Introduction

According to Lyon 2.0 consensus¹, a definitive diagnosis of gastro-esophageal reflux disease (GERD) requires endoscopic and/or pH-metry criteria. The recently developed and validated high-resolution manometry (HRM) metric termed the Milan Score² integrates four HRM variables related to GERD (ineffective esophageal motility (IEM), esophago-gastric junction (EGJ) contractile integral, EGJ morphology and straight leg raise (SLR) maneuver response) to quantify risk for definitive reflux. However, prediction of response to medical and surgical GERD treatment using the Milan Score has not been studied. The aim of this study is to evaluate the ability of the Milan Score to predict treatment outcome in patients with persistent GERD symptoms.

Aims & Methods

Data from patients who underwent HRM and pH-metry for persistent GERD symptoms were prospectively collected. Demographic, clinical and pathophysiological (HRM and pH-metry) data were extracted from the database, including the GERDQ questionnaire, Milan Score and acid exposure time (AET). A Milan Score ≥137 (risk rate 50%) and AET >6% were considered positive for GERD. Change in GERDQ was measured in patients with both pathologic and non-pathologic AET and Milan Score. The two methods were compared using the McNemar test to determine the non-inferiority of the Milan Score in comparison with the AET and Choen’s k coefficient was calculated to quantify the level of agreement. Receiver operating characteristics (ROC) analysis was performed using Milan Score and AET in determining improvement in GERDQ.

Results

Among 157 patients enrolled (median age 48 years, median body mass index (BMI) 24.6 Kg/m², 47% males), 67 (42.7%) had a positive Milan Score, 59 of which (88.1%) had a pathologic AET. Patients with a positive Milan Score had higher BMI and worse GERD-related metrics on HRM and pH-metry. Medical treatment was offered to 99 patients, and anti-reflux surgery to 45 subjects, therefore statistical analysis was performed in 144 patients. Overall, clinical improvement favored surgical over medical treatment (53% vs. 33%, p=0.027), and both treatments were more effective in patients with pathologic AET compared to patients with non-pathologic AET (medical: 52.9% vs. 22.2%, p=0.002; surgical: 69.6% vs. 36.4%, p=0.038). Similarly, patients with a pathologic Milan Score had better outcomes compared to patients with a non-pathologic Milan Score (medical: 61.5% vs. 13.8%, p<0.001; surgical: 76.9% vs. 21.1% surgical, p<0.001). A non-pathologic Milan Score failed to predict good treatment response in 16.7% of the patients, while a negative AET in 24.4%. The AET failed to demonstrated its superiority in predicting treatment response when compared with the Milan Score (p=0.130) and the Choen’s k coefficient was 0.62 (good agreement). ROC analysis showed an area under the curve of 0.790 for Milan Score and 0.715 for AET in predicting improvement in GERDQ.

Conclusion

The Milan Score is non-inferior to the AET in predicting response to medical and surgical GERD management. The Milan Score could therefore help identify patients who could benefit from an escalation of medical or surgical management.

References

1. Gyawali CP, Yadlapati R, Fass R et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024 Jan 5;73(2):361-371. doi: 10.1136/gutjnl-2023-330616. PMID: 37734911; PMCID: PMC10846564.
2. Siboni S, Sozzi M, Kristo I et al. The Milan score: A novel manometric tool for a more efficient diagnosis of gastro-esophageal reflux disease. United European Gastroenterol J. 2024 Mar 27. doi: 10.1002/ueg2.12565. Epub ahead of print. PMID: 38536701.

Introduction

Constipation is one the most common gastrointestinal disorders among women. Causing factors are various. We aimed to assess the role of colonoscopy in evaluation young women with constipation.

Aims & Methods

A multi-center, large cohort, cross-sectional, retrospective study included all colonoscopies performed between 2016 and 2021 in seven endoscopy departments. The indications and findings of the procedures were collected, findings of young women aged 40y and younger with constipation as indication were compared to older women.

Results

A total cohort of 377,795 patients, 198,629 (52.6%) females and 179,166 (47.4%) males. 7872 females underwent colonoscopy for constipation and other indications (Cohort 1). 6852 women referred to colonoscopy for constipation only (Cohort 2). Women younger than 50y had more associated symptoms than older women. 75% of colonoscopies in women < 40y were normal in both cohorts. In Cohort 1, Inflammatory bowel diseases (IBD) was significantly higher in young women <40y, Ulcerative Colitis (UC) 12(1.2%) and Crohn's 7(0.7%) p<0.001. In Cohort 2, among women <40y, UC was found in 6(0.7%) p= 0.01, Crohn's in 2(0.2%) p=0.05. In both cohorts, diverticulosis and polyps rates exponentially increased with age. The increase was remarkably noticed at ages >40y in comparison to younger subjects 18-39y, p<0.001. In Cohort 1, diverticulosis and polyps rates among young women <40y was 0.5% and 7.4% respectively. In Cohort 2 diverticulosis rate 0.4% and polyps 8%. One case (0.1%) of Colorectal cancer (CRC) in <40 y women and 0.3% in women aged 40-49y. In Comparison between two genders: Cohort 1 Similar prevalence of IBD found in males and females in all ages, (UC p=0.94, Crohn's p=0.67). Higher rate of diverticulosis among males in all ages p<0.05. Higher rate of polyps in all ages including young males <40y, p=0.001. In Cohort 2 no significant difference in the prevalence of IBD (p>0.05), diverticulosis rate (p=0.15), polyps rate (p= 0.34) and CRC rate (p=0.5) among young pts<40y of both genders.

Conclusion

The yield of colonoscopy in investigation isolated constipation in young females < 40y is not of a considerable diagnostic value. Clinical understanding should guide each case manager by using the correct beneficial diagnostic tools avoiding unnecessary invasive procedures.