Introduction

The relationship between coronary artery disease (CAD) and gastrointestinal function post-percutaneous coronary intervention (PCI) is complex and multifaceted.

Aims & Methods

This study aims to investigate the implications of CAD on gastric function and endoscopic characteristics in patients following PCI, providing insight into potential clinical interventions that could improve outcomes. A longitudinal study encompassed 116 patients with CAD post-PCI, with a mean age of 62.4 ± 12.5 years and 55% male representation. These patients were observed over a mean duration of 2.3 ± 1.5 years. Comprehensive assessments included cardiac function evaluation via echocardiography and biomarker analysis, alongside detailed gastric function tests (gastric emptying studies, pH monitoring) and endoscopic examinations to identify morphological changes in the gastric lining. Statistical analysis involved the use of independent t-tests and chi-squared tests for baseline comparisons, with paired t-tests and the Wilcoxon signed-rank test applied to assess changes over time. The Cox regression model was employed to determine the impact of altered gastric function and endoscopic findings on the prognosis of CAD patients, adjusting for age, gender, and baseline cardiac function.

Results

Our study identified significant gastric functional impairments in patients post-PCI, including delayed gastric emptying and increased gastric acidity (p<0.01). Endoscopic findings revealed a higher prevalence of gastritis and gastric erosions in this cohort compared to the general population (p<0.05). These gastric alterations were associated with poorer cardiac function and increased incidence of adverse cardiac events. Cox regression analysis further highlighted that specific gastric dysfunctions, particularly delayed gastric emptying and severe gastritis, significantly predicted worse cardiac outcomes (HR=2.3, 95% CI: 1.4-3.8, p=0.001), after controlling for conventional risk factors. This study sheds light on the notable impact of CAD and PCI on gastric function and morphology, underscoring the bidirectional relationship between heart disease and gastrointestinal health. The findings suggest that the stress and systemic inflammation associated with CAD and the intervention process itself may contribute to gastric dysfunction. Addressing these gastric issues through targeted therapies could potentially mitigate some of the adverse cardiac outcomes observed in this patient population.

Conclusion

The presence of impaired gastric function and specific endoscopic changes in CAD patients post-PCI underscores the need for a holistic approach to patient care, integrating cardiovascular and gastrointestinal management strategies. Early detection and treatment of gastric dysfunction in this cohort may offer a novel pathway to improving both gastrointestinal and cardiac outcomes, enhancing overall patient quality of life and reducing the burden of CAD.

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.

Introduction

Autoimmune atrophic gastritis (AAG) leads to significant changes in the gastric mucosa, including hypo-achlorhydria and increased gastrin (G) levels, providing proliferative stimuli on the gastric mucosa (1-5).

Aims & Methods

The aim of our study is to evaluate the occurrence and characteristics of gastric polyps in AAG patients across six tertiary centers in Italy. We conducted a multicentric, cross-sectional study from January to June 2023, prospectively enrolling consecutive patients diagnosed with AAG, from January 2000 to June 2023, who underwent at least one endoscopy. Data on demographics, clinical history, biochemical profiles, serological data, and endoscopic and histopathological findings were collected.

Results

Among 612 AAG patients (73.9% female, median age 66) followed up for a median of 4 (IQR 2-7.5) years, 222 (36.3%) had at least one gastric polyp. Non-endocrine polyps (214) were found in 162 patients, including 151 (70.5%) inflammatory, 29 (13.6%) adenomatous, 18 (8.4%) fundic gland polyps, 13 (6.1%) adenocarcinomas, and one MALT lymphoma. Additionally, 108 patients (48.6% of the population with polyps and 17.6% of the overall AAG patients) presented with gastric neuroendocrine neoplasms (gNENs), 48 of whom also had non-endocrine polyps. The median polyp size was 4 (IQR 2-7) mm. Older age, smoking prevalence, and higher levels of G and chromogranin A (CgA) were associated with polyp presence. No significant differences in OLGA/OLGIM stages or H. pylori status were noted between patients with and without polyps.

Conclusion

This study represents the largest multicentric cohort of AAG patients, highlighting the significant presence of gastric polyps, including gNENs and various non-endocrine types including a not negligible proportion of patients who showed gastric adenocarcinoma. These results emphasize the importance of proactive endoscopic monitoring and comprehensive histopathological evaluation in patients with AAG, to effectively identify and manage these different gastric lesions.

References

1. Zhang H, Jin Z, Cui R, Ding S, Huang Y, Zhou L. Autoimmune metaplastic atrophic gastritis in chinese: a study of 320 patients at a large tertiary medical center. Scand J Gastroenterol. 2017;52(2):150-6.
2. Krasinskas AM, Abraham SC, Metz DC, Furth EE. Oxyntic mucosa pseudopolyps: a presentation of atrophic autoimmune gastritis. Am J Surg Pathol. 2003;27(2):236-41.
3. Kishino M, Nonaka K. Endoscopic Features of Autoimmune Gastritis: Focus on Typical Images and Early Images. J Clin Med. 2022;11(12).
4. Park JY, Cornish TC, Lam-Himlin D, Shi C, Montgomery E. Gastric lesions in patients with autoimmune metaplastic atrophic gastritis (AMAG) in a tertiary care setting. Am J Surg Pathol. 2010;34(11):1591-8.
5. Massironi S, Elvevi A, Gallo C, Laffusa A, Tortorella A, Invernizzi P. Exploring the spectrum of incidental gastric polyps in autoimmune gastritis. Dig Liver Dis. 2023.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) has proven to be an effective technique for treating refractory gastroparesis^1,2. However, data on the long-term outcomes of the technique remain limited. We present findings from a multicenter study with over one year of follow-up.

Aims & Methods

In this retrospective study, patients undergoing G-POEM for refractory gastroparesis at two Italian centers from March 2019 to October 2024 were included. Primary endpoints were clinical success rates at 1 and 2 years. Secondary endpoints included factors associated with long-term clinical success (CS), changes in Gastric Emptying Study (GES) results, and Body Mass Index (BMI). CS was defined as a ≥1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI) and a 25% reduction in two symptom subscales.

Results

A total of 56 patients underwent G-POEM (median age 61 years [IQR 25: 45.8 - IQR 75: 71.5], 57.1% female, and 60.8% with idiopathic gastroparesis).
Technical success was achieved in 54 out of 56 cases (96.4%). Only two adverse events were recorded (3.5%, both grade 1 according to the AGREE classification). The median length of myotomy was 3.00 cm (IQR 25: 3.00 - IQR 75: 5.00). Single-layer myotomy was performed in 12 patients (21.4%), while 42 patients (78.6%) underwent full-thickness myotomy.
CS rates were 70.0% (35/50 patients) at 3 months, 66.7% (31/45 patients) at 6 months, 64.9% (24/37 patients) at 12 months, and 57.1% (16/28) at 24 months, with a significant change over time (𝑄=25.36, p<0.001). Among patients with CS at 12 months, 4 experienced symptoms relapse at 24 months, while 1 patient achieved success at 24 months despite not having CS at 12 months. There were no differences in success rates based on the etiology of gastroparesis (Table 1)
In multivariate regression logistic, age (OR = 1.27, p=0.02) and baseline GCSI (OR = 1.45, p=0.03) were significant predictors of CS at 1 year.
Among patients with CS at two years, there was no significant difference between pre-procedure and post-procedure BMI (median follow-up time 1091 days)(22.6 vs 22.0, p=0.40) or between pre- and post-procedure GES t ½ (median follow-up time 901 days)(174 vs 101 min, p=0.078).

Table 1: Clinical success subgroup analysis

Conclusion

The efficacy of G-POEM decreases over time, reaching approximately 60% at two years. Long-term clinical success does not correlate with changes in BMI or GES parameters. Further studies are needed to better understand factors influencing long-term outcomes of G-POEM and to optimize patient selection.

References

1. Mandarino FV, Vespa E, Barchi A, et al. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel). 2023;13(11):2143. Published 2023 Oct 31. doi:10.3390/life13112143
2. Mandarino FV, Testoni SGG, Barchi A, et al. Gastric emptying study before gastric peroral endoscopic myotomy (G-POEM): can intragastric meal distribution be a predictor of success?. Gut. 2023;72(5):1019-1020. doi:10.1136/gutjnl-2022-327701

Introduction

Gastroesophageal reflux disease (GORD) is a recognised complication of bariatric surgery; however, the clinical phenotype of patients who develop postoperative GORD remains poorly characterised. Improved understanding of this cohort may aid in risk stratification and management.

Aims & Methods

This study aimed to identify the epidemiological and clinical features of patients with upper gastrointestinal symptoms following bariatric surgery and to evaluate whether these vary by surgery type. This retrospective study examined 31 post-bariatric surgery patients with upper gastrointestinal symptoms referred to a quaternary gastroenterology service between 2004 and 2023. Data collected included age, sex, comorbidities, type and number of bariatric procedures, time from surgery to symptom onset, and symptom profile.

Results

Patients were predominantly female (80.6%) with high prevalence of comorbid depression (45.2%) and anxiety (53.3%). Sleeve gastrectomy was the most common procedure (70.9%), followed by adjustable gastric banding (35.5%); 16.1% patients underwent more than one bariatric surgery. On average, symptoms developed 0.19 years postoperatively and persisted for a mean duration of 6.8 years before referral. Dysphagia and heartburn were reported in 77.4% and 74.2% of patients, respectively. All patients who underwent Roux-en-Y gastric bypass (RYGB) reported heartburn. Patients with a history of sleeve gastrectomy appeared to have the highest symptom burden.

Conclusion

Patients who develop GORD after bariatric surgery are predominantly female, frequently have pre-existing mental health conditions, and often undergo sleeve gastrectomy. Symptoms typically emerge early and persist for several years before being investigated. Upper gastrointestinal symptoms appeared more prevalent than previously reported, suggesting possible under-recognition in clinical practice. Although RYGB is the preferred bariatric procedure in patients with co-existing GORD, our findings indicate that significant reflux symptoms may still occur postoperatively. These results support the need for early identification perioperatively and tailored follow-up of at-risk patients.

References

1. Klaus, A., & Weiss, H. (2008). Is preoperative manometry in restrictive bariatric procedures necessary? Obesity Surgery, 18(8), 1039–1042. https://doi.org/10.1007/s11695-007-9399-1
2. Tolone, S., Savarino, E., & Yates, R. B. (2016). The impact of bariatric surgery on esophageal function. Annals of the New York Academy of Sciences, 1381(1), 98–103. https://doi.org/10.1111/nyas.13107
3. Savarino, E., Marabotto, E., & Savarino, V. (2018). Effects of bariatric surgery on the esophagus. Current Opinion in Gastroenterology, 34(4), 243–248. https://doi.org/10.1097/mog.0000000000000439
4. Nguyen, A. D. (2021). Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility. Current Opinion in Gastroenterology, 37(4), 364–371. https://doi.org/10.1097/mog.0000000000000745
5. Kalarchian, M. A., King, W. C., Devlin, M. J., White, G. E., Marcus, M. D., et al. (2017). Surgery-related gastrointestinal symptoms in a prospective study of Bariatric Surgery Patients: 3-year follow-up. Surgery for Obesity and Related Diseases, 13(9), 1562–1571. https://doi.org/10.1016/j.soard.2017.03.028
6. O’Rourke, R. W., Deveney, C. W., McConnell, D. B., Wolfe, B. M., & Jobe, B. A. (2007). Esophageal motility disorders after gastric banding. Diseases of the Esophagus, 20(3), 269–273. https://doi.org/10.1111/j.1442-2050.2007.00685.x

Disclosure

Nil

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