrictive 2.4(0.7-7.0) v obstructive 2.0(0.5-3.4); p=0.53), there was a decrease in AET in restrictive patients (1.7(0.3-3.5);p=0.05) but no change in patients with obstructive disease (3.7(0.6-10.1)p=0.31) post-LTx. Of note, mean nocturnal baseline impedance (5cm above the LES) was similar pre-LTx (1750(1139-2705)ohms v 1799(1058-2540)ohms) and increased in restrictive patients (2480(1511-4413)ohms; p=0.002) but not in those with obstructive disease (1732(1173-2293)ohms; p=0.82), mirroring changes in AET.

Conclusion

Patients with restrictive lung disease are more likely to retain a diagnosis of normal motility or change to normal motility post-LTx than patients with obstructive lung disease. This appears to associate with improved acid exposure time and mean nocturnal baseline impedance. Further data are required on long-term outcome.

References

1. Houghton LA, Lee AS, Badri H, DeVault KR, Smith JA. Respiratory disease and the oesophagus: reflux, reflexes and microaspiration. Nat Rev Gastroenterol Hepatol 2016; 13(8); 445-60
2. Chan WW, Ahuja N, Fisichella PM, Gavini S, Rangan V, Vela MF. Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome. Ann N Y Acad Sci 2020; 1482: 95-105