Introduction

Treatment of non-obstructive esophageal dysphagia (NOD) should consider not only the primary condition, but also its impact on patients’ daily function, their perception and surgical risk. Between surgical, endoscopic, and medical therapies, there is a wide range of choices, most without well-established indications or outcomes.

Aims & Methods

This is an ongoing prospective multicentric study to evaluate the real-life approach to NOD in 7 centers, by comparing the efficacy of different treatments [per-oral endoscopic myotomy (POEM), botulinic toxin (BT), pneumatic dilation (PD), optimization of proton-pump inhibitors (PPI) and expectant], through the Eckardt, EuroQol-5D (TTO and VAS) and PROMIS GI Disrupted Swallowing (PDS) scores.

Results

According to Chicago V4, it included 97 esophagogastric junction (EGJ) outflow disorders, 24 spastic motility disorders, 38 hypomotile disorders and 91 dysphagia with normal manometry. Fifty-seven (22.8%) patients were submitted to therapy.
Forty-three (44.3%) patients with EGJ outflow disorders were treated (31 POEM, 5 BT, 2 PD, 1 surgical and 4 medical). In contrast to untreated, treated patients showed better differences in Eckardt, PDS and EuroQol-5D VAS scores (p-values <0.005) after 6 months.
PPI was introduced and/or optimized in five (13.2%) patients with hypomotile disorders. There were no differences in Eckardt, EuroQol-5D and PDS at 6-months in treated or untreated patients.
Three (12.5%) patients with spastic motility disorders were treated (2 BT and 1 calcium-channel blocker). Both treated and untreated showed no differences in Eckardt or EuroQol-5D scores at 6 months.
Regarding dysphagic patients with normal manometry, medical treatments were optimized in 6 patients (6.6%), without any differences in Eckardt and EuroQol-5D scores at 6-months. Interestingly, the PDS showed a better difference at 6 months in untreated patients (p-value <0.001).

Conclusion

Apart from EGD outflow disorders, which have well-established treatment options, real-life approach of NOD is heterogeneous and showed no clear benefit. To improve clinical results, specialized clinics must be created.

Introduction

Esophageal dysphagia is a common complaint in daily clinical practice. After excluding structural and motility disorders, it may be related to functional disorders, which are challenging to diagnose and manage, leading to high health care utilization and both patient and physician dissatisfaction.

Aims & Methods

This is a prospective multicentric 6-months follow-up study to characterize dysphagic patients with normal esophageal motility, in terms of epidemiology and clinical aspects, focusing on patient-reported outcome measures, and evaluate their evolution at 6-months.

Results

From 2021-2024, 91 patients were recruited, 78.0% female, with a median age of 65 years [22-88]. Of these, 27.5% (n = 25) suffered from rheumatologic or endocrinologic disorders, and 56.0% were previously exposed to medical therapies.
Dysphagic symptoms had a median duration of 3 years [1-31], with a median Eckardt of 3 [0-9], PROMIS GI Disrupted Swallowing (PDS) of 60.4 [40.3-84.1], EuroQol-5D TTO of 0.592 [-0.055-1] and VAS of 70 [0-100].
Compared to non-dysphagic participants (n=123), these patients had significantly worse Eckardt, EuroQol-5D and PDS scores (p-values <0.001).
Compared to esophageal motility disorders (Chicago V4.0), the Eckardt and PDS scores in this group were significantly lower when compared to EGJ outflow disorders (p-value <0.001 and 0.003), without differences regarding EuroQol-5D.
Regarding gastroesophageal reflux, 24 (26.4%) patients had a positive GERD-Q questionnaire and 3 had an objective GERD diagnosis. Even though, compared to motility disorders, this score was significantly lower in this group when compared to EGJ outflow disorders (p-value 0.001).
Medical treatments (PPI, amitriptyline) were optimized in 6 patients (6.6%), without any differences in Eckardt or EuroQol-5D scores at 6-months. However, at 6-months, the PDS improved in untreated patients (p-value <0.001).

Conclusion

Non-obstructive dysphagia with normal esophageal motility has a negative impact on quality of life. However, symptoms tend to have a favorable course independently of treatment, therefore mandating a holistic management.

Introduction

Dysphagia is a common condition with consequences surpassing the physical dimension and extending to the patient’s psychological, personal, and professional life. However, when referring to non-obstructive esophageal dysphagia (NOD) and motility disorders, data is still scarce.

Aims & Methods

Our study consists in a prospective and multicentric evaluation of the severity of dysphagia and its impact on quality of life, that was measured with the Eckardt, EuroQol-5D (TTO and VAS) and PROMIS GI Disrupted Swallowing (PDS) scores, in patients with NOD and underlying motility disorders. We included 373 individuals (250 with NOD and 123 without dysphagia).

Results

Among patients with NOD, 97 had esophagogastric junction (EGJ) outflow disorders on manometry according to Chicago V4.0, 24 spastic motility disorders, 38 hypomotile disorders and 91 normal motility. Compared with non-dysphagic individuals, dysphagic patients had significantly worse scores of both EuroQol-5D and PDS (p-values <0.001).
Among esophageal motility disorders, Eckardt score was significantly different between groups (p-value <0.001) as determined by ANOVA. Specifically, it was significantly higher in EGJ outflow disorders (mean of 5.2), when compared to spastic motility disorders (mean of 3.3) or dysphagic patients with normal motility (mean of 3.2).
With respect to Patient-reported outcomes, PDS score was statistically different between groups (p-value 0.003), being higher in the EGJ outflow disorders (mean T-score of 64.1) when compared to hypomotiity disorders (mean of 60.2) and dysphagic patients with normal motility (mean of 60.3).
Regarding patient-reported quality of life, there were no differences between groups in terms of EuroQol-5D TTO or VAS score (p-value of 0.156 and 0.368, respectively).

Conclusion

Our findings highlights the impact of NOD on the quality-of-life of patients. Although physician and patient reported symptoms’ severity were worse on EGJ outflow disorders, overall quality of life seems equally affected among all esophageal motility profiles.

Introduction

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) is one of the best imaging modalities to visualize tumor blood flow, but conventional observation can sometimes be insufficient, particularly in lesions characterized by rapid changes in blood flow. Inflow-time mapping (ITM) is a colored parametric display of time-to-peak enhancement for each pixel in the display that allows a better differentiation of tissues by their speed of contrast agent uptake. ITM is a simple, easily reproducible computer-aided color parametric imaging (CPI) technique that can bring a more objective approach to CEH-EUS analysis and further improve the differential diagnosis of pancreatic masses.

Aims & Methods

To investigate the potential advantages and limitations of Inflow-time Mapping - a novel computer-aided color parametric imaging technique - in assessing focal pancreatic lesions using contrast-enhanced harmonic endoscopic ultrasound.
A total of 15 patients including 8 cases of pancreatic ductal adenocarcinomas (PDAC), 3 cases of chronic pancreatitis, 2 cases of pancreatic neuroendocrine tumors (NETs), one case of serous cystadenoma (SCA) and one case of intraductal papillary mucinous neoplasm (IPMN) were enrolled. CEH-EUS and ITM examinations were performed for the frames obtained during the arterial phase. All CEH-EUS and ITM images were retrospectively reviewed and two sets of criteria were assigned: (1) Routine CEH-EUS alone, focusing on the degree and pattern of enhancement, and (2) CEH-EUS and ITM, focusing on differentiating pancreatic lesions based on their speed of ultrasound contrast agent (UCA) uptake, compared to adjacent tissue. Final diagnosis was based on EUS-guided tissue fine needle aspiration biopsy (EUS-FNAB).

Results

Based on CEH-EUS, 11 pancreatic lesions were initially considered PDAC based on their hypoenhanced appearance. ITM analysis could not provide additional information in 8 patients due to insufficient vascularization. In 3 patients, by showing no difference in the speed of UCA uptake in the enhanced regions of the lesion compared to the surrounding parenchyma, ITM analysis was able to correctly identify chronic pancreatitis, as proven by histology. Among the 2 hyperenhanced pancreatic lesions described on CEH-EUS, ITM analysis was able not only to correctly diagnose but also to provide an extensive characterization of 2 pancreatic NETs by showing a greater speed of UCA uptake in the lesion and a typical pattern of the parametric map. ITM analysis also proved useful in objectively highlighting the speed and pattern of enhancement (septal/mural) of 2 included cystic lesions, IPMN and SCA.

Conclusion

ITM is a promising tool for an objective, simplistic approach, in the assessment of hypervascular pancreatic lesions, particularly pancreatic NETs. It can also become an important step in the evaluation of focal pancreatic masses in patients with chronic pancreatitis, where parenchymal inhomogeneity and altered local perfusion might influence the purely visual assessment of CEH-EUS.

References

Dietrich CF, Dong Y, Froehlich E, Hocke M. Dynamic contrast-enhanced endoscopic ultrasound: A quantification method. Endosc Ultrasound. 2017 Jan-Feb;6(1):12-20. doi: 10.4103/2303-9027.193595. PMID: 28218195; PMCID: PMC5331837

Introduction

Many CD patients experience clinically „silent“ disease with active inflammation leading to complications and disability. Invasive and resource consuming procedures such as endoscopy, MR enterography and CT imaging have long been the mainstay of monitoring disease activity in CD. Intestinal ultrasound (IUS) is becoming an established non-invasive alternative for everyday point-of-care management of patients with CD. The most important ultrasound parameters associated with active CD include bowel wall thickness (BWT), bowel wall stratification (BWS), color-doppler signal (CDS) and the presence of mesenteric fat (i-fat). Several ultrasound scoring systems using some of these parameteres have been proposed in order to facilitate monitoring of CD patients as well as standardise reporting of intestinal ultrasound findings.

Aims & Methods

The study aim was to compare performance of IBUS-SAS (International Bowel Ultrasound Segmental Activity Score), BUSS (Bowel Ultrasound Score), Simple-US (Simple Ultrasound Score), and SUS-CD (Simple Ultrasound score for Crohn's disease) in detecting disease activity in CD patients. A single center retrospective analysis of stored IUS images and corresponding CD patient charts with endoscopy findings at the time of the ultrasound has been performed. Endoscopic activity was defined as SES-CD>3. After assessment of normal distribution using Kolmogorov-Smirnov and Shapiro-Wilk tests continuous variables were reported as median and interquartile ranges (IQR) or as mean ± standard deviation, whereas categorical variables were reported as frequencies with percentages. ROC curve analyses were conducted in order to determine AUCs and predictive cut-off value scores, with endoscopy serving as the reference standard. The Z statistic and Hanley & McNeil methodology were used to compare ROC curves. P values less than 0.05 were considered statistically significant.

Results

A total of 83 patients were included, 45.8% female with a mean age 41 years and median disease duration of 8 years. Endoscopic disease activity was present in 55 (66.3%) patients. Isolated ileal disease was present in 48.2%. Stricturing and penetrating disease phenotype was present in 41% and 39.8% of patients respectively. The results for ROC analyses, cut-off values for remission, sensitivity and specificity of four different IUS scores are shown in table 1. Statistically significant differences among scores haven't been observed.

Table 1. Comparison of intestinal ultrasound scores for detecting active Crohn's disease

Conclusion

All IUS scores performed well for detecting CD endoscopic activity which shows IUS can reduce the number of endoscopies in the CD patient population without sacrificing accuracy. We found no significant difference in the sensitivity and specificity of different scores in out patient cohort, hence clinicans can rely on the IUS score they are comfortable with using. Our cut-off values are in line with published data further confirming method robustness.

References

1. Dragoni G, Gottin M, Innocenti T, Lynch EN, Bagnoli S, Macrì G, Bonanomi AG, Orlandini B, Rogai F, Milani S, Galli A, Milla M, Biagini MR. "Correlation of ultrasound scores with endoscopic activity in Crohn's disease: a prospective exploratory study". J Crohns Colitis. 2023 Apr 6:jjad068. doi: 10.1093/ecco-jcc/jjad068.
2. Wang L, Xu C, Zhang Y, Jiang W, Ma J, Zhang H. External validation and comparison of simple ultrasound activity score and international bowel ultrasound segmental activity score for Crohn's disease. Scand J Gastroenterol. 2023 Feb 23:1-7. doi: 10.1080/00365521.2023.2181038. Epub ahead of print. PMID: 36825305.