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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.

La Clasificación de Chicago v4.0 (CCv4.0) es el esquema actualizado para clasificar las alteraciones de la motilidad esofágica utilizando la métrica de la manometría de alta resolución (HRM). Para desarrollar la CCv4.0, 52 expertos internacionales diversos separados en siete subgrupos de trabajo utilizaron una metodología formalmente validada, en un periodo de dos años. Las actualizaciones claves de la CCv4.0 consisten en un protocolo de HRM más riguroso y expansivo que incorpora las posiciones en decúbito supino y sedestación, así como pruebas provocadoras; una definición refinada de la obstrucción del flujo de salida de la unión esofagogástrica (EGJOO), criterios diagnósticos más estrictos para la motilidad esofágica inefectiva, y descripción de la métrica basal de la EGJ. Adicionalmente, la CCv4.0 se propuso definir el diagnóstico de alteración de la motilidad como conclusivo o no conclusivo con base en los síntomas asociados, los hallazgos en las pruebas provocadoras, y los resultados de los exámenes de apoyo como el esofagograma con tableta de bario y/o la prueba con sonda para imagen endoluminal funcional. Estos cambios buscan minimizar la ambigüedad presente en iteraciones previas de la Clasificación de Chicago; además proveen criterios más estandarizados y rigurosos para los patrones de alteración de la peristalsis y obstrucción de la EGJ.

Dysphagia is a common symptom which can vary in severity and aetiology; at one end, it can be a benign inconvenience, on the other, there can be serious morbidity associated with malnutrition. It is crucial to identify those with mucosal and structural disease, including malignancy as a priority first. Reflux disease is commonly a culprit and treating empirically with acid reducing medicines should follow exclusion of organic disease. Other benign conditions (including eosinophilic oesophagitis) should be considered. The clinical assessment of dysphagia begins with a detailed history and a focus on symptom severity as well as the pre-test probability of a given condition. Tests are then directed at assessing function, and should employ both high-resolution manometry and barium studies. For motility disorders, begin by assessing the oesophago-gastric junction for obstruction (eg achalasia), followed by oesophageal body function. The latter is divided into major and minor motility disorders. Treatment is directed according to the dysmotility phenotype and is based upon background fitness, age and appetite to intervention. Invasive treatment for achalasia is aimed at disrupting the lower oesophageal sphincter muscle while that of oesophageal body disorders is directed at reducing hypercontraction, improving peristalsis or reducing symptoms.

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition causing esophageal symptoms, particularly dysphagia. Despite the important progress in the treatment of EoE, a significant proportion of patients continue to report symptoms that negatively impact quality of life. Esophageal manometry is used to assess motility and function, but is not routinely used in EoE. We aimed to systematically review and describe current literature evaluating esophageal manometry in EoE. Forty-eight studies meeting the criteria were identified, describing 802 patients. Using standard water swallow protocols, the proportion of abnormalities detected was not dissimilar to other populations, apart from disorders of esophago-gastric outflow, which were found in 5%. Twelve studies described pretreatment and posttreatment manometry, with motility normalization after pharmacological therapy reported in 20%. Early, brief panesophageal pressurization was described in a number of studies and was more prevalent in the few studies utilizing additional provocation testing. Reports in the literature regarding temporal relationships between manometric findings and symptoms are variable. Esophageal manometry may be capable of detecting clinically relevant changes to esophageal function in EoE. Possible mechanisms are altered neuromuscular function because of secretory products of EoE and/or fibroinflammatory processes, manifesting as pressurization because of altered esophageal compliance. Some changes may be reversible with therapy. Drawing strong conclusions from the literature is difficult, with bias toward case reports and retrospective observation. Adaptations to assessment protocols to include provocation testing may provide more robust evaluation and detect clinically relevant, subtle changes in esophageal function, earlier within the patient pathway.

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO. METHODS: In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated. RESULTS: Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02). DISCUSSION: Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.

SCOPUS: re.j, info:eu-repo/semantics/published

Timed barium swallow (TBS) is a recommended ancillary investigation in evaluation of esophagogastric junction (EGJ) obstruction, yet there are little data comparing esophageal stasis across subtypes.A retrospective cohort study was performed. All type III achalasia diagnosed between November 2016 and November 2020 were included, along with matched numbers of consecutive types I and II and conclusive EGJOO cases with concurrent TBS evaluation. Co-primary outcomes were TBS retention at 1 and 5 min. Secondary outcomes were symptoms and manometric metrics of EGJ function and peristaltic integrity.One hundred patients were included (25 each of types I-III and conclusive EGJOO). TBS retention measured by height and width at 1 and 5 min differed significantly across the four subtypes (p 0.0001 all comparisons), with esophageal stasis tending to be significantly greater for types I and II achalasia (88% and 84% with5 cm column at 5 min) compared to type III and EGJOO (24% and 8% with5 cm column; p 0.0001). Eckardt symptom severity was similar across subtypes (p = 0.30). Magnitude of esophageal stasis and integrated relaxation pressure (IRP) were uncorrelated (R = 0.21). In EGJOO, the number of swallows with intact peristalsis inversely correlated with barium column height (R = -0.49) and those with disordered peristalsis were more likely to have any residual barium at 5 min compared to those without disordered peristalsis (43% vs. 0%; p = 0.02).Timed barium swallow findings differed markedly with significantly less esophageal stasis in type III achalasia and EGJOO, despite similar symptom severity and no correlation between degree of emptying and IRP. Preservation of peristalsis may underlie this finding in EGJOO.

BACKGROUND Nasogastric (NG) intubation for esophageal manometry can be traumatic and may be associated with a temporary reduction/absence in esophageal peristalsis. This study explored the prevalence and effect on esophageal motor function. We also hypothesized that baseline anxiety as well as markers of autonomic nerve function were correlated to attenuated esophageal peristalsis. METHODS Twenty-seven patients with esophageal symptoms referred for esophageal manometry investigation (mean age 56.8 ± 16.7 years, range 23-85 years) reported baseline anxiety score (Likert scale) preintubation. Patients had continuous heart rate and blood pressure measured prior to intubation and until 10 min after catheter withdrawal. Quality of motility was assessed for each 5 ml water swallow using standard Chicago Classification metrics. KEY RESULTS Nasogastric-intubation elicited a significant increase in heart rate (p

International recommendations are available to address and help guide departments through some of the challenges posed by the pandemic 1 2 The Association of Gastrointestinal Physiologists (AGIP) council published guidelines regarding GI physiology service provision during the COVID-19 pandemic in May 2020 3 This guidance detailed necessary requirements for personal protective equipment (PPE) as well as highlighting the need to consider workflow changes A traffic light system is used to categorise referral types according to degree of urgency, with red denoting the most urgent [ ]patients with dysphagia are prioritised in order to reduce risk of potential nutritional and symptomatic compromise Green: patients who can be delayed until routine clinical services resume Presenting symptoms Criteria prior to physiology Physiology test Interim approach pending physiology test Suspected primary dysmotility (eg, suspected achalasia) Endoscopy and biopsies HRM Liquid/soft, fortified diet Symptom recurrence following treatment of a known major motor disorder (eg, symptoms post achalasia therapy) Endoscopy (since last therapy or recently) HRM Liquid/soft, fortified diet Optimise acid-reducing/antacid medication if required Suspected dysmotility in patients with known systemic disease (eg, severe dysphagia in known scleroderma) Endoscopy and biopsies HRM±24 hours pH/impedance study (pH/impedance study if reflux-like symptoms and HRM unremarkable) Liquid/soft, fortified diet Optimise acid-reducing/antacid medication if required Combined reflux with (moderate/intermittent) dysphagia Endoscopy and biopsies HRM±24 hours pH/impedance study (pH/impedance study unless obstruction/other explanation on HRM) Liquid/soft, fortified diet Optimise acid-reducing/antacid medication Reflux symptoms — patient is fit for/seeking antireflux surgery Recent endoscopy Barium swallow if suspicion of large HH/postsurgery OGJ anomaly HRM+24 hours pH/impedance study Optimise acid-reducing/antacid medication Refractory confirmed reflux — patient is fit for/seeking antireflux surgery Recent endoscopy Barium swallow if suspicion of large HH/postsurgery OGJ anomaly HRM+24 hours pH/impedance study (on PPI/H2RA) Optimise acid-reducing/antacid medication Atypical reflux symptoms Recent endoscopy Barium swallow if suspicion of proximal oesophageal symptoms or OGJ anomaly HRM+24 hours pH/impedance study Optimise acid-reducing/antacid medication Rumination syndrome Supragastric belching Other suspected functional disorder Recent endoscopy Barium swallow if suspicion of proximal oesophageal symptoms or OGJ anomaly Postprandial HRM±24 hour pH/impedance study Face-to-face (if permissible) or virtual cognitive behavioural therapy±diaphragmatic breathing teaching HH, hiatus hernia;H2RA, histamine H2 receptor antagonist;HRM, high-resolution oesophageal manometry;OGJ, oesophagogastric junction;PPI, proton pump inhibitor

Summary Background Screening for Barrett's oesophagus relies on endoscopy, which is invasive and few who undergo the procedure are found to have the condition. We aimed to use machine learning techniques to develop and externally validate a simple risk prediction panel to screen individuals for Barrett's oesophagus. Methods In this prospective study, machine learning risk prediction in Barrett's oesophagus (MARK-BE), we used data from two case-control studies, BEST2 and BOOST, to compile training and validation datasets. From the BEST2 study, we analysed questionnaires from 1299 patients, of whom 880 (67·7%) had Barrett's oesophagus, including 40 with invasive oesophageal adenocarcinoma, and 419 (32·3%) were controls. We randomly split (6:4) the cohort using a computer algorithm into a training dataset of 776 patients and a testing dataset of 523 patients. We compiled an external validation cohort from the BOOST study, which included 398 patients, comprising 198 patients with Barrett's oesophagus (23 with oesophageal adenocarcinoma) and 200 controls. We identified independently important diagnostic features of Barrett's oesophagus using the machine learning techniques information gain and correlation-based feature selection. We assessed multiple classification tools to create a multivariable risk prediction model. Internal validation of the model using the BEST2 testing dataset was followed by external validation using the BOOST external validation dataset. From these data we created a prediction panel to identify at-risk individuals. Findings The BEST2 study included 40 diagnostic features. Of these, 19 added information gain but after correlation-based feature selection only eight showed independent diagnostic value including age, sex, cigarette smoking, waist circumference, frequency of stomach pain, duration of heartburn and acidic taste, and taking antireflux medication, of which all were associated with increased risk of Barrett's oesophagus, except frequency of stomach pain, with was inversely associated in a case-control population. Logistic regression offered the highest prediction quality with an area under the receiver-operator curve (AUC) of 0·87 (95% CI 0·84–0·90; sensitivity set at 90%; specificity of 68%). In the testing dataset, AUC was 0·86 (0·83–0·89; sensitivity set at 90%; specificity of 65%). In the external validation dataset, the AUC was 0·81 (0·74–0·84; sensitivity set at 90%; specificity of 58%). Interpretation Our diagnostic model offers valid predictions of diagnosis of Barrett's oesophagus in patients with symptomatic gastro-oesophageal reflux disease, assisting in identifying who should go forward to invasive confirmatory testing. Our predictive panel suggests that overweight men who have been taking antireflux medication for a long time might merit particular consideration for further testing. Our risk prediction panel is quick and simple to administer but will need further calibration and validation in a prospective study in primary care. Funding Charles Wolfson Charitable Trust and Guts UK.

BACKGROUND: Gastric antral vascular ectasia (GAVE) is a rare cause of gastrointestinal bleeding, often causing iron deficiency anaemia. Previous studies have looked at the management of this with argon plasma coagulation, laser therapy and endoscopic band ligation. METHODS: This was a single-centre prospective study to evaluate the efficacy and safety of radiofrequency ablation (RFA) in patients with GAVE with persistent anaemia refractory to at least one session of first-line endoscopic therapy. Patients were treated with a through-the-scope (TTS) radiofrequency catheter at two endoscopic sessions six weeks apart. The primary outcome was change in haemoglobin at six months posttreatment. The secondary outcomes were reduction in blood or iron requirements, endoscopic surface area regression and complications. RESULTS: Twenty patients were treated. The mean change in haemoglobin at six months was +12.6 g/l (95% confidence interval 11.7–24.3 g/l), paired t test p

Summary Background Although nighttime reflux symptoms are common, the presence of nocturnal reflux is seldom confirmed with a standard 24 hours pH study. Aim To study patients with supine nighttime reflux symptoms using prolonged wireless pH monitoring. Methods In this retrospective study, patients with typical acid reflux symptoms were studied using 96‐h pH monitoring. Patients with nighttime reflux symptoms were compared to those without. Night‐to‐night variability and diagnostic accuracy of 24‐, 48‐ and 72‐hours pH studies compared to the 96‐hours “gold standard” were evaluated. Results Of the 105 included patients (61.9% females; mean age 46.8 ± 14.4 years), 86 (81.9%) reported nighttime reflux symptoms, of which 67.4% had pathological supine nocturnal acid exposure in at least one night. There was high variance in night‐to‐night acid exposure (94% [IQR0‐144]), which was larger than the variance in upright acid exposure (58% [IQR32‐88]; P, Prolonged pH monitoring provided objective evidence of reflux at night in the majority of patients who complain of nighttime reflux symptoms. High night‐to‐night variability reduces the clinical value of pH monitoring limited to 24h. Prolonged testing improved the diagnostic yield and accuracy for nocturnal reflux diagnosis.

Background and Aim Barrett's esophagus is associated with increased risk of esophageal adenocarcinoma. The optimal management of low‐grade dysplasia arising in Barrett's esophagus remains controversial. We performed a retrospective study from a tertiary referral center for Barrett's esophagus neoplasia, to estimate time to progression to high‐grade dysplasia/esophageal adenocarcinoma in patients with confirmed low‐grade dysplasia compared with those with downstaged low‐grade dysplasia from index presentation and referral. We analyzed risk factors for progression. Methods We analyzed consecutive patients with low‐grade dysplasia in Barrett's esophagus referred to a single tertiary center (July 2006–October 2018). Biopsies were reviewed by at least two expert pathologists. Results One hundred and forty‐seven patients referred with suspected low‐grade dysplasia were included. Forty‐two of 133 (32%) of all external referrals had confirmed low‐grade dysplasia after expert histopathology review. Multivariable analysis showed nodularity at index endoscopy (P, Our large retrospective study from a tertiary Barrett's center shows clear variability in the diagnosis of low‐grade dysplasia. Nodularity at index endoscopy and location of low‐grade dysplasia were associated with risk of progression in true low‐grade dysplasia patients. Endoscopic therapy and resources should potentially be more focused in this sub‐cohort of patients.

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

Achalasia is a rare esophageal motility disorder characterized by the incomplete relaxation of the lower esophageal sphincter (LES) and impaired peristaltic activity. The advent of high-resolution manometry (HRM) and the rapidly evolving role of therapeutic endoscopy have revolutionized the approach to the diagnosis and management of achalasia patients in the last decade. With advances in HRM technology and methodology, fluoroscopy and EndoFlip, achalasia can be differentiated into therapeutically meaningful phenotypes with a high degree of accuracy. Further, the newest treatment option, per-oral endoscopic myotomy (POEM), has become a staple therapy following the last 10 years of experience, and recent randomized trials appear to show no difference between POEM, graded pneumatic dilatation and surgical Heller myotomy in terms of short- and long-term efficacy or complication rate. On the other hand, how treatment outcomes are measured as well as the risk of reflux following therapy remain areas of contention. This review aims to summarize the recent advancements in achalasia testing and therapy, describes the recent randomized clinical trials as well as their potential setbacks, and touches on the future of personalizing achalasia treatment.

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.

Introduction Oesophageal cancer is the 7th commonest cause of cancer death worldwide. Radiological staging of local oesophageal cancer is inaccurate. CT currently relies on attenuation of x-rays to generate contrast. Soft tissues have very similar attenuation properties so minimal contrast is generated. X-ray phase contrast imaging (XPCI) uses refraction of x-rays as they pass through tissue instead of attenuation and provides much higher soft tissue contrast. This technology can be tuned to a resolution of approximately 10 µm. This may allow for easy assessment of extent of disease infiltration. We aimed to use XPCI to image oesophagectomy specimens to assess pathological tumour and nodal stage for oesophageal cancer Methods Following ethical approval, 10 oesophagectomy specimens were obtained from patients having surgery for oesophageal cancers. These included both squamous and adenocarcinomas. Specimens were fixed in formalin for 12 hours. Sutures were placed through tissue to enable co-registration between CT slices and histology sections. For some scans, tissue was then dehydrated with graded ethanol for between 4.5 hours and 72 hours before being imaged. A Rigaku (MicroMax 007) xray source was used at 40 kV and 20 mA; a detector with 50µm pixel size; and sample and detector masks made of graphite substrate with gold overlay. Phase contrast was generated using edge illumination technique. We reconstructed the images using MATLAB® software. Specimens were returned for clinical histopathological assessment allowing correlation between H&E slides and CT images. Results We have performed 25 scans on 10 oesophagectomy samples and correlated them with histology Scans of samples in formalin failed to show adequate contrast between oesophageal layers to enable tumour visualisation and staging. Infiltrating the tissue with ethanol led to much better image contrast. We could easily identify mucosa, submucosa and both layers of muscle in reconstructed CT images. We also identified tumour infiltration through tissue layers and destruction of normal oesophageal morphology (figure 1). This was confirmed histologically and could be recognised by radiologists blinded to pathological staging This is the first time that XPCI has been used to image human oesophageal tissue. We have demonstrated the feasibility of the technique and the possibility of obtaining high resolution images which mimic histology with the extra benefit of demonstrating three dimensional structure.

Introduction The Lyon Consensus 2018 describes nocturnal baseline impedance (MNBI) as a reflection of oesophageal mucosa permeability, with lower values found in erosive than non-erosive reflux disease (NERD); however it is not clear how MNBI correlates with symptoms. This study aims to determine the relationship of MNBI across three common presentations of reflux; Barrett’s oesophagus, NERD and functional heartburn (FH). Methods Between 2014 and 2020, pH-Impedance measurements and symptom index (SI) were collected for 37 consecutive patients with at least 3 cm of Barrett’s oesophagus (13 on and 24 off proton pump inhibitors; PPI). 37 consecutive patients with NERD and 37 with FH were also included for comparison. MNBI was calculated from sensors at 3 and 5 cm above the LOS over 3 × 10 minute intervals during the nocturnal period. Results There was a significant difference in median acid exposure time (AET) between the 3 subgroups; Barrett’s (14.0%(6.3%,23.5%), NERD (8.9%(5.6%13.5%) and FH (1.9(0.7%, 2.7%) (p MNBI was low in Barrett’s compared to NERD and FH (figure 1; p 3 cm) Barrett’s who had attempts at therapy (ablation, mucosal resection) compared to the 27 who had not received therapy (p=0.96). There was a moderately inverse correlation between Barrett’s segment length (median 5 cm (3 cm,9 cm) and MNBI (r = -0.436; p=0.038). Conclusion This study suggests that the impact of reflux disease on mucosal permeability (MNBI) may have an influence on symptom perception. Both MNBI and symptom perception were significantly reduced in Barrett’s compared to NERD. Furthermore, neither MNBI nor symptom perception are affected by use of acid reducing medication despite the difference in AET. This study provides further validation to the Lyon consensus definition of MNBI as a measure of reflux disease severity.

Introduction Endoscopic resection (ER) and radiofrequency ablation (RFA) have become the standard of care worldwide for treatment of early Barrett’s neoplasia. Procedural outcomes are highly dependent on the operator skill and training. Validated tools for assessment of competency in these 2 procedures are currently lacking. We aimed to develop and validate ER and RFA tools for use in clinical practice. Methods A working group of 15 experts who met one or more of the predefined inclusion criteria was set up. Using published evidence-based criteria, the group devised a structured checklist of graded competency descriptors (scores ranged from 1=required maximal supervision to 4=competent). The latter were grouped into four main competency domains, namely: pre-procedural; specific skills; post-procedural; and endoscopic non-technical skills (ENTS). Consensus agreement and piloting was undertaken to ensure content validity. Construct validity was measured by independent assessment of 60 videos per procedure of ER and RFA by 7 assessors (selected from the working group) in a random manner. Procedures were performed by 15 operators with variable expertise including experts and trainees. Statistical analysis was performed using Generalizability theory, which analysed ‘variability components’ between: operators; cases; assessors; assessors across (x) operators; and unexplained variation. Results Data on a minimum of 45 videos per procedure were available for analysis. The mean (± standard deviation) competency scores were 3.4 (0.8) and 3.7 (0.6) for ER and RFA, respectively. The variability components for the analysis are detailed in table 1. Variation in scores between operators, assessors, and assessors across different operators was small accounting for Conclusions The DOBES assessment tools for ER and RFA appear to have good content and construct validity and were produced based on evidence and expert opinion. The analysis shows agreement on scores between expert assessors which strengthens the case for its adoption into clinical practice.

Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ. © 2020 John Wiley & Sons Ltd, National Institute of Diabetes and Digestive and Kidney Diseases, NIDDK: P01 DK092217, National Institute of Diabetes and Digestive and Kidney Diseases, Grant/Award Number: P01 DK092217

Purpose of Review In the absence of mucosal or structural disease, the aim of investigating the oesophagus is to provide clinically relevant measurements of function that can explain the cause of symptoms, identify pathology and guide effective management. One of the most notable recent advances in the field of oesophageal function has been high-resolution manometry (HRM). This review explores how innovation in HRM has progressed and has far from reached a plateau. Recent Findings HRM technology, methodology and utility continue to evolve; simple additions to the swallow protocol (e.g. eating and drinking), shifting position, targeting symptoms and adding impedance sensors to the HRM catheter have led to improved diagnoses, therapeutic decision-making and outcomes. Summary Progress in HRM persists and shows little sign of abating. The next iteration of the Chicago Classification of motor disorders will highlight these advances and will also identify opportunities for further research and innovation.

Background and study aims Cryoablation with the Cryoballoon device is a novel ablative therapy that uses cycles of freezing and thawing to induce cell death. This single-center prospective study evaluated the feasibility of the focal cryoablation device for the treatment of areas of refractory esophageal neoplasia in patients who had undergone first line endoscopic eradication therapy (EET). Complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia (CR-IM) at first follow-up endoscopy, durability of disease reversal, rates of stenosis and adverse events were studied. Patients and methods Eighteen cases were treated. At baseline, nine patients had low-grade dysplasia (LGD), six had high-grade dysplasia (HGD) and three had intramucosal carcinoma (IMC). Median length of dysplastic Barrett’s esophagus (BE) treated was 3 cm. The median number of ablations per patient was 11. Each selected area of visible dysplasia received 10 seconds of ablation. One session of cryoablation was performed per patient. Biopsies were performed at around 3 months post-ablation. Results CR-D was achieved in 78 % and CR-IM in 39 % of patients. There were no device malfunction or adverse events. Stenosis was noted in 11 % of cases. At a median follow up of 19-months, CR-D was maintained in 72 % of patients and CR-IM in 33 %. Conclusions Cryoablation appears to be a viable rescue strategy in patients with refractory neoplasia. It is well tolerated and successful in obtaining CR-D and CR-IM in patients with treatment-refractory BE. Further trials of dosimetry, efficacy and safety in treatment-naïve patients are underway.

BACKGROUND Pathophysiology of rumination syndrome (RS) is not well understood. Treatment with diaphragmatic breathing improves rumination syndrome. The aim of the study was to characterize vagal tone in patients with rumination syndrome during and after meals and during diaphragmatic breathing. METHODS We prospectively recruited 10 healthy volunteers (HV) and 10 patients with RS. Subjects underwent measurement of vagal tone using heart rate variability. Vagal tone was measured during baseline, test meal and intervention (diaphragmatic (DiaB), slow deep (SlowDB), and normal breathing). Vagal tone was assessed using mean values of root mean square of successive differences (RMSSD), and area under curves (AUC) were calculated for each period. We compared baseline RMSSD, the AUC and meal-induced discomfort scores between HV and RS. Furthermore, we assessed the effect of respiratory exercises on symptom scores, and number of rumination episodes. KEY RESULTS There was no significant difference in baseline vagal tone between HV and RS. During the postprandial period, there was a trend to higher vagal tone in RS, but not significantly (P > .2 for all). RS had the higher total symptom scores than HV (P

Background Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome. Methods In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score). Key results Twenty-four achalasics (median age 43 year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P = .03), mean residual barium column height (14.7 ± 8.7 to 7.9 ± 6.0 cm; P = .01) and surface area (52.7 ± 43.5 to 24.5 ± 23.6 cm2 ; P = .02). There were 4 (17%) initial non-responders (Eckardt > 3). % SA was best at discriminating between responders and non-responders (area under curve 0.85 ± 0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response. Conclusions & inferences Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.

Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux (GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett’s oesophagus, adeno- as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pre-test probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.

Summary Background The use of high-resolution manometry (HRM) to diagnose oesophageal motility disorders is based on ten single water swallows (SWS); however, this approach might not be representative of oesophageal function during the ingestion of normal food. We tested whether inclusion of a standardised solid test meal (STM) to HRM studies increases test sensitivity for major motility disorders. Additionally, we assessed the frequency and cause of patient symptoms during STM. Methods Consecutive patients who were referred for investigation of oesophageal symptoms were recruited at Nottingham University Hospitals (Nottingham, UK) in the development study and at University Hospital Zurich (Zurich, Switzerland) in the validation study. HRM was done in the upright, seated position with a solid-state assembly. During HRM, patients ingested ten SWS, followed by a standardised 200 g STM. Diagnosis of oesophageal motility disorders was based on the Chicago Classification validated for SWS (CCv3) and with STM (CC-S), respectively. These studies are registered with ClinicalTrials.gov, numbers NCT02407938 and NCT02397616. Findings The development cohort included 750 patients of whom 360 (48%) had dysphagia and 390 (52%) had reflux or other symptoms. The validation cohort consisted of 221 patients, including 98 (44%) with dysphagia and 123 (56%) with reflux symptoms. More patients were diagnosed with a major motility disorder by use of an STM than with SWS in the development set (321 [43%] patients diagnosed via STM vs 163 [22%] via SWS; p vs 49 [22%]; p=0·014). The increase was most evident in patients with dysphagia (241 [67%] of 360 patients on STM vs 125 [35%] patients on SWS in the development set, p vs 32 [10%] patients in the development set, p=0·00060). Reproduction of symptoms was reported by nine (1%) of 750 patients during SWS and 461 (61%) during STM (p Interpretation The diagnostic sensitivity of HRM for major motility disorders is increased with use of the STM compared with SWS, especially in patients with dysphagia. Observations made during STM can establish motility disorders as the cause of oesophageal symptoms. Funding None.

Main Recommendations ESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2-4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset. Strong recommendation, high quality of evidence, level of agreement 100%. ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM). Strong recommendation, very low quality of evidence, level of agreement 87.5%. ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus. Strong recommendation, low quality of evidence, level of agreement 78.6%. ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed. Strong recommendation, very low quality of evidence, level of agreement 100%. ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis. Strong recommendation, high quality of evidence, level of agreement 92.9%. ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial. Strong recommendation, low quality of evidence, level of agreement 100%., SCOPUS: re.j, info:eu-repo/semantics/published

Endoscopic resections and radiofrequency ablation (RFA) are the established treatments for Barrett's-associated dysplasia and early esophageal neoplasia. The UK RFA Registry collects patient outcomes from 24 centers treating patients in the United Kingdom and Ireland. Learning curves for treatment of Barrett's dysplasia and the impact of center caseload on patient outcomes is still unknown.We examined outcomes of 678 patients treated with RFA in the UK Registry using risk-adjusted cumulative sum control chart (RA-CUSUM) analysis to identify change points in complete resolution of intestinal metaplasia (CR-IM) and complete resolution of dysplasia (CR-D) outcomes. We compared outcomes between those treated at high-volume (100 enrolled patients), medium-volume (51-100), and low-volume (50) centers.There was no association between center volume and CR-IM and CR-D rates, but recurrence rates were lower in high-volume versus low-volume centers (log rank P = .001). There was a significant change point for outcomes at 12 cases for CR-D (reduction from 24.5% to 10.4%; P .001) and at 18 cases for CR-IM (30.7% to 18.6%; P .001) from RA-CUSUM curve analysis.Our data suggest that 18 supervised cases of endoscopic ablation may be required before competency in endoscopic treatment of Barrett's dysplasia can be achieved. The difference in outcomes between a high-volume and low-volume center does not support further centralization of services to only high-volume centers.

BACKGROUND & AIMS: Wireless pH monitoring measures esophageal acid exposure time (AET) for up to 96 hrs. We evaluated competing methods of analysis of wireless pH data. METHODS: Adult patients with persisting reflux symptoms despite acid suppression (n=322, 48.5±0.9 y, 61.7% women) from 2 tertiary centers were evaluated using symptom questionnaires and wireless pH monitoring off therapy, from November 2013 through September 2017; 30 healthy adults (controls; 26.9±1.5 y; 60.0% women) were similarly evaluated. Concordance of daily AET (physiologic 6%) for 2 or more days constituted the predominant AET pattern. Each predominant pattern (physiologic, borderline, or pathologic) in relation to data from the first day, and total averaged AET, were compared with other interpretation paradigms (first 2 days, best day, or worst day) and with symptoms. RESULTS: At least 2 days of AET data were available from 96.9% of patients, 3 days from 90.7%, and 4 days from 72.7%. A higher proportion of patients had a predominant pathologic pattern (31.4%) than controls (11.1%; P=.03). When 3 or more days of data were available, 90.4% of patients had a predominant AET pattern; when 2 days of data were available, 64.1% had a predominant AET pattern (P

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. ispartof: GUT vol:68 issue:10 pages:1731-1750 ispartof: location:England status: published