Introduction

Lymphocytic and eosinophilic esophagitis (LyE and EoE) are immune-mediated esophageal diseases. LyE has been proposed as a variant of EoE but differences and similarities between the diseases have been poorly investigated.

Aims & Methods

We aimed to compare clinical characteristics, endoscopic findings, and treatment response in patients with LyE versus EoE. Consecutive patients diagnosed with LyE (i.e., ≥30 lymphocytes/high-power field, HFP) or EoE (i.e., ≥15 eosinophils/HPF) without evidence of candida esophagitis were enrolled at three esophageal tertiary referral centres in the UK and Italy (London, Pisa, and Padua). For each patient, the following data were retrospectively extracted: clinical characteristics, endoscopy findings at index endoscopy, histology response to proton pump inhibitors (PPI) based on at least six esophageal biopsies, and symptoms response. Treatment efficacy was assessed after a minimum of 12 weeks of treatment. Histological response was defined as the absence of lymphocytes for LyE and as eosinophils <15/HPF for EoE. Symptom response was based on patients’ perception of resolution or persistence/worsening of symptoms. Data are described as median and interquartile range (Q1-Q3) or as counts and percent. Kruskal-Wallis Rank Sum Test was used for continuous data, while Pearson’s Chi-Square test (with continuity correction) and Fisher’s exact test were used for counts. Significance was set at p<0.05.

Results

Thirty LyE and 59 EoE patients were included. Patients with Lye were older [53yrs (33-61) vs 38 (25-47); p=0.005] and more frequently female (46.7% vs 18.6%; p<0.01) compared to EoE. Dysphagia and food bolus impaction requiring endoscopic removal were less common in LyE than EoE (p<0.01 and p<0.001), while heartburn and chest pain had similar prevalence in the two cohorts. Patients with LyE had autoimmune diseases more often than EoE (p=0.001). LyE patients less frequently reported atopy and less frequently had increased serum IgE, atopic dermatitis or allergic rhinitis (p<0.001), while the prevalence of nasal polyposis or asthma was comparable to EoE. At index endoscopy, compared to EoE, LyE patients less frequently had edema, rings, exudates, or furrows (p<0.05 for all), but had a similar and low prevalence of strictures, or Schatzki rings (Table 1). Histological or symptomatic response to proton pump inhibitors (PPI) was consistently lower in LyE compared to EoE. These differences were statistically significant when any dose of PPI was considered (20mg or 40mg or 60mg daily), but the differences were not statistically significant when only patients taking ≥40mg/day were included in the analysis.

Conclusion

LyE and EoE patients are different in terms of demographics, comorbidities, clinical presentation, and endoscopic findings. This suggests different immunological phenotypes. Response to PPI seems lower in LyE, but further studies are needed to confirm these findings.

Introduction

UGI cancer detected within 5 years of a gastroscopy (termed post-OGD UGI cancer – POUGIC) may reflect delayed diagnosis and contribute to poorer prognosis. It has been estimated to be as high as 14% and BSG quality standards (2017) recommend rates do not exceed 10%. UGI cancer often presents late and with limited curative treatment options efforts are increasingly focused on improved screening methods and earlier diagnosis. We undertook a retrospective review of all histological diagnoses of oesophageal and gastric carcinoma at our hospital over a 10-year period to describe this cohort in our own practice.

Aims & Methods

Medical records for 588 histological diagnoses of gastric and oesophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) between 13/01/10 and 24/08/20 were reviewed, including previous OGDs, histology reports, radiological staging and past medical history.
The aim was to profile patients to identify risk factors for the development of POUGIC.

Results

42/588 pts (7%) underwent OGD up to 5y (med 22m) prior to cancer diagnosis.
POUGIC pts: aged 53-96y (med 74.5y), 21% female, 60% White, 10% Asian, 10% Black, and 20% mixed/other.
Non-POUGIC (546pts): aged 24-94y (med 71.5y), 34% female, 57% White, 10% Asian, 11% Black, and 22% mixed/other.

Conclusion

POUGIC were <10% of UGI cancer diagnoses, in accordance with BSG quality standards.
Age, gender and ethnicity were similar in both POUGIC and non-POUGIC, and so were not predictive factors.
Staging and median survival were also similar between POUGIC and non-POUGIC, suggesting that these outcomes were not affected by an OGD within the previous 5y.
Oesophageal cancer was more common in those that had OGD in the preceding 5y compared to those that had not, and BO was the most common abnormality in these procedures. 78% POUGIC had risk factors for UGI cancer on their initial OGD (inflammation, ulcer, BO, hiatus hernia, stricture), raising the possibility that treatment could have been optimised, e.g. acid suppression (45% of POUGIC were on PPI before their cancer diagnosis), anti-reflux surgery, lifestyle modifications or improved surveillance. Importantly, 24% of POUGIC also had a “normal” preceding OGD, and with only 7% of these OGD performed by a Consultant, it is possible that pathology may have been missed on initial OGD. Additional novel screening techniques, such AI-assisted endoscopy, volatile organic compounds and Cytosponge may help obtain earlier diagnoses in future.

References

Beg S, Ragunath K, Wyman A, et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the BSG and AUGIS, Gut (2017).

Introduction

Several scoring systems have been established to identify upper gastrointestinal bleeding (UGIB) patients at high risk of adverse outcomes, being the best ones MAP (ASH) and ABC (1). Traditional scores(Glasgow-Blatchford, Rockall, AIMS65) were validated and compared mostly in nonvariceal-UGIB. On the contrary, MAP (ASH) and ABC included variceal bleed (VB) in their validation and comparison cohorts.
Also, to determine the prognosis of liver cirrhosis there are two frequently used scores, Child-Pugh score (CP) and MELD, and recently, ALBI score. Previous studies have reported the ability of these in predicting VB outcomes. A recent metanalysis show MELD and CP performed better predicting mortality than traditional scores (2). But there are no studies comparing liver scores with MAP (ASH) or ABC.

Aims & Methods

To compare the predictive value of MAP (ASH) and ABC scores vs. liver scores stratifying outcomes of VB.
Retrospective analysis of a prospective registry of UGIB patients admitted to ‘Virgen de las Nieves University Hospital’ (2013-2020). VB was defined as that coming from gastric or esophageal varices. Main outcomes were in-hospital (intervention,rebleeding, misbalance of chronic condition, mortality) and delayed-6months (UGIB, cardiovascular, mortality) ones. Intervention is a composite endpoint including need of transfusion, endoscopy therapy, interventional radiology or surgery. Statistical analysis was performed by SPSS and MedCalc.

Results

We included 1345 UGIB patients, 241 with VB, mean age 60.70+/-12.62, 26.1% females. Main differences between deaths and survivors were hepatocellular carcinoma, (57.1%vs.16.1%,p=0.001, OR 6.97,95%CI 2.28-21.34), misbalance of chronic condition (40.7% vs. 5.5%, p<0.001, OR 11.83,95 % CI 5.15-27.22), intervention (21.1% vs. 3%, p=0.013, OR 8.56,95 % CI 1.14-64.49), rebleeding (50%vs.12.7%, p<0.001, OR 6.88, 95% CI 3.12-15.20) and length hospital stay (15.91vs.9.23,p=0.031). In the multivariate analysis, misbalance of chronic condition was an independent risk factor for mortality (OR 4.23, 95 % CI 1.11-16.06, p=0.034).
Comparisons of ROC curves for relevant outcomes are shown in the table, with statiscal differences only for intervention (MAP(ASH) >CP, p=0.0195), misbalance of chronic condition (MAP(ASH) >ALBI, p=0.023; ABC > CP, p=0.020; ABC > ALBI, p=0.001) and delayed UGIB/liver mortality (MELD > Child, p=0.042).

Conclusion

In our study, MAP (ASH) and ABC scores performed better at prediction intervention and misbalance of chronic condition. On the other hand, MELD is superior to CP in predicting delayed UGIB and liver mortality. None of them performs well in predicting rebleeding or other delayed outcomes. Although we see some differences in AUROCs for the other outcomes, no statical differences were found. Therefore, MAP (ASH) and ABC have a good performance not only in patients with UGIB but also in VB.
Independent risk factor for in-hospital mortality was misbalance of chronic condition, showing once again that it is not UGIB itself what determines the evolution if not the imbalance that it produces.

References

1. Jimenez-Rosales R, Lopez-Tobaruela JM, Lopez-Vico M, Ortega-Suazo EJ, Martinez-Cara JG, Redondo-Cerezo E. Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding. Journal of Clinical Medicine. 2023; 12(3):1085.
2. Yang L, Sun R, Wei N, Chen H. Systematic review and meta-analysis of risk scores in prediction for the clinical outcomes in patients with acute variceal bleeding. Ann Med. 2021 Dec;53(1):1806-1815.

Introduction

There has been a reduction in the rate of successful eradication for H. pylori in recent years, which has been largely attributed to increasing antibiotic resistance to traditional therapies. In areas of high clarithromycin & metronidazole resistance such as ours, Bismuth Quadruple Therapy (BQT) is a recommended first line therapy. In Ireland BQT has only recently been adopted, with doxycycline rather than tetracycline being employed for reimbursement reasons.

Aims & Methods

We aimed to assess efficacy of BQT therapy for H. pylori eradication in an Irish cohort.
All patients testing positive for H. pylori via OGD or UBT in a 2 Irish tertiary centres were treated prospectively with BQT (Bismuth 120mg QDS, Metronidazole 400mg TDS, Doxycycline 100mg BD & Esomeprazole 40mg BD x 14 days) over a period of 8 months. Eradication was confirmed with UBT at least 4 weeks after cessation of therapy (A delta-over-baseline >4% was considered positive) or by stool antigen testing, as available. Patient demographics and treatment outcomes were recorded, analysed and controlled for basic demographics and prior H. pylori treatment

Results

To date 122 BQT-treated patients with post-eradication testing were identified, 60(49%) female, mean age 50 years, 99 (80%) patients were treatment-naive. Overall, 108 (89%) had successful H. pylori eradication. There was no association between successful eradication and age or gender (p= 0.1546 and 0.0336 respectively).
BQT first line treatment success was significantly higher than for subsequent treatments (92/99) 93% versus (16/23) 70% OR 5.7, 95%CI 1.7 – 18.6, p <0.00 3. Neither age nor gender were significant predictors of outcome (p=0.0594)

Conclusion

BQT as first line therapy for H. pylori infection is highly effective in a high dual resistance population. Doxycycline substitution for tetracycline still achieved > 90% eradication. BQT as second line treatment as expected performed less well, and should no longer despite the complicated regime be reserved for rescue therapy.