P-O02 Management Experiences of Post-gastrectomy Severe Alkaline Reflux Oesophagitis

Background Alkaline reflux oeosphagitis is a recognized complication of procedures that compromise the lower oesophageal sphincter (LES), including gastrectomy. Incidence of reflux is dependent on the reconstructive procedure with Roux-en-Y esophagojejunostomy commonly accepted as the optimal method. The authors report their experience of 6 patients who underwent remedial intervention for severe alkaline reflux esophagitis following gastric surgery. Methods A retrospective review of 6 patients who had underwent a previous gastric procedure and developed symptoms of gastroesophageal reflux disease, over a 6-year period (2014-2020). Reflux symptoms were diagnosed by clinical history, radiology, endoscopy and esophageal manometry prior to proceeding to surgical reflux control. Post-operative outcomes following anti-reflux surgery were assessed by means of serial outpatient assessments and endoscopy. Results Six patients were included in this report, 4 males and 2 females with an average age of 73 years (range 58-91). Primary diagnoses encompassed; 4 gastric adenocarcinomas, 1 gastric neuroendocrine tumour and 1 patient with debilitating gastric antral vascular ectasia (GAVE) syndrome. Four patients underwent total gastrectomy and 2 subtotal gastrectomy with Roux-en-Y reconstruction. Onset of post-operative reflux symptoms ranged from 2-weeks to 3-years. Failing medical management, all patients underwent jejunojejunal anastomosis and Roux limb length revision with surgical jejunostomy. At follow up 5 patients had some degree of symptom resolution; 3 complete resolution, 2 initial resolution and 1 with unresolved symptoms. Conclusions Severe alkaline reflux oesophagitis is a recognized complication of gastric procedures compromising the LES. The authors report our experience of managing this complication following gastrectomy with jejunojejunal anastomosis and Roux limb length revision, with a majority of patients having improvement in if not complete resolution of reflux symptoms.

Relationship between Gastroesophageal Reflux and IL-8

Background Gastroesophageal reflux disease (GERD) is a condition that develops by reflux of the stomach contents into the esophagus, and causes troublesome symptoms, such as heartburn and regurgitation. Aim of the work to evaluate the serum level of IL-8 in patients of GERD with its degrees including NERD and refractory GERD and normal controls. Patients and Methods The study included four groups of patients, Group-1 including 15 patients with GERD symptoms who didn’t receive treatment or who received treatment for less than 8 weeks with improvement of symptoms, Group-2 including 15 Patients with NERD, group-3 including 15 patients with refractory GERD and who received PPIs for more than 8 weeks without improvement of symptoms and group-4 of normal controls. Results serum IL8 level was elevated in the group of refractory GERD more than the group of GERD more than the group of NERD more than normal controls. Relation between serum IL8 and pathological findings in each group included in the study revealed statistically significant difference, in the group of GERD IL8 was elevated in the cases of severe reflux oesophagitis more than mild reflux oesophagitis more than moderate reflux oesophagitis more than barrets esophagitis, there is statistically significant difference. While in patients with refractory GERD IL8 was elevated in the cases of severe oesophagitis more than the cases of moderate reflux oesophagitis, there is statistically not significant difference Conclusion Serum Interleukin-8 (IL8) level was elevated in patients with refractory GERD more than patients with GERD more than patients of NERD more than normal controls. Pathological features that we found in patients with GERD were moderate reflux oesophagitis (52%) more than mild reflux oesophagitis (40%) more than severe reflux oesophagitis (8%), while in patients with refractory GERD there were severe reflux oesophagitis (56%) more than Barrett's esophagitis (28%) more than moderate reflux oesophagitis (16%).

Endoscopic findings in patients with refractory dyspepsia at A Tertiary Care Hospital in Peshawar, KPK Province, Pakistan.

Objectives: This study was aimed to describe the endoscopic findings in patients with refractory dyspepsia. Study Design: Observational study. Setting: Rehman Medical Institute Peshawer. Period: March 2017- Feb 2019. Material & Methods: All the patients who were referred for endoscopy for refractory dyspepsia were included by consecutive non probability sample technique. Data was entered and analyzed on SPSS version 22. Results: Out of 727 patients, 51.6% (n=375) were male. Mean age was 43.09±15. 54.30% (n=395) endoscopies were normal. Antral gastritis, Fundal gastritis and Pangastritis were noted in 14% (n=102), 4.40% (n=32) and 8.50% (n=62) patients respectively. Gastroenteritis was found in 5.40 %( n= 39) while 3.20 %( n=23) patients had duodenitis. Reflux oesophagitis was observed in 2.50% (n=18) patients. 1.20 %( n= 9) had erosions while 0.80% (n=6) had gastric ulcers, 1.20% (n=9) had carcinoma, 2.30% (n=17) had hiatal hernia and 2.10% (n=15) had other gastric pathologies. Functional dyspepsia was seen in 89.9% patients. It was observed more in young age, female gender, and in patients from Afghanistan, frequency being 66.3%, 63.4% and 59% respectively. Conclusion: Most patients with refractory dyspepsia had normal endoscopy, it was common in females, young age and Afghanistan patients. Reflux oesophagitis was common pathological finding with predominance in elderly.

Pre-procedural proton pump inhibition is associated with fewer peri-oesophageal lesions after cryoballoon pulmonary vein isolation

Pulmonary vein isolation (PVI) using cryoenergy is safe and efficient for treatment of atrial fibrillation (AF). Pre-existing upper gastrointestinal (GI) pathologies have been shown to increase the risk for AF. Therefore, this study aimed at assessing incidental pathologies of the upper GI tract in patients scheduled for PVI and to analyse the impact of patients’ characteristics on PVI safety outcome. In 71 AF patients, who participated in the MADE-PVI trial, oesophagogastroduodenoscopy and endosonography were prospectively performed directly before and the day after PVI to assess pre-existing upper GI pathologies and post-interventional occurrence of PVI-associated lesions. Subgroup analysis of the MADE-PVI trial identified clinically relevant incidental findings in 53 patients (74.6%) with age > 50 years being a significant risk factor. Pre-existing reflux oesophagitis increased risk for PVI-associated mediastinal oedema, while patients already treated with proton pump inhibitors (PPI) had significantly fewer mediastinal oedema. Our results suggest that AF patients with pre-existing reflux oesophagitis are at higher risk for PVI-associated mediastinal lesions, which is decreased in patients with constant PPI-treatment prior to PVI. Since PVI-associated mediastinal lesions are regarded as surrogate parameter for an increased risk of the fatal complication of an oesophago-atrial fistula, our findings hint at a beneficial effect of pre-interventional prophylactic PPI-treatment to reduce risk for PVI-associated complications.German Clinical Trials Register (DRKS00016006; date of registration: 17/12/2018).

Validation of the Lyon classification for GORD diagnosis: acid exposure time assessed by prolonged wireless pH monitoring in healthy controls and patients with erosive oesophagitis

ObjectiveAcid exposure time (AET) from ambulatory pH studies and reflux oesophagitis are independent measurements used by the Lyon classification to diagnose GORD. This study aimed to validate AET reference ranges and diagnostic thresholds by analysis of 96-hour wireless pH studies from healthy, asymptomatic controls (HCs) and patients with and without oesophagitis.DesignHC and consecutive patients referred for wireless pH studies (off acid suppressants for >7 days) underwent 96-hour pH studies at two tertiary referral centres. Erosive oesophagitis was categorised by the Los Angeles (LA) classification. Linear regression and receiver operating curve (ROC) analysis were performed to define optimal diagnostic cut-offs.ResultsProlonged, 96-hour pH studies were completed in 39 HCs (age 28 (18–53) years, 72% female) and 944 patients (age 46 (16–85) years, 65% female), of whom 136 (14.5%) had reflux oesophagitis. Median AET in HC was 1.3% (upper 95th percentile 4.6%) for any study day and 2.6% (upper 95th percentile 6.9%) for the worst day (24-hour period) during the study. ROC analysis for average AET differentiated HC from patients with moderate-to-severe oesophagitis (LA BCD; sensitivity 87%, specificity 95%, positive predictive value (PPV) 59%, negative predictive value 99% for a cut-off AET of 4.3%; area under the receiver operating curve 0.95). Specificity was higher, but PPV was substantially lower for severe oesophagitis (LA CD). ‘Worst-day’ analysis provided similar results; however, day-to-day variability was high.ConclusionDiagnostic thresholds for average AET were identified that accurately discriminate between HCs and patients with erosive oesophagitis. The findings provide conditional support for diagnostic criteria for GORD proposed by the Lyon Consensus.

415 OCCUPATIONAL PHYSICAL ACTIVITY AND THE RISK OF GORD, BARRETT’S OESOPHAGUS AND OESOPHAGEAL ADENOCARCINOMA A PROSPECTIVE COHORT STUDY IN UK BIOBANK

Recreational physical activity has been shown to protect against the development of oesophageal adenocarcinoma as well as gastroesophageal reflux disease (GORD), but such effects have not been demonstrated for non-recreational activity. We examined whether high levels of occupational physical activity (heavy manual labour or physical work) were associated with the risk of oesophageal adenocarcinoma as well as its sequential precursor diseases; gastroesophageal reflux disease (GORD), reflux oesophagitis and Barrett’s oesophagus. Methods In this population-based prospective cohort study, participants aged between 37 to 73 years were recruited from 22 regions across the United Kingdom. Baseline occupational information of job type and levels of heavy manual activity was assessed using both questionnaires and verbal interviews. Incident cases were identified by linkage with routinely collected hospital inpatient and cancer registry data for England, Scotland and Wales. Primary clinical outcomes were GORD without oesophagitis, GORD with oesophagitis (reflux oesophagitis), Barrett’s oesophagus and oesophageal adenocarcinoma. The effects of heavy manual activity on disease risk were estimated using Cox proportional hazard regression. Results Between 2006 and 2010, 502 524 men and women were enrolled. Main analyses were limited to the working population with a full set of variables of interest (n = 266 453). Compared to jobs with low levels of heavy manual activity, high level jobs had increased hazard ratios (HRs) for GORD (1.20, 95% CI 1.11–1.30), reflux oesophagitis (1.17, 95% CI 1.04–1.31) and Barrett’s oesophagus (1.13, 95% CI 0.98–1.32), but not oesophageal adenocarcinoma (0.91 95% CI 0.54–1.56). Conclusion High levels of occupational heavy manual activity could be used as a risk factor for GORD and reflux oesophagitis, the precursor diseases of Barrett’s oesophagus and oesophageal adenocarcinoma.