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The prevalence of the gastro-oesophageal reflux disease (GORD) in the western world is increasing. Uncontrolled GORD can lead to harmful long-term sequela such as oesophagitis, stricture formation, Barrett’s oesophagus and oesophageal adenocarcinoma. Moreover, GORD has been shown to negatively impact quality of life. The current treatment paradigm for GORD consists of lifestyle modification, pharmacological control of gastric acid secretion or antireflux surgery. In recent years, several minimally invasive antireflux endoscopic therapies (ARET) have been developed which may play a role in bridging the unmet therapeutic gap between the medical and surgical treatment options. To ensure optimal patient outcomes following ARET, considered patient selection is crucial, which requires a mechanistic understanding of individual ARET options. Here, we will discuss the differences between ARETs along with an overview of the current evidence base. We also outline future research priorities that will help refine the future role of ARET.

BackgroundEosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE.MethodsThe Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance.ResultsFifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research.ConclusionsThese comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.

It is now over 20 years since the introduction of multichannel intraluminal impedance monitoring (MII) in the oesophagus.1 Its application in children subsequently followed with the widespread availability of paediatric catheters in 2002. MII detects oesophageal bolus movement by measurement of changes in electrical resistance and is used for assessment of reflux in tandem with pH monitoring (MII-pH). MII-pH heralded an advance in our ability to characterise reflux compared with the previous gold standard, pH monitoring alone. Advantages include the ability to detect nonacid and weakly acid reflux, distinguish between antegrade and retrograde bolus movements, differentiate liquid from gas reflux and assess proximal extent of the refluxate. In the intervening period, the translation of this more sophisticated and accurate measurement into improved patient outcomes has, however, not been as demonstrable as would have been hoped for. The BSPGHAN position statement on MII-pH testing, published in the current issue of the journal, highlights the current state of the technology, practical advice for performance of investigations, as well as many issues and controversies that pertain to the use of the technology in the …

Introduction Endoscopic mucosal resection (EMR) followed by Radiofrequency ablation (RFA) is first line treatment for mucosal Barrett’s oesophagus (BE) related neoplasia. The UK Registry collects data from patients at 28 sites undergoing RFA/EMR. We examine differences in outcomes between sites by patient volume. Methods All visible lesions were entirely removed by EMR. Patients then underwent RFA every 3 months until all visible BE was ablated. Biopsies were taken at 12 months to assess treatment success with repeat biopsies every 6–12 months thereafter. Centres were grouped by total numbers treated; low 100 patients. Only outcomes of those who had completed treatment were analysed. Results 675 patients completed treatment at 24 centres (median follow up 26 months), 414 at high volume (n = 5), 143 at medium volume (n = 4) & 118 at low volume centres (n = 15). There was no difference in entry criteria or demographics between groups. CR-D & CR-IM at 12 months are no different between the groups (CR-D 86–90%, CR-IM 74–81%). IM recurrence is significantly lower in high volume centres (16.1% vs 20.3% and 19.2%, Log Rank p Conclusion Endotherapy for Barrett’s dysplasia is highly effective whatever the centre volume. The rescue EMR rate in medium volume centres is unexplained. Despite lower IM recurrence in high volume centres, dysplasia recurrence rates are not significantly different. Caseload volume of a centre in the UK Registry does not appear to affect outcome. Disclosure of Interest None Declared

Introduction The pH sensor cannot differentiate retrograde from anterograde bolus movement. Physiologists often block meals in pH studies to reduce the artefact of acid-containing food/fluids; however there is no clear evidence with regards to the appropriateness of this practice. The aim of this study was to compare results of ambulatory pH monitoring without and with meals blocked in patients being investigated for reflux symptoms. Methods Standard pH parameters were compared without and with meals blocked in consecutive patients presenting to University College London Hospital Oesophageal Unit, a tertiary referral centre. T-test was used for quantitative and chi-square for qualitative variables. Results are presented as mean±standard deviation(SD) Results pH studies for 99 patients with reflux-like symptoms were collected prospectively over 3 months. Under 17 hour recordings (n = 2) or studies ON acid-reducing therapy (n = 6) were excluded. Mean age of the 91 remaining patients (M31:F60) was 50±15 years. Time spent without and with meals blocked was 1388±100 and 1243±114 minutes respectively (p At individual level, meal exclusion changed TR/UR/SR to become negative in 4 and positive in 2 patients; average 5% (range 2.5–23 min) of the mealtime was taken up swallowing acid-containing products. Food diary occasionally provided guidance, although quality of self-reports was widely variable. There was no difference in qualitative (p = 0.538) or quantitative (p = 0.338) Symptom Index (SI) when meals were not blocked (12 positive; mean 16.9±22.6%) compared to when meals were blocked (16 positive; mean 18.4±25.4%). Also there was no difference in any pH parameters between the two groups with all symptoms pooled, or with typical (heartburn, regurgitation, chest pain; n = 59) and atypical symptoms (laryngopharyngeal reflux, cough, belch, dysphagia; n = 33) analysed separately (p = NS for all). Furthermore there was no difference in any pH parameter when results were analysed with (n = 43) or without (n = 48) a hiatus hernia (p = NS for all). Conclusion In 93% of patients, routine blocking of meals had no impact on the final report. In a small minority, the artefact of swallowing acidic products as well as shortening of the 24 hour study to exclude meals (average ≥2 hours) can also change results from positive to negative and vice versa. Disclosure of Interest None Declared

Introduction Barrett’s oesophagus (BE) is the pre-cursor for oesophageal adenocarcinoma. Endoscopic surveillance is performed in BE patients to detect dysplasia as an early treatment target. Current surveillance relies on random quadrantic biopsies every 1–2 cm through the BE with targeted biopsies for areas of suspicion. This strategy samples less than 5% of the BE mucosa. We present a novel endoscopic classification system utilising magnification chromo-endoscopy with i-Scan (PENTAX HOYA, Japan) image enhancement technology and acetic acid to improve dysplasia recognition in BE. Methods High definition (HD) video recordings of suspicious lesions were collected from patients with non-dysplastic (ND-BE) and dysplastic (D-BE) BE undergoing endoscopy at a high volume tertiary centre. Lesions were recorded with magnification endoscopy in all i-Scan modes both before and after application of 2% acetic acid (ACA) before sampling with biopsy forceps or endoscopic mucosal resection to confirm the histological diagnosis. Six expert endoscopists scored videos using a previously validated mucosal (M) and vascular (V) classification system. Normal mucosa was defined as regular circular or villous pits (M1) and abnormal mucosa defined as distorted or irregular pits or featureless mucosa (M2). Normal vascular pattern was defined as regular and uniform vessels (V1) and abnormal vascular pattern was defined as irregular, dilated corkscrew vessels (V2). Dysplasia was classified if the lesion was felt to be either M2 or V2. Results 63 lesions (36 D-BE, 27 ND-BE) were recorded (30 before ACA and 33 after ACA) for analysis. Experts’ average accuracy for dysplasia prediction was 67.8% pre ACA and 75.9% after ACA (p = 0.01). ACA improved the sensitivity of our novel classification system for neoplasia detection from 81% to 88% (p = 0.04). Interobserver Kappa values were 0.253 pre ACA and 0.369 after ACA. Conclusion Experts can diagnose D-BE in up to three-quarters of cases using i-Scan magnification endoscopy with acetic acid. ACA improves the sensitivity of diagnosing D-BE. The novel classification system for BE neoplasia has fair agreement between expert endoscopists. Disclosure of Interest None Declared

Introduction Eosinophilic oesophagitis (EoE) is a chronic condition of the oesophagus characterised by a dense eosinophilic infiltrate defined as >15 eosinophils/high power field (eos/hpf). The aim of this study was to capture the prevalence of EoE in a tertiary referral centre in London, to identify factors associated with a positive diagnosis and interrogate optimal response to therapy. Methods From February 2013 to November 2015, all patients presenting with solid food dysphagia to University College Hospital had a high resolution white light endoscopy. Those with cancer, achalasia, postoperative stricture or endotherapy for Barrett’s were excluded. Endoscopy, histology and clinical data were collected. >15 oes/hpf were defined as positive for EoE. A separate histopathology search identified patients with >15 eos/hpf and no dysphagia. A prospective follow-up was conducted in focusing on therapy and response in those with >15 eos/hpf. Results Out of the 1566 patients with dysphagia, 524 were excluded for reasons stated. 736/1042 (71%) had oesophageal biopsies. Of those, 67 (9.1%) had more than 15 eos/hpf. Another 14 patients with >15 eos/hpf with symptoms other than dysphagia were identified from histology records, making the total number with eosiniphilia 81. The mean number of biopsies taken in those with >15 eos/hpf (6.3) was greater than those with Conclusion A higher number of biopsies taken raises the diagnostic yield; however still up to 1/3 patients in a modern referral centre have no biopsies taken. EoE should be excluded in those with no dysphagia and refractory reflux symptoms. Although PPIs are provided as first-line therapy, a positive response to steroids is more likely in those with higher numbers eos/hpf, while those with fewer numbers and no endoscopic features could be considered for PPI therapy first. Such findings might be a useful tool to help tailor therapy. Disclosure of Interest None Declared

Introduction Despite advances in HRM and pH monitoring there is wide variation in technique and technology while reporting is often subjective and open to interpretation. This study assesses current practice around the world. Methods Through an on-line platform (Qualtrics LLC), a survey was distributed to unselected oesophageal units through international NGM societies. Questions explored infrastructure, technology, analysis and reporting. Results are presented as % of the total or mean±SD. Results 91 of 102 responses from 29 countries were analysable.(Table) 43 High (HVC) and 48 Low Volume Centres (LVC) were defined as more and less than 500 referrals/year. HVC employ more staff than LVC (p = 0.02) with more clinicians (3.0±1.0 vs. 2.6±1.2;p = 0.05), physiologists (1.6±1.1 vs. 2.0±1.3;p = 0.07) and nurses (3.3±1.2 vs. 2.4±1.1;p 26 sensor HRM and 53 (58%) use HRM-Impedance (some had several systems). Adjunctive testing is increasingly incorporated.(Table) To define pathology, Chicago Classification is used in 65 (71%) units. 60% comment on the upper sphincter. In the presence of a hiatus hernia analysis of oesophago-gastric junction morphology varies widely (p=NS). 64% proceed with pH-monitoring despite ≥Grade B oesophagitis. If intolerant of the catheter, 45% refer for catheter-free monitoring and 16.5% for barium; 14% do nothing further. HVC are more likely to employ catheter-free systems than LVC (47% vs. 17%;p Of 86 (95%) units with Impedance-pH (Imp-pH), studies are performed on acid suppression in 54% with oesophagitis/Barrett’s. Overall, 8% perform all Imp-pH studies on therapy, 9% never do. Dietary modification (acid avoidance) is always recommended in 48%. Meals/snacks are not analysed in 91% units with standard pH and 84% with Imp-pH. Overall 17% do not exclude meals with either. 75% manually analyse every Imp-reflux event while 59% only target symptoms. For symptom-association, 30% units pool symptoms while 74% analyse each separately. Therapy advice is included in 49% HVC and 31% LVC (p = 0.044); 40% overall. Conclusion There is marked heterogeneity in methodology, interpretation and presentation of HRM and pH studies around the world. This survey sets the background from which agreement of standard operating procedures can begin. Disclosure of Interest R. Sweis Conflict with: Symposium funded by Given Img, M. Fox: None Declared

Introduction It is not clear if Barrett’s is a consequence of excessive reflux only or reduced clearance of refluxed materials. This study compares oesophageal reflux over 24 hours and High Resolution Manometry (HRM) response to solids in Barrett’s with non-Barrett’s reflux (NBR). Methods Reports for 19 consecutive patients (M58:F14) with ≥2 cm Barrett’s during 2015 were compared with 25 patients with NBR (M10:F16) and 13 patient controls with normal physiology/endoscopy (M3:F10). All had at least one typical symptom of heartburn, regurgitation or chest pain. All had HRM with the intention of completing 10x5cc water and 5x1cc bread. Contractile vigour was measured with the Distal Contractile Integral (amplitude x length x contraction time); DCI > 450 mmHg.cm.s and breaks in peristalsis of Results Lower oesophageal sphincter pressure was lower in Barrett’s (8 vs. 14 mmHg; p = 0.009). Compared to NBR, patients with Barrett’s (2–10 cm) had significantly reduced DCI for both 5 ml water (318 vs. 650 mmHg.cm.s; p = 0.007) and solid (1096 vs. 2002 mmHg.cm.s; p = 0.009). On the other hand, the likelihood of measuring a DCI of >450 was significantly reduced in Barrett’s only with solids (69% vs. 100%; p only for solids (44% vs. 65%; p = 0.029). All reflux parameters were similar between the two groups: total (p = 0.116), upright (p = 0.233) and supine reflux (p = 0.110), symptom index (p = 0.16), symptom association probability (p = 0.106) and total number of reflux events (p = 0.063). On the other hand, bolus clearance time (BCT) was significantly prolonged for Barrett’s (13 vs. 10 s; p = 0.009) solely due to prolonged supine BCT (14 vs. 10 s; p Comparing those with prior endoscopic Barrett’s therapy (n = 6) with treatment naive (n = 13), there was no difference in any motility or pH monitoring parameter apart from BET which was greater in those who received therapy (5.87% vs. 1.99%; p = 0.046). Conclusion Solids were superior to water swallows in demonstrating ineffective contractility in Barrett’s. This was associated with reduced nocturnal oesophageal clearance and increased exposure to refluxate during the day/night. These findings contribute to the theory of impaired contractility and reduced clearance despite acid-reducing medication in Barrett’s. Disclosure of Interest R. Sweis Conflict with: Organised Symposium funded by Given img/Diagmed, A. Raeburn: None Declared, E. Athanasakos: None Declared, N. Zarate-Lopez: None Declared, L. Lovat: None Declared, R. Haidry: None Declared, M. Banks: None Declared, A. Emmanuel: None Declared

Introduction Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by an increased eosinophil infiltrate combined with typical symptoms of dysphagia/food bolus obstruction although those with refractory-reflux symptoms without inflammation are not commonly suspected. Recent guidance has improved clinical awareness, endoscopic vigilance and biopsy protocols. This study captures recent trends in endoscopy, histology and subsequent response to therapy of patients with EoE in a London tertiary referral centre. Method Between February 2013 and January 2015, reports were collected for all patients who underwent high definition endoscopy and biopsies at University College London Hospital. Patients with oesophageal cancer or surgery were excluded. Demographics, clinical characteristics, eosinophil concentration and response to therapy were collected for all those with >15 eosinophils/high power field (eos/hpf). Mann-Whitney and Kruskal-Wallis tests were used to analyse non-parametric variables. Results Of the 848 patients with dysphagia who had biopsies, 39 (4.6%) had >15 eos/hpf; however a total of 46 patients were found to have >15 eos/hpf (30M; mean age 39.5 ± 14.5 years). Patients with eosinophilia presented mostly with dysphagia (25; 54%) and food impaction (22; 48%) while another 7 (15%) also presented with refractory-reflux symptoms (only 2 with Grade A esophagitis but with >80 eos/hpf in the proximal oesophagus). 22% had a history of atopy/asthma. 26/46 (57%) exhibited EoE-specific endoscopic findings; corrugated rings (18), strictures (5), furrows (6) and Schatzki ring (4). 7/46 (17%) had esophagitis Grade A (4), B (2) and C (1) esophagitis. The remaining 13 (28%) had a normal endoscopy. There was no difference in the mean eos/hpf between patients with EoE-specific endoscopic changes (47 ± 24), esophagitis (46.5 ± 21.2) and normal endoscopy (47.5 ± 24.9) (p = 0.915). Furthermore the mean eos/hpf between those who presented with dysphagia, food bolus obstruction or refractory-reflux was similar (p = 0.804). 37 patients were treated with either proton pump inhibitors (PPI; 19) or topical steroids (18). Of the 26 patients whose outcomes were reported, 10 responded to steroids and 9 to PPIs. Response to PPIs was more likely in those with reflux-predominant symptoms vs. dysphagia (p = 0.027). The maximum number of eos/hpf did not predict response to therapy as a whole (p = 0.586) nor in those treated with steroids versus PPI (p = 0.188). Furthermore, there was no association of response to treatment when compared to age, endoscopic appearance or atopy (p = NS). Conclusion It is increasingly recognised that EoE does not only present with dysphagia. Therapy targeted towards the predominant symptom can improve outcome in patients with EoE. Disclosure of interest None Declared.

Introduction Oesophageal physiology testing has advanced markedly in the last decade. Tools such as high resolution manometry (HRM) have become widely available and have enhanced our understanding of oesophageal (dys)function. However this has also led to wide variation in testing methods and analysis. Before a consensus is built towards setting quality standards in physiological measurement, a better understanding of what procedures and practices actually take place globally is required. Method An on-line survey was distributed to oesophageal laboratories through NGM societies around the world using the internet-based Qualtrics platform. Questions explored infrastructure, staffing, technology, analysis and reporting. Labs responded anonymously. Responses from all labs were then compared. Results To date 41 responses have been received. Of the 17 in Britain/Ireland, 8 see 500–1000 referrals/year (3 >1000) while 9 see In the Britain/Ireland, 7/17 centres use water-perfused and 10/17 use solid-state systems. 14 are high resolution of which 11 consist of at least 26 sensor systems (4 also with Impedance). In contrast, all labs in the USA and in Europe include a solid-state HRM systems with >26 sensors and with Impedance, while in Australia 8/9 labs have >26 sensor HRM systems, 5 of which include Impedance. Upright studies are routinely included in 5 centres in Britain/Ireland, 4 in USA, 3 in Europe and 4 in Australia. Details regarding adjunctive testing are presented in Table 1. In the UK, one HV and 2 LV centres never use the Chicago Classification (CC) to reach a diagnosis unlike all centres in Ireland, USA, Europe and Australia. Across all centres, placement of the lower oesophageal sphincter and gastric markers varies widely with varying sizes of hiatus hernia. Information provided in the final HRM report is fairly uniform apart from ‘therapeutic recommendations’ which is included in 4/17 centres in Britain/Ireland (3/8 HV and 1/9 LV centres), 3/9 in USA, 5/6 in Europe and 4/9 in Australia. Conclusion There is marked heterogeneity in the methodology, analysis and presentation of HRM studies in oesophageal laboratories around the world. This (ongoing) study sets the stage upon which mechanisms to improve quality and uniformity in testing and reporting can be agreed upon internationally. Disclosure of interest R. Sweis Grant/ Research Support from: Grant from Reckitt Benkiser, Conflict with: Invited as speaker for Given Imaging, M. Fox Consultant for: Member of advisory board and research/education funds from Given Imaging/Covidien, MMS and Sandhill.

Introduction Manometry is applied in patients with suspected gastro-oesophageal reflux disease (GORD) to exclude motility disorders as a cause of symptoms. Routine studies use a small number of small volume water swallows, however dysmotility and symptoms are more likely to occur with normal eating behaviour. This approach has not entered clinical practice because of difficulty interpreting complex pressure events during ingestion of solids and a standardised meal as well as a lack of control values. This study aimed to assess the prevalence of symptomatic oesophageal dysfunction following individual liquid and solid bolus swallows and a standardised meal in patients with reflux symptoms and asymptomatic volunteers. Methods 45 consecutive patients with predominant reflux symptoms and 23 healthy volunteers underwent HRM (Manoscan 360°, SSI) with 10×5 ml water and 5×1 cc bread swallows in the upright seated position. A test meal (cheese and onion pie; 500 kcal, 34 g fat) was provided if patients consented. Ambulatory reflux studies were performed in patients. Results Water and bread swallows were completed in 44/45 patients (16 M:28 F, age 32–76) and all healthy volunteers (11 M:12 F, age 20–56). 18 patients and 10 volunteers completed the test meal. No healthy subject had clinically significant dysmotility or symptoms during the study. There were no symptoms with water swallows. 14/44 (32%) complained of symptoms with bread (p =0.0013), 7/18 during the meal and 16/44 (36%) when results of bread and meal were combined (p=0.0006). Bread swallows and a test meal resulted in a change of manometry diagnosis in 18/44 (41%) patients. In 13 patients dysmotility was present with solid but not water swallows: hypertensive contractility (3), oesophageal spasm (4), resistance at the gastro-oesophageal junction (4), variant achalasia (1) and severe peristaltic dysfunction (1). Conversely, normal peristalsis was seen in 5 asymptomatic patients with hypotensive motility on water swallows. Symptoms were associated with oesophageal dysfunction during the test meal in 7/16 (44%) patients: hypertensive contractility (1), oesophageal spasm (3), and resistance at the gastro-oesophageal junction (3). Ambulatory reflux studies were completed in 40/45 patients and 18/40 (45%) patients had an objective diagnosis of GORD. A new diagnoses based on symptomatic dysmotility was present in 1/18 (6%) patients with GORD, and 6/22 (27%) patients without GORD (p=0.016). Conclusion The inclusion of solid swallows and a test meal increased the diagnostic yield of HRM in patients referred for investigation of reflux symptoms compared to standard water swallows, in particular, in the patient group without GORD on reflux studies.

Introduction High Resolution Manometry (HRM) with presentation of pressure data as spatiotemporal plots highlights oesophageal landmarks and contractions that facilitates data analysis and interpretation. Normal values have been published for water swallows in the supine position. Studies in the upright position and with solid swallows reproduce more normal swallowing behaviour and increase test sensitivity for symptomatic dysmotility and dysfunction; however these ‘physiologic challenge swallows’ increase the complexity of pressure activity which may impair interinvestigator agreement. The aim of this study is to assess the interobserver agreement of water and solid swallows in the upright and supine positions for HRM. Methods 12 healthy volunteers (Male:Female 5:7, age 28–56) underwent HRM using a 36 channel solid state assembly (Manoscan 360; Sierra Scientific Instruments) with sensors spaced at 10 mm intervals from the pharynx to the stomach. After baseline measurements of the oesophago-gastric junction, assessment with 5×5 ml water and 3×1 cc bread swallows were assessed in the upright and supine position. Spatiotemporal plots of upright swallows were assessed by 3 investigators and supine swallows were analysed by 2 investigators. The intraclass correlation coefficient (ICC) was used to assess agreement for continuous variables corrected for chance. An ICC of 0.5 good and >0.80 almost perfect agreement. Results In the supine position ICC between two raters was >0.8 for all parameters for liquids and solids. In the upright position the ICC between three raters was significant and >0.5 for all parameters measured using liquid and solid swallows except for velocity ([table 1][1]). View this table: Table 1 PWE-129 Conclusion There is a high rate of agreement between observers for key HRM parameters during liquid and solid swallows. Interobserver agreement for velocity and, to a lesser extent, other parameters was lower in the upright than the supine positions likely due to reduced contractile pressures and coordination in the physiologic position. [1]: #T1

Introduction Recently we presented novel methodology for the assessment of oesophageal function and symptoms during and after a standard test meal. 1 In the absence of a “gold standard”, outcome data provides insight into the clinical impact of this test in patients with reflux symptoms Methods 18 patients referred for investigation of reflux symptoms and 10 healthy volunteers underwent High Resolution Manometry (HRM) with 5ml water, 200ml water drink and test meal followed by 10min post-prandial observation. 24hr pH studies were performed in patients. The number of Symptoms Associated with oesophageal Dysfunction(SAD) was calculated. HRM findings and initial diagnosis were compared with the final diagnosis and outcome at 2 years Results No symptoms occurred with 5ml water. 12/18(67%) patients had SAD (mean SAD 2(range 0–7)) during/after the meal. Compared to 5ml water, manometric diagnosis was altered in 12/18(67%). No healthy volunteers had SAD. 11/18 patients had GORD on pH studies. By 2 years, 5/11 had anti-reflux surgery with excellent outcome. All 5 exhibited dysmotility (e.g. hypotensive/failed peristalsis) during the meal with symptomatic postprandial reflux events (transient lower oesophageal sphincter relaxation + common cavity). Of the 6/11 with GORD who did not have surgery, 2 declined it despite pathological pH results and symptomatic reflux events after the meal; both remain symptomatic despite acid-reducing therapy. The remaining 4 of 6 patients also had symptomatic dysmotility but were not offered surgery. 2 with severe hypotensive dysmotility and symptomatic reflux responded to acid suppression. 1 with (peptic) outlet obstruction and 1 with diffuse spasm did not respond to medication. Of the 7 with functional heartburn (negative pH results), 2 who had normal HRM responded to dietary/stress management. 2 with symptomatic reflux during HRM had good response to acid-suppression (i.e. false neg pH study). The final 3 with reflux-like symptoms had outflow obstruction identified only during the meal; 1 had good outcome after dilatation, 1 was too frail for therapy and remains symptomatic and the last was lost to follow-up. Conclusion HRM studies which include a test meal and post-prandial observation provide an objective explanation for symptoms in the majority of patients referred for investigation of “reflux” symptoms. Long-term follow-up suggests this information can guide management especially in patientswithout definitive diagnosis following standard 5 ml water HRM and negative pH-studies Disclosure of Interest None Declared Reference Sweis R et al. Gastro 2011; 140

Introduction Prolonged wireless pH-monitoring (Bravo) increases diagnostic yield compared to 24 hr pH-studies. Studies have shown a weak association between oesophageal acid exposure from 24 hr pH-studies and mucosal disease on distal oesophageal histology. This study assessed the association between Bravo, endoscopic findings and distal oesophageal histology. Methods From July 2009 to August 2010, 63 consecutive patients with typical reflux symptoms had endoscopy with biopsies taken from 3 & 9 o’clock position at and 2cm proximal to the Z-line prior to pH capsule fixation 6cm proximal to the Z-line for prolonged (up to 96 hr) Bravo. All biopsies were assessed by the 6-parameter Zentilin histology score (Zentilin et al Gastroenterol 2005). GORDdiagnosis was based on “Average” acid exposure (Total Reflux; TR > 5.3% time pH 50%) Results Adequate biopsy samples were available from 57/63 patients (mean age 44 (range 17–78); 27M). 37/57(65%) patients had GORD based on either TR (n = 30) or SI(n = 32). 20/57(35%) were both TR & SI negative (Functional Heartburn; FH). 18 FH patients had no mucosal changes, 2 had grade A oesophagitis. There was no difference in individual histology parameters between GORD vs. FH (p > 0.05) apart from increased ‘intra-epithelial neutrophils’ (IEN) at the Z-line (9/37 vs. 1/20 positive; p = 0.031) and 2cm proximally (6/37 vs. 0/20 positive; p = 0.012). The combined Zentilin histology score was also higher in GORD at the Z-line (p = 0.079) and 2 cm proximally (p = 0.05). Using GORD diagnosis from 96 hr Bravo as reference, ROC analysis revealed that, although sensitivity remained poor, specificity of GORD diagnosis based on histology improved with IEN and total histology score. With increased IEN, sensitivity was 30% at the Z-line and 20% 2 cm above while specificity was 92.6% at the Z-line and 100% 2cm proximally. For the optimal Zentilin histology score of ≥7, sensitivity was 40.5% at the Z-line and 18.9% 2cm above while specificity was 95% at the Z-line and 100% 2 cm proximally. Histology corroborated GORD diagnosis (based on positive TR) in 11/30 and 20/30 patients at the Z-line and in 6/30 and 11/30 patients 2 cm proximally. Conclusion Histology lacks sensitivity as a stand-alone diagnostic test; however high IEN or total histology scores have high specificity for GORD diagnosis based on pH-study results. Thus, routine biopsy of the distal oesophagus may be sufficient to diagnose GORD and obviate the need for ambulatory pH-studies in this subgroup of patients. Disclosure of Interest None Declared.

Introduction Published reference values for oesophageal High Resolution Manometry (HRM) are available only for 5 ml water swallows in the supine position; however this is not representative of normal behaviour and rarely triggers symptoms. Analysis during and after eating a solid meal or drinking larger volumes is likely to increase the sensitivity of manometric studies to symptomatic oesophageal dysmotility and dysfunction. However this increases the complexity of pressure activity and, if it is to be applied in clinical practice, normal values for oesophageal motility and function are required. Methods 10 healthy volunteers (6M:4F, age 20–45) underwent HRM (Manoscan 360, SSI; 36 sensors). After baseline measurements of the oesophago-gastric junction (OGJ) and standard 5 ml water swallows, volunteers were observed eating a test meal (cheese and onion pie; 500 Kcal, 34 g fat) followed by drinking a 200 ml fruit-smoothie (9/10 subjects) and for 10 min afterwards. Physiologic measurements from HRM topographic plots focused on parameters that predict the success of solid bolus transport. Results No subject had hiatus hernia or primary oesophageal dysmotility. All completed liquid swallows and standard meal (consumption time median 6:15 min (range 3:30–13:30 min)). A mean of 1.5 pharyngeal swallows (range 1–3) was required to propel each mouthful into the oesophagus. 20 swallows (range 13–34) were required to ingest the meal of which 89% were successful, 3% were simultaneous (focal spasm) and 5% failed. The median (IQR) for intrabolus pressure (IBP) increased from 8.9 (6.7–13.8) mm Hg for 5 ml water to 18.9 (16.8–24.0) mm Hg for solid meal swallows (p A mean of 20 swallows (range 13–34) was required to drink the smoothie. Complete suppression of oesophageal contractility was achieved in 7/9 subjects. A powerful postcontraction was observed in 8/9 subjects. Apart from postprandial belching, no volunteer reported symptoms during or after the study. Conclusion Peristaltic coordination and pressure increased in response to resistance to bolus passage (raised IBP) with solid compared to liquid swallows. Complete oesophageal relaxation and LOS opening was observed on free drinking. Reference values for future studies are presented to assess the clinical utility of including a standardised meal and free drinking in HRM investigation of patients with oesophageal symptoms.

Introduction Rumination Syndrome is common yet under-diagnosed and is becoming increasingly recognised in healthy individuals. The primary feature is regurgitation occurring 5–10 min after initiating a meal. It is often confused with disorders such as gastro-oesophageal reflux disease, and patients may be subject to extensive yet unnecessary investigations. Treatment effectiveness with acid reducing medications and prokinetics is limited. The most favourable outcome is achieved with Diaphragmatic Breathing exercises. This case presentation describes the journey of a patient who was found to have rumination syndrome following high-resolution manometry (HRM) and was treated successfully with Diaphragmatic Breathing. Methods HRM (Manoscan 360°, SSI) with 10×5 ml water and 5×1 cm3 solid (bread) swallows and a 250 ml milkshake was performed in the in the upright seated position. This was followed by dual channel 24-h catheter-based pH monitoring. Treatment encompassed two sessions of diaphragmatic therapy. Results HRM: During the bread swallows and after drinking the milkshake, typical symptoms of regurgitation were reproduced. These were associated with short, sharp increases in the intragastric pressure sensors typical of Rumination Syndrome. 24-h Ambulatory reflux study: This exhibited a normal measurement for frequency of reflux events and a positive Symptom Index (87.1%; positive greater than or equal to 50%) for regurgitation. Conclusion Although in this example it was discovered with the use of HRM in a tertiary centre, Rumination Syndrome should be easily diagnosed based only on clinical history. This condition is usually treated with diaphragmatic breathing techniques, however patient commitment to therapy and perseverance is paramount. Diaphragmatic breathing is thought to overwhelm the subconscious yet voluntary abdominal wall muscle contractions which lead to regurgitation, and was successful in this case.