Introduction

‘Inability to Belch’, also called retrograde cricopharyngeal dysfunction (R-CPD), is a syndrome characterized by inability or impaired ability to belch, gurgling noises from the chest or lower neck, thoracic or abdominal pain, bloating and flatulence (1). Although awareness of the disorder is increasing, little is known about its cause, characteristics or epidemiology.
Besides recognition of typical symptoms, high resolution impedance manometry (HRiM) is increasingly used to confirm the diagnosis in suspected cases (2, 3).

Aims & Methods

Our aim was to design a diagnostic questionnaire based on the cardinal symptoms, and to validate this questionnaire against the only available objective diagnostic tool at present, i.e. HRiM with belch provocation test (sparkling water) (2, 3).
The questionnaire was developed based on medical history taking of patients that presented to our center with ‘inability to belch’ (4). Fifteen symptoms were included: inability to belch, gurgling noises, thoracic pain, abdominal pain, nausea, fullness, early satiety, bloating, flatulence, heartburn, regurgitation, frequent or painful hiccups, dysphagia, and difficulty to vomit. These were questioned for frequency, severity, bothersomeness and the trigger or timing at which they occurred. A first draft of the questionnaire was evaluated in a cognitive debriefing of the first three R-CPD patients, after which some clarifying changes were made.
Subsequently, the questionnaire was filled out during HRiM prospectively by R-CPD and control patients, each of whom underwent belch provocation test as described by our group (3).
Wilcoxon signed rank test was used to compare between groups. A logistic model was used to compute probabilities with their 95% confidence interval (CI).

Results

The questionnaire was completed by 17 patients reporting inability to belch, and 47 control patients, during HRiM with belch provocation test. In 13 out of 17 patients (sensitivity 76%, positive likelihood ratio of HRiM: 8.44), R-CPD was confirmed with typical findings on HRiM. The indication for HRiM in control patients was GERD (n=27), dysphagia (n=9), chest pain (n=3), known achalasia (n=2), belching (n=1), globus (n=1) and dyspepsia (n=1). In the control patient group, 4 patients were excluded from further analysis because of abnormalities on HRiM similar to R-CPD (specificity 91%, negative likelihood ratio: 0.26).
Using HRiM as a gold standard, we identified the following questions that were significantly different in R-CPD patients vs. controls: frequency of inability to belch (p <0.001, probability of abnormal HRiM when present: 0.6000 CI 0.380:0.786 ), gurgling noises (p = 0.0019, probability when present 0.4000, CI 0.230:0.597), and dysphagia (p = 0.003, probability when present 0.065, CI 0.016:0.022). Even though these symptoms were often present in R-CPD, chest pain, abdominal pain, nausea, fullness, early satiety, bloating, heartburn, regurgitation, hiccups and vomiting did not differ significantly between both patient groups.

Conclusion

We designed a diagnostic questionnaire to help identifying R-CPD. Based on a comparison between R-CPD patients with a control population with a variety of upper motility disorders, the presence of ‘inability to belch’, gurgling noises; and the absence of dysphagia were significantly different between R-CPD patients and controls.
Pending further validation, this questionnaire provides a basis for developing a scoring system for patients with ‘inability to belch’ and it can be used to explore the epidemiology of this peculiar syndrome.

References

1. Bastian RW, Smithson ML. Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment. OTO Open. 2019;3(1):2473974x19834553.
2. Oude Nijhuis RAB, Snelleman JA, Oors JM, Kessing BF, Heuveling DA, Schuitenmaker JM, et al. The inability to belch syndrome: A study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2022;34(5):e14250.
3. Karlien Raymenants FV, Stijn Arnaert, Jan Tack, Tim Vanuytsel, Filip Baert, Lieve Delsupehe, Joris Arts Manometric diagnosis and treatment of retrograde cricopharyngeus dysfunction (R-CPD). United European Gastroenterology Journal. 2023;11.
4. Arnaert S, Arts J, Raymenants K, Baert F, Delsupehe K. Retrograde Cricopharyngeus Dysfunction, a New Motility Disorder: Single Center Case Series and Treatment Results. J Neurogastroenterol Motil. 2024;30(2):177-83.

Introduction

Peroral endoscopic myotomy (POEM) has become a standard endoscopic treatment for patients with achalasia, with many studies reporting on its long-term effectiveness. However, the impact of a patient’s previous surgical history on the long-term outcomes of POEM remains unknown.

Aims & Methods

This study aims to compare the long-term efficacy of POEM in achalasia patients with and without prior surgical interventions. A single center, retrospective review was conducted on achalasia patients who underwent POEM between January 2016 to December 2020. Clinical, demographic, radiographic, endoscopic, and manometric data were collected. Patients with less than two years of follow-up without noted failure were excluded. The analysis compared outcomes between first-time POEM patients (naïve POEM) and those undergoing POEM following failed surgical treatments (redo POEM). The primary outcome was the clinical success rate, defined as an Eckardt Score of 3 or less at final follow-up and no need for additional interventions. Secondary endpoints included the prevalance of postoperative gastroesophageal reflux disesase (GORD), the necessity for acid suppression medications, and additional interventions for achalasia.

Results

Data were collected on 47 naïve POEM and 26 redo POEM patients. After excluding 17 naïve POEM patients and 8 redo POEM patients who did not meet the criteria for long-term follow-up, a total of 30 naïve POEM patients and 18 redo POEM patients were analyzed. In the redo POEM group, 77.8% (14/18) of the patients underwent Heller myotomy with Dor fundoplication, while the surgical details for the remaining patients were unknown. The median length of symptoms was 5 (IQR 3-10) years for naïve patients and 6 (IQR 1.2-17.5) years for redo patients (p=0.29). According to the Chicago classification v4.0, the achalasia subtypes in the naïve POEM group were Type I in 9 patients (30%), Type II in 12 (40%), Type III in 3 (10%), and other types in 6 (20%). For the redo POEM group, subtypes were Type I in 9 patients (50%), Type III in 2 (11.1%), and unspecified in 7 (38.9%). Barium esophagram revealed no significant differences in the maximum diameter between the groups (naïve POEM 45.8 ± 21.4 mm vs. redo POEM 44.9 ± 15.4 mm, p=0.89). Long-term success rates were 76.7% (23/30) in naïve POEM and 83.3% (15/18) in redo POEM, with no significant difference between the groups (p=0.72). Postoperative GORD was noted in 63.3% (19/30) in the naïve POEM versus 67% (12/18) in the redo POEM (p=0.06), with newly prescribed acid suppression medication in 23.3% (7/18) and 55.6% (10/18), respectively (p=0.02). Additional interventions for achalasia were required in 10% (3/30) in the naïve POEM versus 11.1% (2/18) in the redo POEM, with no significant difference between the groups (p=1.0). In the naïve POEM group, one patient required a second POEM, another was hospitalized due to achalasia recurrence, and a third underwent Heller myotomy with Dor fundoplication. In the redo POEM group, one patient underwent endoscopic balloon dilatation, and another required esophagectomy.

Conclusion

POEM is an effective long-term treatment for achalasia, demonstrating similar success rates in patients undergoing either their first or redo POEM procedures. The overall efficacy and safety profiles support POEM as a recommended treatment for managing achalasia regardless of prior surgical treatment failures.

Introduction

Increased interest in ERCP simulator-based education is driven by the need for efficient and safe endoscopy training in a dedicated environment.
This study assessed whether a structured training program including initial training with the Boškoski-Costamagna ERCP Trainer (BCT) offers benefits to conventional training.

Aims & Methods

This was a one-year prospective, multicenter, parallel-arm, randomized controlled trial involving 16 novice ERCP trainees randomly assigned to study (SG) and control (CG) groups. Both underwent hands-on ERCP training. Additionally, SG had simulator-based training during the first three months. Performance was evaluated with TEESAT score in all ERCPs with any degree of trainee involvement until each trainee completed a minimum of 60 ERCPs. The primary outcome was overall trainee competence rate; secondary outcomes included successful biliary cannulation and adverse event (AE) rates. Learning curves were generated cumulatively over the training period. Both outcomes and the analysis of specific ERCP steps predictive of overall competence were assessed using mixed-effect logistic regression models (MELR). The most effective predictive model of overall competence was identified using a stepwise backward procedure. MELR was employed to investigate potential confounding factors.

Results

1,106 ERCPs were included (SG=562,CG=544). SG trainees demonstrated higher success in native biliary cannulation (SG=52%, CG=42%, p<0.001), achieved faster biliary cannulation [SG=3(6)min, CG=5(8)min, p<0.001], and showed a faster evolution on overall performance, native biliary cannulation, and sphincterotomy. Successful biliary cannulation [OR=10.10, 95% CI (5.15-19.83)] and sphincterotomy [OR=7.71, 95% CI (3.77-15.76)] were the most important predictors for overall competence. The multivariate random-effects model demonstrated an almost significant association between simulator-based training [OR=3.24, 95% CI (1.01-10.39), p=0.049] and overall competence, accounting for biliary cannulation, sphincterotomy, and stone removal. No confounding factors were identified.

Conclusion

This study suggests that early simulator training with BCT accelerates the learning curve of trainees in performing key steps of the ERCP procedure and improves overall competence as assessed by dedicated tools during ERCP training.

Clinical Case Summary

Gastrointestinal tuberculosis (GITB) is an uncommon form of extrapulmonary tuberculosis that poses a diagnostic challenge due to its non-specific clinical presentation. Among its varied manifestations, gastrointestinal bleeding as an initial presentation is exceedingly rare. This case report aims to highlight the diagnostic difficulties, treatment modalities, and clinical outcomes in a patient with GITB presenting as gastrointestinal bleeding.
This is a case of a 24/M, no known comorbidities, immunocompetent host, no maintenance medications who came in for sudden onset of hematochezia with progressive drop in hemoglobin levels. Work up revealed a circumferential wall thickening involving the ileocecal region. Bleeding from mass was difficult to control despite medications and colonoscopy attempts hence patient underwent exploratory Laparotomy, right segmental colectomy. Histopathology results revealed caseating chronic granulomatous inflammation and lymph nodes showing caseating granulomas. Patient was then started on anti-Kochs treatment with note of improvement of symptoms post treatment.

References

1. Sharma, V., Mandavdhare, H. S., Lamoria, S., & Dutta, U. (2019). Gastrointestinal tuberculosis: A systematic review and meta-analysis. Scandinavian Journal of Gastroenterology, 54(5), 567-577. doi:10.1080/00365521.2019.1598343
2. Kapoor, A., & Schewitz, I. (2020). Gastrointestinal tuberculosis: Understanding the molecular mechanisms for better diagnosis and treatment. Journal of Digestive Diseases, 21(4), 195-204. doi:10.1111/1751-2980.12866
3. Amarapurkar, D. N., Patel, N. D., & Amarapurkar, A. D. (2018). Gastrointestinal tuberculosis. Indian Journal of Medical Research, 147(5), 401-416. doi:10.4103/ijmr.IJMR_1004_17
4. Sharma, V., Mandavdhare, H. S., & Lamoria, S. (2020). Update on gastrointestinal tuberculosis: Newer techniques and treatment strategies. World Journal of Gastrointestinal Pharmacology and Therapeutics, 11(3), 10-26. doi:10.4292/wjgpt.v11.i3.10

Disclosure

None

Clinical Case Summary

Leiomyomas are benign soft tissue neoplasms that arise from smooth muscle. They are uncommon in the colon. We report two cases of colonic sessile polyps that underwent polypectomy and histology showed leiomyoma.

The first patient previously had a history of polyps with tubular adenoma with low grade dysplasia. A repeat colonoscopy for polyp surveillance was done which found polyps in the ascending colon, and sigmoid. The sigmoid colon polyp was 4mm in size and removed via cold snare polypectomy (Figure 1).
The second patient had underlying non-alcoholic fatty liver disease cirrhosis and iron deficiency anaemia. Colonoscopy showed colonic polyps which were biopsied (Figure 2).

The histology of the first patient’s sigmoid colon polyp showed nodular spindle cell lesion centered in the submucosa/muscularis mucosa. The lesion was composed of spindle cells in fascicles with bland spindled nuclei and eosinophilic cytoplasm. Desmin and SMA stains were done and they were diffusely positive. CD117 stains were negative. DOG1 showed focal nonspecific staining in lesional cells. The overlying lamina propria also showed aggregates of foamy histiocytes and lymphoid aggregates. These were consistent with a leiomyoma.
The second patient’s histology also showed fascicles of spindle cells and immunohistochemistry stain showed positivity for SMA and desmin but negative for CD117 and DOG-1, consistent with leiomyoma.

As the polyps showed smooth margins endoscopically and has similar appearance to hyperplastic polyps, it was likely thought to have a hyperplastic component on top of leiomyoma, hence the patients are to be monitored and followed up for routine surveillance.

References

Miettinen M, Sobin LH, Am J Surg Pathol. 2001;25(11):1433

Introduction

The United Kingdom National Institute for Health and Care Excellence recommends Faecal Immunochemical Testing (FIT) for all patients presenting to primary care with symptoms suggestive of colorectal cancer. How use of this test varies across England is unknown, which this study aimed to quantify.

Aims & Methods

Routinely-collected primary care records (Clinical Practice Research Datalink Aurum) were used to assess variations in symptomatic FIT use in adults (≥18 years) between regions and over time in England from 2019 to 2023. Rates were calculated using the population registered to each primary care practice as the denominator, with analysis split by calendar year.
The first coded FIT test with a numerical result per patient each year was extracted from the primary care records. Rates of testing were calculated using Poisson regression, adjusted for other confounders. Results were described between groups, regions and years at the recommended threshold of ≥10 µgHb/g faeces (results above this threshold henceforth referred to as FIT10), describing the proportions likely to have a secondary care referral based on national guidance. Logistic regression was used to compare the impact of year, region, gender and age on the differences in FIT10.

Results

Between 01/01/2019 and 05/06/2023 there were 531,735 FIT results among 495,121 patients and a denominator population of 17,910,681. The number of completed FITs increased from 8,395 in 2019 to 237,708 in 2022 (the last complete year within the study), with a corresponding ~thirty-fold increase from 0.69 tests per 1000 person-years in 2019 (95%CI 0.68-0.71) to 19.57 per thousand person-years in 2022 (95%CI 19.50-19.65). There was large variation in testing between regions, with rates 3.6 times higher in the North East compared to the West Midlands (17.05 per thousand person-years, 95%CI 16.87-17.23 versus 4.72 per thousand person-years, 95%CI 4.67-4.76). These differences persisted to 2022, with less than half the rate in the West Midlands (11.32) compared to the North East (31.85 per thousand person-years).
20.4% of results were FIT10. Despite increased testing, the overall proportion FIT10 did not change over time. 51.7% of all tests FIT10 were in those over 70 years of age. The percentage FIT10 was lower in regions with higher rates of FIT testing, for example FIT10 ranged from 16.7% in the South West (rate of testing 14.62 per thousand person-years) to 25.3% in the South East (rate of testing 8.00 per thousand person-years). After adjusting for year, region, gender and age, this difference persisted (adjusted OR 0.57, 95%CI 0.55-0.58) comparing FIT10 in the South West to the South East. The difference in proportions FIT10 between regions showed some convergence over time, from a range of 16.6%-26.7% (10.1%) in 2021 to 15.8%-23.7% (7.9%) in 2023.

Conclusion

There has been a marked increase over time in the use of FIT for patients with symptoms in primary care, with large and persistent variations between regions of England. The overall proportion FIT10 has not decreased over time with increasing use, however there were large differences in FIT10 between regions that correlated with rates of testing. These regional differences persisted but reduced over time as testing rates increased nationally. It is likely that clinical pathway differences in the implementation of FIT over time and between regions explain the variations we have observed. If used as a guide to referral, such variation could lead to inequalities in colorectal investigation and diagnosis.

Introduction

Resection of large non-pedunculated colorectal polyps (LNPCP) located in the rectum varies by institution and region with some, particularly colorectal surgeons, favouring TEM and others endoscopic resection (ER). There is a paucity of data directly comparing these strategies and the procedure of choice remains under debate. Our unit is a tertiary referral centre for complex polyps and early colorectal cancer. All rectal LNPCP were treated by TEM until a change in practice from 2011 when the first-line therapeutic strategy for rectal LNPCP changed to ER.

Aims & Methods

We aimed to report the outcomes of TEM and ER of rectal LNPCP from a large tertiary cohort. Large (≥20mm) rectal adenomas resected by TEM or ER (2009 – 2023) were analysed. From 2009-2011 all rectal adenomas were treated by TEM, after which the primary resection strategy changed to ER. Outcomes were compared between techniques. Given the difference in resection strategy, a composite outcome of septic complications included clinically significant perforation for ER (early or delayed perforation requiring any form of unplanned medical or surgical treatment) and septic complications for TEM (peritonitis or pelvic/anorectal sepsis).

Results

704 rectal adenomas were resected by TEM (n=71), EMR (n=145) and ESD/Hybrid ESD (n=488) with a mean size of 45mm for TEM vs 55mm for ER (p<0.001). 100% of patients undergoing TEM required hospital admission vs 15% for ER (p<0.001), and 100% required general anaesthesia (GA) for TEM vs 26%% for ER (GA or propofol sedation, p<0.001). En bloc resection was achieved for 96% of ESD resections, 54% of TEMS, 28% of EMR and 14% of hybrid ESD (p<0.001). The incidence of complications were similar (9.9% for TEM versus 5.0% for ER, p=0.10). Recurrence occurred in 2.7% after ESD, 21.1% after EMR, 23.6% after Hybrid ESD and 36.4% after TEM (p<0.001). No patients undergoing ER or TEM required surgery as a result of a complication.

Conclusion

Despite significantly larger lesion sizes, ER in our institution provides far superior results for patients than TEM with relatively fewer patients requiring hospital admission and lower recurrence rates, especially with ESD. En bloc resection was more likely with ER as a result of the difficulty achieving en bloc resection for extremely large lesions with TEM, which can invariably be resected en bloc by ESD. These results have led to a policy of ER for all apparently benign rectal tumours regardless of size and, in recent years, ESD as the primary approach for all rectal lesions.