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Background & Aims: Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD. Methods: Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted. Results: All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however, proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy. Conclusions: This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice. [ABSTRACT FROM AUTHOR]

Introduction. Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopy. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way. Case report. We report the case of a 83 years old female patient admitted for chest pain associated with difficulty in breathing and fatigue, the symptoms subside at rest. Acute myocardial infarction was excluded but severe anemia was detected with a haemoglobin of 5.9 g/dl. The patient was known with paroxysmal atrial fibrillation controlled by amiodarone, rheumatoid arthritis for which the patient administered methotrexate, the treatment was ceased several years ago due to the reduction of disease activity. Due to CHADs-VASc score of 5, the patient was under chronic anticoagulation with DOAC. In order to identify the source of the supposed bleeding, a Upper Digestive Endoscopy was performed. The investigation revealed grade I esophageal varices without signs of recent bleeding and antral vascular ectasia. Due to local conditions, endoscopic band ligation was preferred. After the management of the anemia the patient was discharged with a haemoglobin of 9 g/dl. After a month from the EBL the patient restarted administration of DOAC which lead to a new episode of acute GI bleeding, a second session of EBL was performed with the recommendation not to administer anticoagulants until a third session which was set after 2 months. Discussion. The first line treatment is considered argon plasma coagulation (APC), given its wider availability, safety, efficacy and cost-effectiveness, though different types of endoscopic treatments are available. Given the condition of a specific patient, the physician can choose which is more appropriate for a better management. Conclusion. A patient with multiple comorbidities must have a comprehensive approach and a good understanding of bleeding versus thrombotic risks. [ABSTRACT FROM AUTHOR]

Introduction. Multichannel intraluminal esophageal impedance combined to pH-metry (pH-MII) is a sensitive tool for evaluating gastroesophageal reflux disease (GERD). The impedance-pH monitoring diagnostic test determines the frequency of reflux episodes (both acid or nonacid and liquid, gas or mixed) and the time relationship of reflux episodes and symptoms. Extradigestive manifestations and refractory GERD are two of the main recommendations for the assessment of upper digestive tract by pH-MII. Material and method. We conducted a prospective study between January 2022 - March 2023 at our tertiary referral center in North-Eastern Romania that included 26 patients suspected of GERD. All patients were investigated through pHMII. We used a ZepHr® system from Sandhill Scientific and single-use catheters with one pH electrode and 6 impedance electrodes. Patients who underwent MII-pH testing for refractory GERD were tested on proton pump inhibitor (PPI), while patients with no previous evidence of GERD were assessed off PPI. The diagnosis of GERD and phenotypes were based on Lyon metrics. Results. Out of the 26 patients, 14 (53.8%) were male and 12 (46.2%) female, with a mean age of 48.6±13.5 years. Nineteen patients (73.07%) presented with extradigestive GERD symptoms, of whom 7 patients (36.8%) with chronic cough, 7 patients (36.8%) with chronic laryngitis, 4 patients (21.05%) with non-cardiac chest pain and 1 patient (5.26%) with bronchial asthma. The rest of 7 (26.92%) patients were investigated for refractory GERD. After the final analysis of pH-MII tracks, we found GERD in 10 (38.5%) patients, functional heartburn in 6 (23.1%) patients and hypersensitive esophagus in 3 (15.4%) patients. All the 10 patients diagnosed with GERD had acid reflux, with a mean DeMeester Score of 46.7±83.8 and a mean AET of 12.8±20.9%. The mean total number of GERD episodes was 100.3±7.5 and the mean longest reflux episode was of 53.7±85.7 minutes. Conclusion. Multichannel intraluminal esophageal impedance combined to pH-metry represents an important instrument for assessing extradigestive GERD and refractory GERD. [ABSTRACT FROM AUTHOR]

Introduction. High-resolution manometry (HRM) is one of the most notable recent advances in the field of esophageal function. In the absence of organic lesions, HRM provides measurements of esophageal function, identifies the pathology and guides the treatment. The aim of this study was to assess the HRM particularities of diagnosis, clinical features and therapeutic management in patients evaluated for esophageal motor dysfunction. Material and Methods. Our study included all patients suspected of esophageal motility disorders, admitted in our tertiary referral center in North-Eastern Romania between July 2022 and March 2023. Demographic, clinical and laboratory characteristics were carefully collected from the patients' medical charts. All patients were investigated by upper digestive endoscopy and barium esophagogram prior to HRM. Patients diagnosed with eosinophilic esophagitis were excluded from the study. An ISOLAB HR® system from Standard Instruments, with a 36-pressure channels solid-state catheter was used. The HRM diagnosis of esophageal motor diseases was established based on Chicago 4 protocol and classification. Results. Out of the 38 patients included in the study, 15 (39.5%) were female and 23 (60.5%) male, with a mean age of 61.2±11.9. Regarding clinical features, the majority of patients presented with dysphagia (80.4%). Seven (18.4%) patients associated significant weight loss and 6 (15.8%) reported non-cardiac chest pain. Esophageal motility disorders were found in 29 patients (76.3%), 9 patients (23.6%) having a normal HRM aspect. Achalasia was identified in 15 patients (39.5%), with type I in 3 patients (7.9%), type II in 7 patients (18.4%) and type III in 5 patients (13.2%). Distal esophageal spasm was found in 4 patients (10.5%), hypercontractile esophagus in 2 patients (5.3%), esophagogastric junction outflow obstruction (EGJOO) in 2 patients (5.3%), ineffective esophageal motility in 1 patient (2.6%), absent contractility in 4 patients (10.5%) and dyshagia lusoria was identified in only one patient (2.6%). Regarding therapeutic management, endoscopic dilation was performed in 10 patients (26.3%) and 3 patients (7.8%) were referred to surgery. Conclusion. Esophageal HRM remains an important tool for assessing esophageal motor dysfunction. The esophageal motility disorders still represent a diagnostic and therapeutic challenge in clinical practice. [ABSTRACT FROM AUTHOR]

Introduction. High-resolution manometry (HRM) is one of the most notable recent advances in the field of esophageal function. In the absence of organic lesions, HRM provides measurements of esophageal function, identifies the pathology and guides the treatment. The aim of this study was to assess the HRM particularities of diagnosis, clinical features and therapeutic management in patients evaluated for esophageal motor dysfunction. Material and Methods. Our study included all patients suspected of esophageal motility disorders, admitted in our tertiary referral center in North-Eastern Romania between July 2022 and March 2023. Demographic, clinical and laboratory characteristics were carefully collected from the patients' medical charts. All patients were investigated by upper digestive endoscopy and barium esophagogram prior to HRM. Patients diagnosed with eosinophilic esophagitis were excluded from the study. An ISOLAB HR® system from Standard Instruments, with a 36-pressure channels solid-state catheter was used. The HRM diagnosis of esophageal motor diseases was established based on Chicago 4 protocol and classification. Results. Out of the 38 patients included in the study, 15 (39.5%) were female and 23 (60.5%) male, with a mean age of 61.2±11.9. Regarding clinical features, the majority of patients presented with dysphagia (80.4%). Seven (18.4%) patients associated significant weight loss and 6 (15.8%) reported non-cardiac chest pain. Esophageal motility disorders were found in 29 patients (76.3%), 9 patients (23.6%) having a normal HRM aspect. Achalasia was identified in 15 patients (39.5%), with type I in 3 patients (7.9%), type II in 7 patients (18.4%) and type III in 5 patients (13.2%). Distal esophageal spasm was found in 4 patients (10.5%), hypercontractile esophagus in 2 patients (5.3%), esophagogastric junction outflow obstruction (EGJOO) in 2 patients (5.3%), ineffective esophageal motility in 1 patient (2.6%), absent contractility in 4 patients (10.5%) and dyshagia lusoria was identified in only one patient (2.6%). Regarding therapeutic management, endoscopic dilation was performed in 10 patients (26.3%) and 3 patients (7.8%) were referred to surgery. Conclusion. Esophageal HRM remains an important tool for assessing esophageal motor dysfunction. The esophageal motility disorders still represent a diagnostic and therapeutic challenge in clinical practice. [ABSTRACT FROM AUTHOR]