Purpose of Review
This paper aims to review the definition and diagnostic criteria for reflux hypersensitivity and comment on the present and future management of this condition.
Recent Findings
In ...2016, the Rome IV criteria redefined reflux hypersensitivity as characterized by typical reflux symptoms, absence of endoscopic mucosal disease, absence of pathologic gastroesophageal reflux, and positive symptom correlation between reflux and heartburn episodes. Though uncertain, TPRV1 receptors have been implicated in the pathophysiology of reflux hypersensitivity. Recent studies have shown neuromodulators like SSRIs, SNRIs, and TCAs may be the future of managing this condition.
Summary
With the release of the Rome IV criteria and availability of continuous pH monitoring, the diagnosis of reflux hypersensitivity has become more streamlined. Though there is no definitive therapy for reflux hypersensitivity, several anti-secretory agents and neuromodulators have shown some efficacy in therapeutic trials. The lack of large-scale, randomized controlled trials, however, reinforces the need for further research into the pharmacotherapy of reflux hypersensitivity.
Consecutive patients with achalasia followed at Stanford Health Care Esophagus Center between July 2022 and June 2023 were recruited to modify the preliminary expert QPL version. Future directions ...will assess patient and physician usability, as well as rigorously test the efficacy of this QPL on patient outcomes. Overview of patient panel member characteristics Characteristics Patient panel (N=9) n (%) Age median (IQR) 64 40, 66.5 Sex Male 4 (44.4%) Female 5 (55.6%) Race/ethnicity White 7 (77.8%) Black or African American 1 (11.1%) Native Hawaiian or Pacific Islander 1 (11.1%) Level of education High School / GED 3 (33.3%) 2-year Degree 1 (11.1%) Bachelor’s 3 (33.3%) Master’s 1 (11.1%) Professional / Doctoral Degree 1 (11.1%) Achalasia Subtype and Treatment Modality Type 1 2 (22.2%) Heller Myotomy followed by POEM 1 (11.1%) Balloon Dilation to 30 mm followed by POEM 1 (11.1%) Type 2 4 (44.4%) POEM 1 (11.1%) Botox followed by POEM 3 (33.3%) Type 3 2 (22.2%) Heller Myotomy with Dor Fundoplication 1 (11.1%) No treatment 1 (11.1%) Author Notes *PresenterStanford University School of Medicine, Redwood City, CA.
Introduction
Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few ...studies comparing the efficacy of POEM versus Heller Myotomy (HM).
Aims
To compare the long-term clinical efficacy of POEM versus HM.
Methods
Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score > 3 for at least 4 weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed.
Results
98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94 years, and 5.44 years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1%
p
= 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%,
p
< 0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications.
Conclusion
POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.
Background
Dysmotility in one region of the gastrointestinal tract has been found to predispose patients to developing motility disorders in other gastrointestinal segments. However, few studies have ...evaluated the relationship between gastroparesis and constipation.
Methods
Retrospective review of 224 patients who completed 4‐hour, solid‐phase gastric emptying scintigraphy (GES), and wireless motility capsule (WMC) testing to evaluate for gastroparesis and slow‐transit constipation, respectively. When available, anorectal manometry data were reviewed to evaluate for dyssynergic defecation. Patients were divided into two groups based on the results of the GES: 101 patients with normal gastric emptying and 123 patients with gastroparesis (stratified by severity). Differences in constipation rates were compared between the groups.
Key results
Slow‐transit constipation was more common in the gastroparesis group, but statistical significance was not reached (42.3% vs 34.7%, p = 0.304). Univariate logistical regression analysis found no association between slow‐transit constipation and gastroparesis (OR 1.38, 95% CI 0.80‐2.38, p = 0.245) nor dyssynergic defecation and gastroparesis (OR 0.88, 95% CI 0.29‐2.70, p = 0.822). However, when stratifying gastroparesis based on severity, slow‐transit constipation was found to be associated with severe gastroparesis (OR 2.45, 95% CI 1.20‐5.00, p = 0.014). This association was strengthened with the exclusion of patients with diabetes mellitus (OR 3.5, 95% CI 1.39‐8.83, p = 0.008) ‐ a potential confounder.
Conclusions & Inferences
Patients with severe gastroparesis (>35% gastric retention at the 4‐hour mark on solid‐phase GES) have an increased likelihood of having underlying slow‐transit constipation. Dyssynergic defecation does not appear to be associated with gastroparesis (of any severity).
Dysmotility in one segment of the gastrointestinal tract may predispose patients to developing motility disorders in other gastrointestinal segments. We reviewed 224 patients for gastroparesis and slow‐transit constipation and found no association between the two conditions unless the patients had severe gastroparesis (>35% gastric retention at the 4‐h mark on gastric emptying scintigraphy).
Healthcare providers are trained to apply a problem-oriented approach that focuses on understanding the etiologic mechanisms of GERD and may reflexively ask “why are her GERD symptoms uncontrolled?” ...or “should we perform diagnostic testing?” However, to solve the limitations with healthcare disparities faced by HLAs, healthcare providers should think beyond this reflex approach and understand that HLA patients are limited by a language barrier, reduced health literacy, and low patient engagement (Figure 1). By contrast, less activated individuals tend to be more passive in their health care, thereby less likely to ask questions during a clinic visit, seek health information, and adhere to medications. Unfortunately, HLAs have significantly lower patient activation levels, particularly among foreign-born and second-generation Hispanics (13). ...HLA patients with GERD are disadvantaged in reaching GERD health success. ...a solution-oriented research approach is needed to create an intervention that increases patient-activation levels. Shared decision making (SDM) is a key component of patient-centered health care and is the collaborative involvement of patients when making treatment decisions.
