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Endoscopic and Surgical Management of Gastroesophageal Reflux Disease
Approximately, 10% to 15% of patients in the United States experience gastroesophageal reflux symptoms on a weekly basis, negatively affecting the quality of life and increasing the risk of reflux-related complications. For patients with symptoms recalcitrant to proton pump inhibitor (PPI) therapy or those who cannot take PPIs, surgical fundoplication is the gold standard. The preoperative workup is complex but vital for operative planning and ensuring good postoperative outcomes. Most patients are highly satisfied after fundoplication, though transient dysphagia, gas bloating, and resumption of PPI use are common postoper...
Source: Gastroenterology Clinics of North America - October 7, 2021 Category: Gastroenterology Authors: Christopher J. Zimmermann, Anne Lidor Source Type: research

Sorting out the Relationship Between Esophageal and Pulmonary Disease
The aim of this review is to explore the relationship between esophageal syndromes and pulmonary diseases considering the most recent data available. Prior studies have shown a close relationship between lung diseases such as asthma, chronic obstructive pulmonary disorders (COPD), Idiopathic pulmonary fibrosis (IPF), and lung transplant rejection and esophageal dysfunction. Although the association has long been demonstrated, the exact relationship remains unclear. Clinical experience has shown a bidirectional relationship where esophageal disease may influence the outcomes of pulmonary disease and vice versa. The impact o...
Source: Gastroenterology Clinics of North America - October 7, 2021 Category: Gastroenterology Authors: Noreen C. Okwara, Walter W. Chan Source Type: research

Dysphagia
Among recent advances in diagnostics for dysphagia and esophageal motility disorders is the update to the Chicago Classification (version 4.0) for interpretation of high-resolution manometry (HRM) and diagnosis of esophageal motility disorders. The update incorporates application of complementary testing strategies during HRM, such as provocative HRM maneuvers, and recommendation for barium esophagram or functional luminal imaging probe (FLIP) panometry to help clarify inconclusive HRM findings. FLIP panometry also represents an emerging technology for evaluation of esophageal distensibility and motility at the time of end...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Amanda J. Krause, Dustin A. Carlson Source Type: research

Early Esophageal Cancer
Endoscopic findings in early esophageal cancer are often subtle and require careful inspection and meticulous endoscopic examination. When dysplasia is suspected, we recommend performing 1 or 2 targeted biopsies of the abnormal area and review with a pathologist specialized in evaluating gastrointestinal diseases. In the case of adenocarcinoma, after resection of any visible cancer, residual Barrett ’s can be treated by ablation. Endoscopic resection can offer the opportunity for patients to avoid surgery. Further studies are needed to evaluate the optimal management of circumferential and near-circumferential lesions as...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Mike T. Wei, Shai Friedland Source Type: research

Eosinophilic Esophagitis
Eosinophilic esophagitis (EoE) is an antigen-mediated esophageal disease defined by the presence of esophageal eosinophilia and symptoms of esophageal dysfunction. The pathophysiology involves an allergen-driven Th2 T  cell response that triggers infiltration of eosinophils into the esophagus leading to inflammation, remodeling, and fibrosis. This results in disruption of esophageal function and accompanying symptoms – most notably dysphagia. Effective therapies target inflammation or fibrostenotic complicatio ns and include proton pump inhibitors, swallowed topical steroids, dietary exclusion, and dilation. Clinical tr...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Nielsen Q. Fernandez-Becker Source Type: research

How to Understand and Treat Laryngopharyngeal Reflux
Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients ’ symptoms are refractory to empiric treatment, pH testing with/without impedance should be consi...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Grace Snow, Shumon I. Dhar, Lee M. Akst Source Type: research

Making Sense of Nonachalasia Esophageal Motor Disorders
Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Benjamin D. Rogers, C. Prakash Gyawali Source Type: research

Functional Chest Pain and Esophageal Hypersensitivity
Functional chest pain, functional heartburn, and reflux hypersensitivity are 3 functional esophageal disorders defined by the Rome IV criteria. Specific criteria, combining symptoms and the results of objective testing, allow for an accurate diagnosis of these conditions. Management may include medications targeted at optimizing acid suppression or neuromodulation, as well as a host of complementary or alternative treatment options. Psychological and behavioral interventions, such as cognitive behavioral therapy and hypnotherapy, have displayed substantial benefits in the treatment of functional chest pain and functional h...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Richa Bhardwaj, Rita Knotts, Abraham Khan Source Type: research

Therapeutic Endoscopy and the Esophagus
Therapeutic gastrointestinal endoscopy is rapidly evolving, and this evolution is quite apparent for esophageal diseases. Minimally invasive endoluminal therapy now allows outpatient treatment of many esophageal diseases that were traditionally managed surgically. In this review article, we explore the most exciting new developments. We discuss the use of peroral endoscopic myotomy for treatment of achalasia and other related diseases, as well as the modifications that have allowed its use in treatment of Zenker diverticulum. We cover endoscopic treatment of gastroesophageal reflux disease and Barrett ’s esophagus. Furth...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Linda Y. Zhang, Anthony N. Kalloo, Saowanee Ngamruengphong Source Type: research

Using Diet to Treat Diseases of Esophagus
The esophagus plays a crucial role in oral nutrition and digestive pathophysiology. In addition, diet is now considered an important primary or augmentative therapy in several esophageal disease states. This review highlights common dietary therapies used in treating diseases of the esophagus as well as the underlying data that support such practices. Specially, diet and its relationship to swallowing dysfunction, motility disorders, malignancies, and inflammatory mucosal diseases such as gastroesophageal reflux disease and eosinophilic esophagitis is explored. (Source: Gastroenterology Clinics of North America)
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Carolyn Newberry, Kristle Lynch Source Type: research

Barrett ’s Esophagus
Barrett ’s esophagus (BE) is the precursor lesion for esophageal adenocarcinoma (EAC) development. Unfortunately, BE screening/surveillance has not provided the anticipated EAC reduction benefit. Noninvasive techniques are increasingly available or undergoing testing to screen for BE among those with/with out known risk factors, and the use of artificial intelligence platforms to aid endoscopic screening and surveillance will likely become routine, minimizing missed cases or lesions. Management of high-grade dysplasia and intramucosal EAC is clear with endoscopic eradication therapy preferred to surg ery. BE with low-gra...
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Karen Chang, Christian S. Jackson, Kenneth J. Vega Source Type: research

Gastroesophageal Reflux Disease and the Patient with Obesity
Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy. (Source: Gastroenterology Clinics of North America)
Source: Gastroenterology Clinics of North America - October 6, 2021 Category: Gastroenterology Authors: Yewande Alimi, Dan E. Azagury Source Type: research

Achalasia
is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endo...
Source: Gastroenterology Clinics of North America - October 2, 2021 Category: Gastroenterology Authors: Sydney Pomenti, John William Blackett, Daniela Jodorkovsky Source Type: research

Irritable Bowel Syndrome and Eating Disorders
Irritable bowel syndrome affects 10% to 15% of the population, and up to 90% of patients with irritable bowel syndrome exclude certain foods to improve their gastrointestinal symptoms. Although focused dietary restrictions are a normal, adaptive response, restrictions can spiral out of control and result in maladaptive restriction. Dietary therapies are rapidly becoming first-line treatment of irritable bowel syndrome, and gastroenterologists need to be aware of red flag symptoms of maladaptive eating patterns and the negative effects of prescribing restrictive diets. There is also growing awareness of the association betw...
Source: Gastroenterology Clinics of North America - July 23, 2021 Category: Gastroenterology Authors: Andrea McGowan, Kimberly N. Harer Source Type: research

Epidemiology and Burden of Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) prevalence rates are based on diagnostic criteria, the basis for case definitions. Diagnostic criteria have a substantial impact on prevalence rates, which are significant for understanding burden of disease, comparing global subpopulations, generating pathophysiologic research, allocating of health care and research resources, and incentivizing and prioritizing new treatments. There are substantial methodological pitfalls in epidemiologic research, so determining regional and global IBS prevalence rates is problematic. The Rome Foundation Global Epidemiology Study was designed to resolve the...
Source: Gastroenterology Clinics of North America - July 23, 2021 Category: Gastroenterology Authors: Ami D. Sperber Source Type: research