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Achalasia: Is POEM first line?

Thomas Rösch 1

1 Clinic for Interdisciplinary Endoscopy, Hamburg, Germany

Event

UEG Week Vienna 2024

Topics

Endoscopy Neurogastroenterology & Motility Surgery

Session

Motility disorders: Is endoscopy the cure?

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Is POEM a good answer in the long-term?

Henriette Heinrich 1

1 Stadtspital Triemli, Zürich, Switzerland

Event

UEG Week Berlin 2025

Topics

Oesophagus Primary Care

Session

Spastic oesophagus: Is it curable?

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Introduction

Systemic sclerosis (SSc) is a rare and complex autoimmune disorder characterized by fibrosis of the skin and internal organs, as well as vasculopathy. The disease can be classified into two main subtypes: diffuse and limited. The diffuse subtype is more frequently associated with significant internal organ fibrosis. In the Asia-Pacific region, Thailand has the highest prevalence of systemic sclerosis, with an incidence of 24.4 per 100,000 population. Gastrointestinal involvement occurs in over 90% of patients with SScwith esophageal involvement being particularly common. Among these, gastroesophageal reflux disease (GERD) is present in approximately 80% of SSc patients. Erosive esophagitis (EE), a severe form of GERD characterized by the erosion of esophageal mucosa, is observed in about 80% of GERD cases. Its severity is classified according to the Los Angeles classification (grades A to D), with 30% of cases classified as severe (Los Angeles grades C and D). Proton pump inhibitors (PPIs) are currently the standard treatment for GERD and EE in SSc patients. However, fewer than 50% of patients demonstrate adequate response to PPIs therapy, highlighting the need for alternative treatments. Vonoprazan, a novel potassium-competitive acid blocker (PCAB), has emerged as a potent and longer-acting alternative to traditional PPIs. It has shown superior efficacy in treating severe erosive esophagitis in the general population. Previous cohort studies have demonstrated promising results with vonoprazan in improving symptoms and healing rates in SSc patients with refractory GERD up to 60% in refractory GERD; However, randomized controlled trials evaluating its efficacy in this population remain limited. This study aims to conduct a randomized controlled trial comparing the efficacy of vonoprazan and PPIs in treating erosive esophagitis in SSc patients.

Aims & Methods

The aim was to compare the efficacy of vonoprazan and lansoprazole in healing erosive esophagitis in patients with systemic sclerosis.
A randomized placebo-controlled trial was conducted in patients with systemic sclerosis (SSc) and refractory GERD who had erosive esophagitis confirmed by endoscopy. Participants were recruited from the systemic sclerosis clinic at Srinagarind Hospital, Khon Kaen University, from June 2024 to March 2025. Patients were randomized to receive either vonoprazan 20 mg once daily or lansoprazole 30 mg once daily for 8 weeks. The primary outcome was the percentage of healing at 8 weeks. Secondary outcomes included improvement in gastro-esophageal reflux disease (GERD) symptoms, as assessed by the Frequency Scale for the Symptoms of GERD (FSSG), GERD Questionnaire (GerdQ), and visual analogue scales (VAS) for heartburn and regurgitation.

Results

A total of 48 patients were enrolled in the study. The healing rates for vonoprazan and lansoprazole were 73.9% and 39.1%, respectively, resulting in an absolute risk reduction of 0.348 (95% CI: 0.081–0.614; p-value: 0.017). Subgroup analysis of patients with severe erosive esophagitis, defined as Los Angeles (LA) grades C-D, demonstrated that vonoprazan was superior to lansoprazole (75% vs. 33.3%; absolute risk reduction: 0.52; 95% CI: 0.167–0.873; p-value: 0.008). No significant difference was observed between the two treatments in patients with LA grades A-B.

Conclusion

Preliminary data suggests that vonoprazan was superior to lansoprazole in the healing of erosive esophagitis in systemic sclerosis patients, with this benefit being particularly evident in cases of severe erosive esophagitis (LA grades C-D).

References

1. Volkmann ER, Andréasson K, Smith V. Systemic sclerosis. Lancet. 2023 Jan 28;401(10373):304–18.
2. Foocharoen C, Ngamjarus C, Pattanittum P, Suwannaroj S, Pongkulkiat P, Onchan T, et al. Incidence and prevalence of systemic sclerosis in Thailand in year 2017-2020: a database from the Ministry of Public Health. Clin Rheumatol. 2023 Jul;42(7):1767–74.
3. Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol. 2016 Aug;13(8):461–72.
4. McMahan ZH. Gastrointestinal involvement in systemic sclerosis: an update. Curr Opin Rheumatol. 2019 Nov;31(6):561–8.
5. Roth E, Bruni C, Petelytska L, Becker MO, Dobrota R, Jordan S, et al. Gastroesophageal reflux disease is associated with a more severe interstitial lung disease in systemic sclerosis in the EUSTAR cohort. Rheumatology. 2025 Jan 8;keaf016.
6. Denaxas K, Ladas SD, Karamanolis GP. Evaluation and management of esophageal manifestations in systemic sclerosis. Ann Gastroenterol. 2018;31(2):165–70.
7. Chunlertrith K, Noiprasit A, Foocharoen C, Mairiang P, Sukeepaisarnjaroen W, Sangchan A, et al. GERD questionnaire for diagnosis of gastroesophageal reflux disease in systemic sclerosis. Clin Exp Rheumatol. 2014;32(6 Suppl 86):S-98-102.

VONOPRAZAN VERSUS LANSOPRAZOLE FOR HEALING EROSIVE ESOPHAGITIS IN PATIENTS WITH SYSTEMIC SCLEROSIS (HEAL-SSC): A PRELIMINARY REPORT OF RANDOMIZED PLACEBO-CONTROLLED TRIAL

Rachaporn Kongbumrung 1, Tanita Suttichaimongkol 2, Wattana Sukeepaisarnjaroen 3, Pisaln Mairiang 1, Chingching Foochareon 1, apichat sangchan 1, Kookwan Sawadpanich 1, Chitchai Rattananukrom 1, Witsarut Manasirisuk 1

1 KhonKaen University, KhonKaen, Thailand

2 Srinagarind Hospital, Khon Kaen, Thailand

3 Faculty of Medicine, Khon Kaen, Thailand

Conference

UEG Week Berlin 2025

Topics

Oesophagus

Submission format

Abstract

Session

GERD (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Introduction

British, Irish and European guidelines recommend interval re-evaluation of LA Grade C and D oesophagitis to identify occult malignancy and Barrett’s oesophagus.

Aims & Methods

We aimed to evaluate our service’s re-evaluation practice, identify factors which predict both malignancy and Barrett’s oesophagus, and determine our yield of re-evaluation.
We queried and cross-referenced our endoscopy and histology databases. Data analysis was conducted in Microsoft Excel and R Studio.

Results

1,700 index cases of Grade C/D oesophagitis were identified over 18.5-years ended November-2023. 62% were male. Median age was 62 (IQR:48-74). 717 had a first re-evaluation (42%).
6 cases were subsequently diagnosed with an oesophageal malignancy. Median age was 77.5 (IQR:50-83). 50% were male. Univariate binary probit logistic regressions identified neither age (≥70 years) (p=0.1), nor gender (p=0.55), nor Grade D oesophagitis (p=0.71) as predictors of malignancy.
Index histology was obtained in each case of malignancy. 3 of these malignancies (50%) were diagnosed on index histology. Of the remaining 3, 1 was diagnosed on a repeat 66-days later. The remaining 2 had non-revelatory re-evaluations, albeit without oesophageal histology, an average of 12.7 weeks later, and were subsequently diagnosed an average of 2.2 years later.
48 cases of occult Barrett’s oesophagus were identified on surveillance procedures, with a total of 183 when index identifications were included (10.8%), closely paralleling background population rates. No cases of occult dysplasia were identified in this context.

Conclusion

Our yield of Grade C/D oesophagitis re-evaluation over almost two decades was low despite the performance of 823 surveillance procedures at an approximate inflation-adjusted expenditure of €580,215.

References

Beg S, Ragunath K, Wyman A, et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) [published correction appears in Gut. 2017 Dec;66(12):2188. doi: 10.1136/gutjnl-2017-314109corr1.]. Gut. 2017;66(11):1886-1899. doi:10.1136/gutjnl-2017-314109
Rodríguez-de-Santiago E, Frazzoni L, Fuccio L, et al. Digestive findings that do not require endoscopic surveillance - Reducing the burden of care: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy. 2020;52(6):491-497. doi:10.1055/a-1137-4721