The Risk of Esophageal Food Impaction In Eosinophilic Esophagitis Patients; The Role of Clinical And Socioeconomic Factors

Background: Eosinophilic esophagitis (EoE) patients present with dysphagia and often suffer from esophageal food impaction (EFI). EFI can lead to life-threatening perforation, and requires emergent endoscopic intervention. The aim of this study is to evaluate the risk factors for EFI in EoE patients.Methods: This is a retrospective study performed at a tertiary health care system. Medical records and endoscopy images of EoE cases were reviewed. Clinical characteristics and outcomes including EFIs were documented. We used Zip-code median household income as a surrogate for patients’ socioeconomic status.Results: 291 EoE cases were included, mean age was 42 years. Most patients (65%) had classic EoE endoscopic findings including linear furrows and/or concentric rings, however, a significant proportion (47%) had findings suggestive of gastroesophageal reflux disease (GERD), such as the presence of erosive-esophagitis, a hiatal hernia or Schatzki’s ring. 48 patients (16%) developed one or more esophageal food impaction (EFI). The risk of EFI was less likely in the absence of furrows and/or rings; odds ratio (OR) = .28, 95%CI (0.11, 0.72) [P = .008]. Females had less EFI risk; OR = 0.42, 95%CI (0.19, 0.95) [P = .04]. The type of medical insurance and socioeconomic status was not associated with EFI risk.Conclusion: EFI risk is higher in EoE patients with esophageal furrows and/or rings and in men. Aggressive treatment might be required in this population. GERD and EoE can coexist in many patients. Further studies are required to examine the role of the socioeconomic status in EoE complications.

CHARACTERISTICS AND SUBSTANTIATION OF THE USE OF PELLETS AS A MODERN DOSAGE FORM ON THE MARKET OF UKRAINE

currently, omeprazole pellets are one of the most common pellet formulations on the pharmaceutical market of Ukraine (Gorobets, Matyash, Pekhenko & Barna, 2019). This medication is available in capsule form. Pellets are multi particular dosage forms that have several advantages over monoparticular dosage forms; therefore, pellets are promising oral delivery systems for active pharmaceutical ingredients (APIs). Pellets are used when the stability of the active substance changes with fluctuations in the pH of the environment, when irritation of the gastric mucosa is possible, to facilitate swallowing (especially important for patients with dysphagia, elderly patients, and children). When using polymers in the shell, it is possible to regulate the release in a certain part of the gastrointestinal tract, this allows you to get a point pharmacological effect. In addition, pellets can be of different sizes (from 0.1 to 2 mm), because of their shape, pellets exhibit abrasion resistance and are more fluid. Omeprazole is a synthetic substance. The active ingredient suppresses gastric acid secretion. In refers to the pharmaceutical group of proton pump inhibitors, it prescribes drugs in this group to treat active duodenal ulcers, gastric ulcers, gastro-oesophageal reflux disease (GERD), severe erosive esophagitis, pathological hypersecretory conditions, for example, Zollinger Ellison syndrome. Among the most commonly used methods for the production of pellets are: stage-by-stage spraying of solutions or suspensions (the second name is stage-by-stage layering); direct pelletization (the second name is extrusion-spheronization); spray drying and spray cooling of melts; agglomeration-spheronization. Unfortunately, at the moment, none of the Ukrainian manufacturers is manufactured enteric pellets on their own (they buy ready-made pellets), while there are medicines of both foreign and Ukrainian origin on the domestic market. The article contains an overview of pharmaceutical preparations as pellets, systematization of information on production methods, a review of omeprazole drugs as pellets, presented on the pharmaceutical market of Ukraine. The purpose of this study was to summarize the cases when the use of such a form as pellets is the most reasonable; make an overview of medicines in Ukraine containing pellets; summarize modern methods of pellet production.

Combination of Symptom Profile, Endoscopic Findings, and Esophageal Mucosal Histopathology Helps to Differentiate Achalasia from Refractory Gastroesophageal Reflux Disease

: Achalasia, a rare primary esophageal motility disorder, is often misdiagnosed as refractory gastroesophageal reflux disease (GERD). This study is aimed to identify the clinical and histopathologic features that may help to differentiate these two entities. Patients with untreated achalasia and those with refractory reflux symptoms despite ≥8 weeks of proton-pump inhibitor treatment were enrolled prospectively. All patients underwent validated symptom questionnaires, esophagogastroduodenoscopy with biopsy, and high-resolution impedance manometry (HRIM). Histopathology of esophageal mucosa was compared based on four pre-determined histological criteria: basal cell hyperplasia or papillae elongation, eosinophilic infiltration, petechiae formation, and hypertrophy of the muscularis mucosae (MM). Compared with the GERD patients, patients with achalasia had similar reflux symptoms, but higher Eckardt scores, fewer erosive esophagitis and hiatal hernia, more esophageal food retention on endoscopy, and higher prevalence of hypertrophy of the MM and petechiae formation on histopathology. Multivariate logistic regression based on Eckardt score ≥4, normal esophagogastric junction morphology or esophageal food retention, and coexistence of petechiae formation and hypertrophy of the MM, established the best prediction model for achalasia. Therefore, combination of routinely accessible variables, including Eckardt score, endoscopic features, and histopathology obtained via esophageal mucosal biopsy, may provide an earlier identification of achalasia.

The Yield of Endoscopy and Histology in the Evaluation of Esophageal Dysphagia: Two Referral Centers’ Experiences

Background and Objectives: The initial diagnostic test required to evaluate esophageal dysphagia is upper endoscopy (EGD) to assess the structure of the esophagus and the esophageo-gastric junction (EGJ). Taking biopsies during EGD has become a common practice in patients with dysphagia to rule out eosinophilic esophagitis (EoE). The aims of this study were to evaluate the endoscopic findings of patients who underwent EGD for esophageal dysphagia, to assess the rate of biopsy taking from the esophagus to diagnose/exclude EoE, and to report histology outcomes of these biopsies. Materials and Methods: This was a retrospective multicenter study that included individuals ≥18 years who underwent EGD due to esophageal dysphagia between the years 2015 and2020, (with no other alarm signs, such as weight loss, new iron deficiency anemia, and lymphadenopathy). We obtained data from patients’ electronic files. The endoscopy and histology findings were obtained from endoscopy reports saved in our electronic files. Results: A total of 209 patients were included in the study. The average age was 57.1 ± 17.1 years. The most common endoscopic findings were normal endoscopy in 76 patients (36.4%) and erosive esophagitis in 75 patients (35.9%). Barrett’s esophagus and esophageal malignancy were encountered in 11 patients (5.3%) and 2 patients (0.95%), respectively. Esophageal biopsies were taken in 50.2% of patients, and one patient had histological evidence of EoE (0.5%). On univariate analysis, there was a trend for association between proton pump inhibitors (PPIs) use and a normal EGD, but it was not statistically significant (OR 0.28, 95% CI 0.07–1.11, p = 0.07). Conclusions: Endoscopic findings were prevalent in dysphagia patients even when no other alarm symptoms exist. Neoplastic lesions and EOE were rare in our study.

Does Sleeve Gastrectomy Worsen Gastroesophageal Reflux Disease in Obese Patients? A Prospective Study

Background To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD). Methods GERD was evaluated by the Modified Italian Gastroesophageal reflux disease—Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB. Results Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P = .0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P = .009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups. Conclusions LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds.

P-BN04 Evaluation of Outcomes of Anti-reflux Surgery in a District General Hospital

Background Gastro-oesophageal reflux disease (GORD) affects up to 20% of the Western population, and is usually associated with presence of hiatus hernia (HH). Proton pump inhibitors (PPI) are the mainstay treatment, but half of PPI users have persistent symptoms. Anti-reflux surgery in the form of fundoplication surgery with HH repair can be considered in patients unable to tolerate or unwilling to persevere with long term medical therapy and those with severe sequalae of reflux, such as those with Barrett esophagus or non-healing erosive esophagitis. We aim to evaluate the outcomes and factors relating to surgical success of anti-reflux surgery. Methods We identified patients who had HH repair and fundoplication surgery from our prospectively maintained theatre database over a eight year period. Retrospective data collection was performed, inclusive of patients’ pre-operative investigations, intraoperative findings and postoperative patient outcomes. Chi Square and Mann Whitney U test were used to calculate the statistical significance. 187 cases were analyzed, involving only 167 unique patients as 14 patients had 1 redo surgery and 2 patients had 2 redo surgeries. Results Male to female ratio was 2:3. Median age was 59 years and median BMI was 29.1. 85% of cases were performed laparoscopically, which had the shorter median length of stay at 2 days. Pre-operative assessment of HH size with barium swallow had the highest sensitivity (82%) and specificity (75%). Large to moderate HH are more prevalent in female patients. Rolling HH are more associated with dysphagia and vomiting whereas sliding HH with reflux symptoms. Rolling HH are more likely to be repaired with an open approach and more likely to require hiatal mesh repair compared to sliding HH. Conclusions In the 96% of patients followed up, we successfully achieved symptom control in 94% of them. Although we were unable to find specific patient or surgical factors contributing to symptom recurrence or redo surgeries, we were able to identify certain pre-operative tests which can predict the difficulty of surgery. Larger scale case series would allow us to predict patient cohort at a higher risk of unsuccessful anti-reflux surgery.