Introduction

Proton pump inhibitors (PPIs) are widely used for the treatment of peptic ulcer and gastro-esophageal reflux diseases, and as mucosal gastric protectors in patients receiving anti-aggregation drugs for cardiovascular diseases.
Although PPIs are well tolerated, concerns have been raised that their chronic use may pose risks of dementia, gastric cancer,and pneumonia.Recently, researchers have suggested that chronic use of PPIs such as omeprazole may also be a risk factor for osteoporotic bone fractures,^1,2 but the findings are controversial.^3,4

Aims & Methods

Aim: The aim of the study was to investigate the potential association of chronic use of omeprazole with the occurrence of osteoporotic fractures (OF) in community-dwelling elderly subjects.
Methods: The cohort consisted of community-dwelling residents aged >65 years registered with a large health maintenance organization in Israel between 01/2002 and 12/2016. Data were retrospectively collected from the electronic medical files on demographics, parameters known to be associated with OF, diagnoses of osteoporotic hip, wrist, and vertebral fractures, and chronic use of omeprazole ( >11 prescriptions/year). Time to OF/death/end of study was calculated from the beginning of the study (2002). The risk of fractures in omeprazole the chronic users was analyzed by multivariate Cox proportional hazard regression model.

Results

Included 46,805 subjects (41% men), mean age 83.4±6.4 years, of whom 10,272 (21.9%) were chronic users of omeprazole.
During 14 years of follow-up, OF were diagnosed in 414 (4.0%) omeprazole users and 1007 (2.8%) omeprazole nonusers (p<0.001). In a Cox regression model adjusted for age and gender only, chronic use of omeprazole was associated with a 16% excess of osteoporotic fractures. However, when parameters known to be associated with osteoporotic fractures were entered into the multivariate Cox regression model, chronic use of omeprazole was not found to be an independent risk factor for osteoporotic fracture, either overall (aHR=0.965, 95% CI 0.86–1.08, p=0.55) or specifically, in the ≥85-year age group (aHR=0.780, 95% CI 0.635–0.958, p<0.05) in which an inverse correlation between omeprazole use and osteoporotic fracture, was demonstrated.

Conclusion

Chronic use of omeprazole wasn’t associated with the occurrence of osteoporotic fractures in community-dwelling elders.

References

References:
1 . Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 2006; 296: 2947‒2953.
2. Targownik LE, Lix LM, Metge CJ, Prior HJ, Leung S, Leslie WD. Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ 2008; 179: 319‒326.
3 . Targownik LE, Lix LM, Leung S, Leslie WD. Proton-pump inhibitor use is not associated with osteoporosis or accelerated bone mineral density loss. Gastroenterology 2010; 138: 896-904.
4. Moayyedi P, Eikelboom JW, Bosch J et al; COMPASS Investigators. Safety of proton pump inhibitors based on a large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology 2019; 157: 682‒691.e2.

Disclosure

Nothing to declare

Introduction

Aging is associated with physiological changes in esophageal function, influencing motility and increasing susceptibility to dysphagia.

Aims & Methods

This study investigates esophageal peristaltic reserve across different age groups by employing multiple rapid swallow (MRS) during high-resolution manometry (HRM). A retrospective analysis was conducted on 331 patients presenting with dysphagia who underwent HRM between 2021 and 2023. Participants were stratified into four age groups: early adulthood (≤34 years, 12.1%), early middle-age (35–49 years, 12.7%), late middle-age (50–64 years, 45.3%), and late adulthood (≥65 years, 29.9%). Peristaltic reserve was assessed using MRS to evaluate esophageal contractile function.

Results

Among the 311 patients included, 195 (58.9%) were male, with a median age of 57 years (IQR 45–66). The prevalence of normal esophageal motility was highest in early adulthood (67.5%) and early middle-age (78.6%) but declined significantly in late middle-age (48.7%; p=0.014) and late adulthood (44.4%; p<0.001). Late adulthood was also characterized by lower median upper esophageal sphincter (UES) pressure (101 mmHg) and reduced UES length (3 cm; p<0.05). Additionally, esophagogastric junction (EGJ) type II and III morphology was more frequently observed in late adulthood (52.5%; p<0.05). In patients with normal motility (n=177), MRS motor wave transmission was lower in late adulthood (75%, p<0.05) compared to early adulthood (96.3%), early middle age (88.1%) and late middle age (93.2%), and the prevalence of incomplete MRS inhibition was higher in late adulthood (79.5%, p<0.05) compared to early adulthood (11.1%), early middle age (21.2%) and late middle age (46.6%). The DCI-MRS and DCI wet ratio were significantly lower in late adulthood (0.51, IQR 0.13 – 0.88; p<0.01).

Conclusion

Peristaltic reserve declines with advancing age, which may contribute to dysphagia. MRS proves to be a useful diagnostic tool for detecting subtle motility impairments related to aging.

Introduction

Transmural oesophageal defects are associated with significant morbidity and mortality. Repeat surgery is often complicated and undesirable with variable outcomes. Increasingly, endoscopic interventions including clip closure devices, temporary full covered self-expanding metal stents (FcSEMS) and endoscopic suturing are being used to treat this problem. Endoscopic vacuum therapy (EVT) relies on a sponge-based device that is placed either within a cavity or the oesophageal lumen to provide continuous negative pressure over the defect which enhances drainage and tissue micro-perfusion.
The VacStent GI^TM (MicroTech) device is an innovative endoscopic solution which synergistically incorporates the advantages of a fcSEMS while synchronously employing the principles of EVT.

Aims & Methods

We retrospectively analysed patients undergoing treatment for transmural oesophageal defects with the VacStent GI^TM (MicroTech) device between October 2023 and Febuary 2025 at two upper GI surgical centres (UCLH and University Hospitals of Derby).
All patients had cross-sectional imaging and any chest contamination was drained before stent insertion. Defects involving the cricopharnyx and/or those more than 5cm were excluded. Continuous negative pressure of 125 mmHg was used for the first 24 hours after stent placement and then reduced to 75 mmHg. The VacStent was exchanged every 7-10 days until defect closure. All cases were performed in endoscopy with a minimum of propofol sedation and were discussed as part of specialist MDT.
The primary outcome was clinical success, defined as the endoscopic and radiological evidence of defect closure. Secondary outcomes included technical success, number of stent exchanges, serious adverse device effect (SADE) and time to defect closure.

Results

The VacStent GI^TM (MicroTech) device was used 33 times in 16 patients with a median age of 65 years (IQR 57-75). The study population comprised 75% male and 25% females. 2/16 (12.5%) had defects secondary to boerhaaves syndrome, 4/16 (25%) had iatrogenic defects and, 10/16 (62.5%) had anastomotic leaks (1=benign:9=malignant).
Clinical success was achieved in 10/16 (62.5%) patients with a technical success rate of 100%. Median time to defect closure following index VacStent implantation was 10 days (IQR 6-15) with a median of 1 VacStent exchange (IQR 0-2). The median defect size was 10mm (IQR 6-14). Cases of VacStent failure appear to be related to defects more than 4cm and those within a conduit (Table 1). There was a single adverse event related to severe bleeding due to the stent becoming embedded to the oesophageal lumen – after the VACStent was removed, a temporary fully covered stent was placed to tamponade any bleeding and later removed uneventfully.

Conclusion

In conclusion, our experience has demonstrated that VacStent is a safe and effective treatment option for oesophageal defect closure achieving this in 62.5% of patients. This is a challenging cohort of patients that usually have limited treatment options. Multi-disciplinary collaboration and early recognition of both appropriate and inappropriate defect dimensions and aetiology is critical to enhancing success rates. Ongoing experience with a more diverse and larger patient population will further clarify the position of the VacStent device in the EVT treatment paradigm.

Introduction

Oesophageal adenocarcinoma (EAC) remains a leading cause of cancer-related mortality, with poor survival outcomes. Early identification and treatment of dysplasia in Barrett’s oesophagus (BE) is critical to reducing the risk of post-endoscopy upper gastrointestinal cancers (PEUGIC). While mucosal cleansing and clear visualisation are recognised as essential, existing evidence also demonstrates that certain procedural factors—such as longer inspection times—can significantly improve dysplasia detection rates (DDR) (2). This raises the possibility that other procedural variables may similarly influence detection outcomes. In this audit, we evaluated whether additional technical and patient-related factors affect dysplasia detection, with the aim of optimising surveillance quality and reducing the risk of Post-Endoscopy Upper GI Cancer (PEUGIC).

Aims & Methods

This audit aimed to assess the impact of procedural variables on dysplasia detection during Barrett’s surveillance endoscopy. A retrospective analysis was conducted in Wales, reviewing 192 patient records from June to December 2023. Factors that may influence dysplasia detection were evaluated including sedation type, use of acetic acid for mucosal enhancement, adherence to the Prague grading system, describing lesions using the Paris classification, NBI use and the Seattle biopsy protocol. Additionally, patient comfort was assessed as it may impact procedural quality and compliance. Analysis was carried out using SPSS (IBM, USA). T-tests were used for parametric data, and Mann Whitney U-tests for non-parametric data. Categorical data were analysed using Chi-square or Fisher’s exact tests. Statistical significance was set at p < 0.01.

Results

Improved imaging quality was significantly associated with higher patient comfort (p = 0.001). Higher doses of midazolam were associated with greater detection of visible lesions, while fentanyl showed less of a significant effect. Additional use of acetic acid and aceto-whitening effect significantly enhanced dysplasia detection, with strong alignment to histological findings (p<0.001). NBI further improved lesion identification when used adjunctively. In procedures performed by expert endoscopists, targeted biopsies identified dysplasia at comparable rates to the Seattle protocol, suggesting limited additional value of the latter in experienced hands.

Conclusion

This study underscores the importance of optimising procedural elements—particularly higher doses midazolam (median 5mg), acetic acid application, and ensuring patient comfort—to improve dysplasia detection in Barrett’s surveillance. Although PEUGIC data seems to show better neoplasia detection rates with combined Midazolam and Fentanyl, we did not demonstrate this(1). seattle protocol may still be helpful for dysplasia detection, but it’s use appears less beneficial than regular use of NBI and acetic acid chromoendoscopy.

References

1. Dhar A. Re: “Dedicated service for Barrett’s oesophagus surveillance endoscopy yields higher dysplasia detection and guideline adherence in a non tertiary setting in the UK: a 5-year comparative cohort study” by Ratcliffe et al. Frontline gastroenterology [Internet]. 2023 Mar;15(3):264. Available from: https://pubmed.ncbi.nlm.nih.gov/38665792/
2. Gupta N, Gaddam S, Wani SB, Bansal A, Rastogi A, Sharma P. Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett’s esophagus. Gastrointestinal Endoscopy. 2012 Sep;76(3):531–8

Introduction

High resolution esophageal manometry (HRM) is commonly used to assess esophageal motility disorders. Data about the effect of age on HRM parameters and diagnoses are contradictory.

Aims & Methods

We aimed to explore the effect of age on HRM parameters and diagnoses in those under and above the age of 65.
We included all patients undergoing HRM within our institution between 2020-2021 (across both Chicago Classification 3 and 4 protocols). Clinically relevant esophagogastric junction outflow obstruction (EJGOO) was defined as having dysphagia or chest pain, elevated integrated relaxation pressure (IRP) in both positions where available, and positive adjunctive tests. Adjunctive tests included timed barium esophagrams, esophagram with a barium tablet, and/or functional lumen imaging probe (FLIP) tests.

Results

Of 486 included patients, 59% were female patients, 81% white, 3% Hispanic. There were 151 (31%) aged 65 and older and 335 (69%) younger than 65. The age≥65 vs. under 65 groups had similar proportions of female patients (61% vs.58%), race and ethnicity distribution, though older patients had lower median (IQR) BMI (26 [23-30] vs. 27 [24-31], p=0.023)
The age≥65 group had a higher IRP and mean lower esophageal sphincter pressure (LES) compared to the age<65 group, p<0.01 for both. Additionally, patients older than 65 had a higher rate of both manometric and clinically relevant EGJOO (p<0.001 for both), and a lower rate of hypomotility diagnoses. See table for details.
Multivariable logistic regression showed that age was independently associated with EGJOO per CC3 (elevated IRP in at least one position [upright or supine] and normal peristalsis): OR= 1.72 (95% CI 1.35-2.19, p<0.001) for each 10-year increase in age and after adjusting for sex, BMI and the study protocol (Chicago 3 or 4). Furthermore, within the group of patients with EGJOO per CC3, the odds of being diagnosed with clinically relevant EGJOO were 4.28 (95% CI 1.34-13.7, p=0.014) for each 10-year increase in age and adjusting for the same variables.

Conclusion

Our data show that HRM results differ in patients referred for manometry and older than 65. Specifically, these patients have a higher rate of clinically relevant EJGOO and greater IRP. This may be related to age related changes in myenteric innervation. Future studies are needed to establish whether patients older than 65 progress to achalasia or will benefit from EGJ directed therapy.

Introduction

Gastroparesis (GP) is defined as symptomatic delayed gastric emptying. The most frequent etiologies are diabetes mellitus, after esophageal or gastric surgery and about a third of patients have idiopathic GP. The gastric emptying study by using a scintigraphy scintigraphy (GES) is considered as a principal diagnostic method. Endoscopic pyloromyotomy (G-POEM) is a method improving symptoms in about 60-70% of patients with GP. Its effect on gastric emptying remains controversial.

Aims & Methods

We performed a retrospective single-center analysis to assess the clinical efficicacy of G-POEM based on GES parameters. Between 2016 – 2024, a total of 72 patients with GP (confirmed by scintigraphy) underwent G-POEM and were later invited for clinical as well as scintigraphic assessment after 3, 12 and 36 months. Of these patients, 4 were excluded for missing data, incomplete follow-up data or non-standard testing meal. GES was always performed using the standardized 4 hours protocol with the standard testing meal mixed with 99Tc-DTPA. For this study, all GES were reanalyzed and the following parameters were established : residual activity after 2 hours, residual activity after 4 hours, biological halftimes of ingested activity and proximal-to-distal count ratio for time 0 (PDCR0).

Results

Mean value of GCSI before G-POEM was 3.1 and decreased to 1.6, 1.0 and 0.7 after 3, 12 and 36 months. Median value of GES after 2 hours was 60.2% before G-POEM and 38%, 32.6% and 24.2% after 3, 12 and 36 months. Median value of GES after 4 hours was 21.9% before G-POEM and 7.8%, 6.5% and 3.9% after 3, 12 and 36 months. Correlation index was weakly positive for GCSI and GES after 4 hours only for the first follow-up visit and negative for all remaining visits.
The residual activity after 2 hours and residual activity after 4 hours decreased after G-POEM during all follow-up visits (p<0,001). Mean decrease of residual activity after 4 hours was 12.89%, 15.13% and 6.7% after 3, 12 and 36 months.
Biological halftime also decreased after the procedure with statistically significant results with the mean halftime before G-POEM being 150 min and 86 min, 78.4 min and 65.8 min after 3, 12 and 36 months.
There was a difference between the diabetic and non-diabetic groups, with higher residual activity after 2 hours [median 29.6% before G-POEM, 9.0% after 3 months (p<0.001) and 11.0% after 12 months (p=0.005)] and 4 hours [median 64.8% before G-POEM, 39.4% after 3 months (p<0.001) and 37.7% after 12 months (p=0.012)] respectively in patients with diabetes.
The predictive value of PDCR0 for treatment success after G-POEM was only calculated for the first follow-up visit but was not statistically proved (p=0,712).

Conclusion

In our group of patients there is a weak correlation between the decrease of GCSI and GES early after G-POEM. The decrease in GES parameters tends to be lower in patients with diabetes compared to non-diabetic patients. Based on our data, predicting clinical success of G-POEM using PDCR0 cannot be recommended.