Background Prior to antireflux surgery, most patients with symptoms of gastroesophageal reflux disease (GERD) have been taking long-term proton pump inhibitors (PPIs). PPIs have been shown to cause changes to the intestinal microbiota, such as small intestinal bacterial overgrowth (SIBO), which is characterised by symptoms of gas bloating. Patients undergoing antireflux surgery are not routinely screened for SIBO, yet many patients experience gas-related symptoms postoperatively. Methods Data from consecutive patients (n = 104) referred to a speciality reflux centre were retrospectively assessed. Patients underwent a routine diagnostic workup for GERD including history, endoscopy, oesophageal manometry and 24-h pH-impedance monitoring off PPIs. Intestinal dysbiosis was determined by hydrogen and methane breath testing with a hydrogen-positive result indicative of SIBO and a methane-positive result indicative of intestinal methanogen overgrowth (IMO). Results 60.6% of patients had intestinal dysbiosis (39.4% had SIBO and 35.6% had IMO). Patients with dysbiosis were more likely to report bloating (74.6% vs 48.8%; P = 0.01) and belching (60.3% vs 34.1%; P = 0.01). The oesophageal acid exposure time and number of reflux episodes were similar between dysbiosis and non-dysbiosis groups, but patients with dysbiosis were more likely to have a positive reflux-symptom association (76.2% vs 31.7%; P < 0.001), especially for regurgitation in those with SIBO (P = 0.01). Hydrogen gas production was significantly greater in patients with a positive reflux-symptom association for regurgitation (228.8 ppm vs 129.1 ppm, P = 0.004) and belching (mean AUC 214.8 ppm vs 135.9 ppm, P = 0.02). Conclusions The prevalence of intestinal dysbiosis is high in patients with GERD, and these patients are more likely to report gas-related symptoms prior to antireflux surgery. Independently, SIBO may be a contributory factor to refractory reflux symptoms and gas bloating in antireflux surgery candidates.
proximal oesophagus. Its importance as a cause of throat symptoms has been recognised, particularly chronic globus.Studies report variable figures regarding the prevalence of heterotopic gastric mucosa in the proximal oesophagus, between 0.03% and 5.9%. It is likely that this variability is due to the quality of endoscopy, with one study demonstrating the detection rate rises 10-fold when endoscopists were aware of the condition.Here, we aimed to evaluate the true prevalence of cervical inlet patch in patients with and without globus following implementation of a structured endoscopy reporting template to enhance detection rate of CIP. Methods A prospective study of presence of inlet patch documented during endoscopic BRAVO capsule procedures performed between 2009 and 2020 was undertaken. Five operators carried out the procedures with expertise in optical image enhancement endoscopy and upper-GI lesion recognition. Endoscopy reports were interrogated including picture photo-documentation to confirm presence of inlet patch. Additionally, patient symptoms and BRAVO capsule pH data were analysed to detect association with globus and reflux. Assessment of normality of data was assessed using the Shapiro Wilks test and subsequently non-parametric analyses were performed using the Mann Whitney U test. Results A total of 1042 patients undergoing Bravo were studied. The use of a structured endoscopy reporting template for BRAVO capsule was used and as such all patients were classified as having the presence or absence of an inlet patch.All had conscious sedation; median dose of fentanyl 100 mcg (75-150 mcg) and midazolam 4 mg (3-7 mg).CIPs were detected in 76/1042 (7.1%). Association of CIP and abnormal BRAVO reading was non-significant for number of reflux events or total acid exposure time but was significantly associated with symptoms such as chest pain (p<0.05).In those with no globus symptoms (n=294), CIP was detected in 13 (4.4%), but in those with globus (n=748), this increased to 63 (8.4%), p=0.03. Conclusions In this large cohort study the prevalence of cervical inlet patch was found to be 7%, and in those with oropharyngeal symptoms, over 8%. Improved detection rate may be related to numerous factors, including endoscopists level of experience at detecting pathology, sedation use and patient comfort, as well as a reporting template focusing the endoscopist to comment on presence/absence of inlet patch. Presence of CIP may be considered as a quality metric of upper-GI endoscopy in the future.
Methods Data collection spanned 16 months (1/1/2016-30/4/ 2017) with 442 patients being identified from the Infoflex endoscopy database. Patients were enrolled if the main indication for upper gastrointestinal endoscopy was coded as 'Barrett's surveillance'. Review of histology reports, Infoflex accounts and clinical notes allowed acquisition of both 'Prague Classification' and 'Seattle Biopsy Protocol' data, alongside operator status (generalist or specialist). The relationship between type of endoscopy and compliance to techniques were assessed statistically through chi-squared independence testing. Results From 442 cases (Mean 66.2 years (Range 24-88)), compliance to both 'Prague Classification' and 'Seattle Biopsy Protocol' were 73% (322/442) and 70% (309/442), respectively. Access to specialist endoscopy was improved at 41% compared to 26% (2014)(2015). Furthermore, specialist endoscopy yielded superior adherence to both, 'Prague Classification' (87%, (157/181) v 63%, (165/261); X 2 =31.04, p<0.0001)) and 'Seattle Biopsy Protocol' (75%, (136/181) v 66%, (173/261); X 2 =4.09, p=0.0432)), compared with generalist counterparts. Conclusions Specialist endoscopy improves adherence to BSG recommendations. The introduction of dedicated specialist lists at this large teaching hospital will help to optimise surveillance further. Ultimately, future work is necessary to help identify whether this specialist service carries value for both, BO screening and outcomes related to oesophageal dysplasia and OAC.
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