Introduction

Retrograde cricopharyngeus dysfunction (R-CPD) is a newly recognized disorder characterized by self-reported inability to belch, accompanied by gastrointestinal symptoms such as chest pain, gurgling noises, bloating and flatulence. It has been linked to ineffective relaxation of the upper esophageal sphincter (UES) in response to gastroesophageal gas reflux, and botulinum toxin (Botox) injection into the UES has demonstrated success in case series (1). However, in the absence of adequate testing, the diagnosis is often missed. Recently, high resolution impedance manometry (HRiM) with belch provocation was suggested as a diagnostic tool (2)

Aims & Methods

Our aim was to confirm manometric findings in patients with R-CPD before and after Botox injection, and to compare with HRiM in control patients and healthy volunteers.
We performed a retrospective analysis of HRiM in patients with suggestive symptoms and control patients from May 2021 to April 2023. Ten swallows and a rapid drinking challenge with sparkling water (until symptom provocation) were added to the Chicago IV protocol, followed by an observation period. Control patients were referred for HRiM for different symptoms/conditions. In 8 patients, HRiM was repeated after Botox injection. The same HRiM protocol was used in 15 healthy volunteers. Gastroesophageal gas reflux was defined as a rapid increase in impedance (>3000Ω) from distal to proximal channels, air entrapment as a period of high impedance levels (>3000Ω) in ≥ 2 proximal channels and oscillations as a continuous up and down movement of air.

Results

HRiM with belch provocation test was available for 35 patients before, and 8 patients after Botox injection. Normal UES relaxation occurred after deglutition in all. Contrary to that, there was a significant increase in UES pressure during a gas reflux event as compared with before (p=0.0042). Mean observation period after belch provocation was 9.5min. We observed a mean of 8.3 gastroesophageal gas reflux events, which resulted in UES relaxation in 6% of events. Median air entrapment time was 35 seconds (range 0-640), oscillations lasted 70 seconds (0-690). After Botox injection, 6/8 patients improved, and were able to belch during HRiM, with significant decrease in UES pressures. Air entrapment time was significantly reduced to a median of 0 seconds (0-30).
In control patients (n=18), median air entrapment time after belch provocation test was 38 seconds (0-250). In healthy volunteers (n=15) median air entrapment time was 29 seconds (range 0-60). Both control patients and healthy volunteers had gastroesophageal gas reflux events. In contrast with R-CPD patients, they had significantly lower UES pressures during a reflux event as compared with before, allowing adequate belching in all.

Conclusion

We can confirm a pattern of suggestive symptoms, and typical anomalies on HRiM with belch provocation test, which is not present in control patients or healthy volunteers. Especially UES pressures during gas reflux are able to discriminate R-CPD patients from controls. These findings can provide a basis for a diagnostic algorithm and a standardized HRiM protocol for patients presenting with ‘inability to belch’.

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. Published 2019 Mar 15. doi:10.1177/2473974X19834553
2. Oude Nijhuis RAB, Snelleman JA, Oors JM, et al. The inability to belch syndrome: A study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2022;34(5):e14250. doi:10.1111/nmo.14250

Introduction

Endoscopic submucosal dissection (ESD) is the first-line treatment for superficial gastric lesions with a negligible or very low risk of lymph node metastasis. However, a permanent risk of developing metachronous lesions persists. We intend to analyze the risk factors associated with the development of metachronous lesions in a population of patients undergoing ESD.

Aims & Methods

Prospective cohort study conducted at a single centre, involving patients who underwent gastric ESD for lesions between 2017 and 2023, with a follow-up period of ≥ 6 months. Lesion characteristics were analyzed, including the rate of metachronous lesions, and logistic regression was performed to identify risk factors associated with the development of metachronous lesions.

Results

Included 78 ESDs performed on gastric epithelial lesions (59% female), with a mean age of 70.3±7.9 years. Regarding family history of gastric adenocarcinoma, 17.9% of patients had a first-degree relative. Among the analyzed lesions: 42.3% measured between 0-20mm, 57.7% ≥ 20mm; 12.8% were sessile, 71.8% flat and 15.4% depressed; 19.2% were located in the cardia, fundus or body, 21.8% in the incisura angularis and 59% in the antrum. Regarding histological findings: 42.3% low-grade dysplasia, 30.8% high-grade dysplasia, 23.1% intramucosal adenocarcinoma and 3.8% adenocarcinoma with submucosal invasion. Nine metachronous lesions (11.5%) were detected, with a median time of occurrence of 24 [13-32] months. In the analysis of risk factors, statistical significance was found for location outside the antrum (21.6% vs. 1.9%; p=0.002) and the presence of adenocarcinoma (23.8% vs. 7%; p=0.039), but not for size ≥20mm (13.7% vs. 5.1%; p=0.178) or ulceration of the lesion (9.1% vs. 10.1%; p=0.915). Logistic regression analysis revealed that only location outside the antrum had a significant risk for the development of metachronous lesions (OR 13.4; 95% CI: 1.4-127.1).

Conclusion

Given the permanent risk of developing metachronous lesions, the identification of associated risk factors is important as it may eventually allow for the adaptation of surveillance programs.

Introduction

Eosinophilic esophagitis (EoE) is a Th2-related disease characterized by dysphagia and food impaction. EoE has been associated with several other atopic disorders, supporting the knowledge that it may represent a late manifestation of the so-called “atopic march”. However; in everyday clinical practice, allergic comorbidities are rarely objectivized by means of specialist consultations and often rely on patients’ self-reporting. This bears the risk of not fully recognizing the burden of Th2-related pathology, since EoE patients may outgrow some of the allergic diseases presenting during childhood; or, conversely, they could underestimate the presence and severity of Th2-diseases. To this aim, a multidisciplinary task-force involving multiple specialists was established at our university hospital, in order to systematically investigate newly referred EoE patients.

Aims & Methods

This is a cross-sectional observational study, involving consecutive EoE patients that were referred to our tertiary center from January 2022. We prospectively collected data about patients’ clinical history, specifically recording the presence of Th2-related comorbidities. Each patient underwent an esophagogastroduodenoscopy with differential esophageal biopsies. After reaching a conclusive diagnosis of EoE, patients were referred to dermatology, ear, nose and throat specialist (ENT) for rhinofibroscopy, immunologist (performing prick test, as necessary) and respiratory consultant for spirometry.

Results

40 EoE patients were included (34M, age 31±12 years), with a mean age of onset of 23±16 years. A clinical history of Th2-comorbidities was reported by 90% of the overall population with rhinitis being the most prevalent comorbidity (77.5%), while no patient reported Chronic Rhinosinusitis with Nasal Polyps (CRwNP). Asthma, food allergy and atopic dermatitis (AD) were reported in 15 (37.5%), 14 (35%) and 9 (22.5%) patients, respectively. Following the consultations, the presence of asthma, food allergy and AD did not significantly differ (37.5 vs 30%, 35 vs 45% and 22.5 vs 20%), since only 3 patients reporting a history of asthma did not confirm the diagnosis at spirometry and one patient with a history of AD had dermographic urticaria. On the contrary, following ENT consultation, 6 patients with rhinitis received the diagnosis of CRwNP (0 vs 15%, p=0.01). Overall, nearly 60% of patients had two comorbid Th2 disorders besides EoE and 25% of the whole population of EoE patients had 3 or more.

Conclusion

Our results clearly support the need for a multidisciplinary team approach to investigate the burden of Th2-related pathology in EoE patients. In our hands, the prevalence of Th2-related comorbidities was as high as 97.5% of EoE patients and up to 63% of our population had 2 or more allergic disorders. Furthermore, CRwNP is frequently under-reported and properly diagnosed only following rhinofibroscopy. This is further from being irrelevant when managing EoE patients. Indeed, it may guide the most appropriate choice of therapy by targeting multiple atopic manifestations at the same time, since many Th2-related diseases share common pathophysiological mechanisms and treatment.