Evaluating the impact of an enhanced triage process on the performance and diagnostic yield of oesophageal physiology studies post COVID-19

ObjectivesThe COVID-19 pandemic significantly impacted on the provision of oesophageal physiology investigations. During the recovery phase, triaging tools were empirically recommended by national bodies for prioritisation of referrals amidst rising waiting lists and reduced capacity. We evaluated the performance of an enhanced triage process (ETP) consisting of telephone triage combined with the hierarchical ‘traffic light system’ recommended in the UK for prioritising oesophageal physiology referrals.DesignIn a cross-sectional study of patients referred for oesophageal physiology studies at a tertiary centre, data were compared between patients who underwent oesophageal physiology studies 6 months prior to the COVID-19 pandemic and those who were investigated within 6 months after service resumption with implementation of the ETP.Outcome measuresAdjusted time from referral to investigation; non-attendance rates; the detection of Chicago Classification (CC) oesophageal motility disorders on oesophageal manometry and severity of acid reflux on 24 hours pH/impedance monitoring.ResultsFollowing service resumption, the ETP reduced non-attendance rates from 9.1% to 2.8% (p=0.021). Use of the ‘traffic light system’ identified a higher proportion of patients with CC oesophageal motility disorders in the ‘amber’ and ‘red’ triage categories, compared with the ‘green’ category (p=0.011). ETP also reduced the time to test for those who were subsequently found to have a major CC oesophageal motility diagnosis compared with those with minor CC disorders and normal motility (p=0.004). The ETP did not affect the yield or timing of acid reflux studies.ConclusionETPs can effectively prioritise patients with oesophageal motility disorders and may therefore have a role beyond the current pandemic.

641 CLINICAL SYMPTOM PATTERNS IN PATIENTS WITH REFLUX ASPIRATION

Multiple papers have discussed pulmonary manifestation of gastro-oesophageal reflux disease (GORD), however little primary reported data exists on presenting symptoms of patients in whom reflux aspiration is confirmed. The aim of this study is to report symptoms and presenting patterns of a large group of patients with confirmed reflux aspiration. Methods Data was extracted from a prospectively populated database of patients referred to a tertiary specialist centre with severe, refractory, or atypical reflux. Patients with reflux aspiration on scintigraphy were included in this study. Separate group included patients with evidence of proximal reflux to the level of pharynx when supine and/or upright. Results Inclusion criteria were met by 243 patients (33% males; mean age 59). Most common symptoms amongst patients with aspiration were regurgitation (72%), cough (67%), heartburn (66%), throat clearing (65%), and dysphonia (53%). The most common two-symptom combinations were heartburn/regurgitation, cough/throat clearing, regurgitation/throat clearing, cough/regurgitation and dysphonia/throat clearing. The most common three-symptom combinations were cough/heartburn/regurgitation, cough/regurgitation/throat clearing and dysphonia/regurgitation/throat clearing. Clusters analysis demonstrated two main symptom clusters one suggestive of proximal large volume reflux symptoms (regurgitation, heartburn) and the other with IBS type symptoms (bloat, dysphagia, constipation). Conclusion Combination of typical symptoms of GORD and a respiratory or upper aero-digestive complaint should prompt consideration of reflux aspiration. Cluster analysis of symptoms in this group supports previously postulated hypothesis of reflux aspiration pathogenesis by either large volume proximal reflux or by ineffective oesophageal motility.

810 REPRODUCIBILITY OF REPEATED MEASUREMENTS OF OESOPHAGEAL MOTILITY METRICS WITHIN A STUDY

To compare reproducibility of repeated measurements of oesophageal motility metrics after 5 wet swallows within a study. Methods Patients referred for high-resolution esophageal manometry (HREM) to assess oesophageal motor function were enrolled. Solid-state 36-channel 10 Fr catheter (Unisensor AG) and Solar (MMS) software were used. Minimum 10 water swallows by 5 mL each were obtained. Two operators independently assessed the results of examination. Records of swallows were divided into 2 series by 5 measurements each. These series were compared by key metrics: integrated relaxation pressure (IRP), distal contractile integral (DCI), distal latency (DL), and contractile front velocity (CFV). Non-parametric statistics was used to compare the results. Results We enrolled 46 men and 68 women, age (mean ± SD) 48.8 ± 11.5 y.o. Of them, 52 patients had GERD, 25-different types of achalasia and 37 had no oesophageal disorders. The inter-observer agreement between 2 series of measurements reached 98%. No significant difference was found between the mean results of IRP, DCI, DL and CFV in 2 series of measurements (table 1). Conclusion No significant differences between studied HREM metrics in two series of measurements were found. The results of two series by 5 measurements within a study are reproducible. This may indicate the possibility of reducing the standard number of measurements. Reduction of time necessary for standard examination may allow additional time for functional tests (solid food swallows, RDC or MRS).

Surgical stabilisation of hiatal hernia and gastroesophageal reflux associated with idiopathic inflammatory polymyopathy in a Wire Fox Terrier

A one-and-a-half-year-old male Wire Fox Terrier weighing 3 kg presented with continuous drooling and vomiting. Its body condition score was 3/9, and severe atrophy of the temporal/masticatory muscle, trismus, and enophthalmos was observed on physical examination. The radiographic examination and fluoroscopic oesophagography revealed a type 1 hiatal hernia with gastroesophageal reflux. The serology tests revealed increased muscle enzyme activities. The antibody tests for acetylcholine receptor, type 2M fibre, and infectious agents were negative. A conventional surgical treatment was performed, and a thickened, stretched, and flaccid diaphragmatic muscle and an extended inelastic oesophageal hiatus were observed. On the histological examination of the diaphragmatic muscle, a diffuse histiocytic myositis was confirmed. Although the postoperative gastroesophageal reflux totally disappeared, the oesophageal motility and clinical signs did not improve significantly. Medical treatment with immunosuppressive agents was attempted and was effective in alleviating the clinical signs and abnormal oesophageal motility. The health condition of the dog was adequately maintained in the 12-month monitoring period. These findings suggest that, although the medical and surgical treatment have different therapeutic effects, they should be considered simultaneously for the management of a hiatal hernia associated with polymyopathy in dogs.

Reflux aspiration associated with oesophageal dysmotility but not delayed liquid gastric emptying

Introduction Severe oesophageal dysmotility is associated with treatment resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying (SGE) has been associated with oesophageal dysmotility, however the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration and oesophageal dysmotility. Methods Data was extracted from a prospectively populated database of patients with severe treatment resistant gastro-oesophageal reflux disease (GORD). All patients with validated reflux aspiration scintigraphy (RASP) and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal (GOR) or laryngo-pharyngeal (LPR) reflux. LGE time of 22 minutes or longer was considered delayed. Results Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81min. Refux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p=0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p<0.001). GOR dominant symptoms were more common in patients with delayed LGE (p=0.03). Conclusion Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

Functional and Patient-reported Changes in Swallowing and Voice After Combined Chemotherapy and Radiotherapy for Limited Stage Small Cell Lung Cancer

Purpose: To describe the nature and impact of dysphagia (difficulty swallowing) and dysphonia (impaired voice) in patients with limited-stage small cell lung cancer (SCLC) before and after chemoradiation.Methods: A prospective cohort study was conducted on patients receiving chemoradiotherapy for limited-stage SCLC. Patients received either 40Gy in 15 fractions, 45Gy in 30 fractions (delivered BD) or 50Gy in 25 fractions, commencing the second cycle of carboplatin/etoposide or cisplatin/etoposide chemotherapy. Outcomes included: videofluoroscopy swallowing studies (VFSS) to investigate aspiration, swallowing function, and oesophageal motility disorders; limitations to oral intake; patient-reported swallowing problems; and patient-reported voice problems. Data were collected before treatment and at one, three and six months post-treatment.Results: Twelve patients were enrolled. The oropharyngeal swallow was safe and functional at all time points. Three patients exhibited oesophageal motility disorders before treatment, while a further three exhibited disorders post-treatment. Oral intake was most compromised one month post-treatment with five patients being either tube dependent or eating only very limited diets. At all other times patients were eating a normal or near-normal diet. Despite normal oropharyngeal swallowing on VFSS, three patients reported moderate or severe swallowing difficulties one month post-treatment. Three additional patients reported moderate or severe difficulties three and six months post-treatment. Patients who reported swallowing difficulties one month post-treatment had all received a mean and maximum radiation dose to the oesophagus of ≥15.7Gy and ≥42Gy respectively. Dose-response relationships were no longer apparent three and six-months post treatment. Voice problems were variable, with the worst scores reported one month post-treatment.Conclusions: Although patient numbers are small, this study identified discordance between observed swallowing function and patient-reported problems, which has clinical implications for the management of patients with SCLC, as well as identifying areas for future research. Ongoing efforts to reduce mucosal toxicity in lung cancer patients are essential.

Oesophageal eosinophilia and oesophageal diseases in children: are the limits clear?

Gastro-oesophageal reflux disease, eosinophilic oesophagitis and oesophageal motility disorders are among the most common diseases accompanying oesophageal eosinophilia. They have similarities and their limits are frequently not well defined. This article reviews the main characteristics relating to their similarities and differences, highlighting existing controversies among these diseases, in addition to current knowledge. In the case of a patient with symptoms of oesophageal dysfunction, it is suggested to carry out an integral analysis of the clinical features and diagnostic test results, including histology, while individualising each case before confirming a definitive diagnosis. Future investigation in paediatric patients is necessary to assess eosinophilic infiltration in the various layers of the oesophageal tissue, along with its clinical and pathophysiological implications.