Introduction

It is known that not all patients with eosinophilic esophagitis (EoE) in histological remission also achieve clinical remission. Several reasons have been postulated among which decreased esophageal compliance without apparent stricture at endoscopy is particularly appealing, but no data are so far available on effectiveness of empirical dilation.

Aims & Methods

Aim of our study was to investigate this topic. A retrospective analysis with prospectively collected data has been conducted on all EoE patients without stenotic features at endoscopy (i.e. no R3/S1 according to EREFS) in whom histological remission with drug and/or diet has been induced in a single referral Center from July 2018 to December 2023. All patients who had not achieved concurrent remission of dysphagia and/or bolus impaction were empirically dilated. At least 6 months of follow-up after remission was needed for inclusion. Demographic, clinical and endoscopic data were compared between patients who needed dilation and those who did not.

Results

A total of 33 patients aged 40; 30-51 yrs (median; IQR range), 23 men, were included. PPI was the main treatment (76% of pts). Nineteen of them (group 1) achieved clinico-histological whereas 14 (group 2) achieved histological remission only and underwent empirical dilation to 15-17 mm with no complications after which clinical remission was achieved in 13 of them. A second dilation was needed in 2 patients at 25 and 31 months respectively, in order to maintain remission. EREFS score at histological remission, but not at diagnosis, was higher in group 2 vs 1 (p=0.02, see table) and was accompanied by a higher % of patients with rings (R1 or R2), 78 vs 37 (p=0.04). A lower % of group 2 patients was treated with topical steroids, 7 vs 26 (p=NS).

Conclusion

In our cohort of stricture free EoE patients achieving histological remission, over 40% still had residual obstructive symptoms which were relieved by empirical esophageal dilation in most, suggesting high relevance of decreased esophageal compliance. Prospective multicenter data with use of FLIP are warranted in order to assess if topical steroids are more effective than PPIs in reversing remodeling and avoiding dilation.

References

(1) Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology. 2022 Jul;163(1):59-76. doi: 10.1053/j.gastro.2022.03.025. Epub 2022 May 20.

Introduction

Gastric emptying scintigraphy (GES) is an accepted standard for gastroduodenal function (GDF) testing, while various other investigations are available for the assessment of dyspeptic symptoms. However, in the absence of guidelines, it remains uncertain which test one should favour.

Aims & Methods

This study examined variation in GDF testing between centres to establish the status of current practice. A web-based questionnaire assessing availability, standard operating procedures and interpretation of 15 different GDF testing techniques was distributed among specialist practitioners via professional organizations. Availability, indication, meal-related characteristics and standard operating procedures (SOP) were compared.

Results

Fifty-nine complete responses (57 clinical practice, 86% tertiary care) were included from 28 countries. Eleven (19%) respondents referred more than 10 patients for further testing monthly. Accessibility for clinical practice were as follows: 100% gastroscopy, 91% measurement of gastric emptying (79% by GES; 19% gastric emptying breath testing (GEBT); 5% SPECT), 39% intragastric pressure measurements (IGP), 33% pyloric Endoflip (PE), 30% gastric MRI, 19% nutrient drinking challenge (NDC), 18% gastric ultrasound (US), 18% motility capsule (MC) and 16% antroduodenal manometry (AM). Other techniques were available to less than 15% of the respondents. In clinical practice, meal-related dyspeptic symptoms and chronic unexplained nausea and vomiting (CUNV) represented the main indications for GE studies as compared to epigastric pain, burning or discomfort (GES: 70% and 94% vs. 20%, p<.00001; GEBT: 100% and 100% vs. 0%, p<.001), Similar results were present for PE (73% and 93% vs. 33%, p=.002), NDC (100 and 82 vs. 27%, p=.0006). MC (33% and 67% vs. 0%, p=.05), AM (28% and 75% vs. 25%, p=.11), MRI (75% and 88% vs. 38%, p=.09) and IGP (33% and 33% vs. 0%, p=.15) By contrast, US was indiscriminately performed (57% and 71% vs. 57%, p=.82).There was a large heterogeneity in the type of meal and meal quantity used for each test as well as between tests. Symptoms were recorded by only half the respondents during GES and MRI, with higher percentages for other testing modalities. Variation in the specific symptoms included in questionnaires was present.

Conclusion

GES is widely available in clinical practice. Meal-related symptoms and CUNV represent the main indications for GDF testing in clinical practice. A large variation in the availability of GDF testing and SOPs exists between centres. This hampers clinical interpretation, data transfer between centres and research collaboration. These findings emphasise the need for an international co-operation effort at standardisation.

Introduction

Peroral endoscopic myotomy (POEM) is considered a standard method for achalasia treatment with excellent long term treatment success. However, the benefits of POEM are tempered by the risk of post-POEM reflux complications.

Aims & Methods

The aim of this retrospective analysis of prospectively collected data was to assess the long-term post-POEM reflux. Data from all consecutive patients who underwent POEM between December 2012 and April 2023 were analyzed. The patients assessed symptoms at 3 and 12 months after the procedure and every year thereafter. The patients underwent upper GI endoscopy, high-resolution manometry (HRM) and 24-hour pH monitoring 3 months after the procedure; endoscopy was then repeated at 2-3 years and at 6 year follow-up. Reflux esophagitis, reflux parameters measured by 24h pH monitoring (off PPIs), reflux symptoms and the use of proton pump inhibitors (PPIs) were the principal outcomes.

Results

A total of 539 POEM procedures (20x re-POEM) were performed in 519 patients. Three months after the procedure, 390 patients underwent 24h pH monitoring with abnormal acid exposure in 178 of them (45.6% [95% CI: 40.7, 50.6]). Reflux esophagitis was present in 181/463 patients (39.1% [95% CI: 34.7, 43.6]; LA C/D in 20 patients, 4.3%) at 3 months, in 94/263 patients (35.7% [95% CI: 30.2, 41.7]; LA C/D in 5 patients, 1.9%) at 24-36 months and in 18/88 patients (20.5% [95% CI: 13.3, 30]; LA C/D in 0 patients) 6 years after procedure. Follow- up questionnaires were completed in 185, 161 and 106 patients 48, 60, 72 months after the procedure and 34.6%, 35.7% and 34.4% of patients claimed occasional heartburn and 18.1%, 20.4% and 19.6% experienced occasional regurgitation of gastric content. However, only the minority (under 2% of the patients at 48, 60, 72 months) experienced the symptoms on daily basis. PPIs were administered to 53.3%, 48.4% and 54.3% of patients at 48, 60 and 72 months after POEM with majority of them (80%) taking PPIs on daily basis. We also investigated whether there were any differences in patients with and without PPIs. In patients with PPIs, there were less cases of reflux esophagitis 3 months after POEM (32.4% vs. 43.5%). More patients with PPIs experienced post-POEM heartburn (42.3% vs. 25.9%) at 48 months and at 60 months (48.7% vs. 25.4%). There were no significant differences in terms of pathological reflux on 24-hour pH monitoring and in the occurrence of severe esophagitis between patients with vs. without PPIs. Regarding severe reflux complications, there were no new cases of Barrett's esophagus and esophageal adenocarcinoma. One patient developed peptic stricture, which was successfully treated with balloon dilation. The outcomes were not different among patients who underwent anterior (60%) vs. posterior myotomy (40%).

Conclusion

The rate of post-POEM reflux esophagitis decreases over time, however approximately 50% of patients require long-term antisecretory treatment. Even if the risk of reflux complications is low, patients after POEM should remain under long-term surveillance.